Pennsylvania Department of Health
WESLEY VILLAGE, THE
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

WESLEY VILLAGE, THE
Inspection Results For:

There are 114 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.


WESLEY VILLAGE, THE - 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 Survey and Abbreviated Complaint Survey, completed on May 9, 2025, it was determined The Wesley Village was not in compliance with the following requirements of 42 CFR Part 483 Subpart B Requirements for Long Term Care and the 28 PA Code Commonwealth of Pennsylvania Long Term Care Licensure Regulations.

Plan of Correction:

483.25 REQUIREMENT Quality of Care:

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

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

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

F0684 Quality of Care
#1 Resident 61's medication orders were reviewed with physician to ensure the timely administration in accordance with orders and professional standards of practice. In collaboration with the medical director and RP, medication administration times were adjusted to ensure that the resident's and family satisfaction, as well as a safe and compliant pass occurs. Palliative policy was updated.
Residents 14 & 39's physicians were contacted for clinical rationale and orders/dx for palliative care. In addition, the facility will obtain consent from RP/Resident. A palliative care plan was developed and supporting progress note was added by the social worker.
#2 In collaboration with IDT, medical director, and residents/RP's, medication administration times were reviewed and adjusted as necessary to ensure timely administration and maintain professional standards of practice. Palliative policy was reviewed
Residents who are on palliative care will be reviewed to ensure proper documentation is in place regarding a physican order, appropriate rationale, resident/RP consent, a plan of care, and social worker documentation (in a progress note, are all present in the EMR.
#3 Licensed nursing staff will be educated on the revised palliative care process as well as the timely administration of medication and professional standards of practice.
#4 DON or designee will conduct a weekly audit including any new resident with an order for palliative care to ensure all expectations are met. This audit will be conducted weekly x 4 weeks and monthly x 2 months. DON or designee will also conduct a weekly audit on 10 random residents to ensure timely administration of medication per policy. This audit will be completed weekly x 4 weeks and monthly x 2 weeks. The results of these audits will be discussed in facility QAPI meeting.

483.10(c)(1)(4)(5) REQUIREMENT Right to be Informed/Make Treatment Decisions:

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(c) Planning and Implementing Care.
The resident has the right to be informed of, and participate in, his or her treatment, including:

§483.10(c)(1) The right to be fully informed in language that he or she can understand of his or her total health status, including but not limited to, his or her medical condition.

§483.10(c)(4) The right to be informed, in advance, of the care to be furnished and the type of care giver or professional that will furnish care.

§483.10(c)(5) The right to be informed in advance, by the physician or other practitioner or professional, of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options and to choose the alternative or option he or she prefers.

Observations:

Based on clinical record review, select facility policy, and staff interviews, it was determined the facility failed to ensure that residents or their representatives were informed of treatment options, as well as the risks and benefits for psychotropic medications for one of 28 residents (Resident 24).

Findings include:

A review of a facility policy titled "Psychotropic Medication," last reviewed by the facility on March 19, 2025, revealed it is the facility policy that residents shall not receive psychotropic medications which are not clinically indicated to treat a specific condition. Further policy review revealed that documented consent, given voluntarily and free from coercion, by the resident or resident representative (if applicable), to use a psychotropic medication after being provided with sufficient information regarding general psychotropic use and specific considerations related to the psychotropic medication being considered for use will be obtained.

A clinical record review revealed that Resident 24 was admitted to the facility on December 22, 2024, with diagnoses that included dementia (irreversible, progressive degenerative disease of the brain, resulting in loss of reality contact and functioning ability) and encephalopathy (dysfunction in brain processes including attention, cognition, and consciousness).

A quarterly Minimum Data Set Assessment (MDS - a federally mandated standardized assessment conducted at specific intervals to plan resident care) of Resident 24, dated December 28, 2024, revealed the resident was severely cognitively impaired with a BIMS score of 05 (Brief Interview for Mental Status, a tool to assess the residents' attention, orientation, and ability to register and recall new information; a score of 0-7 indicates severe cognitive impairment).

Further review of the clinical record revealed that Resident 24 had a designated power of attorney who was their resident representative at the facility.

A review of a physician's order dated December 22, 2024, revealed an order for Seroquel 25 milligrams (mg) (an antipsychotic medication used to treat mood disorders) two times a day.

A review of a form titled Psychoactive Medication Informed Consent, dated December 30, 2024, revealed consent for an antipsychotic medication, Seroquel, with a verbal consent checked at the bottom of the form, indicating Resident 24 gave verbal consent. There was no indication that Resident 24's resident representative was made aware of this consent for the antipsychotic medication Seroquel.

A review of Resident 24's progress notes revealed no indication that the resident's responsible party were notified of the medication, that the risks and benefits were explained or that the resident was offered alternative treatment options.

A review of Medication Administration Records (MARs) from December 2024 to February 2025 for Resident 24 revealed the resident received Seroquel 25 mg twice a day from December 22, 2024, to February 10, 2025.

A review of a progress note dated February 10, 2025, revealed the resident representative inquired about discussing Resident 24's medications and was adamant that she did not want her mother to have Seroquel at all and provided a pre-hospital medication list. The physician then re-evaluated and started a gradual dose reduction of Seroquel, and the resident representative was made aware of same.

A review of a physician's order dated February 10, 2025, revealed an order for Seroquel 12.5 mg two times a day for 7 days, then 12.5 mg daily for 7 days, then discontinue the medicaion.

The facility was unable to provide the pre-hospital list given by the resident representative on February 10, 2025, and it was not part of the clinical record.

Interview with the Nursing Home Administrator (NHA) on May 9, 2025, at 9:00 A.M., confirmed there was no documentation available for review at the time of the survey to indicate that Resident 24's responsible party was informed of the psychotropic medication, that the risks and benefits were explained, or that they were offered alternative treatment options.

28 Pa Code 201.29(a) Resident rights

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

Wesley Village submits that its policies, systems, and procedures related to resident care and comprehensive quality improvement program for monitoring of resident care are appropriate. Additionally, it is important to make clear that the submission of this plan of correction is not to be construed as an admission that the cited deficiencies are accurate or that at the time of the survey, Wesley Village did have policies, procedures and systems in place to maintain compliance with federal and state requirements; however, in an effort to enhance the care furnished to our residents, we have augmented some of our existing policies, procedures and systems.

F0552 The Right to be Informed
#1 Resident 24 and their responsible party were informed, regarding all current antipsychotic medications ordered, including risks vs benefits and potential alternative treatment options as necessary.
#2 The facility will review/revise its policy to ensure it reflects: Initial audit will be done on all residents who take Psychoactive medications to have resident/RP notification regarding current use, risk vs benefits of, and alternate treatment options documented.
#3 Licensed Staff will be educated on the updated policy and procedure with respect to Resident/RP notification, risks vs benefits, and alternative treatment options that are potentially available to the resident.
#4 Residents on Seroquel will be audited to ensure resident/RP are aware the physician order to receive the medication, the Risks/benefits, and the potential alternative treatment options. Following the initial audit, each unit manager will conduct a weekly audit x 4 weeks and monthly x 2 on their unit to ensure all residents with a Seroquel order have the appropriate notification, risk vs benefits, and alternate treatment options were offered. The results of this audit will be discussed in QAPI

483.60(e)(1)(2) REQUIREMENT Therapeutic Diet Prescribed by Physician:

§483.60(e) Therapeutic Diets
§483.60(e)(1) Therapeutic diets must be prescribed by the attending physician.

§483.60(e)(2) The attending physician may delegate to a registered or licensed dietitian the task of prescribing a resident's diet, including a therapeutic diet, to the extent allowed by State law.

Observations:

Based on a review of clinical records, observation, and staff interview it was determined the facility failed to provide a physician ordered therapeutic diet (diet ordered by a physician or other delegated provider that is part of tthe treatment for a disease or clinical condition, to eliminate, decrease, or increase certain substances in the diet, or to provide mechanically altered food when indicated) for one resident out of 28 sampled (Resident 54).

Findings include:

A review of the clinical record of Resident 54 revealed the resident had diagnoses which included Alzheimer's disease (a progressive brain disorder that causes memory loss, confusion, and other cognitive decline) and oral phase dysphagia (difficulty swallowing which includes problems with using the mouth, lips, and tongue to control food or liquid).

Review of a Speech Therapy Treatment Encounter Note dated May 14, 2024, revealed a recommendation for the use of lemon ice to facilitate oral movement for AP transfer [anterior-posterior transfer- the movement of the bolus (food or liquid mass) from the front of the mouth to the back, and then down the throat].

A physician order initially dated May 14, 2024, noted an order for a Pureed NAS (no added salt) diet with lemon ice at meals.

Observation of the resident's lunch meals on May 6, 2025, at 12:00 PM and May 7, 2025, at 12:10 PM revealed the resident did not receive lemon ice on her meal tray. Review of the resident's meal tray ticket revealed no written order for lemon ice with meals.

Interview with employee 1 (LPN) on May 7, 2025, at approximately 12:10 PM confirmed that lemon ice was not designated on the resident's meal tray ticket.

During an interview on May 9, 2025, at approximately 9:30 AM the Certified Dietary Manager (CDM) confirmed that Resident 54's current physician orders included lemon ice with each meal. The CDM confirmed the facility failed to provide lemon ice on the resident's meal trays to facilitate swallowing.

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

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

F 0808
#1 Resident 54's meal ticket was corrected during survey and has been receiving her lemon ice.
#2 Residents with physician orders for lemon ice with each meal will be reviewed to ensure that lemon ice is present on tray.
#3 Licensed nursing staff, SLP, CDM, and RD will be educated on utilizing the proper communication system in our EMR, PCC, to ensure all adjustments and new orders are accounted for.
#4 CDM will randomly audit 10 residents weekly x 4 weeks and monthly x 2 months to ensure that any new physician orders or diet changes are transcribed to the resident meal ticket. The results of this audit will be discussed at facility QAPI meeting.

483.25(k) REQUIREMENT Pain Management:

§483.25(k) Pain Management.
The facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences.

Observations:

Based on clinical record review, select facility policy review, and staff interview, it was determined the facility failed to reassess a resident's pain status and medication prescribed on as-needed (PRN) basis to ensure the development and implementation of an effective, individualized pain management plan for one of 28 residents sampled. (Resident 14).

Findings include:

A review of the facility's policy for pain assessment and management last reviewed, March 2025, revealed the facility will provide the resident with care and services to address and manage the resident's pain to support his or her highest practicable level of physical, mental, and psychosocial well-being. Using the comprehensive assessment and care plan, current professional standards of practice, and the resident's goals and preferences, the resident will have pain identified and assessed, have the type of pain identified along with appropriate management approaches, and have pain adequately managed (eliminated if possible or relieved to a tolerable level). The policy requires a comprehensive pain assessment upon admission, quarterly, annually, with any significant change in status, and with the onset of new pain.

Clinical record review revealed that Resident 14 was admitted to the facility on April 7, 2025, with diagnoses including dementia (group of symptoms affecting intellectual and social abilities severely enough to interfere with daily functioning) and pulmonary hypertension (type of high blood pressure that affects the arteries in the lungs and the right side of the heart).

An admission Minimum Data Set assessment (MDS a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated April 13, 2025, revealed a BIMS score (Brief Interview for Mental Status- the BIMS test is used to get a quick snapshot of cognitive function) of 10 (a score of 8-12 indicates moderate impairment), required staff assistance for activities of daily living, no pain the last five days, did not receive scheduled pain medication, and did not exhibit shortness of breath.

A physician order initially dated April 11, 2025, noted an order for acetaminophen (pain reliever) 325 mg give two tablets po (by mouth) PRN (as needed) for pain scale of 1-5. Do not exceed 3000 mg/24 hours.

A physician order initially dated April 22, 2025, noted an order for oxygen 2L/minute continuous via nasal cannula for shortness of breath.

A physician order initially dated April 22, 2025, and discontinued April 28, 2025, noted an order for Morphine Sulfate (narcotic analgesic pain medication) 20 mg/ml give 0.25 mg po every 6 hours PRN for shortness of breath/pain 6-10 for 14 days.

A physician order initially dated April 28, 2025, noted an order for Morphine Sulfate 20 mg/ml give 0.25 mg by mouth every 6 hours PRN for shortness of breath for 14 days.

A physician order initially dated May 7, 2025, noted an order for Morphine Sulfate Solution 20 mg/ml give 0.25 ml by mouth every 6 hours PRN for shortness of breath for 14 days with instructions to document respiratory assessment.
A care plan-initiated April 9, 2025, identified Resident 14 as at risk for pain and included interventions such as administering acetaminophen as ordered, evaluating effectiveness of pain interventions every shift and as needed. Monitor and report to nurse any signs/symptoms of non-verbal pain: Changes in breathing (noisy, deep/shallow, labored, fast/slow); Vocalizations (grunting, moans, yelling out, silence); Mood/behavior (changes, more irritable, restless, aggressive, squirmy, constant motion); Eyes (wide open/narrow slits/shut, glazed, tearing, no focus); Face (sad, crying, worried, scared, clenched teeth, grimacing) Body (tense, rigid, rocking, curled up, thrashing.
Notify physician if interventions are unsuccessful or if current complaint is a significant change from residents past experience of pain.

Despite the established plan, the resident's Medication Administration Record (MAR) revealed the following:

April 23, 2025, at 10:07 AM the resident received the PRN Morphine Sulfate based /ml 0.25 mg by mouth for a pain level of 4 (despite prescribed for pain level of 6-10).

A review of the resident's May 2025 MAR revealed the PRN Morphine Sulfate 20 mg/ml 0.25 mg for shortness of breath was administered on the following dates:
May 1, 2025, at 5:45 PM for a pain level of 4 (no shortness of breath noted)
May 3, 2025, at 5:28 AM for a pain level of 7 (no shortness of breath noted)
May 3, 2025, at 8:53 PM for a pain level of 5 (no shortness of breath noted)
May 4, 2025, at 9:22 PM for a pain level of 4 (no shortness of breath noted)
May 6, 2025, at 1:15 AM for a pain level of 5 (no shortness of breath noted)

Further review of the clinical record revealed no documented evidence of a comprehensive reassessment of the resident's pain status following the onset of pain on April 22, 2025, nor evidence that the pain management plan was reviewed or modified accordingly.

During an interview on May 9, 2025, at approximately 10:00 AM the Director of Nursing (DON) confirmed the following.
a comprehensive pain assessment was not completed as per facility policy to help identify Resident 14's cause of pain and develop an individualized pain management program for the resident.
Staff administered a narcotic prescribed for pain levels 6-10 when pain levels were consistently documented as 4-5.
After the April 28, 2025, physician order changed the indication to "shortness of breath only," staff continued administering Morphine Sulfate without evidence the resident was experiencing shortness of breath.
Staff administered narcotic pain medication on five occasions between May 1, 2025, and May 6, 2025, without a physician order and with no documented evidence the resident was experiencing shortness of breath and there was no evidence of a comprehensive pain reassessment to determine whether the resident's pain management regimen was effective, appropriate, or in need of adjustment.

At the time of the survey, there was no documentation that the facility evaluated the cause of Resident 14's pain, reassessed the appropriateness of PRN medications, or modified the care plan to address the resident's emerging symptoms. The facility practice failed to ensure pain management was based on comprehensive reassessment and individual needs.

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

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

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

F0697 Pain
#1 Resident 14's pain was evaluated to identify the cause of pain and was reassessed for the appropriateness for the PRN medication. These medications were modified, per the physician, and the care plan was updated in coordination with these changes.
#2 Residents who have a multi-tier pain scale (more than one) will be evaluated for the cause of pain and reassessed for the appropriateness for the PRN medication. These medications will be modified as necessary and the care plan will be updated in coordination with these changes.
#3 Licensed nursing staff will be educated to accurately evaluate the cause of resident pain, the necessity of reassessing the appropriateness of PRN pain medications and the need to modify the care plans to address emerging symptoms related to pain management.
#4 DON or designee will audit residents who have a multi-tier PRN pain medication scale in MAR for appropriate indication for use, cause/location of pain, appropriate pain scale, and effectiveness of pain medication. This audit will be completed weekly x 4 weeks and then monthly x 2 months. The results of these audits will be discussed in facility QAPI.

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

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

Observations:

Based on a review of clinical records, select facility policy, observation, and resident and staff interviews, it was determined the facility failed to ensure oxygen therapy was administered per physician's orders for one resident out of 28 sampled (Resident 43).

Findings include:

A review of the facility policy titled "Administration of Oxygen," last reviewed by the facility on March 19, 2025, revealed it is the facility's policy to provide oxygen therapy to residents upon order of the physician. The policy indicates it is the responsibility of the licensed nurse to initiate and monitor the administration of oxygen per physician's orders.

A clinical record review revealed Resident 43 was admitted to the facility on August 19, 2019, with diagnoses that include chronic respiratory failure with hypoxia (COPD is a condition caused by damage to the airways or other parts of the lung that blocks airflow and makes it hard to breathe).

Further clinical record review revealed Resident 43 had an altered respiratory status initiated on February 19, 2025. Interventions implemented to assist Resident 43 with her goal of maintaining a normal breathing pattern included monitoring for signs and symptoms of respiratory distress, reporting to the physician as needed, and providing the resident oxygen via a nasal cannula (a medical device used to deliver supplemental oxygen to a patient through their nostrils) at 1.0 liters per minute (LPM).

However, a discrepancy was identified. Resident 43 has a physician's order to receive oxygen at 2.0 liters per minute via a nasal cannula initiated on March 26, 2025.

An observation on May 7, 2025, at 12:10 PM revealed Resident 43 was awake and sitting upright in her chair with supplemental oxygen in place via an oxygen concentrator with the liter flow set at 0.0 liters per minute. Tubing connected the oxygen concentrator to her via a nasal cannula. During an interview at the time of the observation, Resident 43 indicated that she couldn't feel any airflow from the nasal cannula.

During an interview on May 7, 2025, at 12:15 PM, Employee 2, Licensed Practical Nurse (LPN), confirmed Resident 43 should be receiving continuous oxygen via a nasal cannula at 2.0 liters per minute. Employee 2, LPN, indicated she would set the oxygenator to correctly administer oxygen and check the resident's vital signs.

A progress note dated May 7, 2025, at 12:32 PM revealed Resident 43's oxygen concentrator was checked and the liter flow was set to 0.0 LPM. The flow rate was immediately adjusted, and the resident's blood-oxygen saturation (SpO2) was measured with a pulse oximeter (a device that measures the percentage of oxygen carried by red blood cells in the blood, which is referred to as oxygen saturation). The resident's blood-oxygen saturation (SpO2) was 93% (a normal range is 95-100%; however, individuals with chronic diseases may have levels below 95%). Resident denied shortness of breath or distress.

During an interview on May 9, 2025, at approximately 10:00 AM, the Nursing Home Administrator (NHA) confirmed it is the facility's responsibility to ensure oxygen therapy is administered per physician's orders. The NHA also confirmed it is the facility's responsibility to ensure each resident's plan of care is congruent with physician's orders, including orders for oxygen therapy.

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

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

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

F0695 oxygen
#1 The discrepancy was corrected during survey for resident #43.
#2 Residents who currently have orders for oxygen will be reviewed to ensure that the care plan is not contradictory to physician's order and that the liter flow will match the order.
#3 Licensed staff will be educated to ensure that the physician order for oxygen matches the administration flow and that there is an appropriate oxygen care plan. Staff responsible for initiating care plan, 02 order, and administration for resident #43 were re-educated on current policy individually.
#4 Unit manager or designee will audit residents who have active oxygen orders, ensuring the liter flow matches the physician order and that an appropriate care plan is entered for that resident. This audit will be conducted weekly x 4 weeks and then monthly x 2 months. The results of this audit will be discussed in QAPI.

483.10(c)(6)(8)(g)(12)(i)-(v) REQUIREMENT Request/Refuse/Dscntnue Trmnt;Formlte Adv Dir:

§483.10(c)(6) The right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.

§483.10(c)(8) Nothing in this paragraph should be construed as the right of the resident to receive the provision of medical treatment or medical services deemed medically unnecessary or inappropriate.

§483.10(g)(12) The facility must comply with the requirements specified in 42 CFR part 489, subpart I (Advance Directives).
(i) These requirements include provisions to inform and provide written information to all adult residents concerning the right to accept or refuse medical or surgical treatment and, at the resident's option, formulate an advance directive.
(ii) This includes a written description of the facility's policies to implement advance directives and applicable State law.
(iii) Facilities are permitted to contract with other entities to furnish this information but are still legally responsible for ensuring that the requirements of this section are met.
(iv) If an adult individual is incapacitated at the time of admission and is unable to receive information or articulate whether or not he or she has executed an advance directive, the facility may give advance directive information to the individual's resident representative in accordance with State law.
(v) The facility is not relieved of its obligation to provide this information to the individual once he or she is able to receive such information. Follow-up procedures must be in place to provide the information to the individual directly at the appropriate time.

Observations:

Based on a review of select facility policy, clinical records, and staff interviews, it was determined the facility failed to ensure physician orders were consistent with a resident's documented code status (hospital designation that means to intercede if a patient's heart stops beating or if the patient stops breathing) preference for one of 28 residents reviewed (Resident 75).

Findings include:

A review of the facility's policy titled "Cardiopulmonary Resuscitation," last reviewed on March 19, 2025, indicated that when a resident's resuscitation preference is determined or changed, the facility is responsible for ensuring that the electronic medical record reflects the resident's choice in the "Advanced Directives" section and that physician orders match the resident's expressed wishes.

A review of the clinical record of Resident 75, revealed the resident was admitted to the facility on April 9, 2025, with diagnoses that included hypertension (blood pressure that is higher than normal) and epilepsy (a chronic brain disorder in which groups of nerve cells, or neurons, in the brain sometimes send the wrong signals and cause seizures).

A review of Resident 75's clinical record revealed a completed and signed CPR Status form (cardiopulmonary resuscitation- life-saving procedure performed when the heart or breathing stops), dated April 9, 2025, which indicated the resident elected not to receive cardiopulmonary resuscitation (CPR) in the event their heart or breathing stopped.

However, further review of the resident's electronic medical record revealed that physician orders entered on April 9, 2025, listed the resident's code status as "CPR," meaning resuscitation should be performed. There was no documentation showing that the resident changed their decision or participated in any discussion suggesting an update to their previously signed CPR Status form

Following surveyor inquiry, a physician's order was entered on May 7, 2025, to change the code status to "DNR" (Do Not Resuscitate-a medical order indicating that CPR should not be administered if the resident's heart or breathing stops).

An interview with the Nursing Home Administrator (NHA) on May 7, 2025, at 10:00 AM confirmed that physician orders are expected to match the resident's signed CPR Status form. The Administrator acknowledged that the original physician order indicating "CPR" did not reflect the resident's expressed wishes documented on April 9, 2025, and stated that the inconsistency should have been corrected prior to surveyor identification.

28 Pa. Code 201.29(a) Resident rights.

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

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

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

F0578 Request/Refuse/Discontinue Treatment; Formulate Advance directive
#1 Resident #75 was interviewed to ensure resident/RP's most current wishes were reflected in both the CPR status form as well in in the resident's care plan.
#2 All resident's code status will be reviewed by each of the unit managers to ensure that they are consistent with the order and care plan.
#3 Licensed staff will be educated on the appropriate method to update a code status form and input code status into the care plan. The nurse who made the error will receive a 1:1 education on this topic.
#4 A random audit consisting of 5 residents per week will be conducted by the DON/designee to ensure that the care plan matches the resident's CPR status form. This audit will be conducted on a weekly basis for 4 weeks and then monthly for 2 months. The results of this audit will be discussed in QAPI

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 review of clinical records, facility-initiated transfer notices, and staff interview, it was determined the facility failed to provide copies of written notice of facility-initiated hospital transfers of residents to a representative of the Office of the State Ombudsman for five out of 28 residents reviewed (Residents 1, 20, 87, 90, and 18).

Findings include:

A review of the clinical record revealed that Resident 1 was transferred to the hospital on March 8, 2025, and was readmitted to the facility on March 12, 2025.

A review of the clinical record revealed that Resident 20 was transferred to the hospital on April 27, 2025, and was readmitted to the facility on April 30, 2025.

A review of the clinical record revealed that Resident 87 was transferred to the hospital on March 17, 2025, and was readmitted to the facility on March 20, 2025.

A review of the clinical record revealed that Resident 90 was transferred to the hospital on January 10, 2025, and was readmitted to the facility on January 14, 2025.

A review of the clinical record revealed that Resident 18 was transferred to the hospital on September 14, 2024, and was readmitted to the facility on September 21, 2024. Resident 18 was also transferred to the hospital on January 3, 2025, and was readmitted to the facility on January 7, 2025.

Although written notices were provided to the resident and resident representative of the facility-initiated transfer, there was no documented evidence the facility sent copies of written notices of these facility-initiated transfers to the representative of the Office of the State Long-Term Care Ombudsman.

An interview with the nursing home administrator on May 9, 2025, at approximately 10:00 AM confirmed there was no documented evidence that copies of facility-initiated transfer notices for Residents 1, 18, 20, 87, and 90 were sent to a representative of the Office of the State Long-Term Care Ombudsman. The administrator further confirmed there was no evidence that copies were sent consistently for resident transfers to a representative of the Office of the State Long-Term Care Ombudsman from July 2024 through May 2025.

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

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

1. This is a past event as it relates to residents 1,18,20,87,and 90 and transfer notification cannot be sent to the Office of the State Long-Term Care Ombudsman retroactively if after 30 days.
2. A report will be generated in our EMR to capture facility initiated transfers and discharges in the past 30 days and will be sent to the Office of the State Long-Term Care Ombudsman.
3. Admissions professionals will be re-educated on appropriate generation of the transfer/discharge list in our EMR, the necessary information to include in spreadsheet, and the correct location to send this information.
4. The LNHA or designee will audit all monthly transfer/discharges spreadsheets to ensure that the list in all inclusive and was successfully sent to the appropriate e mail for the Office of the State Long-Term Care Ombudsman

483.70(m), 483.70(m)(2)(iii)(iv)(6) REQUIREMENT Binding Arbitration Agreements:

§483.70(m) Binding Arbitration Agreements.
If a facility chooses to ask a resident or his or her representative to enter into an agreement for binding arbitration, the facility must comply with all of the requirements in this section.

§483.70(m)(2) The facility must ensure that:
(iii) The agreement provides for the selection of a neutral arbitrator agreed upon by both parties; and
(iv) The agreement provides for the selection of a venue that is convenient to both parties.

§483.70(n)( (6) When the facility and a resident resolve a dispute through arbitration, a copy of the signed agreement for binding arbitration and the arbitrator's final decision must be retained by the facility for 5 years after the resolution of that dispute on and be available for inspection upon request by CMS or its designee.

Observations:

Based on review of the facility's admission agreement and staff interview, it was determined that the facility failed to ensure a neutral and fair arbitration process by ensuring both the resident and resident representative, and the facility agree on the selection of a venue that is convenient to both parties.

Findings include:

A review of the facility's Admission Agreement packet, specifically "Section 19.4 Binding Arbitration Subsection (f) Location of Arbitration," contained "Subject to mutual agreement of the parties, the arbitration will be conducted at the facility or at a site within a reasonable distance of the facility."

During an interview on May 9, 2025, at approximately 10:30 AM, the Nursing Home Administrator (NHA) confirmed the language of the arbitration agreement does not state that the location of the arbitration will be at a venue that is convenient to both the resident/resident representative and the facility. The NHA confirmed the language of the policy states two options for the location of arbitration (1) at the facility or (2) a site within a reasonable distance of the facility.

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

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

28 Pa. Code 201.29(a) Resident rights.

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

F0848 Binding Arbitration
#1 No residents were negatively affected by this citation
#2 Section 19.4 of our Admission Packet "Binding Arbitration" Section (F) will be modified to read that "Subject to mutual agreement of both parties, the arbitration will be conducted at a location agreed upon by both parties" Per attorney recommendations families who entered in binding arbitration were notified of the modification.
#3 LNHA educated facility council on the current regulation and verbiage required.
#4 NHA or designee will audit the 10 random residents weekly x4 and monthly x2 who elected into the binding arbitration to ensure updated notification was sent to these families

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