Pennsylvania Department of Health
CHURCH OF GOD HOME INC
Patient Care Inspection Results

Note: If you need to change the font size, click the "View" menu at the top of the page, place the mouse over the "Text Size" menu item, and select the desired font size.

Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

CHURCH OF GOD HOME INC
Inspection Results For:

There are 99 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.


CHURCH OF GOD HOME INC - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:

Based on a Medicare/Medicaid Recertification survey, State Licensure survey, and Civil Rights Compliance survey completed February 6, 2025, it was determined that Church of God Home was not in compliance with the following requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care and the 28 Pa. Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations as they relate to the Health portion of the survey.

Plan of Correction:

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

This is a more serious deficiency but is isolated to the fewest number of residents, staff, or occurrences. This deficiency results in a negative outcome that has negatively affected the resident's ability to achieve his/her highest functional status.

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

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

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

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

Plan of Correction - To be completed: 03/14/2025

1. R17 corrected with new order in an effort to advance diet texture, along with double portions of protein with each meal, R28 and R58 missing weight and documentation was corrected and MD notification was made aware of current weight along with dietician, all residents continue to reside at the facility.

2. The facility has determined that all residents have the potential to be affected by this deficient practice. The DON and/or Dieticians will conduct an order review by March 14, 2025 to identify any residents that have orders for daily weights perimeters to notify the MD with weight changes to also ensure they are appropriately calculated based on weight and medical diagnosis and following the dietitian comprehensive nutrition assessment.
Facility wide audit will be conducted by the dietician and DON for any resident identified with missing documentation, missing MD notification and physician orders not followed up on by March 14, 2025.

3. DON will educate the Dietitian to fill out a communication form upon a significant weight gain over 30 days, 3 months, and 6 months to be given to the DON and placed in the MDs review folder. In the daily standup meetings, the dietitian notes will be reviewed for significant weight loss/gain with the IDT team to ensure communication and MD notification is implemented and documented timely in the Treatment Administration Record. The DON will also educate the Rehab Department on documenting refusals as evidenced in speech therapy to ensure consult or supplements were discussed with the physician and documented in the EHR (PCC) by March 14, 2025. The DON and Dietician will educate all nursing staff and the IDT team on the policy and procedure of nutrition and hydration status maintenance of the clinical process of fluid and dietary status per individual resident to monitor fluctuations that would be anticipated and may trigger significant weight loss/ gain by March 14, 2025.

4. An audit of all residents will be conducted to ensure weights are being completed according to physician orders, therapy refusals are be conducted, and ensuring documentation is completed weekly x 4 then monthly x 2 by the DON and /or Dietitian to ensure the resident has no signs of significant weight loss, until 100% compliance is achieved. The findings of the audits will be reported at the monthly and quarterly QAPI meeting until consistent compliance has been met.

483.15(c)(3)-(6)(8) REQUIREMENT Notice Requirements Before Transfer/Discharge:

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

§483.15(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(k).

Plan of Correction - To be completed: 03/14/2025

1. Unable to retroactively correct the clinical record for Residents 1, 28, 52, 53, and 58 with a notice upon transfer that included required and revised information. All residents continue to reside at the facility. R69 no longer resides at the facility, no adverse effects related to practice.

2. All residents have the potential to be impacted. R1, R28, R52, R53 and R58 will be given the revised Transfer or Discharge form with the appropriate notice of information no later than March 14, 2025 for any immediate Transfer or Discharge, along with a facility wide audit conducted by the DON and Shift Supervisors.

3. DON will educate the Shift Supervisors by March 14, 2025 upon emergent transfer to the hospital and will provide the revised Notice of Resident Transfer or Discharge form to resident and document in a progress note via the EHR system (PCC) to reflect it was presented with appropriate information. The Shift Supervisor is to then complete a progress note documenting the notice was provided and to whom. The DON will also educate Shift supervisor on the updated Notice of Resident Transfer on Discharge form, and to provide the Notice of Resident Transfer to Discharge Form to the Resident revealing the mailing address of the entity, which receives request for appeals, mailing address of the Office of the State Long Term Care Ombudsman for protection and advocacy of individuals with developmental disabilities and mental disorders. The DON will in-service the Shift Supervisors by March 14, 2025 to ensure the representative is provided the notice and signed the form when received. DON will also educate the Social Worker by March 14, 2025 to send a 30-day log of transfer and discharges to the local Ombudsman's' email box.

4. Social Worker Director and DON will conduct a record audit via the progress notes of all residents who have emergent transfer to the hospital and audit the transfer and discharge log to be sent to the Ombudsman daily x 3 to ensure the Notice of Residents Transfer or Discharge information contained appropriate information and was given and signed appropriately, to whom until 100% completion is achieved. Audits will continue x2 weekly, until 100% is achieved. Findings of the audits will be reported monthly to the QAPI committee meeting to ensure compliance is obtained and maintained.

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: 03/14/2025

1. The dish machine temporary log and utilizing kitchen equipment has been corrected and the NHA educated (E8) Food Service Director and dietary staff immediately on the professional standards for food service safety in the main kitchen, including logging the dishwasher temperatures.

2. The facility has determined that all residents have the potential to be affected by this alleged deficient practice. No adverse effects related to the deficiency cited.

3. The Food Service Director (E8), Assisted Food Director and dietary staff were educated immediately by the NHA and will continued to be monitored by March 14, 2025 and observed by the NHA on utilizing professional standard kitchen equipment for food service safety and logging the dish machine temperature during all meal periods.

4. The Food Director and Assistant Director of Dining Services will be auditing the dish machine logs during each meal period and the dish machine log along with the dinner cook weekly x 4 weeks then monthly x 2 months by the NHA and/or Vice President of Facilities. This plan of correction will be monitored at the monthly QAPI meeting until such time consistent substantial compliance has been met.

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

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

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

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

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

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

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

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

Plan of Correction - To be completed: 03/14/2025

1. R53 potential side effects monitored for behaviors was corrected in the clinical record, care plan updated and resident continues to reside at the facility. R58's potential targeted behavior side effect is being monitored, corrected in the clinical record, care plan updated for behaviors and resident continues to reside at the facility.

2. The facility lacked evidence of side effect monitoring for the residents' individual psychotropic medications and monitoring of target behaviors for unnecessary psychotropic medications. The facility has determined that all residents prescribed psychotropic medication have the potential to be affected by this alleged deficient practice. DON is currently monitoring R53 and R58 prescribed psychotropic medication for side effects and targeted behaviors and will be conducting a facility wide audit by March 14, 2025 with the Shift Supervisors to review and ensure side effects and targeted behaviors are in place and documented in the medical record for each individual resident.

3. DON will re-educate clinical management on monitoring possible side effects and target behaviors for all residents on psychotropic medication by March 14, 2025. Routine GDR meetings are currently being held monthly by the DON, NHA, shift supervisors, medical director, IDT staff members, and Pharmacy Consultant for review.

4. The NHA, DON and Medical Director will conduct 3 random audits of at least five residents receiving psychotropic medication to ensure side effects are monitored. The audit will be conducted once a week for 4 weeks then monthly for 2 months until substantial compliance is achieved or as otherwise determined by the findings reported at the monthly and quarterly QAPI meeting until consistent compliance has been met.

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.

Plan of Correction - To be completed: 03/14/2025

1. R4 unable to retroactively correct care plan. R4 was recently offered to participate in the care planning process and declined on 2/19/25 invited by the Activities Director, documented on clinical record of resident's choice to decline. R4 acknowledged understanding of residents right to participate in the care planning process. R28 unable to retroactively correct clinical record of the presence of the rash, it is confirmed the rash was resolved. R28 care plan was reviewed and updated to reflect all care areas specific to the resident preferences, such as wearing a bra daily. Section V of the MDS care area assessment summary for R28 was also updated for assistance with eating, oral hygiene, toileting hygiene, showering/bathing, upper body dressing, lower body dressing, putting on and taking off footwear, personal hygiene, transfers, and mobility, along with preference of importance to choose clothing. R28's care plan specifics for ADL self-care performance also reviewed for additional interventions and updated. R37 care plan for rash was updated on 2/6/25 for the treatment of the rash. R58 care plan was updated on 2/17/25 to reflect the antipsychotic medication was being utilized to manage residents identified targeted behaviors and on 2/5/25 it was indicated on the R58's care plan that it was updated to reflect antipsychotic use. R4, R28, R37 and R58 currently reside at the facility and no adverse effects related to practice.

2. The facility has determined that all residents have the potential to be affected by this deficient practice. The DON, Shift Supervisors, Social Services, Activities Director and MDS Coordinator will audit all care plans to ensure the comprehensive care plans are being updated or new care plans completed for all residents including readmissions from hospital to reflect individual preferences and Resident-specific ADL information to include interventions by March 14, 2025.

3. To prevent other residents from being affected the DON will re-educate the Social Services and Activities Director, Activities Director and Shift Nurse Supervisors by March 14, 2025 on the requirements and policy of the Comprehensive Care Plan and quarterly review assessments, as well as compliance with the Care Plan Revisions. Additional, training to include residents right to be invited to Comprehensive Care plans and document that the invite was offered or refused, along with documentation that resident understands and acknowledges their rights to attend care plan meetings. The DON will also educate on directives of physician orders, documenting the identification of any medical concerns or progress along with interventions and treatment follow up for residents. The DON and NHA will also in-service the IDT Team on communication of any new information or updates in the daily standup and clinical meetings to include, change of condition or significant change to be updated in the resident's care plan.

4. An audit will be conducted by the DON, Activities and/or Social Services Director to ensure comprehensive care plans and assessments are completed timely, updated/revised for all residents weekly x 4 then monthly for 2 months, until 100% is achieved. Findings of the audits will be reported monthly to the QAPI committee meeting to ensure compliance is obtained and maintained.

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

§483.15(d) Notice of bed-hold policy and return-

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

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

Plan of Correction - To be completed: 03/14/2025

1. Unable to retroactively correct the clinical record for R28 and R53 to provide clinical record of the facility's bed-hold notice upon date of transfer or discharge from the facility. Both residents continue to reside at the facility. Unable to retroactively correct the clinical record for R1, R28, R52, R58 and R69 to provide bed-hold notices that included the required information upon transfer, residents continue to reside at the facility. R69 no longer resides at the facility, no adverse effects related to practice.

2. All residents have the potential to be impacted. R1, 28, 52, 53, and 58 immediately will be given the form regarding Bed Hold Notice regulation no later than March 14, 2025 or any need for bed hold notice immediately of Transitions of Care Policy and Procedure, Admission, Transfers, and Discharge for the Resident and/or Resident Representative. R69 no longer resides at the facility, no adverse effects related to practice.

3. Facility wide Audits of all bed hold transfers or discharges for the past 3 months will be conducted by the DON and/or Shift Supervisor. Any residents who do not have the appropriate information on the bed transfer form will be given a new form with the revised information by March 14, 2025.

4. The DON will in-service the Shift Supervisor upon emergent transfer to the hospital to provide the Notice of Bed Hold form to the resident by March 14, 2025. The Shift Supervisor is to then complete a progress note stating it was provided, and to whom. DON will educate the Shift Supervisors on the revised Notice of Bed Hold Form to the resident upon emergent transfer to the hospital, and document in a progress note in the EHR (PCC) System that it was given.

4. Social Worker Director and DON will conduct a record audit via the progress notes of all residents who have emergent bed-hold notices upon transfer or discharge to the hospital and audit the transfer and discharge log to be sent to the Ombudsman daily x 3 to ensure the Notice of Residents Transfer or Discharge form was given and signed appropriately, to whom until 100% completion is achieved. Audits will continue x2 weekly, until 100% is achieved. Findings of the audits will be reported monthly to the QAPI committee meeting to ensure compliance is obtained and maintained.

483.20(g) REQUIREMENT Accuracy of Assessments:

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

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

Plan of Correction - To be completed: 03/14/2025

1. R17 quarterly MDS was corrected to reflect weight loss, R28 Medicare 5 Day MDS was corrected to reflect weight loss and R58 quarterly MDS was corrected to reflect urinary catheter. All residents reside at the facility. No adverse effects related to practice.

2. All residents have the potential to be impacted. The MDS Coordinator will conduct a facility audit of the most recent completed MDS assessments for all residents to identify correct cording of weight/loss/gain: and correct coding of indwelling catheter by March 14, 2025. Any coding errors identified in the audit will be corrected as well.

3. DON and/or NHA to educate the MDS Coordinator by March 14, 2025 on Section K, Swallowing and Nutritional Status of the RAI Manual; and Section H Bowel and Bladder of the RAI Manual that includes the importance of thoroughly reviewing the medical record prior to completing the MDS Assessment.

4. Audits to be completed by the MDS Coordinator for the MDS section K and Section H on 5 residents weekly x4 then monthly for 2 months, until 100% is achieved. Findings of the audits will be reported monthly to the QAPI committee meeting to ensure compliance is obtained and maintained.

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: 03/14/2025

1. R2 no longer resides at the facility. The DON educated E3 immediately on Initiation of Enhanced Barrier Precautions to be obtained for residents with chronic wounds such as pressure ulcers consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing, this includes all residents under any type of precautions to ensure appropriate signage is posted to reflect as such.

2. The facility has determined that all residents have the potential to be affected by this deficient practice. A facility wide audit will be conducted by the DON and or IP Nurse and nursing staff by March 14, 2025 to identify residents under any type of precautions to ensure appropriate signage is posted prior to employees entering the room.

3. DON and IP Nurse will educate all staff by March 14, 2025 addressing observance of signs posted on the door to determine PPE precautions and the use of gloves, mask, gown when performing high contact procedures and to ensure gowns and gloves available immediately near or outside of the resident's room.

4. Random Audits will be conducted by IP Nurse and or DON of at least five residents per week for 4 weeks then monthly for 2 months until 100% compliance is achieved or as otherwise determined by Risk Management Team/Quality Assurance Committee to ensure compliance is obtained and maintained.

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.

Observations:

Based on record review, observation, and staff interviews, it was determined that the facility failed to prevent accident and hazards for two of 18 residents reviewed (Residents 35 and 47.)

Findings include:

Review of Resident 35's clinical record revealed diagnoses that included Alzheimer's disease (a brain disorder that slowly destroys memory and thinking skills, and, eventually, the ability to carry out the simplest tasks) and hyperlipidemia (high levels of fats in the bloodstream).

Review of Resident 35's fall incident report that occurred on September 8, 2024, revealed Resident 35 had an un-witnessed fall that occurred in the Resident's bathroom. The Incident Description revealed, in part, "This writer was called to residents' room related to unwitnessed fall in bathroom. Walker noted to foot of bed in residents' room. Bathroom call bell was not activated. Staff reports assisting resident to the bathroom and providing her with the call bell prior to fall. No staff member present in the bathroom when resident attempted to get herself off the toilet. No apparent injuries noted."

Review of Resident 35's comprehensive care plan revealed an Activities of Daily Living (ADL) focus area with an intervention for toilet use: assist of one, with an initiation date of June 13, 2024; and an intervention for transfer: one assist with rolling walker and gait belt, with an initiation date of June 13, 2024.

During an interview with Employee 3 on February 5, 2025, at 12:09 PM, revealed Resident 35 was not able to use her call bell and does not ever use it.

During an interview with Employee 4 on February 5, 2025, at 9:57 AM, revealed Resident 35 did not understand how to use their call bell, and will often yell out instead when the Resident needed assistance.

During an interview with Employee 5 on February 5, 2025, at 9:43 AM, revealed Resident 35 did not understand how to use their call bell.

Review of Resident 35's clinical record reveals the Resident has a BIMS (brief interview for mental status) score of 3, which suggest severe cognitive impairment.

During an interview with the Nursing Home Administrator (NHA) on February 5, 2025, revealed that Resident 35 should not have been left alone in the bathroom during the fall incident that occurred on September 8, 2024, and that the staff member involved was terminated. NHA revealed they determine if a resident is able to use a call bell based off of their BIMS in most circumstances.

Review of Resident 47's clinical record revealed diagnoses that included dementia (a brain disorder that causes a decline in cognitive function, memory, and behavior, severe enough to interfere with daily life) and hypertension (high blood pressure).

Observation on February 3, 2025, on 1:04 PM, revealed Resident 47 was not in their room, although there was a fall mat on the floor to the left side of their bed.

Review of Resident 47's comprehensive care plan revealed a focus area for being a fall risk with an intervention for their fall mat to left side of bed when Resident in bed. Remove when out of bed, with an initiation date on April 8, 2024.

Review of Resident 47's clinical record revealed an incident note on December 17, 2024, that read, in part, "A staff member responded to an unwitnessed fall in Resident 47's room. Arrived to Resident 47 sitting on the left side of her bed leaning up against her bed with grip socks on and fall mat not in place. No injuries were found. Staff educated on placing fall mat."

During an interview with the NHA on February 5, 2025, at 8:32 PM, revealed education was provided in ensuring Resident 47's fall mat is properly in place.

28 Pa. Code 201.18(b)(1)(2)Management
28 Pa. Code 211.12(d)(3)(5)Nursing services

Plan of Correction - To be completed: 03/14/2025

1. R35 resides at the facility and R47 no longer resides at the facility, both residents have the potential to be impacted by the deficient practice. The IDT team met and reviewed R35 fall care plan to ensure it reflects appropriate interventions that is appropriate for residents' clinical diagnosis that includes dementia (a brain disorder that causes a decline in cognitive function, memory, and behavior, sever enough to interfere with daily life).

2. Current residents will have their fall risk assessment reviewed and residents identified at risk will have a care plan update to ensure appropriate interventions are in place. Including conducting a fall mat audit by the DON and Facilities Director to ensure care plans match fall mat policy and resident care needs and positioning of the mat, if deemed necessary to prevent future occurrence by March 14, 2025.

3. A fall packet will be placed on the nursing units that will include a list of possible interventions to initiate post fall. DON and IDT Team will be re-educating staff on February 26, 2025 on the implementation of interventions immediately post fall and observance of residents who may not be in compliance with call bell protocol or lack awareness of usage to review and guide the team to the appropriate interventions. All falls will be reviewed in the clinical daily meeting with the IDT team to ensure an appropriate intervention has been added to the resident's care plan.

4. Falls that occurred will be reviewed by the DON and clinical team weekly x 4 weeks then monthly x 3 months to ensure appropriate interventions are initiated, added to the care plan and in place, along with auditing of the use of mats for the individual resident. This plan of correction will be monitored at the monthly Quality Assurance meeting until consistent substantial compliance has been met.

483.55(a)(1)-(5) REQUIREMENT Routine/Emergency Dental Srvcs in SNFs:

§483.55 Dental services.
The facility must assist residents in obtaining routine and 24-hour emergency dental care.

§483.55(a) Skilled Nursing Facilities
A facility-

§483.55(a)(1) Must provide or obtain from an outside resource, in accordance with with §483.70(f) of this part, routine and emergency dental services to meet the needs of each resident;

§483.55(a)(2) May charge a Medicare resident an additional amount for routine and emergency dental services;

§483.55(a)(3) Must have a policy identifying those circumstances when the loss or damage of dentures is the facility's responsibility and may not charge a resident for the loss or damage of dentures determined in accordance with facility policy to be the facility's responsibility;

§483.55(a)(4) Must if necessary or if requested, assist the resident;
(i) In making appointments; and
(ii) By arranging for transportation to and from the dental services location; and

§483.55(a)(5) Must promptly, within 3 days, refer residents with lost or damaged dentures for dental services. If a referral does not occur within 3 days, the facility must provide documentation of what they did to ensure the resident could still eat and drink adequately while awaiting dental services and the extenuating circumstances that led to the delay.

Observations:

Based on clinical record review, resident and staff interviews, and facility document review, it was determined that the facility failed to ensure residents are assisted with obtaining routine dental care for one of one residents reviewed for dental care (Resident 52).

Findings include:

Review of Resident 52's clinical record on February 3, 2025, revealed diagnoses that included hypertension (elevated/high blood pressure) and diabetes mellitus type two (decreased ability of the body to utilize insulin for the transport of glucose from the blood stream into the cells for nourishment).

During a resident interview on February 3, 2025, Resident 52 indicated that he was awaiting teeth extraction of his upper teeth in order to have a full-upper denture created. During the interview, Resident 52 stated that he had a partial top denture that moves around as he eats.

Review of Resident 52's clinical record revealed a dental consultation that was conducted on October 21, 2024.

Review of the dental consultation sheet revealed that section "Treatment notes," stated, "[Patient] wears upper partial denture. [Patient] removed upper partial. Noted [patient] appears to have retained root tips under existing upper partial . recommend FMX [x-rays of the mouth] in order to evaluate dentition ...will follow up with [patient] following xrays ...[patient] will be set up for a oral surgery consult for extractions following xray review ..." Further, review of consult sheet's "Recommended treatment," section revealed the box for "Other X-Ray; FMX needed to evaluate dentition."

Review of Resident 52's clinical record on February 5, 2025, revealed that, as of review, Resident 52 had not had any dental x-rays completed, nor had there been any consultation order for the extraction of Resident 52's upper teeth.

Review of facility document, titled "Visit Summary," submitted on February 6, 2025, at 2:29 PM, revealed it was a document that listed the Resident's evaluated on October 21, 2025, along with recommendations and/or orders made by the dentist, and future treatment(s) recommended by the dentist.

Review of the "Visit Summary," revealed Resident 52's "Recommendations / Orders," and "Future Treatment(s)," did not include the recommendation identified on Resident 52's individual dental consult sheet of dental x-rays and surgical consult for extraction of teeth.

During a staff interview on February 6, 2025, at approximately 3:20 PM, Nursing Home Administrator revealed that the physician reviews the "Visit Summary" and would provide orders that were indicated on that sheet, and since the recommendations identified on Resident 52's individual dental consultation form were not included in the "Visit Summary" document, Resident 52 would not have had further treatment or consultation.

28 Pa code 211.12(d)(3)(5) Nursing services
28 Pa code 211.15 Dental services

Plan of Correction - To be completed: 03/14/2025

1. R52 currently resides at the facility and has been added to the recommended identified contracted dental center for the resident's individual dental consult sheet of dental x-rays and surgical consult for extraction of teeth by March 14, 2025.

2. The facility has determined that all residents have the potential to be affected by this deficient practice. Current residents will be reviewed by the DON and Shift Supervisors to ensure that routine dental services are provided when needed and by March 14, 2025.

3. Re-education will be provided by DON to the licensed nursing staff to include routine and emergency dental services per policy by March 14, 2025.

4. DON and Nurse Supervisors will conduct an audit of at least 5 random residents to determine if dental services have been received as necessary. These audits will be done weekly x4 weeks and then monthly x2 until substantial compliance is achieved or as determined by the findings reported at the monthly and quarterly QAPI meeting until consistent compliance has been met.

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, and staff interviews, it was determined that the facility failed to ensure staff implemented infection control policies to prevent the spread of infection by using PPE (personal protective equipment) in two of four resident care areas reviewed (Love one and Love two), and failed to handle potentially contaminated items to decrease the possibility for transmission of a infectious disease for one of one unit treatment carts observed (Love unit treatment cart).

Findings Include:

Review of facility policy, Transmission-Based (Isolation) Precautions, last reviewed January 17, 2025, revealed that, "Contact precautions" refer to measures that are intended to prevent transmission of infectious agents which are spread by direct or indirect contact with the resident or the resident's environment. Further review of this policy under the section labeled, Contact Precautions, revealed that healthcare personnel caring for residents on Contact Precautions wear a gown and gloves for all interactions that may involve contact with the resident or potentially contaminated areas in the resident's environment. Also, donning personal protective equipment (PPE) upon room entry and discarding before exiting the room is done to contain pathogens, especially those that have been implicated in transmission through environmental contamination.

Review of the aforementioned policy, revealed subsection 7-g, stated, "Use disposable or dedicated noncritical resident-care equipment ...If sharing noncritical equipment between residents, the equipment will be cleaned and disinfected following manufacturer's instructions with an EPA-registered disinfectant after use."

Review of Resident 2's clinical record on February 4, 2025, revealed diagnoses that included dementia (progressive, irreversible degenerative disease of the brain that results in decreased contact with reality and decreased ability to perform activities of daily living) and hypertension (elevated/high blood pressure).

Review of Resident 2's clinical record revealed Resident 2 had an unstageable pressure injury (wound of the skin that has an undetermined depth due to the wound bed being covered with dead tissue or other wound debris) of the third toe on the right foot.

Prior to wound treatment observation on February 5, 2025, at approximately 12:45 PM, Employee 3 (Licensed Practical Nurse) stated that Resident 2 had been diagnosed with influenza.

Observation of Resident 2's room door revealed Resident 2 was on droplet precautions (use of gloves, mask, eye protection, and gown-if there is a risk of contamination e.g., coughing, aerosol treatments, splatter of infectious bodily fluids).

Prior to wound treatment, Employee 3 was observed removing supplies from the Love unit treatment cart, which included individually packaged gauze.

During wound treatment observations, Employee 3 was observed placing the treatment supplies on Resident 2's bedside table.

After Employee 3 was finished with the wound treatment to Resident 2's right third toe, Employee 3 was observed moving an unused, unopened pack of gauze from the bedside table to Resident 2's bed. Employee 3 was observed retrieving the pack of gauze from Resident 2's bed, exiting the room, and returning the pack of gauze into the box in the treatment cart from where they were removed.

During a staff interview directly after the observation, Employee 3 confirmed that the gauze were in the Resident's room, who was on droplet precaution for influenza and that the gauze made contact with Resident 2's table and bed. Employee 3 was observed then removing the box of gauze from the treatment cart.

During a staff interview on February 5, 2025, at approximately 1:30 PM, Director of Nursing (DON) revealed that Employee 3 should have discarded the pack of gauze and not returned them to the treatment cart.

Review of Resident 5's clinical record revealed diagnoses that included dysphagia (difficulty swallowing foods or liquids) and dementia (a brain disorder that causes a decline in cognitive function, memory, and behavior, severe enough to interfere with daily life).

Observation of Resident 5 on February 3, 2025, at 12:45 PM, revealed the Resident was laying in bed in their room. There was a sign on the door that revealed Resident 5 was on droplet precautions, that further read: Everyone must clean their hands, including before entering and when leaving the room. Make sure their eyes, nose, and mouth are fully covered before room entry. Remove face protection before room exit.

Further observation on February 3, 2025, at 12:46 PM, revealed Employee 7 enter room to provide Resident 5 their lunch tray, exit their room and enter another resident's room, then back into Resident 5's room and proceeded to assist Resident 5 in eating their lunch. Employee 7 did not perform any hand hygiene prior to entering Resident 5's room or upon exiting Resident 5's room, and did not wear any face protection upon entering their room.

Review of Resident 5's current physician orders reveal an order for Droplet precautions for influenza A, with an active date of January 30, 2025.

During an interview with the Nursing Home Administrator (NHA) on February 5, 2025, at 8:32 PM, confirmed that droplet precautions were not followed during the observation of Resident 5 being served lunch by Employee 7 on February 3, 2025.

Review of Resident 25's clinical record revealed diagnoses that included diabetes (a chronic disease that occurs when your blood sugar levels are too high) and dementia (a group of diseases and illnesses that affect your thinking, memory, reasoning, personality, mood and behavior).

Observation of Resident 25 on February 3, 2025, at 10:17 AM, revealed the Resident 25 sitting in her room. There was a sign on the door that revealed that the Resident was on contact precautions.

Further observation at 12:19 PM, on February 3, 2025, revealed Employee 1 enter Resident 25's room to bring the Resident's lunch and set it up for Resident 26 to eat. Employee 1 then exited the room and continued taking meal trays to other residents. At no time did Employee 1 use any PPE while in Resident 25's room or even perform hand hygiene.

Review of Resident 25's electronic medical record on February 3, 2025, revealed that Resident 25 was tested for scabies (a contagious skin condition caused by mites burrowing into the skin) on January 30, 2025, and the test returned positive, indicating that Resident 25 had scabies.

Review of Resident 25's physician orders on February 3, 2025, revealed an order dated January 30, 2025, that indicated that Resident 25 was to be on contact precautions.

Interview of the NHA on February 6, 2025, at 11:15 AM, revealed that she would expect employees to follow the facility policies and guidance regarding residents on contact precautions.

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

Plan of Correction - To be completed: 03/14/2025

1. R2 no longer resides at the facility. R5 and R25 continues to reside at the facility. E1, E3 and E7 were educated immediately by the DON and IP Nurse on facility policy review to ensure staff implemented infection control policies to prevent the spread of infection by using PPE (personal protective equipment) and educated on how to handle potentially contaminated items to decrease the possibility for transmission of infectious disease for one of one unit treatment carts observed, along with education on Transmission-based (Isolation) precautions "Contact Precautions" to wear a gown for all interactions that may involve contact with residents or potentially contaminated areas in the residents room and/or environment.

2. The facility has determined that all residents have the potential to be affected by this deficient practice.

3. A Root Cause Analysis was conducted and the cause was determined that the facility staff member E3 failed to implement infection control policies to prevent the spread of infection by not using PPE (Personal Protective Equipment) in R2 care areas while providing wound care to R2, failed to follow droplet precautions to use gloves, mask, eye protection, and gown, then E3 was also observed moving an unused, unopened pack of gauze from the bedside table to R2s bed, while observed exiting the room, and returning the pack of gauze into the box in the treatment cart from where they were moved. E7 failed to perform any hand hygiene prior to entering residents R5 and R7 rooms to provide lunch on a tray, then proceeded to assist R5 with assistance of lunch. E7 failed to adhere to the droplet precautions on R5 door that revealed resident was on droplet precautions. E1 failed to enter R25's room while resident was on contact precautions and enter R25s room with lunch tray, set it up for R25 to eat then E1 exit the room and continued on taking trays to other residents, exiting R5 room without wearing any face protection upon entering room. and failed to handle potentially contaminated items to decrease the possibility for transmission of an infection disease from the Love and Love two units, then to one of one unit treatment carts on the Love unit.

4. A facility wide audit will be conducted by the DON, IP Nurse and Shift Supervisors by March 14, 2025 to review all residents who have the potential to be affected by this deficient practice. Re-educate all staff (including maintenance, housekeeping, dietary, administration, etc.) on donning personal protective equipment (PPE) upon room entry and discarding before exiting the room which is done to contain pathogens, especially those that have been implicated in transmission through environmental contamination. The education will also include, identifying, reporting and prevention of the Transmission-Based (Isolation) accepted national standards and how to use disposable of dedicated noncritical resident-care equipment between residents, the following equipment will be cleaned and disinfected by manufactures instructions with an EPA-registered disinfectant after use. The DON, IP Nurse will also educate all nursing staff on moving any unused, unopened pack of gauze from the bedside table to another resident's room, as to not exit rooms and returning the pack of gauze into the box in the treatment cart from where they were removed initially, then to and from residents' room without proper droplet precaution awareness of signage. DON and IP Nurse will continue to re-education all staff through March 14, 2025 on donning and doffing PPE to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of communicable disease and infection.

5. The audit will be conducted by the DON and IP Nurse at the rate of 10% weekly until 100% compliance is achieved for three consecutive audits. Then the audit will be conducted monthly x 3 months, if 100% compliance is achieved/maintained, the deficiency will be considered resolved. Results of the audits will be presented by the DON and IP Nurse and discussed at the monthly QAPI meeting to determine the need for further audits and or action plans.

483.80(d)(1)(2) REQUIREMENT Influenza and Pneumococcal Immunizations:

§483.80(d) Influenza and pneumococcal immunizations
§483.80(d)(1) Influenza. The facility must develop policies and procedures to ensure that-
(i) Before offering the influenza immunization, each resident or the resident's representative receives education regarding the benefits and potential side effects of the immunization;
(ii) Each resident is offered an influenza immunization October 1 through March 31 annually, unless the immunization is medically contraindicated or the resident has already been immunized during this time period;
(iii) The resident or the resident's representative has the opportunity to refuse immunization; and
(iv)The resident's medical record includes documentation that indicates, at a minimum, the following:
(A) That the resident or resident's representative was provided education regarding the benefits and potential side effects of influenza immunization; and
(B) That the resident either received the influenza immunization or did not receive the influenza immunization due to medical contraindications or refusal.

§483.80(d)(2) Pneumococcal disease. The facility must develop policies and procedures to ensure that-
(i) Before offering the pneumococcal immunization, each resident or the resident's representative receives education regarding the benefits and potential side effects of the immunization;
(ii) Each resident is offered a pneumococcal immunization, unless the immunization is medically contraindicated or the resident has already been immunized;
(iii) The resident or the resident's representative has the opportunity to refuse immunization; and
(iv)The resident's medical record includes documentation that indicates, at a minimum, the following:
(A) That the resident or resident's representative was provided education regarding the benefits and potential side effects of pneumococcal immunization; and
(B) That the resident either received the pneumococcal immunization or did not receive the pneumococcal immunization due to medical contraindication or refusal.

Observations:

Based on facility policy review, clinical record review, and staff interviews, it was determined that the facility failed to provide evidence that education was provided to Residents and/or their Representatives on the risks, benefits, or side effects of the influenza vaccine for two of five residents reviewed for immunizations (Residents 8 and 25).

Findings Include:

Review of facility policy, titled "Influenza Vaccination" with an implementation date of April 7, 2022, and a last review date of January 17, 2025, revealed, in part, "5. Prior to the administration of the influenza vaccine, the person receiving the immunization, or his/her legal representative, will be provided with a copy of CDC's current vaccine information statement relative to the influenza vaccination. 6. The vaccine information statements (VIS) will, as appropriate, be supplemented with visual presentations or oral explanations to assist vaccine recipients in understanding the benefits and potential side effects of the influenza vaccine. (See Vaccine Information Statements Policy.) 7. Individuals receiving the influenza vaccine, or their legal representative, will be required to sign a consent form prior to the administration of the vaccine. The completed, signed, and dated record will be filed in the individual's medical record. 9. The resident's medical record will include documentation that the resident and/or the resident's representative was provided education regarding the benefits and potential side effects of immunization, and that the resident received or did not receive the immunization due to medical contraindication or refusal."

Review of Resident 8's clinical record revealed diagnoses that included hypertension (high blood pressure), diabetes (disease that occurs when your blood glucose, also called blood sugar, is too high), and severe dementia (a chronic disorder of the mental processes caused by brain disease, and marked by memory disorders, personality changes, and impaired reasoning).

Review of Resident 8's clinical record revealed that Resident 8's Representative refused the flu and RSV vaccination on September 4, 2024. Further review of Resident 8's clinical record revealed no evidence that Resident 8's Representative was educated on the benefits, risks, or potential side effects of the vaccine.

Review of Resident 25's clinical record revealed diagnoses that included diabetes, hypertension, and protein-calorie malnutrition (nutritional status in reduced availability of nutrients leads to changes in body composition and function).

Review of Resident 25's clinical record revealed that the Resident last received an influenza vaccine on September 27, 2024. Further review of Resident 25's clinical record revealed no evidence that Resident 25 or Resident 25's Representative were educated on the benefits, risks, and potential side effects of the vaccine.

During a staff interview with Employee 10 (facility Infection Preventionist) on February 4, 2025, at approximately 1:40 PM, Employee 10 revealed that the facility does not utilize influenza or pneumococcal vaccine consent or declination forms. Employee 10 indicated that they speak with Residents and/or their Representatives, distribute the appropriate Vaccine Information Statement to the Resident and/or their Representative and that they then complete a note in the Resident's medical record regarding consent or refusal and education provided.

During a staff interview with the Nursing Home Administrator (NHA) and Director of Nursing on February 6, 2025, at 2:09 PM, the NHA confirmed that influenza vaccine education should have been provided to Residents 8 and 25 and/or their Representative and that documentation should have reflected such.

28 Pa. Code 201.14(a) Responsibility of licensee
28 Pa. Code 201.18(b)(1) Management
28 Pa. Code 211.12(d)(2)(5) Nursing services

Plan of Correction - To be completed: 03/14/2025

1. R8 and R25 continue to reside in the facility and no adverse effects related to the deficiency as cited. R8 Representative was educated on the benefits, risks and potential side effects of the vaccine and noted on clinical record. R25 Representative gave permission for the Influenza and Pneumococcal vaccine and education of the benefits, risks, or potential side effects of the vaccine is on clinical record and no adverse effects related to this practice were observed.

2. The facility has determined that all residents have the potential to be affected by this deficient practice. A facility wide audit will be conducted by the DON and IP Nurse to provide evidence that education will be provided to Residents and/or their Representatives on the risks, benefits, or side effects of the influenza vaccine with confirmed documented on the individuals clinical record to reflect consent or refusal. All residents will be offered the pneumococcal and influenza vaccines as part of the facility vaccination program.

3. After completion of the facility wide audit by the DON, IP Nurse and Nurse Supervisors by March 14, 2025 all licensed nurses will be educated on the policy and procedure for offering and documenting immunizations.

4. Once the vaccination program has been implemented, an audit will be conducted weekly to ensure residents have been offered the appropriate vaccines and documentation is completed by the DON and/or IP Nurse. Throughout flu season, new resident files will be audited to ensure vaccination documentation is completed and residents and representatives were educated on the benefits, risks, and potential side effects of the vaccine and noted on clinical record. Results of these audits will be discussed at the monthly QAPI meeting for three months for further review and recommendations.

483.80(d)(3)(i)-(vii) REQUIREMENT COVID-19 Immunization:

§483.80(d) (3) COVID-19 immunizations. The LTC facility must develop and implement policies and procedures to ensure all the following:
(i) When COVID-19 vaccine is available to the facility, each resident and staff member
is offered the COVID-19 vaccine unless the immunization is medically contraindicated or the resident or staff member has already been immunized;
(ii) Before offering COVID-19 vaccine, all staff members are provided with education
regarding the benefits and risks and potential side effects associated with the vaccine;
(iii) Before offering COVID-19 vaccine, each resident or the resident representative
receives education regarding the benefits and risks and potential side effects associated with the COVID-19 vaccine;
(iv) In situations where COVID-19 vaccination requires multiple doses, the resident,
resident representative, or staff member is provided with current information regarding those additional doses, including any changes in the benefits or risks and potential side effects associated with the COVID-19 vaccine, before requesting consent for administration of any additional doses;
(v) The resident, resident representative, or staff member has the opportunity to accept or refuse a COVID-19 vaccine, and change their decision;
(vi) The resident's medical record includes documentation that indicates, at a minimum,
the following:
(A) That the resident or resident representative was provided education regarding the
benefits and potential risks associated with COVID-19 vaccine; and
(B) Each dose of COVID-19 vaccine administered to the resident; or
(C) If the resident did not receive the COVID-19 vaccine due to medical
contraindications or refusal; and
(vii) The facility maintains documentation related to staff COVID-19 vaccination that
includes at a minimum, the following:
(A) That staff were provided education regarding the benefits and potential risks
associated with COVID-19 vaccine;
(B) Staff were offered the COVID-19 vaccine or information on obtaining COVID-19 vaccine; and
(C) The COVID-19 vaccine status of staff and related information as indicated by the Centers for Disease Control and Prevention's National Healthcare Safety Network (NHSN).

Observations:

Based on facility policy review, clinical record review, and staff interviews, it was determined that the facility failed to provide evidence that education was provided to Residents and/or their Representatives on the risks, benefits, or side effects of the COVID-19 vaccine for two of five residents reviewed for immunizations (Residents 8 and 25).

Findings Include:

Review of facility policy, titled "COVID-19 Vaccination" with a last revised date of June 19, 2023, and a last review date of January 17, 2025, revealed "26. The resident's medical record will include documentation of the following: a. Education to the resident or resident representative regarding the risks, benefits, and potential side effects of the COVID-19 vaccine; b. Each dose of the vaccine administered to the resident, or c. If the resident did not receive the COVID-19 vaccine due to medical contraindication or refusal."

Review of Resident 8's clinical record revealed diagnoses that included hypertension (high blood pressure), diabetes (disease that occurs when your blood glucose, also called blood sugar, is too high), and severe dementia (a chronic disorder of the mental processes caused by brain disease, and marked by memory disorders, personality changes, and impaired reasoning).

Review of Resident 8's clinical record revealed that Resident 8's Representative refused the COVID-19 vaccination on September 4, 2024. Further review of Resident 8's clinical record revealed no evidence that Resident 8's Representative was educated on the benefits, risks, or potential side effects of the vaccine.

Review of Resident 25's clinical record revealed diagnoses that included diabetes, hypertension, and protein-calorie malnutrition (nutritional status in reduced availability of nutrients leads to changes in body composition and function).

Review of Resident 25's clinical record revealed that the Resident last received a COVID-19 booster vaccine on October 20, 2024. Further review of Resident 25's clinical record revealed no evidence that Resident 25 or Resident 25's Representative were educated on the benefits, risks, and potential side effects of the vaccine.

During a staff interview with Employee 10 (facility Infection Preventionist) on February 4, 2025, at approximately 1:40 PM, Employee 10 revealed that the facility does not utilize COVID vaccine consent or declination forms. Employee 10 indicated that they speak with Residents and/or their Representatives, distribute the appropriate Vaccine Information Statement to the Resident and/or their Representative and that they then complete a note in the Resident's medical record regarding consent or refusal and education provided.

During a staff interview with the Nursing Home Administrator (NHA) and Director of Nursing on February 6, 2025, at 2:09 PM, the NHA confirmed that COVID vaccine education should have been provided to Residents 8 and 25 and/or their Representative and that documentation should have reflected such.

28 Pa. Code 201.14(a) Responsibility of licensee
28 Pa. Code 201.18(b)(1) Management
28 Pa. Code 211.12(d)(2)(5) Nursing services

Plan of Correction - To be completed: 03/14/2025

1. R8 and R25 continue to reside in the facility and no adverse effects related to the deficiency as cited. R8 Representative was educated on the benefits, risks and potential side effects of the Covid-19 vaccine and noted on clinical record as refusal, declination documented. R25 last received the COVID-19 booster vaccine on October 20, 2024 and representative was educated on the benefits, risks and potential side effects of the Covid-19 vaccine, no adverse effects related to this practice were observed.

2. The facility has determined that all residents have the potential to be affected by this deficient practice. A facility wide audit will be conducted by the DON and IP Nurse to provide evidence that education will be provided to Residents and/or their Representatives on the risks, benefits, or side effects of the Covid-19 vaccine with confirmed documented on the individuals clinical record to reflect consent or refusal. All residents will be offered the Covid-19 vaccine and or booster as part of the facility vaccination program.

3. After completion of the facility wide audit by the DON, IP Nurse and Nurse Supervisors by March 14, 2025 all licensed nurses will be educated on the policy and procedure for offering and documenting immunizations, including the Covid-19.

4. Once the vaccination program has been implemented, an audit will be conducted weekly to ensure residents have been offered the appropriate Covid-19 vaccines and documentation is completed by the DON and/or IP Nurse. Throughout the uptick of the Covid-19 season, new resident files will be audited to ensure the Covid-19 vaccination documentation is completed and residents and representatives were educated on the benefits, risks, and potential side effects of the Covid-19 vaccine and noted on clinical record. Results of these audits will be discussed at the monthly QAPI meeting for three months for further review and

§ 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 staff interview and review of the facility's Infection Control Committee attendance records, the facility failed to ensure that three of nine required multidisciplinary members were present at the Infection Control Committee meeting (laboratory personnel, physical plant personnel, and a community member).

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, community member, laboratory personnel, pharmacy staff, and infection control team members.

Review of the facility provided attendee signature pages for their monthly Quality Assurance Performance Improvement (QAPI) and Infection Control Meeting revealed in Quarter 2 April/May/June 2024, that no Physical Plant Personnel or laboratory personnel had attended any of the monthly meetings.

Review of the facility provided attendee signature pages for their monthly Quality Assurance Performance Improvement (QAPI) and Infection Control Meeting revealed in Quarter 3 July/August/September 2024, that no Physical Plant Personnel, community member, or laboratory personnel had attended any of the monthly meetings.

Review of the facility provided attendee signature pages for their monthly Quality Assurance Performance Improvement (QAPI) and Infection Control Meeting revealed in Quarter 4 October/November/December 2024, that no Physical Plant Personnel, community member, or laboratory personnel had attended any of the monthly meetings.

During a staff interview with the Nursing Home Administrator on February 5, 2025, at 1:29 PM, she indicated that the facility has the meetings monthly and they try to get all required attendees to attend at least one meeting per quarter. She confirmed that all required members failed to attend at least one meeting per quarter. She further indicated that Physical Plant Personnel had never attended because the corporate office indicated that they did not need to attend.

Plan of Correction - To be completed: 03/14/2025

1. The facility was evaluated on the review of the facilities' Infection control Committee attendance records to ensure this standard of operation set forth by the Department and by other Federal, State and local agencies responsible for the health and welfare of residents were being followed by all attendees present on a monthly basis, the Infection Control Committee meeting includes, Medical Staff, Nursing Staff, Administration, laboratory personnel, physical plant personnel, Safety Officer and a community member, attendance will be mandated accordingly and deficiency corrected by March 14, 2025.

2. The facility has determined that all residents have the potential to be affected by this deficient practice. The Infection Control Committee will continue to meet monthly to ensure an Infection Control plan as stated is developed and implemented that include, multidisciplinary committee including representatives from each of the specific health care facility to include Medical Staff, Administration, Nursing Staff, Patient Safety Officer, Physical Plant Personnel, community member, laboratory personnel, pharmacy staff and infection control team members.

3. All Infection Control Committee members will be re-educated on monthly mandated attendance to ensure three of nine required multidisciplinary members are present to meet compliance standards and regulation by March 14, 2025. The NHA will invite the committee a month before the next meeting and send reminders out a week prior of the scheduled meeting date to ensure 100% participation is achieved.

4. The NHA will conduct monthly audits X 3 months to ensure attendance of members, if 100% compliance is achieved/maintained, the deficiency will be considered resolved. Results of the audits will be presented by the NHA and discussed at the monthly QAPI meeting to determine the need for further audits and or action plans.

Back to County Map

Home : Press Releases : Administration
Health Planning and Assessment : Office of the Secretary
Health Promotion and Disease Prevention : Quality Assurance

Copyright © 2001 Commonwealth of Pennsylvania. All Rights Reserved.
Commonwealth of PA Privacy Statement