Pennsylvania Department of Health
WARREN MANOR
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

WARREN MANOR
Inspection Results For:

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WARREN MANOR - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:

Based on a Medicare/Medicaid Recertification, State Licensure, and Civil Rights Compliance Survey, and an Abbreviated Complaint Survey completed on April 4, 2025, it was determined that Warren Manor was not in compliance with the following requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care Facilities and the 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.

Plan of Correction:

483.25 REQUIREMENT Quality of Care:

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 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 review of clinical records, observations, and staff interviews, it was determined that the facility failed to follow physician's orders for four of 26 residents reviewed (Residents R1, R68, CR109, and R3).

Findings include:

No policy was provided regarding following a physician's order.

Resident's R1's clinical record revealed an admission date of 10/05/16, with diagnoses that included neurologic neglect syndrome (a neurological disorder that makes a person lack awareness to stimuli on one side of the body or space), diabetes mellitus (a disease that affects how blood sugar is regulated in the blood), asthma (a chronic condition in which a person's airways become inflamed making it difficult to breathe), and weakness.

Resident R1's clinical record revealed a physician's order dated 3/20/25, "reposition every two hours offload coccyx."

Observations on 4/02/25, at 8:50 a.m., 9:30 a.m., 10:30 a.m., 11:00 a.m., 11:30 a.m., 12:05 p.m., and 12:40 p.m. revealed Resident R1 out of bed in his/her wheelchair sitting upright. A further observation at 12:58 p.m. revealed Resident R1 laying in bed.

During an interview with Nurse Aide (NA) Employee E7 on 4/02/25, at 12:58 p.m. revealed that Resident R1 was out of bed to his/her wheelchair before 9:00 a.m. on 4/02/25, and not repositioned until he/she was laid down in bed after lunch at approximately 12:50 p.m. by NA Employee E7.

An interview with Licensed Practical Nurse (LPN) Employee E8 on 4/02/25, at 1:00 p.m. confirmed that Resident R1 was out of bed and sitting in his/her wheelchair before 9:00 a.m. and not turned/repositioned until after lunch, a time span of approximately four hours. LPN Employee E8 further confirmed that Resident R1 has a history of a Stage Three (full thickness loss of skin) pressure injury to his coccyx (tailbone), and there were physician's orders to reposition every two hours and offload coccyx.

During an interview on 4/0/25, at 12:57 p.m. the Director of Nursing (DON) confirmed Resident R1 has a history of a Stage Three pressure injury to his coccyx and should be repositioned every two hours per the physician's order dated 3/20/25.

Review of Resident R3's clinical record revealed an admission date of 2/23/22, with diagnoses including broken left hip, spinal stenosis with disc degeneration (narrowing of the space that houses the spinal cord and nerve roots leading to the spinal disks between the vertebrae to wear down), and difficulty walking. The clinical record also revealed a physician's order dated 3/19/25, for "no weight bearing on left leg."

Observation on 4/02/25, at 1:38 p.m. revealed NA Employee E7 transfer Resident R3 into bed and permitted weight bearing to his/her left leg during the transfer.

During an interview on 4/02/25, at 2:13 p.m. NA Employee E7 confirmed that he/she transfers Resident R3 using a "bear hug" and pivot and turn into bed.

Observation on 4/03/25, at 1:05 p.m. revealed that NA Employee E8 assisted Resident R3 to stand from the toilet to the grab bar in the bathroom and adjusted Resident R3's clothing while he/she held onto the bar and permitted weight bearing to his/her left leg during the transfer.

During an interview at that time, NA Employee E8 confirmed that Resident R3 stands and holds onto the bar while transferring from the toilet.

During an interview on 4/03/25, a 3:40 p.m. the Director of Nursing confirmed that Resident R3's current transfer order is "no weight bearing on left leg" and that staff should maintain non-weight bearing until the order is updated.

Resident's R68's clinical record revealed an admission date of 10/20/23, with diagnoses that included morbid (severe) obesity due to excess calories, urinary tract infection, hypokalemia (low potassium in the blood), and hypothyroidism (a condition where the thyroid does not produce enough thyroid hormone).

Resident R68's clinical record revealed a physician's order dated 10/18/24, "BI-PaP at hours of sleep with 4 l/min [liters per minute] oxygen piped in to equal FIO2 of 35% pre set Settings of V=60, Max IPAP=18, EPAP=9 Make Nasal Mask Type." (BiPAP is a non-invasive ventilation therapy that helps a person breathe by delivering pressurized air through a mask).

An interview with Resident R68 on 4/02/25, at 12:30 p.m. revealed that Resident R68 has been without his/her BIPAP for several months. Observations during the interview, revealed Resident R68 laying in bed and no BIPAP machine located in his/her room.

During an interview with LPN Employee E10 on 4/03/25, at 12:00 p.m. confirmed that Resident R68 did not have a BIPAP machine to utilize per the physician order.

During an interview on 4/04/25, at 11:45 a.m. the DON confirmed Resident R68's physician's order dated 10/18/24, was not followed for the resident to utilize a BIPAP at hours of sleep.

Resident CR109's clinical record revealed an admission date of 12/09/24, with diagnoses that included osteomyelitis (inflammation of bone caused by infection) of left ankle and foot, anemia (a condition where the blood does not have enough healthy red blood cells to carry oxygen throughout the body), metabolic encephalopathy (a condition where the brain's function is impaired due to an imbalance in chemicals in the brain affecting cognitive function, consciousness, and behavior), and chronic atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow throughout the heart and body).

Resident CR109's clinical record revealed a physician's order dated 1/10/25, "Active Critical Care two times a day for wound healing 30 ml [milliliters]."

Resident CR109's Medication Administration Record (MAR) dated 1/10/25, lacked evidence of amount of Active Critical Care administered to Resident CR109 on:

1/10/25, 8:00 a.m. and 8:00 p.m.
1/11/25, 8:00 a.m.
1/12/25, 8:00 a.m. and 8:00 p.m.
1/13/25, 8:00 a.m. and 8:00 p.m.
1/14/25, 8:00 a.m. and 8:00 p.m.
and lacked evidence that Active Critical Care was administered on:
1/11/25, at 8:00 p.m. with documentation noted as "HN=Hold/See Nurse Notes" with nurse documentation "needs clarification on amount"
1/17/25, 8:00 p.m. with documentation noted as "HN=Hold/See Nurse Notes" with no evidence of a nurse's documentation in progress notes.

During an interview on 4/04/25, at 11:45 a.m. the DON confirmed Resident R109's physician's order dated 1/10/25, was not followed for the resident to have Active Critical Care 30 ml two times a day for wound healing.

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

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

Plan of Correction - To be completed: 05/30/2025

The four identified resident charts (R1, R3, R68, and CR109) were reviewed. The physician orders were verified for appropriateness and accuracy and updated as deemed necessary in relation to the resident's current condition/status, with the exception of CR109 who is no longer in the building. Facility is ordering new bipap machine for R68
A whole house audit of resident's charts to be completed to review physician orders and follow through of said orders.
The director of nursing or designee will educate the nursing staff by 5/10/25 on reviewing resident's orders and care plans for accuracy.
The director of nursing or designee will review resident's orders and care plans for 10 residents weekly ongoing.
Audit findings will be reviewed through the Quality assurance performance improvement meetings.

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

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

Observations:

Based on review of clinical records, observations, and staff interview, it was determined that the facility failed to promote cleanliness and help prevent the spread of infection regarding respiratory care equipment for three of three residents and failed to provide oxygen according to physician's orders for one of three residents reviewed for respiratory services (Residents R16, R93 and R95).

Findings include:

Review of Resident R16's clinical record revealed an admission date of 8/11/23, with diagnoses that included hypertension (high blood pressure), anxiety (a condition that causes a person to be nervous, uneasy, or worried about something or someone), and hypothyroidism (a condition when the thyroid produces low amounts of thyroid hormones).

Review of Resident R16's physician's orders revealed an order dated 8/11/23, to apply oxygen 1-2 lpm (liters per minute) per nasal cannula (oxygen tubing that has prongs that go into the nostrils and loops around the ears to secure in place to ensure adequate oxygen delivery) continuously to maintain oxygen saturation at or greater than 88%-92%, and an order dated 8/11/23, for Oxygen Maintenance Change O2 [oxygen] tubing and supply bag weekly, Wipe down concentrator and clean filter weekly, Change water jug weekly.

Review of Resident R16's care plan revealed a plan of care with the focus of being at risk for impaired gas exchange and an intervention to administer O2 as ordered dated 3/4/24.

Observations on 4/1/25, at 1:00 p.m. revealed an oxygen concentrator with a large amount of a white fluffy substance covering the top and the back of the concentrator. Observations on 4/2/25, at 9:00 a.m., 10:00 a.m. and 10: 22 a.m. revealed that oxygen was not being administered to Resident R16 and his/her nasal cannula was laying on the floor. Further observations revealed the large amount of a white fluffy substance covering the top and back of the oxygen concentrator remained.

Review of Resident R93's clinical record revealed an admission date of 12/10/24, with diagnoses that included chronic obstructive pulmonary disease (COPD-when your lungs do not have adequate air flow), anxiety, and hyperlipidemia (high cholesterol).

Review of Resident R93's physician's orders revealed an order dated 12/6/24, for Oxygen Maintenance Change O2 tubing and supply bag weekly, Wipe down concentrator and clean filter weekly, Change water jug weekly.

Observation on 4/1/25, at 1:05 p.m. revealed an oxygen concentrator with a large amount of a fluffy white substance covering the top and back of the concentrator and drops of a dried liquid substance on the top of the concentrator. Observations on 4/2/25, at 9:05 a.m., 10:05 a.m. and 10:22 a.m. revealed the large amount of white fluffy substance and drops of dried liquid substance remained on the oxygen concentrator.

Resident R95's clinical record revealed an admission date of 12/23/24, with diagnoses that included acute and chronic respiratory failure (a condition where your lungs don't exchange air properly), COPD, and hypertension.

Review of Resident R95's physician's orders revealed an order for Oxygen Maintenance Change O2 tubing and supply bag weekly, Wipe down concentrator and clean filter weekly, Change water jug weekly 12/6/24.

Observation on 4/1/25, at 1:05 p.m. revealed an oxygen concentrator with a large amount of a fluffy white substance covering the top and back of the concentrator and drops of a dried liquid substance on the top of the concentrator. Observations on 4/2/25, at 9:05 a.m., 10:05 a.m. and 10:22 a.m. revealed the large amount of white fluffy substance and drops of dried liquid substance remained on the oxygen concentrator.

During an interview on 4/2/25, at 10:22 a.m. Licensed Practical Nurse (LPN) Employee E1 confirmed that Resident R16 was not wearing his/her oxygen, and his/her nasal cannula was laying on the floor. LPN Employee E1 confirmed that there was a large amount of a white fluffy substance and a dried liquid substance on the oxygen concentrators. LPN Employee E1 confirmed that the oxygen concentrators should be clean and Resident R16 should have had his/her oxygen being administered per physician's order and that his/her nasal cannula should not be on the floor.

28 Pa. Code 211.10(c) Resident care policies

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

Plan of Correction - To be completed: 05/30/2025

The three identified resident charts (R16, R93, and R95) were reviewed for identified Oxygen maintenance physician orders. The identified O2 concentrators were wiped down and cleansed. Resident R16 had O2 tubing replaced.
A whole house audit of O2 concentrators was conducted and all concentrators were wiped down, cleansed, and O2 tubing was not on the floor.
The environmental services supervisor or designee will educate the housekeeping department by 5/10/25 that during daily rooms cleaning the O2 concentrators will be wiped down and cleansed.
Staff development coordinator or designee will educate nursing staff on O2 tubing not being left on the floor by 5/10/25.
The Environmental Supervisor or designee will conduct an audit on all residents with O2 for cleanliness and tubing placement 3x's a week for one week, weekly for one month, and monthly thereafter.
Audit findings will be reviewed through the Quality assurance performance improvement meetings.

483.10(f)(1)-(3)(8) REQUIREMENT Self-Determination:

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(f) Self-determination.
The resident has the right to and the facility must promote and facilitate resident self-determination through support of resident choice, including but not limited to the rights specified in paragraphs (f)(1) through (11) of this section.

§483.10(f)(1) The resident has a right to choose activities, schedules (including sleeping and waking times), health care and providers of health care services consistent with his or her interests, assessments, and plan of care and other applicable provisions of this part.

§483.10(f)(2) The resident has a right to make choices about aspects of his or her life in the facility that are significant to the resident.

§483.10(f)(3) The resident has a right to interact with members of the community and participate in community activities both inside and outside the facility.

§483.10(f)(8) The resident has a right to participate in other activities, including social, religious, and community activities that do not interfere with the rights of other residents in the facility.

Observations:

Based on review of clinical and facility records, resident and staff interviews, and observations, it was determined that the facility failed to provide a bath/shower as resident preference for one of 26 residents reviewed (Resident R68).

Findings include:

A facility policy entitled, "Quality of Care Policy/Activities of Daily Living," dated 12/04/24, revealed each resident will receive and the Manor will provide the necessary care and services to attain or maintain the highest practicable physical, mental and psychosocial well-being in accordance with the comprehensive assessment and plan of care. Activities of Daily Living - A resident's abilities in activies of daily living will not diminish unless cirmcumstances of the individuals's clinical condition demonstrate that diminution (the act was unavoidable). A resident who is unable to carryout activites of daily living receives the necessary services to maintain good nutrition, grooming, personal and oral hygiene.

Resident's R68's clinical record revealed an admission date of 10/20/23, with diagnoses that included morbid (severe) obesity due to excess calories, urinary tract infection, hypokalemia (low potassium in the blood), and hypothyroidism (a condition where the thyroid does not produce enough thyroid hormone).

Review of Resident R68's bath/shower documentation for 3/06/25, through, 4/02/25, revealed he/she was scheduled for a bath/shower on Wednesday/Saturday 3-11 p.m., however, his/her clincial record lacked evidence that a bath/shower was provided on:
3/10/25, documented as "not applicable"
3/20/25, documented as "not applicable"
3/24/24, documented as "not applicable"
3/27/25, documented as "not applicable"
3/31/25, documented as "not applicable"

An interview with Resident R68 on 4/02/25, at 12:30 p.m. revealed his/her shower was scheduled for Monday and Thursday, but he/she has not received the scheduled shower in the past several weeks. While grabbing his/her hair, Resident R68 stated, "Look, my hair is really greasy and full of knots in the back."

An observation on 4/02/25, at 12:30 p.m. revealed Resident R68 laying in bed with greasy, knotted hair.

An interview with the Director of Nursing on 4/04/25, at 11:45 a.m. confirmed that baths/showers were not provided according to Resident R68's scheduled days and preference for the period of 3/06/25, through 4/02/25.

28 Pa. Code 211.10 (d) Resident care policies

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

Plan of Correction - To be completed: 05/30/2025

The one identified resident(R68) received shower and chart was reviewed and the shower schedule corrected to reflect the correct shower schedule.
A house wide audit was conducted to verify accuracy of shower documentation. Resident interviews conducted as well.
Director of nursing/designee will educate nursing staff on accurate documentation of resident showers, this included Nursing assistant notification to licensed nurses so appropriate follow-up can be completed 5/10/25. Additionally, education will include the elimination of utilizing Not Applicable for documentation purposes.
The director of nursing or designee will audit daily the point of care alerts of shower documentation 5xs week for one week, 2x a week for month, and monthly thereafter and address any inconsistencies with the nursing staff as needed to ensure residents are receiving being offered a shower twice a week.
Audit findings will be reviewed through the Quality assurance performance improvement meetings.

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

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

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

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

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

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

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

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

Observations:

Based on observations, review of manufacturer's guidelines and facility documents, and staff interviews, it was determined that the facility failed to properly clean and prevent the potential for cross contamination during the use of a blood glucose meter (BGM-a device to collect and measure the level of glucose [sugar] in the blood) for two of nine residents observed during the administration of medications (Residents R17 and R65).

Findings include:

Review of manufacturer's cleaning and disinfecting procedures indicated that the BGM should be cleaned and disinfected after use on each patient.

Review of a facility skills demonstration/evaluation form for Blood Glucose Testing revealed that staff are instructed to disinfect the BGM per manufacturer's guidelines after completion of sample testing.

Observation of blood glucose monitoring for Resident R51 on 4/01/25, at 3:27 p.m. revealed that Licensed Practical Nurse (LPN) Employee E9 entered Resident R51's room, obtained the blood specimen using the BGM, then exited Resident R51's room and laid the soiled BGM on the top of the medication cart and failed to clean the BGM per manufacturer's guidelines. It was unable to be determined if the the BGM was cleaned prior to/after use for blood glucose monitoring for Resident R51.

Observation of blood glucose monitoring for Resident R65 on 4/01/25, at 3:39 p.m. revealed that LPN Employee E9 entered Resident R65's room, obtained the blood specimen using the BGM, then exited Resident R65's room and laid the soiled BGM on the top of the medication cart and failed to clean the BGM per manufacturer's guidelines.

Observation of blood glucose monitoring for Resident R17 on 4/01/25, at 4:07 p.m. revealed that LPN Employee E9 entered Resident R17's room, obtained the blood specimen using the BGM, then exited Resident R17's room and laid the soiled BGM on the top of the medication cart and failed to clean the BGM per manufacturer's guidelines.

During an interview on 4/01/25, at 4:10 p.m. LPN Employee E9 confirmed that he/she failed to clean the BGM unit prior to obtaining blood specimens from Residents R65 and R17.

During an interview on 4/02/25, at 12:49 p.m. Infection Control/Infection Preventionist Employee E6 confirmed that the BGM unit should have been cleaned and disinfected after use on each patient.

28 Pa. Code 211.12(d)(1)(2)(5) Nursing services

Plan of Correction - To be completed: 05/30/2025

The identified employee E9 immediately was educated by the director of nursing on cleaning the Blood Glucose Monitor per the manufacturer's guidelines.
No adverse affects were noted to identified residents R17 or R65.
All license nursing staff will be educated by the director of nursing or designee on proper cleaning of the Blood Glucose Monitor per the manufacturer's guidelines by 5/10/25.
The Infection Prevention Nurse or designee will audit licensed nurses on all shifts for infection control procedures related to cleaning of the Blood Glucose Moitor per the manufacturer's guidelines 3x's a week for one week, weekly for one month, and monthly thereafter.
All findings to be discussed at Quality Assurance Process Improvement Plan.

483.70(a)-(c) REQUIREMENT License/Comply w/ Fed/State/Locl Law/Prof Std:

§483.70(a) Licensure.
A facility must be licensed under applicable State and local law.

§483.70(b) Compliance with Federal, State, and Local Laws and Professional Standards.
The facility must operate and provide services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards and principles that apply to professionals providing services in such a facility.

§483.70(c) Relationship to Other HHS Regulations.
In addition to compliance with the regulations set forth in this subpart, facilities are obliged to meet the applicable provisions of other HHS regulations, including but not limited to those pertaining to nondiscrimination on the basis of race, color, or national origin (45 CFR part 80); nondiscrimination on the basis of disability (45 CFR part 84); nondiscrimination on the basis of age (45 CFR part 91); nondiscrimination on the basis of race, color, national origin, sex, age, or disability (45 CFR part 92); protection of human subjects of research (45 CFR part 46); and fraud and abuse (42 CFR part 455) and protection of individually identifiable health information (45 CFR parts 160 and 164). Violations of such other provisions may result in a finding of non-compliance with this paragraph.

Observations:

Based on review of clinical and facility records, and staff interviews, it was determined the facility failed to follow professional standards by ensuring accurate accounts in communication and writing for insurance coverage for resident services for one of 26 residents reviewed (Resident CR109).

Findings include:

Resident CR109's clinical record revealed an admission date of 12/09/24, and discharge date of 1/24/25, with diagnoses that included osteomyelitis (inflammation of bone caused by infection) of left ankle and foot, anemia (a condition where the blood does not have enough healthy red blood cells to carry oxygen throughout the body), metabolic encephalopathy (a condition where the brain's function is impaired due to an imbalance in chemicals in the brain affecting cognitive function, consciousness, and behavior), and chronic atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow throughout the heart and body.

A facility invoice dated 3/17/25, revealed a balance due of $13,939.05 for Resident CR109's stay/services from 12/09/24, through 1/24/25.

An interview with the Business Office Manager (BOM) Employee E5 on 4/03/25, at 2:15 p.m. revealed that he/she communicated to Resident CR109's resident representative on 12/23/24, that Resident CR109 had Medicare days available to cover days of stay/services at the facility, indicating the stay at the facility would be covered by his/her insurance, and that Resident CR109 and/or their responsible party would not be responsible to pay privately. The BOM Employee E5 further confirmed that on 1/28/25, he/she later discovered that Resident CR109 had exhausted his/her Medicare insurance benefits, and Resident CR109 would be financially responsible as private pay for the days of stay/services from 12/09/24, through 1/24/25. The BOM Employee E5 indicated "that it is sometimes confusing how insurance and Medicare coverage plays catch up," and referenced the January 2025 billing cycle that Resident CR109 would be financially responsible as private pay since no Medicare days were available to cover days of stay.

This failure to follow professional standards and adherence to thorough principles of communication resulted in Resident CR109/their resident representative not having an opportunity to make an adequate informed decision to continue Resident CR109's stay at the facility, or have the choice to be discharged to alternative home care services and other financial options.

28 Pa. Code 201.18(g) Management

Plan of Correction - To be completed: 05/30/2025

Resident CR109 no longer resides at the facility and is deceased. The Facility will offer to contact the executor of the resident's estate to for further discussions regarding the outstanding bill.
All new admissions and return admissions benefit eligibility and qualifying stay information will be ran prior to admission to provide them with the most accurate Medicare days available.
House wide audit completed of all resident's in a Medicare stay to verify all responsible parties are aware of Medicare days available, if applicable.
Nursing Home Administrator will educate Business Office Manager (E5) by 5/10/25 on the need to advise residents on admission and readmission whether Medicare days are available, if applicable and to advise new admissions and readmissions that if Medicare information is not up to date at the time of admission, it is possible that this may impact the days available and the need to pay privately. This may occur if a resident is at another facility and that facility does not bill in a timely manner. Those days would not reflect on benefit eligibility as days used. Business Office Manager will also be educated to document in the EHR conversations regarding Medicare days/coverage.
Nursing home administrator or designee to audit new admission and readmission charts for documentation regarding Medicare days available/coverage 3x's for one week, weekly for one month and monthly for two months.
Findings to be discussed at Quality Assurance Performance Improvement meeting, which will follow up as needed.

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

§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 review of a facility policy, observations, and staff interview, it was determined that the facility failed to ensure that food was stored in accordance with standards for food safety in one of one walk-in coolers reviewed in the kitchen.

Findings include:

Review of facility policy entitled "Storage of Perishable Foods" dated 12/4/24, indicated "Prepared or leftover foods should be stored tightly covered, clearly labeled, dated, and used within 3 days or discarded."

Observation during kitchen tour on 4/1/25, at 12:00 p.m. revealed a clear plastic container containing five leftover potato triangles (hashbrowns) with a prepared date of 3/28/25, and no discard date.

During an interview with the Dietary Manager Employee E3 on 4/1/25, during the time of observations he/she confirmed that the clear plastic container containing five leftover potato triangles were beyond their use by date. He/she also confirmed that the potato triangles should have been discarded by their use by date.

28 Pa. Code 201.14(a) Responsibility of licensee

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

Plan of Correction - To be completed: 05/30/2025

Removed identified item from kitchen area Immediately.
Whole house audit completed of kitchen area for any outdated food/perishable items.
Nutrition Services Supervisor will educate dietary staff on storage of perishable foods policy by 5/10/25.
Nutrition services supervisor or designee to audit kitchen area for perishable food items 5xs week for one week, 2x a week for month, and monthly thereafter.
Audit findings will be reviewed through the Quality assurance performance improvement meetings.

483.25(d)(1)(2) REQUIREMENT Free of Accident Hazards/Supervision/Devices:

§483.25(d) Accidents.
The facility must ensure that -
§483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and

§483.25(d)(2)Each resident receives adequate supervision and assistance devices to prevent accidents.

Plan of Correction - To be completed: 05/30/2025

Removed all vaping devices from Identified Resident (R42). Educated resident on smoking policy and safety of facility. Provided resident with a 30 day discharge for refusing to adhere to facility policies.
Whole house audit of smokers/vapers to educate and review policy, safety and remove any devices if found.
Smoking/vaping policy will be reviewed with all new admissions and current residents during care plans.
Director of Nursing will educate staff on smoking/vaping and facility safety by 5/10/25.
Resident council will be held on 4/29/25 to discuss smoking and vaping policy and facility safety.
Nursing home administrator/Designee will audit smokers/vapers for safety risks and smoking products in rooms 5x a week for one week, 2x a week one month and monthly thereafter.
Findings to be discussed at Quality assurance performance improvement meeting.

483.21(b)(2)(i)-(iii) REQUIREMENT Care Plan Timing and Revision:

§483.21(b) Comprehensive Care Plans
§483.21(b)(2) A comprehensive care plan must be-
(i) Developed within 7 days after completion of the comprehensive assessment.
(ii) Prepared by an interdisciplinary team, that includes but is not limited to--
(A) The attending physician.
(B) A registered nurse with responsibility for the resident.
(C) A nurse aide with responsibility for the resident.
(D) A member of food and nutrition services staff.
(E) To the extent practicable, the participation of the resident and the resident's representative(s). An explanation must be included in a resident's medical record if the participation of the resident and their resident representative is determined not practicable for the development of the resident's care plan.
(F) Other appropriate staff or professionals in disciplines as determined by the resident's needs or as requested by the resident.
(iii)Reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments.

Observations:

Based on review of clinical records and facility policy and staff interview, it was determined that the facility failed to show evidence of having resident care plan conference meetings or invitation to care plan meetings and failed to revise comprehensive care plans to reflect the current necessary care and services for two of 26 residents reviewed (Residents R3 and R93)

Findings include:

Review of facility policy entitled "Comprehensive Care Plan" dated 12/04/24, indicated "Residents will have the opportunity to discuss their goals for care ..." and "Periodically reviewed and revised by a team of qualified persons after each assessment."

Review of Resident R3's clinical record revealed an admission date of 2/23/22, with diagnoses including broken left hip, spinal stenosis with disc degeneration (narrowing of the space that houses the spinal cord and nerve roots leading to the spinal disks between the vertebrae to wear down), and difficulty walking.

Further review of Resident R3's clinical record revealed a physician's order dated 3/19/25, for "no weight bearing on left leg." A care plan entitled "Self-Care Deficit" dated 3/01/22, and updated 2/18/25, revealed to transfer with extensive assistance and a rolled walker. A care plan entitled "At Risk for Falls" dated 3/01/22, revealed it was updated 8/13/24, to include "to walk three to six days per week (supervised by staff) with a wheeled walker."

Resident R3's clinical record lacked evidence that his/her care plan was updated to reflect the non-weight bearing status of the left leg.

During an interview on 4/03/25, at 3:40 p.m. the Director of Nursing confirmed that Resident R3's care plan was not updated to reflect his/her current status.

Review of Resident R93's clinical record revealed an admission date of 12/10/24, with diagnoses that included chronic obstructive pulmonary disease (condition when your lungs do not have adequate air flow), anxiety (a condition that causes a person to be nervous, uneasy, or worried about something or someone), and hyperlipidemia (high cholesterol).

Review of Resident R93's clinical record lacked evidence that he/she and/or resident representative had been invited/attended a care plan conference meeting.

During an interview on 4/01/25, at 1:40 p.m. Resident R93 disclosed that he/she had not attended and/or been invited to a care plan conference meeting.

During an interview on 4/03/25, at 12:25 p.m. the Social Service Manager Employee E2 confirmed there was no evidence that Resident R93 and/or his/her representative had attended and/or had been invited to a care plan conference meeting after his/her last assessment dated 3/14/25.

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

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: 05/30/2025

Identified resident care plans R3 was immediately reviewed and updated to reflect current care plans. Identified resident R93 had care plan meeting with family in attendance.
A house wide audit of care plans will be completed to verify accuracy of the current care plan, ensuring all target dates are compliant including invitations sent and meetings held.
Social services will verify care plan schedule and send invites to attendees/families.
Interdisciplinary team will be educated by the Director of Nursing on 5/9/2025 on the importance of care plan timing, revisions and meetings held.
The Director of Nursing or designee will audit 5 resident care plans for accuracy, invitations and meetings being held for 2x's a week and 5 resident care plans weekly for one month to ensure accuracy of care plan invites, timing and revisions.
Findings will be discussed at Quality assurance performance improvement meetings.

483.10(f)(10)(iii) REQUIREMENT Accounting and Records of Personal Funds:

§483.10(f)(10)(iii) Accounting and Records.
(A) The facility must establish and maintain a system that assures a full and complete and separate accounting, according to generally accepted accounting principles, of each resident's personal funds entrusted to the facility on the resident's behalf.
(B) The system must preclude any commingling of resident funds with facility funds or with the funds of any person other than another resident.
(C)The individual financial record must be available to the resident through quarterly statements and upon request.

Observations:

Based on review of facility policy and documents, and resident and staff interviews, it was determined that the facility failed to ensure that resident financial records were made available through quarterly statements for one of 26 residents reviewed (Resident R68).

Findings include:

A facility policy entitled "Resident Personal Funds (Pennsylvania)" dated 12/04/24, revealed the resident understands that they have the right to maintain personal money in the Manor while they are a resident. They also understand that in the event that they become eligible for Medicaid, they will receive a personal needs allowance that they may use as they wish. Quarterly accountings - They also understand that they will receive a quarterly accounting of deposits, interest earned, and withdrawals made from their account.

Resident's R68's clinical record revealed an admission date of 10/20/23, with diagnoses that included morbid (severe) obesity due to excess calories, urinary tract infection, hypokalemia (low potassium in the blood), and hypothyroidism (a condition where the thyroid does not produce enough thyroid hormone).

Facility documentation indicated that the facility was responsible for handling Resident R68's finances through a resident trust fund account which had a balance of $1.74 on 3/07/25.

During an interview on 4/02/25, at 12:30 p.m. Resident R68 indicated that he/she has not received any financial statements regarding his/her funds, and that he/she should have a monthly allowance to use as he/she wishes.

During an interview on 4/03/25, at 2:15 p.m. the Business Office Manager Employee E5 indicated that he/she has not provided quarterly financial statements at the end of the quarter, or within 30-days of the end of the quarter. He/she further confirmed the facility lacked evidence that Resident R68 was provided financial statements including deposits, interest earned, and withdrawals made from his/her account.

28 Pa. Code 201.14(a) Responsibility of licensee

28 Pa. Code 201.18(b)(2) Management

Plan of Correction - To be completed: 05/30/2025

Identified resident (R68) provided statement.
First quarter statements will be sent to all residents by 4/31/25.
A 30 day look back will be conducted to ensure that all other residents have been provided appropriate statements.
Nursing Home Administrator will educate the Business Office Manager on resident financial statements and facility procedures by 4/21/25.
Nursing home administrator or designee will audit the most recent quarter resident financial statements and every quarter thereafter.
Findings to be discussed at Quality Assurance performance improvement meeting.

483.10(g)(17)(18)(i)-(v) REQUIREMENT Medicaid/Medicare Coverage/Liability Notice:

§483.10(g)(17) The facility must--
(i) Inform each Medicaid-eligible resident, in writing, at the time of admission to the nursing facility and when the resident becomes eligible for Medicaid of-
(A) The items and services that are included in nursing facility services under the State plan and for which the resident may not be charged;
(B) Those other items and services that the facility offers and for which the resident may be charged, and the amount of charges for those services; and
(ii) Inform each Medicaid-eligible resident when changes are made to the items and services specified in §483.10(g)(17)(i)(A) and (B) of this section.

§483.10(g)(18) The facility must inform each resident before, or at the time of admission, and periodically during the resident's stay, of services available in the facility and of charges for those services, including any charges for services not covered under Medicare/ Medicaid or by the facility's per diem rate.
(i) Where changes in coverage are made to items and services covered by Medicare and/or by the Medicaid State plan, the facility must provide notice to residents of the change as soon as is reasonably possible.
(ii) Where changes are made to charges for other items and services that the facility offers, the facility must inform the resident in writing at least 60 days prior to implementation of the change.
(iii) If a resident dies or is hospitalized or is transferred and does not return to the facility, the facility must refund to the resident, resident representative, or estate, as applicable, any deposit or charges already paid, less the facility's per diem rate, for the days the resident actually resided or reserved or retained a bed in the facility, regardless of any minimum stay or discharge notice requirements.
(iv) The facility must refund to the resident or resident representative any and all refunds due the resident within 30 days from the resident's date of discharge from the facility.
(v) The terms of an admission contract by or on behalf of an individual seeking admission to the facility must not conflict with the requirements of these regulations.

Observations:

Based on review of facility documentation and staff interview, it was determined that the facility failed to provide the required notice to the resident, or the resident's representative, following the end of Medicare covered services for one of two residents reviewed who remained in the facility for long-term care (Resident R166).

Findings include:

Review of Resident R166's clinical record revealed that he/she began Medicare covered services following the return from a qualifying hospital stay on 12/6/24, and the facility-initiated discharge from Medicare Part A coverage was starting 12/21/24. The resident's benefit days were not exhausted. Resident R166 remained in the facility until 3/02/25.

There was no evidence that a Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN) of Non-coverage (document that provides information to residents so they can decide if they wish to continue skilled services that may not be paid for by Medicare and assume financial responsibility) was provided as required in advance of the time that Medicare Part A was discontinued.

During an interview on 4/03/25, at 2:14 p.m. the Business Office Manager confirmed that the facility did not provide SNFABN form to Resident R166, or his/her representative, when the facility discharged the resident from Medicare covered services.

28 Pa. Code 201.18(b)(2) Management

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

Plan of Correction - To be completed: 05/30/2025

Resident R166 has been provided with an ABN for the period identified.
A house wide audit was conducted to verify SNFABN forms have been completed as required for current residents.
The director of nursing will educate the Case Manager, Registered Nurse Assessment Coordinator, and Business Office Manager that it is required to provide notice to the resident and/or resident's representative following the end of Medicare covered services so they can decide if they wish to continue skilled services that may not be paid for by Medicare and assume financial responsibility by 5/10/25.
The facility will conduct Triple Check Meetings weekly and the interdisciplinary team will audit 5xs week for one week, 2x a week for month, and monthly thereafter current skilled residents to ensure proper notification is completed as required once skilled services are exhausted.
Audit findings will be reviewed through the Quality assurance performance improvement meetings.

483.10(j)(1)-(4) REQUIREMENT Grievances:

§483.10(j) Grievances.
§483.10(j)(1) The resident has the right to voice grievances to the facility or other agency or entity that hears grievances without discrimination or reprisal and without fear of discrimination or reprisal. Such grievances include those with respect to care and treatment which has been furnished as well as that which has not been furnished, the behavior of staff and of other residents, and other concerns regarding their LTC facility stay.

§483.10(j)(2) The resident has the right to and the facility must make prompt efforts by the facility to resolve grievances the resident may have, in accordance with this paragraph.

§483.10(j)(3) The facility must make information on how to file a grievance or complaint available to the resident.

§483.10(j)(4) The facility must establish a grievance policy to ensure the prompt resolution of all grievances regarding the residents' rights contained in this paragraph. Upon request, the provider must give a copy of the grievance policy to the resident. The grievance policy must include:
(i) Notifying resident individually or through postings in prominent locations throughout the facility of the right to file grievances orally (meaning spoken) or in writing; the right to file grievances anonymously; the contact information of the grievance official with whom a grievance can be filed, that is, his or her name, business address (mailing and email) and business phone number; a reasonable expected time frame for completing the review of the grievance; the right to obtain a written decision regarding his or her grievance; and the contact information of independent entities with whom grievances may be filed, that is, the pertinent State agency, Quality Improvement Organization, State Survey Agency and State Long-Term Care Ombudsman program or protection and advocacy system;
(ii) Identifying a Grievance Official who is responsible for overseeing the grievance process, receiving and tracking grievances through to their conclusions; leading any necessary investigations by the facility; maintaining the confidentiality of all information associated with grievances, for example, the identity of the resident for those grievances submitted anonymously, issuing written grievance decisions to the resident; and coordinating with state and federal agencies as necessary in light of specific allegations;
(iii) As necessary, taking immediate action to prevent further potential violations of any resident right while the alleged violation is being investigated;
(iv) Consistent with §483.12(c)(1), immediately reporting all alleged violations involving neglect, abuse, including injuries of unknown source, and/or misappropriation of resident property, by anyone furnishing services on behalf of the provider, to the administrator of the provider; and as required by State law;
(v) Ensuring that all written grievance decisions include the date the grievance was received, a summary statement of the resident's grievance, the steps taken to investigate the grievance, a summary of the pertinent findings or conclusions regarding the resident's concerns(s), a statement as to whether the grievance was confirmed or not confirmed, any corrective action taken or to be taken by the facility as a result of the grievance, and the date the written decision was issued;
(vi) Taking appropriate corrective action in accordance with State law if the alleged violation of the residents' rights is confirmed by the facility or if an outside entity having jurisdiction, such as the State Survey Agency, Quality Improvement Organization, or local law enforcement agency confirms a violation for any of these residents' rights within its area of responsibility; and
(vii) Maintaining evidence demonstrating the result of all grievances for a period of no less than 3 years from the issuance of the grievance decision.

Observations:

Based on a review of facility policy, facility grievances, and resident and staff interviews, it was determined that the facility failed to resolve resident and resident representative's grievance concerns related to care/treatment for four of 26 residents reviewed (Residents R19, R50, R58, and R68).

Findings include:

A facility policy entitled, "Grievances - Resident Rights" dated 12/04/24, revealed "The Manor will assist residents, their representatives, other interested family members, or advocates in filing grievances when such requests are made. It is the policy of the Manor to encourage all residents and visitors to bring to the attention of the Administrator their complaints. The Administrator is the designated Grievance Officer. The Grievance Officer can be reached at the main phone number or by writing the Manor's main mailing address. All persons will be provided with an opportunity to present their complaints through a formal grievance procedure. All complaints or grievances will be resolved promptly and fairly. Sharing concerns with us. If you or another interested party has a concern regarding the Manor's delivery of services, the behavior of other residents or staff members, or any other concern, we encourage you to share your thoughts with us. You are encouraged to discuss your concern with the immediate supervisor or director of the involved department. It is our policy that concerns raised with us will be reviewed, and that we will report back to the person registering the concern with a prompt resolution. Filing of written grievance form. Grievance forms are located in the Administrator's office. A formal grievance must be submitted in writing to the Grievance Officer and signed by the resident or the person filing the grievance. It is our policy to assist residents/sponsors in filing a grievance."

A review of facility Grievances for January through April 2025, lacked evidence of Grievances from Resident 19, Resident 58, Resident R68, and Resident R50's family member. No Grievances were noted for January 2025. Four Grievances for February 2025, involved four residents with missing belongings. Two Grievances for March 2025, involved a resident with hearing aides not working and a resident with missing diabetic slippers. No Grievances were noted for April 2025.

An interview with Resident R19 on 4/01/25, at 1:30 p.m. revealed he/she has concerns with the communication by the nursing staff, as he/she must ask several times for lab and test results. Resident R19 stated, "I am currently awaiting results from a sleep study that I've asked about several times." Resident R19 further indicated that he/she has talked to different employees regarding this concern with no resolve.

An interview with Resident R58 on 4/01/25, at 1:45 p.m. revealed that he/she has communicated a concern to facility staff without any resolution about the resident smoking area which is located outside of his/her window, and frequently the noise level and lingering smoke can be a problem. He/she further indicated that the smoke prevents him/her from opening his/her window, and the noise level prevents him/her from sleeping.

An interview with Resident R68 on 4/2/25, at 12:30 p.m. revealed that he/she has asked several different facility employees regarding his/her BIPAP (BiPAP is a non-invasive ventilation therapy that helps a person breathe by delivering pressurized air through a mask) machine. Resident R68 indicated he/she has been without his/her machine for numerous days with no prompt resolution.

An interview with Resident R50's family member on 4/01/25, at 2:50 p.m. revealed that numerous care concerns were communicated to several different employees of the facility with no prompt resolution. Specific concerns were related to the location of the resident smoking area, which is adjacent to resident rooms, allowing smoke to linger near the rooms, and intrusive noise levels preventing residents from sleeping. Additional Resident R50's family member's concerns were related to resident hydration and times that residents are awakened for morning care.

An interview with the Nursing Home Administrator (NHA) on 4/04/25, at 10:00 a.m. indicated that the facility Grievance process typically only addressed missing/broken items. The NHA further confirmed that the facility lacked evidence of Grievances for Residents R19, R50 (family member), R58, and R68's care and treatment concerns, and the care and treatment concerns were not addressed timely.

28 Pa. Code 201.14(a) Responsibility of licensee

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

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

28 Pa. Code 201.29(a) Resident rights

Plan of Correction - To be completed: 05/30/2025

Residents identified were educated on grievance procedures and declined to file grievances. Concerns identified by residents R19, R50, R58 and R68 have been resolved.
All Staff educated on grievance policy and procedure by 5/9/25.
Resident Council to be held by 4/30/25. Education regarding resident rights and filing grievances provided.
Resident concerns will be reviewed daily (M-F) with the interdisciplinary team to determine plan of action for resident satisfaction.
Social Services Coordinator or designee will audit all grievances for one week, 2 grievances a week for one month and monthly thereafter.
Findings to be discussed at Quality Assurance Performance Improvement meeting.

483.20(g) REQUIREMENT Accuracy of Assessments:

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.

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

Observations:

Based on review of clinical records, facility documentation, and staff interview, it was determined that the facility failed to complete the Minimum Data Set (MDS-periodic assessment of resident care needs) to accurately reflect the resident's status at the time of the assessment for one of 26 residents reviewed (Resident R43).

Findings include:

Resident R43's admission record revealed an admission date of 2/17/24, with diagnoses that included bacterial bone infection in the right ankle and foot, Type 2 diabetes (conditiona when the body cannot use insulin correctly and sugar builds up in the blood), and irregular heartbeat.

Review of Resident R43's Medication Administration Records (MARs) revealed he/she received Trulicity (a non-insulin injectable diabetes medication to help improve blood sugar control by stimulating insulin release) every seven days in May 2024, July 2024, September 2024, October 2024, November 2024, and February 2025.

The Quarterly MDS dated 5/15/24, Medications Section N0350A indicated that Resident R43 received insulin one time during the seven-day look back period.

The Quarterly MDS dated 7/12/24, Medications Section N0350A indicated that Resident R43 received insulin one time during the seven-day look back period.

The Quarterly MDS dated 9/27/24, Medications Section N0350A indicated that Resident R43 received insulin one time during the seven-day look back period.

The Quarterly MDS dated 10/31/24, Medications Section N0350A indicated that Resident R43 received insulin one time during the seven-day look back period.

The Quarterly MDS dated 11/02/24, Medications Section N0350A indicated that Resident R43 received insulin one time during the seven-day look back period.

The Annual MDS dated 2/02/25, Medications Section N0350A indicated that Resident R43 received insulin one time during the seven-day look back period.

During an interview on 4/03/25, 11:00 a.m. Registered Nurse Assessment Coordinator Employee E4 confirmed that Section N - Medications category N0350A Insulin of the Quarterly MDS's dated 5/15/24, 7/12/24, 9/27/24, 10/31/24, 11/02/24, and the Annual MDS dated 2/02/25, were incorrectly coded for Resident R43 (as related to Trulicity) and should have been zero days.

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

Plan of Correction - To be completed: 05/30/2025

The MDS assessment identified for R43 was immediately corrected.
Resident Nurse Assessment Coordinator (RNAC) has completed a house wide audit on all resident MDS assessments that receive Trulicity for accuracy.
RNAC will be educated by the director of nursing by 5/10/25 that Trulicity is a non-insulin injectable diabetes medication.
RNAC will have a double check system in place to verify accuracy of MDS assessments with residents who receive Trulicity and/or other types of non-injectable diabetes medications.
The director of nursing or designee will audit MDS assessments for Trulicity coding for 5xs week for one week, 2x a week for month, and monthly thereafter.
Audit findings will be reviewed through the Quality assurance performance improvement meetings.

483.21(a)(1)-(3) REQUIREMENT Baseline Care Plan:

Least serious deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency has the potential for causing no more than a minor negative impact on the resident.

§483.21 Comprehensive Person-Centered Care Planning
§483.21(a) Baseline Care Plans
§483.21(a)(1) The facility must develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. The baseline care plan must-
(i) Be developed within 48 hours of a resident's admission.
(ii) Include the minimum healthcare information necessary to properly care for a resident including, but not limited to-
(A) Initial goals based on admission orders.
(B) Physician orders.
(C) Dietary orders.
(D) Therapy services.
(E) Social services.
(F) PASARR recommendation, if applicable.

§483.21(a)(2) The facility may develop a comprehensive care plan in place of the baseline care plan if the comprehensive care plan-
(i) Is developed within 48 hours of the resident's admission.
(ii) Meets the requirements set forth in paragraph (b) of this section (excepting paragraph (b)(2)(i) of this section).

§483.21(a)(3) The facility must provide the resident and their representative with a summary of the baseline care plan that includes but is not limited to:
(i) The initial goals of the resident.
(ii) A summary of the resident's medications and dietary instructions.
(iii) Any services and treatments to be administered by the facility and personnel acting on behalf of the facility.
(iv) Any updated information based on the details of the comprehensive care plan, as necessary.

Observations:

Based on review of clinical records and staff interview, it was determined that the facility failed to provide a written summary of the baseline care plan and order summary to the resident and/or representative for one of 26 residents reviewed (Residents R95).

Findings include:

Resident R95's clinical record revealed an admission date of 12/23/24, with diagnoses that included acute and chronic respiratory failure (a condition where your lungs don't exchange air properly), chronic obstructive pulmonary disease (when your lungs do not have adequate air flow), and hypertension (high blood pressure).

Resident R95's clinical record lacked evidence that a written summary of the baseline care plan and order summary was provided to Resident R95 and/or his/her representative.

During an interview on 4/4/25 at 9:40 a.m. the Nursing Home Administrator (NHA) and the Director of Nursing (DON) confirmed that the clinical record of Resident R95 lacked evidence that a written summary of the baseline care plan and order summary were provided the Resident and/or his/her representative upon admission to the facility.

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

Plan of Correction - To be completed: 05/30/2025

I hereby acknowledge the CMS 2567-A, issued to WARREN MANOR for the survey ending 04/04/2025, AND attest that all deficiencies listed on the form will be corrected in a timely manner.

§ 211.5(f)(i)-(xi) LICENSURE Medical records.:

(f) In addition to the items required under 42 CFR 483.70(i)(5) (relating to administration), a resident ' s medical record shall include at a minimum:
(i) Physicians' orders.
(ii) Observation and progress notes.
(iii) Nurses' notes.
(iv) Medical and nursing history and physical examination reports.
(v) Admission data.
(vi) Hospital diagnoses authentication.
(vii) Report from attending physician or transfer form.
(vii) Diagnostic and therapeutic orders.
(viii) Reports of treatments.
(ix) Clinical findings.
(x) Medication records.
(xi) Discharge summary, including final diagnosis and prognosis or cause of death.

Observations:

Based on clinical record review and staff interview, it was determined that the facility failed to complete the recapitulation of stay (summary of resident's stay and course of treatment in the facility) for one of three closed records reviewed (Resident CR109).

Findings include:

Review of facility policy entitled "Discharge Summary" dated 12/4/24, indicated a resident must have a discharge summary that includes, a recapitulation of the resident's stay.

Review of Resident CR109's clinical record revealed an admission date of 12/19/24, with diagnoses that included dementia (a disease that affects short term memory and the ability to think logically), hypertension (high blood pressure), and hyperlipidemia (high cholesterol).

Resident CR109's clinical record revealed that he/she had a discharge from the facility to the hospital on 1/24/25.

Review of Resident CR109's clinical record lacked evidence of a completed recapitulation of Resident CR109's stay.

During an interview on 4/4/25, at 10:50 a.m. with the Nursing Home Administrator (NHA) he/she confirmed that Resident CR109's closed records lacked a completed recapitulation of his/her stay. He/she also confirmed that a complete recapitulation of Resident CR109's stay should have been completed.

28 Pa. Code 211.5(d)(f)(vii) Medical records

Plan of Correction - To be completed: 05/30/2025

Closed record CR109 now includes a recapitulation of stay.
The medical record employee was immediately educated by the director of nursing that all discharge charts including transfers must include a recapitulation of stay within the discharge summary.
Interdisciplinary team immediately educated by director or nursing on recapitulation of stay for respective departments.
The medical record employee is currently reviewing the month of April to ensure that all closed charts have a completed discharge summary that includes the recapitulation of the resident's stay.
Medical records will continue to audit all discharged/closed charts weekly to ensure the discharge summary is completed and to include the recapitalization of the resident's stay.
Audit findings will be reviewed through the Quality assurance performance improvement meetings.

§ 211.10(c) LICENSURE Resident care policies.:

(c) The policies shall be designed and implemented to ensure that each resident receives treatments, medications, diets and rehabilitative nursing care as prescribed.

Observations:

Based on review of facility documents, observations, clinical record reviews and staff interviews, it was determined that the facility failed to develop policies related to respiratory care, resident repositioning, resident transfers, physician's orders, baseline care plans, and cleaning of blood glucose meters (BGMs).

Findings include:

Review of the facility assessment dated 1/15/25, indicated "Policy and Procedures are reviewed at least quarterly during operations meetings or as needed to ensure they meet current professional standards of practice."

Observations of Residents R16, R93, and R95's oxygen use on 4/1/25, at 1:00 p.m. and 1:05 p.m. revealed oxygen concentrators with a large amount of a white fluffy substance covering the top and the back of the concentrator's and drops of a dried liquid substance on the top of two of the concentrators. Observations on 4/2/25, at 9:05 a.m., 10:05 a.m. and 10:22 a.m. revealed the large amount of white fluffy substance and drops of dried liquid substance remained on the oxygen concentrators.

Observations of Resident R16 on 4/2/25, at 9:00 a.m., 10:00 a.m. and 10: 22 a.m. revealed oxygen was not being administered per physician' order and his/her nasal cannula (oxygen tubing that has prongs that go into the nostrils and loops around the ears to secure in place to ensure adequate oxygen delivery) was laying on the floor.

Resident R68's clinical record revealed a physician's order dated 10/18/24, "BI-PaP at hours of sleep with 4L/min [liters per minute] oxygen piped in to equal FIO2 of 35% pre set Settings of V=60, Max IPAP=18, EPAP=9 Make Nasal Mask Type." (BiPAP is a non-invasive ventilation therapy that helps a person breathe by delivering pressurized air through a mask).

Upon request, policies regarding respiratory care to include cleaning of equipment and administration were not provided.

Review of Resident R1's clinical record revealed a physician's order dated 3/20/25, "reposition every two hours offload coccyx."

Interview with Licensed Practical Nurse (LPN) Employee E8 on 4/02/25, at 1:00 p.m. confirmed that Resident R1 was out of bed and sitting in his/her wheelchair before 9:00 a.m. and not turned/repositioned until after lunch, a time span of approximately four hours. LPN Employee E8 further confirmed that Resident R1 has a history of a Stage Three (full thickness loss of skin) pressure injury to his coccyx (tailbone), and physician's orders to reposition every two hours and offload coccyx.

Upon request, policies regarding turning and repositioning at risk residents for pressure ulcers per physician's orders were not provided.

Review of Resident R3's current transfer order included "no weight bearing on left leg" and that staff should maintain non-weight bearing until the order is updated. Observation on 4/02/25, at 1:38 p.m. and 4/03/25, at 1:05 p.m. revealed that Resident R3 was transferred and permitted to bear weight to his/her left leg during the transfer.

Observation on 4/03/25, at 1:05 p.m. revealed that NA Employee E8 assisted Resident R3 to stand from the toilet to the grab bar in the bathroom and adjusted Resident R3's clothing while he/she held onto the bar and permitted weight bearing to his/her left leg during the transfer.

Upon request, policies regarding transfer status per physician's orders were not provided.

Review of Resident R95's clinical record lacked evidence that a written summary of the baseline care plan and order summary was provided to Resident R95 and/or his/her representative.

Upon request, policies regarding providing the resident and/or his/her a summary of his/her baseline care plan were not provided.

Observation of blood glucose monitoring for Residents R51, R65, and R17 on 4/01/25, at between 3:27 p.m. and 4:07 p.m revealed that Licensed Practical Nurse (LPN) Employee E9 failed to clean and disinfect the BGM (blood glucose [sugar] monitor-machine to check blood glucose levels) between/after use on each patient.

Review of the facility's care policies, most recently reviewed by the facility on 12/4/24, lacked evidence that there were policy's regarding respiratory care, resident repositioning, resident transfers, physician's orders, baseline care plans, and BGMs.

During an interview with the Nursing Home Administrator, Director of Nursing, and Regional Director of Clinical Services on 4/4/25, at 9:40 a.m. they confirmed that there were no policies regarding respiratory care, resident positioning, resident transfers, physician's orders, baseline care plans, and BGMs.

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

Plan of Correction - To be completed: 05/30/2025

The facility reviewed the available policies, competencies and procedures regarding the identified care areas including respiratory care, resident repositioning, resident transfers, physician orders, baseline care plans, and Blood Glucose Monitors.
The Director of Nursing will collaborate with the clinical council of nurses to determine what if any changes to current policies will be recommended for corporate consideration.
Nursing home administrator or designee reviewed policies and procedures and will ensure policies and procedures are readily available.
Nursing Home administrator or designee will monitor policies and procedures quarterly/as needed through the Quality Assurance Process Improvement process in review of the facility assessment.
All findings will be discussed in Quality Assurance Process Improvement meeting.

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