Pennsylvania Department of Health
RIDGEVIEW HEALTHCARE & REHAB CENTER
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

RIDGEVIEW HEALTHCARE & REHAB CENTER
Inspection Results For:

There are 159 surveys for this facility. Please select a date to view the survey results.

Surveys don't appear on this website until at least 41 days have elapsed since the exit date of the survey.


RIDGEVIEW HEALTHCARE & REHAB CENTER - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:

Based on a revisit and abbreviated complaint survey completed on March 7, 2024, it was determined that Ridgeview Healthcare and Rehab Center failed to correct federal deficiencies cited during the survey of January 26, 2024, and continued to be out of 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(i)(1)(2) REQUIREMENT Food Procurement,Store/Prepare/Serve-Sanitary:

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(i) Food safety requirements.
The facility must -

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

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

Observations:

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

Findings include:

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

A tour of the facility's kitchen was conducted with Employee 3, Dietary Manager, on March 7, 2023, at approximately 10:00 AM, revealing the following unsanitary practices with the potential to introduce contaminants into food and increase the potential for food-borne illness, were identified:

Multiple wet ceiling tiles were observed in the dry storage room off the kitchen. Maintenance staff were present, cutting and replacing wet ceiling tiles with the food stored in the area, uncovered beneath the work. There were multiple packages of bread and rolls, boxes of dinner rolls, an open box of bananas, a box of muffins, pots and pans, and the ice machine and scoop which were not covered. Debris was observed throughout the room from the work being done to replace the wet ceiling tiles. The wooden slats above the ceiling tile were observed to be wet and currently dripping water. The concrete wall was observed to have been coated with a sealant, and water built up between the wall and sealant. There were holes observed in the coating of sealant with water observed leaking out of the holes.

There was a portable air conditioner in the room but no thermostat to monitor the temperature of the dry storage room for safe and acceptable temperatures.

Multiple wet ceiling tiles were also observed in the kitchen.

There was a gap between the sink in dishroom, where it met the dish machine and wall. The facility had attempted to screw a piece of metal to block the gap, but a gap was still present. Water was observed pouring out of the gap and pooling all over the floor. Under the sinks and dish machine there were multiple broken and cracked tiles. The floor was flooded with water.

An observation of the third floor resident pantry on March 7, 2024, at 11:06 AM revealed the following:

Two pints of ice cream opened not dated or labeled;
Two bottles of Pedialyte opened not dated or labeled. The manufacturing instructions indicate to discard within 24 hours of opening;
Two defrosted Mighty Shakes with no date as when they were defrosted. The manufacturing instructions indicate use within 14 days of thawing;
A Tupperware bowl of leftover food not dated or labeled;
A yellow grocery bag filled with Kentucky Fried Chicken (KFC) not dated or labeled; and
One bag of open pretzels not dated or labeled.

Interview with the Nursing Home Administrator on March 7, 2024, at approximately 2:30 PM, confirmed that food should be stored, prepared, and served under sanitary conditions.

28 Pa. Code 211.6 (f) Dietary services.

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

Plan of Correction - To be completed: 04/02/2024

1. The facility has brought in a consultant to assess the front porch and what will be needed to stop water from coming through it and into the kitchen area. The facility has also repaired the dish room sink to stop the excess water draining onto the floor. The facility has also cleaned out any expired or unlabeled food from the 3rd floor pantry and ensured all food items are properly labeled and dated.
2. Based on the consultant's report the facility will make a plan to repair the porch to prevent water coming into the kitchen area. Staff will ensure all food brought into the pantry area will be properly labeled and dated.
3. Dietary staff will be reeducated on the importance of alerting maintenance to any water ingress issues as well as issues with damaged fixtures. Nursing and dietary staff will also be reeducated on labeling of all food in the pantries.
4. Administrator or designee will conduct weekly sanitation rounds in the kitchen and pantry areas to ensure they are clean and in good working order.

483.10(e)(3) REQUIREMENT Reasonable Accommodations Needs/Preferences:

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.

§483.10(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 observations, review of clinical records, and resident and staff interviews, it was determined that the facility failed to provide reasonable accommodation of the needs of bariatric residents' for showering equipment for two of two bariatric residents reviewed (Residents 11 and 12).

Findings include:

Review of the clinical record revealed that Resident 11 was admitted to the facility on June 18, 2022, with diagnoses of hemiplegia (paralysis of one side of the body) and hemiparesis (weakness on one side of the body) following a cerebral infarction (stroke), Type 2 diabetes (failure of the body to produce insulin), chronic obstructive pulmonary disease (lung disease that blocks airflow and makes it difficult to breathe), and morbid obesity (excess body fat with obesity related health condition).

Review of the Resident 11's quarterly Minimum Data Set Assessment (MDS - a federally mandated standardized assessment completed at specific times to identify resident care needs) dated December 20, 2023, indicated that the resident was cognitively intact with a BIMS (brief interview to assess cognitive status) score of 15 (13-15 represents intact cognitive responses).

Review of Resident 11's weight record revealed that the resident weighed 315.6 pounds on March 6, 2024.

During an interview with Resident 11 on March 7, 2024, at approximately 10:45 AM, he reported that the shower hose is not long enough to reach under the shower chair. He stated, "This morning I got a shower, but the hose is probably 6-12 inches too short, depending on how they position the shower chair." When asked how staff rinse his backside in the shower he replied, "they don't, I come back with a soapy a*s."

Review of the clinical record revealed that Resident 12 was admitted to the facility on February 21, 2023, with diagnoses of morbid obesity, lymphedema (swelling caused by a blockage in the lymphatic system (part of the immune and circulatory systems)) major depressive disorder, and bilateral (both) osteoarthritis of the knee (a degenerative joint disease that occurs when tissues that cushion the ends of bones within the joints break down).

Review of the Resident 12's annual MDS dated February 8, 2024, indicated that the resident was cognitively intact with a BIMS score of 15.

Review of Resident 12's weight record revealed that the resident weighed 521.8 pounds on February 20, 2024.

During an interview with Resident 12 on March 7, 2024, at 11:25 AM, she reported that the shower hose is not long enough to properly clean her private area and backside. When asked how staff are rinsing her private area and backside in the shower, Resident 12 shrugged her shoulders and stated, "I don't know, I guess they aren't."

Observation of the shower room on the second floor on March 7, 2024, at approximately 11:40 AM in the presence of the Assistant Director of Nursing (ADON), revealed that the shower hose would not adequately reach under the bariatric-sized shower chair in order to properly cleanse a residents' genitalia and anal area while receiving a shower.

During an interview with the Nursing Home Administrator (NHA) on March 7, 2024, at approximately 2:30 PM, he confirmed that the facility failed to provide appropriate shower equipment to accommodate the needs of the bariatric residents in the facility.

28 Pa. Code: 211.10 (d) Resident care policies.

28 Pa. Code 204.14 Supplies

Plan of Correction - To be completed: 04/02/2024

1. A new, longer shower hose has been installed.
2. Facility has checked the other shower rooms to ensure hoses are of the correct length.
3. All staff will be educated on identifying resident needs as well as the grievance process and responsibility report any residents complaints immediately. Residents will be reminded of the grievance process so issues like this can be addressed in a timely manner.
4. Administrator or designee will audit resident grievances weekly x4 then monthly x2 to ensure timely response to resident issues.

483.10(f)(5)(i)-(iv)(6)(7) REQUIREMENT Resident/Family Group and Response:

§483.10(f)(5) The resident has a right to organize and participate in resident groups in the facility.
(i) The facility must provide a resident or family group, if one exists, with private space; and take reasonable steps, with the approval of the group, to make residents and family members aware of upcoming meetings in a timely manner.
(ii) Staff, visitors, or other guests may attend resident group or family group meetings only at the respective group's invitation.
(iii) The facility must provide a designated staff person who is approved by the resident or family group and the facility and who is responsible for providing assistance and responding to written requests that result from group meetings.
(iv) The facility must consider the views of a resident or family group and act promptly upon the grievances and recommendations of such groups concerning issues of resident care and life in the facility.
(A) The facility must be able to demonstrate their response and rationale for such response.
(B) This should not be construed to mean that the facility must implement as recommended every request of the resident or family group.

§483.10(f)(6) The resident has a right to participate in family groups.

§483.10(f)(7) The resident has a right to have family member(s) or other resident representative(s) meet in the facility with the families or resident representative(s) of other residents in the facility.

Observations:

Based on review of select facility policy and the minutes from Residents' Council meetings and staff interviews it was determined that the facility failed to put forth sufficient efforts to promptly resolve resident complaints/grievances expressed during Resident Council Meetings.

Findings include:

Review of the facility's Grievance policy and procedure provided by the facility on March 7, 2024, indicated that it is the facility's policy to notify residents of their right to file a grievance, and to ensure the prompt resolution of all filed grievances. A written response to all grievances will be issued to the party who filed the grievance. This written response will be issued within five (5) business days of the receipt of the grievance. Written responses to grievances will include the date the grievance was received, a summary statement of the resident's grievance, the steps taken to investigate the grievance, a summary of pertinent findings or conclusions regarding the resident's concern(s), a statement as to whether the grievance was confirmed or not confirmed, any corrective action to be taken by the facility as a result of the grievance, and the date the written decision was issued.

Review of the notes from the Resident Council meeting conducted on February 20, 2024, revealed that residents in attendance at this meeting voiced their concerns regarding resident care and facility services during the meetings. Concerns expressed during the council meeting included activities being conducted in the hallway were "no good, blocks hallway", a resident's heater was not functioning, multiple concerns with laundry, quality and variety of food, variety of activities programming, and concerns about therapy services.

The facility was unable to provide documented evidence that resident concerns/grievances expressed during the February 2024 Resident Council meeting were communicated to the necessary departments for response and resolution.

There was no evidence that the concerns were investigated and/or resolved through any efforts taken by the facility in response to the residents' expressed concerns.

During an interview with the Nursing Home Administrator (NHA) on March 7, 2024, at approximately 2 PM. the NHA confirmed that there was no documented evidence that the facility had followed-up with the residents' concerns expressed during the resident council meeting.

28 Pa. Code 201.18 (b)(1)(3)(2.1)(4) Management

28 Pa. Code 201.29 (a) Resident Rights

Plan of Correction - To be completed: 04/02/2024

1. Facility has reviewed previous resident council minutes and written up all resident grievances for response.
2. Moving forward, all resident council minutes will be reviewed by IDT to ensure all resident concerns are written up as grievances and responded to appropriately.
3. All staff will be educated on the grievance process.
4. Administrator or designee will review all resident council minutes monthly, as well as all resident grievances weekly x4 then monthly x2 to ensure timely response to resident issues.

483.10(a)(1)(2)(b)(1)(2) REQUIREMENT Resident Rights/Exercise of Rights:

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(a) Resident Rights.
The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility, including those specified in this section.

§483.10(a)(1) A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the resident.

§483.10(a)(2) The facility must provide equal access to quality care regardless of diagnosis, severity of condition, or payment source. A facility must establish and maintain identical policies and practices regarding transfer, discharge, and the provision of services under the State plan for all residents regardless of payment source.

§483.10(b) Exercise of Rights.
The resident has the right to exercise his or her rights as a resident of the facility and as a citizen or resident of the United States.

§483.10(b)(1) The facility must ensure that the resident can exercise his or her rights without interference, coercion, discrimination, or reprisal from the facility.

§483.10(b)(2) The resident has the right to be free of interference, coercion, discrimination, and reprisal from the facility in exercising his or her rights and to be supported by the facility in the exercise of his or her rights as required under this subpart.

Observations:

Based on observation, clinical record review and resident and staff interview it was determined that the facility failed to provide care in an manner that enhances each resident's quality of life by failing to assist residents in maintaining a dignified personal appearance as preferred by for one resident out of 25 sampled (Resident 11) and failed to respond timely to residents' requests for assistance as reported by two residents (Residents 11 and 12).

Findings include:

Review of the clinical record revealed that Resident 11 was admitted to the facility on June 18, 2022, with diagnoses of hemiplegia (paralysis of one side of the body) and hemiparesis (weakness on one side of the body) following a cerebral infarction (stroke), Type 2 diabetes (failure of the body to produce insulin), chronic obstructive pulmonary disease (lung disease that blocks airflow and makes it difficult to breathe), and morbid obesity (excess body fat with obesity related health condition).

Review of the Resident 11's quarterly Minimum Data Set Assessment (MDS - a federally mandated standardized assessment completed at specific times to identify resident care needs) dated December 20, 2023, indicated that the resident was cognitively intact with a BIMS (brief interview to assess cognitive status) score of 15 (13-15 represents intact cognitive responses).

Review of Resident 11's weight record revealed that the resident weighed 315.6 pounds on March 6, 2024.

During an interview with Resident 11 on March 7, 2024, at approximately 10:45 AM, he expressed frustration that the facility ended the practice of cutting his hair while he remained in bed. He reported that he had been receiving haircuts in bed since his admission to the facility in 2022. He stated he was more comfortable in bed and preferred to receive haircuts in that manner but several weeks ago, the beautician informed him that she would no longer be permitted to offer salon services in the residents' rooms. He was told he would have to come to the beauty salon in order to have his haircut. Resident 11 stated that his power bariatric chair would not fit through the salon door due its size.

Observation conducted at the time of the interview revealed Resident 11's power chair measured 32 inches in width. Observation of the beauty salon doorway opening, located on the first floor, revealed that the doorway also measured 32 inches in width.

During a phone interview conducted with Employee 2 (facility beautician) on March 7, 2024, at approximately 2:00 PM, she confirmed that she received notification from the facility's Nursing Home Administrator (NHA) that in-bed hair salon services could no longer be offered to residents. She stated she told the NHA "that's going to be a problem because there are three bariatric guys who don't get out of bed and, if they did, their chairs won't fit through the \ door, and there are three guys who are comatose who won't be able to sit upright." Employee 2 stated that she did not agree with the facility's decision to terminate in-bed hair services.

Further interview with Resident 11 on March 7, 2024. revealed that he waits an excessively long time for staff to answer the call bell in order to provide incontinence care. He stated "last night (March 6, 2024) I messed my pants. I laid here for over an hour. My roommate went out twice to get help for me because no one was coming in to answer my bell." Resident 11 stated he put his light on at 2:45 PM and it was not answered until 4:00 PM. He reported that staff will come in and shut the bell off and say they'll be right back in 10-15 minutes, but that they do not come back.

Interview with Resident 12, a cognitively intact resident, on March 7, 2024, at approximately 12:15 PM, revealed she has recently waited 2 hours for staff to answer her call bell and provide the necessary incontinence care. She stated, "just a couple days ago I had to wait twice, both times 2 hours, while I was sitting in crap."

Interview with the Nursing Home Administrator on March 7, 2024, at approximately 2:45 PM confirmed that he terminated in-bed hair services and that delays in responding to residents' requests for assistance negatively impacted their quality of life in the facility.

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

28 Pa. Code 201.29 (a) Resident Rights.

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

Plan of Correction - To be completed: 04/02/2024

1. RESIDENT 11 IS NO LONGER A RESIDENT OF THE FACILITY.
RESIDENT 12 IS PROVIDED CARE IN A MANNER THAT ENHANCES QUALITY OF LIFE AND RESIDENT REQUESTS ARE RESPONDED TO TIMELY.
2. FACILITY WILL CONDUCT CALL BELL AUDITS TO ENSURE THAT RESIDENT NEEDS ARE MET IN A TIMELY MANNER. THE FACILITY HAS ALSO REINSTATED HAIRCUTS IN RESIDENT ROOMS.
3. EDUCATION WAS PROVIDED TO ALL STAFF IN REGARDS TO TIMELY RESPONSE TO CALL BELLS AND THE NEED FOR STAFF FROM ALL DEPARTMENTS TO MAKE THIS A PRIORITY.
4. NURSING MGT/DESIGNEE WILL AUDIT CALL BELL RESPONSE TIMES WEEKLY X 4, MONTHLY X 2 AND REPORT RESULTS AT FACILITY QA MEETING.

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

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

Observations:

Based on observation and staff interview, it was determined that the facility failed to maintain respiratory and oxygen equipment in a manner to promote optimal functioning for one resident out of 25 sampled residents (Resident 1).

Findings include:

A review of the current facility policy, provided during the survey ending March 7, 2024, entitled "Oxygen Concentrator" revealed that staff will date and time humidification bottles. Staff will change the nasal cannula and tubing at least once a week. The tubing will be labeled with the current date and time.

A review of Resident 1's clinical record revealed the resident was admitted to the facility on June 7, 2023, with diagnoses, which included Chronic Obstructive Pulmonary Disease (COPD a group of lung diseases that block airflow and make it difficult to breathe). The resident had a current physician order initially dated January 5, 2024, for humidified oxygen at 3 liters a minute via nasal cannula continuously.

An observation on March 7, 2024, at 10:58 AM, revealed Resident 1 was not in her room. The resident's oxygen tubing and nasal cannula were lying directly on the floor. The oxygen tubing was not labeled. The bag the tubing was to be stored in, that was attached to the oxygen concentrator, was dated February 11, 2024. The humidification bottle was not dated with the date it was opened and applied. A second opened humidification bottle with tubing attached to it was on top of the window sill, and also not dated as to when it was put into use.

Interview with the Director of Nursing on March 7, 2024, at approximately 2:30 PM, revealed the oxygen tubing should be changed every seven days and the tubing and water canister should be dated and confirmed the facility failed to maintain the residents' oxygen equipment.

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

28 Pa. Code 211.10(a)(d)Resident care policies

Plan of Correction - To be completed: 04/02/2024

Resident 25 oxygen equipment is maintained in a manner that promotes optimal functioning. Equipment is dated and stored according to protocol.
2. The facility will audit residents with oxygen to ensure oxygen equipment is changed as per physician order, tubing and water cannister dated, and the facility maintains the oxygen equipment in a manner that promotes optimal functioning.
3. Nursing staff will be educated on maintaining oxygen equipment according to facility protocol/physician order.
4. Nursing mgt/designee will audit oxygen equipment to ensure equipment is dated and changed per physician order and equipment is maintained per facility protocol.

483.21(c)(1)(i)-(ix) REQUIREMENT Discharge Planning Process:

§483.21(c)(1) Discharge Planning Process
The facility must develop and implement an effective discharge planning process that focuses on the resident's discharge goals, the preparation of residents to be active partners and effectively transition them to post-discharge care, and the reduction of factors leading to preventable readmissions. The facility's discharge planning process must be consistent with the discharge rights set forth at 483.15(b) as applicable and-
(i) Ensure that the discharge needs of each resident are identified and result in the development of a discharge plan for each resident.
(ii) Include regular re-evaluation of residents to identify changes that require modification of the discharge plan. The discharge plan must be updated, as needed, to reflect these changes.
(iii) Involve the interdisciplinary team, as defined by §483.21(b)(2)(ii), in the ongoing process of developing the discharge plan.
(iv) Consider caregiver/support person availability and the resident's or caregiver's/support person(s) capacity and capability to perform required care, as part of the identification of discharge needs.
(v) Involve the resident and resident representative in the development of the discharge plan and inform the resident and resident representative of the final plan.
(vi) Address the resident's goals of care and treatment preferences.
(vii) Document that a resident has been asked about their interest in receiving information regarding returning to the community.
(A) If the resident indicates an interest in returning to the community, the facility must document any referrals to local contact agencies or other appropriate entities made for this purpose.
(B) Facilities must update a resident's comprehensive care plan and discharge plan, as appropriate, in response to information received from referrals to local contact agencies or other appropriate entities.
(C) If discharge to the community is determined to not be feasible, the facility must document who made the determination and why.
(viii) For residents who are transferred to another SNF or who are discharged to a HHA, IRF, or LTCH, assist residents and their resident representatives in selecting a post-acute care provider by using data that includes, but is not limited to SNF, HHA, IRF, or LTCH standardized patient assessment data, data on quality measures, and data on resource use to the extent the data is available. The facility must ensure that the post-acute care standardized patient assessment data, data on quality measures, and data on resource use is relevant and applicable to the resident's goals of care and treatment preferences.
(ix) Document, complete on a timely basis based on the resident's needs, and include in the clinical record, the evaluation of the resident's discharge needs and discharge plan. The results of the evaluation must be discussed with the resident or resident's representative. All relevant resident information must be incorporated into the discharge plan to facilitate its implementation and to avoid unnecessary delays in the resident's discharge or transfer.

Observations:

Based on clinical record review and resident and staff interview it was determined that the facility failed to develop and implement an individualized discharge plan for one of 25 residents sampled (Resident 11).

Findings Include:

A review of the clinical record of Resident 11 revealed admission to the facility on June 18, 2022.

A quarterly Minimum Data Set Assessment (MDS- standardized assessment process conducted at periodic intervals to plan resident care) dated December 20, 2023, revealed that the resident had a BIMS (brief interview to aid in detecting cognitive impairment) score of 15, indicating that his cognition was intact.

Review of Resident 11's care plan, initially dated December 9, 2022, indicated that that discharge planning was complete, and the resident will acclimate to nursing facility placement as skilled nursing facility placement remains appropriate.

The resident's care plan was updated March 16, 2023, indicating that long term care remains appropriate for the resident. The intervention indicated that the resident be allowed the opportunity to verbalize goals and preferences.

An interview conducted with Resident 11 on March 7, 2024, at approximately 10:45 AM revealed that the resident does not want to stay in the facility and prefers to transfer to another facility closer to his family. The resident stated that he expressed his wishes to the social worker approximately 4 months ago but has not been updated to the status of those referrals. He stated, "I gave her a list of places closer to family. She told me referrals were sent to some of the facilities. Then, she asked me if I ever heard back from them." The resident stated that it remains his wish to transfer to a facility closer to family however the facility is not assisting him in this process.

A review of a social service note dated December 22, 2023, at 11:05 AM revealed that the Director of Social Services (DSS) met with the resident, and he stated he would like to move closer to his family and referrals were faxed to three facilities in that locality.

An interview with Employee 1 (Director of Social Services) on March 7, 2024, at approximately 12:40 PM, confirmed that Resident 11 expressed a desire to transfer to another facility closer to family. Employee 1 confirmed that 3 referrals were faxed but no follow-up communication was conducted by social services staff. Employee 1 stated, " I have it written on the form for them to contact me." She indicated that when a facility does not respond to a referral fax, that means that the referral facility denied the resident admission and that social services do not provide a follow-up call." She further stated, "they can hire another social worker to help out" if further follow up is required.

At the time of the survey ending March 7, 2024, there was no documented evidence that the social service staff conducted any follow up efforts regarding the resident's request to transfer to another facility closer to family.

There was no documented evidence that the resident's discharge plan was updated with new goals and interventions for the resident to be transferred to another skilled nursing facility.

Interview with the Nursing Home Administrator on March 7, 2024, at approximately 2:30 PM confirmed that the facility failed to revise and implement a discharge plan based on the resident's expressed desire to transfer to an alternate facility.

28 Pa. Code 201.25 Discharge policy

Plan of Correction - To be completed: 04/02/2024

1. Resident 11 has been discharged.
2. All residents who desire to transfer from another facility have been identified, and referrals have been sent and follow up calls have been scheduled.
3. Social Services director has been educated on the need to for appropriate follow up with referral locations.
4. Administrator of designee will audit follow up call schedule Weekly x4 then monthly x2 to ensure continued follow ups with referral locations.

483.15(c)(3)-(6)(8) REQUIREMENT Notice Requirements Before Transfer/Discharge:

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

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

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

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

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

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

Observations:

Based on review of clinical records and transfer notices and staff interview it was determined that the facility failed to provide sufficiently detailed written notices of facility initiated transfers to the resident and the resident's representative for one out of three residents reviewed (Resident 2)

Findings include:

A review of the clinical record of Resident 2 revealed the resident was transferred to the hospital on February 28, 2024, and returned to the facility on February 28, 2024.

The written notice of transfer lacked the reason for the resident's transfer.

During an interview with the Nursing Home Administrator and Director of Nursing on March 5, 2024, at approximately 2:30 PM, they were unable to provide documented evidence of that the reason for the facility initiated transfer to the hospital was included on the written transfer notice.

28 Pa. Code 201.14(a) Responsibility of Licensee

Plan of Correction - To be completed: 04/02/2024

1. Facility cannot fix the issue for the cited residents as it occurred in the past.
2. All future residents who are discharged from the facility will receive a transfer notice with the reason for transfer in layman's terms.
3. Nursing and social services staff have been educated on properly filling out the transfer notice.
4. Administrator or designee will audit all resident transfer notices weekly x4 then monthly x2 to ensure all are properly filled out.

§ 211.12(f.1)(2) LICENSURE Nursing services. :

(2) Effective July 1, 2023, a minimum of 1 nurse aide per 12 residents during the day, 1 nurse aide per 12 residents during the evening, and 1 nurse aide per 20 residents overnight.

Observations:

Based on a review of nurse staffing and staff interview, it was determined that the facility failed to ensure the minimum nurse aide staff to resident ratio was provided on each shift for 3 shifts out of 27 reviewed.

Findings include:

A review of the facility's weekly staffing records revealed that on the following dates the facility failed to provide minimum nurse aide staff of 1:12 on the evening shift and 1:20 on the night shift based on the facility's census.

February 29, 2024 - 4.50 nurse aides on the night shift, versus the required 5.05 for a census of 101.
March 3, 2024 - 7.43 nurse aides on the evening shift, versus the required 8.42 for a census of 101.
March 3, 2024 - 4.13 nurse aides on the night shift, versus the required 5.05 for a census of 101.

An interview with the Nursing Home Administrator on March 7, 2024, at approximately 2:30 PM, confirmed the facility had not met the required nurse aide to resident ratios on the shifts on the above dates.

Plan of Correction - To be completed: 04/02/2024

Facility will schedule CNAs to meet the current, required staffing ratios.
The facility is currently utilizing agency to bolster facility staffing. The facility is also using multiple outside resources such as partnerships with local high school and trade schools to recruit more staff. The facility is also utilizing a number of employee appreciation efforts to retain current staff.
Nursing Admin team will be re-educated on current staffing ratios and protocol for replacing call offs.
Nursing Admin team will review schedules to ensure proper staffing has been scheduled. When call offs occur the DON will be notified and DON or designee will utilize staff call list as well as agency support to fill the opening created.
IDT designee will conduct an audit on scheduled staffing levels to ensure minimum staffing levels are maintained. Audit will be conducted weekly with results reported to the QAPI as necessary.

§ 211.12(f.1)(4) LICENSURE Nursing services. :

(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.

Plan of Correction - To be completed: 04/02/2024

Facility will schedule LPNs to meet the current, required staffing ratios.
The facility is currently utilizing agency to bolster facility staffing. The facility is also using multiple outside resources such as partnerships with local high school and trade schools to recruit more staff. The facility is also utilizing a number of employee appreciation efforts to retain current staff.
Nursing Admin team will be re-educated on current staffing ratios and protocol for replacing call offs.
Nursing Admin team will review schedules to ensure proper staffing has been scheduled. When call offs occur the DON will be notified and DON or designee will utilize staff call list as well as agency support to fill the opening created.
IDT designee will conduct an audit on scheduled staffing levels to ensure minimum staffing levels are maintained. Audit will be conducted weekly with results reported to the QAPI as necessary.

§ 211.12(i)(1) LICENSURE Nursing services.:

(1) Effective July 1, 2023, 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 2.87 hours of direct resident care for each resident.

Observations:

Based on a review of nurse staffing, resident census and staff interview, it was determined that the facility failed to consistently provide minimum general nursing care hours to each resident daily.

Findings include:

A review of the facility's weekly staffing levels revealed that on the following date the facility failed to provide minimum nurse staffing of 2.87 hours of general nursing care to each resident:

March 3, 2024 -2.75 direct care nursing hours per resident

An interview with the Nursing Home Administrator on March 7, 2024, at approximately 2:30 PM confirmed the facility failed to consistently provide minimum general nursing care hours to each resident daily.

Plan of Correction - To be completed: 04/02/2024

Facility will schedule staff to meet the current, required staffing PPD.
The facility is currently utilizing agency to bolster facility staffing. The facility is also using multiple outside resources such as partnerships with local high school and trade schools to recruit more staff. The facility is also utilizing a number of employee appreciation efforts to retain current staff.
Nursing Admin team will be re-educated on current staffing PPDs and protocol for replacing call offs.
Nursing Admin team will review schedules to ensure proper staffing has been scheduled. When call offs occur the DON will be notified and DON or designee will utilize staff call list as well as agency support to fill the opening created.
IDT designee will conduct an audit on scheduled staffing levels to ensure minimum staffing levels are maintained. Audit will be conducted weekly with results reported to the QAPI as necessary.

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