Squirrel Hill Wellness And Rehabilitation Center

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 protect residents from misappropriation of property, including controlled medications and personal funds, for three residents. Facility policy defined misappropriation as the deliberate misplacement, exploitation, or wrongful use of a resident’s belongings or money without consent. Resident R1, with diagnoses including peripheral vascular disease and dementia and a BIMS score of 1 (severe cognitive impairment), had an order for lorazepam 0.5 mg three times daily. Resident R2, with schizophrenia and an anxiety disorder and a BIMS score of 15 (cognitively intact), had an order for clonazepam 1 mg twice daily. During a routine narcotic count reconciliation on the 6th floor medication cart, one tablet of lorazepam belonging to Resident R1 and one tablet of clonazepam belonging to Resident R2 were found to be missing/unaccounted for. The medications had been stored in a secured, locked medication cart assigned to LPN Employee E1 at the time the discrepancy was discovered. Statements obtained during the investigation revealed conflicting accounts regarding the narcotic count and access to the cart. In an initial verbal statement, LPN Employee E1 reported that the count was wrong that morning when she counted with another LPN and stated she did not have her reading glasses and did not know the count was wrong. In a later written statement, she corrected the name of the nurse she counted with but maintained that the Ativan and Klonopin counts were not correct. However, LPN Employee E2 stated that when she counted the narcotic drawer with LPN Employee E1 at shift change, all counts matched the records and no discrepancies were noted or questioned. Facility documentation indicated that both nurses reported the narcotic count was accurate at the time of shift change, and that the discrepancy was later identified through review of narcotic count sheets and MAR documentation. During the course of the investigation, RN Employee E3, the Assistant Director of Nursing, was found to be in possession of an extra set of medication cart keys and was working in the facility during the timeframe of the discrepancy, indicating that more than one staff member had access to the locked narcotic drawers. The deficiency also involved misappropriation concerns related to Resident R3’s personal property. Resident R3, with cirrhosis of the liver, end stage renal disease, and a BIMS score of 9 (moderate cognitive impairment), had personal items including a wallet, multiple credit/debit and insurance cards, state ID, and $145 in cash stored in a locked narcotic drawer of the 6th floor medication cart. Staff statements conflicted regarding awareness and handling of this property. One LPN stated that on the morning of December 27, while counting off the cart, there was a stack of cards with rubber bands around it that were said to belong to the resident, and that money was never seen or mentioned and therefore never counted. Another LPN reported last seeing the resident’s money in a clear plastic bag in the narcotic drawer on the morning of December 26, noting a visible hundred-dollar bill, and later noticing that the money was no longer visible when counting the drawer the night of December 27, prompting notification of the acting supervisor. A third LPN stated that on December 27, she specifically informed another nurse that the resident had a wallet, a stack of different credit cards, and $145 in cash in a plastic bag labeled with the resident’s name in the narcotic box, and that she picked up and showed the bundle to ensure the other nurse knew it was there. Facility documentation indicated that the resident’s credit/debit cards, ID, insurance cards, and $145 in cash were being stored in the locked drawer over the weekend to be taken to the business office, and that on December 28 the money was reported missing while the cart was under the control of LPN Employee E1, with concern for loss or possible misappropriation of resident property. The facility’s investigation report later noted that, because more than one nurse had access to the locked narcotic drawer during the relevant timeframe, the investigation into the missing funds was inconclusive and could not be substantiated or unsubstantiated.

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 report suspected misappropriation of resident property, specifically controlled substances and other medications, for 12 of 14 residents as required by its Abuse, Neglect, & Exploitation policy and state regulations. The facility’s policy dated 2/14/25 required all alleged violations to be reported to the Administrator, state agency, adult protective services, and other required agencies within specified timeframes, depending on whether abuse or serious bodily injury was involved. Despite this, documentation submitted to the State Survey Agency did not include reports of possible misappropriation for the affected residents, and the Nursing Home Administrator later confirmed that the facility failed to implement its policies and procedures for reporting possible misappropriation of resident property. Surveyors’ review of narcotic sign-out sheets and the electronic MARs for multiple residents showed numerous additional doses of controlled and other medications signed out on paper but not documented in the electronic MAR. For one resident, extra doses of hydromorphone were recorded on paper on several dates without corresponding MAR entries. Other residents had undocumented paper sign-outs for Tramadol, oxycodone, oxycodone/acetaminophen, and alprazolam, including instances where multiple doses were signed out in a short time frame, illegible entries, and doses signed out after the physician’s order had been discontinued. One resident’s record showed three doses signed out between 12:20 a.m. and 5:00 a.m. when only one dose was scheduled, and another resident’s record showed wasted doses and multiple undocumented administrations. Further review showed that for one resident, a narcotic inventory discrepancy was identified, with 4½ tablets of oxycodone 5 mg unaccounted for between two documented counts, and no medication administration recorded during that interval. Activity records indicated that an RN accessed the narcotic drawer shortly before the discrepancy was noted. Despite these discrepancies and the facility’s own policy requiring prompt reporting of alleged violations, the facility did not report these possible misappropriations for 12 residents to the State Survey Agency or other required authorities, resulting in noncompliance with 28 Pa. Code 211.12(d)(1)(5) and 201.29(j).

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 abuse, neglect, and exploitation policy to fully investigate potential misappropriation of resident property, specifically controlled medications, for multiple residents. The policy required an immediate investigation upon suspicion or reports of abuse, neglect, or exploitation, including identifying responsible staff, preserving potential evidence, investigating all types of alleged violations, interviewing all involved persons, and providing complete documentation. An incident was identified in which one tablet of lorazepam 0.5 mg prescribed to a resident with peripheral vascular disease and dementia (BIMS score 1, on scheduled lorazepam) and one tablet of clonazepam 1 mg prescribed to a resident with schizophrenia and anxiety (BIMS score 15, on scheduled clonazepam) were found missing during a narcotic count. The missing medications were stored in a locked medication cart on the sixth floor, and the discrepancy was discovered during routine narcotic count reconciliation while an LPN was in charge of the cart. Following discovery of the two missing controlled substances, the facility’s investigation focused on the LPN assigned to the cart and the nurse who handed off the cart, including obtaining statements about the narcotic count at shift change and the LPN’s report of not having reading glasses and being unaware of an incorrect count. Narcotic count sheets and the MAR were reviewed for the two residents whose medications were missing, and statements were obtained from the involved LPNs. During the course of this focused inquiry, a RN who served as the Assistant DON was later found to be in possession of an extra set of medication cart keys and had been working in the facility during the time frame of the discrepancy. However, the investigation documentation provided did not show that the facility broadened its review beyond the two initially identified missing doses to determine whether misappropriation extended to other residents. When additional narcotic sign-out sheets were reviewed with the DON, numerous discrepancies were identified for twelve other residents, including extra doses of hydromorphone, tramadol, oxycodone, oxycodone/acetaminophen, alprazolam, and other controlled medications signed out on paper but not documented in the electronic MAR, illegible entries, doses recorded after orders had been discontinued, and multiple doses signed out in time frames inconsistent with the physician’s orders. These discrepancies involved residents with various pain and anxiety medication regimens and included instances where orders were no longer active or where extra or wasted doses were recorded without corresponding MAR documentation. The DON confirmed that the facility’s investigation into misappropriation did not include audits of other residents’ medication records, narcotic sign-out sheets, or resident interviews to determine whether misappropriation involved additional residents. The Nursing Home Administrator also confirmed that the facility failed to implement policies and procedures to investigate misappropriation of resident property for 12 of 20 residents, resulting in a deficiency under 28 Pa. Code 211.12(d)(1)(5) Nursing services and 28 Pa. Code 201.29(j) Resident rights.

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 implement and maintain an effective infection prevention and control program during a period when 41 of 109 current residents had active Covid-19 infections. Facility policy on Isolation – Notices of Transmission-Based Precautions required the use of notices to alert personnel and visitors of transmission-based precautions while protecting resident privacy, and the Pennsylvania Department of Health Respiratory Virus Outbreak Toolkit directed that masking and appropriate transmission-based precautions, including airborne and contact precautions for SARS-CoV-2, be used. These precautions included keeping doors to rooms of residents with suspected or confirmed respiratory viral infections closed, using fit-tested N95 or higher-level respirators, and following contact precautions such as gloves, gowns, and dedicated or disinfected equipment. On multiple nursing units, surveyors observed that room doors for numerous residents with active Covid-19 infections were open, contrary to airborne precaution requirements that doors remain closed. On the Five South unit, doors were open for several rooms housing residents with active Covid-19, and an LPN began closing doors only after noticing the surveyor documenting room numbers. The same pattern of open doors for Covid-19 positive residents was observed on the Sixth Floor, Fifth Floor, and Fourth Floor nursing units. Additionally, the LPN confirmed that none of the three PPE caddies on the Five South unit contained N95 masks for staff who chose to wear them. The Nursing Home Administrator confirmed that the facility failed to ensure an environment free from the potential spread of infection for 27 of 41 residents, in violation of multiple cited Pennsylvania regulatory codes.

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 a resident's records were readily accessible to the State Survey Agency, resulting in a delay in the survey process for one of three reviewed residents (Resident R3). Surveyors repeatedly requested investigation documents related to a possible misappropriation of Resident R3's property from both the former Nursing Home Administrator and the Director of Nursing. These requests were made during an in-person interview with the former Nursing Home Administrator on 12/30/25, an in-person interview with the Director of Nursing on 12/31/25, and a telephone interview with the former Nursing Home Administrator on 1/2/26. Additional requests for the same investigation documents were made via electronic communication to the Director of Nursing on 1/5/26 and again on 1/7/26. The investigation documents related to the possible misappropriation of Resident R3's property were not received by the surveyors until the evening of 1/7/25. During an interview on 1/8/26, the Nursing Home Administrator confirmed that the facility failed to ensure residents' records were readily accessible to the State Survey Agency, which caused a delay in the survey process for Resident R3, in violation of 28 Pa. Code: 211.5(f)(g)(h) regarding clinical 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 provide adequate information and access regarding the grievance process on multiple nursing units. Specifically, on two of three nursing units, there was no information posted about how to file a grievance or about the designated Grievance Official. Observations revealed that grievance boxes were either not easily visible or not clearly labeled as being for grievances. Staff interviews indicated that some employees were unaware of the location of the grievance box, and when located, the boxes lacked appropriate signage. Additionally, on all three nursing units reviewed, grievance forms were not available for residents or their representatives to fill out. In some areas, information about the Grievance Official was posted in a separate location, not near the grievance box. The Director of Nursing confirmed these deficiencies, acknowledging the lack of accessible grievance forms and insufficient information about the grievance process and official on the affected units.

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 notify the representative of a resident following incidents of resident-to-resident abuse. Specifically, there were two documented occasions where one resident, who had a diagnosis of dementia and a BIMS score indicating severe cognitive impairment, was subjected to distressing behavior by her roommate, who also had dementia and exhibited behavioral symptoms such as combativeness and wandering. In both incidents, the roommate was observed standing over the resident, yelling and causing the resident to cry and express fear. Despite these events, there was no documentation in the resident's clinical record indicating that her representative was notified of the incidents. Review of facility policy and interviews confirmed that the facility's procedures require notification of a resident's representative in such situations. The Director of Nursing acknowledged that the required notifications were not made. The clinical records and progress notes for the affected resident did not contain any evidence of incident documentation or representative notification, which is inconsistent with both facility policy and regulatory 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

The facility failed to maintain a clean and homelike environment on one of its nursing units, as evidenced by multiple observations during a survey. In the Fourth Floor dining room/lounge, surveyors found refuse in the sink, partially used bottles of shampoo and lotion on a shelf above the sink, and a drawer with a broken handle containing a sock, a soiled Ziploc bag, and a soiled disposable cup lid. The sink only had a hot water handle, and an electrical outlet near the television was missing a faceplate, exposing wires. Additionally, a resident reclining chair was missing an arm cushion, exposing the metal frame, and had dried brown and food substances on its surface, with a broken footrest. Further observations revealed that a restroom door, not designated for staff, visitors, or residents, was unlocked and accessible to residents but lacked a call light system. Personal hygiene items were stored on top of the paper towel dispenser in this restroom. An interior door covered with duct tape over the locking mechanism led to an electrical room with accessible circuit breakers and loose wires. The DON confirmed these findings, indicating the facility did not provide a clean and homelike environment as required by policy.

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 investigate two separate resident-to-resident abuse incidents involving a resident with severe cognitive impairment and another resident with moderate impairment. On two occasions, one resident was observed standing over her roommate, exhibiting aggressive and threatening behavior, including yelling and causing the roommate to cry and express fear. Despite these incidents being documented in progress notes, there was no evidence in the clinical records that an investigation was initiated, nor was there documentation of notification to the affected resident's representative. Additionally, the clinical records did not show any actions taken to prevent recurrence of these incidents, such as offering to move the resident to a different room. Staff interviews confirmed that the facility did not complete an investigation into the incidents, as required by facility policy. The residents involved had significant medical histories, including dementia, heart failure, diabetes, and recent stroke, and both had their children listed as emergency contacts and responsible parties. The lack of investigation and follow-up was confirmed by the Director of Nursing 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

A deficiency occurred when the facility failed to provide adequate supervision to prevent a fall that resulted in actual harm to a resident. The resident, who had a history of paraplegia, hemiplegia following a CVA, and other significant medical conditions, required substantial or maximal assistance for bed mobility and an assist of two for activities of daily living (ADLs). During a bed change, two CNAs were present and the resident was rolled onto his side, but was unable to stop rolling and fell from the bed, sustaining a large laceration on the forehead that required sutures. The incident report and staff statements indicated that while one CNA turned to grab a washcloth, the resident slipped out of bed and staff were unable to prevent the fall due to the resident's weight and loss of balance. The resident's care plan and facility policies required an assist of two for bed mobility and ADLs, and staff were expected to follow these instructions as documented in the Kardex and care orders. Despite these requirements, the fall occurred during routine care, and the resident suffered a significant injury. Staff interviews confirmed knowledge of the care requirements and the use of the Kardex for safety measures, but the incident still resulted in harm. Clinical documentation showed that the resident was alert and oriented at the time of the incident, and after the fall, was assessed and transferred to the hospital for treatment. The facility's failure to ensure adequate supervision and safe handling during bed mobility directly led to the resident's fall and injury. The deficiency was confirmed by review of facility policies, clinical records, incident reports, and staff 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 an effective pest control program as required by its own policy and state regulations. Observations in the Main Kitchen revealed mouse droppings and mouse traps in the kitchen storage area, as well as an open box of brown sugar with mouse droppings on top and tortilla shells that had to be discarded due to mice eating through the packaging. The Assistant Kitchen Manager confirmed ongoing concerns with mice in the Main Kitchen and reported keeping a detailed list of food that needed to be discarded and replaced due to pest contamination. Additionally, multiple mouse traps were observed in resident rooms on several nursing unit floors, and a resident reported that while the mouse problem had improved, mice were still seen running around. Review of pest control records showed repeated findings of bait being eaten and mice being caught in glue traps in various areas of the facility, including the kitchen, dining rooms, breakrooms, and resident areas, over several weeks. Despite regular inspections and interventions by pest control, evidence of active pest infestation persisted. The Nursing Home Administrator and Director of Nursing confirmed that the facility had not maintained an effective pest control program, resulting in the continued presence of pests 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 ensure that the Department of Health's most recent survey results were readily accessible to residents and visitors in three key locations: the first-floor lobby, and the nursing units on the fourth and sixth floors. During an interview, four residents expressed that they were unaware of where the survey results were located. Observations revealed that signage in the lobby, fourth floor, and sixth floor indicated that survey results could be found on the 1st, 4th, and 6th floors, but the survey result book was not found in the lobby or the sixth floor. On the fourth floor, the survey result book was found behind empty folders and contained outdated survey results from 2023, despite the most recent survey being conducted on 2/12/24. The Director of Nursing confirmed the facility's failure to make the Department of Health's most recent survey results readily accessible to residents and visitors. This deficiency was identified through observations and interviews, highlighting a lack of compliance with the requirement to post survey results in a place that is easily accessible to residents, family members, and legal representatives. The facility did not meet the regulatory requirement to ensure transparency and accessibility of survey results, as evidenced by the inability of residents and visitors to locate the necessary information in the designated areas.

Plan Of Correction

No residents were affected by not having access to the survey results. Previous years surveys have been printed and placed in the survey binders. The Director of nursing was educated on Access to survey results. The Director of nursing will audit the binders monthly for up-to-date 2567 information. Findings will be reported in quality assurance and process improvement meetings.

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 meet the required in-service training standards for nurse aides, as mandated by §483.95(g). Specifically, the facility did not ensure that four nurse aides received at least 12 hours of in-service education within 12 months of their hire date anniversary. This deficiency was identified through a review of facility policy, personnel in-service training records, and staff interviews. The facility's policy, last reviewed on 10/20/24, stated that an effective training program would be developed and maintained for all staff, but this was not adhered to. The review of training records revealed that Nurse Aide Employee E1, hired on 10/9/22, had no documented evidence of education between 10/9/23 and 10/9/24. Similarly, Nurse Aide Employee E3, hired on 10/11/04, had no documentation of completed education from 10/11/23 to 10/11/24. Nurse Aide Employee E4, hired on 10/11/05, and Nurse Aide Employee E5, hired on 11/12/13, both had education files with a "12-hour in-service packet," but no dates confirmed that the education occurred within the required timeframe. The Nursing Home Administrator confirmed the facility's failure to conduct the necessary in-service education during an interview on 2/14/25.

Plan Of Correction

No residents were affected by this deficiency. All residents have the potential to be affected by this deficiency. VP of Clinical Services provided education to the Administrator, Director of Nursing, and Human Resources Director regarding the need to track 12 hours of annual training for certified nursing assistants. The facility has developed a tracking form to track these education hours for each nurse's aide. The Human Resources Director will complete a monthly audit on all employees due to complete their 12 hours of training that month to ensure they have received the required 12 hours of training. Audit results will be reviewed by the Risk Management/Quality Assurance Committee until such a time consistent substantial compliance has been achieved as determined by the committee.

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 comply with the requirements for advance directives as outlined in 28 Pa. Code 201.14(a) and 483.10(c)(6)(8)(g)(12)(i)-(v). Specifically, the facility did not provide the opportunity for seven residents to formulate an advance directive or conduct periodic reviews of existing directives. This deficiency was identified through a review of facility policies, clinical records, and staff interviews. The residents involved in this deficiency included individuals with various medical conditions such as anxiety, depression, dementia, coronary artery disease, stroke, and schizoaffective disorder. Despite having cognitive abilities ranging from intact to severely impaired, as indicated by their BIMS scores, there was no documentation in their clinical records of advance directives or evidence of periodic reviews. This lack of documentation suggests that the facility did not adhere to its policy of supporting and facilitating residents' rights to make decisions about their medical treatment. During an interview, the Nursing Home Administrator confirmed the facility's failure to provide the opportunity for these residents to formulate or review advance directives. This deficiency affected seven out of the twenty-two residents reviewed, highlighting a significant oversight in the facility's compliance with federal and state regulations regarding resident rights and advance directives.

Plan Of Correction

Residents R11, R35, R41, R45, R52, and R55 have been provided the opportunity to formulate an advance directive. Residents electing to execute advance directives have been provided assistance. The facility has determined that current residents have the potential to be affected. An audit was completed on current residents to ensure each has been given the opportunity to formulate an advance directive. The facility reviewed with each resident their decision regarding advance directive status and provisions. The Nursing Home Administrator, or designee, has re-educated the interdisciplinary team members responsible for advance directives on the facility's "Advance Directives." The facility will offer residents on admission/readmission the opportunity and assistance to formulate an advance directive. The facility will review during the annual care conference with the resident and responsible party the decisions made regarding advance directives. The Director of Social Services, or designee, will review care conference summary notes to ensure each resident has been provided the opportunity to formulate an advance directive and review any previously made decisions regarding advance directives weekly for 2 months. Results of audits will be reviewed by the Quality Assurance Committee quarterly until the committee determines consistent substantial compliance.

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 Medicare non-coverage for two residents, identified as R217 and R218, which is a requirement under federal regulations. The facility's policy, last reviewed on 10/20/24, mandates that appropriate Advance Beneficiary Notices (ABNs) be issued in accordance with CMS guidelines. However, the facility did not deliver the Notice of Medicare Non-Coverage (NOMNC) to these residents at least two calendar days before the end of their Medicare-covered services, as required. This failure prevented the residents from having the opportunity to appeal the non-coverage decision. Specifically, the SNF ABN form for Resident R218 indicated that payment for skilled nursing services would end on 8/2/24, but the facility did not provide the necessary documentation or time for appeal. Similarly, for Resident R217, the SNF ABN form indicated that payment would end on 10/21/24, yet the facility again failed to provide the document and appeal time. During an interview, the Nursing Home Administrator confirmed the absence of the NOMNC form for Resident R217 and the SNF ABN for both residents, highlighting a lapse in compliance with the required notification process.

Plan Of Correction

Resident 217 and 218 have been discharged on 10/22/2024 and 8/2/2024 respectively. The facility has determined that residents with a qualifying hospital stay and Medicare Part A benefit days available have the potential to be affected. An audit was conducted on current residents who were admitted in the past six months, and corrective actions were completed on 3/21/2025. The Administrator educated the following personnel on the facility's Advance Beneficiary Notices policy: Business Office Manager, Social Services Director and Assistant, MDS Coordinator, Director of Nursing, and Rehabilitation Program Manager. Copies of the relevant forms were placed in a binder in the offices of the Business Office Manager and Social Services Director. The Social Service Director, or designee, will conduct a random audit of five (5) residents weekly for four (4) consecutive weeks to verify that notices were issued timely. This plan of correction will be monitored at the Quality Assurance meeting until such time consistent substantial compliance has been met.

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 a homelike environment across three nursing units, specifically on the 4th, 5th, and 6th floors. Observations revealed multiple deficiencies in resident rooms, including broken vents and dusty debris inside air conditioning/heating units in rooms 409 W, 410 W, 421 W, 423 W, and 424 W. Additionally, room 409 W had missing molding and holes around the night light, while rooms 401 and 425 had exposed tubing and black cables not in use. Dining rooms on these floors had brown vinyl flooring that was lifting and had worn black holes throughout. Further issues were noted in the form of walls with holes and scratches behind beds in rooms 511, 512, and other unnumbered rooms on the 5th floor, as well as room 607 on the 6th floor. These observations were confirmed by the Director of Nursing during an interview, acknowledging the facility's failure to maintain a homelike environment as required by regulations.

Plan Of Correction

By March 27th, 2025, the Maintenance Supervisor fixed the identified area noted in the 2567. All residents have the potential to be affected by this practice. The maintenance director will complete a house audit to ensure no other areas of the facility are affected. The Maintenance director will perform room inspections monthly and as needed to identify and address any needed repairs. Staff will report any identified concerns to the maintenance supervisor upon observation. Results will be reviewed by the Risk Management/Quality Assurance Committee until such time consistent substantial compliance has been achieved as determined by the committee.

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 timeframes for seven residents. According to the Resident Assessment Instrument (RAI) User's Manual, an admission MDS assessment must be completed no later than 14 days following admission, and an annual MDS assessment must be completed by the Assessment Reference Date (ARD). However, the facility did not adhere to these guidelines, resulting in delayed assessments for several residents. Specifically, the report highlights that residents had MDS assessments completed beyond the stipulated deadlines. For instance, one resident had an ARD of November 13, 2024, but the MDS was completed on November 28, 2024. Another resident had an admission date of January 13, 2025, with the MDS due by January 27, 2025, but it was not completed on time. These delays were identified during a review of clinical records and confirmed through staff interviews, indicating a systemic issue in meeting the required assessment timelines.

Plan Of Correction

By time of the annual survey, the MDS Team completed the Comprehensive Assessment for Resident 1, 23, 45, 49, 52, 57, and 58. All residents of this facility have the potential to be affected by this practice. A house wide audit was completed to ensure that comprehensive assessments were completed timely. The facility's MDS Team attended an in-service presented by the MDS Nurse Consultant. The Nurse Consultant will review the assessment schedule monthly to ensure timely completion. Audit results will be reviewed by the Risk Management/Quality Assurance Committee until such time consistent substantial compliance has been achieved as determined by the committee.

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 ten residents. According to the Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, quarterly MDS assessments must be completed no later than 14 days after the Assessment Reference Date (ARD). However, the facility did not meet this requirement for residents R12, R14, R20, R30, R34, R35, R41, R43, R44, and R55. The completion dates for these residents' MDS assessments exceeded the 14-day requirement, with delays ranging from a few days to several weeks. During an interview on February 14, 2025, the Nursing Home Administrator and the Director of Nursing were informed of the facility's failure to complete the quarterly MDS assessments within the required timeframe for six of the 25 residents reviewed. This deficiency was identified based on a review of the Resident Assessment Instrument User's Manual, clinical records, and staff interviews, indicating a systemic issue in adhering to the mandated assessment schedule.

Plan Of Correction

By the time of the Annual Survey, the MDS Team completed the Quarterly Review for Resident 12, 14, 20, 30, 34, 35, 41, 43, 44, and 55. All residents of this facility have the potential to be affected by this practice. A house wide audit was completed to ensure quarterly assessments were done timely. The facility's MDS Team attended an in-service presented by the MDS Nurse Consultant. The Nurse Consultant or designee will review the assessment schedule monthly to ensure timely completion. Audit results will be reviewed by the Risk Management/Quality Assurance Committee until such time consistent substantial compliance has been achieved as determined by the committee.

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 comprehensive Minimum Data Set (MDS) assessments were accurate and fully completed for seven out of ten residents. The deficiencies were identified through a review of the Resident Assessment Instrument User's Manual, clinical records, and staff interviews. The manual specifies that certain sections of the MDS, such as Section C: Cognitive Patterns and Section D: Mood, should be completed based on the resident's ability to be understood. However, for several residents, these sections were either inaccurately coded or marked as 'Not Assessed,' despite indications that assessments should have been conducted. For instance, Resident R8 was noted as 'sometimes understood' in Section B: Hearing, Speech, and Vision, yet Sections C and D were marked as 'rarely understood,' and the necessary assessments were not completed. Similarly, other residents, such as R10, R13, R29, R36, R40, and R54, had incomplete or inaccurately coded assessments, with critical sections left unassessed. The Resident Nurse Assessment Coordinator confirmed these findings, acknowledging the facility's failure to complete the MDS assessments accurately.

Plan Of Correction

Resident 8, 10, 13, 29, 36, 40, and 54 was reassessed to include Section C and BIMS be conducted. The facility has determined that all residents have the potential to be affected. A house audit has been completed to ensure that section C and BIMS were completed appropriately. An in-service education program was conducted by the Director of Nursing Services or designee with MDS Coordinator(s) and Social Service to addressing the importance of making certain that the comprehensive minimum data set assessments were accurate and fully completed. The Director of Nursing Services, or designee, will conduct a random audit of five (5) residents per week on their MDS for four (4) consecutive weeks. These residents and their medical records will be assessed to ensure that the BIMS section is completed correctly in the MDS. This plan of correction will be monitored at the monthly Quality Assurance meeting until such a time consistent substantial compliance has been met.

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 an ongoing program of activities to meet the interests and support the physical, mental, and psychosocial well-being of eight out of ten residents. This deficiency was identified through a review of facility policies, clinical records, and staff interviews. The residents reported a significant reduction in activities following the resignation of the activity director and another staff member, leaving only one part-time activity aide to manage the program. Several residents, including those with diagnoses such as anxiety, depression, dementia, coronary artery disease, and schizoaffective disorder, expressed dissatisfaction with the lack of activities. Their preferences, as documented in their care plans, included reading, music, group activities, and going outside. However, the facility's records showed minimal participation in group activities, with some residents not participating at all during the review period. Interviews with residents revealed a consistent theme of reduced activities and a lack of updated activity calendars. The facility was unable to provide requested documentation, including activity calendars for several months and the personnel file of the activity staff. The Nursing Home Administrator confirmed the facility's failure to meet the residents' activity needs, as required by regulations.

Plan Of Correction

Resident R5, R11, R26, R35, R41, R45, R52, and R55 were interviewed by Activities Staff to determine activity preferences. Structured activities were placed on the Activity Calendar and led by Activities Staff. Attendance and participation were documented and maintained in the Activities Office, to be filed with the resident's medical record by the 5th day of the following month. The facility has determined that all residents have the potential to be affected. The Activity Director reviewed activity attendance and participation records of residents for trends regarding activities. Follow-up interviews were conducted on 5 residents and completed to see if we are meeting their activity needs. The Activities Director provided education to Activities and Nursing Staff on their roles and responsibilities regarding activities. Attendance and participation in activities will be documented and maintained in the Activities Office during the current month and filed in each resident's medical record by the 5th day of the following month. The Activities Director will review activity attendance and participation records monthly for trends regarding activities. Activities Staff will interview five residents weekly to determine activity preferences and to guide activity planning for 3 months. Findings will be discussed with the Resident Council and at the monthly Quality Assurance meeting until such a time consistent satisfaction is reported by the Resident Council.

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 qualified professional to direct the activities program for two months, from December 6, 2024, through February 14, 2025. This deficiency was identified based on staff interviews and a review of facility-provided documentation. The job description for the Activities Director required that the program be directed by a qualified therapeutic recreation specialist or an activities professional. However, during an interview on February 13, 2025, the Nursing Home Administrator (NHA) and Director of Nursing (DON) confirmed that the facility did not meet this requirement for the specified period.

Plan Of Correction

An activity director has been hired and is starting on March 17th, 2025. This has the potential to have a negative effect on the residents. The administrator will be educated by the clinical consultant on the policy of hiring a qualified Activity Director. The administrator will audit to ensure for 3 months there is a qualified activity professional on staff. Findings will be reported to the quality assurance and performance improvement committee.

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 Quality Assessment and Assurance (QAA) meetings at least quarterly with all required committee members for three out of four quarterly meetings in 2024. According to the facility's policy, the QAA committee is required to meet at least quarterly to coordinate and evaluate activities under the Quality Assurance and Performance Improvement (QAPI) program. However, the review of the Quality Assurance attendance records indicated that the facility only held a first-quarter meeting on February 22, 2024, and did not provide evidence of conducting meetings for the second, third, and fourth quarters of 2024. During an interview, the Director of Nursing (DON) confirmed the facility's failure to conduct the required QAA meetings with all necessary committee members for the specified quarters. This deficiency was identified based on the facility's policy review, attendance records, and staff interviews, highlighting a lapse in maintaining the mandated schedule and composition of the QAA committee meetings.

Plan Of Correction

Facility determined that not having quarterly quality assurance meetings could negatively affect the residents. Administrator and Director of nursing will be educated and educate all managers on the importance of regularly scheduled quality assurance meetings by regional clinical nurse. Administrator or designee will audit compliance with the quality assurance meetings. Findings will be reported at the quality assurance meetings.

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 and maintain an effective training program for its staff, as required by §483.95. This deficiency was identified through a review of facility policy, personnel in-service training records, and staff interviews. Specifically, the facility's policy on 'Training Requirements,' last reviewed on October 20, 2024, mandates the development and maintenance of an effective training program for all staff. However, the facility did not adhere to this policy for four nurse aides, identified as Employees E1, E3, E4, and E5. The training records for these employees were either incomplete or missing, indicating a lack of documented training within the specified timeframe. Employee E1, hired on October 9, 2022, had no documented dates or times of training in their education file. Employee E3, hired on October 11, 2004, had no education file or documentation of completed education from October 11, 2023, through October 11, 2024. Employee E4, hired on October 11, 2005, had a '12-hour in-service packet' in their file, but no dates confirmed the training occurred within the required period. Similarly, Employee E5, hired on November 12, 2013, had a '12-hour in-service packet' without dates confirming the training occurred between November 12, 2023, and November 12, 2024. During an interview, the Nursing Home Administrator confirmed the facility's failure to provide training on infection prevention and control for six of nine staff members.

Plan Of Correction

No residents were affected by this deficiency. All residents have the potential to be affected by this deficiency. VP of Clinical Services, Administrator and Director of Nursing developed a facility Training Plan to include: - Effective communication for direct care staff. - Resident rights and facility responsibilities for caring of residents. - Elements and goals of the facility's QAPI program. - Written standards, policies, and procedures for the facility's infection prevention and control program. - Written standards, policies, and procedures for the facility's compliance and ethics program. - Behavioral health. - Dementia management and care of the cognitively impaired. - Abuse, neglect, and exploitation prevention. - Safety and emergency procedures. All staff will receive education in these areas, provided by the Administrator and Director of Nursing or designee. Completed training will be signed and dated by staff after receiving the training. Moving forward, staff will receive this training upon hire (during orientation) and annually. Human Resources Director will complete a weekly audit for 4 weeks on all new hires to ensure they have received the required trainings in the training plan and will complete a monthly audit that all staff have completed the assigned monthly trainings to ensure continued annual training. Audit results will be reviewed by the Quality Assurance Committee until such a time consistent substantial compliance has been achieved as determined by the committee.

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 mandatory training on effective communication for five out of nine staff members, as required by §483.95(a). The deficiency was identified through a review of facility policy, personnel in-service training records, and staff interviews. The facility's policy, last reviewed on October 20, 2024, mandates an effective training program for all staff, including training on effective communication for direct care staff. However, documentation revealed that Nurse Aide Employees E1, E3, and E4, Dietary Employee E7, and Licensed Practical Nurse Employee E8 did not receive the required training within the specified time frames. The Nursing Home Administrator confirmed during an interview that the facility did not provide the necessary training on effective communication for these staff members. The lack of training was in violation of the facility's policy and the regulatory requirements, as outlined in 28 Pa Code sections 201.14(a), 201.18(b)(1), and 201.20(a)(c), which pertain to the responsibility of the licensee, management, and staff development, respectively.

Plan Of Correction

No residents were affected by this deficiency. Residents have the potential to be affected by this deficiency. VP of Clinical Services, Administrator and Director of Nursing developed a facility Training Plan to include: - Effective communication for direct care staff. - Resident rights and facility responsibilities for caring of residents. - Elements and goals of the facility's QAPI program. - Written standards, policies, and procedures for the facility's infection prevention and control program. - Written standards, policies, and procedures for the facility's compliance and ethics program. - Behavioral health. - Dementia management and care of the cognitively impaired. - Abuse, neglect, and exploitation prevention. - Safety and emergency procedures. All staff will receive education in these areas, provided by the Administrator and Director of Nursing or designee. Completed training will be signed and dated by staff after receiving the training. Moving forward, staff will receive this training upon hire (during orientation) and annually. Human Resources Director will complete a weekly audit for 4 weeks on all new hires to ensure they have received the required trainings in the training plan and will complete a monthly audit that all staff have completed the assigned monthly trainings to ensure continued annual training. Audit results will be reviewed by the Quality Assurance Committee until such a time consistent substantial compliance has been achieved as determined by the committee.

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 mandatory training on Resident Rights to six out of nine staff members, as required by §483.95(b). The deficiency was identified through a review of facility policy, personnel in-service training records, and staff interviews. The facility's policy, last reviewed on October 20, 2024, mandates an effective training program for all staff, including training on resident rights and facility responsibilities. However, documentation revealed that several staff members, including nurse aides, a dietary employee, an LPN, and the Maintenance Director, did not receive the required training within the specified timeframe. The staff members affected include Nurse Aide Employees E1, E3, and E4, Dietary Employee E7, LPN Employee E8, and Maintenance Director Employee E9. Each of these employees had specific hire dates, and the review showed they did not receive resident rights training between their respective hire anniversaries in 2023 and 2024. The Nursing Home Administrator confirmed the lack of training during an interview, acknowledging the facility's failure to comply with the training requirements. This deficiency is in violation of several Pennsylvania Code regulations related to the responsibility of the licensee, management, and staff development.

Plan Of Correction

No residents were affected by this deficiency. All residents have the potential to be affected by this deficiency. VP of Clinical Services, Administrator and Director of Nursing developed a facility Training Plan to include: - Effective communication for direct care staff. - Resident rights and facility responsibilities for caring of residents. - Elements and goals of the facility's QAPI program. - Written standards, policies, and procedures for the facility's infection prevention and control program. - Written standards, policies, and procedures for the facility's compliance and ethics program. - Behavioral health. - Dementia management and care of the cognitively impaired. - Abuse, neglect, and exploitation prevention. - Safety and emergency procedures. All staff will receive education in these areas, provided by the Administrator and Director of Nursing. Completed training will be signed and dated by staff after receiving the training. Moving forward, staff will receive this training upon hire (during orientation) and annually. Human Resources Director will complete a weekly audit for 4 weeks on all new hires to ensure they have received the required trainings in the training plan and will complete a monthly audit that all staff have completed the assigned monthly trainings to ensure continued annual training. Audit results will be reviewed by the Risk Management/Quality Assurance Committee until such a time consistent substantial compliance has been achieved as determined by the committee.

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 mandatory training on abuse and neglect prevention to six out of nine staff members, as required by §483.95(c). The deficiency was identified through a review of facility policy, personnel in-service training records, and staff interviews. The facility's policy, last reviewed on October 20, 2024, mandates an effective training program for all staff, including training on abuse, neglect, and exploitation prevention. However, documentation revealed that several employees, including nurse aides, a dietary employee, a licensed practical nurse, and the maintenance director, did not receive the required in-service education on abuse and neglect prevention within the specified timeframes. The specific staff members who lacked documented training were identified as Employee E1, E3, E4, E7, E8, and E9. These employees had hire dates ranging from 2004 to 2018, and each failed to receive the necessary training between 2023 and 2024. During an interview, the Nursing Home Administrator confirmed the facility's failure to provide the required training. This deficiency is in violation of the facility's policy and the regulatory requirements set forth in §483.95(c), as well as Pennsylvania Code sections related to staff development and management responsibilities.

Plan Of Correction

No residents were affected by this deficiency. All residents have the potential to be affected by this deficiency. VP of Clinical Services, Administrator and Director of Nursing developed a facility Training Plan to include: - Effective communication for direct care staff. - Resident rights and facility responsibilities for caring of residents. - Elements and goals of the facility's QAPI program. - Written standards, policies, and procedures for the facility's infection prevention and control program. - Written standards, policies, and procedures for the facility's compliance and ethics program. - Behavioral health. - Dementia management and care of the cognitively impaired. - Abuse, neglect, and exploitation prevention. - Safety and emergency procedures. All staff will receive education in these areas, provided by the Administrator and Director of Nursing or designee. Completed training will be signed and dated by staff after receiving the training. Moving forward, staff will receive this training upon hire (during orientation) and annually. Human Resources Director will complete a weekly audit for 4 weeks on all new hires to ensure they have received the required trainings in the training plan and will complete a monthly audit that all staff have completed the assigned monthly trainings to ensure continued annual training. Audit results will be reviewed by the Risk Management/Quality Assurance Committee until such a time consistent substantial compliance has been achieved as determined by the committee.

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 mandatory training on the Quality Assurance and Performance Improvement (QAPI) program to six out of nine staff members, as required by federal regulations. The deficiency was identified through a review of facility policy, personnel in-service training records, and staff interviews. The facility's policy, last reviewed on October 20, 2024, mandates an effective training program for all staff, including training on the elements and goals of the QAPI program. However, documentation revealed that Nurse Aides E1, E3, and E4, Dietary Employee E7, Licensed Practical Nurse E8, and Maintenance Director E9 did not receive the required QAPI training within the specified timeframe. The Nursing Home Administrator confirmed during an interview that the facility did not provide the necessary QAPI training to these staff members. The lack of training was noted for employees with hire dates ranging from 2004 to 2022, indicating a systemic issue in maintaining compliance with training requirements. This deficiency is a violation of the facility's responsibility to ensure staff are adequately trained in quality assurance and performance improvement, as outlined in the facility's policy and federal regulations.

Plan Of Correction

No residents were affected by this deficiency. All residents have the potential to be affected by this deficiency. VP of Clinical Services, Administrator and Director of Nursing developed a facility Training Plan to include: - Effective communication for direct care staff. - Resident rights and facility responsibilities for caring of residents. - Elements and goals of the facility's QAPI program. - Written standards, policies, and procedures for the facility's infection prevention and control program. - Written standards, policies, and procedures for the facility's compliance and ethics program. - Behavioral health. - Dementia management and care of the cognitively impaired. - Abuse, neglect, and exploitation prevention. - Safety and emergency procedures. All staff will receive education in these areas, provided by the Administrator and Director of nursing or designee. Completed training will be signed and dated by staff after receiving the training. Moving forward, staff will receive this training upon hire (during orientation) and annually. Human Resources Director will complete a weekly audit for 4 weeks on all new hires to ensure they have received the required trainings in the training plan and will complete a monthly audit that all staff have completed the assigned monthly trainings to ensure continued annual training. Audit results will be reviewed by the Risk Management/Quality Assurance Committee until such a time consistent substantial compliance has been achieved as determined by the committee.

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 mandatory training on the Infection Prevention and Control program for six out of nine staff members, as required by §483.95(e). The deficiency was identified through a review of facility policy, personnel in-service training records, and staff interviews. The facility's policy, last reviewed on October 20, 2024, mandates an effective training program for all staff, including infection prevention and control. However, documentation revealed that several employees, including nurse aides, a dietary employee, a licensed practical nurse, and the maintenance director, did not receive the required training within the specified timeframe. Specifically, the training records showed that Nurse Aide Employees E1, E3, and E4, Dietary Employee E7, Licensed Practical Nurse Employee E8, and Maintenance Director Employee E9 did not have documented in-service education on the infection prevention and control program. The Nursing Home Administrator confirmed the lack of training during an interview, acknowledging the facility's failure to comply with the training requirements. This deficiency was noted under the Pennsylvania Code sections related to the responsibility of the licensee, management, and staff development.

Plan Of Correction

No residents were affected by this deficiency. All residents have the potential to be affected by this deficiency. VP of Clinical Services, Administrator and Director of Nursing developed a facility Training Plan to include: - Effective communication for direct care staff. - Resident rights and facility responsibilities for caring of residents. - Elements and goals of the facility's QAPI program. - Written standards, policies, and procedures for the facility's infection prevention and control program. - Written standards, policies, and procedures for the facility's compliance and ethics program. - Behavioral health. - Dementia management and care of the cognitively impaired. - Abuse, neglect, and exploitation prevention. - Safety and emergency procedures. All staff will receive education in these areas, provided by the Administrator and Director of Nursing or designee. Completed training will be signed and dated by staff after receiving the training. Moving forward, staff will receive this training upon hire (during orientation) and annually. Human Resources Director will complete a weekly audit for 4 weeks on all new hires to ensure they have received the required trainings in the training plan and will complete a monthly audit that all staff have completed the assigned monthly trainings to ensure continued annual training. Audit results will be reviewed by the Risk Management/Quality Assurance Committee until such a time consistent substantial compliance has been achieved as determined by the committee.

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 required behavioral health training to seven out of nine staff members, as evidenced by a review of facility policy, personnel in-service training records, and staff interviews. The facility's policy, last reviewed on October 20, 2024, mandates an effective training program for all staff, including behavioral health training. However, documentation revealed that several employees, including nurse aides, environmental services, dietary staff, and a maintenance director, did not receive the necessary behavioral health in-service education within the specified timeframes after their hire dates. During an interview, the Nursing Home Administrator confirmed the lack of behavioral health training for these staff members. This deficiency was identified in the context of the facility's broader training requirements, which also include communication, resident rights, infection prevention, and other critical areas. The failure to provide behavioral health training was noted alongside a separate issue regarding infection prevention and control training, which was also not provided to six of the nine staff members.

Plan Of Correction

No residents were affected by this deficiency. All residents have the potential to be affected by this deficiency. VP of Clinical Services, Administrator and Director of Nursing developed a facility Training Plan to include: - Effective communication for direct care staff. - Resident rights and facility responsibilities for caring of residents. - Elements and goals of the facility's QAPI program. - Written standards, policies, and procedures for the facility's infection prevention and control program. - Written standards, policies, and procedures for the facility's compliance and ethics program. - Behavioral health. - Dementia management and care of the cognitively impaired. - Abuse, neglect, and exploitation prevention. - Safety and emergency procedures. All staff will receive education in these areas, provided by the Administrator and Director of Nursing or designee. Completed training will be signed and dated by staff after receiving the training. Moving forward, staff will receive this training upon hire (during orientation) and annually. Human Resources Director will complete a weekly audit for 4 weeks on all new hires to ensure they have received the required trainings in the training plan and will complete a monthly audit that all staff have completed the assigned monthly trainings to ensure continued annual training. Audit results will be reviewed by the Risk Management/Quality Assurance Committee until such a time consistent substantial compliance has been achieved as determined by the committee.

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

Squirrel Hill Wellness and Rehabilitation Center was found to be non-compliant with resident rights as outlined in 42 CFR Part 483, Subpart B, and the 28 Pa. Code. The facility failed to honor the rights of residents to smoke, affecting four residents who were reviewed during the survey. The facility had a policy allowing supervised smoking in designated areas, but this was changed to a smoke-free policy, prohibiting smoking on the premises. The residents involved, who had a history of smoking and expressed a desire to continue, were informed of the new policy. Despite their wishes, the facility did not provide alternatives that were acceptable to the residents, such as transferring them to a facility that allows smoking. The residents, who were alert and able to make their needs known, declined the offer of nicotine patches and expressed their dissatisfaction with the inability to smoke or be transferred to a smoking facility. Interviews with the residents revealed their frustration and desire to either smoke or be moved to a facility that accommodates their smoking habits. The Director of Nursing confirmed the change in policy and acknowledged that the residents' rights to smoke were no longer honored. This change in policy and the facility's failure to accommodate the residents' rights led to the deficiency noted in the survey.

Plan Of Correction

A meeting regarding the facility's Non-Smoking Policy was conducted with residents #R11, R19, R28, and R53 (the "grandfathered residents"), each of whom had signed a smoking agreement prior to the non-smoking policy going into effect on February 5, 2025. The information discussed at that meeting included smoking times and rules for these grandfathered residents. The information was incorporated into the plan of care for these residents. The facility has determined that all residents have the potential to be affected. New residents are informed about the facility's Non-Smoking Policy prior to admission and are offered smoking cessation products. In-service education programs were conducted separately with licensed and non-licensed staff by the Director of Nursing Services (DON), or designee. In-service education regarding the Non-Smoking Policy included the grandfathered residents who are permitted to smoke. The Director of Nursing Services (DON), or designee, will conduct random observations to ensure that the smoking rights of the grandfathered residents are being met. Such observations will take place once per week for four weeks, then bi-weekly for one month, then monthly for one month. This plan of correction will be monitored at the monthly Quality Assurance meeting until such time consistent substantial compliance has been met.

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 the Resident Council with the opportunity to hold meetings for three months, specifically September, October, and November of 2024. This deficiency was identified through a review of facility policy, documentation, and interviews with residents and staff. The facility's policy, titled "Resident Council Meetings," mandates that the council meets at least quarterly or as determined by the group. However, residents reported that meetings were not arranged during the specified months due to staffing issues in the activities department. The activity director and another staff member had resigned, leaving only one part-time activity aide to manage the department. During a Resident Group meeting attended by four alert and oriented residents and the Ombudsman, it was confirmed that the lack of meetings was due to the absence of sufficient staff to organize them. The Nursing Home Administrator acknowledged the facility's failure to provide the Resident Group with the opportunity for meetings during the specified months. This deficiency is in violation of the residents' rights to organize and participate in resident groups as outlined in the regulations.

Plan Of Correction

The Resident Council will be interviewed to see when they would like to have their meetings. No residents were affected by not having 3 months of resident council. Resident Council education was given to the Activity Director. A monthly review of resident council minutes will be completed by Administrator or designee. Findings will be discussed at quality assurance and process improvement meetings.

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 and make accessible grievance forms and a grievance box to residents and visitors on the fourth-floor nursing unit. During an observation, it was noted that a trash bin was placed in front of the grievance box, obstructing access. Additionally, grievance forms were not present on the fourth-floor nursing unit, which is a requirement for residents to voice their grievances effectively. The Director of Nursing confirmed these findings during an interview, acknowledging the facility's failure to comply with the requirement to make grievance forms and the grievance box accessible. This deficiency was identified based on a review of the facility's policy and observations made during the survey.

Plan Of Correction

No residents were affected by not having the forms and box accessible due to the trash in front of the box and no forms present. This does present a potential and the Grievance Officer was educated on the Grievance policy by the NHA and or designee. Trash bins removed and forms added. Grievance officer or designee will audit forms being present and no obstructions 3 times a week for 4 weeks in identified locations. Results will be reported to the quality improvement and process improvement.

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 thoroughly investigate allegations of abuse, neglect, exploitation, or mistreatment for one of the two residents reviewed, specifically Resident R46. The facility's policy on 'Abuse, Neglect, and Exploitation' requires complete documentation of investigations, including interviews with all involved parties. However, there was no documented evidence that Resident R46 was interviewed regarding the alleged incident of abuse. The incident involved RN Employee E14 and LPN Employee E15, who reportedly made inappropriate comments to Resident R46 when the resident inquired about delayed pain medication. Despite the facility's policy, the investigation report dismissed Resident R46 as a credible source based on past behaviors and medical history, without attaching any interview documentation. Resident R46, who was admitted to the facility with diagnoses including cerebrovascular accident, anxiety disorder, depression, and chronic osteomyelitis, was cognitively intact as indicated by a BIMS score of 14. The incident occurred when Resident R46 was reportedly given a hard time by the nursing staff, leading to an escalation. The facility's failure to conduct a thorough investigation was confirmed by the Nursing Home Administrator and Director of Nursing, highlighting a deficiency in adhering to the required investigative procedures.

Plan Of Correction

Resident R46 was discharged to another facility and unable to be interviewed. The facility has determined that all residents have the potential to be affected if allegations of abuse are not investigated in a timely manner. An in-service education program was conducted by the Director of Nursing Services and the Administrator with direct care staff addressing circumstances that require reporting for timely investigations, and their responsibilities related to investigations. Policy and education on Resident Abuse Prevention and Reporting: The Director of Nursing Services, or designee, will review nursing notes five days per week to identify any allegations of abuse weekly for four (4) consecutive weeks. These residents will be assessed and interviewed to ensure that any injuries are identified, properly investigated, and reported to the appropriate people. This plan of correction will be monitored at the monthly Quality Assurance meeting until such time consistent substantial compliance has been met.

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 a resident receiving tube feedings, as evidenced by observations and staff interviews. Resident R20, who has a history of diabetes, dysphagia, and hemiplegia following a stroke, was admitted to the facility with a requirement for tube feedings. The resident's care plan indicated the need for tube feedings due to dysphagia. A physician's order specified that the resident was to receive Glucerna 1.5 via peg-tube at a rate of 80 ml per hour from 8:00 p.m. to 8:00 a.m. However, during observations on two consecutive days, it was noted that the tube feeding formula container was not dated when opened, which is against the manufacturer's guidelines that require the formula to be used within 24 hours of opening. Interviews with staff, including a Registered Nurse and the Director of Nursing (DON), confirmed that the tube feeding container was left hanging beyond the recommended time without a date and time, increasing the risk of using the formula beyond the 24-hour limitation. The DON acknowledged that the formula should not be used after being opened for 24 hours and that the container should be removed when the feeding is stopped at 8:00 a.m. The Nursing Home Administrator and the DON confirmed the facility's failure to provide appropriate care and services to residents receiving tube feedings, as evidenced by the lack of adherence to the manufacturer's guidelines and facility policy.

Plan Of Correction

Resident R20's tube feeding was taken down and hung with the correct date on the next administration. The facility has determined that all residents receiving tube feeding have the potential to be affected if the tube feeding is not dated properly. All residents receiving tube feeding, bottle checked for proper dates and correct orders. In-service education programs regarding the Tube Feeding Policy were conducted separately with licensed staff by the Director of Nursing Services (DON), or designee. The Director of Nursing Services (DON), or designee, will conduct observations of dating tube feeding to take place three days per week for four weeks, then bi-weekly for one month, then monthly for one month. Findings of this audit will be discussed with the Resident Council. This plan of correction will be monitored at the monthly Quality Assurance meeting until such time consistent substantial compliance has been met.

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 staff failed to maintain ongoing communication with the hemodialysis center for a resident who required dialysis services. The facility's policy on 'Hemodialysis' mandates that residents ordered for dialysis should have continuous communication and collaboration with the dialysis facility regarding their care and services. This communication is to be documented via a written format using a dialysis communication form. However, a review of the resident's 'Dialysis Hand Off Communication Report' forms revealed that the section to be completed by the dialysis center and returned with the resident was left blank for all nine scheduled treatments between January 14 and February 13, 2025. The resident in question, identified as Resident R18, was re-admitted to the facility with diagnoses including end-stage renal disease and low blood pressure. The resident was scheduled to receive dialysis three times a week, as indicated in the physician's order summary and nurse progress notes. Despite this, the necessary communication forms were not completed, as confirmed by the Director of Nursing during an interview. This lack of communication between the facility and the dialysis center constitutes a failure to meet the requirement of ensuring that residents who require dialysis receive services consistent with professional standards of practice and their care plan.

Plan Of Correction

Dialysis book of #R18 reviewed by the Director of Nursing Services, or designee, with the attending physician and dialysis provider. We are unable to correct uncharted documentation from the dialysis center. The facility has determined that residents who receive dialysis have the potential to be affected by poor communication between the nursing facility and the dialysis center. In-service education was conducted by the Director of Nursing Services or designee on dialysis communication to the licensed staff. The dialysis center was informed of the proper procedure as it relates to the nursing facility's documentation and communication. The Director of Nursing Services or designees will review the dialysis communication books of each resident receiving dialysis weekly for four weeks, then bi-weekly for one month to ensure the dialysis center's documentation is complete. Audited records will be reviewed by the Risk Management/Quality Assurance Committee until such time consistent substantial compliance has been achieved as determined by the committee.

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 culturally competent, trauma-informed care for three residents who are trauma survivors. Resident R58, admitted with a history of gunshot wounds and significant pain, did not have an assessment for trauma-informed care or PTSD in their evaluations. Despite experiencing anxiety and depression, their care plan lacked goals and interventions related to trauma-informed care. Additionally, Resident R58 expressed concerns about safety and privacy, which were not adequately addressed by the facility, as evidenced by the placement of their name outside their door against their wishes. Similarly, Residents R20 and R30, both diagnosed with anxiety, depression, and PTSD, did not have assessments for trauma-informed care or PTSD in their evaluations. Their care plans also failed to include goals and interventions related to their PTSD. The Director of Nursing acknowledged the facility's failure to provide trauma-informed care in accordance with professional standards, considering the residents' past experiences and preferences to prevent re-traumatization.

Plan Of Correction

Resident #58 continues to reside in the facility. Password for visitors has been added to her profile per resident request. Residents #20, 30 & 58 will have Trauma Informed Assessment and Care plan with interventions. Residents who have experienced Trauma in their lives have the potential to be affected. Social Services and Nursing will assess residents with Trauma Informed Assessment and develop care plans with interventions for the residents that require them. Facility administrator or designee provided education to Social Services Director and Licensed Nursing Staff regarding the need to assess residents for Trauma and develop care plans with interventions. Social Services will conduct weekly audit on all new admissions for 4 weeks, then monthly for 2 months to ensure that a Trauma Informed Care Assessment has been completed and if necessary, care plan with interventions has been developed. Audit results will be reviewed by the Risk Management/Quality Assurance Committee until such a time consistent substantial compliance has been achieved as determined by the committee.

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 annual performance evaluations for one of its nurse aides, identified as Employee E3, who was hired on October 11, 2004. This deficiency was discovered through a review of the facility's policy, personnel records, and staff interviews. The absence of a performance evaluation for Employee E3 was confirmed during an interview with the Nursing Home Administrator on February 14, 2025. This failure to conduct the required annual performance review is a violation of the regulatory requirement for regular in-service education and performance evaluations for nurse aides.

Plan Of Correction

A performance review was conducted with E3 by the Director of Nursing. Residents of the facility have the potential to be affected by this practice. The Human Resources Director will audit the Nurse Aide Employee files to ensure an annual performance review has been completed with Nurse Aides. Any Nurse Aide without an annual performance review will have one. A facility procedure regarding the annual performance review process was put into place 2/21/25. Director of Nursing and Human Resources Director received education from the Administrator, regarding the process of providing Nurse Aides Annual Performance Reviews. The Human Resources Director will review the schedule for each nurse's aides file that is due that month and corresponding documentation for (3) months to ensure compliance. Audit results will be reviewed by the Risk Management/Quality Assurance Committee until such a time consistent substantial compliance has been achieved as determined by the committee.

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 the pharmacy completed a Medication Regimen Review (MRR) at least once a month for two residents. According to the facility's policy, the drug regimen of each resident should be reviewed monthly by a licensed pharmacist to promote positive outcomes and minimize adverse consequences. However, the clinical records for two residents, one admitted with diagnoses including dementia, depression, and diabetes, and another with high blood pressure, diabetes, and dementia, showed that MRRs were not completed for several months in 2024. For the first resident, the clinical record lacked evidence of MRRs for February, April, May, June, July, September, October, and November 2024. Similarly, the second resident's record did not indicate MRRs for September, October, November, and December 2024. The Director of Nursing confirmed during an interview that the facility failed to complete the required monthly pharmacy MRRs, which is a violation of the facility's policy and federal regulations.

Plan Of Correction

Residents R 5 and R 56 medication regime review was completed by clinical pharmacist. Like residents have the potential to be affected. A house audit was completed by a clinical pharmacist to ensure current residents had a completed medication regime review. The Director of nursing and clinical pharmacist were educated on medication regime reviews by administrator of designee. The Director of nursing will audit the clinical pharmacist medication regime reviews monthly for compliance. Findings will be reported to quality assurance meetings.

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 medical records for two residents were complete and accurately documented. Resident R59 was admitted to the facility and passed away on December 2, 2024. However, the 'Interdisciplinary Discharge Summary' and 'Disposition of Medications' forms dated December 2, 2024, were not completed. Similarly, Resident R61 was admitted and discharged from the facility, but the same forms dated November 19, 2024, were also incomplete. During an interview, the Director of Nursing confirmed these findings, acknowledging that the facility did not maintain complete and accurate medical records for these residents. The facility's policy requires that clinical records be completed within 30 days of a resident's discharge, which was not adhered to in these cases.

Plan Of Correction

R 59 and R 61 have been discharged so we cannot update the discharge summary and disposition of medication. Like residents can be affected. Medical records and licensed staff have been educated by the director of nursing or designee on discharge medical records to include discharge summary and disposition of medications. Medical records will audit 5 discharge records a week for 4 weeks to ensure that discharge summaries and disposition of medications are completed. Findings will be reported to the quality assurance and process improvement committee meetings.

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 pre-employment tuberculosis (TB) screening procedures for two of five newly hired employees, as required by Pennsylvania State regulations and CDC recommendations. The regulations stipulate that all healthcare personnel should undergo a TB screening upon hire, which includes a baseline individual TB risk assessment, TB symptom evaluation, and a TB test. The facility's policy also mandates that new staff receive two Mantoux TB Skin Tests given two weeks apart unless there is a documented history of a positive TB test. However, the personnel records for Environmental Services Employee E11 and Registered Nurse Supervisor Employee E12 did not meet these requirements. Employee E11's record showed only evidence of a one-step tuberculin skin test, which is insufficient according to the facility's policy. Additionally, Employee E12's record included documentation of a prior positive tuberculin skin test but had a chest x-ray that was over a year old, contrary to the requirement for a chest radiograph at the time of hire unless a recent one is documented. These oversights were identified during a review of personnel records and confirmed in an interview with the Nursing Home Administrator, indicating a lapse in adherence to the established TB screening protocols.

Plan Of Correction

No residents were affected by pre-employment tuberculosis testing issues. Residents may be affected if practice does not change. Human Resources will review employee files to ensure tuberculosis testing was completed on both employees. Human Resources was educated by the director of nursing or designee on the pre-employment tuberculosis policy. The director of nursing or designee will audit new hire charts for pre-employment tuberculosis testing weekly for 4 weeks for compliance. Findings will be reported to the quality assurance and process improvement meetings.

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 a resident was sufficiently oriented to the facility upon admission, as required by their admission policy. The policy mandates that a Resident handbook and/or Facility Orientation material should be provided to the resident or family prior to or upon admission. However, a review of Resident R212's clinical record indicated that these materials were not provided upon their admission on February 9, 2025. Resident R212, who was admitted with diagnoses including breast cancer, high blood pressure, and anxiety disorder, confirmed during an interview that they did not receive the necessary orientation materials. Further investigation revealed that the Admission Director, Employee E13, confirmed the absence of evidence in Resident R212's clinical record regarding the provision of admission information. Additionally, the Director of Nursing (DON) acknowledged that the facility failed to ensure the resident was sufficiently oriented to the facility upon admission. This deficiency was identified through staff interviews and a review of facility policy and clinical records.

Plan Of Correction

The facility orientation handbook was developed for Squirrel Hill Wellness and Rehab. It was determined that not having the orientation could affect the new residents. The handbook was given to Resident 212. The Admissions Director was educated in giving the handbook to new residents. The Director of nursing will interview 2 new admissions per week to see if they have received a copy of the handbook. Once a week for 2 weeks, then every 2 weeks for 2 weeks, then monthly for 2 months. The findings will be reported to the quality assurance and performance improvement committee.

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 meet the required staffing levels for nurse aides during the night shift on one occasion. Specifically, on February 8, 2025, the facility had a census of 67 residents, which necessitated the presence of 4.47 nurse aides to meet the regulatory requirement of one nurse aide per 15 residents. However, only 2 nurse aides were available to provide care during that night shift. This staffing shortage was confirmed by the Nursing Home Administrator during an interview conducted on February 12, 2025.

Plan Of Correction

No residents were affected during the day identified in 2567. The Director of Nursing and Staffing Coordinator was re-educated regarding staffing ratios for nursing assistants by the Administrator. The facility has previously reviewed the staffing plan and has assessed wages, provided extra shift pick up bonuses to qualified staff, provided flexible scheduling, and has advertised in several ways for staff including on online help wanted sites. The facility will have each morning the administration staff meets to review the staffing for the day and any critical days in the future, weekly staffing meetings, staffing to include increased employees to cover for any call offs, progressive disciplinary action if necessary and weekly review of new staff that has been hired and will be joining the facility team in the future and any staff that has resigned or has been terminated. Corporate leadership included strategies and any needs of the facility. The Nursing Home Administrator, Director of Nursing, and Staffing Coordinator, or designees, will review the ratios daily and look ahead in the upcoming week schedule. The Director of Nursing or designee will monitor the ratios 5 times a week for 4 weeks then weekly times 4. Results of audits will be reviewed at the facilities quality assurance performance improvement meeting.

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 maintain an emergency preparedness communication plan that complies with federal, state, and local laws. This deficiency was identified during a review of the facility's Emergency Preparedness (EP) Plan. On February 6, 2025, at 9:00 a.m., an interview and documentation review revealed that the EP Plan lacked a communication plan that met the required legal standards. This finding was confirmed during an interview with the Facility Administrator and Maintenance Director later that day at 1:00 p.m., who acknowledged the absence of a compliant communication plan in the EP Plan.

Plan Of Correction

Facility emergency preparedness plan will be updated to include communication plan that complies with local, state and federal laws by 3/21/2025. A review of policies and procedures will be conducted on an annual basis by the Administrator or designee. Findings will be reported to the Quality Assurance and Performance Improvement committee meeting.

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 was found to have a deficiency in its Emergency Preparedness (EP) program, specifically in the area of training and testing staff. During a review of the facility's EP Plan, it was discovered that the plan did not specify the type and frequency of training and testing required to ensure staff knowledge of emergency procedures. This lack of detail in the EP training and testing policy was identified during an interview and documentation review conducted on February 6, 2025. Further interviews with the Facility Administrator and Maintenance Director confirmed that the facility's EP plan was incomplete, as it did not include specific requirements for training and testing. This omission indicates that the facility failed to fully develop and maintain an EP program that meets regulatory standards, as it did not provide clear guidelines for staff training and testing to demonstrate their knowledge of emergency procedures.

Plan Of Correction

Facility trained staff on emergency procedures and tested staff on emergency procedures on March 21, 2025. Review of training and testing will be done on an annual basis by Administrator or designee. Findings will be reported to the Quality Assurance and Performance Improvement committee meeting.

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 its fire alarm system, as evidenced by multiple unresolved trouble codes on the main fire alarm control panel. This deficiency was identified during a documentation review and observation conducted on February 6, 2025, at 8:30 a.m. The issue affected the entire facility. An interview with the Facility Administrator and Maintenance Director later that day confirmed the presence of the fire alarm system deficiency.

Plan Of Correction

Fire panel repairs will be completed by 3/21/2025 by a contracted vendor. Fire panel will be inspected weekly for 4 weeks by Maintenance Director or designee, then monthly to see if there are any troubles in the system. The administrator or designee will reeducate Maintenance Director on Fire Alarm System - K324. Findings will be reported to the Quality Assurance and Performance Improvement committee meetings.

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 automatic sprinkler system, as evidenced by document review, observation, and interview. On February 6, 2025, it was found that the facility lacked documentation for quarterly or semiannual sprinkler inspections, with only one inspection completed in October 2024. Additionally, there were missing ceiling tiles in several areas, including four missing tiles in the Rehabilitation Room on the third floor, one missing tile in the maintenance supervisor's office, and four missing tiles above the Nurses Station on the seventh floor. These deficiencies were confirmed during an interview with the Facility Administrator and Maintenance Director.

Plan Of Correction

Ceiling tiles identified will be replaced by 3/21/2025. House audit for ceiling tiles was completed on February 28th, 2025. Monthly inspection of the ceiling tiles will be conducted by the Maintenance Director or designee. Quarterly and Semiannual sprinkler inspections will be conducted by 3/21/2025. The administrator or designee will reeducate Maintenance director on Sprinkler System - Testing and Maintenance -K353. Findings of sprinkler inspection and ceiling tile audit will be reported to the Quality Assurance and Performance Improvement committee meetings.

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 perform the required annual fire door assembly inspection, which affects the entire facility. During a documentation review on February 6, 2025, at 9:30 a.m., it was discovered that there was no documentation available for the annual fire door assembly inspection. This was confirmed in an interview with the Facility Administrator and Maintenance Director at the same time, who acknowledged the absence of the necessary documentation.

Plan Of Correction

Annual fire door assembly was completed on February 21st, 2025. The administrator or designee will reeducate the Maintenance Director on Annual Fire Door Inspection - K761. The annual inspection of this audit will be conducted by the Maintenance Director or designee and reported to Quality Assurance and Performance Improvement committee meetings.

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 proper documentation for emergency generator maintenance and testing, as required by NFPA standards. During a review on February 6, 2025, it was found that the facility did not have records for several critical tests and inspections that should have been conducted within the last 12 or 36 months. Specifically, the facility lacked documentation for the annual 90-minute load bank test, the triennial four-hour load test, the annual preventative maintenance and inspection, and the annual fuel quality test. An interview with the Facility Administrator and Maintenance Director confirmed that the necessary documentation for these tests was not available at the time of the survey. This deficiency affects the entire facility, as the absence of these records indicates a failure to comply with essential maintenance and testing protocols for the emergency generator system, which is crucial for ensuring the safety and reliability of the facility's power supply in emergencies.

Plan Of Correction

Identified generator tests: 1. Annual 90-minute load bank test 2. Triennial 4-hour load bank test 3. Annual preventative maintenance and inspection 4. The annual fuel quality test will be completed by 3/21/2025. The administrator or designee will reeducate the Maintenance Director on Electrical Systems - Generator - K918. Tests will be placed on an annual/triennial schedule by the Maintenance Director or designee. Results will be reported to the Quality Assurance and Performance Improvement committee meeting.

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 proper vertical opening enclosures, as evidenced by an observation on February 6, 2025. During the inspection, it was noted that floors five and seven, which were unoccupied at the time, had multiple unsealed openings in a bathroom pipe chase wall. These openings were present due to ongoing work to replace a leaking drain pipe. This deficiency affected two out of twelve smoke compartments in the facility. The issue was confirmed through an interview with the Facility Administrator and Maintenance Director on the same day.

Plan Of Correction

Unsealed openings on floors 5 and 7 will be repaired by 3/21/2025. House audit will be completed by Maintenance Director or designee on unsealed openings. The administrator or designee will reeducate Maintenance Director on unsealed openings - K311. Identified rooms will be inspected for new openings monthly by the Maintenance Director or designee. Findings will be reported to Quality Assurance and Performance Improvement committee meetings.

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 corridor doors in compliance with NFPA 101 standards, as observed during a survey on February 6, 2025. The deficiencies were noted in four instances across two of the twelve smoke compartments. Specifically, the door to the dining room on the eighth floor was improperly held open with rubber stoppers, which is not compliant with the requirement for doors to resist the passage of smoke. Additionally, three doors on the sixth floor, including those to Rooms 624 and 609, as well as Room 302, failed to latch properly when tested, indicating a failure to ensure positive latching hardware as required. These deficiencies were confirmed during an interview with the Facility Administrator and Maintenance Director on the same day. The failure to maintain proper door functionality could potentially compromise the safety and fire protection measures within the facility, as corridor doors are essential in preventing the spread of smoke and fire. However, the report does not detail any immediate consequences or risks to residents or staff resulting from these deficiencies.

Plan Of Correction

Identified doors will be fixed to latch by 3/21/2025. House audit was completed for fully closure and latching doors. 1 floor of doors will be audited per week for closure and latching for 4 weeks, then monthly by the Maintenance Director or designee. The administrator or designee will reeducate Maintenance director on Proper latching corridor doors -K363. Results will be reported to Quality Assurance and Performance Improvement committee meetings.