Pennsylvania Department of Health
YORK SOUTH SKILLED NURSING AND REHABILITATION CENTER
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

YORK SOUTH SKILLED NURSING AND REHABILITATION CENTER
Inspection Results For:

There are 157 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.


YORK SOUTH SKILLED NURSING AND REHABILITATION CENTER - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:

Based on a Medicare/Medicaid Recertification survey, State Licensure survey, Civil Rights Compliance survey completed on May 8, 2025, it was determined that York South Skilled Nursing and Rehabilitation Center 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:

483.20(g)(h)(i)(j) REQUIREMENT Accuracy of Assessments:

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.

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

§483.20(h) Coordination. A registered nurse must conduct or coordinate each assessment with the appropriate participation of health professionals.

§483.20(i) Certification.
§483.20(i)(1) A registered nurse must sign and certify that the assessment is completed.
§483.20(i)(2) Each individual who completes a portion of the assessment must sign and certify the accuracy of that portion of the assessment.

§483.20(j) Penalty for Falsification.
§483.20(j)(1) Under Medicare and Medicaid, an individual who willfully and knowingly-
(i) Certifies a material and false statement in a resident assessment is subject to a civil money penalty of not more than $1,000 for each assessment; or
(ii) Causes another individual to certify a material and false statement in a resident assessment is subject to a civil money penalty or not more than $5,000 for each assessment.
§483.20(j)(2) Clinical disagreement does not constitute a material and false statement.

Observations:

Based on clinical record review and staff interviews, it was determined that the facility failed to ensure that the resident assessment accurately reflected the resident's status for three of 31 residents reviewed (Residents 48, 86, and 101).

Findings include:

Review of the clinical record for Resident 48 on May 5, 2025, revealed diagnoses that include bilateral trochanter (hip bone) decubitus ulcers (pressure wounds over bony prominences) and End Stage Renal Disease (kidney function is severely impaired requiring dialysis or transplant).

A review of Resident 48's care plan dated May 2025 revealed a focus for "Documented Pressure Ulcer: bilateral hips. Date Initiated: 04/23/2025 Created on: 04/23/2025".

A review of Resident 48's physician orders on May 6, 2025, revealed the following orders: "Cleanse wounds on bilateral hips with Vashe (wound cleanser); soak 2-5 minutes; scrub 30 seconds; apply skin prep to peri wound; apply Medihoney (aids in removal of necrotic tissue and wound healing); cover with border foam. Every day shift every other day for decubitus ulcers."

A review of Resident 48's Admission MDS (Minimum Data Set - an assessment tool to review all care areas specific to the resident such as a resident's physical, mental or psychosocial needs) dated April 29, 2025, failed to reflect the bilateral trochanter decubitus ulcers on admission to the facility in Section M: Skin Conditions.

During an interview with the Director of Nursing (DON) on May 8, 2025, at 11:04 AM, the DON confirmed that the MDS should be marked based on the data in the clinical record and that the trochanter wounds were marked as other wounds on the MDS.

Review of Resident 86's clinical record revealed diagnoses that included protein calorie malnutrition (an imbalance between the nutrients the body needs to function and the nutrients it gets) and muscle weakness.

Review of Resident 86's clinical record revealed he had a 5.1% weight loss from January 1 to 17, 2025, and that his diagnosis of protein calorie malnutrition was added on February 14, 2025.

Review of Resident 86's Quarterly MDS, State MDS, and Modification of Quarterly MDS, all with ARD of January 23, 2025, under Section K: Swallowing / Nutritional Status, subsection K0300. Weight Loss: Loss of 5% or more in the last month or loss of 10% or more in last 6 months, revealed Resident 86 was marked no or unknown.

Review of Resident 86's Significant Change MDS with ARD of February 14, 2025, under Section I: Active Diagnoses, subsection I5600, revealed Resident 86 was marked no for risk of malnutrition or having an active diagnosis of malnutrition.

During an interview with the DON on May 8, 2025, at 10:56 AM, she revealed the aforementioned MDS assessments had been modified for accuracy, and she would expect MDS assessments to be coded accurately.

Review of Resident 101's clinical record revealed diagnoses that included Alzheimer's Disease (irreversible, progressive degenerative brain disease that results in decreased ability to perform activities of daily living and decreased contact with reality) and hypertension (elevated/high blood pressure).

Review of Resident 101's clinical record revealed that Resident 101 was admitted to hospice services on December 13, 2024.

Review of Resident 101's Quarterly MDS revealed that Section O0100, "Special Treatments, Procedures, and Programs," subsection K1, "Hospice," was coded to reflect that Resident 101 was not receiving hospice services at the time of the assessment.

During a staff interview on May 7, 2025, at approximately 10:30 AM, the DON confirmed that Resident 101 was receiving hospice services at the time of the Quarterly MDS assessment and that the Quarterly MDS assessment should have been coded to reflect Resident 101's hospice status.

28 Pa. Code 211.5(f) Medical records
28 Pa. Code 211.12(c)(d)(3)(5) Nursing services

Plan of Correction - To be completed: 06/24/2025

Residents #48, #86 and #101 have had their MDS corrected due to incorrect coding on the MDS. Corrections will be made according to RAI manual guidance. No residents found to have been affected by the alleged deficient practice.
MDS's will continue to be reviewed for sections that capture Skin Conditions, Active Diagnoses and Special Treatments, Procedures and Programs by the RNAC/designee to identify any potential areas of concern on the MDS. Any corrections needed will be submitted according to the RAI Manual guidance.
Re-education will be provided to the Interdisciplinary team that participates in the MDS process by the Regional RNAC regarding the importance of accurate assessment completion and following the RAI manual guidelines.
Audits of assessments will be completed by the DON/designee 3 per week for 4 weeks and then 3 per month for 3 months. Results will be reviewed by QAPI.

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.

Plan of Correction - To be completed: 06/24/2025

Multiple items in kitchen areas and nutrition rooms that were undated were subsequently discarded, food items were removed from floor area and drain plate was replaced by maintenance. Temperature logs were all updated and in force, including food prep logs.
Food storage areas have been inspected to ensure compliance to storage, dating and labeling as appropriate. Temp logs have been reviewed and are completed, including food prep logs.
Dietary and nursing staff will be re-educated by SDC/designee in regards to storage of food and dietary items along with dating of food items and temperature logs. ICP will re-educate dietary staff on hand hygiene.
Audits of dietary storage, kitchen and nutrition rooms, and temperature logs will be conducted by the NHA/designee weekly times 4 weeks. Maintenance to audit air gaps weekly times 4. Audits will be reviewed by QAPI.

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 facility policy review, observations, clinical record review, and staff interviews, it was determined that the facility failed to ensure that a resident who needs respiratory care is provided such care, consistent with professional standards of practice, for three of four residents reviewed for respiratory care (Residents 17, 23, and 78).

Findings include:

Review of facility policy, titled "Procedure: Nebulizer: Small Volume" last revised November 1, 2023, read, in part, "Upon completion of the treatment, check patient's heart rate, respiratory rate, pulse oximetry, and breath sounds. Rinse small volume nebulizer mouthpiece and 'T' piece with sterile water and dry. Place in treatment bag labeled with patient's name and date. Replace and date the set up daily, if used. Check compressor for air filters that require replacement and cleaning every 30 days. Follow manufacturer's instructions."

Review of Resident 17's clinical record revealed diagnoses that included muscle weakness, need for assistance with personal care, and dysphagia (difficulty swallowing).

Review of Resident 17's physician orders revealed an order for "Ipratropium-Albuterol Inhalation Solution 0.5-2.5 (3) MG/3ML, 1 vial inhale orally every 6 hours as needed for shortness of breath, wheezing," with a start date of April 8, 2025.

Observations in Resident 17's room on May 5, 2025, at 10:58 AM; May 6, 2025, at 12:13 PM; and May 7, 2025, at 9:33 AM; revealed a nebulizer machine with tubing and a mask, the mask was laying out directly on her bedside table and the tubing was dated April 7, 2025.

Review of Resident 17's April 2025 MAR (Medication Administration Record- documentation for treatments/medication administered or monitored) revealed she received her albuterol treatment via nebulizer April 8-13, 2025.

During an interview with the Director of Nursing (DON) on May 7, 2025, at 10:56 AM, the surveyor revealed the concern with the observations throughout the week of Resident 17's nebulizer mask laying out at bedside and tubing dated prior to noted albuterol administrations in April 2025.

Follow up interview with the DON on May 8, 2025, at 10:16 AM, revealed she would expect respiratory care and treatment to be administered and stored consistent with professional standards.

Review of Resident 23's clinical record revealed she was admitted to the facility on March 3, 2025, with diagnoses that included hypertension (high blood pressure), fibromyalgia (a chronic condition that causes pain in muscles and soft tissues all over the body), and generalized anxiety disorder (a persistent feeling of worry, nervousness, or unease).

Observations of Resident 23 in her room on May 5, 2025, at 12:11 PM; May 6, 2025, at 12:15 PM; and May 7, 2025, at 9:43 AM, revealed she was wearing oxygen via a nasal cannula (a device that delivers oxygen through a tube and into your nose) that was connected to an oxygen concentrator (medical device that contains oxygen).

Review of Resident 23's clinical record failed to reveal a physician order for oxygen or a comprehensive care plan for oxygen use.

Interview with the DON on May 8, 2025, at 10:16 AM, revealed she would expect Resident 23 to have physician order for oxygen and comprehensive care plan for oxygen use.

Review of Resident 78's clinical record revealed diagnoses that included chronic obstructive pulmonary disease (COPD- a group of lung diseases that block airflow and make it difficult to breathe), localized edema (swelling caused by too much fluid trapped in the body's tissues), and muscle weakness.

Review of Resident 78's physician orders revealed an order for "Ipratropium-Albuterol Solution 0.5-2.5 (3) MG/3ML 1 vial inhale orally every 4 hours as needed for COPD," with a start date of March 25, 2023.

Observations in Resident 78's room on May 5, 2025, at 1:49 PM; May 6, 2025, at 9:36 AM; May 7, 2025, at 9:39 AM; revealed a nebulizer machine with tubing and a mask, the mask was laying out directly on her bedside table, and the tubing was not dated.

Review of Resident 78's February 2025 MAR revealed she last received her albuterol treatment via nebulizer on February 15, 2025.

During an interview with the DON on May 7, 2025, at 10:56 AM, the surveyor revealed the concern with the observations throughout the week of Resident 78's nebulizer mask laying out at bedside and tubing not dated.

Follow up interview with the DON on May 8, 2025, at 10:16 AM, revealed she would expect respiratory care and treatment to be administered and stored consistent with professional standards.

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

Plan of Correction - To be completed: 06/24/2025

Resident #17 had an order for duonebs which was placed on 4/8. The order had a stop date for 4/13. Documentation shows that no nebulizing treatments were administered after 4/13. The nebulizer machine has been removed from her room. Resident #23 continues to require supplemental O2. Oxygen orders and care plan have been initiated. Resident #78 has not used nebulizer since February 2025. Nebulizer machine was removed from her room. Request made for MD/APP to review continued need for PRN nebulizer treatments.
Current residents with oxygen orders will be reviewed for compliance with maintaining equipment including dating tubing and storing in the proper treatment bag. Current residents requiring supplemental oxygen will be reviewed to ensure there are physician orders for use and corresponding care plan.
Nursing staff will be re-educated by the NPE/designee on the facility policy regarding oxygen maintenance, requirement for provider orders and updated care plan.
Audits will be completed by the DON/designee to ensure maintenance compliance by performing random observations. Audits will be conducted 3 times per week for 4 weeks and then monthly for 3 months. Audits will be completed of residents with newly required oxygen needs to ensure compliance with physician orders and O2 care plans for 4 weeks. Results will be reviewed with QAPI.

483.25(b)(1)(i)(ii) REQUIREMENT Treatment/Svcs to Prevent/Heal Pressure Ulcer:

§483.25(b) Skin Integrity
§483.25(b)(1) Pressure ulcers.
Based on the comprehensive assessment of a resident, the facility must ensure that-
(i) A resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable; and
(ii) A resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing.

Plan of Correction - To be completed: 06/24/2025

Residents #4, #122 and #238 were not found to be affected by the alleged deficient practice. Residents were seen by a PA certified in wound care and the appropriate measurements and descriptions have been documented in the EMR.
Wound care rounds, treatment and documentation will occur based on facility policy to ensure pressure injuries are followed, treated, measured and documented as appropriate to ensure proper care and best practical resolution.
Re-education will be provided to nursing staff by DON/designee to ensure knowledge of wound care policy to include but not limited to rounds, treatment, measurements and documentation.
Audits will be completed by DON/designee of 10 residents with current wound care needs per week times 4 weeks then 10 residents monthly times 3 months to ensure proper measurements, assessment, treatments and documentation are within policy compliance. Results will be reviewed by QAPI.

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 facility policy review, clinical record review, observation, and staff interviews, it was determined that the facility failed to ensure that the comprehensive care plan was reviewed and revised for three of 31 reviewed (Residents 39, 51, and 55).

Findings include:

Review of facility policy, titled "Person-Centered Care Plan" last revised October 24, 2022, read, in part, "The care plan will be prepared by the interdisciplinary team. The care plan must be customized to each individual patient's preferences and needs. Care plans will be reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments, and as needed to reflect the response to care and changing needs and goals."

Review of Resident 39's clinical record revealed diagnoses that included diabetes (a disease characterized by high blood glucose) and muscle weakness (when your full effort doesn't produce a normal muscle contraction or movement).

Review of Resident 39's care plan revealed a care plan with a focus are of: Pressure Ulcer, Left great toe, with a date initiated of August 11, 2024.

Review of Resident 39's physician's orders revealed a physician order for a dressing change to Resident 39's left great toe, discontinued April 17, 2025, with discontinue reason of, "resolved".

Interview with the Director of Nursing (DON) on May 8, 2025, at 10:40 AM, Resident 39's pressure ulcer was resolved on April 17, 2024, and the care plan should have been resolved also.

A review of Resident 51's clinical record on May 6, 2025, at 11:00 AM, revealed diagnoses that included atrial fibrillation (irregular and rapid heart rate) and convulsions (seizures).

A review of Resident 51's physician orders on May 2025, reveals an order for Eliquis (anticoagulant medication that prevents clot formation) 5 milligrams by mouth twice a day for atrial fibrillation.

A review of Resident 51's care plan on May 6, 2025, revealed the facility never revised the care plan to reveal Resident 51 was receiving an anticoagulant medication.

During an interview with the DON on May 7, 2025, the DON confirmed the care plan should have been revised to include the usage of an anticoagulant with appropriate interventions.

Review of Resident 55's clinical record revealed diagnoses that included repeated falls, diabetes, and muscle weakness.

Review of Resident 55's comprehensive care plan on May 6, 2025, revealed a focus area that he is at nutritional risk last revised on October 29, 2024, with an intervention for "1-1 Feeding assistance required to promote adequate oral intake," last revised on October 29, 2024.

Observation on May 5, 2025, at 12:06 PM, revealed he was sitting up in bed feeding himself lunch.

Review of Resident 55's nurse aid tasks for eating ability revealed he was documented as being independent with feeding after set-up help for the 14 days of look back documentation April 26, 2025-May 8, 2025.

During an interview with Employee 12 (Director of Rehabilitation) on May 8, 2025, at 1:22 PM, revealed the intervention for feeding assistance was implemented when Resident 55 was first admitted to the facility last fall, and was related to a nutritional intervention to remain alert during meals, rather than a functional recommendation from therapy, she further revealed this intervention should have been revised at least since therapy has been working with him since April 2025, as he is noted to be independent with eating after set-up help.

Review of Resident 55's fall report from February 27, 2025, revealed he had sustained a fall that morning, and under "Immediate Action Taken" it was noted "Intervention of perimeter mattress to be added."

Review of Resident 55's care plan on May 6, 2025, revealed a comprehensive fall care plan but failed to reveal an intervention for a perimeter mattress.

Review of Resident 55's care plan on May 8, 2025, at 9:40 AM, revealed an intervention for a perimeter mattress had been added to his care plan on May 7, 2025.

Interview with the DON on May 8, 2025, at 1:40 PM, revealed she would expect care plans to be reviewed and revised as needed to reflect the response to care and changing needs.

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

Plan of Correction - To be completed: 06/24/2025

Residents #39, #51 and #55 have had their care plans revised to reflect current level of care.
Current residents' care plans related to pressure injuries, anticoagulant medication use, nutritional risk and feeding assistance will be reviewed to ensure care plans are reflective of current level of care. Care plans will be revised/updated as necessary.
Members of the Interdisciplinary Team will be re-educated by the NPE/designee to the care plan process. Changes to treatment/care will be reviewed at morning clinical meeting. Licensed nurses will be re-educated to fall intervention initiation and subsequent care plan revision. Care plans will be revised as changes are identified to reflect residents' current status. Care plans will be reviewed/revised quarterly, annually and/or with a significant change.
Audits will be conducted by the DON/designee on 5 residents daily times 2 weeks, then 5 residents weekly times 4 weeks, then monthly for 2 months. Results will be reviewed at QAPI.
Date of compliance 6/24/2025.

483.10(e)(3) REQUIREMENT Reasonable Accommodations Needs/Preferences:

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(e)(3) The right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents.

Observations:

Based on observations, record review, policy review, and staff interview, it was determined that the facility failed to ensure the environment meets the individual needs of each resident by ensuring the call bell was in reach for three of 31 residents reviewed (Residents 31, 59, and 67).

Findings include:

Review of facility policy, Call lights, with a revision date of June 1, 2021, revealed, All Genesis HealthCare patients will have a call light or alternative communication device within their reach at all times.

Review of Resident 31's clinical record revealed diagnoses that included diabetes (a disease characterized by high blood glucose) and muscle weakness (when your full effort doesn't produce a normal muscle contraction or movement).

Review of Resident 31's current care plan revealead a focus area of, at risk for falls due to history of cardiovascular accident, and an intervention of, Reinforce need to call for assistance.

Observation of Resident 31 on May 5, 2025, at 9:42 AM, revealed Resident 31 lying in bed and his call bell was lying on the floor under the center of the Resident's bed.

Observation of Resident 31 on May 6, 2025, at 9:40 AM, revealed Resident 31 lying in bed and his call bell was still lying on the floor under the center of the Resident's bed.

Review of Resident 59's clinical record revealed diagnoses that included protein calorie malnutrition (a nutritional status in which reduced availability of nutrients leads to changes in body composition and function) and peripheral vascular disease (a progressive circulation disorder).

Observation of Resident 59 on May 6, 2025, at 8:51 AM, revealed Resident 59 lying in bed and her call bell was lying on the floor under the center of the Resident's bed.

Review of Resident 67's clinical record revealed diagnoses of sepsis (a serious condition in which the body responds improperly to an infection) and urinary tract infection (an infection of any part of the urinary system).

Observation of Resident 67 on May 5, 2025, at 9:54 AM, revealed Resident 67 lying in bed and his call bell was in the top drawer of his bedside stand, behind the head of his bed, where Resident 67 could not access it.

Interview with the Director of Nursing on May 8, 2025, at 10:30 AM, revealed that all residents should have their call bells within their reach, and they have reeducated their staff.

Pa. Code 211.12(d)(1) Nursing Services

Plan of Correction - To be completed: 06/24/2025

Residents 31, 59 and 67 were not found to be affected by the alleged deficient practice. All residents were determined to have the ability to use a call bell. Immediate education was provided at the time the alleged deficient practice was identified.
All residents' call bells will be visualized and reviewed with the interdisciplinary team to ensure they have the most appropriate style. Care plans will be reviewed to ensure accuracy.
Re-education will be completed with licensed nurses and certified nursing assistants that all residents must have a call light or alternative communication device within their reach at all times.
DON/designee will complete random visual audits on 5 residents per day, 3 times per week for 4 weeks and then 10 residents a month for 3 months. Results will be reviewed by the QAPI committee.

483.15(c)(2)(iii)(3)-(6)(8)(d)(1)(2); 483.21(c)(2)(i)-(iii) REQUIREMENT Discharge Process:

§483.15(c)(2) Documentation.
When the facility transfers or discharges a resident under any of the circumstances specified in paragraphs (c)(1)(i)(A) through (F) of this section, the facility must ensure that the transfer or discharge is documented in the resident's medical record and appropriate information is communicated to the receiving health care institution or provider.
(iii) Information provided to the receiving provider must include a minimum of the following:
(A) Contact information of the practitioner responsible for the care of the resident.
(B) Resident representative information including contact information
(C) Advance Directive information
(D) All special instructions or precautions for ongoing care, as appropriate.
(E) Comprehensive care plan goals;
(F) All other necessary information, including a copy of the resident's discharge summary, consistent with §483.21(c)(2) as applicable, and any other documentation, as applicable, to ensure a safe and effective transition of care.

§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).

§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.

§483.21(c)(2) Discharge Summary
When the facility anticipates discharge, a resident must have a discharge summary that includes, but is not limited to, the following:
(i) A recapitulation of the resident's stay that includes, but is not limited to, diagnoses, course of illness/treatment or therapy, and pertinent lab, radiology, and consultation results.
(ii) A final summary of the resident's status to include items in paragraph (b)(1) of §483.20, at the time of the discharge that is available for release to authorized persons and agencies, with the consent of the resident or resident's representative.
(iii) Reconciliation of all pre-discharge medications with the resident's post-discharge medications (both prescribed and over-the-counter).

Observations:

Based on facility policy review, clinical record review, and staff interview, it was determined that the facility failed to ensure that the resident and/or their representative received written notice of the facility bed-hold policy at the time of transfer for one of six residents reviewed for hospitalization (Resident 86).

Findings Include:

Review of facility policy, titled "Bed Holds" last revised January 16, 2023, read, in part, " Bed hold notification is required per Federal Regulation. The resident/resident representative may choose to pay to hold the bed privately if the bed hold is not covered by Medicaid, Medicare, insurance, etc. If the resident representative is not present to receive the written notice upon transfer, the notice is delivered via e-mail, fax, or hard copy via mail. Purpose: To properly secure a private payer source, if applicable, to ensure a bed is reserved and available upon the resident's return."

Review of Resident 86's clinical record revealed diagnoses that included protein calorie malnutrition (an imbalance between the nutrients the body needs to function and the nutrients it gets) and muscle weakness.

Review of Resident 86's clinical record revealed that he was transferred and admitted to the hospital on February 18, 2025, and March 6, 2025.

Further review of Resident 86's clinical record failed to reveal notation that the written notice of bed hold notification was provided to the Resident or Resident Representative upon transfer.

During an interview with the Director of Nursing on May 8, 2025, at 10:54 AM, she revealed she would expect that Resident 86 and/or his Representative were provided with a written notice of the facility's bed hold notice at the time of either hospitalization.

28 Pa. Code 201.14(a) Responsibility of licensee

Plan of Correction - To be completed: 06/24/2025

Resident 86 was not found to be affected by the alleged deficient practice. The resident did return to the facility and to the same room following the hospital stay.
Discharges, planned and unplanned will be reviewed at the morning Department Head meetings. Documentation in the EMR will be reviewed to ensure that the bed-hold notice was provided at the time of transfer. The Admissions Director will follow up with the resident/resident representative regarding the bed-hold notice. Documentation of the bed-hold notice will be maintained by the Business Office.
Re-education to Nursing, Social Services, AD and BOM/ABOM to ensure that the bed-hold notice requirement is happening with each transfer to the hospital or therapeutic leave per facility policy. Residents who are transferred or discharged will be issued a bed-hold notice at the time of their departure.
AD/BOM/designee will audit all hospital transfers and therapeutic leaves of absence to ensure the requirement to provide the bed-hold notice to the resident/representative took place. Audits will continue for 4 weeks and then audits of 5 transfers/therapeutic leaves per month times 3 months. Results will be reviewed with the QAPI committee.

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

§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.

Plan of Correction - To be completed: 06/24/2025

Resident 238 was found not to be affected by the alleged deficient practice. His care plan was updated to reflect wound/skin concerns, pain, and use of anticoagulant medication.
Current residents that were admitted with wound care needs, documented pain and use of anticoagulant use will be reviewed to ensure care plans are reflective of current level of care.
Licensed nurses will be re-educated that within 48 hours of admission, the baseline care plan should include the minimum healthcare information necessary to properly care for a resident.
Audits of baseline care plans will be completed on 5 new admissions per week for 4 weeks and then monthly for 3 months. Results will be reviewed by the QAPI committee.

483.25(c)(1)-(3) REQUIREMENT Increase/Prevent Decrease in ROM/Mobility:

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

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

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

Observations:

Based on policy review, clinical record review, and staff interviews, it was determined that the facility failed to ensure that each resident with limited range of motion receives appropriate treatment and services to increase range of motion and/or prevent further decrease in range of motion for one of 31 residents reviewed (Resident 95).

Findings Include:

Review of the facility's policy, titled "Restorative Nursing," recently revised August 7, 2023, defined its purpose "To promote the patient's ability to adapt and adjust to living as independently and safely as possible." Also, "To help the patient attain and maintain optimal physical, mental, and psychosocial functioning. ... Restorative programs are coordinated by nursing or in collaboration with rehabilitation and are patient-specific based on individual patient needs."

Review of Resident 95's physician's orders revealed diagnoses that included muscle weakness (a decrease in muscle strength, where the muscles may not contract or move as easily as usual) and reduced mobility (a partial or total loss of the ability to move around freely, whether due to physical limitations, age, or other factors).

Review of Resident 95's interdisciplinary plan of care, revised on October 12, 2023, revealed an identified problem area that read "At risk for loss of range of motion r/t [related to] physical limitations, Will exhibit no decline in ROM [range of motion] within confines of disease processes."

The interventions included "Restorative Active ROM: upper extremities during ADLs [ activities of daily living - a term used in healthcare to refer to an individual's daily self-care activities], 15 minutes, 10 reps each (shoulders, elbows, wrists, fingers)."

Review of the facility's documentation for Resident 95's restorative nursing program revealed that staff documented "not applicable" for 21 of the 30 days reviewed.

An interview with the Staff Educator (Employee 1) on May 8, 2025, at 9:46 AM, revealed that staff were documenting "not applicable" when Resident 95 refused the program and were educated on documenting "resident refused" instead. The interview also revealed that Resident 95 refuses when she has pain, and staff are educated to inform Employee 1 to determine the appropriateness of the restorative nursing program for any resident.

An interview with the Director of Nursing on May 7, 2025, at 10:06 AM, also revealed that staff should document "resident refused" instead of "not applicable."

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

Plan of Correction - To be completed: 06/24/2025

Resident #95 will be reviewed for continued appropriateness in the Restorative program. If the program remains appropriate, restorative tasks will be performed and documented in the medical record. If program is no longer appropriate, care plans, care cards and tasks will be updated.
Current residents with Restorative programs in their care plan will be reviewed for continued appropriateness. If issues are identified, corrective action will be taken. Care plans, care cards and tasks will be updated as necessary.
DON/designee will re-educate nursing staff on the provision of the Restorative program and proper documentation in the medical record. Restorative program status will be reviewed on admission, quarterly, annually and with a change in condition. Care plans, care cards and tasks will be updated to reflect the current level of care.
Audits will be completed by the DON/designee on 10 residents per week for 4 weeks and then 10 residents monthly for 3 months. Results of the audits will be reviewed at QAPI.

483.25(g)(1)-(3) REQUIREMENT Nutrition/Hydration Status Maintenance:

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

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

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

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

Plan of Correction - To be completed: 06/24/2025

Resident #78 fluid restriction order has been updated to clarify that nursing is responsible for documenting the fluids offered by nursing and dietary. Care plan was updated to clarify that nursing is responsible for documenting all fluid intake. Tasks were updated for nursing assistants to sign off that no additional water was provided. A weight was obtained on resident #131 on 5/5/2025 which did not indicate any significant change since his admission on 3/8/2025. An order for routine weights was placed for continued monitoring. Residents were reviewed by attending provider who determined that there were no adverse affects related to the alleged deficient practice.
Current residents on physician ordered fluid restrictions have been reviewed to ensure that accurate fluid intake is documented in the EMR. Orders were updated as necessary. None of those residents were identified to be affected by the alleged deficient practice. All residents have been reviewed to ensure they have physician orders for routine weight monitoring as appropriate. None were identified.
Registered Dietician (RD) will be re-educated by the Regional Dietician regarding weight loss monitoring and physician notification. RD will also be re-educated to the requirement for accurate documentation related to fluid consumption.
Audits of all residents on fluid restriction orders will be completed by the DON/designee one time a week for 4 weeks and then once monthly for 3 months. All new admissions will be reviewed to ensure weight orders were entered per weight policy. All new admissions will be reviewed weekly for 8 weeks. Results will be reviewed with QAPI.

483.60(d)(1)(2) REQUIREMENT Nutritive Value/Appear, Palatable/Prefer Temp:

§483.60(d) Food and drink
Each resident receives and the facility provides-

§483.60(d)(1) Food prepared by methods that conserve nutritive value, flavor, and appearance;

§483.60(d)(2) Food and drink that is palatable, attractive, and at a safe and appetizing temperature.

Observations:

Based on staff and resident interviews, observation, and completion of one meal test tray, it was determined that the facility failed to provide foods that are palatable, attractive, and at appetizing temperatures at one of one meal observed (May 6, 2025, lunch meal).

Findings include:

During an interview with Resident 23 on May 5, 2025, at 12:11 PM, revealed meals are often served cold.

Review of Resident Council Minutes for February 17th, 2025; March 17th, 2025; and April 21st, 2025, concerns were expressed regarding hot food being served cold.

Review of facility form, Test Tray Evaluation, dated May 1, 2023, read, in part, test tray standard for hot entree and vegetable is greater than 140 degrees Fahrenheit (F). Test tray is also evaluated for taste, portion, and appearance of the food.

A test tray completed on May 6, 2025, at 12:35 PM, revealed inadequate portions of coffee. The peas and coffee weren't palatable for temperature. The roast pork and mashed potatoes did not meet the standard. The test tray was placed on a meal cart to be delivered with room trays; 22 minutes had elapsed between the time the test tray was prepared from the service line and presented for evaluation.

Employee 9 (Food Service Director) took temperatures of the food items at the time the test tray was served for evaluation. The following were the recorded highest temperatures:
Roast Pork - 131 degrees F
Mashed Potato- 133 degrees F
Peas- 122 degrees F
Ice Cream - 22 degrees F
Apple Juice- 53 degrees F
Coffee- 104 degrees F; and insufficient portion (the cup was less than half full)

During an interview with Employee 9 at the time the test tray was completed it was revealed that the peas and coffee should've been warmer, and the portion of coffee should've been larger.

During an interview with the Nursing Home Administrator on May 7, 2025, at 10:14 AM, it was revealed that foods should be served at adequate temperatures and portion size.

28 Pa. Code 201.14. Responsibility of licensee
28 Pa code 211.6 - Dietary Services

Plan of Correction - To be completed: 06/24/2025

F804 Nutritive Value/Appear, Palatable/Prefer Temp

Resident 23 stated they were dissatisfied with the temperature of their food. Resident Council Meeting Minutes show concerns with hot food being served cold. Registered Dietician and Dietary Manager have addressed the Resident Council concerns with the standing president. They will continue to be present at Resident Council meetings.
Current residents are encouraged to bring dietary concerns to staff daily through grievances or during the monthly resident council meetings. These concerns will then flow through the grievance process and be reviewed by QAPI.
Education with dietary staff will be conducted in regards to temperature and resident preferences by SDC/designee. The education will include accountability as to who is responsible for the temp logs and process oversight from the Dietary Manager.
Audits of tray temperatures and palatability will be conducted twice weekly times 4 weeks by NHA/designee. Audits will be reviewed by the QAPI committee.
Compliance date: 6/24/2025

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, facility policy review, clinical record review, and staff interviews, it was determined that the facility failed to ensure staff implemented infection control policies to prevent the spread of infection for two of 31 residents on transmission-based precautions reviewed (Residents 67 and 238)

Findings Include:

Review of facility policy, Transmission Based Precautions, revised May 1, 2025, revealed in a section: Initiating Transmission Based Precautions, Signage that includes instructions for use of specific PPE will be placed in a conspicuous location outside the patient's room. Additionally, either the CDC category of Transmission Based Precautions (e.g., Contact, Droplet, or Airborne) or instructions to see the nurse before entering the room will be included in the signage.

Review of Resident 67's clinical record revealed diagnoses of sepsis (a serious condition in which the body responds improperly to an infection) and urinary tract infection (an infection of any part of the urinary system).

Review of Resident 67's clinical record revealed a urine culture dated September 17, 2024, showing that Resident 67 had MRSA (methicillin-resistant staphylococcus aureus) in their urine.

Review of Resident 67's current physician orders revealed an order for Resident 67 to be on contact precautions due to MRSA in their urine, the order was dated September 24, 2024.

Review of Resident 67's care plan revealed a current care plan for, patient has an actual infection(i) MRSA and is at risk for sepsis, initiated September 24, 2024, with an intervention of "Contact Precautions", dated September 20, 2024.

Observation of Resident 67 on May 5, 2025, at 9:43 AM, revealed Resident 67 lying in bed. Hanging on the door of their room was a sign annotating that Resident 67 was on Enhanced barrier precautions. There was no sign or annotation that Resident 67 was on Contact precautions or what personal protective equipment (PPE) would be required.

Interview of the Director of Nursing (DON) on May 7, 2025, at 12;15 PM, revealed that Resident 67 no longer required contact precautions and that the order and care plan should have been removed previously.

Review of facility policy, titled "NSG241 Treatments," last revised June 1, 2021, revealed the policy's purpose was, "To provide a safe and effective administration of treatments." Subsection titled, "Practice Standards," included: "8. Unused supplies are discarded according to infection control procedures or remain dedicated to the patient and stored appropriately. 8.1 Opened specialty supplies (i.e., wound dressings) are discarded per manufacturer's instructions ..."

Review of facility policy, titled "IC307 Standard Precautions," last revised May 1, 2024, revealed subsection definitions included, "'Standard Precautions' refer to the infection prevention practices that apply to all patients, regardless of suspected or confirmed diagnosis or presumed infection status. This includes hand hygiene, selection and use of personal protective equipment (PPE) (e.g., gloves, gowns, facemasks, respirators, eye protection), respiratory hygiene/cough etiquette, safe infection practices, environmental cleaning and disinfection, and reprocessing of reusable patient medical equipment."

Within the "Process" section of the aforementioned policy it stated to, "1. Perform hand hygiene per Hand Hygiene policy ...3. Change Gloves: 3.1 Between tasks and procedures on the same individual and after contact with material that may contain a high concentration of microorganisms; 3.2 After contact with patient and/or surrounding environment (including medical equipment) ...7. Prevent transmission of microorganisms from used equipment. 7.3 Discard single use items promptly.

Review of facility policy, titled "IC203 Hand Hygiene," last revised May 1, 2025, revealed the policy statement included, "Adherence to hand hygiene practices is maintained by all Center personnel. This includes hand washing with soap and water when hands are visibly soiled ...and the use of alcohol-based hand rubs (ABHR) for routine decontamination in clinical situations ...The use of gloves does not replace hand hygiene. If a task requires gloves, perform hand hygiene before donning gloves and immediately after removing gloves ..." Further, subsection, "Process," stated, "2. Hand hygiene techniques: 2.1 To wash hands with soap and water: Wet hands with warm (not hot) water, apply soap to hands, and rub hands vigorously outside the stream of water for 20 seconds covering all surfaces of the hands and fingers. Rinse hands with warm water and dry thoroughly with a disposable towel. Use clean, disposable towel to turn off faucet."

Review of facility policy, titled "IC308 Enhanced Barrier Precautions, last revised December 16, 2024, defined enhanced barrier precautions (EBP) as, " ...infection control intervention designed to reduce the transmission of novel or multi-drug resistant organisms. It employs targeted personal protective equipment (PPE) use during high contact patient/resident [sic] activities." Review of subsection 4, "Implement Contact Precautions versus EBP per following table" revealed that enhanced barrier precautions should be put in place when a resident, "Has a wound or indwelling medical device without secretions or excretions that are unable to be covered or contained and not known to be infected or colonized with any [Multi-Drug Resistant Organism]."

Review of facility procedure titled, "Enhanced Barrier Precautions," last revised May 1, 2025, revealed enhanced barrier precautions included staff wearing gloves and gown (PPE) during high contact care activities, which included wound care.

Review of Resident 238's clinical record revealed diagnoses that included pressure ulcers to the left and right heel (wound that can extend into the deep tissue and bone that is caused by pressure over a bony prominence), atrial fibrillation (irregular heartbeat), and history of gangrene infection (infection that results in the death of tissue) of the right second toe, which resulted in the partial amputation of the second right toe.

Review of Resident 238's clinical record revealed that Resident 238 had pressure ulcers to the left and right heel, along with a surgical wound that was not healed at the right, second toe.

Review of Resident 238's physician orders, including discontinued orders, from the time of admission revealed no physician order for enhanced barrier precautions.

Observation of Resident 238's room revealed that no signage was posted indicating that Resident 238 was on enhanced barrier precautions. It was observed that no personal protective equipment (PPE - gowns, gloves, facemasks, etc.,) were available at Resident 238's room.

Observations of wound dressing treatment changes for Resident 238 were started on May 8, 2025, at approximately 11:25 AM. Prior to wound dressing observations, Resident 238 was observed consuming his lunch meal, which was on his bedside table. Prior to the wound dressing observation, Employee 7 (Registered Nurse), with the help of a nurse aide, were observed transferring Resident 238 from the chair to the bed. At which time the meal tray was removed from the bedside table and removed from the room. The bed side table was not cleansed with a disinfectant agent and Resident 238's cup of water remained on the table.

Employee 7 was then observed retrieving treatment supplies from the treatment cart and placing them on the uncleaned bedside table. The items placed directly on Resident 238's bedside table included: One tube of medical grade honey, one packet of 4x4 gauze approximately half full, one box of foam adhesive dressing (containing multiple individually wrapped dressings), one packet of xeroform petroleum dressing, three single-use normal saline vials, two alcohol swap packets, and two packets of skin prep. Employee 7 then washed her hands with soap and water. Employee 7 then left the room, accessed the treatment cart and returned with a disposable drape, then entered the resident bathroom and retrieved a box of disposable gloves. The disposable drape was placed on the bedside table. Employee 7 then moved the aforementioned treatment supplies onto the drape. The box of disposable gloves was placed partially on the side of the drape. Employee 7 then left the room again, accessed the treatment cart, retrieved a pair of scissors and placed the scissors on the drape without cleansing them with an antimicrobial agent.

Employee 7 then donned gloves, without performing hand hygiene, and proceeded to remove Resident 238's left sock. Employee 7 was observed palpating the skin around the pressure ulcer of Resident 238's left heel. The left heel skin was observed to be non-intact at that time with a wound base that appeared to be dry tissue. After that, Employee 7 removed Resident 238's right sock and touched the area around the pressure ulcer of Resident 238's right heel, which was observed to be approximately 2 to 3 cm in diameter, covered in dark brown eschar (dead tissue). It was also observed that Resident 238 also had an area of dark brown eschar between the first and third toe of the right foot; the site of surgical amputation of the second toe which was part of the treatment for a gangrene infection. Employee 7 was observed handling the foot near the area of the amputated toe to observe the area. Employee 7 then checked the physician orders and replaced the sock on Resident 238's right foot. Employee 7 did not perform glove changes nor hand hygiene between Resident wounds.

Without changing gloves or performing hand hygiene, Employee 7 proceeded to cleanse the left heel pressure ulcer with normal saline and 4x4 gauze. After cleansing, Employee 7 changed gloves with no hand hygiene performed, then applied skin prep to the area around the left heel pressure ulcer. Employee 7 then changed gloves again, with no hand hygiene, then retrieved a foam adhesive bandage from the box, applied medihoney to the foam area of the bandage, and proceeded to apply the bandage to the left heel. Then with her gloved hand, Employee 7 reached into the pocket of her clothing, retrieved a pen and used the pen to initial and date the foam adhesive bandage. Employee 7 then removed Resident 238's right sock, removed her gloves, washed her hands in the bathroom sink for less than 20 seconds, and proceeded to used her bare hand, not a clean paper towel, to turn the sink faucet off.
Employee 7 was then observed leaving the room, accessing the treatment cart and retrieving a bottle of betadine solution. Employee 7 placed the bottle of betadine solution onto the bedside table and not on the drape. Observation of the bottle of the betadine solution revealed a partial pharmacy label that had been torn off. The only visible information that was left of the pharmacy label was part of the pharmacy company name.

Employee 7 then donned gloves, cleaned the right second toe amputation site with normal saline then changed gloves without performing hand hygiene. Employee 7 then used the betadine solution and 4x4 gauze retrieved from the pack to apply the betadine to the area of the surgical wound. Employee 7 then took off gloves, did not perform hand hygiene, and used her bare hand to close the bottle of betadine solution. Employee 7 then reviewed her computer, left the room to access the treatment cart and returned with a role of cling wrap, which she placed on the drape. Employee 7 then washed her hands in the bathroom sink for no more than five seconds before turning to the room.

Prior to accessing a skin tear on Resident 238's left arm, Employee 7 donned gloves. However, after observing the skin tear, Employee 7 moved the bedside table to the left side of the bed, and then proceeded to grab the resident room trashcan with her gloved hands and moved that to the left side of Resident 238's bed. Employee 7 then changed gloves without performing hand hygiene and proceeded to clean the skin tear with normal saline. After placing the xeroform petroleum dressing to the skin tear and wrapping the area with cling wrap, Employee 7 retrieved a pen from her pocket to initial and date tape used to secure the cling wrap. Employee 7 then replaced Resident 238's right sock, and removed her gloves. Employee 7 did not perform hand hygiene after removing her gloves.

At that time, Employee 7 stated she had completed the treatments for Resident 238.

Employee 7 was then observed moving the treatment items off the drape, onto the surface of the bedside table. At that time, the box of foam adhesive bandages fell off the table onto the floor. Employee 7 picked up the box and placed it back on top of the bedside table. Employee 7 then took the drape into the bathroom, discarded the drape and washed her hands with soap and water.

After exiting the bathroom, Employee 7 collected the treatment supplies in her hands, against her body, and exited the room. As Employee 7 was returning items to the treatment cart, Employee 7 dropped the bottle of betadine solution onto the floor of the resident hallway. Employee 7 picked up the betadine solution and placed it in the treatment cart drawer. Employee 7 was also observed placing the box of foam adhesive bandages into the treatment cart drawer after they had made contact with the resident room floor. Employee 7 also returned the opened single-use xeroform petroleum dressing to the treatment drawer.

Finally, during the entirety of the wound dressing change observation, Employee 7 did not wear the appropriate PPE (gown, facemask) as required by the facility's enhanced barrier precautions policy.

During a staff interview on May 8, 2025, at approximately 1:20 PM, the observations above were discussed with the Director of Nursing (DON). During the staff interview, the DON confirmed that hand hygiene should be performed between glove changes and per the facility's policy, that single-use, sterile dressings should be discarded after opening, that treatment items should be handled in a manner that is consistent with the facility's infection control and prevention policies, and that gloves and hand hygiene should be performed between accessing separate wounds on a resident. During the staff meeting, the DON confirmed that Employee 7 should have had the appropriate PPE on while performing the wound treatment changes, per the facility's enhanced barrier precautions policy.

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

Plan of Correction - To be completed: 06/24/2025

Resident #67 no longer requires contact precautions for MRSA in the urine. Physician orders have been discontinued and care plan has been resolved. Resident #238 continues to require Enhanced Barrier Precautions related to chronic pressure injuries. Physician orders have been placed and care plan has been initiated. Resident #238 was found not to be affected by the alleged deficient practice.
All residents have the potential to be affected if precautions are not implemented when required and when proper infection control measures are not followed per policy. Current residents with wounds and/or an indwelling medical device will be reviewed for the need/appropriateness for use of Enhanced Barrier Precautions. For residents that do require EBP, physician orders will be reviewed and entered if needed and care plan initiated. Employee # 7, has been educated on the treatment policy/procedure and proper hand hygiene. Hand hygiene competency has been completed with Employee # 7.
Re-education with nursing staff will be completed by the ICP/designee on Enhanced Barrier Precautions and the proper steps to initiate EBP. Hand hygiene competencies will be completed with clinical staff by the NPE/designee. Re-education on treatment procedure and proper infection control practices will be completed with licensed nurses by ICP/NPE/designee.
Audits of residents with wounds and indwelling medical devices will be reviewed weekly for 4 weeks and then monthly for 3 months by DOB/designee to ensure PPE is available, proper signage is placed, physician orders and care plan are entered. Visual observations of treatment procedures will be completed on 5 residents per week for 4 weeks and then monthly for 3 months by DON/designee. Immediate corrective action will be taken with any non-compliance with infection control practices. Audits of hand hygiene will be completed on 10 staff members a week for 4 weeks, then monthly for 3 months. Results will be reviewed with QAPI.

§ 201.14(a) LICENSURE Responsibility of licensee.:

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

Observations:

Based on an interview and review of the facility's Infection Control Meeting attendance record, the facility failed to ensure one of the required nine multidisciplinary members were present at the Infection Control meetings ( laboratory personnel).

Findings include:

Review of Act 52 (The Act of March 20, 2002, P.L.154, No. 13), known as the Medical Care Availability and Reduction of Error (Mcare) Act, Chapter 4, Section 403(1) Infection Control plan stated, "A health care facility... shall develop and implement an internal infection control plan that shall include...a multidisciplinary committee including representatives from each of the following if applicable to that specific health care facility." A review of the applicable members included Medical Staff, Administration, Nursing Staff, Patient Safety Officer, Physical Plant Personnel, a community member, laboratory personnel, pharmacy staff, and infection control team members.

Review of the facility's infection control meeting attendee list for June 20, 2024; September 5, 2024; November 21, 2024; and February 27, 2025, failed to reveal laboratory personnel were in attendance, and were not listed as a regular member of the infection control attendees.

During an interview with the Nursing Home Administrator (NHA) on May 6, 2025, at approximately 1:30 PM, the NHA confirmed the absence of laboratory personnel at the infection control meetings.

Plan of Correction - To be completed: 06/24/2025

No residents were affected by the alleged deficient practice.
Wellspan Laboratory Services was contacted and the Manager for Laboratory Client Services has verbally agreed to attend the facility's Infection Control Meetings per the requirements set forth by Act 52, Chapter 4, Section 403(1). Calendar invites for the remaining 2025 meetings have been sent to the Manager of Client Services.
Re-education will be provided to the representatives of the committee as to the requirements set forth in Act 52.
NHA/designee will audit the Infection Control Meeting attendee list times 4 to ensure compliance with the mandated attendees.

§ 201.22(b) LICENSURE Prevention, control and surveillance of tuber:

(b) Recommendations of the Centers for Disease Control and Prevention (CDC), United States Department of Health and Human Services (HHS) shall be followed in screening, testing and surveillance for TB and in treating and managing persons with confirmed or suspected TB.

Observations:

Based on personnel file review and staff interview, it was determined that the facility failed to follow the Centers for Disease Control and Prevention's guidelines for screening and testing of new employees for three of five new hires reviewed (Employees 2, 3, and 5).

Findings include:

Review of the Centers of Disease Control's (CDC) current "Clinical Testing Guidance for Tuberculosis: Health Care Personnel", dated December 15, 2023, revealed it stated, "All U.S. health care personnel should be screen for TB upon hire (i.e., preplacement) ...TB [tuberculosis] screening includes: A baseline individual TB risk assessment; TB symptom evaluation; a TB test (e.g., TB blood test or TB skin test), and Additional evaluation for TB disease as needed."

Review of the Employee 2's personnel record revealed that Employee 2's hire date was April 23, 2025. Review of Employee 2's personnel record revealed Employee 2 was not screened for tuberculosis upon hire. Review of Employee 2's employee record revealed that Employee 2 received a T. Spot blood test, which was dated March 16, 2024 (more than one year prior to hire).

Review of Employee 3's personnel record revealed that Employee 3's hire date was March 19, 2025. Review of Employee 3's personnel record revealed Employee 3 was not screened for tuberculosis upon hire. Review of Employee 3's employee record revealed that Employee 3's record had a chest x-ray dated November 1, 2024.

Review of Employee 5's personnel record revealed that Employee 5's hire date was March 11, 2025. Review of Employee 5's personnel record revealed Employee 5 was not screen for tuberculosis upon hire. Review of Employee 5's employee record revealed that Employee 5 had received a two-step PPD skin test, which was completed on November 1, 2025, prior to employment.

During a staff interview on May 8, 2025, at approximately 11:25 AM, Nursing Home Administrator revealed it was the facility's expectation that tuberculosis screening of new hire employees is conducted per the CDC's guidelines.

Plan of Correction - To be completed: 06/24/2025

Employees #2, #3 and #5 had a TB symptom evaluation completed prior to start of employment. They experienced no signs or symptoms of Tuberculosis. Employee #3 no longer works at the facility. Employee #2 has received a TB-gold with a negative result. Employee #5 has started the 2-step PPD process. No residents were affected by the alleged deficient practice.
Current employee files will be reviewed to ensure compliance with the Centers of Disease Control's current "Clinical Testing Guidance for Tuberculosis: Healthcare Personnel". New employees will be reviewed prior to their start date to ensure compliance with current CDC guidelines.
Human Resources, Staff Development, and Nursing Leadership will be re-educated by the NHA/designee regarding the Clinical Testing Guidelines. Employee files will be reviewed and signed off prior to start of employment to ensure compliance.
Audits will be completed on all new hires weekly times 4 weeks and then monthly times 3 months. Results will be reviewed at QAPI to determine the need for continued review.

§ 211.12(f.1)(3) LICENSURE Nursing services. :

(3) Effective July 1, 2024, a minimum of 1 nurse aide per 10 residents during the day, 1 nurse aide per 11 residents during the evening, and 1 nurse aide per 15 residents overnight.

Observations:

Based on staffing document review and resident and staff interviews, it was determined that the facility failed to ensure a required minimum of one Nurse Aide (NA) per 10 residents on the day shift for one of the 21 days reviewed (May 5, 2025); and one NA per 11 residents on evening shift for three of 21 days reviewed (November 28, 2024; December 1, 2024; and May 6, 2025); as calculated by full time equivalent (FTE - Number of staff required calculated by determining the required number of hours of full-time shifts worked to meet the minimum staff to resident ratio).

Findings include:

During an interview with Resident 78 on May 6, 2025, at 9:36 AM, she revealed that the facility is short staffed.

A review of staffing information for the day shift of May 5, 2025, revealed a resident census of 137, which resulted in a minimum NA FTE of 13.70; submitted information revealed the facility provided 12.88.

A review of staffing information for the evening shift of November 28, 2024, revealed a resident census of 137, which resulted in a minimum NA FTE of 12.45; submitted information revealed the facility provided 7.45.

A review of staffing information for the evening shift of December 1, 2024, revealed a resident census of 135, which resulted in a minimum NA FTE of 12.27; submitted information revealed the facility provided 9.09.

A review of staffing information for the evening shift of May 6, 2025, revealed a resident census of 140, which resulted in a minimum NA FTE of 12.73; submitted information revealed the facility provided 12.30.

During an interview with the Director of Nursing on May 8, 2025, at 10:15 AM, she acknowledged that the facility was not meeting the minimum staffing requirements per the state regulation.

Plan of Correction - To be completed: 06/24/2025

Nursing ratios were adjusted to ensure a 1:10 ratio on days, 1:11 ratio on evenings and 1:15 ratio on night shift. The shifts that were identified as falling below the state minimum requirement were due to call offs.
Nursing ratios will be scheduled at a 1:10 ratio for days, 1:11 ratio for evenings and 1:15 ratio for night shift. Labor management meetings are scheduled daily Monday through Friday with the NHA, DON, HRD and scheduler to review current and expected staffing needs.
Re-education has been provided to the scheduler and HRD to ensure the ratios are met for each shift per the regulations. Re-education has also been provided to the clinical staff about the attendance policy and the consequences of attendance infractions. The facility has begun using an online agency platform (Clipboard) that allows nursing administrators to post PRN shifts. Clipboard offers monetary incentives for picking up shifts that are added the same day as the need. The Director of Nursing is on call and re-education to the nursing supervisors will be done as a reminder to notify the DON when staffing falls below the state minimum requirement.
DON/designee will do random audits of 5 shifts per week for 4 weeks to ensure compliance. Results will be submitted to QAPI to determine if audits will continue.

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