Inners Creek Skilled Nursing And Rehabilitation Ce

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 food and ice were stored, prepared, and distributed in accordance with professional food service safety standards in nourishment rooms and the main kitchen. In the Station 3 nourishment room, surveyors observed a non-working ice machine and staff using a cooler with melted ice sitting on the counter as the ice source. The ice scoop used to dispense ice to residents was found resting directly on top of the cooler rather than in a clean, uncovered holder as required by facility policy. The same area also had a towel on the floor under the ice machine and visible debris and dirt surrounding the machine. In the Station 2 nourishment room, multiple cups and lids were observed on the floor under the ice machine along with debris and dirt. The Nursing Home Administrator stated that housekeeping was responsible for cleaning nourishment rooms and acknowledged that the ice scoop should be contained and not exposed to prevent contamination. In the kitchen, surveyors observed that food service areas were not maintained in a clean and sanitary condition at all times, contrary to facility policy. There was a significant amount of water on the floor in front of the kitchen ice machine, and the Dining Services Manager reported that the ice machine was out of order. A large dish tub and a silver pan had been placed on the floor under the ice machine to catch leaking water. Additionally, a plastic tub was observed under the three-compartment sink; the Dining Services Manager explained that the sink drain was leaking and the tub was being used to catch water from the sink to prevent it from spilling onto the kitchen floor.

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

Surveyors identified a deficiency in the facility’s pest control program based on observations in multiple resident care and food service areas. In the Station 3 nourishment room, they observed multiple gnats, both alive and dead, on the walls, on the floor, and on equipment stored by staff for resident use. On the Rehabilitation Hall, flying gnats were seen in the hallway outside resident rooms. In the kitchen, surveyors observed gnats, alive and dead, flying in the area and stuck on wall surfaces. These findings occurred despite existing facility policies titled “Safe and Homelike Environment” and “Pest Control,” which state that residents have the right to a safe, clean, comfortable, and homelike environment and that a program will be established for control of insects and rodents, with regular monitoring of preparation, service, and storage areas for signs of pests. During interviews, the Food Service Director confirmed that the kitchen drain produces gnats and that roaches are present in the kitchen coolers and/or refrigerator fans. The Nursing Home Administrator reported that the facility was in the process of seeking a new pest control company and that kitchen staff had recently been educated on pest control and required to institute a cleaning schedule. The combination of observed gnats in resident nourishment and rehabilitation areas, as well as gnats and roaches in the kitchen, demonstrated that the facility failed to maintain an effective pest control program to keep resident and food service areas free of pests, in violation of its own policies and 28 Pa. Code 201.18(b)(1) regarding management responsibilities.

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

Surveyors identified a deficiency related to the facility’s failure to ensure a safe, clean, comfortable, and homelike environment in one of three shower rooms observed (Station 3). Review of the facility’s “Safe and Homelike Environment” policy, last reviewed November 14, 2025, showed that residents have the right to a safe, clean, comfortable, and homelike environment and that the center must provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior. During an observation of the Station 3 shower room on April 20, 2026, at 9:30 AM, one shower head was found wrapped with tape and a large piece of white linen, and other showers in the same room were noted to be non‑working. In an interview, an LPN stated that the shower heads had been reported as out of order and in need of repair, and the Nursing Home Administrator later confirmed that multiple shower heads throughout the facility were non‑functioning.

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 treated with respect and dignity during the admission process. Upon arrival, the resident, who had diagnoses of congestive heart failure and community-acquired pneumonia, was being admitted to a room already occupied by another resident. During this process, an LPN loudly stated that the new resident could not be placed in the room because she was Black. The staff were aware that the current occupant of the room had a history of racist behavior, and the new resident was subsequently subjected to a racial slur by the existing resident. The transport team then removed the new resident from the room and relocated her elsewhere in the facility. Interviews confirmed that staff had prior knowledge of the existing resident's racist tendencies and typically would have intervened to prevent such an incident if they had been notified in advance of the admission. The new resident expressed shock at the incident and stated her intention to participate in rehabilitation services with the goal of returning home. The facility's policy requires that all residents be treated with respect and dignity, and the events observed and described in interviews demonstrated a failure to uphold these standards for the new resident.

Penalty

No penalty information released

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

Summary

The facility failed to post the current daily nurse staffing information as required. During an observation in the facility lobby, the most recent nurse staffing posting was found to be dated two days prior, rather than reflecting the current date. The posted information did not include the required details such as the facility name, current date, resident census, and the total number of direct care hours for licensed and unlicensed nursing staff. An interview with the Administrator in Training confirmed that the information should have been updated by the night shift and weekend staff, but this was not done.

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 obtain timely diagnostic services to meet the needs of a resident who experienced a fall. The resident, who had diagnoses including a right femur fracture and Alzheimer's Disease, fell and staff documented that a Certified Registered Nurse Practitioner (CRNP) was notified and ordered a STAT x-ray of the right hip at 9:20 PM. Despite the STAT order, which indicates the need for immediate action, the x-ray was not performed until the following day at 12:09 PM by the contracted mobile x-ray provider. The x-ray revealed a right subcapital hip fracture and osteopenia. Further review indicated that the delay occurred because the x-ray order was entered incorrectly as a one-time only order instead of STAT. The facility's contracted x-ray provider stated that their turnaround time for STAT requests is four hours. The deficiency was cited under 28 Pa. Code 211.12 (d) (5) for failing to ensure prompt diagnostic services were obtained to meet the resident's needs.

Penalty

No penalty information released

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

Summary

The facility failed to provide routine dental services to one resident, as required by its own policy and state regulations. The policy specifies that routine dental services include an annual oral inspection, diagnosis of dental disease, radiographs as needed, dental cleaning, fillings, denture adjustments, and other minor dental procedures. Review of the clinical record for a resident with diagnoses including hypertension and chronic pain, and an identified risk for dental or oral cavity health problems due to aging teeth, showed no evidence of dental consultations or access to routine or emergency dental care since admission in 2022. This lack of dental care was confirmed by facility staff through email correspondence.

Penalty

Fine: $22,080

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

Summary

The facility failed to protect a resident from sexual abuse, resulting in actual harm. Two nurse aides discovered a male resident, who had moderate cognitive impairment, in the bed of a female resident with severe cognitive impairment. The male resident was found naked, with his fingers inserted into the female resident's vagina, while the female resident was crying. The female resident's brief had been removed, and the incident was witnessed by multiple staff members. The female resident was subsequently transported to the emergency department, where a small tear was found on her labia during a forensic exam. Both residents involved resided on the locked memory care unit at the time of the incident. The facility's policy prohibits all forms of abuse, including sexual abuse, and defines sexual abuse as non-consensual sexual contact of any type. The incident was documented in staff witness statements and the facility's incident report, which detailed the discovery of the abuse and the immediate response by staff. The deficiency was cited under regulations requiring the facility to ensure residents are free from abuse and to provide adequate management and nursing services.

Penalty

No penalty information released

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

Summary

The facility failed to ensure that food was served at a safe and appetizing temperature, as required by its own policy. During a lunch meal test tray observation, the temperature of ham slices was measured at 124 degrees Fahrenheit, which is below the facility's policy requirement that food must remain at 135 degrees or above. Resident Council Minutes documented that residents had previously reported concerns about cold food and trays. The Dietary Manager confirmed awareness of these concerns and acknowledged that the food temperature was out of range during the test tray observation. The Nursing Home Administrator also confirmed awareness of resident complaints regarding cold food and the need for equipment replacement in the dining services department.

Penalty

No penalty information released

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

Summary

The facility failed to ensure that residents were able to exercise their right to vote in a recent local election. Three residents had documented preferences in their care plans to vote by absentee ballot while residing in the facility. However, their applications for absentee/mail-in ballots were not processed in a timely manner. Staff interviews revealed that all resident applications for absentee ballots were received months before the election but were misplaced and only discovered after the deadline had passed, making it impossible for the residents to vote by mail as they had requested. Additionally, one resident requested transportation to her polling place but was unable to vote in person because the facility did not have a means of transportation available on election day. The Director of Therapeutic Recreation confirmed that the facility lacked access to a van for transporting residents to polling places. The Nursing Home Administrator acknowledged these issues and confirmed that transportation was not readily accessible for residents wishing to vote in person.

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 care and services were provided in accordance with professional standards of practice for one resident. The resident, who had a history of depression, anxiety, and hypertension, reported chest pain to a nurse aide, which was then communicated to an LPN. The LPN documented that the resident's vital signs were within normal limits and noted the resident's concern about possible atrial fibrillation (AFib), but did not notify the RN or the resident's provider about the complaint of chest pain. There was also no evidence of any diagnostic testing being performed to assess for AFib or other causes of the chest pain. Additionally, the LPN did not communicate the resident's complaint during the change of shift report. Subsequently, the resident called 911 after feeling that her concerns were not addressed, and was later transferred to the hospital where she was diagnosed with a pleural effusion and lower extremity edema. Interviews with facility leadership confirmed that neither the RN nor the provider was notified of the resident's chest pain, and the information was not passed on during shift change. The facility's policies and job descriptions require that significant changes in a resident's condition, such as chest pain, be reported to the RN and provider, which did not occur in this instance.

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 supervision and prevent accident hazards for a resident with diagnoses including PTSD and bipolar disorder. The resident exhibited confusion, expressed intentions to leave, and was observed packing belongings in anticipation of being picked up. Despite being fitted with a Wander Guard device, the resident was able to exit the building on two occasions. On one occasion, the resident left in a manual wheelchair and was observed by the receptionist, who summoned staff to assist. The Wander Guard did not alarm as expected, and staff reported that the device was replaced on the resident's wheelchair. On another occasion, the resident was found in the parking lot near the main entrance by an activities staff member, who was unable to persuade the resident to return inside and required assistance from supervisors. Interviews with the DON and a registered nurse confirmed that the resident had a recent change in condition, was difficult to redirect, and had learned the code to exit the building, allowing them to leave without staff knowledge. The facility's policy defined elopement as any situation in which a patient leaves the premises without the facility's knowledge and supervision. Documentation and staff interviews confirmed that the resident was outside the building without staff awareness, indicating a failure to ensure adequate supervision and prevent accident hazards as required by facility policy and state regulations.

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 minimum nurse aide (NA) staffing ratios across multiple shifts from January 23 to January 29, 2025. Specifically, the night shifts on January 23, 24, 25, 26, 27, and 29 did not have enough NAs to meet the required ratios for the number of residents present. For instance, on January 23, there were 188 residents but only 10 NAs, falling short of the required ratio of 12.53. Similarly, on January 24, there were 192 residents with only 9 NAs, not meeting the required ratio of 12.80. The evening shift on January 26 also failed to meet the required ratio, with 188 residents and only 16.40 NAs, instead of the required 17.09. The deficiency was confirmed during an electronic communication with the Nursing Home Administrator on January 31, 2025. It was acknowledged that the facility had not met the staffing requirements and that there were 30 vacant NA positions. The facility was attempting to address these vacancies by utilizing multiple agencies to fill the gaps. However, despite these efforts, the staffing levels remained below the mandated minimums, leading to the deficiency noted in the report.

Plan Of Correction

1. All residents received care in accordance with their plan of care and attending physician orders. 2. The Clinical Leadership Team and scheduler review the schedule daily. In the event of call offs, the facility follows staffing policies including exhausting all possible replacements from internal staffing pool and contracted agency staff. The facility continues to offer incentives, coordinate staffing schedules, and replace call-offs per policy while actively continuing to hire for all open positions and additional pool staff. 3. All Nursing Staff have been educated on the 7/1/2024 Nursing Ratios and PPD requirements and the importance of maintaining the schedule as posted. 4. To monitor and maintain ongoing compliance, the DON or designee will audit staffing weekly for 4 weeks, then monthly for two months. Results will be taken to the QAPI for review and revision as needed.

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 regulatory requirement of providing a minimum of 3.2 hours of direct nursing care per resident in a 24-hour period for six out of seven days reviewed. Specifically, from January 23 to January 28, 2025, the facility's staffing hours were consistently below the required threshold, with direct care hours ranging from 2.91 to 3.10 per resident. This deficiency was confirmed through a review of staffing documents and an electronic communication with the Nursing Home Administrator, who acknowledged the shortfall in meeting the staffing requirements.

Plan Of Correction

1. All residents received care in accordance with their plan of care and attending physician orders. 2. The Clinical Leadership Team and scheduler review the schedule daily. In the event of call offs, the facility follows staffing policies including exhausting all possible replacements from internal staffing pool and contracted agency staff. The facility continues to offer incentives, coordinate staffing schedules, and replace call-offs per policy while actively continuing to hire for all open positions and additional pool staff. 3. All Nursing Staff will be educated on the Nursing Ratios and PPD requirements and the importance of maintaining the schedule as posted. 4. To monitor and maintain ongoing compliance, the DON or designee will audit staffing weekly for 4 weeks, then monthly for two months. Results will be taken to the QAPI for review and revision as needed.

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 physician reviewed a resident's total program of care, including medications, which led to a medication error. A resident with bilateral knee osteoarthritis and muscle weakness was prescribed Tylenol 1000 mg every 8 hours by an Orthopaedic Surgery Specialist. However, the resident was already receiving Tylenol 8-hour oral tablet extended release three times a day for pain, with a maximum dosage of 3 grams per 24 hours. This oversight resulted in the resident receiving over 15,000 mg of Tylenol over three days, significantly exceeding the recommended dosage. The error occurred because the Certified Nurse Practitioner, working in coordination with the resident's attending physician, signed off on the new order without realizing the existing Tylenol prescription. Interviews with staff revealed that the resident should not have received more than 3,000 mg per day due to potential liver damage. Despite the excessive dosage, subsequent laboratory testing and monitoring showed no concerns with the resident's condition.

Plan Of Correction

1. The facility cannot retroactively correct the failure to ensure sufficient nursing staff with the appropriate competencies and skills sets to provide nursing services to assure resident safety or maintain the highest practicable physical well-being of each resident. All Tylenol orders will be updated to ensure max dose/24 hrs alert is noted on the order to prevent from over medicating. All orders must be handwritten and signed by the provider on facility order sheets; there will be no more taking After Visit Summaries and circling orders, they must be written out on the correct order sheet or verbal can be taken with readback to prevent confusion with new orders. 2. DON/designee will perform a house sweep on all residents who are on Tylenol to ensure dosing is correct, max dose alert on order, and there are no duplicate orders. 3. DON/designee will re-educate nursing staff on 5 rights of medication administration, and will have updated competencies over the next 90 days. Nursing staff will also be educated on Tylenol dosing, including max dose in 24 hours. Nursing staff and providers (MD's, CRNP's, PA-C's) will be educated on our Physician Order Entry-Clinical System Process which reviews the following topics: guidance/expectations of order entry, date required prior to order entry, orders and interim order entry, order alerts, custom medications, dispense as written, practitioner read back, drug recalls, duplicate orders, utilizing the lab logs, and additional topics which include respiratory, dietary, etc. 4. DON/designee will perform weekly audits x4 on residents batch orders (standard orders) to ensure they are appropriately placed, no duplicates. Batch orders include medications like Tylenol, MOM, stool softeners. This will hopefully minimize duplicate orders for commonly ordered medications as mentioned above. Audit will contain 8 residents per week. 5. Results will be reported to QAPI for review and further recommendations if needed.

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 sufficient nursing staff with the appropriate competencies and skills to provide safe nursing services, as evidenced by the case of a resident who received an excessive dosage of Tylenol. The resident, diagnosed with bilateral knee osteoarthritis and muscle weakness, was prescribed Tylenol 1000 mg every 8 hours by an Orthopaedic Surgery Specialist. However, the resident was already receiving Tylenol 8-hour oral tablet extended release three times a day, with a maximum dosage limit of 3 grams per 24 hours. This oversight led to the resident receiving over 15,000 mg of Tylenol over three days, significantly exceeding the safe dosage limit. The error occurred because the Registered Nurse entered the new Tylenol order without realizing the existing order, and the Certified Nurse Practitioner signed off on the consult without clarifying the total dosage. The Medication Administration Record showed that the resident received both the existing and new Tylenol orders simultaneously, leading to the excessive dosage. Interviews with staff confirmed that the resident should not have received more than 3000 mg per day due to potential liver damage, highlighting a failure in the facility's medication administration process.

Plan Of Correction

1. The facility cannot retroactively correct failure to ensure the physician reviews the resident's total program of care, including medications. Once Resident 1 was found to have incorrect orders, proper notifications were made, resident was placed on alert charting along with vital signs, labs were ordered to monitor liver function for side effects of additional Tylenol. DON/designee will reiterate and audit the chart checks which are to be done on 3rd shift. Each chart will have a check list that needs to be signed off by third shift LPN daily to ensure orders are correct and there are no duplicate orders. They are monitored by the nursing supervisors to ensure they are being completed. 24 hour report binders were implemented and are placed on each unit. These are to be filled out each shift and reviewed in the change of shift report. This ensures changes to medications/orders that may have happened on off shifts via on call are properly documented, placed in the chart, and the PCP will follow up the next day to ensure orders are correct. A new admission check list has been created by NPE, and will be brought to the next morning meeting after admission arrives to go over with clinical staff. This includes all BATCH orders which are ordered on admission, the residents after visit summary orders from the hospital to ensure their medications are appropriately dosed and correct. 2. DON/nursing designee will perform an initial audit on the past 30 days on residents who have gone to outside appointments/consults to ensure physician recommendations are properly placed in the provider binders for review on the appropriate order sheet. Initial audit will also include admissions the past 30 days to ensure there are no duplicate BATCH orders placed (which are most common medications with potential medication duplicates/errors). 3. DON/nursing designee will re-educate on chart checks, and explain the chart check process. Medical records will place charts in each chart for these to be signed off of. NPE is also educating staff on "second checks," meaning we get 2 LPN's to review orders and agree they are correct. This now ensures we have 3 steps in place to be ordered to check orders correctly. Nursing staff and providers will be educated to complete orders on the appropriate order sheet only, to avoid confusion. 4. DON/designee will perform weekly audits x4 weeks to ensure new admission checklist are being done on new admissions, medication administration reviews on new admissions to ensure BATCH orders are appropriately placed, and that the admission checklist was brought and completed to morning meeting for review. Audit will focus on new admissions for that week. 5. Results will be reported to QAPI for review and further recommendations if needed.

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 nurse aide (NA) staffing ratios across multiple shifts over a seven-day period. On the day shift of December 7, 2024, the facility had a census of 186 residents but did not meet the required NA ratio, having only 18.27 NAs instead of the required 18.60. Similarly, on the evening shift of December 9, 2024, with a census of 190 residents, the facility had an NA ratio of 16.07, falling short of the required 17.27 NAs. The most significant deficiency was observed on the overnight shifts from December 3 to December 9, 2024. Each night, the facility failed to meet the required NA ratios, with the census ranging from 180 to 190 residents. The NA ratios varied from 9.00 to 11.53, consistently below the required ratios, which ranged from 12.00 to 12.67 NAs. An interview with the Nursing Home Administrator confirmed that the facility was aware of not meeting the required NA ratios.

Plan Of Correction

1. All residents received care in accordance with their plan of care and attending physician orders. 2. The Clinical Leadership Team and scheduler review the schedule daily. In the event of call offs, the facility follows staffing policies including exhausting all possible replacements from internal staffing pool and contracted agency staff. The facility continues to offer incentives, coordinate staffing schedules, and replace call-offs per policy while actively continuing to hire for all open positions and additional pool staff. 3. All Nursing Staff have been educated on the 7/1/2024 Nursing Ratios and PPD requirements and the importance of maintaining the schedule as posted. 4. To monitor and maintain ongoing compliance, the DON or designee will audit staffing weekly for 4 weeks, then monthly for two months. Results will be taken to the QAPI for review and revision as needed.

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 regulatory requirement of providing a minimum of 3.2 hours of direct nursing care per resident in a 24-hour period for three out of seven days reviewed. Specifically, on December 7, 2024, the facility provided only 2.84 hours of direct care per resident, 3.13 hours on December 8, 2024, and 3.06 hours on December 9, 2024. This deficiency was identified through a review of staffing documents and confirmed during an interview with the Nursing Home Administrator, who acknowledged that the facility was not meeting the required minimum hours of direct care.

Plan Of Correction

1. All residents received care in accordance with their plan of care and attending physician orders. 2. The Clinical Leadership Team and scheduler review the schedule daily. In the event of call offs, the facility follows staffing policies including exhausting all possible replacements from internal staffing pool and contracted agency staff. The facility continues to offer incentives, coordinate staffing schedules, and replace call-offs per policy while actively continuing to hire for all open positions and additional pool staff. 3. All Nursing Staff will be educated on the Nursing Ratios and PPD requirements and the importance of maintaining the schedule as posted. 4. To monitor and maintain ongoing compliance, the DON or designee will audit staffing weekly for 4 weeks, then monthly for two months. Results will be taken to the QAPI for review and revision as needed.

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 timely radiological diagnostic studies for two residents, as required by physician's orders. Resident 1, who had a history of surgical repair for a hip fracture and anxiety disorder, reported potential re-injury of their hip. A stat x-ray was ordered by the on-call practitioner, but the examination was conducted over 10 hours later, revealing no acute fracture. This delay in obtaining the x-ray was inconsistent with the facility's contract with their radiology provider, which stipulates that stat orders should be honored promptly in urgent situations. Resident 2, diagnosed with Alzheimer's Disease and anxiety disorder, experienced a fall and complained of hip pain. A stat x-ray was ordered following the fall, but the examination was conducted nearly five hours later, revealing a displaced intertrochanteric fracture. The delay in obtaining the x-ray was significant, given the urgent nature of the situation and the facility's contractual obligations to provide timely radiological services. Interviews with the Director of Nursing (DON) and the Nursing Home Administrator (NHA) revealed a lack of clarity and consistency in expectations for the timeliness of stat x-rays. The DON was unsure of the specific timeframes outlined in the radiology provider's contract, while the NHA indicated that the timing of x-rays depended on the time of day and was subject to interpretation. Despite the delays, the DON believed that radiology services were appropriately provided, highlighting a potential gap in understanding and adherence to the facility's contractual obligations and standards for urgent care.

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 promptly notify the physician of abnormal x-ray results for a resident, leading to a deficiency. The resident, who had Alzheimer's Disease, anxiety disorder, and unspecified abnormalities of gait and mobility, was observed falling and complaining of hip pain. An x-ray was ordered stat, but the results indicating a displaced intertrochanteric fracture of the right femur were not communicated to the physician until the following morning, despite being available the previous night. The facility's policies required immediate notification of physicians for urgent conditions, but these were not followed. The x-ray results were available at 11:02 PM, but the physician was not informed until approximately 10:00 AM the next day. The Director of Nursing confirmed that the supervisor should have notified the physician when the results were received, but this did not occur. The delay in communication was attributed to a lack of clarity on when the results were actually received by the facility. Interviews with staff revealed that the facility relied on an electronic health record portal to monitor pending results, and there was no direct communication from the radiology provider for negative findings. The Nursing Home Administrator acknowledged the delay in notifying the physician but believed it did not affect the resident's outcome, as the resident was kept comfortable and had a prearranged transfer to the hospital. However, the deficiency was noted due to the failure to adhere to the facility's notification policies.

Penalty

No penalty information released

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

Summary

The facility failed to provide altered texture diets as prescribed by physicians for nine residents who required dysphagia advanced or mechanically altered texture diets. These diets are essential for individuals with difficulty chewing and swallowing. Observations during meal service revealed that these residents were served regular pieces of meatloaf or fish instead of the required ground or minced versions, as indicated on their meal tickets and the facility's master menu diet guide sheets. The facility's policy, titled Consistency Alterations and Therapeutic Menus, mandates that diets be provided as ordered by the physician, with specific modifications for individuals having difficulty chewing meat. However, the dietary manager admitted to serving whole pieces of meatloaf and fish to residents on these special diets, mistakenly believing that the meat was adequately prepared by being ground before baking and that the fish was soft enough to be served whole. This oversight was not questioned or corrected until the survey. The deficiency placed 31 additional residents with similar dietary needs at high risk for death, resulting in an Immediate Jeopardy situation. Interviews with staff, including a speech-language pathologist and the dietary manager, confirmed the expectation that diets should be served according to the facility's guidelines. The nursing home administrator also expressed that the master menu diet guide sheets should be adhered to, highlighting a significant lapse in following prescribed dietary orders.

Removal Plan

• Food Service Director will immediately re-educate the dietary and nursing team members on following the master menu diet guide sheet in regards to altered texture diets. Remaining team members will be educated prior to the start of their next shift. Speech Language Pathologist will re-evaluate current residents on an altered texture diet to determine appropriateness.
• Meal service will be audited to assure the appropriate diet textures are being followed.
• Results will be reported to QAPI to further follow-up and recommendations.

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 care and services were provided in a manner that promoted resident dignity in one of its dining areas, specifically the Station 3 Dining Room. Observations on two consecutive days revealed that nurse aides were standing while feeding residents, which is contrary to the facility's policy that staff should be seated when assisting residents with eating. This was observed with three different residents, indicating a pattern of non-compliance with the facility's dignity policy. The Director of Nursing confirmed the expectation that staff should be seated during such activities, highlighting a discrepancy between expected and actual practices.

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 proper monitoring and documentation for the use of restraints on a resident diagnosed with dementia with behavioral disturbance and unspecified psychosis. The facility's policy requires that restraints be used as the least restrictive alternative, with ongoing re-evaluation and documentation of the need for restraints. However, the clinical record for the resident did not contain a physician order, initial assessment, or consent for the use of a jumpsuit/onesie, which was used to prevent stool ingestion. The jumpsuit was applied without the necessary documentation and evaluations, and there was no evidence of re-evaluation every 30 days or scheduled removal every two hours as required. The resident's care plan included an intervention to use a jumpsuit daily, but the necessary documentation and evaluations were not completed. The Director of Nursing acknowledged that an as-needed order for the restraint was added, but the resident had not needed the jumpsuit since becoming bed-bound. The facility's failure to follow its policy and regulatory requirements for restraint use resulted in a deficiency, as there was a lack of proper documentation, consent, and ongoing evaluation for the restraint applied to the resident.

Penalty

No penalty information released

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

Summary

The facility failed to implement physician's orders for Resident 49, who had diagnoses including chronic obstructive pulmonary disease and chronic kidney disease. Despite a physician's order for a hospice evaluation and treatment starting on August 23, 2024, there was no documentation that Resident 49 had been evaluated by hospice services. This was confirmed during an interview with the Nursing Home Administrator and Director of Nursing, who acknowledged the lack of documentation and stated that it was the facility's expectation to follow physician orders. Resident 162, who had a PEG feeding tube removed due to an inability to eat by mouth and a history of cerebral infarction, reported that the dressing applied by the hospital was still on his abdomen and causing skin irritation. The facility staff had not assessed the stoma site or contacted the physician for further orders. The Infection Control Preventionist confirmed that the dressing should have been evaluated and the wound team notified. The Director of Nursing also confirmed that the stoma site should have been assessed and the physician notified for additional treatment. Resident 228, with a history of transient cerebral ischemic attack and diabetes mellitus, experienced an unwitnessed fall resulting in a laceration. Although neurological checks were initiated, they were not resumed after the resident returned from the hospital, leaving a 32-hour gap in monitoring. Additionally, Resident 522, diagnosed with diabetes mellitus type 2 and hypertension, had orders for blood sugar checks that were not consistently documented due to an error in the electronic health record. The Director of Nursing revealed that the orders were incorrectly added, leading to missed blood sugar checks.

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 proper monitoring and notification regarding significant weight changes and fluid restrictions for residents. Resident 72 experienced a 6.2% weight loss over one month, but there was no documentation indicating that the physician was notified of this significant change, as required by the facility's policy. Similarly, Resident 157 experienced a weight loss of greater than 5% in 30 days and 10.5% since June 2024, yet there was no evidence that a practitioner was informed of this significant weight loss. The nursing staff, practitioner, and dietician had not addressed this issue by the time of the survey. Additionally, Resident 92, who had a fluid restriction order due to congestive heart failure and edema, was given fluids exceeding the prescribed daily amount. The Medication Administration Record showed that nursing staff provided more fluids than allowed on several days, and the dietary department also exceeded the fluid amounts specified in the resident's meal ticket. These actions were contrary to the physician's orders and the facility's policy on fluid restriction, indicating a lack of adherence to prescribed care plans.

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 a performance review of every nurse aide at least once every 12 months, as required by regulations. This deficiency was identified through a review of documents and staff interviews, which revealed that five nurse aides (Employees 11, 12, 13, 14, and 15) did not have recent performance evaluations. Employee 11 and Employee 12 were hired on December 10, 2022, while Employees 13, 14, and 15 were hired in August and September 2023. Despite these hire dates, none of these employees had undergone a performance evaluation. The Nursing Home Administrator confirmed during an interview that these evaluations had not been completed, which is a violation of the facility's personnel policies and procedures as outlined in 28 Pa. Code 201.19 (2).

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 Medication Regimen Reviews (MRRs) were completed by a consultant pharmacist and responded to in a timely manner by the attending physician or prescriber for four out of five residents reviewed for unnecessary medications. The facility's policy requires that MRRs be conducted at least monthly and that any recommendations be communicated to the responsible prescriber, medical director, and director of nursing. However, for Residents 12, 15, 25, and 72, there was a lack of documentation regarding the recommendations made by the pharmacist and the responses from the physicians. Resident 12, diagnosed with type two diabetes mellitus and vascular dementia, had MRRs completed on several occasions, but the specific recommendations were not documented. Similarly, Resident 15, with Alzheimer's disease and major depressive disorder, had MRRs with undocumented recommendations. Resident 25, diagnosed with dementia, muscle weakness, and hypertension, lacked documentation of an MRR for April 2024. Resident 72, with dementia, muscle weakness, and severe protein calorie malnutrition, also had missing documentation of physician responses to MRRs. Interviews with the Director of Nursing (DON) revealed an inability to locate the necessary documentation, and the Nursing Home Administrator (NHA) indicated that the previous DON was responsible for the record-keeping and communication process, which was not properly followed.

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 adequate monitoring of psychotropic medications, resulting in a deficiency for one of the five residents reviewed for unnecessary medications. The facility's policy on antipsychotic medication use, dated June 2022, states that such medications should only be considered for elderly patients with dementia after evaluating and addressing medical, physical, functional, psychological, emotional, social, and environmental causes. Additionally, these medications must be prescribed at the lowest possible dosage for the shortest period of time. However, the clinical record of a resident with diagnoses of dementia with behavioral disturbance and major depressive disorder revealed an order for risperidone, an antipsychotic medication, without evidence of side effect monitoring, including AIMS testing, or routine behavioral monitoring to ensure the medication's effectiveness. During an interview, the Clinical Resource Nurse confirmed the absence of documentation regarding side effect or behavioral monitoring related to the resident's antipsychotic use. This lack of monitoring contravenes the facility's policy and the regulatory requirements, as outlined in 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services, which emphasize the necessity of ensuring residents are free from unnecessary medications. The deficiency highlights the facility's failure to adhere to its own policy and regulatory standards in monitoring the use of psychotropic medications.

Penalty

No penalty information released

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

Summary

The facility failed to adhere to professional standards for food storage and equipment utilization in its main kitchen and pantry areas. Observations revealed multiple instances of improperly stored food items, such as an open bag of pasta without an open date, milk cartons past their expiration date, and unlabeled open containers of chocolate topping and energy drinks in the walk-in refrigerator. Additionally, the walk-in freezer contained bags of spinach removed from their original containers and not dated. The facility's policy required all foods to be labeled with the name of the product, date opened, and 'use by' date, which was not followed. Further issues were identified with the facility's equipment and temperature logging practices. The sanitizer concentration in the three-compartment sink was found to be inadequate, as test strips did not change color, indicating improper sanitization. There was no log to record the concentration of the sanitizer when used. Temperature logs for dish machines and refrigerators/freezers were incomplete or missing for several days, indicating a lack of consistent monitoring. This included missing logs for the dish machine and various station refrigerators and freezers over several months. Interviews with the Dietary Manager and Nursing Home Administrator confirmed that the facility's expectations were not met regarding food labeling, storage, and equipment utilization. The Dietary Manager acknowledged that certain items, such as a slushie and energy drink, belonged to staff and should not have been stored in facility equipment. The facility's failure to maintain proper food storage, labeling, and equipment sanitization practices led to the identified deficiencies.

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 Enhanced Barrier Precautions (EBP) as required by their policy and CDC guidance, which led to a deficiency in infection prevention and control. Observations revealed that six residents with conditions necessitating EBP, such as indwelling medical devices or open wounds, did not have appropriate signage indicating the need for these precautions. Additionally, staff members were observed not wearing the required personal protective equipment (PPE) during care activities for these residents. The clinical records of the affected residents, including those with pressure ulcers, indwelling catheters, and other relevant medical conditions, did not contain orders for EBP. This oversight was confirmed through interviews with the Director of Nursing (DON), who acknowledged that these residents should have been on EBP due to their medical conditions. The lack of signage and PPE use was consistent across multiple observations and interviews, indicating a systemic issue in the facility's infection control practices. The deficiency was further highlighted by the absence of EBP notations in the care plans and physician orders for the residents involved. Despite the facility's policy and CDC guidelines, the necessary precautions were not implemented, increasing the risk of infection transmission. The DON's interviews confirmed the expectation for EBP, yet the facility's practices did not align with these expectations, resulting in the identified deficiency.

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 nurse aides received the required in-service training of no less than 12 hours per year, which must include dementia management and resident abuse prevention training. This deficiency was identified through a review of employee files and staff interviews, revealing that three out of five nurse aides did not meet the training requirements. Specifically, one nurse aide had only 6 hours and 13 minutes of documented training without dementia management or abuse prevention training. Another nurse aide had 9 hours of training, lacking abuse prevention training, and a third had only 3 hours and 8 minutes of training without dementia management training. The Nursing Home Administrator acknowledged these deficiencies during an interview.

Penalty

No penalty information released

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

Summary

The facility failed to maintain a clean, comfortable, and homelike environment for its residents, as evidenced by the condition of wheelchairs used by three residents. Observations conducted on multiple days revealed that the wheelchairs of Residents 53, 72, and 96 were soiled with crumbs, pieces of food, dried debris, and smears. Specifically, Resident 53's wheelchair had an accumulation of crumbs and dried debris on the rails, Resident 96's wheelchair had dried smears and crumbs on the seat, wheels, and rails, and Resident 72's wheelchair had dried food and crumbs on the seat, handle, and rails. During an interview, the Director of Nursing acknowledged the need for cleaning the aforementioned wheelchairs, indicating awareness of the deficiency in maintaining a clean environment for the residents.

Penalty

No penalty information released

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

Summary

The facility failed to provide bed-hold notices to residents or their representatives upon transfer to a hospital, as required by their policy. This deficiency was identified during a review of the facility's policy, clinical records, and staff interviews. The policy, last reviewed in July 2024, mandates that staff provide the bed-hold policy notice and authorization form to both the resident and their representative prior to a transfer, regardless of the payer. However, for two residents reviewed, this procedure was not followed. Resident 71, who had diagnoses including cervical spinal cord injury and neuromuscular dysfunction of the bladder, was hospitalized twice in 2024. The clinical records did not contain documentation that the bed-hold policy information was provided to Resident 71 or their representative. Similarly, Resident 157, diagnosed with congestive heart failure and cerebral infarction, was transferred to the hospital following a change in condition, but there was no evidence that she or her representative received the bed-hold notice. Interviews with the Nursing Home Administrator and the Director of Nursing confirmed the lack of documentation and information regarding the provision of bed-hold notices for these residents.

Penalty

No penalty information released

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

Summary

The facility failed to provide appropriate care for a resident with pressure ulcers, as evidenced by a review of facility policy, clinical records, observations, and staff interviews. The resident, who had pressure ulcers on the left heel and left buttock, had specific physician orders for wound care that were not followed. During an observation of a dressing change, an LPN did not apply medihoney to the resident's left ischium wound as ordered by the physician. Additionally, the Treatment Administration Record (TAR) did not document the completion of the wound treatment for the left ischium on a specific date. Further review revealed discrepancies in the treatment of the resident's right heel wound. There were conflicting physician orders regarding the frequency and type of treatment, and the TAR did not reflect the most recent order to cleanse the wound with normal saline solution and apply a foam dressing daily. Instead, the nursing staff documented that the treatment was being completed every other day, which was inconsistent with the wound care consult reports. The Director of Nursing acknowledged these issues during interviews.

Penalty

No penalty information released

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

Summary

The facility failed to ensure the availability of medications ordered by the physician for a resident, identified as Resident 229, upon admission. The resident, who was cognitively intact and diagnosed with congestive heart failure, hypertension, and diabetes mellitus, did not receive several critical medications, including Entresto, Hydralazine, Diltiazem, and Levemir insulin, for up to two days after admission. Despite physician orders, these medications were not available at the specified times on multiple occasions. The facility's documentation revealed that the pharmacy was working on delivering the medications, but there was no evidence that the physician was notified about the missed doses, nor was there documentation showing that the staff followed the escalation process to notify administration or the DON about the medication unavailability. Additionally, the facility failed to provide documentation of the disposition of medications for a discharged resident, identified as Resident 170. The resident's clinical record, which included diagnoses of muscle weakness and hypertension, lacked documentation for the disposition of 11 medications upon discharge. An interview with the DON confirmed the absence of a medication disposition record, which was expected to be completed. These deficiencies indicate a failure to adhere to the facility's policies and applicable regulations regarding pharmaceutical services and medication management.

Penalty

No penalty information released

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

Summary

The facility failed to adhere to its medication labeling policy, as observed during a survey. Specifically, the survey revealed that medications in one of the four medication carts and one of the two medication storage rooms were not labeled with open dates. This included insulin pens and vials, as well as tuberculin purified protein vials, which were found without open dates. The facility's policy requires that medications and biologicals be labeled with open dates to ensure their integrity and safe administration. Interviews with facility staff, including Employee 21 and Employee 20, confirmed that insulin and tuberculin solutions should be labeled with open dates when first opened. The Director of Nursing also acknowledged that the facility's expectation is for these medications to be labeled with open dates. The lack of compliance with the labeling policy was identified as a deficiency under the relevant Pennsylvania Code sections governing management and pharmacy services.

Penalty

Fine: $50,275

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 care and services in accordance with professional standards of practice for a resident diagnosed with end stage renal disease and idiopathic pulmonary fibrosis. On August 10, 2024, the resident exhibited symptoms of anxiety, excessive sweating, and reported not receiving oxygen from their nasal cannula. Blood pressure readings taken by an LPN showed significantly low levels, but there was no evidence that the LPN notified the registered nurse or the provider about the resident's condition or low blood pressures. Interviews revealed that the LPN could not recall if the provider was notified but claimed to have informed the RN supervisor. The RN, however, stated she was not aware of the low blood pressures and did not document any assessment of the resident, although she acknowledged that she should have. The Nursing Home Administrator confirmed that the resident's condition should have been communicated to the provider and that the RN's assessment should have been documented in the clinical record.

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 food and beverages at safe and appetizing temperatures for one observed meal on the short-stay rehabilitation unit. The facility's Food and Nutrition Services Policies and Procedures, revised May 1, 2023, require that hot entrees, starches, vegetables, and hot beverages be served at temperatures greater than 140 degrees Fahrenheit, while milk should be at or below 45 degrees Fahrenheit, and cold beverages and desserts should be at or below 55 degrees Fahrenheit. However, during a test tray evaluation on March 6, 2024, the temperatures of the chicken breast, mashed potatoes, mixed vegetables, and coffee were found to be below the acceptable levels, while the ambrosia and orange juice were at acceptable temperatures. The Registered Dietitian confirmed that the hot foods should have been warmer and the cold items cooler. Further observation revealed that the middle well on the steam table in the kitchen was not functioning and was used to hold the chicken during meal service. The Resident Council meeting minutes for January and February 2024 also indicated ongoing concerns with the quality and temperature of food during mealtimes. The Nursing Home Administrator acknowledged that the food and beverage temperatures during the test tray were not acceptable and that maintenance was informed about the malfunctioning steam table well, which was in the process of being repaired.

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 pharmaceutical services to meet the needs of Resident 4, who had diagnoses including Parkinson's Disease, hypertension, and depression. Resident 4 was admitted to the facility and had physician orders for Carbidopa-Levodopa, Carvedilol, and Mirtazapine. These medications were not administered as scheduled due to pending pharmacy delivery, despite being available in the facility's Omnicell system. Specifically, Carbidopa-Levodopa was not administered on the morning of February 21, 2024, and Carvedilol and Mirtazapine were not administered on the evening of February 20, 2024. During an interview with the Nursing Home Administrator, it was confirmed that the medications should have been administered using the Omnicell stock. The failure to administer these medications as prescribed resulted in a deficiency in the facility's pharmaceutical services, as they did not ensure the accurate acquiring, receiving, dispensing, and administration of drugs to meet the needs of Resident 4.