Pennsylvania Department of Health
 SOMERSET HEALTHCARE & REHABILITATION CENTER
Patient Care Inspection Results

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SOMERSET HEALTHCARE & REHABILITATION CENTER
Inspection Results For:

There are  180 surveys for this facility. Please select a date to view the survey results.

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SOMERSET HEALTHCARE & REHABILITATION CENTER - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:
Based on a Medicare/Medicaid Recertification survey, State Licensure survey, Civil Rights Compliance survey, and a complaint survey completed on March 13, 2025, it was determined that Somerset Healthcare 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:


483.60(d)(1)(2) REQUIREMENT Nutritive Value/Appear, Palatable/Prefer Temp:This is a less serious (but not lowest level) deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents. 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.
§483.60(d) Food and drink
Each resident receives and the facility provides-

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

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


Based on review of facility policies and observations, as well as resident and staff interviews, it was determined that the facility failed to serve food items at appetizing temperatures.

Findings include:

The facility's policy regarding food quality and palatability, dated February 24, 2025, indicated that food would be palatable, attractive, and served at a safe and appetizing temperature. Food was to be at the appropriate temperature as determined by the type of food to ensure resident's satisfaction and minimize the risk for scalding and burning.

Food Committee meeting minutes, dated February 5 and March 7, 2025, revealed that residents complained that food was not served at the proper temperature and the food was cold.

Interview with Resident 6, during the initial tour on March 10, 2025, at 11:49 a.m. revealed that meals were usually served cold. Resident 6 was alert and oriented, able to make her needs known, and usually eats in her room.

Interview with Resident 14 on March 10, 2025, at 10:31 a.m. revealed that he will eat his meals in his room and in the main dining room and at times they are served food that is not hot enough.

Interview with Resident 84 on March 10, 2025, at 10:48 a.m. revealed that she eats her meals in her room, and at times they were not served hot enough and that her meals arrived with food being cold. She stated that her waffles this morning were "cold and slimy."

Observations in the main kitchen on March 11, 2024, revealed that the food cart for C-wing left the main kitchen at 12:03 p.m. and arrived on the C-wing at 12:04 p.m. Trays were passed to the residents in their rooms and the last resident was served at 12:15 p.m. At 12:15 p.m. the temperature of the crusted pork was 126.3 degrees Fahrenheit (F) and the peas were 127.7 degrees F. The pork and peas were lukewarm and not served at an appetizing temperature.

Interview with the Dietary Manager March 11, 2025, at 12:48 p.m. confirmed that she was aware that residents were complaining about food temperatures and was also aware of the policy regarding food that is to be served at appetizing temperatures.

28 Pa. Code 211.6(b) Dietary Services.




 Plan of Correction - To be completed: 04/10/2025

- Dietary Manager will participate in immediate training and complete the following educations prior to returning to work: Test Tray Policy; Resident satisfaction survey and Food committee policy and procedure on palatability and food temperatures.
- Audits will be completed by Dietary Manager or designee to include 3 test trays weekly for 30 days, and 3 test trays weekly for additional 60 days and then on test tray weekly ongoing. Audits will be completed on resident satisfaction survey weekly with a minimum of 10 residents for 12 weeks, followed by 1 resident satisfaction survey monthly ongoing.
- All dietary Staff educated on the following policies: Food Quality and Palatability Policy; Plate Presentation; Service Line Procedures
- Results of audits will be presented to the Quality Assurance Performance Improvement Committee for review and recommendations.
- AOC 4/10/2025

483.21(b)(1)(3) REQUIREMENT Develop/Implement Comprehensive Care Plan: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.
§483.21(b) Comprehensive Care Plans
§483.21(b)(1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at §483.10(c)(2) and §483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following -
(i) The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under §483.24, §483.25 or §483.40; and
(ii) Any services that would otherwise be required under §483.24, §483.25 or §483.40 but are not provided due to the resident's exercise of rights under §483.10, including the right to refuse treatment under §483.10(c)(6).
(iii) Any specialized services or specialized rehabilitative services the nursing facility will provide as a result of PASARR recommendations. If a facility disagrees with the findings of the PASARR, it must indicate its rationale in the resident's medical record.
(iv)In consultation with the resident and the resident's representative(s)-
(A) The resident's goals for admission and desired outcomes.
(B) The resident's preference and potential for future discharge. Facilities must document whether the resident's desire to return to the community was assessed and any referrals to local contact agencies and/or other appropriate entities, for this purpose.
(C) Discharge plans in the comprehensive care plan, as appropriate, in accordance with the requirements set forth in paragraph (c) of this section.
§483.21(b)(3) The services provided or arranged by the facility, as outlined by the comprehensive care plan, must-
(iii) Be culturally-competent and trauma-informed.
Observations:


Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included specific and individualized interventions for three of 37 residents reviewed (Residents 38, 57, 60).

Findings include:

A facility policy for comprehensive care plans, dated February 24, 2025, included that the facility will develop and implement a person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing and mental and psychological needs and all services that are identified in the resident's comprehensive assessment and meet professional standards of quality. The comprehensive care plan will be developed within seven days after the completion of the comprehensive MDA assessment.

CDC guidance on isolation precautions and Implementation of Personal Protective Equipment (PPE) use in Nursing Homes to Prevent Spread of Multidrug-Resistant Organisms (MDRO's - bacteria that have become resistant to certain antibiotics, and these antibiotics can no longer be used to control or kill the bacteria), dated July 12, 2022, indicates that MDRO transmission is common in skilled nursing facilities, contributing to substantial resident morbidity and mortality and increased healthcare costs. Enhanced Barrier Precautions (EBP's) are an infection control intervention designed to reduce transmission of resistant organisms that employs targeted gown and glove use during high contact resident care activities. CMS updated its infection prevention and control guidance effective April 1, 2024. The recommendations now include the use of EBP's during high-contact care activities for residents with chronic wounds or indwelling medical devices, regardless of their MDRO status, in addition to residents who have an infection or colonization with a CDC-targeted or other epidemiologically important MDRO when contact precautions do not apply.

The facility's policy regarding EBP, dated February 24, 2025, indicated that EBP are used as an infection prevention and control intervention to reduce the spread of MDROs to residents. EBPs were necessary when performing high-contact resident care. Gloves and gown are applied prior to performing the high-contact resident-care activity (as opposed to before entering the room). EBP's are indicated for residents with wound care. EBPs remain in place for the duration of the resident's stay or until resolution of the wound or discontinuation of the indwelling medical device that places them at increased risk.

A quarterly Minimum Data assessment Set (MDS) (a mandated assessment of a resident's abilities and care needs) for Resident 38, dated January 8, 2025, revealed that the resident could usually make himself understood, was cognitively intact, and received nutrition through a feeding tube. Physician's orders, dated January 8, 2025, included orders for the resident to be on EBP every shift due to having a feeding tube, and physician's orders, dated January 28, 2025, included orders for the resident to receive continuous feedings of Jevity 1.2 (a tube feeding formula that contains 1.2 calories in every milliliter) at 65 cubic centimeters (cc's) per hour.

Observations of Resident 38 on March 11, 2025, at 1:04 p.m. revealed that the resident was in bed and his tube feeding of Jevity 1.2 was running at 65 cc/hr, and there was an EBP sign on his closet door.

Review of Resident 38's current care plan revealed no documented evidence that a care plan was developed to address the resident's care needs related to EBP.

Interview with the Assistant Director of Nursing on March 11, 2025, at 12:41 p.m. confirmed that there was no care plan developed to address the resident's need for EBP.

A quarterly MDS assessment for Resident 57, dated February 24, 2024, indicated that the resident was cognitively intact, was independent with personal hygiene care needs, and had diagnoses that included anoxic brain damage (an acquired brain injury that occurs when the brain is deprived of oxygen).

Physician's orders for Resident 57, dated November 11, 2024, included an order that the resident may go out to smoke. However, there was no documented evidence that a care plan regarding Resident 57's smoking was developed until March 10, 2025.

Interview with the Assistant Director of Nursing on March 12, 2025, at 12:25 p.m. revealed that a care plan for smoking was not developed until March 10, 2025, and it should have been developed in November 2024 when Resident 57 was identified as a smoker.

A quarterly MDS assessment for Resident 60, dated February 1, 2025, indicated that the resident was cognitively intact, was dependent on staff for daily care needs, and had diagnosis that included diabetes and paraplegia (loss of muscle function in the lower half of the body, including both legs).

Physician's orders for Resident 60, dated January 6, 2025, included an order that the resident have his percutaneous endoscopic gastrostomy (PEG) tube (a medical device inserted through the abdominal wall directly into the stomach) checked for placement every shift.

Interview with the Director of Nursing on March 12, 2025, at 3:36 p.m. revealed that as of March 11, 2025, a care plan for the care and treatment of Resident 60's PEG tube was not developed.

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




 Plan of Correction - To be completed: 04/10/2025

- Comprehensive care plans completed to reflect that R38 requires Enhanced Barrier Precautions (EBP), R57 is identified as a smoker, and R60 has a percutaneous endoscopic gastrostomy (PEG) tube. Residents with EBP, identified as smokers and with enteral feedings will be reviewed x 30 days for completion of comprehensive care plans.
- Audits will be completed by Registered Nurse Assessment Coordinator (RNAC) or designee on comprehensive care plans to ensure residents with peg tubes, residents who smoke, and residents requiring EBP have comprehensive care plans in place. Audits will be completed weekly x 4 weeks, then monthly x 2 months.
- Education will be completed with RNAC, Director of Nursing (DON), and Assistant Director of Nursing (ADON) on facility policy for comprehensive care plans. By 4/4/2025.
- Results of Comprehensive care plan audits will be presented to the Quality Assurance Performance Committee for review and recommendations.
- AOC 4/10/2025

483.25(l) REQUIREMENT Dialysis: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(l) Dialysis.
The facility must ensure that residents who require dialysis receive 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 reviews and staff interviews, it was determined that the facility failed to complete treatments as ordered by the physician for one of 37 residents reviewed (Resident 48) who received dialysis services.

Findings include:

An Admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 48, dated February 9, 2025, revealed that the resident understood and understands, was cognitively intact, received dialysis, and had diagnoses that included end-stage renal disease. A care plan, dated February 4, 2025, revealed that the resident received peritoneal dialysis (a treatment for kidney failure that uses the lining of your abdomen, or belly, to filter your blood inside your body), and staff were to check and change the dressing at the access site daily. Physician's orders for Resident 48, dated February 3, 2025, and February 13, 2025, respectively, included orders for the resident to have 0.1 percent Gentamicin ointment applied to the peritoneal dialysis site topically every day shift and to receive peritoneal dialysis every night shift.

Resident 48's Treatment Administration Record (TAR's) for February and March 2025 revealed no documented evidence that Gentamicin was applied to the peritoneal dialysis site on February 4, 5, 7, 10, 13, 14, 18, 19, 22, and March 1, 3, 4, 11, and 12, 2025.

Interview with the Director of Nursing on March 13, 2025, at 12:31 p.m. confirmed that there was no documented evidence that staff completed the treatment of Gentamicin as ordered on the dates mentioned above.

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




 Plan of Correction - To be completed: 04/10/2025

- Physician notified that antibiotic treatment was not completed as ordered for R48. Residents with antibiotic treatment orders will be reviewed x 30days.
- Audits will be completed on all residents ordered antibiotic treatments to peritoneal dialysis(PD) sites by Infection Preventionists or designee to ensure treatments are being completed as ordered. Audits will be completed weekly x 4 weeks, then monthly x 2 months.
- Education will be completed with all licensed nursing staff regarding PD, including ordered dressings to PD access site by Director of Nursing/Assistant Director of Nursing. By 4/4/2025
- Results of PD site treatment audits will be presented to the Quality Assurance Performance Committee for review and recommendations
- AOC 4/10/2025

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


Based on clinical record reviews and staff interviews, it was determined that the facility failed to ensure that interventions to prevent weight loss were provided as recommended by the dietician for one of 37 residents reviewed (Resident 46).

Findings include:

A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 46, dated August 8, 2024, revealed that the resident had moderate cognitive impairment, required set up and clean up assistance with eating, had diagnoses that included left hemiplegia (loss of strength in the arm, leg, and sometimes the face on one side of the body) following a stroke, and had unplanned weight loss.

A care plan for Resident 46, dated August 8, 2024, indicated that the resident had the potential for a nutritional problem and that a registered dietician was to evaluate and make diet change recommendations as needed, and Med Pass supplement (a fortified nutritional shake that provides additional calories and protein) was to be provided as ordered.

A Nutritional Review assessment for Resident 46, dated February 9, 2025, indicated that Resident 46 was to continue receiving 60 milliliters (ml) of Med Pass three times a day to provide 720 kilocalories and 30 grams of protein which will help meet the deficit from sporadic meal intakes.

Review of the Medication Administration Record (MAR) for Resident 46, dated February 2025 and March 2025, revealed no documented evidence that the resident was provided the Med Pass supplement between February 10, 2025, and March 11, 2025.

Review of the weight record for Resident 46 revealed that on February 4, 2025, the resident weighed 177.8 pounds (lbs) and on March 4, 2025, the resident's weight was 162.4 lbs.

Interview with the Assistant Director of Nursing on March 11, 2025, at 3:44 p.m. revealed that a Med Pass supplement order was originally entered to be given for one month and was completed on February 9, 2025; however, the Med Pass supplement should have been re-ordered per the dietician's recommendation and was not.

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




 Plan of Correction - To be completed: 04/10/2025

- Physician notified of weight loss for resident R46, supplement reordered per recommendations. Residents will be reviewed x 30days for supplement orders.
- Audits will be completed by DON or designed of recommendations sent by the Registered Dietitian on all residents with significant weight loss to ensure these supplements have corresponding physician orders. These audits will be completed weekly x 4 weeks, then monthly x 2 months.
- Education will be provided to dietitian regarding facility policy Nutrition Management by Director of Nursing By 4/4/2025.
- Results of Significant weight loss / supplement audits will be presented to the Quality Assurance Performance Committee for review and recommendations
- AOC 4/10/2025

483.10(e)(3) REQUIREMENT Reasonable Accommodations Needs/Preferences:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
§483.10(e)(3) The right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents.
Observations:


Based on review of policies and clinical records, as well as observations and resident and staff interviews, it was determined that the facility failed to ensure that call bells were within reach for one of 37 residents reviewed (Resident 8).

Findings include:

The facility's policy for call lights: accessibility and response, dated February 24, 2025, indicated that the purpose was to ensure the facility is adequately equipped with a call light at each residents' bedside, toilet, and bathing facility, to allow residents to call for assistance. Staff will ensure the call light is within reach of residents and secured, as needed.

A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's care needs and abilities) for Resident 8, dated February 18, 2025, revealed that the resident had moderate cognitive impairment, required assistance from staff for care needs, and had diagnoses that included right-sided hemiplegia (loss of strength in the arm, leg, and sometimes face on one side of the body) following a stroke.

A care plan for Resident 8, dated March 7, 2025, indicated that the resident was at risk for falls and that staff were to be sure the resident's call light was within reach and encourage the resident to use it. A care plan, dated November 20, 2024, indicated that the resident required assistance with activities of daily living, and that staff were to encourage the resident to use his call bell to call for assistance.

Observations of Resident 8 in his room on March 10, 2025, at 11:05 a.m. revealed that the resident was lying in his bed and his call bell was not seen on or near his bed. The resident was asked how he would call for help if he needed it, and he shrugged his shoulders.

Interview with Licensed Practical Nurse 1 on March 10, 2025, at 11:05 a.m. confirmed that Resident 8 did not have his call bell within reach and should have.

Interview with the Director of Nursing on March 10, 2025, at 12:48 p.m. confirmed that Resident 8's call bell should have been within his reach.

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




 Plan of Correction - To be completed: 04/10/2025

- Call bell immediately placed in R8's reach.
- Audits will be completed to ensure residents' call bells are within reach. Audits will be completed daily x 2 week, weekly x 4 weeks and monthly for 2 months then randomly ongoing Audits to be completed by Nursing Home Administrator (NHA), Director of Nursing (DON), or designee.
- Education will be completed with all staff on the facility call bell policy, "Call Lights, Accessibility and Timely response". By 4/4/2025
- Results of call bell audits will be presented to the Quality Assurance Performance Improvement Committee for review and recommendations
- AOC 4/10/2025

483.10(h)(1)-(3)(i)(ii) REQUIREMENT Personal Privacy/Confidentiality of Records: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(h) Privacy and Confidentiality.
The resident has a right to personal privacy and confidentiality of his or her personal and medical records.

§483.10(h)(l) Personal privacy includes accommodations, medical treatment, written and telephone communications, personal care, visits, and meetings of family and resident groups, but this does not require the facility to provide a private room for each resident.

§483.10(h)(2) The facility must respect the residents right to personal privacy, including the right to privacy in his or her oral (that is, spoken), written, and electronic communications, including the right to send and promptly receive unopened mail and other letters, packages and other materials delivered to the facility for the resident, including those delivered through a means other than a postal service.

§483.10(h)(3) The resident has a right to secure and confidential personal and medical records.
(i) The resident has the right to refuse the release of personal and medical records except as provided at §483.70(h)(2) or other applicable federal or state laws.
(ii) The facility must allow representatives of the Office of the State Long-Term Care Ombudsman to examine a resident's medical, social, and administrative records in accordance with State law.
Observations:


Based on review of facility policies and observations, as well as interviews with staff, it was determined that the facility failed to maintain the confidentiality of medical information for one of 37 residents reviewed (Resident 54).

Findings include:

The facility's policy regarding confidentiality and medical records, dated February 24, 2024, indicated that employees are to ensure computer screens with health information are minimized or closed to ensure resident confidentiality.

Observations on March 12, 2025, at 8:00 a.m. revealed a laptop on top of a medication cart in the hallway outside of room 106 that was open and the Medication Administration Record (MAR) for Resident 54 was visible to staff, residents, and visitors in the hallway. No nurse was observed near the medication cart.

Interview with Registered Nurse 2 on March 12, 2025, at 8:06 a.m. revealed that she had walked away from the medication cart for a few minutes to get something she needed and did not minimize the laptop screen, allowing Resident 54's confidential medical information to be visible to anyone passing by and that she should have minimized her screen.

Interview with the Nursing Home Administrator on March 12, 2025, at 11:09 a.m. confirmed that laptop screens with confidential medical information should not be unattended or viewable by unauthorized people.

28 Pa. Code 201.29(a) Resident Rights.

28 Pa. Code 211.5(b) Clinical Records.




 Plan of Correction - To be completed: 04/10/2025

- No harm resulted to R54.
- Audits will be completed by Registered Nurse Supervisors or designee to ensure residents' private health information is kept confidential and computer screens with private health information are not left unattended. Audits will be completed daily x 2 weeks, weekly x 4 weeks and monthly for 2 months then randomly ongoing Audits to be completed by Nursing Home Administrator (NHA), Director of Nursing (DON), or designee.
- Education will be completed with licensed nursing staff on facility policy for "Confidentially of Personal and Medical records" by DON/Assistant Director of Nursing (ADON) By 4/4/2025
- Results of Health Insurance Portability and Accountability Act (HIPAA) audits will be presented to the Quality Assurance Performance Improvement Committee for review and recommendations
- AOC 4/10/2025

483.15(c)(3)-(6)(8) REQUIREMENT Notice Requirements Before Transfer/Discharge: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.
§483.15(c)(3) Notice before transfer.
Before a facility transfers or discharges a resident, the facility must-
(i) Notify the resident and the resident's representative(s) of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand. The facility must send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman.
(ii) Record the reasons for the transfer or discharge in the resident's medical record in accordance with paragraph (c)(2) of this section; and
(iii) Include in the notice the items described in paragraph (c)(5) of this section.

§483.15(c)(4) Timing of the notice.
(i) Except as specified in paragraphs (c)(4)(ii) and (c)(8) of this section, the notice of transfer or discharge required under this section must be made by the facility at least 30 days before the resident is transferred or discharged.
(ii) Notice must be made as soon as practicable before transfer or discharge when-
(A) The safety of individuals in the facility would be endangered under paragraph (c)(1)(i)(C) of this section;
(B) The health of individuals in the facility would be endangered, under paragraph (c)(1)(i)(D) of this section;
(C) The resident's health improves sufficiently to allow a more immediate transfer or discharge, under paragraph (c)(1)(i)(B) of this section;
(D) An immediate transfer or discharge is required by the resident's urgent medical needs, under paragraph (c)(1)(i)(A) of this section; or
(E) A resident has not resided in the facility for 30 days.

§483.15(c)(5) Contents of the notice. The written notice specified in paragraph (c)(3) of this section must include the following:
(i) The reason for transfer or discharge;
(ii) The effective date of transfer or discharge;
(iii) The location to which the resident is transferred or discharged;
(iv) A statement of the resident's appeal rights, including the name, address (mailing and email), and telephone number of the entity which receives such requests; and information on how to obtain an appeal form and assistance in completing the form and submitting the appeal hearing request;
(v) The name, address (mailing and email) and telephone number of the Office of the State Long-Term Care Ombudsman;
(vi) For nursing facility residents with intellectual and developmental disabilities or related disabilities, the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with developmental disabilities established under Part C of the Developmental Disabilities Assistance and Bill of Rights Act of 2000 (Pub. L. 106-402, codified at 42 U.S.C. 15001 et seq.); and
(vii) For nursing facility residents with a mental disorder or related disabilities, the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with a mental disorder established under the Protection and Advocacy for Mentally Ill Individuals Act.

§483.15(c)(6) Changes to the notice.
If the information in the notice changes prior to effecting the transfer or discharge, the facility must update the recipients of the notice as soon as practicable once the updated information becomes available.

§483.15(c)(8) Notice in advance of facility closure
In the case of facility closure, the individual who is the administrator of the facility must provide written notification prior to the impending closure to the State Survey Agency, the Office of the State Long-Term Care Ombudsman, residents of the facility, and the resident representatives, as well as the plan for the transfer and adequate relocation of the residents, as required at § 483.70(k).
Observations:


Based on clinical record reviews and staff interviews, it was determined that the facility failed to notify the resident and legal guardian in writing regarding the reason for hospitalization for three of 37 residents reviewed (Residents 27, 49, 71).

Findings include:

A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 27, dated January 17, 2025, indicated that the resident was understood, could understand others, and was cognitively intact.

A nursing note, dated October 20, 2024, at 3:28 p.m., revealed that the Certified Registered Nurse Practitioner (CRNP) was notified of the resident's laboratory test results showing an elevated white blood cell count and the resident's continued complaint of abdominal pain, nausea, and chills. Orders were received to transfer the resident to the hospital for evaluation and treatment.

Interview with the Assistant Director of Nursing on March 11, 2025, at 12:41 p.m. confirmed that there was no documented evidence that a written notice of Resident 27's transfer to the hospital was provided to the resident's representative regarding the reason for transfer to the hospital on October 20, 2024.

A quarterly MDS assessment for Resident 49, dated February 1, 2025, indicated that the resident was cognitively impaired, required assistance with daily care needs, and had diagnoses that included dementia.

A nurse's note for Resident 49, dated January 5, 2025, at 4:41 p.m., revealed that results of an x-ray were provided to the facility, which indicated that the resident had a left hip fracture, and orders were obtained to send the resident to the hospital for follow up care.

There was no documented evidence that a written notice of Resident 49's transfer to the hospital was provided to the resident and/or the resident's responsible party regarding the reason for transfer.

Interview with the Director of Nursing on March 11, 2025, at 1:36 p.m. confirmed that there was no documented evidence that a written notice of Resident 49's transfer to the hospital was provided to the resident's representative regarding the reason for transfer to the hospital on January 1, 2025.

An annual MDS assessment for Resident 71, dated February 3, 2025, revealed that the resident was understood, could understand others, and had diagnoses that included hypertension (high blood pressure), diabetes, and Chronic obstructive pulmonary disease (COPD - a group of lung diseases that cause airflow obstruction and breathing difficulties).

Nursing notes for Resident 71, dated February 19, 2025, at 9:15 a.m., revealed that the resident was lethargic (feeling tired, sluggish, or lacking in energy) and hard to arouse. Pulse oximeter (an electronic device that measures the saturation of oxygen carried in your red blood cells) on oxygen at two liters per minute via nasal cannula (a device that delivers extra oxygen through a tube and into your nose) was 84 percent (a normal pulse oximeter reading for your oxygen saturation level is between 95 and 100 percent). Certified Registered Nurse Practitioner (CRNP - are RNs with additional education and training that allows them to work under a wider scope of practice) was in and examined the resident. The resident was placed on oxygen at four liters per minute via face mask and still unable to raise the resident's oxygen level. Orders were received to send the resident to emergency department for further evaluation and treatment. A nursing note at 9:50 a.m. revealed that the resident was sent to the emergency department via ambulance.

There was no documented evidence that a written notice of Resident 71's transfer to the hospital was provided to the resident and/or the resident's responsible party regarding the reason for transfer.

Interview with the Nursing Home Administrator on March 13, 2025, at 3:18 p.m. confirmed that there was no documented evidence that a written notice of Resident 71's transfer to the hospital was provided to the resident and/or the resident's responsible party regarding the reason for transfer.

28 Pa. Code 201.25 Discharge Policy.

28 Pa. Code 201.29(f)(g) Resident Rights.







 Plan of Correction - To be completed: 04/10/2025

- Written notification of Transfer to Hospital completed and sent to residents identified R27, R49. R71 ceased to breathe on 02/22/2025. Residents that were transferred for the last 30 day were reviewed for written notification by the Director of Nursing/Designee
- Audits will be completed by Business office Manager or designee to ensure that resident representatives are notified of all resident transfers from facility. These audits will be completed on all facility transfers weekly x 4 weeks then monthly for 2 months then ongoing
- Education will be completed with nursing staff / medical records/ business office manager on requirement of Written Notification of Transfer from facility to ensure notification by Nursing Home Administrator (NHA) will be completed. By 4/4/2025
- Results of Written Transfer to Hospital audits will be presented to the Quality Assurance Performance Improvement Committee for review and recommendations
- AOC 4/10/2025


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


Based on review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to issue a bed-hold notice at the time of an anticipated leave of absence from the facility for one of 37 residents reviewed (Resident 71).

Findings include:

The facility's policy regarding bed hold notices and transfer, dated February 24, 2025, indicated that in the event of an emergency transfer of a resident, the facility will provide written notice of the facility's bed-hold policies to the resident and/or the resident's representative within 24 hours. The facility will document multiple attempts to reach the resident's representative in cases where the facility was unable to notify the representative. The facility will keep a signed and dated copy of the bed-hold notice information given to the resident and/or resident's representative in the resident's file and/or medical record. The facility will provide this written information to all facility residents, regardless of their payment source.

An annual Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 71, dated February 3, 2025, revealed that the resident was understood, could understand others, and had diagnoses that included hypertension (high blood pressure), diabetes, and chronic obstructive pulmonary disease (COPD - a group of lung diseases that cause airflow obstruction and breathing difficulties).

Nursing notes for Resident 71, dated February 19, 2025, at 9:15 a.m., revealed that the resident was lethargic (feeling tired, sluggish, or lacking in energy) and hard to arouse. Pulse oximeter (an electronic device that measures the saturation of oxygen carried in your red blood cells) on oxygen at two liters per minute via nasal cannula (a device that delivers extra oxygen through a tube and into your nose) was 84 percent (a normal pulse oximeter reading for your oxygen saturation level is between 95 and 100 percent). Certified Registered Nurse Practitioner (CRNP - are RNs with additional education and training that allows them to work under a wider scope of practice) was in and examined the resident. The resident was placed on oxygen at four liters per minute via face mask and still unable to raise the resident's oxygen level. Orders were received to send the resident to emergency department for further evaluation and treatment. A nursing note at 9:50 a.m. revealed that the resident was sent to the emergency department via ambulance.

There was no documented evidence that a bed-hold notice was issued to Resident 71 or her responsible party at the time of her transfer to the hospital.

Interview with the Nursing Home Administrator on March 13, 2025, at 3:18 p.m. confirmed that there was no documented evidence that a bed-hold notice was issued to Resident 71 or her responsible party at the time of her transfer to the hospital.

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

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






 Plan of Correction - To be completed: 04/10/2025

- Resident R71 ceased to breathe on 2/22/2025. Residents were reviewed for the last 30 days for bed hold notice by the Director of Nursing/Designee
- Audits will be completed by Business office Manager or designee to ensure all residents being transferred from facility receive notification of facility bed hold policy weekly x 4 weeks then monthly for 2 months
- Education will be provided to Business office manager regarding requirement for completion of bed hold status of resident upon resident transfer from facility by Nursing Home Administrator (NHA) by 4/4/2025.
- Results of Bed hold Policy audits will be presented to the Quality Assurance Performance Improvement Committee for review and recommendations.
- AOC 4/10/2025

483.20(b)(2)(ii) REQUIREMENT Comprehensive Assessment After Signifcant Chg:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
§483.20(b)(2)(ii) Within 14 days after the facility determines, or should have determined, that there has been a significant change in the resident's physical or mental condition. (For purpose of this section, a "significant change" means a major decline or improvement in the resident's status that will not normally resolve itself without further intervention by staff or by implementing standard disease-related clinical interventions, that has an impact on more than one area of the resident's health status, and requires interdisciplinary review or revision of the care plan, or both.)
Observations:


Based on review of the Resident Assessment Instrument User's Manual and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that comprehensive significant change Minimum Data Set assessments were completed in the required time frame for one of 37 residents reviewed (Resident 65).

Findings include:

The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which provides instructions and guidelines for completing required Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2024, indicated that the Assessment Reference Date (ARD) was to be no later than the 14th calendar day after determination that a significant change in the resident's status occurred (determination date + 14 calendar days) and the significant change comprehensive MDS assessment was to be completed no later than the 14th calendar day after determination that significant a change in the resident's status occurred (determination date + 14 calendar days).

A care plan for Resident 65, dated July 24, 2024, revealed that the resident required hospice care (medical care to help someone with a terminal illness) related to an end-stage illness.

Physician's orders for Resident 65, dated July 23, 2024, included an order for the resident to be admitted to hospice.

There was no documented evidence that a significant change in status MDS assessment was completed for Resident 65 after being admitted to hospice care on July 23, 2024.

Interview with the Nursing Home Administrator on March 11, 2025, at 2:57 p.m. confirmed that the significant change comprehensive MDS assessment for Resident 65 was not completed within the required time frame.

28 Pa. Code 211.5(f) Clinical Records.




 Plan of Correction - To be completed: 04/10/2025

- R65's Significant change in status Minimum Data Set (MDS) assessment scheduled for 3/11/2025. Assessment completed and submitted. Residents will be reviewed x 30 days with significant changes for MDS assessments.
- Audits will be completed by Registered Nurse Assessment Coordinator (RNAC) or designee to ensure all significant change in status MDS assessments are completed timely weekly x 4 weeks, monthly x 2 months.
- Education will be provided to RNAC regarding Resident Assessment Instrument (RAI) guidelines for timely completion of a significant change in status assessment. By 4/4/2025.
- Results of Significant Change in Status MDS audits will be presented to the Quality Assurance Performance Improvement Committee for review and recommendations
- AOC 4/10/2025.

483.20(g) REQUIREMENT Accuracy of Assessments:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
§483.20(g) Accuracy of Assessments.
The assessment must accurately reflect the resident's status.
Observations:


Based on a review of the Resident Assessment Instrument User's Manual and clinical records, as well as staff interviews, it was determined that the facility failed to complete accurate Minimum Data Set assessments for seven of 37 residents reviewed (Residents 9, 23, 36, 39, 49, 55, 57).

Findings include:

The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which provides guidance and instructions for the completion of Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2024, indicated that Section N0415I1 (Antiplatelet Medications - medications used to reduce the risk of blood clots) was to be checked if the resident received an anti-platelet medication during the seven-day assessment period.

Physician's orders for Resident 9, dated January 7, 2021, included an order for the resident to receive 81 milligrams (mg) of aspirin daily. The resident's Medication Administration Record (MAR) for February 2025 revealed that the resident received aspirin daily during the seven-day look-back period. However, a quarterly MDS assessment for Resident 9, dated February 1, 2025, revealed that Section N0415I1 was coded zero (0), indicating that the resident did not receive an anti-platelet during the last seven days.

An interview with the Registered Nurse Assessment Coordinator (RNAC - a registered nurse who is responsible for the completion of MDS assessments) on March 13, 2025, at 2:45 p.m. confirmed that Resident 9's MDS assessment was not coded accurately.

Physician's orders for Resident 23, dated February 25, 2024, included an order for the resident to receive 81 mg of aspirin daily. The resident's MAR for January 2025 revealed that the resident received aspirin daily during the seven-day look-back period. However, an annual MDS assessment for Resident 23, dated January 10, 2025, revealed that Section N0415I1 was coded zero (0), indicating that the resident did not receive an anti-platelet during the last seven days.

An interview with Nursing Home Administrator on March 11, 2025, at 2:57 p.m. confirmed that the MDS assessment for Resident 23 was coded incorrectly.

Physician's orders for Resident 36, dated September 10, 2022, included an order for the resident to receive 81 mg of aspirin daily. Review of the resident's MAR for January 2025 and February 2025 revealed that the resident received aspirin daily during the seven-day look-back period. However, a quarterly MDS assessment for Resident 36, dated February 1, 2025, revealed that Section N0415I was coded (0) indicating that the resident did not receive an anti-platelet during the last seven days.

An interview with the RNAC on March 13, 2025, at 2:44 p.m. confirmed that Resident 36's MDS assessment dated February 1, 2025, was coded incorrectly.

Physician's orders for Resident 49, dated January 9, 2025, included an order for the resident to receive 81 mg of aspirin daily. Review of the resident's MAR for January 2025 revealed that the resident received aspirin daily during the seven-day look-back period. However, a quarterly MDS assessment for Resident 49, dated February 1, 2025, revealed that Section N0415I was not coded (1) is taking, indicating that the resident did not receive an anti-platelet during the last seven days.

An interview with the RNAC on March 13, 2025, at 2:47 p.m. confirmed that Resident 49's MDS assessment dated February 1, 2025, was not coded accurately.

The RAI User's Manual, dated October 2024, indicated that Section O0110J1 (Dialysis) was to be checked if the resident received peritoneal or renal dialysis at the nursing home or at another facility during the 14-day assessment period.

Physician's orders for Resident 39, dated February 15, 2025, included an order for the resident to have hemodialysis every Tuesday, Thursday, and Saturday. The resident's dialysis communication form, dated February 25, 2025, revealed that the resident received hemodialysis. However, a quarterly MDS assessment for Resident 39, dated February 28, 2025, revealed that Section O0110J1b was coded zero (0), indicating that the resident did not receive dialysis during the last 14 days while a resident.

An interview with the RNAC on March 13, 2025, at 2:44 p.m. confirmed that Resident 39's MDS assessment was coded incorrectly.

The Long-Term Care Facility RAI User's Manual, dated October 2024, indicated that the purpose of Section J0100B (Received as needed pain medication?) was to identify if the resident received any as needed pain medication during the seven-day look-back period.

Review of the MAR for Resident 55, dated February, 2025, revealed that the resident did not receive as needed pain medication during the seven-day look-back period. However, a quarterly MDS assessment for Resident 55, dated February 13, 2025, revealed that Section J0100B was coded (yes), indicating that the resident did receive as needed pain medication during the seven-day look-back period.

An interview with the RNAC on March 13, 2025, at 2:46 p.m. confirmed that Resident 55's MDS assessment dated February 13, 2025, was coded incorrectly.

The Long-Term Care Facility RAI User's Manual, dated October 2024, indicated that Section N0451K was to be coded (1) is taking, if the resident received an anti-convulsant during the seven-day assessment period.

Physician's orders for Resident 57, dated November 21, 2023, included an order for the resident to receive three 125 mg capsules of gabapentin (anticonvulsant medication) three times a day. Review of the MAR for Resident 57, dated February 2025, revealed that staff administered three 125 mg capsules of gabapentin three times a day during the seven-day look-back period. However, a quarterly MDS assessment for Resident 57, dated February 24, 2025, revealed that Section N0415K was coded (0), indicating that the resident did not receive an anti-convulsant medication during the seven-day assessment.

Interview with the Director of Nursing on March 12, 2025, at 12:30 p.m. confirmed that Resident 57's MDS assessment dated February 14, 2025, was coded incorrectly.

28 Pa. Code 211.5(f) Clinical Records.




 Plan of Correction - To be completed: 04/10/2025

- Minimum Data Set (MDS) assessments for residents R9, R23 , R36, R49, R55, R57, R39 that were identified as coded inaccurately modified to reflect accurate coding. Residents will be reviewed x 30 days for accurate coding.
- Audits will be completed by Registered Nurse Assessment Coordinator (RNAC) or designee on all residents ordered aspirin, gabapentin and all residents receiving dialysis. Identified residents' most recent MDS assessment will be reviewed to ensure that medications and dialysis are coded accurately. Audits will be completed weekly x 4 weeks, then monthly x 2 months.
- Education will be provided to the RNAC regarding the Resident Assessment Instrument (RAI) guidelines on accurate coding of medications and dialysis on MDS assessments. By 4/4/2025.
- Results of MDS coding audits will be presented to the Quality Assurance Performance Improvement Committee for review and recommendations.
- AOC 4/10/2025.


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


Based on review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that a resident's care plan was updated/revised to reflect the resident's specific care needs for two of 37 residents reviewed (Residents 8, 55).

Findings include:

A facility policy for care plan revision upon status change, dated February 24, 2025, indicated that the comprehensive care plan will be reviewed and revised as necessary when the resident experiences a status change. The care plan will be updated with new or modified interventions.

A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's care needs and abilities) for Resident 8, dated February 18, 2025, revealed that the resident had moderate cognitive impairment, required assistance from staff for care needs, and had diagnoses that included right-sided hemiplegia (loss of strength in the arm, leg, and sometimes face on one side of the body) following a stroke.

Care plan for Resident 8, dated March 7, 2025, included that the resident was dependent on staff for meeting emotional, intellectual, physical, and social needs. Staff were to apply bilateral TED (thrombo-embolic deterrent) hose (medical compression stockings designed to prevent blood clots) in the morning and remove in the evening and apply a right-hand thumb splint (immobilizes the thumb to support and protect it) daily. There was no documented evidence that the TED hose or right-hand thumb splint were being applied.

Observations of Resident 8 on March 11, 2025, at 11:39 a.m. revealed the resident was not wearing TED hose or a right-hand thumb splint.

Interview with the Director of Nursing on March 11, 2025, at 1:22 p.m. revealed that the TED hose and right-hand thumb hand splint were discontinued, and that Resident 8's care plan should have been revised to reflect that; however, it was not.

A quarterly MDS assessment for Resident 55, dated February 13, 2025, revealed that the resident was cognitively intact, required assistance from staff for care needs, and had diagnoses that included Spina Bifida (a birth defect where the spinal cord does not close completely) with hydrocephalus (a buildup of fluid in and around the brain).

Care plan for Resident 55, dated April 14, 2022, indicated that the resident was receiving an anticoagulant (medication used to prevent and treat blood clots). A care plan, dated August 11, 2022, indicated that the resident was receiving and an antidepressant (medication that can help treat depression). There was no documented evidence that the resident was receiving anticoagulant or antidepressant medication.

Interview with the Nursing Home Administrator on March 13, 2025, at 3:27 p.m. revealed that Resident 55 was not receiving anticoagulant or antidepressant medication, and that his care plan should have been revised to reflect that, and it was not.

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





 Plan of Correction - To be completed: 04/10/2025

- Revision of comprehensive care plans completed to reflect that
R8's ted hose and thumb splint have been discontinued and
R55's anticoagulant and antidepressant medications have been discontinued. Residents with discontinued Ted hose, anticoagulants and Antidepressants care plans will be reviewed x 30days.
- Audits will be completed by Registered Nurse Assessment Coordinator (RNAC) or designee on revision of comprehensive care plans, to ensure care plans are revised upon discontinuation of care planned items. Audits will be completed weekly x 4 weeks, then monthly x 2 months.
- Education will be completed with RNAC regarding facility policy for Care plan revisions upon status change with Nursing Home Administrator (NHA), By 4/4/2025
- Results of Revision of Comprehensive care plan audits will be presented to the Quality Assurance Performance Committee for review and recommendations
- AOC 4/10/2025

483.21(c)(2)(i)-(iv) REQUIREMENT Discharge Summary: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.
§483.21(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).
(iv) A post-discharge plan of care that is developed with the participation of the resident and, with the resident's consent, the resident representative(s), which will assist the resident to adjust to his or her new living environment. The post-discharge plan of care must indicate where the individual plans to reside, any arrangements that have been made for the resident's follow up care and any post-discharge medical and non-medical services.
Observations:


Based on clinical record reviews and staff interviews, it was determined that the facility failed to ensure that a discharge summary, including a recapitulation of the resident's stay, was completed for one of one discharged residents reviewed (Resident 70).

Findings include:

Physician's orders for Resident 70, dated January 4, 2025, included an order for the resident to be discharged home with the services of Home Health including physical therapy, occupational therapy, and nursing.

A nursing note for Resident 70, dated January 4, 2025, revealed that the resident was discharged from the facility at 11:15 a.m. to home with all of his possessions.

As of March 13, 2025, there was no documented evidence that a discharge summary that included a recapitulation of the resident's stay was completed for Resident 70.

Interview with the Assistant Director of Nursing on March 13, 2025, at 3:18 p.m. confirmed that there was no documented evidence that a discharge summary was completed for Resident 70.

28 Pa. Code 211.5(d) Clinical Records.




 Plan of Correction - To be completed: 04/10/2025

- Discharge Plan and Instructions including Recapitulation of staff completed for R70 on 1/3/25. Residents discharged x 30days will be reviewed for Discharge Plan and Instructions.
- Audits will be completed by Medical Records personnel or designee on all residents discharged from facility to ensure Recapitulation of stay forms are completed on all discharged residents weekly x 4 weeks, then monthly x 2 months.
- Education will be completed with Medical Records by Nursing Home Administrator (NHA) on Completion of Discharge Plan and Instructions for all residents discharged from facility. By 4/4/2025.
- Results of Recapitulation of Stay audits will be presented to the Quality Assurance Performance Committee for review and recommendations
- AOC 4/10/2025

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


Based on review of facility policy and clinical records, as well as staff interviews, it was determined that the facility failed to follow physician's orders for medication administration for one of 37 resident (Resident 27) and failed to follow physician's orders related to bowel protocols for two of 37 residents reviewed (Residents 9, 60).

Findings include:

A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 27, dated January 17, 2025, revealed that the resident was cognitively intact and had diagnoses that included septicemia (a life-threatening condition where bacteria or other microorganisms enter the bloodstream and cause a systemic infection).

Physician's orders for Resident 27, dated January 10, 2025, included orders for the resident to receive 100 milligrams (mg) of Doxycycline every 12 hours for cellulitis (a common bacterial infection of the skin and underlying tissues) for 10 days. The resident's Medication Administration Record (MAR) for January 2025 revealed that the 9:00 p.m. dose of Doxycycline was not given on January 10, 2025, due to waiting for the delivery from the pharmacy. Doxycycline was administered at 9:00 a.m. on January 11 through January 20, 2025; however, there was no documented evidence that the course of Doxycycline was extended to complete the administration every 12 hours for 10 days as ordered.

Physician's orders for Resident 27, dated January 10, 2025, included orders for the resident to receive 5 grams of Erythromycin ointment in her left eye at bedtime for blepharitis (an inflammation of the eyelids, typically affecting the edges where the eyelashes grow) for 10 days. The resident's MAR for January 2025 revealed that the 9:00 p.m. dose of Erythromycin was not given on January 10, 2025, due to waiting for the delivery from the pharmacy and Erythromycin was administered at 9:00 a.m. on January 11 through January 19, 2025 (nine days). There was no documented evidence that the course of Erythromycin was extended to complete the administration at bedtime for 10 days as ordered.

Physician's orders for Resident 27, dated February 19, 2025, included orders for the resident to receive 5 grams of Erythromycin ointment in her right eye twice a day for bacterial conjunctivitis (an inflammation of the conjunctiva, the clear membrane that covers the white part of the eye and lines the inside of the eyelids) for seven days. The resident's MAR for February 2025 revealed that the 9:00 p.m. dose of Erythromycin was not given at 9:00 p.m. on January 10, 2025, due to waiting for the delivery from the pharmacy and Erythromycin was administered at 9:00 a.m. on January 11 through January 26, 2025. There was no documented evidence that the course of Erythromycin was extended to complete the administration twice a day for seven days as ordered.

Interview with the Assistant Director of Nursing on March 11, 2025, at 12:41 p.m. confirmed that the first dose of the resident's orders for antibiotics mentioned on the above dates were not administered, and the order was not extended to complete the full ordered duration.


A facility policy for the bowel protocol, dated February 24, 2025, indicated that all shifts are to record bowel elimination times, amount, and consistency of stool on appropriate documentation tool. If the record indicates that the resident did not have a bowel movement for three days, Milk of Magnesia will be administered on the three-to-eleven shift. If the resident does not have a bowel movement by morning, the eleven-to-seven shift will administer a suppository as ordered by the physician. If this protocol is not effective, the three-to-eleven shift will administer an enema as ordered by the physician. Document interventions and results in the nurses' notes and Medication Administration Records.

Physician's orders for Resident 9, dated January 16, 2021, and December 31, 2024, included orders for staff to administer 30 milliliters (ml's) of Milk of Magnesia (MOM - an oral laxative) every 72 hours as needed for constipation or no bowel movement in three days, a 10 milligram (mg) Bisacodyl suppository (a laxative inserted rectally) every 96 hours as needed for constipation if MOM was not effective - to be given the morning of the fourth day, and a Fleets enema (a liquid inserted rectally to stimulate a bowel movement) rectally every 96 hours as needed for constipation or if there was no result from the suppository- to be given at bedtime on the fourth day.

Resident 9's bowel movement records for January and February 2025 revealed that the resident did not have a bowel movement January 13 through 17 (five days), February 4 through 9 (six days), February 12 through 17 (six days), and February 19 through 23, 2025 (five days). The MARs for February and March 2025 revealed no documented evidence that staff administered any of the bowel protocol medications to Resident 60 between February 24, 2025, and March 5, 2025 (10 days). However, there was no documented evidence in the clinical record that the physician's orders for bowel protocol were initiated.

Interview with the Director of Nursing on March 13, 2025, at 3:20 p.m. confirmed that bowel protocol was not followed for Resident 9 on the above-mentioned dates and should have been.


A quarterly MDS assessment for Resident 60, dated February 1, 2025, indicated that the resident was cognitively intact, was dependent on staff for daily care needs, and had diagnoses that included diabetes and paraplegia (loss of muscle function in the lower half of the body, including both legs).

Physician's orders for Resident 60, dated January 6, 2025, included orders for staff to administer 30 milliliters (ml's) of Milk of Magnesia (MOM - an oral laxative) every 72 hours as needed for constipation or no bowel movement in three days, a 10 milligram (mg) Biscolax suppository (a laxative inserted rectally) every 96 hours as needed for constipation or no results from the MOM, and a Fleets enema (a liquid inserted rectally to stimulate a bowel movement) every 96 hours as needed for constipation or if there was no result from the suppository.

Resident 60's bowel movement records for February and March 2025 revealed that the resident did not have a bowel movement on February 24 through March 6, 2025. The MARs for February and March 2025 revealed no documented evidence that staff administered any of the bowel protocol medications to Resident 60 between February 24, 2025, and March 5, 2025 (10 days).

A nurse's note for Resident 60, dated March 7, 2025, at 6:32 p.m. indicated that the resident had no bowel movement as indicated by the nurses for the past 10 days, even after treated with bowel protocol. A nurse's note dated March 8, 2025, at 8:13 a.m. revealed that abdominal x-ray results were obtained and the findings included a moderate colonic ileus (colon (large intestine) loses its ability to move food and waste properly) and moderate stool was noted in the colon. A nursing note, dated March 10, 2025, at 11:20 a.m. revealed that services were on site to complete an abdominal x-ray. A palliative care note, dated March 12, 2025, indicated that x-ray results revealed an increased colonic fecal accumulation and moderate to severe constipation and nonobstructive ileus pattern.

Interview with the Director of Nursing on March 12, 2025, at 3:36 p.m. confirmed that bowel protocol was not followed for Resident 60 on the above-mentioned dates.

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





 Plan of Correction - To be completed: 04/10/2025

- Physician notified that R27 did not receive full course of antibiotics.
Physician notified of facility bowel protocol not being followed on R9 and R60. Residents reviewed x 30 days for full course of antibiotics and bowel protocol being followed.
- Audits will be completed by Infection Preventionist or designee on all residents prescribed antibiotic medications to ensure residents are receiving the entire course of antibiotics. Audits will be completed weekly x 4 weeks, then monthly 2 months. Audits will be completed by Registered Nurse Supervisors or designee to ensure all residents are following the facility bowel protocol daily x 4 weeks, then monthly x 2 months.
- Education will be provided to licensed nursing staff regarding Medication Administration / Medication regimen and the facility Bowel Protocol / Bowel regimen by Director of Nursing/Assistant Director of Nursing By 4/4/2025.
- Results of antibiotic and bowel protocol audits will be presented to the Quality Assurance Performance Committee for review and recommendations
- AOC 4/10/2025

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


Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that recommended pressure ulcer interventions were provided to prevent skin breakdown for one of 37 residents reviewed (Resident 56).

Findings include:

A facility policy regarding pressure injury prevention and management, dated February 24, 2025, revealed that the facility was to provide treatment and services to heal the pressure ulcer, prevent infection, and the development of additional pressure ulcers.

A quarterly Minimum Data assessment Set (MDS) (a mandated assessment of a resident's abilities and care needs) for Resident 56, dated February 26, 2024, revealed that the resident had no speech, was rarely or never understood, was dependent on staff for all care areas, had diagnoses that included Alzheimer's disease and non traumatic brain dysfunction, and had one non-stageable pressure ulcer (unable to determine the depth of the wound) that was not present on admission.

A pressure ulcer investigation for Resident 56, dated December 9, 2024, revealed that there was deep tissue injury area on the left heel with interventions to provide education and encouragement for small frequent position changes and turning and repositioning.

Skin and wound practitioner notes for Resident 56, dated December 12, 19, 26, 2024; January 2, 9, 16, 23, 30, 2025; February 6, 13, 20, 27, 2025; and March 6, 2025, each recommended the preventative measure to turn and reposition the resident at least every two hours.

Physician's orders for Resident 56, dated December 10, 2024, included an order to cleanse the left heel with wound cleanser, then paint the wound with Betadine 10 percent (infection and promote healing pressure sores), and cover with an abdominal pad (an absorptive dressing) once a day and as needed.

Observations of Resident 56 on March 11, 2025, between 10:33 a.m. and 1:38 p.m. revealed that the resident remained midline in bed on his back with his legs bent and his knees leaning towards the door. There was a wedge cushion on the chair next to the resident's bed.

Interview with Nurse Aide 3 on March 11, 2025, at 1:38 p.m. revealed that Resident 56 was to be turned and repositioned every two hours. Staff would use pillows or the wedge cushion to turn and reposition him. Hospice comes in every morning Monday through Friday and they will position him, then staff will reposition him in the morning, and he is usually in his chair in the afternoons.

Interview with the Nursing Home Administrator on March 11, 2025, at 2:19 p.m. confirmed that Resident 56 should have been turned and repositioned and also revealed that the facility does not document turning and repositioning of residents as it is a nursing measure.

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

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



 Plan of Correction - To be completed: 04/10/2025

- Upon notification, R56 was repositioned as recommended. Weekly wound rounds noted no change in skin condition.
- Residents with recommendations to turn and reposition every 2 hours by wound Nurse Practitioner will be identified. Audits will be completed by wound nurse or designee on identified residents to ensure recommendations for turning and repositioning are followed. These audits will be completed weekly x 4 weeks, then monthly x 2 months.
- Education will be provided to all nursing staff regarding pressure ulcer prevention and management to ensure residents requiring frequently turning and repositioning are identified, and recommendations are being followed by Director of Nursing/Assistant Director of Nursing By 4/4/2025
- Results of Turn and Reposition audits will be presented to the Quality Assurance Performance Committee for review and recommendations.
- AOC 4/10/2025

483.45(g)(h)(1)(2) REQUIREMENT Label/Store Drugs and Biologicals: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.
§483.45(g) Labeling of Drugs and Biologicals
Drugs and biologicals used in the facility must be labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable.

§483.45(h) Storage of Drugs and Biologicals

§483.45(h)(1) In accordance with State and Federal laws, the facility must store all drugs and biologicals in locked compartments under proper temperature controls, and permit only authorized personnel to have access to the keys.

§483.45(h)(2) The facility must provide separately locked, permanently affixed compartments for storage of controlled drugs listed in Schedule II of the Comprehensive Drug Abuse Prevention and Control Act of 1976 and other drugs subject to abuse, except when the facility uses single unit package drug distribution systems in which the quantity stored is minimal and a missing dose can be readily detected.
Observations:


Based on review of facility policies, observations, and staff interviews, it was determined that the facility failed to properly label a multi-use vial of Aplisol in one of one medication rooms reviewed, and failed to secure medication in a medication cart.

Findings include:

The facility's policy regarding medication labeling and storage, dated February 24, 2025, indicated that multi-dose vials that have been opened or accessed are dated and discarded within 28 days unless the manufacturer specifies a shorter or longer dated for the open vial. The facility stores all medications and biologicals in locked compartments under proper temperature, humidity, and light controls. Compartments (including but not limited to drawers, cabinets, rooms, refrigerators, carts, and boxes) containing medications and biologicals are locked when not in use.

Current manufacturer's directions for Aplisol (tuberculin purified protein derivative) indicated that vials in use for more than 30 days should be discarded due to possible oxidation and degradation, which may affect potency.

Observations in the facility's A-wing medication room refrigerator on March 13, 2025, at 9:01 a.m. revealed one multi-use vial of Aplisol that was open and undated. Interview with Licenced Practical Nurse 4 at the time of the observation confirmed that the vial was not dated and should be discarded.

An interview with the Nursing Home Administrator on February 13, 2025, at 11:49 a.m. confirmed that the multi-use vial of Aplisol should have been dated when opened.

Observations on March 12, 2025, at 8:00 a.m. revealed an unlocked and unattended medication cart in the hallway outside of room 106.

Interview with Registered Nurse 3 on March 12, 2025, at 8:06 a.m. confirmed that she had walked away from the medication cart for a few minutes to get something and should have locked it but did not.

Interview with the Nursing Home Administrator on March 12, 2025, at 11:09 a.m. confirmed that medication carts should be locked when not in use.

28 Pa Code 211.9(a)(1) Pharmacy Services.

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



 Plan of Correction - To be completed: 04/10/2025

- Nurse educated that medication carts must be locked if unattended. Tuberculin multidose vial identified without an open date was discarded.
- Audits will be completed by Director of Nursing or designee to ensure medications carts are locked and when unattended and all refrigerated multidose vials are dated upon opening. These audits will be completed weekly x 4 weeks, then monthly x 2 months.
- Education will be completed with all nursing staff on facility policy for "Medication Labeling and Storage by DON/Assistant Director of Nursing By 4/4/2025
- Results of Medication storage audits will be presented to the Quality Assurance Performance Improvement Committee for review and recommendations.
- AOC 4/10/2025

483.70(n)(1)-(4) REQUIREMENT Hospice Services: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.
§483.70(n) Hospice services.
§483.70(n)(1) A long-term care (LTC) facility may do either of the following:
(i) Arrange for the provision of hospice services through an agreement with one or more Medicare-certified hospices.
(ii) Not arrange for the provision of hospice services at the facility through an agreement with a Medicare-certified hospice and assist the resident in transferring to a facility that will arrange for the provision of hospice services when a resident requests a transfer.

§483.70(n)(2) If hospice care is furnished in an LTC facility through an agreement as specified in paragraph (o)(1)(i) of this section with a hospice, the LTC facility must meet the following requirements:
(i) Ensure that the hospice services meet professional standards and principles that apply to individuals providing services in the facility, and to the timeliness of the services.
(ii) Have a written agreement with the hospice that is signed by an authorized representative of the hospice and an authorized representative of the LTC facility before hospice care is furnished to any resident. The written agreement must set out at least the following:
(A) The services the hospice will provide.
(B) The hospice's responsibilities for determining the appropriate hospice plan of care as specified in §418.112 (d) of this chapter.
(C) The services the LTC facility will continue to provide based on each resident's plan of care.
(D) A communication process, including how the communication will be documented between the LTC facility and the hospice provider, to ensure that the needs of the resident are addressed and met 24 hours per day.
(E) A provision that the LTC facility immediately notifies the hospice about the following:
(1) A significant change in the resident's physical, mental, social, or emotional status.
(2) Clinical complications that suggest a need to alter the plan of care.
(3) A need to transfer the resident from the facility for any condition.
(4) The resident's death.
(F) A provision stating that the hospice assumes responsibility for determining the appropriate course of hospice care, including the determination to change the level of services provided.
(G) An agreement that it is the LTC facility's responsibility to furnish 24-hour room and board care, meet the resident's personal care and nursing needs in coordination with the hospice representative, and ensure that the level of care provided is appropriately based on the individual resident's needs.
(H) A delineation of the hospice's responsibilities, including but not limited to, providing medical direction and management of the patient; nursing; counseling (including spiritual, dietary, and bereavement); social work; providing medical supplies, durable medical equipment, and drugs necessary for the palliation of pain and symptoms associated with the terminal illness and related conditions; and all other hospice services that are necessary for the care of the resident's terminal illness and related conditions.
(I) A provision that when the LTC facility personnel are responsible for the administration of prescribed therapies, including those therapies determined appropriate by the hospice and delineated in the hospice plan of care, the LTC facility personnel may administer the therapies where permitted by State law and as specified by the LTC facility.
(J) A provision stating that the LTC facility must report all alleged violations involving mistreatment, neglect, or verbal, mental, sexual, and physical abuse, including injuries of unknown source, and misappropriation of patient property by hospice personnel, to the hospice administrator immediately when the LTC facility becomes aware of the alleged violation.
(K) A delineation of the responsibilities of the hospice and the LTC facility to provide bereavement services to LTC facility staff.

§483.70(n)(3) Each LTC facility arranging for the provision of hospice care under a written agreement must designate a member of the facility's interdisciplinary team who is responsible for working with hospice representatives to coordinate care to the resident provided by the LTC facility staff and hospice staff. The interdisciplinary team member must have a clinical background, function within their State scope of practice act, and have the ability to assess the resident or have access to someone that has the skills and capabilities to assess the resident.
The designated interdisciplinary team member is responsible for the following:
(i) Collaborating with hospice representatives and coordinating LTC facility staff participation in the hospice care planning process for those residents receiving these services.
(ii) Communicating with hospice representatives and other healthcare providers participating in the provision of care for the terminal illness, related conditions, and other conditions, to ensure quality of care for the patient and family.
(iii) Ensuring that the LTC facility communicates with the hospice medical director, the patient's attending physician, and other practitioners participating in the provision of care to the patient as needed to coordinate the hospice care with the medical care provided by other physicians.
(iv) Obtaining the following information from the hospice:
(A) The most recent hospice plan of care specific to each patient.
(B) Hospice election form.
(C) Physician certification and recertification of the terminal illness specific to each patient.
(D) Names and contact information for hospice personnel involved in hospice care of each patient.
(E) Instructions on how to access the hospice's 24-hour on-call system.
(F) Hospice medication information specific to each patient.
(G) Hospice physician and attending physician (if any) orders specific to each patient.
(v) Ensuring that the LTC facility staff provides orientation in the policies and procedures of the facility, including patient rights, appropriate forms, and record keeping requirements, to hospice staff furnishing care to LTC residents.

§483.70(n)(4) Each LTC facility providing hospice care under a written agreement must ensure that each resident's written plan of care includes both the most recent hospice plan of care and a description of the services furnished by the LTC facility to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, as required at §483.24.
Observations:


Based on review of hospice contracts and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that the designated interdisciplinary team member obtained the required information from the contracted hospice provider for one of two residents reviewed (Resident 65) who received hospice care.

Findings include:

An agreement between the facility and a hospice provider (provider of end-of-life services), dated April 8, 2024, indicated that the hospice provider would provide the following information to the facility to facilitate coordination of care: a hospice election form (a form signed to indicate that the individual waives all rights to traditional Medicare Part A payments for treatment related to the terminal illness). The skilled nursing facility shall identify a skilled nursing facility designee within the skilled nursing facility and shall be responsible for obtaining the follow information from the hospice: the hospice election form.

A care plan for Resident 65, dated July 24, 2024, revealed that the resident required hospice care (medical care to help someone with a terminal illness) related to an end-stage illness.

Physician's orders for Resident 65, dated July 23, 2024, included an order for the resident to be admitted to hospice.

However, as of March 11, 2025, there was no documented evidence in the resident's clinical record, or in the hospice provider's clinical record, that the facility obtained the hospice election form from the hospice provider.

Interview with Registered Nurse 5 on March 11, 2025, at 2:09 p.m. confirmed that Resident 65's election benefit form was not in the resident's clinical record and/or in the hospice provider's clinical record. Registered Nurse 5 contacted the hospice provider and they faxed the resident's election benefit form to the facility today.

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



 Plan of Correction - To be completed: 04/10/2025

- Election of Benefits form placed in R65's Hospice chart / binder. Hospice charts reviewed for all residents receiving hospice services.
- Audits will be completed by Social Service Director or designee to ensure all current residents receiving hospice services have an Election of Benefits form on their Hospice Chart. These audits will be completed monthly x 3 months.
- Education will be provided to social service director and medical records personnel regarding requirement for all residents receiving hospice services to have an election of benefits form on hospice chart by Nursing Home Administrator By 4/4/2025.
- Results of Hospice election of benefits form audits will be presented to the Quality Assurance Performance Improvement Committee for review and recommendations.
- AOC 4/10/2025

483.75(c)(d)(e)(g)(2)(i)(ii) REQUIREMENT QAPI/QAA Improvement Activities: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.
§483.75(c) Program feedback, data systems and monitoring.
A facility must establish and implement written policies and procedures for feedback, data collections systems, and monitoring, including adverse event monitoring. The policies and procedures must include, at a minimum, the following:

§483.75(c)(1) Facility maintenance of effective systems to obtain and use of feedback and input from direct care staff, other staff, residents, and resident representatives, including how such information will be used to identify problems that are high risk, high volume, or problem-prone, and opportunities for improvement.

§483.75(c)(2) Facility maintenance of effective systems to identify, collect, and use data and information from all departments, including but not limited to the facility assessment required at §483.71 and including how such information will be used to develop and monitor performance indicators.

§483.75(c)(3) Facility development, monitoring, and evaluation of performance indicators, including the methodology and frequency for such development, monitoring, and evaluation.

§483.75(c)(4) Facility adverse event monitoring, including the methods by which the facility will systematically identify, report, track, investigate, analyze and use data and information relating to adverse events in the facility, including how the facility will use the data to develop activities to prevent adverse events.

§483.75(d) Program systematic analysis and systemic action.

§483.75(d)(1) The facility must take actions aimed at performance improvement and, after implementing those actions, measure its success, and track performance to ensure that improvements are realized and sustained.

§483.75(d)(2) The facility will develop and implement policies addressing:
(i) How they will use a systematic approach to determine underlying causes of problems impacting larger systems;
(ii) How they will develop corrective actions that will be designed to effect change at the systems level to prevent quality of care, quality of life, or safety problems; and
(iii) How the facility will monitor the effectiveness of its performance improvement activities to ensure that improvements are sustained.

§483.75(e) Program activities.

§483.75(e)(1) The facility must set priorities for its performance improvement activities that focus on high-risk, high-volume, or problem-prone areas; consider the incidence, prevalence, and severity of problems in those areas; and affect health outcomes, resident safety, resident autonomy, resident choice, and quality of care.

§483.75(e)(2) Performance improvement activities must track medical errors and adverse resident events, analyze their causes, and implement preventive actions and mechanisms that include feedback and learning throughout the facility.

§483.75(e)(3) As part of their performance improvement activities, the facility must conduct distinct performance improvement projects. The number and frequency of improvement projects conducted by the facility must reflect the scope and complexity of the facility's services and available resources, as reflected in the facility assessment required at §483.71. Improvement projects must include at least annually a project that focuses on high risk or problem-prone areas identified through the data collection and analysis described in paragraphs (c) and (d) of this section.

§483.75(g) Quality assessment and assurance.

§483.75(g)(2) The quality assessment and assurance committee reports to the facility's governing body, or designated person(s) functioning as a governing body regarding its activities, including implementation of the QAPI program required under paragraphs (a) through (e) of this section. The committee must:

(ii) Develop and implement appropriate plans of action to correct identified quality deficiencies;
(iii) Regularly review and analyze data, including data collected under the QAPI program and data resulting from drug regimen reviews, and act on available data to make improvements.
Observations:


Based on review of the facility's plans of correction for previous surveys, and the results of the current survey, it was determined that the facility's Quality Assurance Performance Improvement (QAPI) committee failed to correct quality deficiencies and ensure that plans to improve the delivery of care and services effectively addressed recurring deficiencies.

Findings include:

The facility's deficiencies and plans of corrections for a State Survey and Certification (Department of Health) survey ending April 25, 2024; July 10, 2024; October 23, 2024; November 20, 2024; December 13, 2024; December 30, 2024; and January 22, 2025, revealed that the facility developed plans of correction that included quality assurance systems to ensure that the facility maintained compliance with cited nursing home regulations. The results of the current survey, ending March 13, 2025, identified repeated deficiencies related to personal privacy and confidentiality of records, abuse and neglect policy, accuracy of assessments, comprehensive care plans, care plan revision, quality of care, treatment and prevention of pressure ulcers, accident hazards, dialysis, labeling and storage of drugs and biologicals, nutritive value, appearance, palatability and preferred temperature of food, and infection prevention and control.

The facility's plan of correction for a deficiency regarding a failure to provide personal privacy and confidentiality of records, cited during the surveys ending December 30, 2024, and March 13, 2025, revealed that the facility developed a plan of correction that included completing audits and reporting the results of the audits to the QAPI committee for review. The results of the current survey, cited under F583, revealed that the facility's QAPI committee failed to successfully implement their plan to ensure ongoing compliance with regulations regarding personal privacy and confidentiality of records.

The facility's plan of correction for a deficiency regarding a failure to provide implementation of abuse and neglect policies, cited during the surveys ending April 25, 2024, and January 22, 2025, revealed that the facility developed a plan of correction that included completing audits and reporting the results of the audits to the QAPI committee for review. The results of the current survey, cited under F607, revealed that the facility's QAPI committee failed to successfully implement their plan to ensure ongoing compliance with regulations regarding the development and implementation of abuse and neglect policy.

The facility's plan of correction for a deficiency regarding a failure to provide accurate resident Minimum Data Set (MDS) assessments, cited during the surveys ending April 25, 2024; December 13, 2024; and March 13, 2025, revealed that the facility developed a plan of correction that included completing audits and reporting the results of the audits to the QAPI committee for review. The results of the current survey, cited under F641, revealed that the facility's QAPI committee failed to successfully implement their plan to ensure ongoing compliance with regulations regarding accuracy of MDS assessments.

The facility's plan of correction for a deficiency regarding a failure to provide comprehensive resident care plans, cited during the surveys ending October 23, 2024, and March 13, 2025, revealed that the facility developed a plan of correction that included completing audits and reporting the results of the audits to the QAPI committee for review. The results of the current survey, cited under F656, revealed that the facility's QAPI committee failed to successfully implement their plan to ensure ongoing compliance with regulations regarding comprehensive resident care plans.

The facility's plan of correction for a deficiency regarding a failure to provide revisions to resident care plans, cited during the surveys ending April 25, 2024; November 20, 2024; and March 13, 2025, revealed that the facility developed a plan of correction that included completing audits and reporting the results of the audits to the QAPI committee for review. The results of the current survey, cited under F657, revealed that the facility's QAPI committee failed to successfully implement their plan to ensure ongoing compliance with regulations regarding revisions to resident care plans.

The facility's plan of correction for a deficiency regarding a failure to provide quality of care, cited during the surveys ending April 25, 2024; October 23, 2024; December 13, 2024; and March 13, 2025, revealed that the facility developed a plan of correction that included completing audits and reporting the results of the audits to the QAPI committee for review. The results of the current survey, cited under F684, revealed that the facility's QAPI committee failed to successfully implement their plan to ensure ongoing compliance with regulations regarding quality of care.

The facility's plan of correction for a deficiency regarding a failure to provide treatment and prevention of pressure ulcers, cited during the surveys ending November 20, 2024, and March 13, 2025, revealed that the facility developed a plan of correction that included completing audits and reporting the results of the audits to the QAPI committee for review. The results of the current survey, cited under F686, revealed that the facility's QAPI committee failed to successfully implement their plan to ensure ongoing compliance with regulations regarding the treatment and prevention of pressure ulcers.

The facility's plan of correction for a deficiency regarding accident hazards, cited during the surveys ending July 10, 2024, and November 20, 2024, revealed that the facility developed a plan of correction that included completing audits and reporting the results of the audits to the QAPI committee for review. The results of the current survey, cited under F689, revealed that the facility's QAPI committee failed to successfully implement their plan to ensure ongoing compliance with regulations regarding accident hazards.

The facility's plan of correction for a deficiency regarding a failure to provide dialysis services, cited during the surveys ending April 25, 2024, and March 13, 2025, revealed that the facility developed a plan of correction that included completing audits and reporting the results of the audits to the QAPI committee for review. The results of the current survey, cited under F698, revealed that the facility's QAPI committee failed to successfully implement their plan to ensure ongoing compliance with regulations regarding dialysis.

The facility's plan of correction for a deficiency regarding a failure to label and store drugs and biologicals, cited during the surveys ending December 30, 2024, and March 13, 2025, revealed that the facility developed a plan of correction that included completing audits and reporting the results of the audits to the QAPI committee for review. The results of the current survey, cited under F761, revealed that the facility's QAPI committee failed to successfully implement their plan to ensure ongoing compliance with regulations regarding labeling and storage of drugs and biologicals.

The facility's plan of correction for a deficiency regarding a failure provide food of the nutritive value, appearance, preferred temperatures and palatability cited during the surveys ending April 25, 2024, and March 13, 2025, revealed that the facility developed a plan of correction that included completing audits and reporting the results of the audits to the QAPI committee for review. The results of the current survey, cited under F804, revealed that the facility's QAPI committee failed to successfully implement their plan to ensure ongoing compliance with regulations regarding the nutritive value, appearance, preferred temperature and palatability of foods.

The facility's plan of correction for a deficiency regarding a failure provide infection control and prevention practices cited during the surveys ending April 25, 2024; December 13, 2024; and March 13, 2025, revealed that the facility developed a plan of correction that included completing audits and reporting the results of the audits to the QAPI committee for review. The results of the current survey, cited under F880, revealed that the facility's QAPI committee failed to successfully implement their plan to ensure ongoing compliance with regulations regarding infection control and prevention..

Refer to F583, F607, F641, F656, F657, F684, F686, F689, F698, F761, F804, and F880.

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

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



 Plan of Correction - To be completed: 04/10/2025

- A subcommittee of the Quality Assurance Performance Improvement Committee will be developed to review the following F tags (F583, F607, F641, F656, F657, F684, F686, F689, F698 F671, F804, and F880). Each F tag mentioned will be audited to determine if there is improvement.
- If improvement is not noted, then the subcommittee will utilize a root cause analysis to determine what could be changed to prevent these recurring deficiencies.
- Performance Improvement Plans (PIPs) will be developed for each F tag mentioned before to directly monitor each F tag's improvement.
- The findings will be presented, by the head of the subcommittee (the Executive Director/designee), monthly, to the Quality Assurance Performance Improvement for review and recommendations
- AOC 4/10/2025

483.80(a)(1)(2)(4)(e)(f) REQUIREMENT Infection Prevention & Control: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.
§483.80 Infection Control
The facility must establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections.

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

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

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

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

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

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


Based on review of established infection control guidelines, facility policies, and clinical records, as well as observations and staff interviews, it was determined that the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one of 37 residents reviewed (Residents 56).

Findings include:

CDC guidance on Implementation of Personal Protective Equipment (PPE) use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs), dated July 12, 2022, indicated that multidrug-resistant organism (MDRO) transmission was common in skilled nursing facilities, contributing to substantial resident morbidity and mortality and increased healthcare costs. Enhanced Barrier Precautions (EBP) are an infection control intervention designed to reduce transmission of resistant organisms that employs targeted gown and glove use during high contact resident care activities. CMS updated its infection prevention and control guidance effective April 1, 2024. The recommendations now include the use of EBP during high-contact care activities for residents with chronic wounds or indwelling medical devices, regardless of their MDRO status, in addition to residents who have an infection or colonization with a CDC-targeted or other epidemiologically important MDRO when contact precautions do not apply.

The facility's policy regarding EBP, dated February 24, 2025, indicated that EBP are used as an infection prevention and control intervention to reduce the spread of MDROs to residents. EBPs were necessary when performing high contact resident care. Gloves and gown are applied prior to performing the high contact resident care activity (as opposed to before entering the room EBP's are indicated for residents with wound care. EBPs remain in place for the duration of the resident's stay or until resolution of the wound or discontinuation of the indwelling medical device that places them at increased risk.

A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 56, dated February 26, 2024, revealed that the resident had no speech and was rarely or never understood, was dependent on staff for all care, had a diagnoses that included Alzheimer's disease, non-traumatic brain dysfunction, and had one non-stageable pressure ulcer (unable to determine the depth of the wound) that was not present on admission. A care plan, dated December 9, 2024, revealed that Resident 56 had an unstageable pressure ulcer to his left heel related to immobility. A care plan, dated February 11, 2025, revealed that the resident was on EBP related to the area on the left heel.

Physician's orders for Resident 56, dated February 11, 2025, included an order for the resident to be on EBPs for the pressure area to the left heel.

Observations of Resident 56's wound care to his left heel and left great toe on March 11, 2025, at 10:49 a.m. revealed that Licensed Practical Nurse 6 washed her hands and donned clean gloves; however, she did not don a gown. She then performed the wound treatment to the resident's left heel.

Interview with Licensed Practical Nurse 6 on March 11, 2025, at 10:59 a.m. confirmed that she did not don a gown prior to performing Resident 56's wound treatment. She indicated that she did not think that she need to wear any other PPE for the dressing change.

Interview with the Infection Control Preventionist on March 11, 2025, at 3:14 p.m. confirmed that Licensed Practical Nurse 6 should have donned a gown prior to performing Resident 56's wound treatment.

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

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

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



 Plan of Correction - To be completed: 04/10/2025

- Nurse educated on Infection Control – Enhanced Barrier Precautions (EBP). R56 had no negative outcome.
- Audits will be completed by Infection Preventionist or designee to ensure nursing staff are utilizing EBP on residents who require EBP . These audits will be completed weekly x 4 weeks, then monthly x 2 months.
- Education will be provided to all nursing staff regarding Infection Control - Enhanced Barrier Precautions, which are designed to reduce transmission of resistant organisms that employ glove and gown use during high contact resident care activities by Director of Nursing/Assistant Director of Nursing By 4/4/2025
- Results of EBP audits will be presented to the Quality Assurance Performance Improvement Committee for review and recommendations.
- AOC 4/10/2025


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

Observations:


Based on review of Pennsylvania state law, as well as staff interviews, it was determined that the facility failed to ensure that the multi-disciplinary infection control committee included representation from applicable members.

Findings include:

The Act 52 Infection Control Plan, dated March 20, 2002, revealed that a health care facility should develop and implement an internal infection control plan that should be established for the purpose of improving the health and safety of residents and health care workers, and should include a multi-disciplinary committee including a representative from each of the following, if applicable to the specific health care facility. Applicable members included medical staff that could include the chief medical officer or the nursing home medical director, the nursing home administrator, laboratory personnel, nursing staff that could include the director of nursing or a nursing supervisor, pharmacy staff, physical plant personnel, a patient safety officer, and a community member that may not be an agent, employee or contractor of the facility.

The facility's policy regarding infection control, dated February 24, 2025, indicated that the Infection Control Committee would include the medical director or infectious disease physician, executive director, director of clinical services, infection control nurse/designee, pharmacy, environmental services, laboratory, at least one employee representative, and a member of the community.

The facility's Infection Control Committee meeting attendance records for May 2024 revealed that there was no physician, pharmacy, laboratory, or a community member in attendance at the meeting.

The facility's Infection Control Committee meeting attendance records for July 18, 2024; September 19, 2024; and December 19, 2024, revealed that there was no nursing home administrator, physician, pharmacy, laboratory, or a community member in attendance at the meetings.

Interview with the Assistant Director of Nursing/Infection Control Preventionist on March 13, 2025, at 9:30 a.m. confirmed that a physician, pharmacy, laboratory, or a community member did not attend the Infection Control Committee meeting in May 2024, and that a nursing home administrator, physician, pharmacy, laboratory, or a community member did not attend the Infection Control Committee meetings for July 18, 2024; September 19, 2024; and December 19, 2024.




 Plan of Correction - To be completed: 04/10/2025

- Infection Control Committee attendees including Nursing Home Administrator, Pharmacy, Laboratory, physician, and community member will attend upcoming infection control committee meeting.
- Audits will be completed by NHA or designee to ensure all members required to attend Infection Control Committee meeting are present quarterly. These audits will be completed monthly x 6 months.
- Infection Preventionist will be educated by Vice President of Clinical Services on the Infection Control Committee attendees should include the following Nursing Home Administrator, Pharmacy, Laboratory, physician, and community member.
- Results of ICC meetings attendance audits will be presented to the Quality Assurance Performance Improvement Committee for review and recommendations
- AOC 4/10/2025

§ 211.1(a) LICENSURE Reportable diseases.:State only Deficiency.
(a) When a resident develops a reportable disease, the administrator shall report the information to the appropriate health agencies and appropriate Division of Nursing Care Facilities field office. Reportable diseases, infections and conditions are listed in § 27.21a (relating to reporting of cases by health care practitioners and health care facilities).

Observations:


Based on review of Pennsylvania Department of Health Event Reporting System (ERS) and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that they reported Influenza positive residents to the Pennsylvania Department of Health for two of 37 residents reviewed (Residents 6, 72), and failed to ensure that they reported positive Respiratory syncytial virus (RSV) residents to the Pennsylvania Department of Health for one of 37 residents reviewed (Resident 14).

Findings include:

A nursing note for Resident 6, dated February 26, 2025, revealed that the resident was positive for Flu A (Influenza) and placed on droplet precautions for seven days.

A nursing note for Resident 72, dated February 12, 2025, revealed that they received a verbal report from the laboratory stating that the resident tested positive for Flu A (Influenza).

A review of the Pennsylvania Department of Health's ERS revealed that there were no reports from the facility regarding positive Influenza results of Residents 6 and 72 in February 2025.

Interview with the Assistant Director of Nursing/Infection Preventionist on March 12, 2025, at 1:46 p.m. confirmed that the facility did not report the above Influenza-positive residents to the Pennsylvania Department of Health's ERS as they should have.

A nursing note for Resident 14, dated February 18, 2025, revealed that the resident was positive for RSV (a virus that causes infections of the respiratory tract).

Interview with the Nursing Home Administrator on March 12, 2025, at 11:50 a.m. confirmed that the facility did not report the above RSV positive resident to the Pennsylvania Department of Health's ERS as they should have.



 Plan of Correction - To be completed: 04/10/2025

- Infection Preventionist will report past Flu positive and Respiratory Syncytial Virus (RSV) cases to Department of Health.
- Audits will be completed by Nursing Home Administrator (NHA) or designee to ensure all reportable diseases are reported to DOH in an appropriate time frame.
- Infection Preventionist educated by Vice President of Clinical Services reporting Reportable Disease to the appropriate Division of Nursing Care Facilities Field Office by 4/3/25.
- Results of reportable disease audits will be presented to the Quality Assurance Performance Improvement Committee for review and recommendations
- AOC 4/10/2025

§ 211.12(f.1)(3) LICENSURE Nursing services. :State only Deficiency.
(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 review of nursing schedules and staffing information furnished by the facility, as well as staff interview, it was determined that the facility failed to ensure a minimum of one nurse aide (NA) per 10 residents on the day shift for eight of 21 days reviewed for February 20 through March 12, 2025; to ensure a minimum of one NA per 11 residents on the evening shift for 13 of 21 days reviewed for February 20 through March 12, 2025; and to ensure a minimum of one NA per 15 residents on the overnight shift for five of 21 days for February 20 through March 12, 2025.

Findings include:

Review of facility census data indicated that on February 22, 2025, the facility census was 75, which required 7.50 NA's during the day shift. Review of the nursing time schedules revealed 5.44 NA's provided care on the day shift on February 22, 2025. Review of facility census data indicated that on February 23, 2025, the facility census was 76, which required 7.60 NA's during the day shift. Review of the nursing time schedules revealed 5.56 NA's provided care on the day shift on February 23, 2025. Review of facility census data indicated that on February 24, 2025, the facility census was 78, which required 7.80 NA's during the day shift. Review of the nursing time schedules revealed 7.59 NA's provided care on the day shift on February 24, 2025. Review of facility census data indicated that on February 28, 2025, the facility census was 76, which required 7.60 NA's during the day shift. Review of the nursing time schedules revealed 7.09 NA's provided care on the day shift on February 28, 2025. Review of facility census data indicated that on March 3, 2025, the facility census was 78, which required 7.80 NA's during the day shift. Review of the nursing time schedules revealed 7.69 NA's provided care on the day shift on March 3, 2025. Review of facility census data indicated that on March 6, 2025, the facility census was 78, which required 7.80 NA's during the day shift. Review of the nursing time schedules revealed 7.03 NA's provided care on the day shift on March 6, 2025. Review of facility census data indicated that on March 8, 2025, the facility census was 78, which required 7.80 NA's during the day shift. Review of the nursing time schedules revealed 4.84 NA's provided care on the day shift on March 8, 2025. Review of facility census data indicated that on March 9, 2025, the facility census was 80, which required 8.00 NA's during the day shift. Review of the nursing time schedules revealed 6.41 NA's provided care on the day shift on March 9, 2025.

Review of facility census data indicated that on February 21, 2025, the facility census was 75, which required 6.91 NA's during the evening shift. Review of the nursing time schedules revealed 6.00 NA's provided care on the evening shift on February 21, 2025. Review of facility census data indicated that on February 24, 2025, the facility census was 78, which required 7.09 NA's during the evening shift. Review of the nursing time schedules revealed 5.97 NA's provided care on the evening shift on February 24, 2025. Review of facility census data indicated that on February 25, 2025, the facility census was 78, which required 7.09 NA's during the evening shift. Review of the nursing time schedules revealed 5.38 NA's provided care on the evening shift on February 25, 2025. Review of facility census data indicated that on February 26, 2025, the facility census was 79, which required 7.18 NA's during the evening shift. Review of the nursing time schedules revealed 6.41 NA's provided care on the evening shift on February 26, 2025. Review of facility census data indicated that on March 1, 2025, the facility census was 76, which required 6.91 NA's during the evening shift. Review of the nursing time schedules revealed 5.88 NA's provided care on the evening shift on March 2, 2025. Review of facility census data indicated that on March 2, 2025, the facility census was 76, which required 6.91 NA's during the evening shift. Review of the nursing time schedules revealed 5.81 NA's provided care on the evening shift on March 2, 2025. Review of facility census data indicated that on March 5, 2025, the facility census was 78, which required 7.09 NA's during the evening shift. Review of the nursing time schedules revealed 6.50 NA's provided care on the evening shift on March 5, 2025. Review of facility census data indicated that on March 6, 2025, the facility census was 78, which required 7.09 NA's during the evening shift. Review of the nursing time schedules revealed 5.81 NA's provided care on the evening shift on March 6, 2025. Review of facility census data indicated that on March 7, 2025, the facility census was 79, which required 7.18 NA's during the evening shift. Review of the nursing time schedules revealed 5.31 NA's provided care on the evening shift on March 7, 2025. Review of facility census data indicated that on March 8, 2025, the facility census was 78, which required 7.09 NA's during the evening shift. Review of the nursing time schedules revealed 5.91 NA's provided care on the evening shift on March 8, 2025. Review of facility census data indicated that on March 9, 2025, the facility census was 80, which required 7.27 NA's during the evening shift. Review of the nursing time schedules revealed 6.44 NA's provided care on the evening shift on March 9, 2025. Review of facility census data indicated that on March 10, 2025, the facility census was 80, which required 7.27 NA's during the evening shift. Review of the nursing time schedules revealed 6.72 NA's provided care on the evening shift on March 10, 2025. Review of facility census data indicated that on March 11, 2025, the facility census was 81, which required 7.36 NA's during the evening shift. Review of the nursing time schedules revealed 6.50 NA's provided care on the evening shift on March 10, 2025.

Review of facility census data indicated that on February 25, 2025, the facility census was 78, which required 5.20 NA's during the overnight shift. Review of the nursing time schedules revealed 4.84 NA's provided care on the overnight on February 25, 2025. Review of facility census data indicated that on February 26, 2025, the facility census was 79, which required 5.27 NA's during the overnight shift. Review of the nursing time schedules revealed 5.00 NA's provided care on the overnight on February 26, 2025. Review of facility census data indicated that on February 27, 2025, the facility census was 80, which required 5.33 NA's during the overnight shift. Review of the nursing time schedules revealed 4.81 NA's provided care on the overnight on February 27, 2025. Review of facility census data indicated that on March 1, 2025, the facility census was 76, which required 5.07 NA's during the overnight shift. Review of the nursing time schedules revealed 5.00 NA's provided care on the overnight on March 1, 2025. Review of facility census data indicated that on March 3, 2025, the facility census was 78, which required 5.20 NA's during the overnight shift. Review of the nursing time schedules revealed 5.00 NA's provided care on the overnight on March 3, 2025.

No additional excess higher-level staff were available to compensate for these deficiencies.

Interview with the Nursing Home Administrator on March 13, 2025, at 11:49 a.m. confirmed that the facility did not meet the required NA-to-resident staffing ratios for the days listed above, as there were call offs.




 Plan of Correction - To be completed: 04/10/2025

The facility will make every attempt to maintain the minimum of one Nurse Aide per 10 residents on the day shift and one Nurse Aide per every 11 residents on the evening shift and one Nurse Aide per 15 residents on night shift.

To ensure that this regulatory requirement is met the following action plan will be implemented: Education will be provided to the scheduler no later than (4/3/25) by Nursing Home Administrator (NHA) to ensure that they understand the regulatory staffing requirements for nursing assistants.
The nursing assistant schedule will be reviewed by the scheduler and Director of Nursing/or Designee to ensure that nursing assistant ratios are met prior to posting of the schedule.
In the event of call-offs by staff, all other staff/agency will be contacted to cover any open shifts to ensure ratios are met.
An audit will be developed and completed by the scheduler daily for 4 weeks, and then weekly x 2 weeks to ensure that nursing assistant ratios are met for the daylight, evening and overnight shifts.
The audit will be monitored by the Director of Nursing or Designee.
Findings will be reported to the Quality Assurance Performance Improvement Committee for review and recommendations

§ 211.12(f.1)(4) LICENSURE Nursing services. :State only Deficiency.
(4) Effective July 1, 2023, a minimum of 1 LPN per 25 residents during the day, 1 LPN per 30 residents during the evening, and 1 LPN per 40 residents overnight.
Observations:


Based on review of nursing schedules and staffing information furnished by the facility, as well as staff interview, it was determined that the facility failed to ensure a minimum of one licensed practical nurse (LPN) per 40 residents on the night shift for four of 21 days for February 20 through March 12, 2025.

Findings include:

Review of facility census data indicated that on February 20, 2025, the facility census was 75, which required 1.88 LPN's during the night shift. Review of the nursing time schedules revealed 1.66 LPN's provided care on the evening shift on February 20, 2025. Review of facility census data indicated that on February 23, 2025, the facility census was 76, which required 1.90 LPN's during the night shift. Review of the nursing time schedules revealed 1.13 LPN's provided care on the evening shift on February 23, 2025. Review of facility census data indicated that on March 6, 2025, the facility census was 78, which required 1.95 LPN's during the night shift. Review of the nursing time schedules revealed 1.59 LPN's provided care on the evening shift on March 6, 2025. Review of facility census data indicated that on March 7, 2025, the facility census was 79, which required 1.98 LPN's during the night shift. Review of the nursing time schedules revealed 1.66 LPN's provided care on the evening shift on March 7, 2025

No additional excess higher-level staff were available to compensate for these deficiencies.

Interview with the Nursing Home Administrator on March 13, 2025, at 11:49 a.m. confirmed that the facility did not meet the required LPN-to-resident staffing ratios for the days listed above as there was call offs.





 Plan of Correction - To be completed: 04/10/2025

The facility will make every attempt to staff the minimum of one Licensed Practical
Nurse (LPN) per 25 residents on the day shift and one LPN per 30 residents on the evening shift and one LPN for every 40 residents on the overnight shift.
To ensure that this regulatory requirement is met the following action plan will be implemented: Education will be provided to the scheduler no later than ( 4/3/25) by Nursing Home Administrator (NHA) to ensure that they understand the regulatory staffing requirements for Licensed Practical Nurses.
The LPN schedule will be reviewed by the scheduler and Director of Nursing to ensure that nursing assistant ratios are met prior to posting of the schedule. In the event of call-offs by staff, all other staff/agency will be contacted to cover any open shifts to ensure ratios are met.
An audit will be developed and completed by the scheduler daily for 4 weeks, and then weekly for 2 weeks, to ensure that LPN ratios are met for the daylight, evening and overnight shifts. The audit will be monitored by the Director of Nursing or Designee.
Findings will be reported to the Quality Assurance Performance Improvement Committee for review and recommendations


§ 211.12(i)(2) LICENSURE Nursing services.:State only Deficiency.
(2) Effective July 1, 2024, the total number of hours of general nursing care provided in each 24-hour period shall, when totaled for the entire facility, be a minimum of 3.2 hours of direct resident care for each resident.

Observations:


Based on review of staffing information furnished by the facility and staff interviews, it was determined that the facility failed to provide 3.20 hours of direct resident care for each resident for 12 of 21 days (24-hour periods) reviewed.

Findings include:

Nursing time schedules provided by the facility for the days of February 20 through March 12, 2025, revealed that the facility provided only 3.13 hours of direct care for each resident on February 22, 2025. The facility provided only 2.92 hours of direct care for each resident on February 23, 2025. The facility provided only 3.16 hours of direct care for each resident on February 24, 2025. The facility provided only 3.09 hours of direct care for each resident on February 25, 2025. The facility provided only 3.08 hours of direct care for each resident on February 26, 2025. The facility provided only 3.09 hours of direct care for each resident on March 1, 2025. The facility provided only 3.18 hours of direct care for each resident on March 3, 2025. The facility provided only 2.95 hours of direct care for each resident on March 6, 2025. The facility provided only 3.02 hours of direct care for each resident on March 7, 2025. The facility provided only 2.88 hours of direct care for each resident on March 8, 2025. The facility provided only 2.99 hours of direct care for each resident on March 9, 2025. The facility provided only 3.13 hours of direct care for each resident on March 11, 2025.

Interview with the Nursing Home Administrator on March 13, 2025, at 11:49 a.m. confirmed that the facility did not meet the required daily direct resident care hours on the day listed above.




 Plan of Correction - To be completed: 04/10/2025

The facility will make every attempt to staff a minimum of 3.2 hours of direct resident care for each resident.

To ensure that this regulatory requirement is met the following action plan will be implemented: Education will be provided to the scheduler no later than ( 4/3/25) by Nursing Home Administrator (NHA) to ensure that they understand the regulatory staffing requirements of 3.2 hours of direct resident care for each resident
The nursing schedule will be reviewed by the scheduler, Director of Nursing or Designee to ensure that 3.2 hours of direct resident care is scheduled per day prior to posting of the schedule.
In the event of call-offs by staff, all other staff/agency will be contacted to cover any open shifts to ensure staffing requirements are met
An audit will be developed and completed by the scheduler daily for 4 weeks, then weekly x 2 weeks, to ensure that 3.2 hours of direct resident care was met each day
Findings will be reported to the Quality Assurance Performance Improvement Committee for review and recommendations



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