Pennsylvania Department of Health
VALLEY VIEW HAVEN, INC.
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

There are 68 surveys for this facility. Please select a date to view the survey results.

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


VALLEY VIEW HAVEN, INC. - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:

Based on a Medicare/Medicaid Recertification Survey, State Licensure Survey, and Civil Rights Compliance survey completed on May 31, 2024, it was determined that Valley View Haven, Inc., was not in compliance with the following 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:

483.60(i)(1)(2) REQUIREMENT Food Procurement,Store/Prepare/Serve-Sanitary:

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

§483.60(i) Food safety requirements.
The facility must -

§483.60(i)(1) - Procure food from sources approved or considered satisfactory by federal, state or local authorities.
(i) This may include food items obtained directly from local producers, subject to applicable State and local laws or regulations.
(ii) This provision does not prohibit or prevent facilities from using produce grown in facility gardens, subject to compliance with applicable safe growing and food-handling practices.
(iii) This provision does not preclude residents from consuming foods not procured by the facility.

§483.60(i)(2) - Store, prepare, distribute and serve food in accordance with professional standards for food service safety.

Observations:

Based on observation and staff interview, it was determined the facility failed to store food and maintain food service/storage equipment in a sanitary manner in the facility's main kitchen and five of five open nursing units (unit 200, 400, 500, 600, 700).

Findings include:

An observation in the facility's main kitchen on May 28, 2024, at 10:00 AM with Employee 2, assistant director of nutrition services, revealed the following:

The wall area to the right of the dish machine contained significant dried food splatter from ceiling to floor, which extended to a door in the area and the wall past the door towards the kitchen preparation area.

The exterior of a large garbage can by the pot washing sink was covered with dried liquid spills and food.

Vents along the front of the hood unit above the cooking area were covered in dust.

A dolly by the food serving line stacked with racks of bowls and cups had a buildup of crumbs, dried food, and debris.

An observation of the nourishment area on the 400 unit on May 31, 2024, at 11:12 AM revealed a large brown water stain in the interior of the cabinet under the pipes of the sink, dried brown water stains were also present along a plastic tube extending across the interior of the cabinet. The interior of a drawer located beside the refrigerator with beverage mugs and thickening packets was significantly worn with the wipeable finish removed throughout most of the drawer exposing a paperboard surface with the potential to absorb liquid/contaminants. Another cabinet drawer located in the nourishment area contained several individual packs of peanut butter, two bags of ketchup packs, a bag of tartar sauce packets, and a bag of saltine cracker packets. There was no evidence of a date the packets were placed in the area or when they expired.

An observation of the 500-unit nourishment area on May 31, 2024, at 11:23 AM revealed a refrigerator/freezer in the nourishment room. The freezer had multiple ice cream cups in it also contained a folded towel on the lower shelf as several therapeutic ice packs. The bottom storage bins of the refrigerator contained dust, debris, and a dried brown substance covering the interior of one of the drawers. The wall beside and behind the trash receptacle located in the room contained dried liquid splatter, and large gauged areas of the drywall.

An observation of the 200-unit nourishment area on May 31, 2024, at 11:33 AM revealed a refrigerator/freezer unit in the room. Ice cream cups and bowls of ice cream were observed in the freezer. Multiple therapeutic ice packs were stored in the freezer with the ice cream.

An observation of the 600-unit kitchen area on May 31, 2024, at 11:39 AM revealed a small upright freezer unit in which multiple packs of meat were stored including a bag of beef patties and a pan of fish. A box of ice cream sandwiches was stored touching the bags of frozen meat products on the same shelf.

An observation of the 700-unit kitchen area at 11:46 AM on May 31, 2024, revealed a small upright freezer with multiple packs of frozen meat products, and a plastic bag with packs of ice cream bars was stored on the same shelf and packed in with the frozen meat products.

The above information was reviewed with the Director of Nursing on May 30, 2024, at 1:30 PM and May 31, 2024, at 12:00 PM.

483.60 (i)(2) Food storage safe and sanitary
Previously cited 6/9/23

28 Pa. Code 201.14(a) Responsibility of licensee

Plan of Correction - To be completed: 07/09/2024

The wall area to the right of the dish machine, large garbage can, vents along the front of the hood unit, dolly was cleaned.
The nourishment cabinets on 400 unit were cleaned/repaired as necessary.
The packets of peanut butter, ketchup packs, tartar sauce and saltine crackers were discarded.
The fridge on 500-unit nourishment room was cleaned and the therapeutic ice packs were removed from the freezer. The surrounding area was cleaned, and the gauged areas repaired.
The therapeutic ice packs were removed from the fridge in the 200-unit nourishment room.
The ice cream sandwich was discarded on the 600- and 700-unit kitchen area.
Condiment packets will be dated with the expiration date when issued from the kitchen.
Therapeutic ice packs will not stored with food.
Meat products will be stored separately.
Kitchen and neighborhood kitchens will be placed on a cleaning schedule.
Nutrition Services and Nursing Staff will be educated on the process changes.
Kitchen cleaning will be audited weekly for 4 weeks and then monthly to follow. Neighborhood nourishment rooms will be audited weekly for 4 weeks and then monthly to follow. Results of this audit will be reviewed by the Quality Assurance committee to evaluate the need for ongoing auditing or further education.

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 clinical record review, review of select facility policies and procedures, and staff interview, it was determined that the facility failed to respect a resident's privacy for one of 25 residents reviewed (Resident 11).

Findings include:

The policy entitled "Sound Monitoring," last reviewed without changes on May 22, 2024, revealed the facility may utilize a sound monitoring system in a resident's room to alert staff when a resident is attempting to rise without assistance. The sound monitoring system will only be used when other interventions have proven to be ineffective to prevent falls or injury. Permission for sound monitoring will be received from the resident or resident representative before sound monitoring is initiated. The consent will be documented in the resident's electronic medical record.

Observation of the 700-nursing unit on May 28, 2024, at 11:42 AM revealed there was an audio monitor in the nurses' station. Resident 61 was in her wheelchair in the nurses' station at this time. There was a male and female voice coming from the audio monitor. The female voice was discussing toileting needs with Resident 11.

Observation of the 700-nursing unit on May 29, 2024, at 9:12 and 11:07 AM revealed there were again voices on the audio monitor.

Clinical record review for Resident 11 revealed the facility admitted Resident 11 on August 11, 2022. Further review of Resident 11's clinical record revealed no consent for Resident 11's audio monitor.

A review of Resident 11's plan of care revealed the facility added a sound detection monitor to be utilized during sleeping hours to help alert the team when Resident 11 is rising on October 4, 2023.

Interview with the Nursing Home Administrator and Director of Nursing on May 29, 2024, at 2:04 PM revealed the facility utilizes audio monitors in resident rooms and confirmed there was no evidence in Resident 11's clinical record that the facility obtained permission for the audio monitor. The Director of Nursing confirmed Resident 11's audio monitor was only to be used during sleeping hours.

The facility failed to protect Resident 11's right to privacy.

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

Plan of Correction - To be completed: 07/09/2024

This Plan of Correction is submitted under Federal and state regulations and status applicable to long term care providers. This Plan of Correction does not constitute an admission of liability on the part of the facility and such liability is hereby denied. The submission of this Plan of Correction does not constitute agreement by the facility that the surveyor's findings or conclusions are accurate, that the findings constitute a deficiency, or that the scope and severity regarding any of the deficiencies are cited correctly. Please accept this plan as our credible allegation of compliance.
The interdisciplinary team reviewed the use of the personal sound monitor fir Resident 11 and determined that it is no longer effective as a fall prevention measure. The personal sound monitor has been discontinued.
Personal sound monitors are not used for any other resident.
The facility will no longer use personal sound monitors as a fall prevention method. Nursing staff will be educated on the change of process and maintaining resident privacy.
Risk management reports will be monitored to ensure that personal sound monitors is not used in violation of the resident's privacy. The reports will be monitored weekly for three months. Results of this audit will be reviewed by the Quality assurance committee to evaluate the need for ongoing auditing or further education.

483.25(n)(1)-(4) REQUIREMENT Bedrails:

§483.25(n) Bed Rails.
The facility must attempt to use appropriate alternatives prior to installing a side or bed rail. If a bed or side rail is used, the facility must ensure correct installation, use, and maintenance of bed rails, including but not limited to the following elements.

§483.25(n)(1) Assess the resident for risk of entrapment from bed rails prior to installation.

§483.25(n)(2) Review the risks and benefits of bed rails with the resident or resident representative and obtain informed consent prior to installation.

§483.25(n)(3) Ensure that the bed's dimensions are appropriate for the resident's size and weight.

§483.25(n)(4) Follow the manufacturers' recommendations and specifications for installing and maintaining bed rails.

Observations:

Based on observation, clinical record review, and staff interview, it was determined that the facility failed to assess for the risk of side rail entrapment for two of four residents reviewed for accident hazards (Residents 97 and 106).

Findings include:

A Test Results Worksheet (form the facility used to document the assessment of entrapment risk zones) revealed that the facility only assessed zones one (within the rail), two (between the bottom of the rail and top of compressed mattress), and three (between the edge of the mattress and inside of the rail). The assessment did not capture zone four (between the top of the compressed mattress and the bottom of the rail at the end of the rail, zone five (between the split [head and foot] bed rails), zone six (between the end of the rail and the side edge of the head or foot board), or zone seven (between head or foot board and end of mattress).

Observation of Resident 97's room on May 28, 2024, at 12:23 PM, and May 29, 2024, at 9:26 AM revealed that there were bilateral halo (circular) enabler bars observed on the bed.

Clinical record review for Resident 97 revealed a Test Results Worksheet dated April 30, 2024, that revealed the facility measured, assessed, and passed the halo enabler bars for zones one, two, and three. Staff who completed the form indicated "N/A" (not applicable) for zones four, six, and seven. Zone five will not apply to this resident as they did not have head and foot split bed rails.

Observation of Resident 106 on May 28, 2024, at 11:52 AM revealed that there was a halo enabler bar on the door side of the bed.

There was no documentation that indicated the facility assessed Resident 106's halo enabler bar for entrapment zones six or seven. Zone five will not apply to this resident as they did not have head and foot split bed rails.

The surveyor reviewed the above information during an interview with the Director of Nursing on May 30, 2024, at 2:25 PM.

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

Plan of Correction - To be completed: 07/09/2024

Residents 97 and 106 no longer reside in the facility. The facility cannot retroactively correct the Zone Entrapment evaluations for these Residents.
A Zone Entrapment evaluation will be completed for current residents with physician orders for enabler bars to ensure that all applicable entrapment zones are evaluated.
Maintenance staff will be re-educated on completion of the Zone Entrapment evaluations to ensure that all applicable areas of entrapment are evaluated.
Zone Entrapment evaluations will be randomly audited to ensure that the evaluation is completed and all applicable areas of entrapment are evaluated. This audit will be completed weekly for 4 weeks. Results of this audit will be reviewed by the Quality assurance committee to evaluate the need for ongoing auditing or further education.

483.25 REQUIREMENT Quality of Care:

§ 483.25 Quality of care
Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices.

Observations:

Based on clinical record review, observation, and staff interview, it was determined that the facility failed to provide the highest practicable care regarding physician ordered interventions and treatments for one of 25 residents (Resident 105).

Findings include:

Clinical record review for Resident 105 revealed a current physician order for staff to place a bilateral halo (circular) enabler bar on her bed.

Observation of Resident 105's bed on May 28, 2024, at 12:01 PM revealed that the bed did not have bilateral halo bars on it.

Clinical record review for Resident 105 revealed that she attended a podiatry appointment on April 24, 2024, for a right ankle fracture. Resident 105 was ordered a boot to the RLE (right lower extremity) as a result of the fracture. The podiatrist indicated to take the RLE boot off daily and wash the leg. When staff reapplied the RLE boot, they were to ensure that Resident 105 was wearing a sock, that the foot was flat in the boot, and the heel was in the back of the boot. Facility staff acknowledged the podiatrist's orders on April 24, 2024.

Review of Resident 105's physician orders and treatment and task documentation revealed no indication that staff were removing, washing, ensuring proper placement of the RLE boot, and reapplying daily after April 24, 2024, until identified by the surveyor.

The surveyor reviewed the above information during an interview on May 30, 2024, 1:02 PM with the Director of Nursing.

28 Pa. Code 211.10(c) Resident care policies

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

Plan of Correction - To be completed: 07/09/2024

Resident 105 was re-evaluated by therapy on 5/30/24 and it was determined that Resident 105 no longer required Halo bar enablers. The physician order for the Halo bars was discontinued. Tasks were entered into the medical record based on the podiatry recommendation on 5/29/24.
An audit of consultations from outside providers from the last 2 weeks will be reviewed to ensure that recommendations were addressed and entered into the resident's medical record as appropriate.
Residents with physician orders for enabler bars will be reviewed to ensure that the enablers were placed on the Resident's bed.
Nursing staff will be re-educated on addressing recommendations and entering those recommendations as per physician order.
Maintenance staff will be re-educated on the importance of placing enabler bars as directed.
An audit of recommendations for Residents will be completed to ensure that recommendations were addressed and entered into the medical record as appropriate. This audit will be completed for 3 months. An audit of new physician orders for enablers will be completed to ensure that the enablers have been placed on the resident's bed. Results of this audit will be reviewed by the Quality assurance committee to evaluate the need for ongoing auditing or further education.

483.20(g) REQUIREMENT Accuracy of Assessments:

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

Observations:

Based on clinical record review and staff interview, it was determined that the facility failed to ensure complete and accurate Minimum Data Set (MDS) assessments for one of 25 residents reviewed (Resident 37).

Findings include:

Review of Resident 37's clinical record revealed a Minimum Data Set Assessment (MDS, a form completed at specific intervals to determine care needs) dated February 21, 2024, and May 14, 2024, that indicated the facility assessed him an having an active pneumonia infection and a sepsis (a life-threatening condition when the body responds to an infection) diagnosis. Resident 37 had not had an active pneumonia infection and/or sepsis since December 16, 2023.

Interview with the Administrator on May 30, 2024, at 12:03 PM confirmed the above findings for Resident 37.

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

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

Plan of Correction - To be completed: 07/09/2024

MDSs date for February 21, 2024, and May 14, 2024, have been corrected and resubmitted.
MDSs completed in the last 2 weeks will be reviewed to ensure that diagnosis included are correct.
Assessment Coordinators will be educated on ensuring accuracy of MDS data prior to submission.
A random audit of 5 MDS submissions monthly will be completed to ensure accuracy of diagnosis entered. This audit will be completed for 3 months. Results of this audit will be reviewed by the Quality assurance committee to evaluate the need for ongoing auditing or further education.

483.15(d)(1)(2) REQUIREMENT Notice of Bed Hold Policy Before/Upon Trnsfr:

§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 clinical record review and staff interview, it was determined that the facility failed to ensure that the resident or resident representative received written notice of the facility bed hold policy at the time of transfer for three of five residents reviewed for hospitalizations (Residents 56, 97, and 105).

Findings include:

Clinical record review revealed that Resident 97 was transferred to the hospital on April 26, 2024, after they had a change in condition. There was no documentation available that the facility provided written notice regarding a bed hold to the resident and the resident's responsible party upon transfer out to the hospital.

Clinical record review revealed that Resident 105 was transferred to the hospital on April 2, 2024, and April 27, 2024, after they had a change in condition. There was no documentation available that the facility provided written notice regarding a bed hold to the resident's responsible party upon transfer out to the hospital.

The surveyor reviewed the above information for Residents 97 and 105 during an interview with the Director of Nursing on May 30, 2024, at 2:15 PM.

Clinical record review revealed that Resident 56 was transferred to the hospital on April 9, 2024, after he had a change in condition. There was no documentation available that the facility provided written notice regarding a bed hold to the resident and the resident's responsible party upon transfer out to the hospital.

The Nursing Home Administrator and Director of Nursing confirmed these findings for Resident 56 on May 30, 2024, at 11:17 AM.

28 Pa. Code 201.14(a) Responsibility of licensee

28 Pa. Code 201.29(f) Resident rights

Plan of Correction - To be completed: 07/09/2024

A copy of the Bedhold Notice for Resident 56, 97, and 105 will be mailed to the Resident or Resident Representative. A progress note will be entered into each resident's medical record stating that the Bedhold Notice was provided.
Bedhold Notices for residents transferred in the last 30 days will be resent to the Resident or Resident Representatives and a progress note entered stating that the notice was sent.
The medical secretary responsible the mailing of this notice will be educated on the change of process.
An audit of Residents transferred will be completed to ensure that there is documentation to support that the Bedhold Notice was provided in writing to the Resident or Resident Representative. This audit will be completed for 3 months. Results of this audit will be reviewed by the Quality assurance committee to evaluate the need for ongoing auditing or further education.

483.12(b)(1)-(5)(ii)(iii) REQUIREMENT Develop/Implement Abuse/Neglect Policies:

§483.12(b) The facility must develop and implement written policies and procedures that:

§483.12(b)(1) Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property,

§483.12(b)(2) Establish policies and procedures to investigate any such allegations, and

§483.12(b)(3) Include training as required at paragraph §483.95,

§483.12(b)(4) Establish coordination with the QAPI program required under §483.75.

§483.12(b)(5) Ensure reporting of crimes occurring in federally-funded long-term care facilities in accordance with section 1150B of the Act. The policies and procedures must include but are not limited to the following elements.

§483.12(b)(5)(ii) Posting a conspicuous notice of employee rights, as defined at section 1150B(d)(3) of the Act.

§483.12(b)(5)(iii) Prohibiting and preventing retaliation, as defined at section 1150B(d)(1) and (2) of the Act.

Observations:

Based on clinical record review, review of select policies and procedures, and staff interview, it was determined that the facility failed to implement their abuse policy regarding completion of a thorough investigation of missing medications for one of three residents reviewed (Resident 21).

Findings include:

The policy entitled "Abuse Prevention Program" reviewed on May 24, 2024, indicates that the facility will develop investigation protocols for misappropriation of property. This surveyor attempted multiple times to obtain further facility policies and/or procedures regarding the investigation protocols for misappropriate of medications without success.

The policy entitled "Medication Error Guidelines" reviewed on May 24, 2024, indicates that the facility will do a search for a missing medication. If the medication cannot be found, the responsible staff member may have to be suspended pending outcome of an investigation conducted by facility administration.

Review of Resident 21's clinical record revealed nursing documentation dated April 27, 2024, at 4:56 AM that Resident 21's narcotic count was "off." Resident 21's medication card was checked, and it was determined that one of her Phenobarbital (a medication used to treat seizures that has the potential for diversion due to its sedative and hypnotic properties) pills were missing and not signed out by the medication nurse. The documentation indicated that Employee 1, licensed practical nurse, did not know "what happened to the pill" and that it was unknown if she gave it to Resident 21 as an extra dose.

Review of the facility's investigation into Resident 21's missing Phenobarbital revealed that the facility only determined that Employee 1 must have given Resident 21 an extra dose (possibly) and did not investigate the missing medication thoroughly to determine if misappropriation took place.

The facility was not able to provide documented evidence that an investigation was initiated regarding Resident 21's missing phenobarbital, and its possible misappropriation. There were no witness statements from Employee 1, previous shift medication nurse, or the registered nurse supervisor on duty at the time of the findings.

Interview with the Director of Nursing on May 30, 2024, at 2:30 PM confirmed the above findings for Resident 21.

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

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

Plan of Correction - To be completed: 07/09/2024

Resident 21 suffered no ill effect from the missing phenobarbital. Statements will be obtained from Emploee1, the previous shift medication nurse and the RN supervisor on duty at the time the missing phenobarbital was reported by Employee 1.
Records for current residents ordered controlled substances will be reviewed to ensure that there is no discrepancy in the count of the medications. Any discrepancies noted will be thoroughly investigated.
The medication error investigation form will be revised to ensure that a more thorough investigation of controlled medications is conducted. The Medication Error Guidelines and the Abuse Prevention policies will be reviewed and revised accordingly.
Nursing staff will be educated on the change of process and policy.
All reports of missing controlled medications will be reviewed to ensure that a thorough investigation is completed to ensure that a misappropriation of resident property has not occurred. Results of this audit will be reviewed by the Quality assurance committee to evaluate the need for ongoing auditing or further education.

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 clinical record review and staff interview, it was determined that the facility failed to notify a resident and/or their responsible party in writing of a transfer to the hospital for three of five residents reviewed (Residents 56, 97, and 105).

Findings include:

Clinical record review for Resident 97 revealed that they were transferred to the hospital on April 26, 2024, after a change in their condition. There was no documentation that the facility provided written notification to the resident's responsible party regarding the transfer that included the required contents: reason for the transfer, effective date of the transfer, location to which the resident was transferred to, contact and address (mailing and email) information for the Office of the State Long-Term Care Ombudsman, and information (mailing and email address and telephone number) for the agency responsible for the protection and advocacy of individuals with developmental disabilities, and a statement of resident's appeal rights, including name, address (mailing and email) and telephone number of entity which receives requests.

Clinical record review for Resident 105 revealed that they were transferred to the hospital on April 2, 2024, and April 27, 2024, after there was a change in their condition. There was no documentation that the facility provided written notification to the resident, or their responsible party as required regarding the transfer that included the required contents listed above.

The surveyor reviewed the above information during an interview with the Director of Nursing on May 30, 2024, at 2:15 PM.

Clinical record review 56 revealed that they transferred him to the hospital from April 9 to 11, 2024, after a change in his condition. There was no evidence to indicate that Resident 56's responsible party was provided written notification that included the above required contents.

The Nursing Home Administrator and Director of Nursing confirmed these findings for Resident 56 regarding transfer notices on May 30, 2024, at 11:17 AM.

483.15(c)(3)-(6)(8) Notice Requirements Before Transfer/discharge
Previously cited 6/9/23.

28 Pa. Code 201.14 (a) Responsibility of license

28 Pa. Code 201.29(a) Resident rights

Plan of Correction - To be completed: 07/09/2024

A copy of the Transfer Notice for Resident 56, 97, and 105 will be mailed to the Resident or Resident Representative. A progress note will be entered into each resident's medical record stating that the Transfer Notice was provided.
Transfer Notices for residents transferred in the last 30 days will be resent to the Resident or Resident Representatives and a progress note entered stating that the notice was sent.
The medical secretary responsible the mailing of this notice will be educated on the change of process.
An audit of Residents transferred or discharged will be completed to ensure that there is documentation to support that the Transfer Notice was provided in writing to the Resident or Resident Representative. This audit will be completed for 3 months. Results of this audit will be reviewed by the Quality assurance committee to evaluate the need for ongoing auditing or further education.

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