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

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

LINWOOD NURSING AND REHABILITATION CENTER
Inspection Results For:

There are 116 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.


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

Initial comments:

Based on a Medicare/Medicaid Recertification, State Licensure, Civil Rights Compliance and Abbreviated Complaint Survey completed on May 21, 2025 it was determined that Linwood 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:

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

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(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 observation, review of clinical records and select facility documentation, and staff and resident interviews, it was determined that the facility failed to ensure that staff implemented a physician-ordered adaptive device (lidded cup) to mitigate the risk of injury from hot liquids for one of 21 sampled residents (Resident 60) resulting in actual harm, a burn injury to the upper thigh area and failed to ensure nurse aides demonstrated the necessary skills and competencies to safely perform mechanical lift transfers for one of 21 residents reviewed (Resident 195). These failures resulted in actual harm to both residents.

Findings include:

A review of Resident 60's clinical record revealed the resident was admitted to the facility February 1, 2024, with diagnoses to include dementia (the loss of cognitive functioning - thinking, remembering, and reasoning - to such an extent that it interferes with a person's daily life and activities).

A quarterly Minimum Data Set assessment (MDS - a federally mandated standardized assessment process conducted at specific intervals to plan resident care) dated May 2, 2025, revealed that the resident was severely cognitively impaired with no BIMS score recorded (Brief Interview for Mental Status, a tool to assess the resident's attention, orientation, and ability to register and recall new information). The assessment noted that during eating, the resident had the ability to use suitable utensils to bring food and /or liquid to the mouth and required set up and clean up assistance

Review of physician orders revealed that as of November 5, 2024, and active through May 20, 2025, the resident was to be provided with lidded cups for all liquids.

An Occupational Therapy treatment encounter note dated May 13, 2025, identified the resident required set up/clean up assistance for all meals.

A nurse's note dated May 19, 2025, at 2:16 PM, indicated that at approximately 11:45 AM that day, Resident 60 spilled hot coffee into her lap. The nurse noted pink, non-blanchable skin and four clear, fluid-filled blisters, each approximately 0.5 cm x 0.5 cm, located on the left anterior thigh. Silvadene was applied per protocol, and the practitioner and resident's family were notified. Resident denied pain and discomfort at that time.

A Skin Evaluation completed by Employee 1 the RN Supervisor on May 20, 2025, at 9:15 AM, described six intact, clear fluid-filled blisters across multiple areas of the upper thigh.
Left proximal 2 cm x1. 5 cm
Left lateral 2 cm x1 cm
Left lateral 1cm x 0.5cm
Left distal 3. 5cm x 1. 5cm
Left distal/ lateral 0.5cm x 0.5cm
Left medial 3.5 cm x 1cm

Silvadene was applied per physician order during the assessment. The resident denied having pain and was resting comfortably in bed with the call bell within reach.

A Wound Care Physician evaluation dated May 20, 2025, at 1:53 PM, identified the burn as measuring 8 cm x 25 cm x 0 depth, with no exudate (discharge of moisture) or odor. The wound area was warm to the touch and the skin remained closed. The resident reported no pain.

A review of facility's investigative report completed by the Director of Nursing (DON) dated May 19, 2025, at 11:45 AM, indicated the resident had been provided coffee without a lid, in violation of the physician's order, and subsequently spilled the beverage into her lap.

A witness statement from Employee 5, Nurse Aide, dated May 19, 2025, revealed during the lunch meal, she placed the coffee in front of the resident without a lid and turned her back toward this resident to prepare another resident's beverage. When she turned back toward the resident she noticed Resident 60 had spilled the coffee into her lap. She reported to the Nursing Home Administrator (NHA) and Director of Nursing (DON) being unaware of the resident's requirement for a lidded cup. Employee 5 was suspended pending investigation and was unavailable to be reached by phone for an interview.

On May 21, 2025, at approximately 10:00 AM, with the resident's permission, an observation of the resident's burn was conducted in the presence of the DON. The resident's burn was visible on her upper left thigh. The burn appeared pink, with scattered areas of white. Four blister like clusters remained, with no open areas seen, and no evidence of drainage or odor.

Review of Resident 60's Kardex, which is used by staff to determine whether a resident required adaptive equipment for meals, prior to May 19, 2025, revealed the order for a lidded cup was not on the Resident's Kardex. However, the resident did have a physician's order dated originally November 5, 2024, for lidded cups for all fluids. An interview with the NHA on May 21, 2025, at approximately 9:00 AM revealed there was an error in linking the active physician's order for lidded cups to the resident's Kardex.

Review of the food and beverage temperature logs maintained by the facility at resident meal service for May 19, 2025. The food/beverage temperatures for May 19, 2025, showed the coffee temperature for lunch tested at 139 degrees Fahrenheit.

Interview with the NHA on May 21, 2025, at approximately 10:00 AM confirmed, the resident was not provided the ordered adaptive device (cup with lid). The administrator acknowledged the omission directly contributed to the hot liquid spill and subsequent injury.

Following the incident on May 19, 2025, corrective actions were implemented by May 20, 2025, and included:
Immediate clinical intervention following the incident, including removal of soiled clothing, application of cool compresses, wound treatment, and notification of the practitioner and family.

Resident was evaluated by the Occupational Therapist for safety in consuming hot liquids. Occupational Therapist updated orders to include Kennedy Cup (spill proof cup that can be turned upside down without spilling) to further reduce spill risk.

Residents with current adaptive equipment orders were prescreened by the Occupational Therapist to verify current orders and interventions are appropriate. Director of Nursing will review each order to verify the order is care planned and visible on the Kardex.

Regional Dietician re-educated the facility Dietician on appropriate steps to document orders, so they flow to the care plan and the Kardex. The DON/designee provided in-service to facility staff on hot beverage policy. Staff not present during initial training were reeducated before their next shift.

The DON/designee will review new resident orders for adaptive equipment to verify that they are documented correctly including link to Kardex. Implementation of an audit system to review adaptive equipment use, ensure consistency between physician orders, care plans, and Kardex, and present findings to the facility's QAPI committee.

A review of the clinical record revealed that Resident 195 was admitted to the facility on April 29, 2021, with diagnoses to include, transient ischemic attach (TIA-a short period of symptoms similar to those of a stroke, caused by a brief blockage of blood flow to the brain), cerebral infarction (occurs when the blood supply to part of the brain is blocked or reduced and prevents brain tissue from getting oxygen and nutrients that results in brain cells beginning to die) without residual deficits (recovered without any effect), age related osteoporosis (a condition in which the bones become thinner, weaker, and more likely to break), and aphasia (a result of a stroke or brain injury that affects a person's ability to communicate).

A Significant Change Minimum Data Set assessment (MDS- a federally mandated standardized assessment process conducted at specific intervals to plan a resident's care) dated January 14, 2025, revealed that Resident 195 had severe cognitive impairment with a BIMS score of 3 (Brief Interview for Mental Status - a tool to assess cognitive function - a score of 0 -7 indicates severe cognitive impairment), dependent (helper does all of the effort to complete the activity or the assistance of two or more helpers required to complete the activity) for bed mobility, transfers, toileting, and bathing. The resident was assessed to require a mechanical lift (a mechanical device used to assist with transfers and movement of individuals who require support for mobility beyond the manual support provided by caregivers alone) for all transfers.

A review of Resident 195's physician's orders dated December 3, 2024, at 2:02 AM, specified mechanical lift use for all transfers.

A review of a facility policy entitled "Mechanical Lifting" last reviewed February 18, 2025, indicated the facility utilizes floor-based full body sling lifts and overhead full body sling lifts with universal slings (intended as a general transfer sling, designed to be interchangeable between all manufacture's lifts and provides trunk and leg support for patients with limited upper body tone) and refer to the manufacturer's instructions for use of the universal slings.

A review of facility provided investigative documentation completed by Employee 1, Registered Nurse (RN) Supervisor, dated January 30, 2025, revealed that at 8:00 AM, Resident 195 had a witnessed fall by Employee 2, an agency Nurse Aide (NA), and Employee 3, an agency Licensed Practical Nurse (LPN), the resident slid from the sling during a Hoyer lift transfer performed by Employee 2 (agency nurse aide) and Employee 3 (agency LPN), and struck her head on the floor.

Employee 1 assessed Resident 195 and noted that the resident was moaning and not answering questions and 911 was called. The Resident's RP (Responsible Party), her son, was made aware and agreeable to send resident to the emergency department and the MD was made aware.

A review of a witness statement completed by Employee 2, agency NA, dated January 30, 2025, no time indicated, Employee 2 reported: "I was getting her \ dressed and washed. I put the sling under her and strapped her up real good. The LPN was in with me when I lifted her up with the Hoyer. She slipped right out, landed on the bed and then on the floor. Wasn't a fall, she slipped onto the floor and hit her head. The LPN went to get the supervisor, and I tried to get her vitals, but she wouldn't let me. She was halfway on the bed when it happened."

Employee 3's, agency LPN, witness statement dated January 30, 2025, no time indicated, noted "I was called in by the nursing assistant to transfer the resident via Hoyer lift, with safety harness intact. The NA pulled the lift back and the resident slid out of the pad and bounced off the bed to the floor. Resident hit head on the floor. Supervisor was called and safety protocols initiated."

A witness statement completed by Employee 4, former Director of Nursing (DON), dated January 30, 2025, documented the reenactment of the event that occurred at approximately 8:20 AM. The DON noted:

Employee 2 stated she had retrieved a sling from the laundry, "hooked the resident up appropriately," and sought assistance with the transfer. Unable to locate another aide, she was assisted by Employee 3. During the lift, the resident "slid out from the bottom of the pad (sling) onto the bed and then onto the floor." When asked whether she crossed the leg straps of the sling, Employee 2 replied, "no."

Employee 3 described the lift transfer as follows: She was asked to come in and spot the resident transfer. She entered the room and stood by the bed while the lift was being performed. Upon elevation of the resident on the lift, the resident slid out of the bottom onto the bed and then the floor.

A review of the emergency department after visit summary dated January 30, 2025, at 11:03 AM, revealed that she was being seen due after a fall off the Hoyer lift. Imaging results completed and CAT scan (computerized axial tomography - uses x-rays to take pictures of your blood vessels, tissues, bones, or organs) of the chest/abdomen/pelvis and CAT scan of her head, brain, and spine and determine that imaging was negative for intercranial bleed and fractures but positive for left posterior scalp hematoma (a condition characterized by the accumulation of blood beneath the scalp and occurs as a result of various factors, including trauma, head injuries, or medical conditions that affect blood clotting) with a planned discharge back to the facility for 11:30 AM.

A review of Resident 195's clinical record revealed a nurses' progress notes dated February 4, 2025, at 10:28 PM, that indicated that the resident was complaining of increased pain to the left thigh area. Resident offered PRN (as needed) Tylenol and declined; resident was agitated and yelling at staff. Refusing all PRN medication but allowed the NA to reposition her in bed. Orders were obtained from the CRNP (Certified Nurse Practitioner) for left hip and femur x-rays and to increase Tramadol (opioid pain medication used to manage moderate to severe pain) to 25 mg po BID (twice per day) to TID (three times per day) and hold for sedation.

Further review of the resident's clinical record revealed final x-ray results that indicated a left hip fracture, not present on prior study; clinical correlation and follow up radiographs suggested. CRNP made aware new orders received and noted to send the resident to the hospital emergency room (ER).

A review of Resident 195's hospital discharge summary for admission February 5, 2025, through February 10, 2025, revealed the resident was admitted due to a left periprosthetic fracture (are considered fractures associated with an orthopedic implant, whether a replacement or internal fixation device) and multiple closed fractures of ribs (is a common injury that occurs when one of the bones in the rib cage breaks or cracks caused by hard impacts from falls, car accidents or contact sports) of the left side.

A review of the manufacturer's instructions for the universal lift sling use during transfers from bed to chair indicated that for maximum security, gently raise the individual's legs, and pull the leg loops forward and under the thigh, cross the loops over the thighs, pull one strap through the other, and bring the lift over to the bed and roll the base as far underneath the bed as possible while positioning the cradle over the individual. When both sides of the sling are attached to their respective sides of the cradle, raise the individual slowly. Place the specific loop or chain the individual requires to ensure the proper fit to prevent from sliding out of the sling.

The instructions for the universal sling confirmed that sling leg loops were to be crossed under the thighs and properly secured to prevent the resident from sliding.

A review of a facility provided document entitled "New Employee Orientation" handbook provided by the Nurse Staffing Agency, reviewed and signed by Employee 2, Agency Nurse Aide (NA) on May 11, 2022 (date of hire with the nursing agency), acknowledged that Hoyer lift safety was completed on that date. Additionally, Employee 2 completed the facility's "Nursing Agency Orientation" on January 17, 2025, which included resident transfer safety.

A review of the nursing agency's new hire documentation for Employee 3, Agency LPN, revealed that she was hired by the agency on August 17, 2023, however, no documentation was provided by the facility or staffing agency to demonstrate that Employee 3 had ever received training or competency validation on mechanical lift use.

During on-site survey, telephone calls were placed to both Employee 2 and Employee 3, but the employees did not return the calls.

During an interview with the Nursing Home Administrator (NHA) on May 20, 2025, at 10:45 AM, he acknowledged that Employee 2 failed to properly apply the universal sling and failed to cross the leg straps, resulting in the resident sliding from the sling onto the bed and then the floor. He further confirmed the facility was unable to produce documented evidence that Employee 3 had ever received mechanical lift training prior to assisting with the transfer.

Further interview with the NHA confirmed that Employee 2 failed to ensure Resident 195's safety when applying the universal sling when performing a Hoyer/mechanical lift transfer that resulted in Resident 195 sliding out of the bottom of the sling onto the bed and then onto the floor hitting her head. Subsequently, Resident 195 sustained a left posterior scalp hematoma, left periprosthetic fracture, and multiple closed fractures of ribs on the left side.

The facility failed to ensure that all nursing staff had the necessary clinical competency validation skills when operating mechanical lifts with universal slings for resident transfers to prevent injuries sustained from unsafe transfer practices by staff.

Following the incident with Resident 195 on January 30, 2025, the facility provided evidence that corrective actions were completed by January 31, 2025.

Resident was assessed for injury (no injury apparent) and was sent to the hospital for an evaluation.

The current residents who utilize a Hoyer lift for care were audited to determine the following
a-proper sling fitment
b-care plan updated

The maintenance director/designee re-audited all lifts to ensure proper functioning. Lifts are on a monthly preventative maintenance schedule.

The DON/designee will in-service the nursing staff on proper sling use, colors, sizes and location.

The ESD audited all slings in the building to ensure they are functional.

The NHA/designee will randomly audit nursing staff 2x/week for 4 weeks to ensure the slings/lifts are being used in accordance with manufacturer recommendation and facility policy.

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

28 Pa Code 211.10 (d) Resident care policies.

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

Plan of Correction - To be completed: 07/01/2025

Use of lidded beverage cup for coffee cannot retroactively be corrected. Improper use of universal mechanical lift sling for transfer of a resident cannot retroactively be corrected.

Following the incident with resident 60 that occurred 5/19/ 25 the facility implemented corrective actions by 5/20/25 to include resident evaluation by OT of safety in consuming hot beverages. The Resident's adaptive equipment was changed to include a Kennedy cup. Other residents were prescreened by OT to verify current orders and interventions are appropriate. The Director of Nursing reviewed orders to ensure they were care planed and visible on Kardex.
Educations were completed with Dietician related to care plan to Kardex flow and with facility staff regarding hot beverage policy.

Following the incident with resident 195 on 1/30/25 the facility provided evidence that corrective actions were completed by 1/21/25 which included and audit of the current residents who utilize the Hoyer lift. The residents were audited to determine proper sling fit, care plan accuracy. The lifts were audited by maintenance to ensure were functioning correctly.

In-service training was performed for nursing staff regarding lift sling use, size, colors and location.

The Environmental service director audited all slings in building to ensure functionality.

Audits were initiated and completed for both events separately.

IDT review will be conducted to discuss both event scenarios to ensure changes and updates made to facility practice/policy are still maintained and applicable for prevention of further like incidents.

The Director or nursing/designee will perform an audit to ensure protocols put in place at time of incidents are still active and in place.

The Director of nursing/designee will reeducate staff on facility practice/policy related to lift sling use and adaptive equipment related to hot beverages.

In addition, facility will contract with an appropriate outside company recommended by the Department of Health to complete directed in-service training related to Federal Regulation 0689 with, at a minimum, all licensed and non-licensed nursing staff.

The completed audits will be extended 2x/week for 4 weeks.

The Director of nursing/designee will audit adaptive equipment use to ensure consistency between physician orders, care plans and Kardex.

The NHA/designee will randomly audit nursing staff 1x/week for 4 weeks to ensure slings/lifts are being used in accordance with the manufacturer recommendation and facility policy.

The results of the audits will be presented to the QA Committee for review and recommendations.

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

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.

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

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

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

Observations:

Based on observation and staff interview, it was determined that the facility failed to maintain acceptable practices for the storage and service of food to prevent the potential for contamination and microbial growth in food, which increased the risk of food-borne illness in the dietary department.

Findings include:

Food safety and inspection standards for safe food handling indicate that everything that comes in contact with food must be kept clean and food that is mishandled can lead to foodborne illness. Safe steps in food handling, cooking, and storage are essential in preventing foodborne illness. You cannot always see, smell, or taste harmful bacteria that may cause illness according to the USDA (The United States Department of Agriculture, also known as the Agriculture Department, is the U.S. federal executive department responsible for developing and executing federal laws related to food).

Review of a facility policies titled "Refrigerator and Frozen Food Storage" last reviewed by the facility on February 18, 2025, indicated that all TCS (time, temperature, control foods) and ready to eat foods prepared on site and held for longer than 24-hours, must be properly labeled and dated with the date by which it should be consumed or discarded (use by date).

The initial tour of the dietary department was conducted with the facility's weekend dietary supervisor on May 18, 2025, at 8:45 AM, revealed the following unsanitary practices with the potential to introduce contaminants into food and increase the potential for food-borne illness, were identified:

Observations of inside the reach-in tray line refrigerators revealed that the following foods failed to include use by date or thaw date as follows, two opened half gallons of chocolate milk, one prepared plated tossed salad with chicken, one opened gallon of milk, and one opened can 8-ounce cola.

Further observations of the reach-in tray line refrigerators revealed that the following nutritional supplements were thawed but failed to include a thaw date or discard date as follows, four thawed 6-ounce nutritional juice drinks (high calorie/high protein supplement) and twelve thawed Magic Cup (high calorie/high protein supplement) supplements. The manufacture's safe food handling instructions indicate that once defrosted, supplements should be used within 14-days. However, the actual discard date was not able to be determined due to items lacking a noted thaw date or discard date on each item.

The dietary supervisor confirmed the above observations and indicated that all food items that were opened and/or thawed inside the refrigerator should have a use by date or thaw date listed on the items to prevent the potential for food contamination and foodborne illness.

28 Pa. Code 201.18 (e) (2.1) Management

28 Pa. Code 211.6 (f) Dietary Services

Plan of Correction - To be completed: 07/01/2025

The milk, salad cola and supplements were disposed of immediately.
No other food items were affected.

The Dietary Manager/designee will in-service the dietary department regarding the prompt labeling and dating of food items and supplements.

The Dietary Manager/designee will conduct an audit of food and supplements to ensure they are labeled and dated 3x/week for 4 weeks, 2x/week for 4 weeks, and then 1x/week for 4 weeks to ensure compliance.

The results of the audit will be presented to the QA Committee for review and recommendations.

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

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

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

Observations:

Based on document review, clinical record review, and staff interviews, it was determined that the facility failed to timely provide the required Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNF-ABN) to notify one of three residents reviewed (Resident 95) that Medicare Part A coverage for skilled nursing services was ending.

Findings Include:

A review of Resident 95's clinical record revealed admission to the facility on December 9, 2024, with diagnoses to include fusion of the spine (a surgical procedure that connects two or more vertebrae in the spine to eliminate movement between them, providing stability and pain relief).

Review of the resident's Medicare coverage documentation revealed the last day of covered Medicare Part A services was February 24, 2025.

Further review revealed the facility did not issue the Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNF-ABN) form to Resident 95 until February 25, 2025, after Medicare Part A coverage had ended.

An interview conducted with the Director of Social Services on May 19, 2025, at 11:00 a.m., confirmed the resident had exhausted Medicare Part A benefits as of February 24, 2025, and acknowledged that the SNF-ABN form had not been provided until the following day.

An interview with the Nursing Home Administrator on May 20, 2025, at 1:45 p.m., confirmed the facility's failure to issue the required notice prior to the end of coverage.

28 Pa. Code 201.14 (a) Responsibility of licensee.

Plan of Correction - To be completed: 07/01/2025

The facility cannot correct the SNF ABN notice as it relates to Resident 95 as it occurred in February of 2025.

The facility will review the last 30-days to ensure no other residents were affected

The NHA/designee will in-service the social services director regarding the distribution of the SNF ABN (advanced beneficiary notice) and the importance of timely notification.

The NHA/designee will audit the SNF ABN timely distribution 1x/day for 30 days, 1x/week for 4 weeks, and 1x/month for 1 month.

The results of the audit will be presented to the QA Committee for review and recommendations.

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: 07/01/2025

Resident 51 weight review by dietician was completed and nutritional assessment updated.

Dietician reviewed weights for the last 30 days to ensure assessments and notifications to medical provider and resident/resident representative were completed as indicated for residents with significant weight changes.

The Director of nursing/designee reviewed the weight and reweight process with the direct care staff for input. The facility process for obtaining weights and reweights will include the nurse aide's ability to document weights and re weights in the plan of care. The process review by which medical providers and families are notified has been reviewed and updated.

The Director of Nursing/designee will educate the nursing staff on timely completion of weights and reweights, notification to dietician, medical provider and resident/resident representative.

The Director of nursing/designee will educate the dietician on timely review of weights and reweights and completion of nutrition assessments.

The Director or Nursing/designee will conduct an audit of weight changes, notifications and required nutrition assessments related to weight changes 3x/week for 4 weeks, 2x/week for 4 weeks, and then 1x/week for 4 weeks to ensure compliance.

The results of the audit will be presented to the QA Committee for review and recommendations.

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

§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 a review of clinical records, the Resident Assessment Instrument (RAI), and staff interview, it was determined the facility failed to ensure the Minimum Data Set Assessments accurately reflected the status of one resident out of 21 sampled (Resident 72).

Findings include:

According to the Resident Assessment Instrument (RAI) User's Manual (an assessment tool utilized to gather definitive information on a resident's strengths and needs, which must be addressed in an individualized care plan, and the RAI also assists staff to evaluate goal achievement and revise care plans accordingly by enabling the facility to track changes in the resident's status) dated October 2024, Section N Medications Subsection N0350A: Insulin, indicate the number of days during the 7-day look-back period that the resident received insulin (a hormone medication used to treat diabetes) injections.

A clinical record review revealed Resident 72 was admitted to the facility on April 10, 2023.

A review of a quarterly Minimum Data Set assessment (MDS-a federally mandated standardized assessment process conducted periodically to plan resident care) dated April 11, 2025, Section N Medication Subsection N0250. Insulin revealed that Resident 72 received one injection of insulin during the 7-day look-back period.

A review of Resident 72's medication administration record dated April 2025 revealed no documented evidence Resident 72 received an insulin injection during the seven-day look-back period.

During an interview on May 21, 2025, at approximately 11:00 AM, the Director of Nursing (DON) confirmed Resident 72 did not receive an insulin injection during the seven-day look-back period, as indicated in the resident MDS assessment dated April 11, 2025. After inquiries made during the survey, the facility corrected the error and submitted a modification to the April 11, 2025, MDS assessment for Resident 72.

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

Plan of Correction - To be completed: 07/01/2025

Resident 72's MDS was corrected immediately during the survey

The facility RNAC reviewed current residents most recent MDS to ensure those that captured insulin on MDS subset N0350A are accurate. Corrections will be made as identified.

The NHA/designee will in-service MDS staff on accurate coding of N0350A, with a review of non-insulin medications commonly used.

The RNAC/designee will conduct 5 random audits of MDS subset N0350A 1x/week for 4 weeks, then 1x/month for 2 months to ensure accuracy of N0350A.

The results of the audit will be presented to the QA Committee for review and recommendations

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

Least serious deficiency but affects more than a limited number of residents, staff, or occurrences. This deficiency has the potential for causing no more than a minor negative impact on the resident but is not found to be throughout this facility.

§483.15(c)(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 a review of clinical records, facility-initiated transfer notices, and staff interview, it was determined the facility failed to notify the resident and the resident's representative(s) of the transfer in writing and in a language and manner they understand and to provide copies of written notice of facility-initiated hospital transfers of residents to a representative of the Office of the State Ombudsman for one out of 21 residents reviewed (Resident 72).

Findings include:

A clinical record review revealed Resident 72 was admitted to the facility on April 10, 2023.

Further clinical record review revealed Resident 72 was transferred to a community hospital on December 29, 2024, and was readmitted to the facility on January 3, 2025.

The facility was unable to provide documented evidence the resident and resident representative were notified of the reasons for the transfer in writing or provide documented evidence the facility sent copies of written notices of these transfers to the representative of the Office of the State Long-Term Care Ombudsman.

An interview with the nursing home administrator on May 21, 2025, at approximately 10:00 AM confirmed there was no documented evidence that copies of transfer notices for Resident 72 were sent to a representative of the Office of the State Long-Term Care Ombudsman. The nursing home administrator was unable to provide documented evidence that Resident 72 or his representative was notified of the reasons for the transfer on December 29, 2024.

28 Pa. Code 201.14(a) Responsibility of licensee.

Plan of Correction - To be completed: 07/01/2025

The facility cannot correct the untimely transfer or state ombudsman notification as it relates to Resident 72 which occurred December 29, 2024.

A 30 day look back will be completed. Any missing notification for a resident, responsible party or state ombudsman will be corrected.

The NHA/designee will in-service the social services director regarding the timely notification of the patient and/or the responsible party/patient representative in addition to the state ombudsman's office.

The Director of Nursing/designee will in-service licensed staff on F-Tag 0628 requirements and timely documentation of hospital transfer notifications.

The Director of Nursing/Designee will audit transfer notifications to residents/responsible party 1x/day for 1 week, 3x/a week for 1 week, then monthly for 1 month.

The NHA/designee will audit the monthly state ombudsman notification 1x/month for 3 months.

The results of the audit will be presented to the QA Committee for review and recommendations.

§ 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 a review of nurse staffing and staff interview, it was determined the facility failed to ensure the minimum nurse aide staff to resident ratio was provided on each shift for 7 shifts out of 63 reviewed. Findings include:

A review of the facility's weekly staffing records revealed that on the following dates the facility failed to provide minimum nurse aide staff of 1:10 on the day shift, 1:11 on the evening shift, and 1:15 on the night shift based on the facility's census.

May 15, 2025, 9.56 NAs on the day shift, versus the required 9.7, for a census of 97
May 18, 2025, 9 NAs on the day shift, versus the required 9.3, for a census of 93
March 21, 2025, 8.28 NAs on the evening shift, versus the required 8.45, for a census of 93
March 26, 2025, 8.19 NAs on the evening shift, versus the required 8.36, for a census of 92
May 14, 2025, 8.03 NAs on the evening shift, versus the required 8.73, for a census of 96
May 17, 2025, 8.28 NAs on the evening shift, versus the required 8.64, for a census of 95
March 21, 2025, 5.69 NAs on the night shift, versus the required 6.2, for a census of 93

On the above dates mentioned no additional excess higher-level staff were available to compensate this deficiency.

An interview with the Director of Nursing, on May 20, 2025, at approximately 10:00 a.m., confirmed the facility had not met the required NA to resident ratios on the above dates.

Plan of Correction - To be completed: 07/01/2025

The facility cannot retroactively correct this deficiency.

A scheduling system is in place to assist with replacing call offs and fill open shifts by sending instant communication to employees. Open shifts are presented to staff daily, weekly and monthly.

The facility will use employee incentives or agency staff when needed to replace call offs and meet the ratio.

The NHA/designee will meet daily with the scheduler to ensure the ratio is met.

The facility has an active recruitment and retention committee to help hire and retain employees.

The results of the daily ratio audit will be presented to the QA committee for review and recommendations.

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