Pennsylvania Department of Health
BARNES-KASSON COUNTY HOSPITAL SNF
Patient Care Inspection Results

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Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

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BARNES-KASSON COUNTY HOSPITAL SNF - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:

Based on a State Licensure, Civil Rights Compliance survey, completed on October 17, 2025, it was determined that Barnes Kasson County Hospital Skilled Nursing Facility 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:

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

§483.21 Comprehensive Person-Centered Care Planning
§483.21(a) Baseline Care Plans
§483.21(a)(1) The facility must develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. The baseline care plan must-
(i) Be developed within 48 hours of a resident's admission.
(ii) Include the minimum healthcare information necessary to properly care for a resident including, but not limited to-
(A) Initial goals based on admission orders.
(B) Physician orders.
(C) Dietary orders.
(D) Therapy services.
(E) Social services.
(F) PASARR recommendation, if applicable.

§483.21(a)(2) The facility may develop a comprehensive care plan in place of the baseline care plan if the comprehensive care plan-
(i) Is developed within 48 hours of the resident's admission.
(ii) Meets the requirements set forth in paragraph (b) of this section (excepting paragraph (b)(2)(i) of this section).

§483.21(a)(3) The facility must provide the resident and their representative with a summary of the baseline care plan that includes but is not limited to:
(i) The initial goals of the resident.
(ii) A summary of the resident's medications and dietary instructions.
(iii) Any services and treatments to be administered by the facility and personnel acting on behalf of the facility.
(iv) Any updated information based on the details of the comprehensive care plan, as necessary.

Observations:

Based on review of facility policy and clinical records, and staff interviews, it was determined the facility failed to develop a baseline care plan within 48 hours of admission for oxygen therapy for one of 12 residents reviewed (Resident 15).
Findings include:
A review of the policy titled "Initiating the Care Plan Process" last reviewed by the facility on September 30, 2025, revealed that every resident will have an Interdisciplinary care plan, with the interim interdisciplinary care plan initiated within 24 hours of admission. The care plan will identify priority problems and needs to be addressed by the interdisciplinary team, and will reflect the residents' strengths, limitations and goals.
Review of Resident 15's clinical record revealed the resident was initially admitted to the facility on September 29, 2025, with a diagnosis of emphysema (chronic lung condition leading to shortness of breath and reduced lung function), and shortness of breath.
A review of Resident 15's clinical record revealed a physician's order, dated October 5, 2025, for Oxygen, 2 Liters/Min, via nasal cannula (a device used to deliver supplemental oxygen or increased airflow to a patient or person in need of respiratory help. This device consists of a lightweight tube which on one end splits into two prongs which are placed in the nostrils and from which a mixture of air and oxygen flows) as needed for diagnosis of shortness of breath.
A review of Resident 15's care plan revealed there was no care plan developed for the resident receiving oxygen therapy.
An interview was conducted with the Nursing Home Administrator (NHA) on October 16, 2025, at 9:10 AM to review the above findings related to the facility's failure to develop a baseline care plan.

28 Pa. Code 211.12(d)(1)(5) Nursing services
28 Pa. Code 211.10(c)(d) Resident care policies

Plan of Correction - To be completed: 12/02/2025

The facility acknowledges that the baseline care plan for Resident #15 cannot be retroactively corrected.

Effective immediately, the facility will ensure that a baseline care plan is developed and implemented for all new admissions within 48 hours of admission, in accordance with facility policy and regulatory requirements.

All licensed nursing staff will be in-serviced on the facility policy titled "Initiating Care Plan Process." Staff will also receive instruction and demonstration on how to access and complete the baseline care plan in PointClickCare.

The Nursing Home Administrator or designee will develop and implement a Quality Assurance study to monitor compliance with the initiation of baseline care plans for new admissions x 6 months. Results will be reviewed in the facility's monthly QA Committee meetings, and corrective actions will be implemented as needed to ensure ongoing compliance.

483.21(b)(1)(3) REQUIREMENT Develop/Implement Comprehensive Care Plan:

§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 facility policy and clinical records, and staff interviews, it was determined the facility failed to develop a comprehensive care plan for oxygen therapy for one of 12 residents reviewed (Resident 15).
Findings include:
A review of the policy titled "Initiating the Care Plan Process" last reviewed by the facility on September 30, 2025, revealed that every resident will have an Interdisciplinary care plan, with the interim interdisciplinary care plan initiated within 24 hours of admission. The care plan will identify priority problems and needs to be addressed by the interdisciplinary team, and will reflect the residents' strengths, limitations and goals.
Review of Resident 15's clinical record revealed the resident was initially admitted to the facility on September 29, 2025, with a diagnosis of emphysema (chronic lung condition leading to shortness of breath and reduced lung function), and shortness of breath.
A review of Resident 15's clinical record revealed a physician's order, dated October 5, 2025, for Oxygen, 2 Liters/Min, via nasal cannula (a device used to deliver supplemental oxygen or increased airflow to a patient or person in need of respiratory help. This device consists of a lightweight tube which on one end splits into two prongs which are placed in the nostrils and from which a mixture of air and oxygen flows) as needed for diagnosis of shortness of breath.
A review of Resident 15's care plan revealed there was no care plan developed for the resident receiving oxygen therapy.
An interview was conducted with the Nursing Home Administrator (NHA) on October 16, 2025, at 9:10 AM to review the above findings related to the facility's failure to develop a comprehensive care plan.

28 Pa. Code 211.12(d)(1)(5) Nursing services
28 Pa. Code 211.10(c)(d) Resident care policies

Plan of Correction - To be completed: 12/02/2025

Care plan initiated for Resident #15 addressing oxygen therapy.

All residents' care plans reviewed to ensure comprehensive and individualized care plans are in place.

All licensed nursing staff will be in-serviced on the facility policy titled "Initiating Care Plan Process."

The Director of Nursing (DON) or designee will develop and implement a Quality Assurance study to monitor compliance with comprehensive care plan development. The QA study will utilize the IDCT (Interdisciplinary Care Team) meeting schedule to sample care plans for accuracy and completeness x 6 months. Results of the QA study will be reviewed during the facility's monthly QA Committee meetings.
Corrective actions will be implemented as needed to ensure ongoing compliance with care planning requirements.

483.25(k) REQUIREMENT Pain Management:

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

Observations:

Based on clinical record and select facility policy review and staff interview, it was determined that the facility failed to provide effective pain management and administer pain medication as prescribed by the physician and failed to attempt non-pharmacological interventions to alleviate pain prior to the administration of a narcotic pain medication prescribed on an as needed basis for one resident out of 12 sampled residents (Resident 2).
Findings include:
A review of the facility ' s policy titled " Pain Management " (last reviewed September 25, 2025) indicated that pain should be rated on intensity using a numerical scale (0-10) or a visual descriptor preferred by the resident. Nonpharmacological pain management interventions include but are not limited to adjusting the room temperature, smoothing linens, turning and repositioning, lessening any constrictive bandages or device, apply splinting, physical modalities, exercise to address stiffness, cognitive/behavioral intervention, and relaxation techniques. When treating pain, start with a drug appropriate to the residents ' current level of pain and progress by increasing the dose of that drug until the maximum benefit is obtained. Use the least invasive route of administration as possible. Prior to administering pain medications, attempt nonpharmacological interventions and reassess one hour after administration of any pain medication and document its effectiveness.
A review of Resident 2 ' s clinical record revealed admission on December 12, 2019, with diagnoses including chronic pain (pain persisting longer than six months and associated with ongoing medical conditions), heart failure (a condition in which the heart cannot adequately pump blood to meet the body ' s needs), and constipation (difficulty or infrequent bowel movements, typically fewer than three per week).

A review of Resident 2 ' s physician orders revealed an order dated October 1, 2024, for Tylenol Oral Tablet 325 mg (Acetaminophen is used to reduce fever and relieve minor pain caused by conditions such as colds or flu, headache, muscle aches, arthritis, menstrual cramps and fevers), give 2 tablets by mouth every 4 hours as needed (PRN) for mild pain with a pain scale of 1 to 3 and an order for Tramadol HCl (an opioid agonist that may be used to treat moderate to moderately severe chronic pain in adults) Tab 50 mg, give 1 tablet orally every 12 hours as needed (PRN) for moderate pain related to pain, give for moderate pain or pain scale of 4 to 6.
A review of the resident ' s electronic Medication Administration Record (eMAR is used to document medications taken by each resident) dated July 2025, revealed that the PRN Tramadol (opioid pain medication) ordered to manage moderate pain was administered on the following dates and times without any documented pain scale assessment or evidence that non-pharmacological interventions were attempted prior to administration.:

July 2, 2025, at 8:02 AM, July 3, 2025, at 8:29 AM, July 4, 2025, at 12:39 AM, July 9, 2025, at 8:19 AM, July 11, 2025, at 7:35 AM, July 24, 2025, at 8:14 AM, July 26, 2025, at 9:25 AM, and July 31, 2025, 2025, at 8:19 AM.

Further review of Resident 2 ' s clinical record revealed the eMAR dated August 2025, licensed nursing staff continued to administer PRN Tramadol (opioid pain medication) to manage moderate pain on the following dates and times without any documented pain scale assessment or evidence that non-pharmacological interventions were attempted prior to administration.:

August 1, 2025, at 8:02 AM, August 7, 2025, at 12:44 AM, August 10, 2025, at 12:16 PM, August 14, 2025, at 8:18 AM, August 15, 2025, at 8:24 AM, August 19, 2025, at 8:14 AM, August 21, 2025, at 8:15 AM, August 22, 2025, at 8:34 AM, August 23, 2025, at 7:51 AM, August 27, 2025, at 7:36 AM, August 30, 2025, at 10:38 AM, and August 31, 2025, at 8:39 AM.
Further review revealed no documented evidence that the non-opioid medication (Tylenol) was offered or administered prior to giving the opioid (Tramadol), contrary to the physician ' s prescribed pain management plan.

The facility failed to assure licensed nursing staff assessed Resident 2 ' s reported pain level and recorded the corresponding numeric pain response prior to administering an opioid pain medication, Tramadol, and assure documented attempts of non-pharmacological interventions prior to administration of pain medications.

Additionally, the facility failed to assure licensed nursing staff administered a physician prescribed pain management regimen as prescribed, as evidence by administering an opioid medication, Tramadol, prior to a non-opioid medication, Tylenol.

The above findings were reviewed and confirmed by the Nursing Home Administrator (NHA) on October 16, 2025, at 1:30 PM.

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

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

Plan of Correction - To be completed: 12/02/2025

The facility acknowledges that documentation for Resident #2's PRN pain medication cannot be retroactively corrected.

All residents receiving PRN pain medication will have a documented pain scale assessment and evidence of non-pharmacological interventions attempted prior to medication administration, in accordance with facility policy.

All licensed nursing staff will receive in-service education on the facility's policy titled "Pain Management", emphasizing proper pain assessment, documentation, and implementation of non-pharmacological interventions.

The Nursing Home Administrator or designee will develop and implement a Quality Assurance study to monitor ongoing compliance. The QA study will include regular audits of pain management documentation to ensure pain scale assessments are completed prior to PRN administration x 6 months.
In addition, non-pharmacological interventions are attempted and documented prior to medication use. Results of the QA study will be reviewed during the monthly QA committee meetings, and continued monitoring will occur until substantial compliance is achieved and sustained.

483.40(b)(3) REQUIREMENT Treatment/Service for Dementia:

§483.40(b)(3) A resident who displays or is diagnosed with dementia, receives the appropriate treatment and services to attain or maintain his or her highest practicable physical, mental, and psychosocial well-being.

Observations:

Based on a review of clinical records and staff interview, it was determined the facility failed to develop and implement an individualized person-centered plan to address dementia and cognitive loss displayed by one out of 12 residents reviewed. (Resident 33)
Findings include:
A review of Resident 33's clinical record revealed the resident was admitted to the facility on September 10, 2020, with diagnoses which included dementia (a chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning).
A review of Resident 33's Annual Minimum Data Set Assessment (MDS, a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated September 22, 2025, revealed the resident was severely cognitively impaired.
A review of Resident 33's nursing progress notes between June 2025 and end of the survey October 16, 2025, revealed the resident had decreased ability to communicate as evidenced by the inability to complete the BIMS (Brief Interview for Mental Status, a tool to assess the residents attention, orientation and ability to register and recall new information, a score of 13-15 equates to being cognitively intact) for the review period ending September 22, 2025, the resident had scored a 9 indicating moderate cognitive impairment (08 -12 moderately impaired) during the review period ending June 30, 2025.
A review of the resident ' s current care plan initially dated October 1, 2024, last revised September 25, 2025, revealed there were no new interventions to address these concerns. Further review revealed no documented evidence the facility had developed an individualized person-centered plan for the resident's dementia care, while maximizing the resident's dignity, autonomy, privacy, socialization, independence, choice, and safety and using individualized, non-pharmacological approaches to care, including purposeful and meaningful activities that address the resident's customary routines, interests, preferences, and choices to enhance the resident's well-being.
The facility failed to develop and implement an individualized person-centered plan to address, modify and manage this resident's dementia-related behaviors. The resident's care plan for dementia failed to include individualized interventions based on an assessment of the resident's preferences, social/past life history, customary routines, and interests in an effort to manage, modify or decrease the resident's dementia-related behavioral symptoms.
Interview with Nursing Home Administrator on October 16, 2025, at 10:00 AM, confirmed the facility was unable to provide evidence of the development and implementation of an individualized person-centered plan to address the resident's dementia care.
28 Pa Code 211.12 (d)(3)(5) Nursing services

Plan of Correction - To be completed: 12/02/2025

A dementia care plan was implemented for Resident #33.

All residents with a diagnosis of dementia have an individualized, person-centered care plan developed and implemented to address their specific strengths, needs and preferences.

All licensed nursing staff and social service staff will receive in-service education on the facility policy titled "Dementia Care." Education will include the importance of individualized, person-centered approaches and the integration of appropriate interventions into each resident's care plan.

The Director of Nursing (DON) or designee will develop and implement a Quality Assurance (QA) study to monitor compliance with comprehensive and person-centered care plan development. The QA study will utilize the Interdisciplinary Care Team (IDCT) meeting schedule to review a sample of care plans for accuracy, completeness, and evidence of individualized interventions x 6 months.
Results of the QA study will be reviewed during the facility's monthly QA Committee meetings. Corrective actions, including staff re-education or revisions to care plans, will be implemented as necessary to ensure ongoing compliance with regulatory care planning requirements.

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