Highland Hills Post Acute

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that necessary resident information was communicated to receiving health care providers during transfers for two residents. Facility policy on transfer and discharge, last reviewed on 11/1/25, required that residents or their representatives receive written notification of impending transfer or discharge and that specific information be conveyed to the receiving provider, including practitioner contact information, resident representative information, advance directives, special instructions or precautions for ongoing care, comprehensive care plan goals, and all other necessary information, including a copy of the discharge summary. The policy also required that the medical record contain the discharge summary information and identify the recipient of the summary. For one discharged resident (R1), admitted on an unspecified date with diagnoses including hypertension, anxiety, and chronic respiratory failure, the clinical record showed the resident was transferred to the hospital on 3/8/26 and did not return. There was no documented evidence that the facility communicated the resident’s care plan goals, advance directive information, specific instructions for ongoing care, resident representative information, or all information necessary to meet the resident’s specific needs to the receiving provider. For another resident (R3), admitted on an unspecified date with diagnoses of hypertension, diabetes, and hyperlipidemia, nursing notes documented an episode of unresponsiveness during lunch with abnormal vital signs, subsequent partial recovery, and a decision by the nurse practitioner to send the resident to the hospital with the niece’s agreement. Review of this resident’s record likewise revealed no documented evidence that the required information, including care plan goals, advance directives, instructions for ongoing care, resident representative information, and all necessary information, was communicated to the receiving provider. In an interview, the ADON confirmed the facility failed to ensure necessary information was communicated for these two residents.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to obtain appropriate physician orders related to a hospital transfer and to the management of blood glucose levels. One resident (R3), with diagnoses including hypertension, diabetes, and hyperlipidemia, became unresponsive and flaccid during lunch while in a wheelchair. Vital signs at that time showed blood pressure of 88/50, heart rate 75, oxygen saturation 95%, and respirations 26, and the resident required maximum assistance of four staff to return to bed. After returning to bed, the resident became more aroused, with blood pressure 110/58, heart rate 71, respirations 21, and oxygen saturation 94%, and was able to answer questions appropriately. The nurse practitioner directed that the resident be sent to the hospital for evaluation, and the resident’s niece agreed to the transfer; however, review of the physician orders showed there was no physician order documented for the hospital transfer. The ADON confirmed that the facility failed to obtain a physician order for this transfer. A second deficiency was identified for another resident (R2), who had diagnoses including anemia, diabetes, and hypertension. Review of this resident’s physician orders showed an order for Humalog (insulin lispro) 100 units/mL to be administered subcutaneously before meals and at bedtime according to a sliding scale based on capillary blood glucose readings, with specific insulin doses corresponding to blood glucose ranges from 0 to 400 mg/dL. However, the order did not include parameters for when to contact the physician regarding hypoglycemia (low blood sugar) or hyperglycemia (high blood sugar) in relation to these capillary blood glucose checks. During interview, the ADON confirmed that the facility failed to obtain physician orders that included management parameters for hypoglycemia and hyperglycemia for this resident.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide necessary nail care for four out of ten residents who were unable to perform this activity of daily living themselves. According to the facility's policy, nail care should include daily cleaning and regular trimming. Observations and interviews revealed that several residents had long fingernails, some with brown debris underneath, and expressed that their nails had not been cut or cleaned by staff. One resident's representative reported having to cut the resident's nails themselves due to lack of care from facility staff. These findings were confirmed during walking rounds with the Assistant Director of Nursing, who acknowledged the deficiency. The affected residents had significant medical conditions, including stroke with hemiplegia, high blood pressure, difficulty swallowing, malnutrition, muscle weakness, dementia, low back pain, Parkinson's disease, and hip fracture. Despite these conditions, which limited their ability to perform self-care, the facility did not ensure that nail care was provided as required by policy. The deficiency was identified through review of records, direct observation, and interviews with both residents and staff.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that residents with limited mobility received appropriate services, equipment, and assistance to maintain or improve their mobility, as required by physician orders and facility policy. Three residents with diagnoses including stroke, high blood pressure, and hemiplegia had specific orders for the use of splints, braces, and guards to prevent contractures, maintain joint alignment, and support functional use of extremities. Documentation reviews revealed multiple instances where these devices were not applied as ordered, with records showing days marked as 'No', 'Not Applicable', or left blank, indicating the devices were not used or there was no evidence of their application. For one resident, the ankle brace was not applied on 14 out of 29 days, the palm guard on 6 days, the elbow splint on 14 days, and the hand brace on 15 days. Another resident did not have a hand splint applied on 18 out of 29 days, and during an interview, the resident stated they did not know the location of the splint. A third resident's hand splint was not applied on 14 out of 29 days, with documentation similarly marked as 'Not Applicable' or left blank. Interviews with residents and staff confirmed the lack of consistent application of prescribed orthotic devices. The Assistant Director of Nursing acknowledged that the facility failed to provide the necessary services, equipment, and assistance to maintain or improve mobility for all three residents reviewed. These findings were based on facility policy review, clinical record review, observations, and interviews.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to maintain the confidentiality of a resident's personal and medical records as required by its own policy. During an observation, a sign was posted above a resident's bed that included specific medical information, such as the use of a specialized cup for thin water, instructions on limiting liquid intake to reduce aspiration risk, and the need for the resident to sit up while drinking. The resident's clinical record did not contain documentation indicating that the resident or their representative had approved the posting of this private health information. This was confirmed by the Assistant Director of Nursing during an interview.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to revise the care plan for one resident to accurately reflect the current physician's order and the resident's needs. The resident, who had a history of stroke, high blood pressure, and difficulty swallowing, was admitted with a physician's order specifying 'No straws.' Despite this, a concern was raised by the resident's representative that the resident was still being given thin water through a straw. Review of the resident's care plan showed that the intervention 'No straws' was not included, and this omission was confirmed by the Assistant Director of Nursing during an interview. The facility's policy requires that care plans be updated as residents' conditions or orders change, but this was not done in this case.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to accommodate the call bell needs of one resident, identified as Resident R149, who had diagnoses including hepatic encephalopathy, diabetes mellitus, and morbid obesity. On 12/16/25, an observation showed that the resident's call light was activated at 9:29 a.m. but was not responded to until 9:45 a.m., resulting in a 16-minute delay. Facility-provided call bell audit documents revealed additional delayed response times for the same resident's room, including a 21-minute response on 12/11/25 and a 20-minute response on 12/12/25. During an interview, a registered nurse confirmed that the facility did not meet the resident's call bell needs.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A deficiency occurred when a resident with dementia, diabetes, and hyperlipidemia was subjected to verbal and possible physical abuse by an LPN during a transfer using a sit-to-stand lift. The resident's care plan specified that, in the event of conflict, she should be placed in a calm and safe environment and allowed to vent. However, during the transfer, the LPN was observed by the Assistant Director of Nursing (ADON) and a CNA to be yelling at the resident, telling her to stop acting like a child, and appeared to push the resident into a chair while the sling was still around her waist. The incident was documented in the nurse's note and corroborated by witness statements. The LPN involved had received annual re-education on psychosocial needs and abuse prevention, as indicated in her personnel record. Despite this training, the LPN's actions did not align with facility policy, which states that residents have the right to be free from abuse, neglect, and exploitation. The incident was reported to facility leadership, and it was determined that the facility failed to maintain an environment free of abuse for the resident, as required by state regulations.

Penalty

Fine: $28,020

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A deficiency occurred when the facility failed to provide adequate supervision to prevent the elopement of a resident identified as high risk for wandering. The resident, who had a diagnosis of dementia, hypertension, and insomnia, and was assessed as having moderately impaired cognition, exhibited a history of wandering and aggressive behaviors. Despite these risk factors, the resident was transferred from a secured dementia unit to a non-secured long-term care unit without documented interdisciplinary team review or updated elopement evaluation prior to the move. The care plan indicated the resident was at risk for elopement, but interventions and assessments were not consistently updated or implemented as required by facility policy. On the day of the incident, the resident was able to exit the facility through an emergency door that was not properly secured. Staff interviews and resident accounts confirmed that the door was either left unlatched or the resident was able to open it, possibly by guessing the keypad code or due to the door not being pulled shut. The resident was found outside in the parking lot, having exited the building without staff knowledge. Staff were unaware of the resident's absence until alerted by another resident, and there was no immediate staff presence in the area to prevent the elopement. Following the incident, it was revealed that there was no incident report completed, no documentation of family or physician notification, and no reportable notification to the Department of Health. The facility's policies on elopement, accidents, and care planning were not followed, as evidenced by the lack of timely assessment, care plan updates, and supervision. The Director of Nursing confirmed that the facility failed to provide adequate supervision, resulting in the resident's elopement and the creation of an immediate jeopardy situation.

Removal Plan

• Staff retrieved Resident R1 from the rear parking lot after being alerted by Resident R2.
• Nursing staff will be re-educated on updating the elopement care plan form immediate interventions and elopement assessment.
• All residents will be reassessed by the unit manager/designee for an elopement risk.
• All staff will be educated on elopement risk and assessments, care plans and supervision of residents by the unit manager/designee.
• A care plan with measurable goals and interventions for residents will be implemented to identify residents at risk for eloping by the unit manager/designee.
• Review and revise policies if needed to identify residents who are at risk for eloping.
• Door will be monitored by staff stationed at the door until vendor arrives to verify functioning of the door and residents are unable to exit.
• Facility will review the incidents at an ad hoc QAPI (Quality Assurance and Performance Improvement) meeting.
• New admissions, change in condition or any new behavior will be monitored by the DON/designee to ensure elopement assessments are completed and care plans updated as required.
• Maintenance/designee will audit the doors are secure.
• Findings of audits will be submitted through facility QAPI program.
• Vendor will check that everything is functioning on the door, the magnetic lock and the keypad to the door itself.
• The door alarm will be set to alarm instantly instead of a delay.
• Deliveries will be changed to the front door.
• Code will be changed to an eight-digit number instead of four digits.
• All staff will be educated on risk, assessments, care plan, and supervision and verified with signatures.
• In-person interviews will be conducted of all staff to confirm education and understanding.
• Residents identified as elopement risks will be identified, including new residents at risk for elopement within the dementia secured unit.
• Policy will be reviewed and revised by the Director of Nursing to identify residents who are at risk for eloping.
• Door monitor by staff will be in place.
• Ad Hoc QAPI will be held.
• Audit tool for new admissions, change in condition or any new behavior will be used to ensure elopement assessments are completed and care plans updated as required and reviewed at the QAPI meeting.
• Audit by maintenance will be completed on the doors being secure and reviewed at the QAPI meetings.

Penalty

Fine: $28,020

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to employ a full-time qualified social worker for the period between 7/27/25 and 9/2/25, as confirmed by payroll documentation and an interview with the Human Resources Director. Payroll records showed that the previous social worker's last day was 7/27/25, and the new social worker did not begin employment until 9/2/25. This gap in employment was acknowledged by the Human Resources Director, indicating that the facility did not have a full-time qualified social worker on staff during this timeframe, as required by regulations for facilities with more than 120 beds.

Penalty

Fine: $28,020

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide mandatory training on its Quality Assurance and Performance Improvement (QAPI) program to three out of five reviewed staff members, specifically two nurse aides and one LPN. According to the facility's own assessment, staff training on QAPI is required during general orientation upon hire, annually, and as needed. However, a review of training records revealed that these three employees did not receive the required QAPI education. This deficiency was confirmed during a telephonic interview with a human resources employee, who acknowledged the lapse in training documentation for the affected staff members.

Penalty

Fine: $28,020

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to protect a resident from abuse by another resident with a history of aggressive behaviors. Resident R1, who had diagnoses including dementia and moderately impaired cognition, was identified in the care plan as requiring behavior monitoring due to frustration and aggression. Despite interventions such as diversional conversation and redirection, Resident R1 was involved in multiple incidents of physical aggression. On one occasion, Resident R1 entered another resident's room, refused to leave, and physically struck the resident and a staff member who attempted to intervene. On a separate occasion, Resident R1 was observed holding Resident R3 by the arm and striking her in the back with a closed fist while in the dining room. Staff intervened and separated the residents, and no injury was observed on Resident R3. Resident R3, who also had dementia with severely impaired cognition, was the victim in these incidents. The facility's policy required protection of residents from abuse by anyone, including other residents, and emphasized monitoring and intervention for those with behavioral issues. Documentation and staff interviews confirmed that the facility did not ensure Resident R3 was free from abuse by Resident R1, as required by policy and regulation. The Director of Nursing acknowledged the failure to protect the resident from abuse.

Penalty

Fine: $28,020

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to implement its written policies and procedures to ensure a complete and thorough investigation of two separate allegations of abuse involving two residents. In the first incident, a resident with moderately impaired cognition and diagnoses including dementia and insomnia was found outside the facility in the parking lot near a fire hydrant after eloping through an emergency door that was not locked. Documentation of the event, including notification to the family and physician, was missing from the clinical record, and the facility did not investigate the elopement or report it as required by policy. Staff and resident interviews confirmed the resident's exit through the emergency door, which was used for supply deliveries and was not secured at the time. In the second incident, another resident with severely impaired cognition and multiple diagnoses, including dementia and muscle weakness, was physically struck in the back by the first resident while in the dining room. Staff witnessed the event and completed two witness statements, but the physical abuse was not reported as required, and the facility did not follow its written policies and procedures for investigating abuse. The Director of Nursing confirmed that the facility failed to ensure a complete and thorough investigation in both cases.

Penalty

Fine: $28,020

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to report and investigate two separate incidents involving suspected abuse and neglect for two residents. In the first incident, a resident with moderately impaired cognition, dementia, and insomnia was found outside in the parking lot near a fire hydrant after eloping from the facility through an emergency door that was not locked. The event was discovered by another resident, who alerted staff. There was no documentation of the event in the clinical record, and required notifications to the family and physician were not completed. The facility did not investigate the elopement or the possibility of neglect, nor did it report the incident as required by policy. In the second incident, a resident with severely impaired cognition, dementia, muscle weakness, and coronary artery disease was physically struck in the back by another resident while attempting to walk past with a walker. Staff witnessed the event and completed witness statements, but the physical abuse was not reported as required. The Director of Nursing confirmed that both the elopement and the resident-to-resident abuse incidents were not reported according to regulatory requirements.

Penalty

Fine: $28,020

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to conduct a thorough investigation and proper reporting following an elopement incident involving a resident with dementia and moderately impaired cognition. The resident, who had diagnoses including high blood pressure, dementia, and insomnia, was found outside in the parking lot near a fire hydrant after exiting through an emergency door that was not locked. The event was discovered by another resident, who alerted staff after noticing the door was open and the resident was outside. Staff interviews confirmed that the door was used for deliveries and was not secured at the time, allowing the resident to leave the building unsupervised. Review of the clinical record revealed that there was no documentation of the elopement event, nor was there evidence of required notifications to the resident's family or physician. Additionally, the facility did not initiate or complete an investigation into the incident or the possibility of neglect, as required by facility policy. The Director of Nursing confirmed that no investigation was conducted, and the event was not reported to the appropriate agencies, constituting a failure to respond appropriately to an alleged violation.

Penalty

Fine: $28,020

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A deficiency occurred when a resident with a history of stroke, hemiplegia, and aphasia, who was admitted to the facility, did not receive appropriate services and equipment to maintain or improve mobility. The resident was observed in bed without a hand splint, although a hand splint was present in the bedside stand. The resident had previously been discharged from therapy to a Rehab Restorative transition program, which recommended the use of a right resting hand splint during the evening and removal in the morning. However, a review of the resident's current physician orders and care plan revealed no documentation or orders for the use of the right resting hand splint. Staff interviews confirmed that the recommendations from the Rehab Restorative Transition Program were not processed, and there was a failure in the facility's process for transitioning residents from rehab to the long-term care unit. This resulted in the resident not receiving the necessary equipment and assistance as outlined in facility policy and the resident's care needs.

Penalty

Fine: $28,020

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide sufficient and timely medically-related social services to assist a resident with behavioral issues in transferring to a Veterans Affairs (VA) facility for a behavioral bed. The resident, who had diagnoses including high blood pressure, dementia, and insomnia, exhibited a pattern of aggressive and combative behaviors, including physical aggression toward other residents and staff, verbal abuse, and attempts to take items from other residents. Documentation shows that the resident was moved from a secured dementia unit to a non-secured LTC unit, after which the frequency and severity of behavioral incidents increased, resulting in multiple episodes of aggression and threats to staff and other residents. Despite the escalating behaviors and repeated incidents, there was a significant delay in the facility's social services department actively pursuing a transfer to the VA for specialized behavioral care. Initial efforts to contact the VA and initiate a transfer were documented, but after the departure of the original social worker, there was a nearly three-month gap before further transfer efforts resumed. During this period, the resident continued to display aggressive behaviors, including physical altercations and threats involving staff and other residents, and required multiple interventions from crisis services and law enforcement. The deficiency was identified based on the lack of timely and consistent social services intervention to facilitate the resident's transfer to a more appropriate behavioral care setting, as evidenced by the prolonged delay in follow-up and coordination with the VA. This failure to provide adequate social services support contributed to ongoing behavioral incidents and did not help the resident achieve the highest possible quality of life, as required by regulatory standards.

Penalty

Fine: $28,020

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The Nursing Home Administrator (NHA) failed to effectively manage the facility to ensure that proper supervision was provided for residents identified as high risk for elopement. This failure resulted in a resident elopement, which created an immediate jeopardy situation. The NHA's job description required directing the day-to-day functions of the facility in accordance with federal, state, and local regulations to assure the highest degree of quality care. However, based on a review of the job description, facility and clinical records, and staff interviews, it was determined that the facility did not provide adequate supervision as required for high-risk residents. This deficiency led to a breach in the fundamental principles of treatment and care, and the facility did not ensure that residents received care in accordance with professional standards of practice and facility policies.

Penalty

Fine: $28,020

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to notify the State agency in writing of a change in the Nursing Home Administrator (NHA) at the time the change occurred. Documentation showed that the Interim NHA assumed responsibility effective 9/5/25, as indicated in the facility's password agreement document. During interviews, the Director of Nursing confirmed that the previous NHA was on leave and that the Interim NHA was acting as administrator. It was also confirmed that the required written notification to the State agency regarding this administrative change was not provided at the time of the change, which did not meet regulatory requirements.

Penalty

Fine: $28,020

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide required training on effective communication for two of five direct care staff members, specifically Nurse Aide Employee E15 and Nurse Aide Employee E5. Review of facility education documents and training records showed that these two staff members did not receive education on effective communication as mandated. This deficiency was confirmed during a telephonic interview with a Human Resource employee, who acknowledged the lack of training for the identified staff members. The findings reference violations of 28 Pa Code: 201.14 (a), 201.18 (b)(1), and 201.20 (a)(6)(d), which pertain to the responsibility of the licensee, management, and staff development requirements.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A deficiency occurred when a resident identified as a wander and elopement risk exited the facility unsupervised. The resident, who had a diagnosis of unspecified dementia and mood disturbance, was assessed as moderately cognitively impaired with a BIMS score of 9 and had a documented elopement risk score of 9. Despite being equipped with a wander alarm, the resident was able to leave the facility through a delivery door that was equipped with magnetic locks and an alarm system. The incident took place when the delivery door was left open and the alarm system was not engaged due to an employee accidentally entering a bypass code upon exiting. This allowed the resident to leave the building undetected. The resident was observed outside the facility by staff and was returned after being gone for approximately 14 minutes. At the time of the incident, the resident was appropriately dressed for the weather and was assessed for injury or emotional trauma upon return, with no concerns noted. Interviews and documentation confirmed that the last employee to use the door was a maintenance assistant, and only three staff members had access to the codes for the door, one of which allowed for bypassing the alarm system. The failure to ensure the alarm was properly engaged and to provide adequate supervision for a resident at risk for elopement resulted in the resident leaving the facility without staff knowledge.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that residents were protected from abuse, as evidenced by its handling of three separate allegations involving two residents. Both residents had significant care needs, including frequent incontinence and assistance with daily hygiene, grooming, and dressing. One resident reported to a Certified Occupational Therapy Assistant (COTA) that an employee, while assisting with incontinence care, touched her inappropriately and that she did not want him to assist her further. The other resident reported that the same employee opened her house dress without reason, looked at her, and ran his hand up and down her body, causing her fear. Additionally, the first resident reported that the employee pushed and shoved the second resident during a transfer to bed. All incidents were reported to a supervisor immediately by the COTA. Despite these reports, the facility did not recognize the allegations as sexual and physical abuse and failed to initiate or complete investigations into the incidents before allowing the accused employee to return to work. The employee was initially suspended but was brought back to work after receiving education, without the completion of the required investigations. It was only after several days that the facility realized not all allegations had been investigated, leading to the employee's suspension again. This failure to follow policy and ensure a thorough investigation before allowing the employee to have resident contact resulted in the facility not protecting residents from potential abuse.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to implement its written policies and procedures to ensure a complete and thorough investigation of three allegations of abuse involving two residents. Specifically, after two residents reported allegations of sexual and physical abuse by an employee to a Certified Occupational Therapy Assistant, the facility did not recognize or investigate the reported sexual abuse on the date it was reported. Documentation shows that the employee accused of abuse was suspended but returned to work the following day after receiving education, without a completed investigation into the allegations. Additionally, the facility did not assess one of the residents after the alleged abuse, nor did it notify the resident's physician or family as required. The clinical record lacked evidence of a physician assessment following the abuse allegation. These failures were confirmed by the Nursing Home Administrator, who acknowledged that the facility did not follow its own policies and procedures for investigating abuse allegations.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to report and investigate an allegation of sexual abuse involving a resident who required assistance with daily hygiene and incontinence care. The resident, who had diagnoses including high blood pressure, depression, and arthritis, and was frequently incontinent, reported to a Certified Occupational Therapy Assistant (COTA) that an employee assisting with incontinence care touched them inappropriately and that they did not want that employee to assist them further. The COTA immediately reported the incident to a supervisor. Despite the facility's policy requiring all allegations of abuse to be reported and investigated, the facility did not recognize, report, or investigate the allegation of sexual abuse. The Director of Nursing was made aware of the allegation on the same day it was reported, but no investigation was conducted, and the incident was not reported to the appropriate authorities. The Nursing Home Administrator confirmed that the facility was unable to provide documentation of an investigation or reporting for this incident.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to conduct a thorough investigation into three separate allegations of abuse involving two residents. According to the facility's own policy, all reports of abuse, neglect, exploitation, or misappropriation are to be reported to appropriate agencies and thoroughly investigated, with findings documented and reported. However, documentation revealed that when one resident reported to a Certified Occupational Therapy Assistant (COTA) that an employee had inappropriately touched them during incontinence care, the facility did not recognize or investigate this as an allegation of sexual abuse. Additionally, another resident reported to the same COTA that the same employee had opened their house dress without reason, looked at them, and ran his hand up and down their body, which was not thoroughly investigated. The roommate of this resident also reported that the employee pushed and shoved the resident during a transfer, but again, no thorough investigation was conducted. The review found that no witness statements or interviews of staff or residents were completed for these allegations. Furthermore, there was no documented assessment of one resident after the abuse allegation was made, and neither the physician nor the family was notified. The Nursing Home Administrator confirmed that the investigations were incomplete and did not meet the facility's policy requirements. These failures were cited under multiple Pennsylvania Codes related to management, resident rights, and nursing services.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to properly respond to three abuse allegations involving two residents. In each case, the facility did not notify the physician or the residents' families after the allegations were made. Additionally, the facility did not complete a resident assessment following the abuse reports. The incidents included allegations of sexual and physical abuse during incontinence care and transfers, as reported by the residents to a Certified Occupational Therapy Assistant, who then informed a supervisor. Despite these reports, the facility did not recognize or investigate the allegations as required. The clinical records for both residents showed relevant diagnoses, including depression, heart failure, diabetes, and frequent incontinence, with care plans indicating the need for assistance with daily activities. Documentation revealed that no thorough investigation was conducted, as there were no witness statements or interviews with staff or residents. The Nursing Home Administrator confirmed that the abuse investigations were incomplete and that required notifications and assessments were not performed for the affected residents.

Penalty

Fine: $9,113

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that nursing staff had the specific competencies and skill sets necessary to provide care for residents with a Life Vest, a wearable defibrillator designed to protect residents from sudden cardiac death. This deficiency placed two residents in immediate jeopardy, impacting their health and safety. The report highlights that the facility did not provide adequate training or education to the nursing staff regarding the operation and care of the Life Vest, as evidenced by multiple staff interviews where employees expressed unfamiliarity with the device and its alarms. Resident R1 was admitted to the facility with a Life Vest, as indicated in the discharge form from the hospital. However, upon review of the clinical records and care plans, there were no specific instructions or physician orders related to the care and monitoring of the Life Vest. Interviews with various nursing staff members revealed a lack of training and understanding of the Life Vest's operation, including battery changes, alarm meanings, and bathing protocols. This lack of knowledge was consistent across several staff members, including registered nurses and nursing assistants, who were responsible for the care of Resident R1. Similarly, Resident R2 was also admitted with a Life Vest, but the facility again failed to provide the necessary training and education to the staff. The clinical records for Resident R2 also lacked specific physician orders and care plans related to the Life Vest. Interviews with nursing assistants caring for Resident R2 further confirmed the absence of training and understanding of the device. The facility's failure to ensure that nursing staff had the appropriate competencies and skill sets necessary to care for residents with a Life Vest resulted in immediate jeopardy for both residents.

Removal Plan

• Educate all clinical staff on the care and operation of Life Vests, including alarms, electrical shock dangers, battery care, garment laundering, monitoring and placement, skin integrity checks, and special needs for bathing.
• Clinical staff will complete competencies, pre and posttests.
• Obtain physician orders and ensure implementation for Resident R1, and R2.
• Develop a resident-centered comprehensive care plan outlining the care of Resident R1 related to the Life Vest.
• Update Resident R2's comprehensive care plan outlining the care related to the Life Vest.
• Obtain additional physician orders for the implementation of the Life Vest and ensure the orders are complete.
• Educate clinical staff on updates and policies related to specialty equipment.
• Educate Admission Staff on updates and policies related to specialty equipment.
• Update Resident R1's physician's orders and care plan.
• Update Resident R2's physician's orders and care plan.
• Review/develop and update the policy related to specialty equipment.
• Review/develop policy and procedure related to the admission of residents with anticipated equipment.
• Audit 100 percent of residents for Life Vests placement, operation, battery backup, and associated documentation daily for one week, weekly thereafter for three weeks, and monthly thereafter with reporting through QAPI.
• Conduct random competency audits of two clinical staff per shift that have assignment with Life Vest residents daily for one week, weekly thereafter for three weeks, and monthly thereafter with reporting through QAPI.
• Review the education plan by QAPI and further recommendations.

Penalty

Fine: $9,113

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to develop a baseline care plan that included necessary interventions for two residents who were admitted with specific medical needs. The baseline care plan, which should have been developed within 48 hours of admission according to the facility's policy, did not include the presence of a Life Vest for either resident. The Life Vest is a wearable defibrillator designed to protect residents from sudden cardiac death, and its omission from the care plan indicates a lack of comprehensive planning for the residents' care. Resident R1 was admitted with diagnoses of diabetes, coronary artery disease, and high blood pressure, yet their baseline care plan did not reflect the need for a Life Vest. Similarly, Resident R2, who was admitted with high blood pressure, heart failure, and diabetes, also had a baseline care plan that failed to include the Life Vest. The Director of Nursing confirmed the oversight during an interview, acknowledging the facility's failure to provide effective and person-centered care planning for these residents.

Penalty

Fine: $9,113

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to develop a comprehensive, person-centered care plan for a resident, identified as Resident R1, which included necessary instructions for the use of a Life Vest. Resident R1 was admitted with diagnoses of diabetes, coronary artery disease, and high blood pressure. Despite physician orders on March 5, 2025, to change the battery for a Life Vest daily, the care plan dated February 8, 2025, did not include goals and interventions related to the Life Vest. This deficiency was confirmed during an interview with the Director of Nursing, who acknowledged the incomplete care plan for Resident R1's needs.

Penalty

Fine: $9,113

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that a physician completed the initial comprehensive visit for three residents, identified as R3, R4, and R5. The clinical records for these residents indicated that their initial comprehensive assessments were conducted by Certified Registered Nurse Practitioners (CRNPs) rather than a physician, as required. Resident R3 was admitted with diagnoses including high blood pressure, depression, and muscle weakness, and their assessment was completed by CRNP Employee E12. Resident R4, diagnosed with Alzheimer's Disease, muscle weakness, and restlessness, had their assessment completed by CRNP Employee E13. Resident R5, with diagnoses of depression, urine retention, and arthritis, also had their assessment completed by CRNP Employee E12. During an interview, the Director of Nursing confirmed the facility's failure to comply with the requirement for a physician to conduct the initial comprehensive visit. This deficiency was identified through a review of clinical records and staff interviews, highlighting a lapse in adherence to regulatory standards. The report cites specific Pennsylvania Code regulations that were not met, emphasizing the responsibility of the licensee and the provision of nursing services.

Penalty

Fine: $9,113

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The Nursing Home Administrator (NHA) and the Director of Nursing (DON) failed to ensure that nursing staff possessed the necessary competencies and skills to care for residents equipped with a Life Vest, a wearable defibrillator designed to prevent sudden cardiac death. This deficiency was identified through a review of job descriptions, clinical records, and staff interviews. The job descriptions for both the NHA and DON, dated 11/1/24, outlined their responsibilities to manage the facility and oversee resident care in compliance with relevant standards and regulations. However, the facility's failure to provide adequate training and ensure staff competency in handling Life Vests resulted in an immediate jeopardy situation for two residents, identified as R1 and R2. During an interview, both the NHA and DON acknowledged their failure to manage the facility effectively in this regard.

Penalty

Fine: $9,113

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to conduct and document a comprehensive facility-wide assessment to determine the necessary resources for resident care, both during regular operations and emergencies. This deficiency was identified through a review of clinical records, staff interviews, and the facility's assessment documentation. Specifically, the facility's assessment did not include the use of Life Vests, which are critical for residents with complex medical conditions such as coronary artery disease and heart failure. This oversight was evident in the cases of two residents who were admitted with Life Vests, yet the facility's assessment did not account for the specialized care and management these devices require. Resident R1 was admitted with a Life Vest following a hospital discharge, as indicated in the correspondence between the facility and the hospital. The resident's Minimum Data Set (MDS) documented diagnoses of diabetes, coronary artery disease, and high blood pressure. Similarly, Resident R2 was admitted with a Life Vest, with physician orders confirming its use. The facility's failure to include Life Vests in their assessment highlights a gap in identifying and planning for the specific needs of their resident population. The Nursing Home Administrator acknowledged this deficiency, confirming that the facility's assessment did not adequately identify the resources necessary for the care of residents with Life Vests.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to accurately account for controlled substances for four residents, leading to a deficiency in pharmaceutical services. Resident R1, who was admitted with emphysema and lung cancer, had discrepancies in the administration of oxycodone ER and oxycodone 5 mg. The facility was unable to provide the narcotic sign-out sheets for these medications, and there were inconsistencies in the Medication Administration Record (MAR) and pharmacy shipping manifests. Resident R2, diagnosed with dementia, a history of stroke, and osteoarthritis, had issues with tramadol administration. The Controlled Drug Record showed additional doses signed out without corresponding documentation of administration. There were also instances where doses were signed out on multiple records for the same administration time, indicating a lack of proper tracking and documentation. Resident R3, with COPD and hemiplegia, and Resident R4, who had a knee replacement, also experienced similar issues with controlled substances. For Resident R3, additional doses of Norco were signed out without documentation of administration. Resident R4's records showed discrepancies in the number of oxycodone tablets signed out versus what was documented in the MAR. The facility's Director of Nursing and Nursing Home Administrator confirmed these deficiencies during interviews.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to adhere to proper food storage and sanitation practices in the main kitchen, as observed during a survey. In the walk-in cooler, ground beef was found thawing on the second shelf, and deli turkey and bag salad mix were stored without dates. In the dry storage area, a metal bowl of raisin bran was uncovered and unlabeled, and various items such as liquid butter, oatmeal cream pies, and [NAME] buddies were stored without dates. The reach-in cooler contained American cheese, boiled eggs, and hot dogs, all lacking labels or dates. Additionally, the dish room was found to have unsanitary conditions, including a wall fan and walls with brown debris and an ice machine with a brown, slimy substance. These observations were confirmed by the Dietary Manager, indicating a failure to maintain sanitary conditions and proper food storage, which could lead to foodborne illness and cross-contamination.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide a clean, safe, comfortable, and homelike environment for several residents, as evidenced by the condition of seven resident wheelchairs, which were observed to be corroded with dried food substances and grime. Additionally, structural issues were noted, including a continuous gouge in the wall of the Arcadia Dining Room and Resident R144's room. The facility also failed to maintain an adequate supply of washcloths for staff use on two of four units, as observed when a nurse aide was unable to find a washcloth for a resident's shower. The laundry room was found to be lacking clean washcloths, with the emergency linen storage area missing washcloths, and the District Manager of Housekeeping confirmed that washcloths were on back order. Furthermore, the facility did not ensure that privacy curtains were clean and sanitary in two resident rooms, as evidenced by visible brown stains on the room dividing curtains facing Residents R81 and R124. These deficiencies were confirmed through staff interviews, including with a Registered Nurse Supervisor and the Nursing Home Administrator, who acknowledged the facility's failure to provide a clean, safe, comfortable, and homelike environment. The report cites violations of specific Pennsylvania Code regulations related to the responsibility of the licensee and management.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to complete comprehensive Minimum Data Set (MDS) assessments within the required time frame for six out of ten residents reviewed. According to the Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, an admission MDS assessment must be completed no later than 14 calendar days following admission, and an annual MDS assessment must be completed no later than the Assessment Reference Date (ARD) plus 14 calendar days. However, the review revealed that the MDS assessments for Residents R2, R91, R107, R132, R256, and R259 were not completed within these time frames. The delay in completing the MDS assessments was attributed to a transition in the facility's computer system, which was down for a week. Additionally, the Registered Nurse Assessment Coordinators (RNACs) were incorrectly set up in the new system, resulting in a lack of access to charting for two weeks. This led to the facility being approximately three weeks behind in completing the assessments. The Director of Nursing confirmed the failure to complete the assessments within the required time frame during an interview.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that quarterly Minimum Data Set (MDS) assessments were completed within the required time frame for 21 out of 38 residents reviewed. According to the Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, quarterly MDS assessments must be completed no later than 14 calendar days after the Assessment Reference Date (ARD). However, the review conducted on December 10, 2024, revealed that the MDS assessments for these residents were not completed by their respective due dates, which ranged from November 16, 2024, to December 9, 2024. The delay in completing the assessments was attributed to a transition in the facility's computer system when they switched companies. The Registered Nurse Assessment Coordinator (RNAC) reported that the system was down for a week, and when it was restored, the RNACs were incorrectly set up, preventing them from charting. It took two weeks to resolve the access issues, resulting in the facility being approximately three weeks behind on completing the assessments. This was confirmed by the Director of Nursing during an interview.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to develop and implement comprehensive care plans for two residents, leading to deficiencies in meeting their care needs. Resident R139, who re-entered the facility with diagnoses including anemia, GERD, and anxiety, had a feeding tube as indicated in their MDS. However, the care plan for Resident R139 did not include the route of feeding tube administration, despite physician orders and medication administration records indicating specific enteral feeding instructions. Similarly, Resident R143, admitted with conditions such as hemiplegia, COPD, and hydrocephalus, also had a feeding tube. The care plan for Resident R143 lacked focus, goals, and interventions for enteral nutrition support, even though physician orders and medication records specified the feeding regimen. These omissions were confirmed by the Registered Dietician and acknowledged by the Nursing Home Administrator and Director of Nursing, indicating a failure to develop and implement comprehensive care plans for these residents.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that residents were properly monitored, assessed, and received necessary services to prevent the development or worsening of pressure ulcers for three residents. Resident R140, who was at moderate risk for pressure ulcers, did not have the prescribed air mattress on their bed and was not seated on the appropriate Vicare cushion in their wheelchair. This discrepancy was noted during observations and confirmed by staff interviews, indicating a lapse in following the care plan designed to prevent pressure ulcers. Resident R150 was admitted with a right ischial wound and a coccyx pressure ulcer, but there was no documentation of the wound's measurements upon admission. This lack of documentation suggests that the facility did not fully assess the resident's condition, which is crucial for monitoring and treatment. The facility's records also failed to accurately reflect the resident's pressure ulcer status, as indicated by the Pressure Sore List. Resident R152 was admitted with a coccyx pressure injury, but the Minimum Data Set (MDS) was incorrectly coded, failing to indicate the presence of a pressure ulcer. Furthermore, there was no weekly documentation of the pressure ulcer from 11/10/24 through 12/7/24, as confirmed by the Director of Nursing. This oversight in documentation and assessment highlights a failure in the facility's processes to ensure proper care and monitoring of pressure ulcers, as required by their policies.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide appropriate treatment and services for residents with urinary catheters, compromising their dignity and care. Resident R12, who has anemia, obstructive uropathy, and anxiety, was observed with an uncovered catheter bag, contrary to the care plan that required a privacy cover. Similarly, Resident R97, diagnosed with multiple sclerosis, atrial fibrillation, and high blood pressure, also had an uncovered catheter bag. Additionally, the acetic acid solution used for flushing R97's catheter was improperly stored and undated, which was confirmed by RN Employee E4 and E8. The Director of Nursing acknowledged the facility's failure to ensure proper treatment for these residents. Resident R65, with anemia, multiple sclerosis, and anxiety, was using a Pure Wick external catheter system without a physician's order, despite being able to use it independently. The resident expressed satisfaction with the system, which was introduced by a nurse and supported by instructional materials. However, the Director of Nursing confirmed the absence of orders for the Pure Wick system, indicating a lapse in ensuring appropriate treatment and services for this resident.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide appropriate care and services to residents receiving tube feedings, as evidenced by deficiencies in the physician orders for three residents. Resident R139, who was re-admitted with diagnoses including anemia and GERD, had a physician order for enteral nutrition that did not specify the enteral access device being used. Similarly, Resident R143, admitted with conditions such as hemiplegia and COPD, had an order that failed to indicate the total volume of enteral nutrition to be administered over a 16-hour period and did not specify the enteral access device. Resident R259, with diagnoses including diabetes and dysphagia, also had a physician order lacking the specification of the enteral access device. The Registered Dietitian confirmed these deficiencies during an interview, acknowledging that the orders for enteral nutrition were incomplete and did not meet the facility's policy requirements. The facility's policy on Enteral Nutrition mandates that orders must include details such as the enteral nutrition product, delivery site, specific enteral access device, administration method, volume and rate of administration, and instructions for flushing. The failure to include these details in the physician orders resulted in the facility not providing the appropriate care and services to the residents receiving tube feedings.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure consistent communication and accurate care planning for residents requiring dialysis services. Specifically, the facility did not maintain complete communication forms for three residents, identified as R14, R33, and R48, who were dependent on renal dialysis. The facility's policy required agreements with contracted End-Stage Renal Disease (ESRD) facilities to include all aspects of resident care management, including information exchange. However, the clinical records for these residents showed multiple instances of incomplete or missing communication sheets, which are essential for coordinating care between the facility and the dialysis provider. Resident R14 had nine incomplete communication sheets, while Resident R33 had two incomplete forms and three missing communication sheets. Similarly, Resident R48 had four incomplete communication sheets. Interviews with the Director of Nursing and a Unit Manager confirmed the deficiencies in maintaining consistent dialysis communication. These lapses were in violation of several Pennsylvania Code regulations related to the responsibility of the licensee, resident care policies, management, and nursing services.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to properly store and secure medications in three of six medication carts and left medications unsecured at the bedside of three residents. During observations, it was noted that multiple medications, including insulin, B12 injections, nasal sprays, and inhalers, were opened and undated in the LTC medication carts and the Grand Heritage cart. Interviews with LPNs confirmed that these medications were not dated as required by the facility's policy. Additionally, medications were found unsecured at the bedside of three residents, including an Albuterol inhaler and a bottle of TUMS, which were confirmed by an RN to be improperly stored. Resident R110, who has a history of anxiety, depression, and PTSD, was involved in an incident where medications were left unsecured in his room. The progress notes indicated that the resident refused to take his medication and hid it under a towel on his bed, leading to the medication being left unsecured. The Director of Nursing confirmed these findings, acknowledging the failure to store medications properly and securely in the facility.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to address repetitive grievances and concerns voiced by residents and their families during resident council meetings and through individual grievances over a period of four months. The grievances included issues such as inadequate cleanliness and appearance of the Arcadia unit, insufficient availability of linens and washcloths, and restrictions on the number of transfers in or out of bed per shift. Additionally, residents expressed concerns about the lack of a policy for microwaving foods, long call bell wait times, and the unavailability of staff to provide assistance, particularly with obtaining ice and water. Further concerns were raised about staff behavior, including the use of ear buds and cell phones, which residents felt hindered communication and care. Residents reported feeling like an inconvenience to staff, who were perceived as unresponsive and unwilling to assist unless specifically assigned to a resident. The grievances also highlighted issues with meal service, such as late delivery of meal trays due to staff disagreements, and the lack of a microwave to heat meals. Despite these repeated concerns being documented in resident council meetings and grievance logs, the facility did not take adequate action to resolve them, as confirmed by the Nursing Home Administrator.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide timely notice of the Notice of Medicare Non-Coverage (NOMNC) for a resident, identified as Closed Resident Record CR1. According to the Code of Federal Regulations, the NOMNC, Form CMS-10123, must be given to all Medicare beneficiaries at least two days before the end of a Medicare-covered Part A stay or when all Part B therapies are ending. The NOMNC informs beneficiaries of their right to an expedited review by a Quality Improvement Organization. The resident, who was admitted with diagnoses including breast cancer, atrial fibrillation, and heart failure, was discharged to home before the NOMNC was presented. The facility planned to mail the NOMNC to the resident's home address, which was confirmed during an interview with the Nursing Home Administrator. This oversight was identified in one of three sampled resident records.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that residents were free from neglect, as evidenced by two incidents involving Residents R67 and R106. Resident R67, who was ordered to be transferred using a mechanical lift, was instead assisted by a Nurse Aide (NA) to transfer without the lift, based on the resident's claim of improved mobility. This resulted in the resident slipping and being lowered to the floor, although no injuries were reported. The Director of Nursing (DON) confirmed that the transfer order had not been updated to reflect the resident's therapy progress, leading to the neglect of the resident's care plan. Resident R106, who had a displaced bimalleolar fracture and required pin care for an external fixator device, did not receive the ordered wound care on multiple occasions. The Treatment Administration Record (TAR) showed that pin care was not documented as completed on several shifts, and the resident alleged that care was missed on the night shift. The DON confirmed that the facility failed to provide the necessary wound care as ordered, resulting in neglect of the resident's medical needs. Both incidents highlight the facility's failure to adhere to care plans and physician orders, leading to neglect of the residents' needs. The facility's policies on abuse prohibition and safe resident handling were not followed, resulting in the neglect of Residents R67 and R106. The DON acknowledged these failures during interviews, confirming the deficiencies in the care provided to these residents.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure consistent post-fall monitoring for two residents, R15 and R79, following incidents where they were assisted to the floor during transfers. Resident R15, who had a history of diabetes, renal insufficiency, and obstructive uropathy, was lowered to the floor by a nurse aide during a transfer to the toilet. Despite the incident being documented, the progress notes and vital signs log did not include the required post-fall monitoring for every shift over seventy-two hours. Additionally, the resident's care plan was not updated with new interventions following the fall. Similarly, Resident R79, who had renal insufficiency, anemia, and peripheral vascular disease, experienced a fall when his legs gave out during a transfer. Although the incident was noted, the facility failed to document the necessary post-fall monitoring in the progress notes and vital signs log for every shift over seventy-two hours. The care plan for Resident R79 also lacked updated interventions related to the fall. Interviews with the Director of Nursing and a Registered Nurse confirmed these deficiencies in post-fall monitoring for both residents.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide appropriate respiratory care for two residents, R39 and R121, as observed during a survey. Resident R39, who was admitted with diagnoses including anemia, stroke, and high blood pressure, had a physician's order for albuterol sulfate nebulization as needed for wheezing. However, the resident's care plan did not include goals and interventions for the nebulizer medication and respiratory concerns. Additionally, the nebulizer was observed not being stored in a plastic bag as required by the facility's policy. Resident R121, diagnosed with hypertension, hyperlipidemia, and COPD, had a physician's order for continuous oxygen at 2 liters per minute via nasal cannula. During the survey, it was noted that the nasal cannula and humidifier bottle were not labeled with a date as required. Both the RN and LPN confirmed these deficiencies during interviews. The Director of Nursing acknowledged the facility's failure to provide appropriate respiratory care for these residents.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide trauma-informed care to a resident identified as a trauma survivor, specifically a resident diagnosed with Post Traumatic Stress Disorder (PTSD), anxiety, and depression. The resident's care plan, dated June 5, 2024, acknowledged the PTSD diagnosis but did not identify specific triggers or strategies to avoid them, which is essential to prevent re-traumatization. This deficiency was confirmed during an interview with the Director of Nursing on December 10, 2024, who acknowledged the facility's failure to identify and mitigate PTSD triggers for the resident. The facility's policy on comprehensive, person-centered care plans, last reviewed on November 1, 2024, requires the development and implementation of care plans that meet residents' physical, psychosocial, and functional needs, which was not adhered to in this case.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide sufficient nursing staff to meet the needs of residents during breakfast meal observations on the Arcadia Unit over a five-day period. The facility's policy indicated that staffing should be sufficient to meet the cognitive and physical needs of residents, including those with dementia or Alzheimer's. However, observations revealed that the staffing levels were inadequate, with only one LPN and varying numbers of NAs assigned to 28 residents. This resulted in delays in meal service, with food carts arriving but not being served promptly, and residents waiting to be assisted into the dining room. Interviews with staff indicated that the process was slower due to insufficient staffing, and agency staff unfamiliar with the unit further contributed to the delays. The deficiency was observed consistently over the five days, with staff interviews confirming the challenges faced due to inadequate staffing. On some days, only one regular NA was present, which slowed down the process of getting residents out of bed and into the dining room. The Director of Nursing confirmed the facility's failure to provide sufficient nursing staff to ensure the highest practicable physical, mental, and psychosocial well-being of the residents during these meal observations. The report cites specific Pennsylvania codes related to the responsibility of the licensee, management, resident care policies, and nursing services, indicating non-compliance with these regulations.