§483.21(b)(3) Comprehensive Care Plans
The services provided or arranged by the facility, as outlined by the comprehensive care plan, must-
(i) Meet professional standards of quality.
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Observations:
Based on review of clinical records an interview with staff it was determined that the facility failed to ensure that residents who have a change in clinical status were evaluated by a provider. For one of ten residents observed (Resident R1)
Findings include:
Review of Resident R1's clinical record revealed Resident R1 was admitted to the facility on September 7, 2023, with diagnosis of but not limited to Centrilobular Emphysema (chronic lung disease).
Review of progress note dated November 30, 2025, at 10:00 p.m. written bylicensed nurse Employee E3revealed a change in condition. "At the time of evaluation resident/patient vital signs, weight and blood sugar were: Blood Pressure 92/43 (normal blood pressure 110/80) , Pulse: 90 (normal pulse 60 per 100 beats per minute) RR (respiration rate):18.0 (normal 30 to 60 breath per minute)-Temperature: T 99.5 (normal body temperature 97.-95.5 degrees Fahrenheit), Weight: 91.2 pounds, Pulse Oximetry: O2 89.0 % (norma oxygen level 95%-100%) - Method: Room Air. Outcomes of Physical Assessment: Positive findings reported on the resident/patient evaluation for this change in condition were: Relevant medical history is: COPD Dementia, Functional Status Evaluation: General weakness, Respiratory Status Evaluation: Shortness of breath. Nursing observations, evaluations, and recommendations are: Resident is very weak/tired this shift. She is SOB (short of breath) at times, with decreased pulse ox and a low-grade temp. Placed on 2L(liters) O2(oxygen) with positive results. Her appetite is poor and fluids are encouraged. Spoke with Nurse Practitioner 1 Employee E4 who said that patient will be seen on rounds byNurtse Practitioner 2 Employee E5.
Further review of Resident R1's clinical record revealed that there was no documentation by Nurse Practitioner 1 Employee E4 related to Resident R1's change in condition that was reported to her by licensed nurse Employee E3. Further, there was no documented evidence that Nurse Practitioner 1 Employee E4 had addressed Resident R1's change in status and Oxygen saturation of 89.0%.
Review of Resident R1's physician's orders dated December 1, 2026, at 12:36PM revealed an order for: STAT Chest X-ray: 2-view for cough, weakness.
Review of Chest XC-ray results and conclusion dated December 1, 2026, at 4:38PM revealed Bilateral patchy infiltrates.
Review of Resident R1's Medical Practitioner Note (Nurse Practitioner 2), Employee E5 note dated December 1, 2026, at 9:05PM revealed "Resident seen for follow up - staff reported increased weakness and decreased PO (oral) intake over the weekend as well as needing supplemental oxygen 2/2 low SpO2 at 89%.
Review resident R1's progress note dated December 7, 2025, at 6:10PM revealed that Resident R1 was admitted to local hospital with diagnoses of B/L (bilateral) pneumonia (infection that inflames the air sacs of one or both lungs), UTI (urinary tract infection), leukocytosis, hyponatremia low sodium in the body).
Interview with Director of Nursing Employee E2 conducted on May 7, 2026, at 11:24 AM, confirmed that Nurse Practitioner 1 Employee E4 did not address Resident R1's change of status and did not have any documentation after licensed nurse Employee E3 notified Employee E4 of Resident R1's change in status and oxygen saturation of 89%.
Licensed nurse Employee E3, Nurse Practitioner 1 Employee E4 and Nurse Practitioner 2 Employee E5 were not available for interview.
28 Pa. Code 211.12(d)(5) Physician services
| | Plan of Correction - To be completed: 06/17/2026
F 0658 Services Provided Meet Professional Standards
S/S=D
Preparation and submission of this plan of correction is required by state and federal law. This plan of correction does not constitute an admission for purposes of general liability, professional malpractice or any other court proceeding.
Resident R1 discharged from the facility on 12/9/2025 and has not returned.
DON or designee will conduct an initial audit on all residents to ensure residents with a change in condition in the last 3 days were notified and the nurse/providers documentation includes evidence of interventions/orders to address change of condition.
NPE or designee will inservice licensed nursing staff on Nursing Policy NSG115 Physician/Advanced Practice Provider (APP) Notification, Nursing Policy NGS122 Notification of Change in Condition, and NSG113 Nursing Documentation.
DON or designee will conduct random weekly audits (5 residents) x4, then monthly x2 to ensure residents with a change in condition were notified and the nurse/providers documentation includes evidence of interventions/orders to address change of condition.
Results of the audits will be presented at the monthly QAPI meeting for review and recommendation.
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