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

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RIVER VIEW NURSING AND REHABILITATION CENTER
Inspection Results For:

There are  151 surveys for this facility. Please select a date to view the survey results.

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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, and Abbreviated Complaint Survey completed on June 14, 2024, it was determined that River View Nursing and Rehabilitation Center was not in compliance with the follow requirements of 42 CFR Part 483 Subpart B Requirements for Long Term Care and the 28 PA Code Commonwealth of Pennsylvania Long Term Care Licensure Regulations.



 Plan of Correction:


483.10(a)(1)(2)(b)(1)(2) REQUIREMENT Resident Rights/Exercise of Rights: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.
§483.10(a) Resident Rights.
The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility, including those specified in this section.

§483.10(a)(1) A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the resident.

§483.10(a)(2) The facility must provide equal access to quality care regardless of diagnosis, severity of condition, or payment source. A facility must establish and maintain identical policies and practices regarding transfer, discharge, and the provision of services under the State plan for all residents regardless of payment source.

§483.10(b) Exercise of Rights.
The resident has the right to exercise his or her rights as a resident of the facility and as a citizen or resident of the United States.

§483.10(b)(1) The facility must ensure that the resident can exercise his or her rights without interference, coercion, discrimination, or reprisal from the facility.

§483.10(b)(2) The resident has the right to be free of interference, coercion, discrimination, and reprisal from the facility in exercising his or her rights and to be supported by the facility in the exercise of his or her rights as required under this subpart.
Observations:



Based on resident and staff interviews, it was determined that the facility failed to provide care in a manner and environment that promotes each resident's quality of life by failing to respond timely to residents' requests for assistance, including experiences reported by nine out of the 11 residents during a resident group interview (Residents 6, 18, 24, 37, 41, 51, 83, 107, and 114).

Findings include:

During a resident group interview with alert and oriented residents on June 12, 2024, at 10:00 AM, the residents in attendance expressed concerns regarding the long wait times for staff to provide assistance with their care when requested/needed.

During the resident group interview, Resident 6 stated that when she needs assistance for care, she waits 15 to 20 minutes for staff to provide the needed care.

During the resident group interview, Resident 18 stated that she waits a very long time for staff to provide needed assistance with care. She explained that staff will sometimes initially respond to her calls for assistance and say they will assist her shortly, but do not come back to provide the needed care. She stated that she often attempts to change and clean herself, even though she understands it is unsafe for her to ambulate without staff assistance. She explained that it bothers her when she is dirty from soiling her brief. Resident 18 also stated that if she wants a shower after soiling herself, staff tells her that she can only take a shower on her scheduled shower days twice a week. Resident 18 stated that she often asks for clean linens for her bed but staff tell her that she is only allowed clean linens on her shower days twice a week. She explained that she would change the sheets herself, but staff refused to provide her clean bed linens. Resident 18 also stated that sometimes nursing staff send the residents to common areas or programs without helping them get dressed. She stated that she was sent to the dining room in her nightgown, and that these experiences make her feel terrible.

During the resident group interview, Resident 24 expressed that she is upset when staff tells her that she is not allowed to ring her call bell for assistance when meals are being passed out at breakfast, lunch, or dinner. She explained that the staff tell her that she needs to go to the bathroom before the meal or wait until after meal service. She stated that she sometimes must sit in her urine or feces while she waits for staff assistance. Resident 24 expressed that it makes her angry because she is over 90 years old and can't "hold it" when she needs to use the bathroom. She stated that she is not sure how long it takes for staff to respond, but often longer than her body could wait. Resident 24 stated that she has been taking herself to the bathroom, even though she knows it is unsafe for her to do so.

During the group interview, Resident 37 stated that she is upset that she waits 15-20 minutes for staff to respond to her call bell when she needs assistance. She explained that nursing staff will initially respond, turn her call bell off, but leave without providing her care. She stated that she would holler and yell until someone responds. Resident 37 said it bothers her when she must wait 15 minutes for staff when seated on the toilet because it hurts to sit so long.

During the group interview, Resident 41 stated that she often waits 45 minutes for care from staff when needed. She explained that she is on a medication that causes her to frequently urinate and often needs her brief changed. Resident 41 stated that she often sits in a urine puddle, waiting for staff assistance. She explained that if she needs to be changed in the morning, staff will tell her "after breakfast" and tell her "you need to wait." Resident 41 indicated that it upsets her because she does not want to sit in her urine.

During the group interview, Resident 51 stated that she waits 45 minutes to an hour for care from staff when needed. She explained that after 15 or 20 minutes of waiting for staff to respond to her call bell ring for assistance, she will use her cell phone to call the nursing station or the front desk. Also, she stated that staff will call her cellphone instead of physically checking on her when she rings her call bell for assistance.

During the group interview, Resident 83 stated that he tries to care for himself as much as possible. He explained that last week staff did not respond to his call-bell for assistance, and he had to use his cell phone to get staff to bring him a cup of water. Resident 83 stated that it took him an hour to get a drink of water.

During the group interview, Resident 107 stated that she waits a long time to receive care after ringing her bell for assistance. She explained that she waits 15 minutes or longer for care. Resident 107 expressed that she is upset when she is not allowed to have a shower, and nursing staff tell her she can only shower on her scheduled days twice a week. She stated that she enjoys feeling clean and wants to be able to shower more often than twice a week.

During the group interview, Resident 114 stated on several recent occasions, she has waited over an hour for care after ringing her call bell for assistance. She expressed anger and frustration that she has to sit in her soiled brief because she does not have the ability to clean herself. Resident 114 stated that she had loose stools and had to sit in the dirty brief for 45 minutes. She explained that sometimes she will ring for assistance, and staff will walk right past her door without looking or saying a word to her. Resident 114 expressed frustration that staff refuse to change her during meal times, forcing her to remain in a soiled brief until the meal service is over. Resident 114 also expressed being upset when staff tell her during the early afternoon that "if we change you now, then you have to stay in bed the rest of the day." She is angry and frustrated because she can't control when she soils herself and needs staff assistance with care.

During an interview on June 14, 2024, at approximately 11:00 AM, the Nursing Home Administrator (NHA) and Director of Nursing (DON) verified that all residents at the facility should be treated with dignity and respect. The NHA and DON were unable to explain why residents are reporting (1) untimely staff responses to residents' requests for assistance, (2)staff refusing to shower residents at there desired frequency, (3) staff refusing to provide residents with clean linens, and (4) residents being told not to ring their call bells during meals, which is negatively affecting their quality of life in the facility.



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

28 Pa. Code 201.29 (a) Resident Rights

28 Pa. Code 211.12 (c) Nursing services





 Plan of Correction - To be completed: 07/30/2024

1.Resident's 6,18,24,37,41,51,83,107, and 114 were interviewed and concerns were addressed.

2.Call bell audits to be preformed to ensure timely response to call bells and care.

3.Facility staff will be in serviced on Resident Rights /Dignity and responding timely to call bells and resident needs by the DON or designee. Call bell audits will be completed to ensure timely response time of call bells.

4.NHA/Designee will review call bell audits response time, weekly x 4. Results will be reviewed monthly at QAPI meeting, the committee will determine the need for further audits.

483.75(g)(1)(i)-(iii)(2)(i); 483.80(c) REQUIREMENT QAA Committee: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.
§483.75(g) Quality assessment and assurance.
§483.75(g) Quality assessment and assurance.
§483.75(g)(1) A facility must maintain a quality assessment and assurance committee consisting at a minimum of:
(i) The director of nursing services;
(ii) The Medical Director or his/her designee;
(iii) At least three other members of the facility's staff, at least one of who must be the administrator, owner, a board member or other individual in a leadership role; and
(iv) The infection preventionist.

§483.75(g)(2) The quality assessment and assurance committee reports to the facility's governing body, or designated person(s) functioning as a governing body regarding its activities, including implementation of the QAPI program required under paragraphs (a) through (e) of this section. The committee must:
(i) Meet at least quarterly and as needed to coordinate and evaluate activities under the QAPI program, such as identifying issues with respect to which quality assessment and assurance activities, including performance improvement projects required under the QAPI program, are necessary.

§483.80(c) Infection preventionist participation on quality assessment and assurance committee.
The individual designated as the IP, or at least one of the individuals if there is more than one IP, must be a member of the facility's quality assessment and assurance committee and report to the committee on the IPCP on a regular basis.
Observations:

Based on a review of facility documents of QA meeting attendance and staff interview, it was determined that the facility failed to ensure that the Medical Director or designee attended quarterly Quality Assurance Process Improvement (QAPI) Committee meetings for two of three quarters reviewed (August 2023 through June 2024).

Findings include:

A review of QAPI Committee meeting sign-in sheets for the period of August 2023 through June 2024, revealed that the Medical Director or other physician was not in attendance, virtually or in-person, at the QA meetings held from October 2023 through April 2024 missing 2 quarterly meetings (October 27, 2023, and December 5, 2023).

An interview with the Nursing Home Administrator (NHA) on June 14, 2024, at 9:00 AM, revealed that the facility was unable to provide documented evidence that the physician attended the facility's QAPI meetings on a quarterly basis as required.



28 Pa. Code 211.2 (d)(3)(4)(5)(6) Medical Director

28 Pa. Code 201.18 (e)(1)(3) Management





 Plan of Correction - To be completed: 07/30/2024

1.Facility will continue to have QAPI meetings Quarterly.

2.The minutes for the past two quarters will be reviewed to ensure the medical director's attendance.

3.NHA will provide education of required attendance to the QAPI meetings at least on a quarterly basis. To the medical director.

4.NHA will monitor QAPI meetings quarterly for Medical Director's attendance requirements. The results of the audit will be reviewed by the QAPI committee.

483.25(h) REQUIREMENT Parenteral/IV Fluids: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.
§ 483.25(h) Parenteral Fluids.
Parenteral fluids must be administered consistent with professional standards of practice and in accordance with physician orders, the comprehensive person-centered care plan, and the resident's goals and preferences.
Observations:

Based on review of clinical records and select facility policy, and staff and resident interviews it was determined that the facility failed to ensure that physician ordered intravenous antibiotics were administered as prescribed for two residents out of 27 sampled (Resident 86 and 72).

Findings include:

Review of a facility policy titled "Administering Medications" last reviewed by the facility on April 18, 2024, indicated that medications are administered in a safe and timely manner. It indicated that medications are administered in accordance with prescriber orders, including any required time frame. Medication errors are documented, reported, and reviewed by the QAPI committee to inform process changes and/or the need for additional staffing. Prescribed medications are to be administered within one hour of their prescribed time, unless otherwise specified.

Review of Resident 86's clinical record revealed that the resident was admitted to the facility on July 12, 2022, with diagnoses to include quadriplegia (paralysis of all four limbs), infection and inflammatory reaction due to indwelling urethral catheter (a flexible tube which is placed into the bladder to drain urine), and sepsis (life-threatening complication of an infection).

A physician order dated April 29, 2024, was noted for a Vancomycin HCL (an antibiotic used to treat bacterial infections) Intravenous Solution 1250 MG/250 ML, use 1250 mg intravenously two times a day for sepsis until June 3, 2024, 23:59, flush with 10cc NSS pre/post admin. To be administered by an RN only.

During an interview with Resident 86 on June 11, 2024, at 2:00 PM, he reported that when receiving his IV medication of Vancomycin, nursing staff were often late in hanging his IV. He reported that he was scheduled to receive his dose of IV antibiotics at 12:00 AM and 12:00 PM but that frequently he did not receive his IV medication until "2 or more hours after I was due to receive it."

Review of Resident 86's Medication Administration Record (MAR) for May 2024, indicated that he was scheduled to receive Vancomycin at 0000 hours (12:00AM) and 1200 hours (12:00 PM). The MAR indicated that on May 10, 2024, the 1200-hour (12:00 PM) dose was not administered as scheduled.

Review of nursing progress notes for May 10, 2024, revealed no documentation of the reason for the missed dose of Vancomycin nor was there any documentation to indicate the physician was notified of the missed dose.

Review of a facility-provided real-time administration detail report (a report that indicates the actual time the medication was administered) for administration of IV Vancomycin from April 29, 2024, to May 29, 2024, revealed that on the following dates Resident 86's IV Vancomycin medication was administered one hour or more beyond the physician prescribed time:

May 3, 20241:27 PM - one hour and 27 minutes overdue
May 6, 20242:57 PM - two hours and 57 minutes overdue
May 15, 20241:20 PM - one hour and 20 minutes overdue
May 18, 20241:36 PM - one hour and 36 minutes overdue
May 21, 20242:43 PM - two hours and 43 minutes overdue
May 23, 20241:18 PM - one hour and 18 minutes overdue

Interview with the Director of Nursing (DON) on June 13, 2024, at 12:00 PM, confirmed that the facility failed to timely administer 6 doses of the IV antibiotic therapy prescribed for Resident 86, and failed notify the attending physician of a missed dose.

Review of Resident 72's clinical record revealed that the resident was admitted to the facility on May 17, 2023, with diagnoses to include poliomyelitis (polio- illness caused by a virus that mainly affects nerves in the spinal cord or brain stem) and sepsis secondary to chronic infected wounds.

A physician order dated May 3, 2024, was noted for a Vancomycin HCL (an antibiotic used to treat bacterial infections) Intravenous Solution 500 MG/100 ML, use 500 mg intravenously every eight hours until June 12, 2024, for a diagnosis of osteomyelitis (inflammation of the bone caused by infection), flush with 10cc NSS pre/post admin. To be administered by an RN only.

Review of Resident 72's Medication Administration Record (MAR) for May 3 through May 28, 2024, indicated that the resident was scheduled to receive Vancomycin at 0000 hours (12:00AM), 8:00 AM, and 1600 hours (4:00 PM). The MAR indicated that on May 11, 2024, the 1600 hours (4:00 PM) dose was not administered.

Review of nursing progress notes for May 11, 2024, revealed no documentation of the reason for the missed dose of Vancomycin nor was there any documentation to indicate the physician was notified of the missed dose.

Review of a facility-provided real-time administration detail report (a report that indicates the actual time the medication was administered) for administration of IV Vancomycin from May 3, 2024, through May 31, 2024, revealed that on the following dates Resident 72's IV Vancomycin medication was administered one hour or more beyond the physician prescribed time:

May 6, 2024 11:24 AM- 2 hours and 24 minutes overdue
May 8, 2024 11:07 AM - hours and 7 minutes overdue
May 8, 2024 6:18 PM - 1 hours and 18 minutes overdue
May 9, 2024 10:53 AM- 1 hour and 53 minutes overdue
May 12, 2024 10:25 AM- 1 hours and 25 minutes overdue
May 13, 2024 12:06 PM- 3 hours and 6 minutes overdue
May 21, 2024 10:33 AM-1 hours and 33 minutes overdue
May 21, 2024 7:51 PM- 2 hours and 51 minutes overdue

A physician order dated May 29, 2024, noted an order change to Vancomycin HCL (an antibiotic used to treat bacterial infections) Intravenous Solution 500 MG/100 ML, use 500 mg intravenously two times per day until June 19, 2024, for a diagnosis of osteomyelitis (inflammation of the bone caused by infection), flush with 10 cc NSS pre/post admin. To be administered by an RN only.

Review of Resident 72's Medication Administration Record (MAR) for May 29, through May 31, 2024, and June 1, 2024, through June 12, 2024, indicated that the resident was scheduled to receive Vancomycin at 9:00 AM and 21:00 hours (9:00 PM). The MAR indicated that on June 7, 2024, the 2100 hours (9:00 PM) dose was not administered.

Review of nursing progress notes for June 7, 2024, revealed no documentation of the reason for the missed dose of Vancomycin nor was there any documentation to indicate the physician was notified of the missed dose.

Interview with the Director of Nursing (DON) on June 13, 2024, at approximately 1:00 PM, failed to provide documented evidence that the facility timely administered 8 doses of the IV antibiotic therapy prescribed for Resident 72, and failed to notify the attending physician of two missed doses of the prescribed antibiotic.




28 Pa. Code 211.9(a)(1)(k) Pharmacy services

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

28 Pa. Code 211.10 (a)(c)(d) Resident care policies















 Plan of Correction - To be completed: 07/30/2024

1.Resident 72 IV antibiotic was discontinued, unable to correct past administration times.

2.Current resident on IV antibiotics will be reviewed to ensure IV antibiotics are administered in a timely manner.

3.Licensed nursing staff in serviced on timely administering IV antibiotics per prescriber's orders, including required time frame.

4.DON/designee will audit IV antibiotic medication administration times weekly x4 weeks to ensure IV antibiotics are administered timely. Results of audit will be provided to QAPI, the committee will determine the need for further audits.

483.25(c)(1)-(3) REQUIREMENT Increase/Prevent Decrease in ROM/Mobility: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.
§483.25(c) Mobility.
§483.25(c)(1) The facility must ensure that a resident who enters the facility without limited range of motion does not experience reduction in range of motion unless the resident's clinical condition demonstrates that a reduction in range of motion is unavoidable; and

§483.25(c)(2) A resident with limited range of motion receives appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion.

§483.25(c)(3) A resident with limited mobility receives appropriate services, equipment, and assistance to maintain or improve mobility with the maximum practicable independence unless a reduction in mobility is demonstrably unavoidable.
Observations:


Based on review of select facility policy and clinical records and staff interview, it was determined that the facility failed to provide restorative nursing services planned to maintain mobility and functional abilities of four of 27 residents sampled (Residents 63, 114, 72, and 2).

Findings included:

A review of facility policy titled "Restorative Nursing Services," last reviewed by the facility on April 18, 2024, revealed that it is the facility policy that residents will receive restorative nursing care as needed to help promote optimal safety and independence. The policy indicates restorative goals and objectives are individualized and resident-centered and are outlined in the resident's plan of care.

A review of the clinical record of Resident 63 revealed admission to the facility on September 13, 2023, with diagnoses to include cerebrovascular disease (stroke), hemiplegia (one sided paralysis - weakness) and hemiparesis (one sided weakness) following cerebral infarction affecting left non-dominant side, muscle weakness, difficulty in walking, muscle wasting and atrophy, and lack of coordination.

A review of Resident 63's Occupational Therapy (OT) Discharge Summary dated September 20, 2023, indicated that the resident was receiving OT services from September 14, 2023, to September 20, 2023, and that the discharge recommendations were to receive restorative range of motion program.

A "Rehab Discharge Recommendation form: Occupational Therapy" dated September 20, 2023, indicated that the resident was to receive restorative services, active range of motion (AROM)/active assist range of motion (AAROM)/passive range of motion (PROM), of bilateral upper extremity (BUE) and bilateral lower extremity (BLE) as tolerated.

During an interview on June 13, 2024, at approximately 9:10 AM, with the Director of Therapy Services, confirmed Resident 63 should have received restorative range of motion program, from September 20, 2023, to the present.

A review of the resident's clinical record to include the Documentation Survey Report v2 from September 2023, through the survey ending June 14, 2024, revealed that Resident 63's restorative range of motion program was not implemented, as recommended by the OT discharge summary, and the "Rehab Discharge Recommendation form: Occupational Therapy".

Interview with the Director of Nursing (DON) on June 13, 2024, at approximately 9:30 AM failed to provide documented evidence that Resident 63 was provided with the restorative range of motion program.

A clinical record review revealed that Resident 114 was admitted to the facility on February 7, 2024, with diagnoses to include cauda equina syndrome (a condition that occurs when the nerve roots in the lumbar spine are compressed, cutting off sensation and movement).

A review of a quarterly Minimum Data Set assessment dated May 8, 2024 revealed that Resident 114 is cognitively intact with a BIMS score of 15.

A physical therapy discharge summary dated March 8, 2024, revealed that Resident 114's functional status at discharge was given to the restorative nursing program coordinator.

A physical therapy rehab discharge recommendation form, dated March 10, 2024, indicated that the resident would benefit from active and passive lower extremity range of motion and strengthening while in bed and while seated on the resident's hips, knees, and ankles.

Resident 114's care plan noted the problem of impaired physical mobility and lower extremity weakness related to Caude Equina syndrome initiated on February 8, 2024. There was no documented evidence that recommendations for active range of motion or passive range of motion exercise interventions were incorporated into Resident 114's plan of care.

A certified registered nurse practitioner note dated April 9, 2024, at 2:47 PM indicated that Resident 114 should be on restorative therapy while not on physical therapy for strengthening to not lose muscle tone.

During an interview on June 11, 2024, at 10:45 AM Resident 114 stated that her therapy services ended in March 2024. She explained that she spoke with therapy staff and nursing staff about her interest in participating in restorative nursing services on several occasions. She indicated that staff do not provide her with active or passive exercises. She indicated that she had a meeting last month specifically to address this issue; however, no services were implemented. Resident 114 stated that it is very important for her to participate in any program that would assist her in her physical recovery.

During an interview on June 14, 2024, at approximately 11:00 AM, the Director of Nursing (DON) confirmed that Resident 114's care plan was not updated to include physical therapy restorative program recommendations for active range of motion and passive range of motion exercise interventions. The DON was unable to provide evidence that Resident 114 was receiving active range of motion exercises while seated and while in bed for her hips, knees, or ankles, consistent with physical therapy recommendations and the resident's individual goals.

A review of the clinical record of Resident 72 revealed admission to the facility on May 17, 2023, with diagnoses to include poliomyelitis (polio- illness caused by a virus that mainly affects nerves in the spinal cord or brain stem).

A review of Resident 72's Physical Therapy Discharge Summary dated February 22, 2024, indicated that the resident was receiving services from February 8, 2024, to February 22, 2024, and that the discharge recommendations were to receive restorative range of motion program.

During an interview on June 13, 2024, at approximately 9:30 AM, with the Director of Therapy Services, confirmed Resident 72 should have received restorative range of motion program upon conclusion of physical therapy on February 22, 2024.

Further review of the clinical record revealed no documented evidence that a restorative range of motion program was implemented for Resident 72.

Interview with the Director of Nursing (DON) on June 13, 2024, at approximately 9:45 AM failed to provide documented evidence that Resident 72 was provided with the restorative range of motion program.

A review of the clinical record of Resident 2 revealed the resident was admitted to the facility on May 24, 2024, with diagnoses to include cerebral palsy (group of conditions that affect movement and posture caused by damage to the developing brain most often before birth).

A review of Resident 2's Rehab Discharge Recommendation from Physical Therapy dated May 28, 2024, indicated that the resident was recommended for restorative lower extremity range of motion/strengthening.

Further review of the clinical record revealed no documented evidence that a restorative range of motion program was implemented for Resident 2.

Interview with the Director of Nursing (DON) on June 13, 2024, at approximately 9:45 AM failed to provide documented evidence that Resident 2 was provided with the restorative range of motion program.



28 Pa. Code: 211.5(f) Medical records

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

28 Pa. Code 211.10 (a)(c)(d) Resident care policies





 Plan of Correction - To be completed: 07/30/2024

1.Residents 63, 114, 72, 2 restorative nursing programs added to plan of care.

2.RNP program audited for current residents to ensure recommended restorative nursing programs are in place per therapy recommendations.

3.Therapy/licensed nursing staff and nursing staff educated on the facility policy for Restorative Nursing Program initiation and on-going maintenance .

4.DON/Designee will audit restorative nursing programs put in place weekly x4 weeks to ensure restorative programs are in place as recommended by therapy. Results of audit will be provided to QAPI, the committee will determine the need for further audits.

483.15(d)(1)(2) REQUIREMENT Notice of Bed Hold Policy Before/Upon Trnsfr: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.
§483.15(d) Notice of bed-hold policy and return-

§483.15(d)(1) Notice before transfer. Before a nursing facility transfers a resident to a hospital or the resident goes on therapeutic leave, the nursing facility must provide written information to the resident or resident representative that specifies-
(i) The duration of the state bed-hold policy, if any, during which the resident is permitted to return and resume residence in the nursing facility;
(ii) The reserve bed payment policy in the state plan, under § 447.40 of this chapter, if any;
(iii) The nursing facility's policies regarding bed-hold periods, which must be consistent with paragraph (e)(1) of this section, permitting a resident to return; and
(iv) The information specified in paragraph (e)(1) of this section.

§483.15(d)(2) Bed-hold notice upon transfer. At the time of transfer of a resident for hospitalization or therapeutic leave, a nursing facility must provide to the resident and the resident representative written notice which specifies the duration of the bed-hold policy described in paragraph (d)(1) of this section.
Observations:



Based on a review of clinical records and select facility policy, staff, and resident interviews, it was determined the facility failed to provide written notice of the facility's bed hold policy to a resident and the resident's representative upon the resident's transfer to the hospital for eight residents out of the 27 sampled (Residents 7, 114, 101, 9, 63, 112, 2, and 106).

Findings include:

A review of facility policy titled "Bed-Holds and Returns," last reviewed on April 18, 2024, revealed it is the facility's policy to inform all residents and/or resident representatives in writing of the facility and state bed-hold policies. The policy indicates that all residents and resident representatives, regardless of payor source, are provided written information regarding the facility and state bed-hold policies, which address holding or reserving a resident's bed during periods of absence at least twice: (1) on admission and (2) at the time of transfer (if the transfer was an emergency, within 24 hours).

A clinical record review revealed that Resident 114 was transferred to the hospital on March 11, 2024, and returned to the facility on March 15, 2024.

A clinical record review revealed no documentation that Resident 114 was made aware of a facility's bed-hold and reserve bed payment policy upon transfer to the hospital.

During an interview on June 11, 2024, at 10:45 AM, Resident 114 stated that she didn't know she was going to lose her room and was very upset when she returned to the facility and was placed in a new room. She stated that she was never provided any written or verbal notification when she was transferred to the hospital. Resident 114 explained that she learned that she lost her room upon return to the facility, which was five days after transfer to the hospital.

A clinical record review revealed that Resident 7 was transferred to the hospital on June 8, 2024, and returned to the facility on June 10, 2024.

A nursing progress note dated June 8, 2024, at 2:09 PM indicated that Resident 7 was sent to the receiving provider and "sent with all appropriate paperwork."

Further review revealed no documentation that Resident 7 was made aware of a facility's bed-hold and reserve bed payment policy upon transfer to the hospital.

A clinical record review revealed that Resident 101 was transferred to the hospital on March 3, 2024, and returned March 15, 2024. The resident was again transferred to the hospital on March 30, 2024 and returned April 2, 2024.

Further review revealed no documentation that Resident 101 was made aware of a facility's bed-hold and reserve bed payment policy upon transfer to the hospital on March 3, 2024 or March 30, 2024.

A clinical record review revealed that Resident 63 was transferred to the hospital on December 5, 2023, and returned December 7, 2023. The resident was again transferred to the hospital on January 5, 2024, and returned January 9, 2024.

Further review revealed no documentation that Resident 63 was made aware of a facility's bed-hold and reserve bed payment policy upon transfer to a community hospital on December 5, 2023 or January 5, 2024.

A clinical record review revealed that Resident 112 was transferred to the hospital on December 22, 2023, and returned December 28, 2023, on January 2, 2024, and returned January 4, 2024, on February 19, 2024, and returned on February 27, 2024, on March 6, 2024, and returned March 11, 2024, and on March 21, 2024, and returned on March 25, 2024. The resident was again transferred to the hospital on May 20, 2024, and returned May 24, 2024.

Further review revealed no documentation that Resident 112 was made aware of a facility's bed-hold and reserve bed payment policy upon transfer to the hospital on December 22, 2023, January 2, 2024, February 19, 2024, March 6, 2024, March 21, 2024, and May 20, 2024.

A clinical record review revealed that Resident 2 was transferred to the hospital on March 28, 2024, and returned May 24, 2024.

Further review revealed no documentation that Resident 2 was made aware of a facility's bed-hold and reserve bed payment policy upon transfer to the hospital on March 28, 2024.

A clinical record review revealed that Resident 106 was transferred to the hospital on May 3, 2024, and returned May 11, 2024.

Further review revealed no documentation that Resident 106 was made aware of a facility's bed-hold and reserve bed payment policy upon transfer to the hospital on May 3, 2024.

During an interview on June 14, 2024, at approximately 11:30 AM, the Nursing Home Administrator (NHA) and Director of Nursing (DON) were unable to provide evidence that the facility made Residents 7, 114, 101, 63, 112, 2, and 106 or the residents' representatives aware of a facility's bed-hold and reserve bed payment policy upon transfer to the hospital.


28 Pa Code 201.18 (e)(1) Management

28 Pa Code 201.29 (b) Resident rights




 Plan of Correction - To be completed: 07/30/2024

1.Residents 114, 101, 9, 63, 112, 2, and 106. Were transferred out and returned prior to the survey, no corrections possible.

2.Residents transferred to the hospital within the past 14 days that qualify for a bed hold were checked to ensure a written bed hold policy was provided.

3.Business Office Manager /Nursing staff will be educated by NHA/Designee on the Notice of Bed Hold Policy.

4.Social Services /Designee will audit weekly transfers that qualify for bed hold for 4xweeks and monthly for 2 months to ensure the written Bed Hold Policy was provided. Results of audits will be reviewed by 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;
Observations:


Based on a review of clinical records, select facility policy and investigative reports, and staff interviews, it was determined that the facility failed to ensure that four residents out of 30 sampled were free from physical abuse (Residents 62, 85, 97, and 119).

Findings include:

A facility policy titled "Abuse Prevention Program," reviewed on April 18, 2024, revealed it is facility policy that residents have the right to be free from abuse, including physical abuse. Further policy review revealed that the administration will implement protocols to protect residents from abuse by anyone, including other residents.

A clinical record review revealed Resident 62 was admitted to the facility on September 27, 2019 with diagnoses that include dementia (a condition characterized by the loss of cognitive functioning such as thinking, remembering, and reasoning, to such an extent that it interferes with a person's daily life and activities). A review of a quarterly Minimum Data Set assessment (MDS - a federally mandated standardized assessment process conducted periodically to plan resident care) dated May 2, 2024, revealed that Resident 62 is severely cognitively impaired with a BIMS score of 3 (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 01-07 indicates severe cognitive impairment).

A clinical record review revealed Resident 85 was admitted to the facility on February 3, 2022, with diagnoses that include dementia. A review of quarterly, MDS dated May 28, 2024, Section C - Cognitive Patterns, C1000, revealed that Resident 85 has severe impairment to make decisions regarding tasks of daily life. The MDS indicates that a BIMS assessment should not be completed because the resident is rarely or never understood.

A clinical record review revealed that Resident 97 was admitted to the facility on October 29, 2022, with diagnoses that include alzheimer's disease (a brain disorder that slowly destroys memory and thinking skills and, eventually, the ability to carry out the simplest tasks). and dementia.

A review of a quarterly MDS dated May 3, 2024 revealed that Resident 97 is severely cognitively impaired with a BIMS score of 3 (a score of 01-07 indicates severe impairment).

A plan of care indicating that Resident 97 has a behavior problem related to dementia with episodes of agitation, confusion, aggressive episodes, and physical aggression was initiated on March 16, 2023, with revisions on October 19, 2023. Interventions include administering medication as ordered, providing positive interactions, anticipating and meeting the resident's needs, decreasing the overstimulating environment by walking with the resident to a calmer area, attempting to engage the resident in conversation or activity involving cars, avoiding violent movies or shows, offering a program of activities of interest, providing quiet space, and redirection.

A clinical record review revealed Resident 119 was admitted to the facility on April 2, 2024, with diagnoses that include alzheimer's disease and dementia. A review of admission MDS dated April 8, 2024 revealed that Resident 119 is severely cognitively impaired with a BIMS score of 3 (a score of 01-07 indicates severe impairment).

A review of incident and investigation reports revealed Resident 97 elbowed Resident 62 in the chest on February 19, 2024.

A review of incident and investigation reports revealed Resident 97 pushed Resident 85, causing her to fall to the floor on April 2, 2024.

A review of incident and investigation reports revealed Resident 97 hit Resident 62 in the back of the head and Resident 62 hit Resident 97's right arm on May 26, 2024.

A review of incident and investigation reports revealed Resident 97 hit Resident 119's head twice with a closed fist on June 9, 2024.

A witness statement dated February 19, 2024, indicated that Employee 6, Nurse Aide, witnessed Resident 97 elbow Resident 62 in his chest. Employee 6, Nurse Aide, explained that she yelled for help, and staff were able to separate the residents.

A nursing note dated February 19, 2024, at 5:42 PM indicated that a Registered Nurse assessment was completed and Resident 62 had no injuries.

A nursing note dated February 19, 2024, at 5:49 PM indicated that a Registered Nurse assessment was completed and Resident 97 had no injuries.

A social services progress note dated February 20, 2024, at 2:05 PM revealed that Resident 97 had no recollection of the incident, and no ill effects were noted. The entry noted that Resident 97 denied concerns and complaints and responded well to support and encouragement.

A social services progress note dated February 20, 2024, at 2:08 PM revealed that Resident 119 was pleasantly confused, had no recollection of the event, and presented no signs or symptoms of distress. Resident 119 denied concerns and complaints and responded well to support and encouragement.

A witness statement dated April 2, 2024, indicated that Employee 7, Nurse Aide, was in the dining room and saw Resident 97 push Resident 85, causing the resident to lose her balance and fall to the floor.

A clinical record review revealed no evidence that Resident 85 was assessed for injury on April 2, 2024, after Resident 97 pushed the resident to the floor.


A social services note dated April 3, 2024, at 1:10 PM indicated that Resident 85 was seen following the incident during which Resident 97 pushed Resident 85 to the floor. The note indicated that Resident 85 was pleasant throughout the conversation, smiling appropriately, and had no recollection of the incident. The resident appeared with no signs or symptoms of acute distress or discomfort.

A social services note dated April 3, 2024, at 1:10 PM indicated that Resident 97 reported that he had no recollection of the event, no concerns or complaints regarding his peer, and appeared with no signs or symptoms of acute distress or discomfort.

A witness statement dated May 26, 2024, indicated Employee 8, Nurse Aide, was in the activity room when Resident 97 got up and smacked Resident 62 on the back of the head.

A witness statement dated May 26, 2024, indicated that Employee 9, Nurse Aide, was in the dining room when Resident 97 stood up and aggressively smacked Resident 62 in the back of his head. Resident 62 then smacked Resident 97 on the arm. Nurse Aide, indicated he intervened and separated the residents.

A progress note dated May 26, 2024, at 5:36 PM revealed that Resident 97 was assessed with no injuries noted.

A progress note dated May 26, 2024, at 5:40 PM revealed that Resident 62 was assessed with no injuries noted.

An incident note dated June 9, 2024, at 12:30 PM indicated Resident 119 was struck by another resident in the dayroom. The note indicated that the resident had no apparent injuries and denied pain.

A witness statement, dated June 9, 2024, revealed that Employee 10, Licensed Practical Nurse, received a report that Residents 97 and 119 were arguing when Resident 97 punched Resident 119. Residents were separated and assessed for injuries.

A witness statement dated June 9, 2024, revealed that Visitor 1 was in the activity room visiting with her mom when she saw Resident 97 yell at Resident 119 and hit him in the head. She indicated that she went to get help.

A witness statement dated June 9, 2024, revealed that Visitor 2 witnessed Resident 97 hit Resident 119.

A social service note, dated June 11, 2024, at 9:02 AM, indicated Resident 97 had no issues or concerns and was offered support.

A social service note, dated June 11, 2024, at 9:05 AM, indicated Resident 119 had no issues or concerns and was offered support.

During an interview on June 14, 2024, at approximately 11:00 AM, the DON (director of nursing) and NHA (nursing home administrator) confirmed the facility failed to protect the above residents from physical abuse perpetrated by other residents. The DON and NHA confirmed that residents have the right to be free from abuse, including physical abuse perpetrated by other residents.


28 Pa. Code 201.14 (a) Responsibility of licensee

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

28 Pa. Code 201.29(a) Resident Rights

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






 Plan of Correction - To be completed: 07/30/2024

1.Residents 62,85,97 and 119 behavior care plans have been updated with individualized interventions. Residents will be monitored for further behaviors and interventions will be updated as needed.

2.A review of Resident-to-Resident incidents for the last 14 days have been reviewed to ensure appropriate interventions are in place on the resident's care plan and monitoring tracking behaviors.

3.The staff educator or designee will educate nursing staff and IDT Team on de-escalation of residents with aggressive behavior.

4.DON/Designee will review 24 hr. nursing report for any Resident to Resident incidents, to ensure appropriate interventions are in place on the residents care plan , this will take place weekly x4 than monthlyx2 . Results of Audits will be reviewed monthly at QAPI.

483.10(c)(7) REQUIREMENT Resident Self-Admin Meds-Clinically Approp: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)(7) The right to self-administer medications if the interdisciplinary team, as defined by §483.21(b)(2)(ii), has determined that this practice is clinically appropriate.
Observations:


Based on observation, a review of clinical records and select facility policy, staff and resident interviews, it was determined that the facility failed to ensure the self-administration of medications was clinically appropriate for one of the 27 residents sampled (Resident 7).

Findings include:

A review of facility policy titled "Self-Administration of Medications," provided by the facility on April 18, 2024, indicated residents have the right to self-administer medications if the interdisciplinary team has determined that is clinically appropriate and safe for the resident. If it is deemed safe and appropriate for a resident to self-administer medications, this is documented in the medical record and care plan.

A clinical record review revealed Resident 7 was admitted to the hospital on October 14, 2022, with diagnoses that include acute respiratory failure (a condition where the respiratory system is unable to remove carbon dioxide from or provide oxygen to the body) and chronic kidney disease (gradual loss of kidney function).

A review of a quarterly Minimum Data Set assessment (MDS - a federally mandated standardized assessment process conducted periodically to plan resident care) dated March 29, 2024, revealed that Resident 7 is cognitively intact with a BIMS score of 14 (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 13-15 indicates cognition is intact).

During an interview and observation on June 11, 2024, at 12:00 PM, Resident 7 was observed seated by her bed. On her bedside table were five pills in a small, clear plastic cup. The resident stated that she is unable to swallow them all at once, so the nurses leave the pills by her table, and she takes the medications one at a time as she is able.

During an interview on June 11, 2024, at 12:08 PM, Employee 11, Licensed Practical Nurse (LPN), confirmed that she left the pills with Resident 7 because the resident was unable to swallow them all at once. Employee 11, LPN, was unable to confirm if Resident 7 was assessed or approved to safely self-administer medication.

An authorization of self-administration of drugs \ form, with no date indicated, revealed that Resident 7 elected not to exercise her right to self-administer medications.

A clinical record review failed to find documented evidence that Resident 7 was assessed and deemed safe and appropriate to self-administer her medications.

During an interview on June 14, 2024, at approximately 11:00 AM, the Director of Nursing (DON) confirmed that there was no documented evidence that Resident 7 was assessed and deemed safe and clinically appropriate to self-administer her medications. The DON confirmed that without an assessment, Resident 7 should not have been allowed to self-administer her medications.


28 Pa Code: 211.9 (a)(1) Pharmacy services.

28 Pa Code 211.10 (c)(d) Resident care policies.

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




 Plan of Correction - To be completed: 07/30/2024

1.Resident 7 will be assessed for medication self-administer her medications.

2.The DON or designee will review the policy for self-administration of medications. Residents who request to self-administer will be assessed per policy. An AD HOC Resident Council Meeting will be held to review the policy.

3.The DON or designee will educate licensed nursing staff on the reviewed self-administration policy.

4.The IDT will review residents with requests for medication self-administration. An audit will be completed weekly for four weeks on residents who request self-administration of medication. Results of these audits will be reported to QAPI for further guidance.

483.25(l) REQUIREMENT Dialysis: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.
§483.25(l) Dialysis.
The facility must ensure that residents who require dialysis receive such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences.
Observations:

Based on observation, a review of clinical records, and staff interview it was determined that the facility failed to ensure the ready availability of necessary emergency supplies for one resident out of two sampled receiving hemodialysis (Resident 59).

Findings include:

According to the National Kidney Foundation, patients receiving hemodialysis should keep emergency care supplies on hand.

A review of the clinical record revealed that Resident 59 was admitted to the facility on May 24, 2024, with a diagnosis to include end stage renal disease, and dependence on renal dialysis (process of removing waste products and excess fluid from the body when the kidneys are not able to adequately filter the blood).

Resident 59's clinical record indicated he was receiving hemodialysis through a right upper chest Tesio port (dialysis access site) for dialysis access every Tuesday, Thursday and Saturday.

Resident 59's clinical record revealed a physician order dated June 11, 2024, for an emergency kit at bedside for the dialysis port .

The resident's plan of care, dated May 26, 2024, indicated that staff are to check for a pressure dressing and clamp at bedside for emergency care of the port every shift and document in the Treatment Administration Record (TAR).

Observation conducted on June 11, 2024, and at 12:20 PM and on June 12, 2024, at 8:20 AM revealed no emergency kit or supplies available at the resident's bedside.

Interview with Employee 4 (registered nurse supervisor) on June 12, 2024, at 8:28 AM, revealed that each resident in the facility receiving dialysis should have emergency supplies at bedside. Employee 4 confirmed that there were no emergency supplies available at Resident 59's bedside.

Interview with the Director of Nursing on June 14, 2024, at approximately 11:00 AM confirmed the facility failed to assure an emergency kit was readily available in the event of an emergency with the resident's dialysis access site.


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




 Plan of Correction - To be completed: 07/30/2024

1.Resident 59 was provided an emergency supply kit at bedside.

2.Audit of all dialysis residents completed to ensure that emergency kit is at bedside .

3.Nursing staff educated to ensure that emergency kits are placed at beside for dialysis residents on admission and replaced as needed.

4.DON/Designee will audit emergency kits weekly for 4 weeks to ensure placement of same at bedside. Results of audit will be provided to QAPI, the committee will determine the need for further audits.

483.25(g)(1)-(3) REQUIREMENT Nutrition/Hydration Status Maintenance: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.
§483.25(g) Assisted nutrition and hydration.
(Includes naso-gastric and gastrostomy tubes, both percutaneous endoscopic gastrostomy and percutaneous endoscopic jejunostomy, and enteral fluids). Based on a resident's comprehensive assessment, the facility must ensure that a resident-

§483.25(g)(1) Maintains acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that this is not possible or resident preferences indicate otherwise;

§483.25(g)(2) Is offered sufficient fluid intake to maintain proper hydration and health;

§483.25(g)(3) Is offered a therapeutic diet when there is a nutritional problem and the health care provider orders a therapeutic diet.
Observations:

Based on observation, clinical record review, and staff interview, it was determined that the facility failed to failed to timely implement a nutritional support regimen to meet the nutritional needs and prevent weight loss for one resident (Resident 90) and failed to accurately monitor a fluid restriction prescribed to address a resident's clinical condition and maintain fluid balance and adequate hydration status for one resident (Resident 178) out of 27 sampled.

Findings include:

A review of a facility policy "Weight Assessment and Intervention" last reviewed by the facility April 18, 2024, indicated that resident weights are monitored for undesirable or unintended weight loss or gain. Residents are weighed upon admission, weekly x 4 weeks, and then monthly or per physician orders. If the weight loss is 5-pound difference from the last weight, a re-weight will be obtained and validated. The dietician will review the weight record to follow individual weight trends. The threshold for significant unplanned and undesired weight loss is based on the following criteria:
a.1 month - 5% weight loss is significant; greater than 5% is severe.
b.6 months - 10% weight loss is significant; greater than 10% is severe.

The policy further indicated that undesirable weight change is evaluated by the physician and dietitian. The physician and multidisciplinary team identify conditions and medications that may be causing anorexia, weight loss or increasing the risk of weight loss.

Review of Resident 90's clinical record revealed that the resident was admitted to the facility on May 22, 2024, with diagnoses to include osteomyelitis (inflammation of the bone caused by an infection), muscle wasting and atrophy.

A review of Resident 90's care plan, initiated May 23, 2024, identified that the resident may be nutritionally at risk related to diet restrictions, obesity, weight loss and variable PO intake, and skin integrity. The resident's goal was to consume at least 50% of at lest 2 meals daily and maintain weight within 3% of CBW (current body weight). Planned interventions included to assist with meals as needed, monitor/document/report refusals to eat, and for the registered dietitian to make diet change recommendations as needed.

Review of Resident 90's resident's weight record revealed:

May 22, 2024160.2 pounds
May 29, 2024157.8 pounds
June 6, 2024149.2 pounds - 6.87% significant weight loss

There was no evidence of a re-weight being obtained to confirm Resident 90's significant weight loss as per facility policy There was no evidence that facility notified Resident 90's physician of the 6.87% significant weight loss in one week.

A review of the resident's survey documentation report (a computer-generated report that records the data that nurse aides enter for meal consumption and other care tasks performed) dated June 2024, revealed that from June 1, 2024, through June 13, 2024, Resident 90 refused 8 meals out of 37 served meals, consumed 25% or less for 8 meals, and consumed 50% or less for 9 meals. Resident's consumption of 51% to 100% of meals occurred only 12 times out of 37 meals served.

Observation on June 12, 2024, at 7:50 AM, revealed Resident 90 in bed, positioned upright, asleep. Her breakfast tray was positioned in front of her, untouched. Resident 90 was observed to be alone with no staff present to provide assistance.

There was no indication that the facility identified and acted upon Resident 90's weight loss and had determined if nutritional support interventions were necessary to prevent further weight loss. There also was no indication that the physician, and resident representative were informed of the significant weight loss.

The facility failed to identify Resident 90's weight loss, failed to identify and act upon her decreased meal intakes, failed to provide feeding assistance as needed as indicated in her plan of care, and failed to implement nutritional support to prevent further weight loss. There was also no evidence that the facility had notified the resident's attending physician and resident representative of the significant weight loss.

Interview with the Director of Nursing on June 14, 2024, at 8:30 AM, confirmed that the facility failed to timely identify, address, and implement weight loss interventions to improve Resident 90's nutritional status.

Clinical record review revealed that Resident 178 was admitted to the facility on June 5, 2024, with diagnoses which included congestive heart failure (a chronic condition in which the heart does not pump blood as well as it should).

A physician order dated June 6, 2024, was noted for a 1500 cc fluid restriction.

Review of Resident 178's lunch meal tag on June 11, 2024, revealed no evidence that the resident was on a fluid restriction.

Further review of the clinical record revealed no documented evidence that the physician prescribed fluid restriction was implemented to ensure that the resident did not exceed 1500 cc's of fluid per day.

During an interview June 13, 2024, at approximately 10:00 AM the Director of Nursing confirmed that the facility failed to implement the physician prescribed fluid restriction for Resident 178.



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

28 Pa. Code 211.5(f) Medical records









 Plan of Correction - To be completed: 07/30/2024

1.Resident 178-physician prescribed fluid restriction was implemented as ordered. Resident 90 placed on interventions on 6/13 for weight loss.

2.Weight and fluid restriction audit completed on current residents to ensure that weight loss is identified. Current residents on fluid restriction audited to ensure physician order is in place.

3.Dietician in-service regarding monitoring weights per facility policy and implementing interventions as needed. Licensed nursing staff will be reeducated on notifying the physician and resident representative with changes in weight per policy. Licensed nursing staff/dietician/dietary in serviced on monitoring any current/new physician order fluid restriction that is put into place is followed as ordered.

4.Dietician/Designee will audit weights and fluid restrictions weekly for 4 weeks. Results of audit will be provided to QAPI, the committee will determine the need for further audits.

483.25(e)(1)-(3) REQUIREMENT Bowel/Bladder Incontinence, Catheter, UTI: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.
§483.25(e) Incontinence.
§483.25(e)(1) The facility must ensure that resident who is continent of bladder and bowel on admission receives services and assistance to maintain continence unless his or her clinical condition is or becomes such that continence is not possible to maintain.

§483.25(e)(2)For a resident with urinary incontinence, based on the resident's comprehensive assessment, the facility must ensure that-
(i) A resident who enters the facility without an indwelling catheter is not catheterized unless the resident's clinical condition demonstrates that catheterization was necessary;
(ii) A resident who enters the facility with an indwelling catheter or subsequently receives one is assessed for removal of the catheter as soon as possible unless the resident's clinical condition demonstrates that catheterization is necessary; and
(iii) A resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible.

§483.25(e)(3) For a resident with fecal incontinence, based on the resident's comprehensive assessment, the facility must ensure that a resident who is incontinent of bowel receives appropriate treatment and services to restore as much normal bowel function as possible.
Observations:

Based on review of clinical records, and staff interviews, it was determined that the facility failed to thoroughly assess and evaluate bladder function and implement individualized interventions to restore bladder function to the extent possible for one resident (Residents 47), andprovide care and services to prevent potential complications with the use of an indwelling foley catheter (a flexible tube which is placed into the bladder to drain urine) for one resident out of two sampled with a foley catheter (Resident 101).

Findings include:

Department of Health & Human Services, USA. Centers for Disease Control and Prevention, Guideline for Prevention of Catheter-Associated Urinary Tract Infections 2009, last updated June 6, 2019, III Proper Techniques for Urinary Catheter Maintenance, B. Maintain unobstructed urine flow. 2. Keep the collecting bag below the level of the bladder at all times. Do not rest the bag on the floor.

Review of Resident 47's clinical record revealed admission to the facility on August 9, 2022, with diagnoses that included Parkinson's disease (a long-term neurodegenerative disease of mainly the central nervous system), diabetes, and hypertension.

A review of the residents Quarterly Minimum Data Set Assessments (MDS - a federally mandated standardized assessment completed at specific intervals to define resident care needs) dated May 12, 2023, Annual MDS dated August 12, 2023, and Quarterly MDS dated November 12, 2023, Section H Bladder and Bowel, all indicated the resident was coded a (2) indicating frequently incontinent of bladder.

Resident 47's Quarterly MDSs dated February 12, 2024, and May 14, 2024, Section H Bladder and Bowel, noted that the resident was always incontinent of bladder (a decline of urinary bladder function).

The resident's plan of care for bladder incontinence, date-initiated August 16, 2022, revealed planned measures included to check the resident per protocol and as required for incontinence, monitor/document for sign/symptoms of UTI, urinary frequency, change in behavior, and preventative skin care per protocol.

During an interview with the Director of Nursing (DON) on June 12, 2024, at approximately 1:50 PM, it was confirmed that there was no documented evidence that the facility had recognized the increased urinary incontinence and completed incontinence evaluations or implemented any scheduled toileting programs in response to the resident's decline in bladder function.

A review of Resident 101's clinical record revealed admission to the facility on January 22, 2024, with diagnosis to include benign prostatic hyperplasia (BPH- age-associated prostate gland enlargement that can cause urination difficulty) with lower urinary tract symptoms, retention of urine, and Alzheimer's disease.

The resident had a physician order, initially dated May 22, 2024, for a foley catheter (a flexible tube inserted through the urinary opening (urethra) and into the bladder. The device drains the urine into a drainage bag).

Observation of Resident 101 in the resident's room on June 11, 2024, at 10:40 AM revealed that the resident was lying in bed with the bed lowered close to the floor. The resident's urinary collection bag, which was attached to the base of the bedframe, was directly in contact with the floor without a barrier or additional protective covering.

Further observation of Resident 101, accompanied by Employee 5 (Licensed Practical Nurse), in the resident's room, on June 13, 2024, at 9:48 AM, revealed that the resident's bed was in a low position with the urinary collection bag directly in contact with the floor and without a barrier or protective covering.

Interview with Employee 5, on June 13, 2024, at 9:50 AM confirmed that the collection bag should not have been directly in contact with the floor to prevent urinary tract infection.

Interview with the Director of Nursing (DON) on June 14, 2024, at approximately 11:00 AM confirmed that the facility failed to maintain Resident 101's foley catheter in a manner to prevent potential infection.


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

28 Pa. Code 211.10 (a)(d) Resident care policies






 Plan of Correction - To be completed: 07/30/2024

1.Residents 47 will be assessed to evaluate bladder function and will implement individualized interventions to restore bladder function to extent possible. Resident 101 staff are preventing Foley catheter for encountering the floor .

2.Foley catheter bags will be evaluated to ensure that the bag is not in direct contact with the floor. Residents with mixed continence will be assessed to evaluate bladder function and will implement individualized interventions to restore bladder function to the extent possible.

3.Nursing staff will be in-service on ensuring that any resident's Foley catheter is not seen in contact with the floor. Nursing staff will be in-service on evaluating and implementing bladder interventions to restore bladder function.

4.DON/Designee will audit Foley catheters and bladder interventions weekly x4 weeks. Results of audit will be provided to QAPI, the committee will determine the need for further audits.

483.21(b)(1)(3) REQUIREMENT Develop/Implement Comprehensive Care Plan: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.
§483.21(b) Comprehensive Care Plans
§483.21(b)(1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at §483.10(c)(2) and §483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following -
(i) The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under §483.24, §483.25 or §483.40; and
(ii) Any services that would otherwise be required under §483.24, §483.25 or §483.40 but are not provided due to the resident's exercise of rights under §483.10, including the right to refuse treatment under §483.10(c)(6).
(iii) Any specialized services or specialized rehabilitative services the nursing facility will provide as a result of PASARR recommendations. If a facility disagrees with the findings of the PASARR, it must indicate its rationale in the resident's medical record.
(iv)In consultation with the resident and the resident's representative(s)-
(A) The resident's goals for admission and desired outcomes.
(B) The resident's preference and potential for future discharge. Facilities must document whether the resident's desire to return to the community was assessed and any referrals to local contact agencies and/or other appropriate entities, for this purpose.
(C) Discharge plans in the comprehensive care plan, as appropriate, in accordance with the requirements set forth in paragraph (c) of this section.
§483.21(b)(3) The services provided or arranged by the facility, as outlined by the comprehensive care plan, must-
(iii) Be culturally-competent and trauma-informed.
Observations:


Based on observation, review of clinical records, and staff interview it was determined that the facility failed to address a resident's active diagnoses and treatment and individualized communication methods and needs on the resident's care plan for one resident out of 27 sampled (Resident 112).

Findings included:

A review of Resident 112's clinical record revealed he was admitted to the facility on November 29, 2023, with diagnosis to include diabetes, Parkinson's disease (a long-term neurodegenerative disease of mainly the central nervous system), and peripheral vascular disease (a slow, and progressive disorder of the blood vessels -
PVD).

A review of the admission Minimum Data Set assessment (MDS-a federally mandated standardized assessment process conducted at specific intervals to plan resident care) dated December 5, 2023, revealed that the resident is Hispanic, Latino/a, or Spanish in origin, and that Resident 112's preferred language is Spanish (Espaniol and ) and that the resident does need - wants an interpreter to communicate with a doctor or health care staff.

A review of Resident 112's clinical record, Social Determinants of Health notes dated November 30, and December 28, 2023, and March 27, 2024, stating the resident is Hispanic, Latino/a, or Spanish in origin, and his language is Spanish. The resident does need -want an interpreter to communicate.

A nurses note dated January 2, 2024, at 1655 (4:55 PM) indicated that a language barrier was noted as the resident does not speak English. A CNA (certified nursing assistant) was present, speaks Spanish and was assisting with translation.

An observation on June 11, 2024, at approximately 11:10 AM, revealed no visible communication tool, such as a communication board or translation device available to aid the resident in communication with others.

A second observation and attempted interview with Resident 112's, in his room on June 11, 2024, at approximately 11:55 AM, upon entering the room, the alert resident sat up in his bed and smiled. In the presence of Employee 1, nurse aide (NA), the observation of the residents room to include his wardrobe, dresser, nightstand, and wheelchair revealed no visible communication device, board, tablet, or picture book, was available to aid communication with the resident.

At this time, Employee 2, Licensed Practical Nurse (LPN), confirmed the observation, and stated the facility utilizes the services of a phone interpreter. However, the observation of Resident 112's room failed to reveal the contact information for the interpreter, phone number, and or directions to access the service.

A review of Resident 112's care plan in effect during the survey ending June 14, 2024, indicated the residents admission date was November 29, 2023, and revealed that the resident's comprehensive care plan did not include the resident's known conditions to include Parkinson's disease, PVD, nor his preferred language, and or any assistive devices to be used in an attempt to communicate with Resident 112.

During an interview with the Director of Nursing (DON) on June 12, 2024, at approximately 9:10 AM, confirmed facility failed to fully develop and implement person-centered comprehensive care plan in a manner that assures staff are aware of the resident's specific and individualized interventions to address a resident's health needs, including communication methods.









 Plan of Correction - To be completed: 07/30/2024

1.Resident 112 comprehensive care plan was completed on 6/14/2024 to assure staff are aware of resident specific and individualized interventions to address active diagnosis and communication methods.

2.Current residents with communication deficits will be completed by nursing staff to ensure care plans included specific communication methods and individualized diagnosis.

3.Licensed nursing staff will be educated on updating and completing care plans. New admissions and readmissions care plans will be completed by nursing staff to ensure care plans include specific communication methods and individualized diagnosis.

4.DON/Designee will audit care plans weekly x4 weeks to ensure communication methods and diagnosis. Results of the audit will be provided to QAPI, the committee will determine the need for further audits.

483.20(f)(1)-(4) REQUIREMENT Encoding/Transmitting Resident Assessments: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.
§483.20(f) Automated data processing requirement-
§483.20(f)(1) Encoding data. Within 7 days after a facility completes a resident's assessment, a facility must encode the following information for each resident in the facility:
(i) Admission assessment.
(ii) Annual assessment updates.
(iii) Significant change in status assessments.
(iv) Quarterly review assessments.
(v) A subset of items upon a resident's transfer, reentry, discharge, and death.
(vi) Background (face-sheet) information, if there is no admission assessment.

§483.20(f)(2) Transmitting data. Within 7 days after a facility completes a resident's assessment, a facility must be capable of transmitting to the CMS System information for each resident contained in the MDS in a format that conforms to standard record layouts and data dictionaries, and that passes standardized edits defined by CMS and the State.

§483.20(f)(3) Transmittal requirements. Within 14 days after a facility completes a resident's assessment, a facility must electronically transmit encoded, accurate, and complete MDS data to the CMS System, including the following:
(i)Admission assessment.
(ii) Annual assessment.
(iii) Significant change in status assessment.
(iv) Significant correction of prior full assessment.
(v) Significant correction of prior quarterly assessment.
(vi) Quarterly review.
(vii) A subset of items upon a resident's transfer, reentry, discharge, and death.
(viii) Background (face-sheet) information, for an initial transmission of MDS data on resident that does not have an admission assessment.

§483.20(f)(4) Data format. The facility must transmit data in the format specified by CMS or, for a State which has an alternate RAI approved by CMS, in the format specified by the State and approved by CMS.
Observations:

Based on a review of the Resident Assessment Instrument Manual and clinical records, and staff interview, it was determined that the facility failed to timely submit Minimum Data Set (MDS) assessments to the required electronic system, the CMS Quality Improvement and Evaluation System (QIES) Assessment Submission and Processing (ASAP) System, for one of eight sampled (Resident 72).

Findings Include:

The Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, which provides instructions and guidelines for completing the Minimum Data Set (MDS) dated October 2023, requires that discharge assessments-return anticipated (non-comprehensive) be completed no longer than the resident's discharge date + 14 calendar days.

A clinical record review revealed that Resident 72 was transferred to the hospital on April 30, 2024.

A progress note dated May 3, 2024, revealed that Resident 72 returned to the facility.

Further review of the clinical record revealed no documented evidence that an MDS discharge assessment-return anticipated (non-comprehensive) was completed for Resident 72.

During an interview on June 13, 2024, at approximately 1:00 PM, the director of nursing confirmed that Resident 72's discharge return anticipated MDS assessment was not completed and submitted within the required timeframes.






 Plan of Correction - To be completed: 07/30/2024

1.Resident 72 discharge assessment-return anticipated (non-comprehensive) was completed on 6/13/24.

2.The facility will audit all discharged residents in the past 7 days, checking for appropriate MDS discharge assessment completion.

3.MDS coordinator/staff will be educated on ensuring the completion of discharge MDS assessments are completed in a timely manner.

4.NHA/designee will audit MDS discharge assessments weekly for 4 weeks to ensure all MDS discharge assessments are submitted timely to the required electronic system. Results of audit will be provided to QAPI, the committee will determine the need for further audits.

483.10(h)(1)-(3)(i)(ii) REQUIREMENT Personal Privacy/Confidentiality of Records: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(h) Privacy and Confidentiality.
The resident has a right to personal privacy and confidentiality of his or her personal and medical records.

§483.10(h)(l) Personal privacy includes accommodations, medical treatment, written and telephone communications, personal care, visits, and meetings of family and resident groups, but this does not require the facility to provide a private room for each resident.

§483.10(h)(2) The facility must respect the residents right to personal privacy, including the right to privacy in his or her oral (that is, spoken), written, and electronic communications, including the right to send and promptly receive unopened mail and other letters, packages and other materials delivered to the facility for the resident, including those delivered through a means other than a postal service.

§483.10(h)(3) The resident has a right to secure and confidential personal and medical records.
(i) The resident has the right to refuse the release of personal and medical records except as provided at §483.70(i)(2) or other applicable federal or state laws.
(ii) The facility must allow representatives of the Office of the State Long-Term Care Ombudsman to examine a resident's medical, social, and administrative records in accordance with State law.
Observations:

Based on review of select facility incident reports and staff and resident interview, it was determined that the facility failed to ensure that mail was delivered unopened to one of 11 residents interviewed during a resident group interview (Resident 106).

Findings include:

Definitions under the regulatory guidance for The facility must respect the residents right to personal privacy, including the right to privacy in his or her oral (that is, spoken), written, and electronic communications, including the right to send and promptly receive unopened mail and other letters, packages and other materials delivered to the facility for the resident, including those delivered through a means other than a postal service.

During a resident group interview on June 12, 2024, at 11:40 AM, Resident 106 stated that he does not receive his incoming mail and packages unopened. Resident 106 stated in the past there was a mix-up with prescription medication arriving in a package from a healthcare facility addressed to him instead of being sent directly to the facility.

Review of a facility incident report dated May 21, 2024, Resident 106 was found with Buprenophine patches (opioid analgesic, controlled substance) in his room. The patches arrived in a package from a local healthcare clinic where Resident 106 was seen for an appointment. The local healthcare clinic was contacted to address the mistake of sending medication directly to Resident 106 while a resident at the facility. A procedure was put in place that any future packages from the healthcare clinic would be addressed to the care of nursing supervisor for Resident 106.

To avoid similar incidents staff who receive Resident 106's were inserviced on May 29, 2024, to identify and record any packages which arrive for Resident 106 which are addressed care of nursing supervisor and alert the nursing supervisor upon receiving any such packages.

Interview with the director of nursing (DON) on June 13, 2024, at 1:30 PM confirmed that any packages which were received care of nursing supervisor for Resident 106 should still be opened by the resident with the nursing supervisor present. The DON confirmed that there have been no further incidents of Resident 106 receiving packages addressed care of the nursing supervisor. The DON confirmed that Resident 106's mail or packages should not be opened by staff. The DON confirmed that all residents including Resident 106 have the right to receive mail and packages unopened.



28 Pa. Code 201.29(a) Resident rights.









 Plan of Correction - To be completed: 07/30/2024

1.Resident 106 mail/packages will be delivered unopened.

2.An AD HOC Resident council meeting will be held to review the mail delivery process. Any concerns will be immediately addressed, and a plan implemented.

3.NHA/Designee will provide education to front desk staff and activities staff regarding the resident right to have to receive mail delivery process.

4.Social Services/Designee will complete random audit of mail for 4 weeks to ensure mail and packages are delivered unopened. Results of audit will be reviewed at QAPI, the QAPI committee will determine the need further audits.

483.15(c)(1)(i)(ii)(2)(i)-(iii) REQUIREMENT Transfer and Discharge Requirements: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.
§483.15(c) Transfer and discharge-
§483.15(c)(1) Facility requirements-
(i) The facility must permit each resident to remain in the facility, and not transfer or discharge the resident from the facility unless-
(A) The transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in the facility;
(B) The transfer or discharge is appropriate because the resident's health has improved sufficiently so the resident no longer needs the services provided by the facility;
(C) The safety of individuals in the facility is endangered due to the clinical or behavioral status of the resident;
(D) The health of individuals in the facility would otherwise be endangered;
(E) The resident has failed, after reasonable and appropriate notice, to pay for (or to have paid under Medicare or Medicaid) a stay at the facility. Nonpayment applies if the resident does not submit the necessary paperwork for third party payment or after the third party, including Medicare or Medicaid, denies the claim and the resident refuses to pay for his or her stay. For a resident who becomes eligible for Medicaid after admission to a facility, the facility may charge a resident only allowable charges under Medicaid; or
(F) The facility ceases to operate.
(ii) The facility may not transfer or discharge the resident while the appeal is pending, pursuant to § 431.230 of this chapter, when a resident exercises his or her right to appeal a transfer or discharge notice from the facility pursuant to § 431.220(a)(3) of this chapter, unless the failure to discharge or transfer would endanger the health or safety of the resident or other individuals in the facility. The facility must document the danger that failure to transfer or discharge would pose.

§483.15(c)(2) Documentation.
When the facility transfers or discharges a resident under any of the circumstances specified in paragraphs (c)(1)(i)(A) through (F) of this section, the facility must ensure that the transfer or discharge is documented in the resident's medical record and appropriate information is communicated to the receiving health care institution or provider.
(i) Documentation in the resident's medical record must include:
(A) The basis for the transfer per paragraph (c)(1)(i) of this section.
(B) In the case of paragraph (c)(1)(i)(A) of this section, the specific resident need(s) that cannot be met, facility attempts to meet the resident needs, and the service available at the receiving facility to meet the need(s).
(ii) The documentation required by paragraph (c)(2)(i) of this section must be made by-
(A) The resident's physician when transfer or discharge is necessary under paragraph (c) (1) (A) or (B) of this section; and
(B) A physician when transfer or discharge is necessary under paragraph (c)(1)(i)(C) or (D) of this section.
(iii) Information provided to the receiving provider must include a minimum of the following:
(A) Contact information of the practitioner responsible for the care of the resident.
(B) Resident representative information including contact information
(C) Advance Directive information
(D) All special instructions or precautions for ongoing care, as appropriate.
(E) Comprehensive care plan goals;
(F) All other necessary information, including a copy of the resident's discharge summary, consistent with §483.21(c)(2) as applicable, and any other documentation, as applicable, to ensure a safe and effective transition of care.
Observations:


Based on a clinical record review and staff interview, it was determined that the facility failed to ensure that the necessary resident information was communicated to the receiving health care provider for one resident out of 27 residents sampled with facility-initiated transfers (Residents 7).

Findings include:

A clinical record review revealed that Resident 7 was transferred to a community hospital on June 8, 2024, and returned to the facility on June 10, 2024.

A nursing progress note dated June 8, 2024, at 2:09 PM indicated that Resident 7 was sent to the receiving provider and "sent with all appropriate paperwork." There was no documented evidence that the facility had communicated specific information to the receiving health care provider for the residents transferred and expected to return, including contact information of the practitioner responsible for the care of the resident, resident representative information including contact information, advance directive information, all special instructions or precautions for ongoing care, as appropriate, and any other documentation, as applicable, to ensure a safe and effective transition of care.

During an interview on June 14, 2024, at approximately 11:30 AM, the Director of Nursing (DON) and Nursing Home Administrator (NHA) confirmed that there was no evidence that the necessary information was communicated to the receiving health care institution or provider for Resident 7's facility-initiated transfers on June 8, 2024.


28 Pa. Code 201.29 (a)(c.3)(2) Resident rights

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



 Plan of Correction - To be completed: 07/30/2024

1.Resident 7 was sent out and returned, not able to correct.

2.The facility will audit all transfers out in the past 7 days, checking for necessary resident information was communicated to the receiving health care provider.

3.The staff educator or designee will re-educate Licensed nursing staff on the appropriate documentation to be completed to communicate with receiving provider with a transfer out.

4.DON/Designee will audit transfer documentation requirements for residents being transferred out to another receiving provider for 4 weeks to ensure that all appropriate paperwork is completed. Results of audit will be provided to QAPI, the committee will determine the need for further audits.

483.35(g)(1)-(4) REQUIREMENT Posted Nurse Staffing Information:Least serious 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 has the potential for causing no more than a minor negative impact on the resident.
§483.35(g) Nurse Staffing Information.
§483.35(g)(1) Data requirements. The facility must post the following information on a daily basis:
(i) Facility name.
(ii) The current date.
(iii) The total number and the actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift:
(A) Registered nurses.
(B) Licensed practical nurses or licensed vocational nurses (as defined under State law).
(C) Certified nurse aides.
(iv) Resident census.

§483.35(g)(2) Posting requirements.
(i) The facility must post the nurse staffing data specified in paragraph (g)(1) of this section on a daily basis at the beginning of each shift.
(ii) Data must be posted as follows:
(A) Clear and readable format.
(B) In a prominent place readily accessible to residents and visitors.

§483.35(g)(3) Public access to posted nurse staffing data. The facility must, upon oral or written request, make nurse staffing data available to the public for review at a cost not to exceed the community standard.

§483.35(g)(4) Facility data retention requirements. The facility must maintain the posted daily nurse staffing data for a minimum of 18 months, or as required by State law, whichever is greater.
Observations:

Based on observations and staff interview, it was determined that the facility failed to post nurse staffing information on a daily basis to include the resident census and the total number and actual hours worked by licensed and unlicensed staff.

Findings Include:

Observations in the facility lobby on June 11, 2024, at 8:45 AM and 3:10 PM, and June 12, 2024, at 9:00 AM revealed that the facility's nurse staffing information was not posted in the facility's designated area.

An interview with the Director of Nursing on June 12, 2024, at 9:10 AM revealed that the nurse staffing information should be posted daily at the beginning of each shift in a prominent location.


28 Pa. Code 201.14 (a) Responsibility of licensee






 Plan of Correction - To be completed: 07/30/2024

1.The Nursing scheduled hours was posted and indicated the entire 24-hour period. The Nursing hour posting is updated and changed at the beginning of the shift to reflect any changes ensuring correct hours are posted. Each shift is/was updated. The Scheduler posts out the daily staffing for all 24 hours.

2.Facility cannot retroactively correct.

3.NHA/Designee will educate scheduler/RN Supervisor, ensuring posting is completed and updated per shift.

4.NHA/Designee will audit randomly nursing hours posting, to ensure posting is updated at the beginning of the shift and per shift. Audits will be weekly x4 weeks, then monthly x2. Results of audits will be reviewed at QAPI meetings.

483.15(c)(3)-(6)(8) REQUIREMENT Notice Requirements Before Transfer/Discharge:Least serious deficiency but affects more than a limited number of residents, staff, or occurrences. This deficiency has the potential for causing no more than a minor negative impact on the resident but is not found to be throughout this facility.
§483.15(c)(3) Notice before transfer.
Before a facility transfers or discharges a resident, the facility must-
(i) Notify the resident and the resident's representative(s) of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand. The facility must send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman.
(ii) Record the reasons for the transfer or discharge in the resident's medical record in accordance with paragraph (c)(2) of this section; and
(iii) Include in the notice the items described in paragraph (c)(5) of this section.

§483.15(c)(4) Timing of the notice.
(i) Except as specified in paragraphs (c)(4)(ii) and (c)(8) of this section, the notice of transfer or discharge required under this section must be made by the facility at least 30 days before the resident is transferred or discharged.
(ii) Notice must be made as soon as practicable before transfer or discharge when-
(A) The safety of individuals in the facility would be endangered under paragraph (c)(1)(i)(C) of this section;
(B) The health of individuals in the facility would be endangered, under paragraph (c)(1)(i)(D) of this section;
(C) The resident's health improves sufficiently to allow a more immediate transfer or discharge, under paragraph (c)(1)(i)(B) of this section;
(D) An immediate transfer or discharge is required by the resident's urgent medical needs, under paragraph (c)(1)(i)(A) of this section; or
(E) A resident has not resided in the facility for 30 days.

§483.15(c)(5) Contents of the notice. The written notice specified in paragraph (c)(3) of this section must include the following:
(i) The reason for transfer or discharge;
(ii) The effective date of transfer or discharge;
(iii) The location to which the resident is transferred or discharged;
(iv) A statement of the resident's appeal rights, including the name, address (mailing and email), and telephone number of the entity which receives such requests; and information on how to obtain an appeal form and assistance in completing the form and submitting the appeal hearing request;
(v) The name, address (mailing and email) and telephone number of the Office of the State Long-Term Care Ombudsman;
(vi) For nursing facility residents with intellectual and developmental disabilities or related disabilities, the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with developmental disabilities established under Part C of the Developmental Disabilities Assistance and Bill of Rights Act of 2000 (Pub. L. 106-402, codified at 42 U.S.C. 15001 et seq.); and
(vii) For nursing facility residents with a mental disorder or related disabilities, the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with a mental disorder established under the Protection and Advocacy for Mentally Ill Individuals Act.

§483.15(c)(6) Changes to the notice.
If the information in the notice changes prior to effecting the transfer or discharge, the facility must update the recipients of the notice as soon as practicable once the updated information becomes available.

§483.15(c)(8) Notice in advance of facility closure
In the case of facility closure, the individual who is the administrator of the facility must provide written notification prior to the impending closure to the State Survey Agency, the Office of the State Long-Term Care Ombudsman, residents of the facility, and the resident representatives, as well as the plan for the transfer and adequate relocation of the residents, as required at § 483.70(l).
Observations:


Based on review of clinical records and transfer notices, and staff interviews, it was determined that the facility failed to provide written notices of facility-initiated transfers to the resident and the resident's representative for eight out of the 27 residents reviewed (Residents 7, 114, 101, 9, 63, 112, 2, and 106).

Findings include:

A clinical record review revealed that Resident 114 was transferred to the hospital on March 11, 2024, and returned to the facility on March 15, 2024.

A clinical record review revealed no documented evidence that a notice of transfer or discharge letter was provided to Resident 114 and her resident representative regarding her transfer to the hospital on March 11, 2024, or as soon as practical.

A clinical record review revealed that Resident 7 was transferred to the hospital on June 8, 2024, and returned to the facility on June 10, 2024.

A clinical record review revealed no documented evidence that a notice of transfer or discharge letter was provided to Resident 7 and her resident representative regarding her transfer to the hospital on June 8, 2024.

A clinical record review revealed that Resident 101 was transferred to the hospital on March 3, 2024, and returned March 15, 2024. The resident was again transferred to the hospital on March 30, 2024 and returned April 2, 2024.

Clinical record review revealed no documented evidence that a notice of transfer or discharge letter was provided to Resident 101 and his resident representative regarding his transfer to the hospital on March 3 and March 30, 2024.

A clinical record review revealed that Resident 9 was transferred to the hospital on May 15, 2024, and returned to the facility on May 21, 2024.

A clinical record review revealed no documented evidence that a notice of transfer or discharge letter was provided to Resident 9 and her resident representative regarding her transfer to the hospital on May 15, 2024.

A clinical record review revealed that Resident 63 was transferred to a community hospital on December 5, 2023, and returned December 7, 2023. The resident was again transferred to the hospital on January 5, 2024, and returned January 9, 2024.

Clinical record review revealed no documented evidence that a notice of transfer or discharge letter was provided to Resident 63 and his resident representative regarding his transfer to the hospital on December 5, 2023, and January 5, 2024.

A clinical record review revealed that Resident 112 was transferred to the hospital on December 22, 2023, and returned December 28, 2023, on January 2, 2024, and returned January 4, 2024, February 19, 2024, and returned on February 27, 2024, March 6, 2024, and returned March 11, 2024, and on March 21, 2024, and returned on March 25, 2024. The resident was again transferred to the hospital on May 20, 2024, and returned May 24, 2024.

Clinical record review revealed no documented evidence that a notice of transfer or discharge letter was provided to Resident 112 and his resident representative regarding his transfer to the hospital on December 22, 2023, January 2, 2024, February 19, 2024, March 6, 2024, March 21, 2024, and May 20, 2024.

A clinical record review revealed that Resident 2 was transferred to a community hospital on March 28, 2024, and readmitted to the facility as a new admission on May 24, 2024, after a stay in a specialty hospital unit.

Clinical record review revealed no documented evidence that a notice of transfer or discharge letter was provided to Resident 2 and his resident representative regarding his transfer to the hospital on March 28, 2024.

A clinical record review revealed that Resident 106 was transferred to the hospital on May 3, 2024, and readmitted to the facility on May 11, 2024.

Clinical record review revealed no documented evidence that a notice of transfer or discharge letter was provided to Resident 106 and his resident representative regarding his transfer to the hospital on May 11, 2024.

During an interview on June 14, 2024, at approximately 11:30 AM, the Nursing Home Administrator and Director of Nursing confirmed that the facility had no documented evidence that Residents 7, 14, 101, 9, 63, 112, 2, and 106 and their representatives were provided written notices for the facility-initiated transfers.


28 Pa. Code 201.29 (a)(c.3)(2) Resident rights




 Plan of Correction - To be completed: 07/30/2024

1.Resident 7, 114, 101, 9, 63, 112, 2 and 106, were sent out and returned, not able to correct.

2.The facility will audit residents/representatives that were discharged to the hospital for the past 7 days, check if proper communication occurred with receiving written notice for facility – initiated transfers.

3.Social Services/business Office and licensed staff will be educated on facility – initiated transfers to the resident and the resident representative.

4.NHA/Designee will audit written notice of facility – initiated transfers to the resident and the resident's representative for 4 weeks to ensure written notice is provided. Results of audit will be provided to QAPI, the committee will determine the need for further audits.

§ 211.9(j.1) (1) - (5) LICENSURE Pharmacy services.:State only Deficiency.
(j.1) The facility shall have written policies and procedures for the disposition of medications that address all of the following:
(1) Timely and safe identification and removal of medications for disposition.
(2) Identification of storage methods for medications awaiting final disposition.
(3) Control and accountability of medications awaiting final disposition consistent with standards of practice.
(4) Documentation of actual disposition of medications to include the name of the individual disposing of the medication, the name of the resident, the name of the medication, the strength of the medication, the prescription number if applicable, the quantity of medication and the date of disposition.
(5) A method of disposition to prevent diversion or accidental exposure consistent with applicable Federal and State requirements, local ordinances and standards of practice.

Observations:

Based on observation, and staff interview it was determined that the facility failed to store drugs and pharmacy supplies in a safe manner in two medication storage room out of two medication storage rooms and failed to remove medications awaiting final disposition in a timely manner.

Findings include:

Observation of the 2 nd floor medication storage room performed on June 11, 2024, at approximately 10:30 AM, in the presence of Employee 2, Licensed Practical Nurse (LPN) revealed 2 large, plastic totes stacked upon each other directly on the floor. The top filled tote was overflowing with medication blister card, some laying directly on the floor. Observation revealed that the totes contained discontinued resident prescription medications, plastic medication sleeves, and medication bottles, that were left unsecured.

Interview with Employee 3, Registered Nurse Supervisor (RNS), on June 11, 2024, at approximately 10:40 AM, also present in the 2 nd floor medication storage room, confirmed the observation, and stated the medications in the crates were all discontinued resident medications. Employee 3 (RNS), stated that pharmacy makes deliveries on a daily basis and that it is her understanding the medications should be picked up by pharmacy personnel every 2 weeks. Employee 3 confirmed that the discontinued medications should have been returned to pharmacy in a timely manner and that the medications should have been stored in a secured manner to prevent unauthorized access and the potential for drug diversion.

Observation of the 3 rd floor medication storage room performed on June 11, 2024, at approximately 11:05 AM, in the presence of the Director of Nursing (DON) revealed a large, grey, plastic tote on countertop. The tote was filled with discontinued resident prescription medication blister cards, plastic medication sleeves, medication bottles, breathing treatments, and antibiotic vials that were left unsecured.

During an interview with DON on June 11, 2024, at approximately 11:10 AM, the DON confirmed that the medications were not returned to pharmacy in a timely manner which could lead to a potential drug diversion.



 Plan of Correction - To be completed: 07/30/2024

1.All discontinued medication was either returned to Pharmacy or disposed of in the appropriate container.

2.Audit of all three medication rooms was conducted.

3.DON/ Designee will provide education to all Licensed personnel on the proper procedure of discontinued, expired, and change in dosage medication.

4.Audits to be done x4weeks then weekly x2months to ensure all discontinued , expired medications are disposed of in a timely manner .


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