Pennsylvania Department of Health
HAIDA NURSING AND REHAB
Patient Care Inspection Results

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Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

HAIDA NURSING AND REHAB
Inspection Results For:

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HAIDA NURSING AND REHAB - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:Based on a Medicare/Medicaid Recertification survey, State Licensure survey, and Civil Rights Compliance survey, completed on December 4, 2025, it was determined that Haida Nursing and Rehab 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:

483.20(b)(1)(2)(i)(iii) REQUIREMENT Comprehensive Assessments & Timing:

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 Resident Assessment
The facility must conduct initially and periodically a comprehensive, accurate, standardized reproducible assessment of each resident's functional capacity.

§483.20(b) Comprehensive Assessments
§483.20(b)(1) Resident Assessment Instrument. A facility must make a comprehensive assessment of a resident's needs, strengths, goals, life history and preferences, using the resident assessment instrument (RAI) specified by CMS. The assessment must include at least the following:
(i) Identification and demographic information
(ii) Customary routine.
(iii) Cognitive patterns.
(iv) Communication.
(v) Vision.
(vi) Mood and behavior patterns.
(vii) Psychological well-being.
(viii) Physical functioning and structural problems.
(ix) Continence.
(x) Disease diagnosis and health conditions.
(xi) Dental and nutritional status.
(xii) Skin Conditions.
(xiii) Activity pursuit.
(xiv) Medications.
(xv) Special treatments and procedures.
(xvi) Discharge planning.
(xvii) Documentation of summary information regarding the additional assessment performed on the care areas triggered by the completion of the Minimum Data Set (MDS).
(xviii) Documentation of participation in assessment. The assessment process must include direct observation and communication with the resident, as well as communication with licensed and nonlicensed direct care staff members on all shifts.

§483.20(b)(2) When required. Subject to the timeframes prescribed in §413.343(b) of this chapter, a facility must conduct a comprehensive assessment of a resident in accordance with the timeframes specified in paragraphs (b)(2)(i) through (iii) of this section. The timeframes prescribed in §413.343(b) of this chapter do not apply to CAHs.
(i) Within 14 calendar days after admission, excluding readmissions in which there is no significant change in the resident's physical or mental condition. (For purposes of this section, "readmission" means a return to the facility following a temporary absence for hospitalization or therapeutic leave.)
(iii)Not less than once every 12 months.

Plan of Correction - To be completed: 01/05/2026

1. Admission assessments for residents 2, 16, 24, 52, 70 and 71 were completed and submitted to the Centers for Medicare and Medicaid Services.

2.A review of Admissions for 14 days will be completed to ensure timely assessments.

3.Education regarding the completing the Admission Minimum Data Set assessment within the correct timeframe – by day 14 of the resident stay per the Resident Assessment Instrument Manual, provided to the Registered Nurse Assessment Coordinator by the Registered Nurse Assessment Coordinator Consultant.
Nursing Home Administrator or designee will complete an audit of new admissions Admission Minimum Data Set assessment weekly times 4 weeks and monthly times 2 months.

4. Results will be reviewed at the Quality Assurance Performance Improvement meeting.

483.20(g)(h)(i)(j) REQUIREMENT Accuracy of Assessments:

§483.20(g) Accuracy of Assessments.
The assessment must accurately reflect the resident's status.

§483.20(h) Coordination. A registered nurse must conduct or coordinate each assessment with the appropriate participation of health professionals.

§483.20(i) Certification.
§483.20(i)(1) A registered nurse must sign and certify that the assessment is completed.
§483.20(i)(2) Each individual who completes a portion of the assessment must sign and certify the accuracy of that portion of the assessment.

§483.20(j) Penalty for Falsification.
§483.20(j)(1) Under Medicare and Medicaid, an individual who willfully and knowingly-
(i) Certifies a material and false statement in a resident assessment is subject to a civil money penalty of not more than $1,000 for each assessment; or
(ii) Causes another individual to certify a material and false statement in a resident assessment is subject to a civil money penalty or not more than $5,000 for each assessment.
§483.20(j)(2) Clinical disagreement does not constitute a material and false statement.

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 complete accurate Minimum Data Set assessments for three of 37 residents reviewed (Resident 4, 12, 68).

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 2025, indicated that Section N0415K1 (Anticonvulsant-medications medication used to prevent or treat seizures) was to be coded (1) was taking, if the resident received an anticonvulsant medication during the seven day look back period.

A quarterly MDS assessment for Resident 4 dated October 2, 2025, revealed that Section N0415K Anticonvulsant was coded that the resident received anticonvulsants during the lookback period. However, a review of the MAR for Resident 4 for September and October 2025 revealed that the resident did not receive an anticonvulsant during the look back period.

An interview with the Nursing Home Administrator on December 3, 2025, at 9:48 a.m. confirmed that Resident 4's MDS assessment was coded inaccurately, and the resident did not receive anticonvulsants during the seven-day lookback period.

Physician's orders for Resident 12, dated April 2, 2025, included an order for the resident to receive 750 milligrams (mg) of Keppra (an anticonvulsant) two times a day for seizures.

A quarterly MDS assessment for Resident 12, dated October 30, 2025, revealed that Section N0415K1 was not coded (1) indicating that the resident did not receive an anticonvulsant during the seven-day look-back period. However, a review of the MAR for Resident 12 for October 2025 revealed that the resident received Keppra two times a day every day in October.

Interview with the Director of Nursing on December 3, 2025, at 3:15 p.m. confirmed that Resident 12's MDS dated October 30, 2025, was not coded correctly for anticonvulsant medication use.

The Long-Term Care Facility RAI User's Manual, dated October 2025, indicated that Section N0415F Antibiotic was to be coded (1) was taking, if the resident received an antibiotic medication during the seven day look back period.

Physician's orders for Resident 68 dated October 28, 2025, included an order for the resident to receive 500 mg of Levofloxacin (antibiotic) intravenously (inserted through the vein) once a day.

A quarterly MDS assessment for Resident 68 dated November 1, 2025, revealed that Section N0415F1 Antibiotic was not coded (1), indicating that the resident did not receive an antibiotic during the lookback period. However, a review of the MAR for Resident 68 for October 2025, revealed that the resident received an antibiotic intravenously on October 28-31, 2025, during the look back period.

An interview with the Nursing Home Administrator on December 3, 2025, at 9:48 a.m. confirmed that Resident 68's MDS assessment was coded inaccurately and that the resident received an antibiotic during the seven-day lookback period.

28 Pa. Code 211.5(f) Clinical records.

Plan of Correction - To be completed: 01/05/2026

1. Residents 4, 12 and 68 Minimum Data Set assessment was corrected and coded correctly for anticonvulsants: N0415K and antibiotics: N0415F.

2.A lookback of one week of Minimum Data Set assessments will be reviewed for correct coding on anticonvulsants and antibiotics (N0415K and N0415F).

3.Registered Nurse Assessment Coordinator Consultant will educate the Register Nurse Assessment Coordinator on the accurate coding the Minimum Data Set for N0415K and N415F per the Resident Assessment Instrument Manual.
Registered Nurse Assessment Coordinator Consultant or designee will audit Minimum Data Set assessments for correct coding and accuracy on anticonvulsants and antibiotics (N0415K and N0415F) 3 times per week for 2 weeks, 2 times per week for 2 weeks and monthly for 2 months.

4.Results of the audit will be reviewed at the Quality Assurance Performance Improvement meeting.

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 policies, clinical records, and staff interviews, it was determined that the facility failed to develop a comprehensive care plan that included specific and individualized interventions to address the care needs of residents for one of 37 residents reviewed (Resident 1 ).

Findings include:

The facility's policy for care plans, dated October 15, 2025, indicated that the resident and his or her representative were encouraged to participate in the development and implementation of the resident's person-centered care plan.

A quarterly Minimum Data Set (MDS) assessment (a federally mandated assessment of a resident's abilities and care needs) for Resident 1, dated October 27, 2025, revealed that the resident was severely cognitively impaired, required extensive assistance from staff with daily care tasks, and had diagnoses that included chronic kidney disease, anemia and acute respiratory failure.

Physician's orders for Resident 1, dated October 22, 2025, included orders for the resident to receive oxygen at 4 liters per minute, due to an onset of shortness of breath, and physician's orders, dated November 14, 2025, indicated the resident was to begin hospice services due to a loss of appetite and general decline of health.

There was no documented evidence that care plans were developed to address Resident 1's individual care and treatment needs related to the use of oxygen and hospice care.

Interview with the Registered Nurse Assessment Coordinator (RNAC- responsible for developing care plans) and Nursing Home Administrator on December 3, 2025, at 10:12 a.m. and 11:15 a.m. respectively, confirmed that care plans to address Resident 1's need for oxygen and hospice services were not developed, and should have been.

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

Plan of Correction - To be completed: 01/05/2026

1. A care plan was developed for resident 1 for oxygen use and hospice services.

2.Care plans of residents that use oxygen and hospice services were reviewed to ensure appropriate care plans were developed.

3.Director of Nursing or designee will educate Registered Nurses and Registered Nurse Assessment Coordinator on the importance of developing care plans for residents using oxygen and hospice services.

4.Director of Nursing or designee will complete an audit on residents that use oxygen and hospice to ensure a care plan is developed 1 time per week for 4 weeks and monthly for 2 months.

5.Results of the audit will be reviewed at the Quality Assurance Performance Improvement meeting.

483.21(b)(3)(i) REQUIREMENT Services Provided Meet Professional Standards:

§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.

Observations:

Based on review of Pennsylvania's Nursing Practice Act, facility policies, clinical records, and facility investigation documents, as well as staff interviews, it was determined that the facility failed to clarify physician's orders for one of 37 residents reviewed (Resident 8).

Findings include:

The Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing 21.11 (a)(1)(2)(4) indicated that the registered nurse was responsible for assessing human responses and plans, implementing nursing care, analyzing/comparing data with the norm in determining care needs, and carrying out nursing care actions that promote, maintain and restore the well-being of individuals.

The facility's medication administration policy, dated October 15, 2025, revealed that medications were administered by licensed nurses, or other staff who were legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. They will ensure the six rights of medication administration were followed: right resident, right drug, right dosage, right route, right time, and right documentation.

A quarterly minimum data set (MDS) assessment (mandated to assess the resident abilities and care needs) for Resident 8, dated October 1, 2025, revealed that the resident was cognitively impaired, required assistance from staff for personal care needs, had a gastrostomy (feeding tube) and had diagnoses that included a stroke.

Physician's orders for Resident 8, dated July 10, 2025, included an order for the resident to be NPO (nothing by mouth) and included orders for the resident to receive 10 milligrams (mg) of Baclofen (muscle relaxant) 1 tablet by mouth one time a day, 325 mg of Ferrous sulfate (medication used for low iron) 1 tablet by mouth one time a day, 300 mg of gabapentin (medication used nerve pain) 1 capsule by mouth one time a day, and 400 mg of milk of magnesia (medication used for constipation) by mouth as needed.

A review of Resident 8's December 2025 Medication Administration Record revealed that staff signed off the medications listed above as given by mouth. There was no documented evidence in the clinical record to indicate that the orders for Resident 8's medications were clarified and written to be given via peg tube due to the resident's NPO status.

Interview with the Director of Nursing on December 3, 2025, at 3:22 p.m. confirmed that Resident 8's medications were not clarified and that they should have been written to be administered through the feeding tube.

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

Plan of Correction - To be completed: 01/05/2026

1.Resident 8 remains in the facility; his medications were reviewed with the physician and remain appropriate. All medications were clarified to be administered via peg tube.

2.New admissions to the facility with a feeding tube and NPO will have their medications reviewed on the day of admission by the registered nurse, Director of Nursing/Designee, and by the Registered Nurse Assessment Coordinator.

3.The Director of Nursing/Designee will educate the registered nurses, and licensed practical nurses on the importance of administering medication per the physician orders and the need to ensure that the correct route of medication administration is included in the physician orders and on the medication administration record,and completing the admission check list on new admissions.

4.The Director of Nursing/Designee will audit new admissions to the facility that has a feeding tube and review medications to ensure they are ordered via feeding tube. The Director of Nursing/Designee will also review the order listing report for any new medications ordered on residents with feeding tubes to ensure medications are administered via the feeding tubes. This audit will be completed on new admissions and on new medications ordered that are to be administered via feeding tube daily X 5 days, then weekly X 4 weeks then monthly x 2 months.

5.Results of the audits will be reviewed at the Quality Assurance Performance Improvement Meetings until substantial compliance has been met.

483.24(a)(2) REQUIREMENT ADL Care Provided for Dependent Residents:

§483.24(a)(2) A resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene;

Observations:

Based on review of facility policies, clinical records, and shower schedules, as well as staff interviews, it was determined that the facility failed to ensure that residents were provided with showers as scheduled for two of 37 residents reviewed (Residents 36 and 66).

Findings include:

The facility's policy for resident showers, dated October 15, 2025, indicated that it was the practice of the facility to assist residents with bathing to maintain proper hygiene, stimulate circulation and help prevent skin issues as per current standards of practice. Residents would be provided showers as per request or as per facility schedule protocols and based upon resident safety.

An annual Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 36, dated November 11, 2025, indicated that the resident was cognitively impaired, required assistance from staff for personal hygiene care including showers, and had a diagnosis of dementia.

A review of the shower records for Resident 36, dated October 2025 and November 2025, revealed that resident was to receive a shower on Wednesdays and Sundays during the evening shift. However, staff documented "not applicable" for providing showers on October 3, 6, 13, 17, 20, 24, 27, 31 and November 3, 7, 10, 14, 17, 21, 24, 28. There was no documented evidence that the resident was offered or refused a shower on these days or any days in between.

A quarterly MDS assessment for Resident 66, dated October 30, 2025, indicated that the resident was cognitively impaired, required assistance from staff for personal hygiene care including showers, and had a diagnosis of dementia.

A review of the shower records for Resident 66, dated October 2025 and November 2025, revealed that the resident was to receive a shower on Wednesdays and Saturdays during the day shift. However, staff documented "not applicable" for providing showers on October 3, 10, 14, 21, 24, 28, 31 and November 4, 7, 11, 14, 18, 25. There was no documented evidence that the resident was offered or refused a shower on these days or any other days in between.

Interview with the Director of Nursing on December 3, 2025, at 3:05 p.m. confirmed there was no documented evidence that Residents 36 and 66 were provided with showers or baths on the above-mentioned dates and times.

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

Plan of Correction - To be completed: 01/05/2026

1.Resident 36 and resident 66 remain in the facility, their bath/shower preference was reviewed with the resident's representative and remain appropriate. Their care plan has been reviewed, and shower days are correct.

2.The other residents in the facility had their bath/shower preference reviewed with the resident/resident's representative to ensure their shower preference are correct. Care plan has been reviewed/updated to reflect the correct bath/shower preference. Residents shower/bath preferences are now on the daily report sheet.

3.The Director of Nursing/Designee will educate the nursing staff on the importance of residents receiving their bath/shower per their preference. Residents that refuse a shower will notify the licensed practical nurse, the licensed practical nurse will approach resident and educate resident on the risk/benefits of a bath/shower and offer another time/day, if resident still refuses the licensed practical nurse will document in the medical record the reason resident refusal.

4.The Director of Nursing/Designee will audit bath/ showers daily x 5 days, then weekly x 4 weeks, then monthly x 2 months.

5.Results of the audits will be reviewed at the Quality Assurance Performance Improvement meetings until substantial compliance has been met.

483.25(b)(1)(i)(ii) REQUIREMENT Treatment/Svcs to Prevent/Heal Pressure Ulcer:

§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 clinical records, observations, and staff interviews, it was determined that the facility failed to ensure that pressure relieving devices were in place as ordered by the physician for one of 37 residents reviewed (Resident 5).

Findings include:

A quarterly Minimum Data Set (MDS) assessment (a federally mandated assessment of a resident's abilities and care needs) for Resident 5, dated November 21, 2025, revealed that the resident was cognitively impaired, required assistance from staff for daily care needs, was at risk for developing pressure ulcers, and had diagnoses that included diabetes and heart failure.

Physician's orders for Resident 5, dated September 17, 2025, included orders for the resident to wear Prevalon boots (a type of heel protector used in medical settings to prevent pressure injuries) on both feet for heel protection. A care plan for Resident 5, dated September 18, 2025, indicated that the resident was at risk for altered skin integrity and Prevalon boots were to be worn on both feet at all times when in bed.

Observations of Resident 5 on December 3, 2025, at 10:24 a.m. revealed the resident was resting in bed without Prevalon boots on. A pillow was noted under her legs; however, her right heel, and left heel and outer ankle were resting directly on the bed.

Interview with Licensed Practical Nurse 1 on December 3, 2025, at 10:24 a.m. confirmed that Resident 5 should have had Prevalon boots on while she in bed.

Interview with the Director of Nursing on December 3, 2025, at 10:57 a.m. confirmed that Resident 5 should have had Prevalon boots on while in bed as ordered by the physician.

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

Plan of Correction - To be completed: 01/05/2026

1.Resident 5 still resides in the facility, her medical record and care plan was reviewed and resident remains appropriate for the Prevalon Boots due to risk of developing a pressure sore.

2.An audit was completed and no other residents in the facility are ordered Prevalon boots. Nursing staff who identify any residents that become at risk for developing a pressure ulcer to the heels will notify the physician, if an order is obtained for Prevalon boots the care plan will be updated with the intervention of the Prevalon boots.

3.The Director of Nursing/Designee will educate the nursing staff on the importance of ensuring Prevalon boots/pressure relieving devices are in place per physician order/resident care plan to decrease/prevent skin breakdown.

4.The Director of Nursing/Designee will audit Prevalon boots on Resident 5 and with any new orders for Prevalon boots. This audit will be completed daily x 5 days, weekly x 4 weeks, then monthly x 2 months.

5.Results of the audits will be reviewed at the Quality Assurance Performance Improvement meetings until substantial compliance has been met.

483.25(e)(1)-(3) REQUIREMENT Bowel/Bladder Incontinence, Catheter, UTI:

§483.25(e) Incontinence.
§483.25(e)(1) The facility must ensure that resident who is continent of bladder and bowel on admission receives services and assistance to maintain continence unless his or her clinical condition is or becomes such that continence is not possible to maintain.

§483.25(e)(2)For a resident with urinary incontinence, based on the resident's comprehensive assessment, the facility must ensure that-
(i) A resident who enters the facility without an indwelling catheter is not catheterized unless the resident's clinical condition demonstrates that catheterization was necessary;
(ii) A resident who enters the facility with an indwelling catheter or subsequently receives one is assessed for removal of the catheter as soon as possible unless the resident's clinical condition demonstrates that catheterization is necessary; and
(iii) A resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible.

§483.25(e)(3) For a resident with fecal incontinence, based on the resident's comprehensive assessment, the facility must ensure that a resident who is incontinent of bowel receives appropriate treatment and services to restore as much normal bowel function as possible.

Observations:

Based on review of policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that a resident received proper care for an indwelling urinary catheter for one of 37 residents reviewed (Residents 20).

Findings include:

The facility's policy regarding urinary catheters (a tube inserted and held in the bladder to drain urine), dated October 15, 2025, indicated that the purpose of the policy was to ensure safe handling of the urinary catheter in order to reduce the risk of urinary tract infections.

A quarterly Minimum Data Set (MDS) assessment for Resident 20, dated October 21, 2025, revealed that the resident was cognitively impaired, had an indwelling urinary catheter (a flexible tube inserted and held in the bladder to drain urine) and had diagnoses that included obstructive and reflux uropathy (blockage of urine and a condition where urine flows backward from the bladder up the ureters).

Physician's orders for Resident 20, dated September 23, 2025, included an order for the resident to have an indwelling urinary catheter due to havingobstructive uropathy.

Observations on December 1, 2025, at 10:31 a.m. revealed that Resident 20 was in a low bed, and her catheter drainage bag was lying on the floor on the right side of the bed.

Observations on December 1, 2025, at 2:05 p.m. revealed that Resident 20 was in her wheelchair self-propelling down the hall and her catheter tubing was sliding across the floor.

Interview with Nurse Aide 2, on December 1, 2025, at 10:51 a.m. confirmed that Resident 20's catheter drainage bag should not have been touching the floor.

Interview with Licensed Practical Nurse 3, on December 1, 2025, at 2:06 p.m. confirmed that Resident 20's catheter tubing should not be sliding across the floor, and that they used to have clips to help keep the tubing off the floor.

Interview with the Director of Nursing on December 1, 2025, at 2:10 p.m. confirmed that Resident 20's catheter drainage bag should not have been touching the floor, and that the catheter tubing should not have been sliding across the floor as the resident self- propelled herself down the hall.

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

Plan of Correction - To be completed: 01/05/2026

1. Resident 20 resides in the facility; her medical record was reviewed and her indwelling catheter remines appropriate due to diagnosis of obstructive uropathy. Resident 20 catheter tubing now has a clip attached to the tubing to prevent it from touching the floor. A clean basin is also used to place catheter bag in to prevent indwelling catheter bag from touching the floor when in bed.

2.The medical records of other residents in the facility who have indwelling catheters were reviewed and have an appropriate diagnosis for the use of the indwelling catheter. Residents with indwelling catheters will have a catheter clip to prevent tubing from touching the floor. Residents who are in bed will have a clean basin to prevent catheter bag from touching the floor. Care plan will be updated to reflect the clip and clean basin.

3.The Director of Nursing/Designee will educate the nursing staff of the importance of keeping indwelling catheter bags and tubing off the floor to prevent infection.

4.The Director of Nursing/Designee will audit residents with indwelling catheters to ensure the clip and basin is in place. This audit will be completed daily x 5 days, weekly x 4 weeks, then monthly x 2 months.

5.Results of the audits will be reviewed at the Quality Assurance Performance Improvement meetings until substantial compliance has been met.

483.70(n)(1)-(4) REQUIREMENT Hospice Services:

§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 37 residents reviewed (Resident 9) who were receiving hospice services.

Findings include:

A hospice contract, dated July 31, 2025, indicated that all hospice assessments, plans of care, progress notes and services provided will be maintained in the medical record and integrated with the facility plan of care. Nursing staff would ensure there was a current physician's order, physician progress notes regarding hospice care, and hospice documentation that was current and available on the medical record.

A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 9, dated October 18, 2025, indicated that the resident was cognitively impaired, dependent on staff for daily care needs, had diagnoses that included a cancerous tumor of the pelvic bones, and was receiving hospice (program of care and support for individuals with a terminal illness) services.

Physician's orders for Resident 9, dated April 3, 2025, included an order for the resident to receive hospice services. A care plan for Resident 9, revised May 8, 2025, indicated that the resident was receiving Hospice for end-of-life care.

As of December 3, 2025, there was no documented evidence in the resident's clinical record, or in the hospice provider's clinical record, that the facility obtained updated hospice nurse aide charting (last communication was October 2, 2025).

Interview with the Director of Nursing on December 3, 2025, at 11:06 a.m. confirmed that Resident 9's hospice nurse aide charting was not up to date in the resident's clinical record and/or in the hospice provider's clinical record and should have been.

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

Plan of Correction - To be completed: 01/05/2026

1. Resident 9 remains at the facility, and his hospice clinical record binder was reviewed, and hospice nurse aide documentation was obtained and placed in the hospice clinical record binder.

2.An audit was completed on residents who are receiving hospice services and their hospice clinical record binders were reviewed to ensure all nurse aide documentation was present and up to date.

3. The Director of Nursing/Designee will educate all hospice agencies who provide services in facility to ensure that they are providing up to date nurse aide documentation at each visit in the hospice clinical record binder.

4.The Director of Nursing/ Designee will audit the hospice clinical record binders of residents who are ordered hospice services for the presence of up-to-date nurse aide documentation. The audit will be conducted daily x 5 days, weekly x 2 weeks, and monthly x 2 month.

5.The results of the audits will be reviewed at the Quality Assurance Performance Improvement meetings until substantial compliance has been met.

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