Pennsylvania Department of Health
RIVER VIEW NURSING AND REHABILITATION CENTER
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

RIVER VIEW NURSING AND REHABILITATION CENTER
Inspection Results For:

There are 159 surveys for this facility. Please select a date to view the survey results.

Surveys don't appear on this website until at least 41 days have elapsed since the exit date of the survey.


RIVER VIEW NURSING AND REHABILITATION CENTER - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:

Based on a Medicare/Medicaid Recertification, State Licensure, Civil Rights Compliance, Abbreviated Complaint, and state revisit survey completed on April 25, 2025, it was determined that River View Nursing and Rehabilitation Center corrected the state deficiencies cited during the survey of February 5, 2025, but was not in compliance with the following requirements of 42 CFR Part 483 Subpart B and the 28 PA Code Commonwealth of Pennsylvania Long Term Care Licensure Regulations.

Plan of Correction:

483.80(a)(1)(2)(4)(e)(f) REQUIREMENT Infection Prevention & Control:

This is a less serious (but not lowest level) deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.

§483.80 Infection Control
The facility must establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections.

§483.80(a) Infection prevention and control program.
The facility must establish an infection prevention and control program (IPCP) that must include, at a minimum, the following elements:

§483.80(a)(1) A system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon the facility assessment conducted according to §483.71 and following accepted national standards;

§483.80(a)(2) Written standards, policies, and procedures for the program, which must include, but are not limited to:
(i) A system of surveillance designed to identify possible communicable diseases or
infections before they can spread to other persons in the facility;
(ii) When and to whom possible incidents of communicable disease or infections should be reported;
(iii) Standard and transmission-based precautions to be followed to prevent spread of infections;
(iv)When and how isolation should be used for a resident; including but not limited to:
(A) The type and duration of the isolation, depending upon the infectious agent or organism involved, and
(B) A requirement that the isolation should be the least restrictive possible for the resident under the circumstances.
(v) The circumstances under which the facility must prohibit employees with a communicable disease or infected skin lesions from direct contact with residents or their food, if direct contact will transmit the disease; and
(vi)The hand hygiene procedures to be followed by staff involved in direct resident contact.

§483.80(a)(4) A system for recording incidents identified under the facility's IPCP and the corrective actions taken by the facility.

§483.80(e) Linens.
Personnel must handle, store, process, and transport linens so as to prevent the spread of infection.

§483.80(f) Annual review.
The facility will conduct an annual review of its IPCP and update their program, as necessary.

Plan of Correction - To be completed: 06/10/2025

1.Resident 56 was placed on isolation precautions per facility policy.

2. Current residents who are on contact precautions were reviewed to ensure contact precautions are being followed.

3.DON/designee will educate IP nurse/nursing staff in implementing contact precautions, surveillance and timely analysis of infections, completing disease trends and documentation of same.

4.DON/Designee will audit infection control tracking to ensure that surveillance, timely analysis and documentation is present weekly x4 then monthly x2 and report findings to QAPI committee .

483.12(a)(1) REQUIREMENT Free from Abuse and Neglect:

This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.

§483.12 Freedom from Abuse, Neglect, and Exploitation
The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms.

§483.12(a) The facility must-

§483.12(a)(1) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion;

Plan of Correction - To be completed: 06/10/2025

1. Resident 18, 104, 108 and 224 had no ill effects from this alleged deficient practice. Resident 57 had no ill effects from this alleged deficient practice.

2. Residents with identified aggressive behaviors had review of care plans completed to ensure effective interventions are in place to protect other residents from potential harm.
Current residents transfer status was reviewed to ensure correct transfer status is on Kardex.

3. DON/designee educated Nursing staff on protecting residents from residents who have aggressive behaviors.
DON/designee educated Nursing staff on how to determine residents transfer status to prevent potential neglect of resident.

4. DON/designee will review 24 hour report weekly x4 then monthly x2 for residents exhibiting aggressive behaviors and assure care plan is updated with effective interventions to protect residents from potential harm and report findings to QAPI committee monthly.
DON designee will review fall Incident reports to verify appropriate assistance was provided during transfers weekly x4 then monthly x2 and report findings to QAPI committee .

483.25(i) REQUIREMENT Respiratory/Tracheostomy Care and Suctioning:

§ 483.25(i) Respiratory care, including tracheostomy care and tracheal suctioning.
The facility must ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals and preferences, and 483.65 of this subpart.

Observations:

Based on observation, clinical record review, and staff interview it was determined the facility failed to ensure respiratory care including tracheostomy (surgical procedure where a hole is created in the neck and a tube is inserted into the trachea or windpipe to help a person breathe) care was provided in accordance with physician orders for one of three sampled residents (Resident 2).

Findings include:

Review of the clinical record revealed Resident 2 had diagnoses which included chronic respiratory failure (condition that occurs when the lungs cannot get enough oxygen into the blood or eliminate enough carbon dioxide from the body) with tracheostomy and cerebral palsy (brain disorder that appears in infancy or early childhood and permanently affects body movement and muscle coordination).

A physician order dated February 3, 2025, was noted for a Pulmonary Consult on February 17, 2025.

Review of the Pulmonary Consult dated February 17, 2025, revealed that Resident 2 was weaned to room air (normal air without supplemental oxygen) during the appointment. The plan/medical decision making/recommendations included to use oxygen as needed to maintain O2 level (oxygen saturation- the amount of oxygen carried by red blood cells in blood) was greater than 89%. Maintain humidification (process of adding moisture to the air a person with a tracheostomy breathes, without humidification the air can dry out secretions, making them thick and difficult to clear) via trach even if on room air. Start vest (SmartVest- provides high frequency chest wall oscillation to simulate repetitive mini-coughs to shear mucus away from the walls of the lung's airways and reduce the viscosity [thickness] of secretions) twice daily as tolerated for airway clearance. Use Albuterol (bronchodilator which works by relaxing and opening the air passages to the lungs to make breathing easier) twice daily with vest. Follow-up with pulmonary medicine in three months for evaluation.

A physician order following the Pulmonary Consult dated February 17, 2025, noted to use oxygen as need to keep O2 level greater than 89%. Use humidification for trach. Start vest therapy twice daily to assist with mucous clearance if the resident tolerates. Use Albuterol nebulizer twice daily with vest therapy.

Observation of Resident 2 on April 24, 2025, at 1:25 PM revealed the resident was in bed. Further observation revealed the resident was not receiving oxygen or humidification via the resident's tracheostomy. There was no evidence of a SmartVest in the resident's room.

Interview with Employee 8 (RN) on April 24, 2025, at approximately 1:40 PM confirmed that humidification was not being used for the resident when the resident is on room air. Employee 8 (RN) confirmed the resident had not yet received a SmartVest.

Further review of the clinical record revealed no documented evidence that arrangements had been made to obtain a SmartVest for the resident based on the physician order dated February 17, 2025, for vest therapy twice daily.

Upon surveyor inquiry on April 24, 2025, the facility clarified recommendations from the resident's pulmonary consult on February 17, 2025.

A telephone encounter note dated April 25, 2025, confirmed the resident should be receiving humification when on room air to keep secretions moist and easier for the resident to cough the secretions out or be suctioned. A phone number to obtain a SmartVest was also provided.

Interview with the director of nursing on April 25, 2025, at 12:23 PM failed to provide documented evidence that physician orders related to respiratory and tracheostomy care for Resident 2 were timely implemented.

28 Pa. Code 211.5 (f)(i) Medical records.

28 Pa. Code 211.12 (c)(d)(1)(3)(5) Nursing services

Plan of Correction - To be completed: 06/10/2025

1.Resident 2 has all recommendations from pulmonology in place.

2. All residents receiving respiratory care have been audited to ensure the physicians' orders are being implemented.

3.Licensed nurses were educated that when resident returns from physician visits, consult needs to be reviewed with attending physician/NP and approved recommendations implemented timely.

4.DON/designee will audit random resident pulmonary consults weekly x4 then monthly x2 to ensure that recommendations made are reviewed and implemented timely and report findings to QAPI committee.

483.10(c)(6)(8)(g)(12)(i)-(v) REQUIREMENT Request/Refuse/Dscntnue Trmnt;Formlte Adv Dir:

This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.

§483.10(c)(6) The right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.

§483.10(c)(8) Nothing in this paragraph should be construed as the right of the resident to receive the provision of medical treatment or medical services deemed medically unnecessary or inappropriate.

§483.10(g)(12) The facility must comply with the requirements specified in 42 CFR part 489, subpart I (Advance Directives).
(i) These requirements include provisions to inform and provide written information to all adult residents concerning the right to accept or refuse medical or surgical treatment and, at the resident's option, formulate an advance directive.
(ii) This includes a written description of the facility's policies to implement advance directives and applicable State law.
(iii) Facilities are permitted to contract with other entities to furnish this information but are still legally responsible for ensuring that the requirements of this section are met.
(iv) If an adult individual is incapacitated at the time of admission and is unable to receive information or articulate whether or not he or she has executed an advance directive, the facility may give advance directive information to the individual's resident representative in accordance with State law.
(v) The facility is not relieved of its obligation to provide this information to the individual once he or she is able to receive such information. Follow-up procedures must be in place to provide the information to the individual directly at the appropriate time.

Observations:

Based on clinical record review and staff interview it was determined the facility failed to accurately identify a resident's request for future health care and advance directives (a written instruction such as a living will or durable power of attorney for health care for when the individual is incapacitated) as evidenced by one resident (Resident 173) out of 27 residents sampled.

Findings include:

A review of the clinical record of Resident 173, revealed the resident was admitted to the facility on April 18, 2025, with diagnoses that included osteoarthritis (type of arthritis that causes joints to become painful and stiff) and atrial fibrillation (an irregular heart rate that commonly causes poor blood flow).

Review of Resident 173's clinical record revealed a completed and signed POLST (Physician Orders for Life-Sustaining Treatment a medical order form used to communicate a resident's preferences for life-sustaining measures across care settings) dated April 18, 2025. The POLST indicated that the resident elected DNR status (Do Not Resuscitate a medical order directing that cardiopulmonary resuscitation [CPR], a life-saving procedure performed when the heart or breathing stops, should not be attempted), with a goal of allowing a natural death.

Further review of the resident's current physician orders, initially entered on April 18, 2025, in the electronic health record, identified the resident's code status as "Full Code," indicating CPR was to be performed in the event of cardiopulmonary arrest.

There was no documentation to indicate that Resident 173 had revised the advance directive or changed the preference documented on the POLST. No clinical notes or care conference records reflected a discussion or update to the resident's wishes regarding life-sustaining treatment.

An interview with the Director of Nursing (DON) on April 25, 2025, at 9:10 AM confirmed that physician orders are required to align with the most current, signed POLST. The DON acknowledged that Resident 173 had elected "DNR" status on the POLST form and the current physician orders incorrectly reflected "Full Code," which did not honor the resident's documented treatment preferences.

28 Pa. Code 201.29(a) Resident rights.

28 Pa. Code 211.5 (f)(i) Medical records.

28 Pa. Code 211.12 (d)(1)(3)(5) Nursing services.

Plan of Correction - To be completed: 06/10/2025

1.R173 code status was corrected.

2.Current resident's POLST/advanced directives were reviewed to ensure that physicians order are correct.

3.DON/designee will educate social services on reviewing POLST/advanced directive to physicians orders to assure they are correct.

4.Social Services will audit new admissions to ensure residents POLST/advanced directive matches physician orders weekly x4 then monthly x2 and report findings to QAPI committee

483.12(c)(2)-(4) REQUIREMENT Investigate/Prevent/Correct Alleged Violation:

§483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must:

§483.12(c)(2) Have evidence that all alleged violations are thoroughly investigated.

§483.12(c)(3) Prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress.

§483.12(c)(4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken.

Observations:

Based on observation, clinical record review, review of facility policy, investigative documentation, and staff and resident interviews, it was determined the facility failed to thoroughly investigate an incident involving a fall with minor injury to determine whether neglect occurred and failed to identify that planned fall interventions were not in place for one of 27 sampled residents (Resident 57).

The findings include:

A review of the facility policy titled "Abuse, Neglect, Exploitation, and Misappropriation Prevention Program," last reviewed by the facility on January 22, 2025, revealed it is the facility's policy that residents have the right to be free from abuse and neglect. The policy indicated the facility's resident abuse and neglect prevention program consists of a facility-wide commitment and resource allocation to support the following objectives: (1) protect residents from abuse and neglect by anyone, including, but not necessarily limited to, facility staff and other residents.

Further review of the facility policy revealed the facility will identify and investigate all possible incidents of abuse, neglect, mistreatment, or misappropriation of resident property, and will investigate and report any allegations within time frames required by federal requirements.

A review of Resident 57's clinical record revealed the resident was admitted to the facility on May 24, 2024, with diagnoses to include end-stage renal disease (the final stage of kidney decline where the kidneys are no longer able to function to meet the body's needs) dependent on dialysis (the process of removing waste products and excess fluid from the body when the kidneys are unable to adequately filter the blood) and bilateral below-the-knee amputation of the lower extremities.

A review of a quarterly Minimum Data Set assessment (MDS-a federally mandated standardized assessment process conducted periodically to plan resident care) dated December 12, 2024, revealed that Resident 57 had moderately impaired cognition with a BIMS score of 12 (Brief Interview for Mental Status-a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 8-12 indicates cognition is moderately impaired).

Additionally, the MDS indicated the resident had functional limitations in range of motion with impairments to both sides of the lower extremities, and the resident was indicated to be dependent with bed-to-chair transfer (the ability to transfer to and from a bed to a chair or wheelchair).

The most current review of a quarterly MDS, dated April 7, 2025, revealed that Resident 57 is cognitively intact with a BIMS score of 14 (a score of 13-15 indicates cognition is intact).

Resident 57's comprehensive person-centered plan of care initiated on November 23, 2024, indicated the resident required the assistance of two staff members with transfers. The care plan was revised on December 16, 2024, to include the use of a mechanical lift (a mechanical device designed to lift/transfer individuals that have limited mobility in a safe manner and reduce injuries) with transfers.

A review of Resident 57's clinical record revealed physician's orders dated December 6, 2024, to utilize a mechanical lift for all transfers and bed mobility with the assistance of two staff members.

A review of Resident 57's task report (an electronic record that summarized planned resident-centered tasks completed by nursing) initiated on December 8, 2024, revealed that Resident 57 was an assist of two staff members via the mechanical lift for transferring.

A review of a facility investigative report dated December 13, 2024, at approximately 2:30 PM, revealed that Employee 14, an agency nurse aide, was transferring Resident 57 and experienced a fall during the transfer.

A review of a facility investigative report dated December 13, 2024, at approximately 2:30 PM, revealed that Employee 14, an agency nurse aide was transferring Resident 57 and experienced a fall during the transfer.

A review of a witness statement from Employee 14, dated 2:30 PM, indicated he was transferring the resident to his wheelchair and grabbed the resident under both arms, and that Resident 57 was holding onto him with both arms and while during the transfer his left below-the-knee amputation stump became stuck in the wheelchair arm. Employee 14 then called out for help and received assistance from Employee 15, the maintenance director, to help dislodge his stump from the wheelchair arm. Employee 14 then attempted to reposition the resident into the wheelchair but stumbled over clutter on the floor and placed the resident on the floor to prevent harm. The statement did not acknowledge that the mechanical lift, as required by physician order and care plan, had not been used.

A review of a witness statement from Employee 15, dated 2:30 PM, indicated that he heard someone yelling for help and witnessed Employee 14 holding Resident 57 under both arms while Resident 57 had both of his arms wrapped around Employee 14, and Employee 14 asked Employee 15 to help dislodge his left stump from the wheelchair arm. Employee 15 assisted in freeing the resident's stump from the wheelchair arm. After the stump was freed, Employee 14 lost balance and the resident was found lying on the floor. Employee 15 also observed clutter on the floor and water from a bottle that spilled during the incident.

A review of a nurse's incident/accident statement dated December 13, 2024, at 4:21 PM, revealed that they found Resident 57 on the floor lying next to Employee 14 and noted debris of a cup, paper, and water on the floor.

The facility investigation failed to obtain a resident statement from Resident 57 at the time of the incident. During the survey, the Nursing Home Administrator (NHA) was unable to explain the omission of the resident's statement. When interviewed on April 24, 2025, at 8:40 AM, Resident 57 stated that he had informed Employee 14 he required a mechanical lift with two-person assistance, but the aide proceeded to transfer him manually. The resident believed the aide
in a hurry to get the transfer done faster.

A nurse's progress note dated December 14, 2024, at 10:37 AM documented complaints of rib pain, and a subsequent x-ray was ordered. Although the December 17, 2024, radiology report showed no fracture, a physician's note dated December 19, 2024, noted that Resident 57 was likely to have a right rib contusion (bruise), as x-ray findings were negative, and the resident was experiencing pain.
The resident required Tylenol for rib pain on multiple occasions between December 14-20, 2024, with reported pain scores ranging from 3 to 8 (pain scale of 1 to 10 1 being no pain and 10 being the worst pain).

The facility investigation lacked evidence the facility evaluated whether the plan of care for Resident 57 was implemented as directed. There was no documentation identifying the resident was transferred by only one staff member or that the mechanical lift was not used. The facility failed to identify or document the deviation from the care plan.

Furthermore, attempts to re-contact Employee 14 during the on-site survey were unsuccessful. The NHA was unable to provide documentation or rationale for the staff member's departure from the facility. Employee 15, interviewed on April 24, 2025, stated he did not know why the aide was transferring the resident alone.

A review of Employee 14 personnel file acknowledged that he completed training and was deemed proficient to perform all assigned tasks, including proper transfer techniques, and received training on abuse and neglect of a resident.

Despite this documented training and acknowledgment of competency, review of Resident 57's clinical record confirmed that Employee 14 failed to adhere to established protocols by not using the required mechanical lift to transfer Resident 57 along with another staff member on December 13, 2024.

The facility failed to implement its established procedures in response to a fall with minor injury by failing to conduct a thorough investigation to rule out potential abuse, neglect, or mistreatment of the resident as a potential cause of the fall with minor injury. There was no indication the facility identified at the time of the incident that there was only one nurse aide, Employee 14, and no use of a mechanical lift for transfers.

During an interview conducted on April 24, 2025, at 1:30 PM, the NHA confirmed that the facility could not provide documented evidence the facility fully investigated to rule out potential neglect following Resident 10's fall with minor injury. The facility failed to identify that planned interventions were not in place and/or implemented in a manner to ensure the resident's safety to prevent the fall and prevent future reoccurrence to the extent possible and implement appropriate corrective actions to prevent recurrence.

Refer F600

28 Pa. Code 201.14 (a)(c) Responsibility of licensee

28 Pa. Code 201.18(e)(1) Management

28 Pa. Code 201.29 (a)(c) Resident Rights

28 Pa. Code 211.12 (c)Nursing Services

Plan of Correction - To be completed: 06/10/2025

1.Resident 57 had no ill effects from alleged deficient practice.

2. Residents with falls in past 10 days were reviewed to ensure investigation was completed to rule out abuse.

3.RDCS/designee educated Administrator and DON on conducting a through investigation timely to rule out abuse, neglect or mistreatment.

4.DON/designee will audit random fall incident reports for timely and thorough investigation to rule out abuse, neglect or mistreatment weekly x4 and monthly x2 and report findings to QAPI committee.

483.20(g) REQUIREMENT Accuracy of Assessments:

§483.20(g) Accuracy of Assessments.
The assessment must accurately reflect the resident's status.

Observations:

Based on a review of clinical records and the Resident Assessment Instrument (RAI) and staff interviews, it was determined the facility failed to ensure the Minimum Data Set Assessments (MDS - a federally mandated standardized assessment conducted at specific intervals to plan resident care) accurately reflected the status of three residents out of 27 sampled (Residents 2, 40, and 47).

Findings included:

A review of Resident 2's clinical record revealed the resident was admitted to the facility on May 24, 2024, with diagnoses that included chronic respiratory failure (a condition that occurs when the lungs cannot get enough oxygen into the blood or eliminate enough carbon dioxide from the body) and atrial fibrillation (an irregular heart rate that commonly causes poor blood flow).

A current physician order initially dated January 28, 2025, noted an order for Warfarin Sodium (an anticoagulant medication also known as a blood thinner) 4 mg via PEG-tube (percutaneous endoscopic gastrostomy- feeding tube placed directly into the stomach through the abdominal wall to provide liquid nutrition, medications, and fluids into the stomach) at bedtime for diagnosis of atrial fibrillation.

A review of Resident 2's February 2025 Medication Administration Record revealed Apixaban 5 mg (anticoagulant) was administered daily as ordered by the physician.

A review of Resident 2's quarterly MDS Assessment dated February 27, 2025, indicated the resident did not receive an anticoagulant (blood thinner) medication during the 7-day look-back period.

An interview with the RNAC (registered nurse assessment coordinator) on April 23, 2025, at approximately 1:30 PM confirmed Resident 2's MDS assessment was not accurate.

A review of Resident 40's clinical record revealed the resident was admitted to the facility on March 6, 2023, with diagnoses that included dementia (chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning) and peripheral vascular disease (circulatory condition in which narrowed blood vessels reduce blood flow to the limbs).

A review of Resident 40's annual MDS Assessment dated February 22, 2025, Section I active diagnoses, infection in the past seven days, indicated infections of MDRO (multi-drug resistant organism is a germ that is resistant to many antibiotics) and pneumonia (infection that affects one or both lungs, which makes it difficult to breathe and can cause a fever and cough). However, review of the clinical record revealed no documented evidence the resident had an MDRO infection or pneumonia.

An interview with the RNAC on April 23, 2025, at approximately 1:45 PM confirmed that Resident 40 did not have an MDRO infection or pneumonia during the seven-day look-back period of the MDS assessment. The RNAC confirmed that Resident 40's MDS assessment was not accurate.

A clinical record review revealed Resident 47 was admitted to the facility on September 8, 2022, with diagnoses to include diabetes (a chronic disease that occurs either when the pancreas does not produce enough insulin or when the body cannot effectively use the insulin it produces).

A review of a 5-day MDS assessment dated February 11, 2025, Section N0350. Insulin: Resident 47 did not receive any insulin injections during the seven-day look-back period. However, a review of Resident 47's Medication Administration Record dated February 2025 revealed Resident 47 received a Lantus 100 unit/ml solution pen injector (insulin) on five occasions from February 7, 2025, through February 11, 2025.

During an interview on April 24, 2025, at approximately 1:30 PM, the RNAC confirmed Resident 47's February 11, 2025, MDS, Section N0350. Insulin was not accurate.

28 Pa. Code 201.18(e)(1) Management

28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing services

Plan of Correction - To be completed: 06/10/2025

1.Resident 2, 40 and 47 MDS data were corrected and resubmitted.

2.MDS's submitted in past 10 days were reviewed for accuracy.

3.RDCS/designee educated RNAC on coding accuracy.

4.RNAC/designee will review 5 MDS's weekly x4 then random MDS's monthly x2 and report findings to QAPI committee.

483.21(b)(3)(i) REQUIREMENT Services Provided Meet Professional Standards:

§483.21(b)(3) Comprehensive Care Plans
The services provided or arranged by the facility, as outlined by the comprehensive care plan, must-
(i) Meet professional standards of quality.

Observations:

Based on clinical record review, facility policy review, and staff interview, it was determined the facility failed to ensure that nursing services met professional standards of quality according to the Pennsylvania Code Title 49, Professional and Vocational Standards, by failing to implement nursing practices for the administration of intravenous medication via a peripheral IV (thin, flexible plastic tube inserted into a peripheral vein to allow for the administration of fluids, medications, and other therapies into the bloodstream and used for short-term intravenous therapy) for one of 27 residents reviewed (Resident 101).

Findings include:

According to the Pennsylvania Code Title 49, Professional and Vocational Standards Department of State, Chapter 21 State Board of Nursing, Chapter 21.145 Functions of the LPN (Licensed Practical Nurse) requires the following:
The LPN is prepared to function as a member of the health care team by exercising sound nursing judgement based on preparations, knowledge, skills, understandings and past experiences in nursing situations. The LPN participates in the planning, implementation and evaluation of nursing care in settings where nursing takes place. (b) The LPN administers medication and carries out the therapeutic treatment ordered for the patient in accordance with the following: (d) The Board recognizes codes of behavior as developed by appropriate practical nursing associations as the criteria for assuring safe and effective practice.

Chapter 21.145b. IV therapy curriculum requirements;
(f) An LPN may perform only the IV therapy functions for which the LPN
possesses the knowledge, skill and ability to perform in a safe manner, except as
limited under 21.145a (relating to prohibited acts), and only under supervision
as required under paragraph (1).
(1) An LPN may initiate and maintain IV therapy only under the direction
and supervision of a licensed professional nurse or health care provider authorized
to issue orders for medical therapeutic or corrective measures (such as a
CRNP, physician, physician assistant, podiatrist or dentist).

(g) An LPN who has met the education and training requirements of 21.145b (relating to IV therapy curriculum requirements) may perform the following IV therapy functions, except as limited under 21.145a and only under supervision as required under subsection (f):
(1) Adjustment of the flow rate on IV infusions.
(2) Observation and reporting of subjective and objective signs of adverse reactions to any IV administration and initiation of appropriate interventions.
(3) Administration of IV fluids and medications.
(4) Observation of the IV insertion site and performance of insertion site care.
(5) Performance of maintenance. Maintenance includes dressing changes, IV tubing changes, and saline or heparin flushes.
(6) Discontinuance of a medication or fluid infusion, including infusion devices.
(7) Conversion of a continuous infusion to an intermittent infusion.
(8) Insertion or removal of a peripheral short catheter.
(9) Maintenance, monitoring and discontinuance of blood, blood components and plasma volume expanders.
(10) Administration of solutions to maintain patency of an IV access device via direct push or bolus route.
(11) Maintenance and discontinuance of IV medications and fluids given via a patient-controlled administration system.
(12) Administration, maintenance and discontinuance of parenteral nutrition and fat emulsion solutions.
(13) Collection of blood specimens from an IV access device.

A review of the facility Continuous Administration of IV Fluids by Pump Policy dated January 22, 2025, indicated that continuous infusions of IV fluids or medications in volumes greater than 250 ml may be controlled via electronic pump. Further review of the policy failed to include which licensed nursing staff (RN or LPN) would be responsible for the infusion of physician ordered IV fluids or medications.

Interview with the administrator (NHA) and director of nursing (DON) on April 24, 2025, at approximately 10:00 AM confirmed the facility did not have a written policy or protocols to allow LPNs to administer IV fluids or medications. The NHA and DON failed to provide written evidence that LPNs employed at the facility had completed a Board approved educational program to start and discontinue an intravenous infusion and administer and withdraw intravenous fluids and medications with a physician's order. The NHA and DON also failed to provide documented evidence that a yearly in-service on administration of IV fluids and medications was provided to LPNs who have completed the Board certified educational program.

Clinical record review revealed that Resident 101 was admitted to the facility on October 23, 2023, with diagnoses which included dementia (chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning).

A physician order dated April 16, 2025, noted an order for Meropenem-Sodium Chloride Intravenous Solution (an antibiotic) reconstituted 500 MG/50ML use 500MG intravenously every 8 hours for urinary tract infection for seven days.

An IV therapy note dated April 16, 2025, noted that a peripheral IV was placed in the right forearm.

Review of the Resident 101's April 2025 Medication Administration Record (MAR) revealed that between April 16 through April 22, 2025, Employee 1 (LPN), Employee 2 (LPN), Employee 3 (LPN), Employee 4 (LPN), and Employee 5 (LPN) signed the MAR as administering the IV antibiotic medication to the resident through the peripheral IV.

Interview on April 24, 2025, at approximately 11:00 AM with Employee 1 (LPN), stated she never administered medications through residents' intravenous lines at the facility based on facility policy. She confirmed that she did sign out on April 16, 2025, at 2:00 PM that she had administered the medication even though the RN was the one who had administered the IV medication through the resident's peripheral IV. Employee 1 (LPN) indicated she was never educated at the facility on the administration of intravenous medications.

There was no documented evidence of any education or supervision regarding IV administration for any LPNs working at the facility.

During an interview on April 25, 2025, at approximately 9:00 AM the DON failed to provide documented evidence that LPNs in the facility received education regarding the administration of intravenous medications. The DON further confirmed that facility policy indicated the nurse administering the medications are to sign the MAR indicating it was administered.

28 Pa. Code 201.20(a) Staff Development.

28 Pa Code 211.12 (d)(5) Nursing services.

Plan of Correction - To be completed: 06/10/2025

1.Resident 101 had no ill effects from alleged deficient practice.

2. Current residents on IV medications were reviewed for documentation on administration of IV medication to determine if an LPN or RN documented administration of the medication.

3.DON/designee will provide education to LPN's not to sign out IV fluids or medications if they did not administer, as well as R.N.'s are only allowed to administer medications or fluids via IV.

4.DON/designee will audit IV administration weekly x4 then monthly x2 to ensure only RN's provide IV medication/fluids and report findings to QAPI committee.

483.25(m) REQUIREMENT Trauma Informed Care:

§483.25(m) Trauma-informed care
The facility must ensure that residents who are trauma survivors receive culturally competent, trauma-informed care in accordance with professional standards of practice and accounting for residents' experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization of the resident.

Observations:

Based on a review of clinical records, resident, and staff interviews, it was determined the facility failed to develop and implement an individualized person-centered plan to render trauma informed care to a resident with a diagnosis of Post-Traumatic Stress Disorder for one out of 27 residents reviewed (Resident 55).

Findings include:

A review of Resident 55's clinical record revealed the resident was admitted to the facility on June 18, 2024, with diagnoses that included Post Traumatic Stress Disorder (PTSD a mental health condition that's caused by an extremely stressful or terrifying event, either being part of it or witnessing it. Symptoms may include flashbacks, nightmares, severe anxiety, and uncontrollable thoughts about the event).

A review of the clinical record also revealed a physician's order dated March 12, 2025, for Prazosin HCL (a medication that decreases levels of norepinephrine in the central nervous system thereby reducing nightmares related to PTSD), with instructions to administer 1 mg tablet by mouth at bedtime for nightmares.

During an interview conducted on April 23, 2025, at approximately 12:45 PM, Resident 55 indicated he served two tours in Vietnam and had nightmares every night prior to the initiation of the Prazosin.

The resident's current care plan, in effect at the time of review on April 25, 2025, did not identify the resident's PTSD symptoms or triggers related to this diagnosis and resident specific interventions to meet the resident's needs for minimizing triggers and/or re-traumatization.

The facility failed to develop and implement an individualized person-centered plan to address, this resident's diagnosis of PTSD according to standards of practice to promote the resident's emotional well-being and safety.

Interview with the Nursing Home Administrator and Director of Nursing on April 25, 2025, at 8:50 AM, confirmed the facility was unable to demonstrate the facility provided culturally competent, trauma-informed care in accordance with professional standards of practice and accounting for resident's experiences and preferences to eliminate or mitigate triggers that may cause re-traumatization of the resident.

28 Pa Code 211.12 (d)(3)(5) Nursing services.

Plan of Correction - To be completed: 06/10/2025

1. Resident 55 care plan was updated with resident's PTSD symptoms, as resident states he does not have triggers and interventions to support resident when nightmares occur.

2. Residents with diagnosis of PTSD care plans were reviewed to ensure PTSD triggers, if known and cause is identified and interventions in place to meet the residents' needs to mitigate or eliminate triggers that may cause the resident distress.

3. DON/Designee educated Social services on Trauma informed care and need to identify trigger's and behaviors and identify specific interventions to mitigate or eliminate triggers that may cause the resident distress.

4. SS/designee will audit residents with PTSD care plans to ensure resident PTSD triggers and behaviors are care planned and identify specific interventions to mitigate or eliminate triggers that may cause the resident distress weekly x4 then monthly x2 and report to QAPI committee.

483.45(d)(1)-(6) REQUIREMENT Drug Regimen is Free from Unnecessary Drugs:

§483.45(d) Unnecessary Drugs-General.
Each resident's drug regimen must be free from unnecessary drugs. An unnecessary drug is any drug when used-

§483.45(d)(1) In excessive dose (including duplicate drug therapy); or

§483.45(d)(2) For excessive duration; or

§483.45(d)(3) Without adequate monitoring; or

§483.45(d)(4) Without adequate indications for its use; or

§483.45(d)(5) In the presence of adverse consequences which indicate the dose should be reduced or discontinued; or

§483.45(d)(6) Any combinations of the reasons stated in paragraphs (d)(1) through (5) of this section.

Observations:

Based on a review of clinical records, select facility policy, and staff interviews, it was determined the facility failed to ensure that a resident's drug regimen was free of unnecessary antibiotics for one out of 27 residents sampled (Resident 47).

Findings included:

A review of the facility policy titled "Antibiotic Stewardship," last reviewed by the facility on January 22, 2025, revealed it is the facility's policy that antibiotics will be prescribed and administered to residents under the guidance of the facility's antibiotic stewardship program. The policy indicates when a resident is admitted from an emergency department, the admitting nurse will review discharge and transfer paperwork for current antibiotic and anti-infective orders. When a culture and sensitivity (C&S) is ordered, lab results and the current clinical situation will be communicated to the prescriber as soon as available to determine if antibiotic therapy should be started, continued, modified, or discontinued.

A clinical record review revealed Resident 47 was admitted to the facility on September 8, 2022, with diagnoses that include epilepsy (a chronic brain disorder in which groups of nerve cells, or neurons, in the brain sometimes send the wrong signals and cause seizures).

A progress note dated March 24, 2025, at 2:06 PM revealed Resident 47 was sent to the community emergency department related to lethargy and a change in mental status.

A progress note dated March 24, 2025, at 10:49 PM, indicated that Resident 47 returned to the facility from a community emergency department visit. The note documented the physician to verify new medications from the hospital, including Cephalexin 500 mg (an antibiotic medication), and instructed that all hospital-prescribed medications be continued. The note further indicated that the physician planned to evaluate the resident in person the following day. Resident 47's vital signs at the time were assessed to be within normal limits.

A physician's order initiated on March 25, 2025, at 10:30 PM directed administration of Cephalexin oral capsule 500 mg by mouth four times daily for a urinary tract infection (UTI), with a stop date of April 1, 2025.

Laboratory review revealed a urine culture (method to grow and identify bacteria that may be in the urine) and quantitative report dated March 26, 2025, at 7:35 AM. The results showed no significant growth, indicating the absence of detectable bacteria or other microorganisms in the urine. A concurrent urinalysis noted an elevated white blood cell (WBC) count at 30-49 per high-powered field (normal range: 0-2/HPF), but no clinical documentation correlated this laboratory result with active symptoms of a urinary tract infection.

A review of the Medication Administration Record (MAR) for March 2025 revealed that Resident 47 was administered a total of 25 doses of Cephalexin 500 mg from March 24, 2025, through April 1, 2025.

A comprehensive review of the clinical record failed to reveal documentation of any clinical signs or symptoms of a UTI from March 24, 2025, through April 1, 2025, including but not limited to, acute dysuria (painful urination), elevated temperature, increased urinary urgency, suprapubic pain, increased urinary incontinence, or gross hematuria.

During an interview on April 24, 2025, at approximately 1:30 PM, the facility's Infection Preventionist (IP) confirmed that the clinical record did not contain documentation of a clinical rationale supporting the continued use of Cephalexin for Resident 47 during the noted period.

In an interview conducted on April 25, 2025, at approximately 10:00 AM, the Nursing Home Administrator (NHA) was unable to provide documentation of a clinical rationale for the administration of Cephalexin oral capsule 500 mg. The NHA acknowledged it is the facility's responsibility to ensure that each resident's drug regimen remains free from unnecessary antibiotics.

28 Pa. Code 211.2(d)(3)(5) Medical Director

28 Pa. Code 211.12(d)(3)(5) Nursing services

Plan of Correction - To be completed: 06/10/2025

1.Resident 47 had no ill effects from alleged deficient practice.

2. All residents in house on antibiotics were reviewed to ensure antibiotics are appropriate.

3. DON/designee will educate IP on antibiotic stewardship policy with emphasis on when residents return from hospital with antibiotic orders they are to follow up on testing results and review with MD to determine if antibiotic therapy is appropriate for resident.

4.DON/designee will audit random residents sent to hospital that returned on antibiotic therapy to ensure test results were reviewed with physician to determine appropriate treatment is in place weekly x4 and monthly x2 and report to QAPI committee .

483.45(c)(3)(e)(1)-(5) REQUIREMENT Free from Unnec Psychotropic Meds/PRN Use:

§483.45(e) Psychotropic Drugs.
§483.45(c)(3) A psychotropic drug is any drug that affects brain activities associated with mental processes and behavior. These drugs include, but are not limited to, drugs in the following categories:
(i) Anti-psychotic;
(ii) Anti-depressant;
(iii) Anti-anxiety; and
(iv) Hypnotic

Based on a comprehensive assessment of a resident, the facility must ensure that---

§483.45(e)(1) Residents who have not used psychotropic drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record;

§483.45(e)(2) Residents who use psychotropic drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs;

§483.45(e)(3) Residents do not receive psychotropic drugs pursuant to a PRN order unless that medication is necessary to treat a diagnosed specific condition that is documented in the clinical record; and

§483.45(e)(4) PRN orders for psychotropic drugs are limited to 14 days. Except as provided in §483.45(e)(5), if the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she should document their rationale in the resident's medical record and indicate the duration for the PRN order.

§483.45(e)(5) PRN orders for anti-psychotic drugs are limited to 14 days and cannot be renewed unless the attending physician or prescribing practitioner evaluates the resident for the appropriateness of that medication.

Plan of Correction - To be completed: 06/10/2025

1. Resident 45 has current order for antipsychotic side effect monitoring.

2. Current residents who are receiving antipsychotic medications were reviewed for side effect monitoring in place.

3. Licensed nurses were educated side effects that can be caused by antipsychotic medication use and on monitoring for side effects on residents currently receiving antipsychotic medications.

4. DON/designee will audit random residents receiving antipsychotic medications has side effect monitoring in place weekly x4 then monthly x2 and report findings to QAPI committee.

§ 201.14(a) LICENSURE Responsibility of licensee.:

(a) The licensee is responsible for meeting the minimum standards for the operation of a facility as set forth by the Department and by other Federal, State and local agencies responsible for the health and welfare of residents. This includes complying with all applicable Federal and State laws, and rules, regulations and orders issued by the Department and other Federal, State or local agencies.

Observations:

Based on a review of select facility policy and staff interviews, it was determined the facility did not comply with the requirements of the Act 52 Infection Control Plan.

Findings include:

Act 52, Infection Control Plan, requires long-term care (LTC) facilities to develop and implement a facility-specific infection control (IC) plan, which must be submitted to and approved by the Pennsylvania Department of Health (PA DOH). Section iii. Surveillance Subsection 2. External surveillance reporting indicates a facility's IC plan shall include:

A healthcare-acquired infection (HAI) reporting process that aligns with MCARE Section 404.a. requirements:

i. All HAIs are deemed serious events and are reported to PA-PSRS within 24 hours of occurrence, discovery, or confirmation.
ii. Residents (or family, guardian, or power of attorney, as appropriate) receive written notification of serious events within seven days of occurrence, discovery, or confirmation.

A review of the facility policy titled "Infection Prevention and Control Program," last reviewed by the facility on January 22, 2025, revealed it is the facility's policy to establish an infection prevention and control program (IPCP) to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. The IPCP provides a system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement. The policy indicates a function of Infection Surveillance is procedures for reporting incidents of communicable diseases or infections.

During an interview on April 25, 2025, at approximately 9:00 AM, the infection Preventionist was unable to provide documented evidence the facility was providing written notification of healthcare-acquired infections deemed serious events within seven days of occurrence, discovery, or confirmation.

During an interview on April 25, 2025, at approximately 10:00 AM, the Nursing Home Administrator (NHA) confirmed there was no documented evidence the facility was providing written notification of healthcare-acquired infections that were deemed serious events to residents or residents' representatives, as applicable.

Plan of Correction - To be completed: 06/10/2025

1. The facility is unable to retroactively correct this alleged deficient practice.

2.Residents with infections in the past 10 days were reviewed for serious events and resident or responsible party was notified.

3.DON/designee educated IP on providing written notification of healthcare acquired illnesses deemed serious events within 7 days to resident or residents responsible party.

4.DON/designee will audit random infections deemed serious events for resident/responsible party notification weekly x4 then monthly x2 and report findings to QAPI committee.

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