Nursing Investigation Results -

Pennsylvania Department of Health
BETHLEN HOME OF THE HUNGARIAN REFORMED FEDERATION OF AMERICA
Patient Care Inspection Results

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
BETHLEN HOME OF THE HUNGARIAN REFORMED FEDERATION OF AMERICA
Inspection Results For:

There are  57 surveys for this facility. Please select a date to view the survey results.

Surveys don't appear on this website until at least 41 days have elapsed since the exit date of the survey.
BETHLEN HOME OF THE HUNGARIAN REFORMED FEDERATION OF AMERICA - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on a Medicare/Medicaid Recertification survey, State Licensure survey, Civil Rights Compliance survey, and a Complaint survey completed on January 31, 2019, it was determined that The Bethlen Home of the Hungarian Reformed Federation of America was not in compliance with the following requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care Facilities and the 28 Pa. Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.




 Plan of Correction:


483.10(e)(2) REQUIREMENT Respect, Dignity/Right to have Prsnl Property:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
483.10(e) Respect and Dignity.
The resident has a right to be treated with respect and dignity, including:

483.10(e)(2) The right to retain and use personal possessions, including furnishings, and clothing, as space permits, unless to do so would infringe upon the rights or health and safety of other residents.
Observations:


Based on clinical record reviews, observations and staff interviews, it was determined that the facility failed to provide a dignified dining experience for six of 55 residents reviewed (Residents 24, 30, 31, 36, 58, 61) who required assistance with eating and who were not served their meals at the same time as their table mates.

Findings include:

A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 30, dated December 6, 2018, revealed that the resident was sometimes understood and could sometimes understand, requires extensive assistance for eating, and had medical diagnoses that included Alzheimer's disease (a progressive loss of brain cells that leads to the loss of memory and other thinking skills).

An admission MDS assessment for Resident 31, dated December 5, 2018, revealed that the resident was usually understood and could usually understand, required limited assistance for eating, and had medical diagnoses that included dementia (a group of symptoms associated with a decline in memory or other thinking skills, severe enough to reduce a person's ability to perform everyday activities).

A quarterly MDS assessment for Resident 58, dated January 1, 2019, revealed that the resident was sometimes understood and could sometimes understand, required limited assistance for eating, and had medical diagnoses that included Alzheimer's disease.

Observations during the lunch meal on the secured dementia unit on January 28, 2019, revealed that Resident 50 was seated at a table with Residents 31 and 58, and Resident 50 was served her lunch at 12:04 p.m. However, Residents 31 and 58 were not served their lunch until 12:48 p.m. At 12:15 p.m., Resident 30 was seated at a table with five other residents (Residents 4, 7, 11, 30, 36) and three of them had food. Resident 30 reached and grabbed for food and cups from other residents at her table while Licensed Practical Nurse 5 was seated at that same table and did not attempt to redirect her. Resident 30 was not served any food or drink until 1:01 p.m., and was the last resident to receive food. After Resident 30 received her food, she grabbed her cup and put her green beans into her drink and then took a drink from the cup. Two staff members who were seated at the table with her did not intervene.

Interview with the Dementia Unit Director on January 30, 2019, at 12:41 p.m. revealed that she did not want to see residents sitting at the tables with food while other residents were sitting at the same table without food.


An annual MDS assessment for Resident 36, dated December 11, 2018, revealed that the resident was severely cognitively impaired, required extensive assistance from staff for eating, and had medical diagnoses that included diabetes (a disease that interferes with blood sugar control) and dementia. The resident's care plan, dated December 12, 2018, included that staff were to provide set-up help and supervision to extensive assistance with meals.

Observation during the breakfast meal in the 200 unit dining room on January 30, 2019, at 8:50 a.m. revealed that Resident 36 was seated at a table with two other residents. At 8:51 a.m. staff served the two residents who were sitting with Resident 36; however, Resident 36 was not served her meal until 9:01 a.m.


A significant change MDS assessment for Resident 24, dated November 26, 2018, revealed that the resident was sometimes understood, could sometimes understand, required extensive assistance from staff for eating, and had medical diagnoses that included dementia and diabetes. The resident's care plan, dated December 1, 2018, included that staff were to provide set-up help and supervision to extensive assistance with meals.

A significant change MDS assessment for Resident 61, dated January 1, 2019, revealed that the resident was severely cognitively impaired, required supervision from staff for eating, and had medical diagnoses that included dementia. The resident's care plan, dated January 3, 2019, revealed that staff were to provide set-up help and supervision to limited assistance with meals.

Observation during the breakfast meal in the 200 unit dining room on January 30, 2019, at 8:50 a.m. revealed that Resident 24 and Resident 61 were seated at a table with three other residents. At 8:51 a.m. staff served the three residents who were sitting with Residents 24 and 61; however, Residents 24 and 61 were not served their meals until 9:02 a.m.

Interview with Nurse Aide 8 on January 30, 2019, at 10:14 a.m. revealed that they try to serve the residents who can feed themselves first, and due to one resident exhibiting behaviors, they try to feed her first, prior to serving the residents who need assistance. She indicated that Resident 36 requires assistance and takes a long time to eat, and Residents 24 and 61 both require assistance to eat.

Interview with the Director of Nursing on January 30, 2019, at 2:25 p.m. revealed that staff were aware that it was her expectation that residents sitting at the same table were to be fed at the same time.

28 Pa. Code 201.29(j) Resident rights.
Previously cited 2/15/18.




 Plan of Correction - To be completed: 03/30/2019

The preparation and/or execution of the Plan of Correction does not constitute admission or agreement by the provider of truth of the facts or conclusions set forth in the statement of deficiencies. This Plan of Correction is prepared and/or executed solely because it is required by the provision of federal and state laws.

* All residents receiving Restorative Dining Services were immediately separated into two groups to ensure that all Restorative Residents were experiencing a dignified dining experience.
A Restorative Dining process was completed. No negative outcome was identified by the cited practice.

* All Restorative residents have the potential to be affected by the same cited practice. Adequate levels of staff members, including Nursing Administration, will be available to ensure that all Restorative residents are being assisted and fed as they prefer.
The residents are separated into two groups. Group one will be assisted in the Dining areas first while the others are participating in activities with the Therapeutic Engagement staff. No residents will be seated in the dining area unless they are receiving their meal along with all of the other residents.

* Measures implemented to ensure future compliance with the above corrective action include:
All staff members will receive in-service education on this Plan of Correction, and others, on Wednesday, February 20th, 2019. The in-service education will be provided by the Administrator, Director of Nursing and The Clinical Education Coordinator. Additional in-service education will be provided to nursing staff members on the Restorative Dining process, by the Director of Nursing, on a date prior to the date of completion of this Plan of Correction.

* Monitoring of the above corrective action will occur via the utilization of a newly developed auditing tool.
The Director of Nursing, or her designee, will monitor the dining of residents in the Restorative Program to ensure that they all have a timely and dignified dining experience.

* Monitoring of the Restorative Dining Process will occur daily for two weeks, then weekly for two weeks, then bi-weekly for one month and then randomly in order to ensure that all Restorative residents continue to experience a dignified dining experience.
Results of the above corrective action will be forwarded to the Quality Assurance/Improvement Committee for review and/or recommendation.

* Compliance for the above Plan of Correction will attained by 3/30/2019.
483.75(g)(2)(ii) REQUIREMENT QAPI/QAA Improvement Activities:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
483.75(g) Quality assessment and assurance.

483.75(g)(2) The quality assessment and assurance committee must:
(ii) Develop and implement appropriate plans of action to correct identified quality deficiencies;
Observations:


Based on review of the facility's previous plans of correction and the results of the current survey, it was determined that the facility's Quality Assurance Performance Improvement (QAPI) committee failed to correct quality deficiencies and ensure that plans to improve the delivery of care and services effectively addressed recurring deficiencies.

Findings include:

The facility's deficiencies and plans of correction for a State Survey and Certification (Department of Health) survey ending February 15, 2018, revealed that the facility developed plans of correction that included quality assurance systems to ensure that the facility maintained compliance with cited nursing home regulations. The results of the current survey, ending January 31, 2019, identified repeated deficiencies related to a failure to complete a registered nurse assessment after a change in condition, accident hazards, unnecessary medications, labeling and storage of drugs, storing and preparing food under sanitary conditions, incomplete clinical records, and an effective infection control program.

The facility's plan of correction for a deficiency regarding a failure to ensure that a registered nurse assessed a resident after a change in condition, cited during the survey ending February 15, 2018, revealed that the facility developed a plan of correction that included completing audits and reporting the results of the audits to the QAPI committee for review. The results of the current survey, cited under F658, revealed that the facility's QAPI committee failed to successfully implement their plan to ensure ongoing compliance with regulations regarding registered nurse assessment after a change in condition.

The facility's plan of correction for a deficiency regarding accident hazards, cited during the survey ending February 15, 2018, revealed that the facility developed a plan of correction that included completing audits and reporting the results of the audits to the QAPI committee for review. The results of the current survey, cited under F689, revealed that the facility's QAPI committee failed to successfully implement their plan to ensure ongoing compliance with regulations regarding accident hazards.

The facility's plan of correction for a deficiency regarding unnecessary medications, cited during the survey ending February 15, 2018, revealed that the facility developed a plan of correction that included completing audits and reporting the results of the audits to the QAPI committee for review. The results of the current survey, cited under F758, revealed that the facility's QAPI committee failed to successfully implement their plan to ensure ongoing compliance with regulations regarding unnecessary medications.

The facility's plan of correction for a deficiency regarding labeling and storing drugs, cited during the survey ending February 15, 2018, revealed that the facility developed a plan of correction that included completing audits and reporting the results of the audits to the QAPI committee for review. The results of the current survey, cited under F761, revealed that the facility's QAPI committee failed to successfully implement their plan to ensure ongoing compliance with regulations regarding labeling and storing drugs.

The facility's plan of correction for a deficiency regarding preparing food under sanitary conditions, cited during the survey ending February 15, 2018, revealed that the facility developed a plan of correction that included completing audits and reporting the results of the audits to the QAPI committee for review. The results of the current survey, cited under F812, revealed that the facility's QAPI committee failed to successfully implement their plan to ensure ongoing compliance with regulations regarding preparing food under sanitary conditions.

The facility's plan of correction for a deficiency regarding resident records, cited during the survey ending February 15, 2018, revealed that the facility developed a plan of correction that included completing audits and reporting the results of the audits to the QAPI committee for review. The results of the current survey, cited under F842, revealed that the facility's QAPI committee failed to successfully implement their plan to ensure ongoing compliance with regulations regarding complete resident records.

The facility's plan of correction for a deficiency regarding infection control, cited during the survey ending February 15, 2018, revealed that the facility developed a plan of correction that included completing audits and reporting the results of the audits to the QAPI committee for review. The results of the current survey, cited under F880, revealed that the facility's QAPI committee failed to successfully implement their plan to ensure ongoing compliance with regulations regarding infection control.

Refer to F658, F689, F758, F761, F812, F842, F880.

42 CFR 483.75(g)(2)(ii) QAPI/QAA Improvement Activities.
Previously cited 2/15/18.

28 Pa. Code 201.14(a) Responsibility of licensee.
Previously cited 2/15/18.

28 Pa. Code 201.18(e)(1) Management.
Previously cited 2/15/18.






 Plan of Correction - To be completed: 03/30/2019

The preparation and/or execution of the Plan of Correction does not constitute admission or agreement by the provider of truth of the facts or conclusions set forth in the statement of deficiencies. This Plan of Correction is prepared and/or executed solely because it is required by the provision of federal and state laws.

* Immediate corrective actions to ensure future compliance with the cited deficiency F658- related to Registered Nurse Assessment following change in resident condition include:

* All Licensed Practical and Registered Nurses are receiving educational instruction on the regulatory requirement of Registered Nurse assessment regarding resident change in condition.
Continued Registered Nurse oversight will be provided in the secured Dementia Unit to ensure adequate Supervision and assessment and documentation of resident change in condition.
Nursing Supervisors will attend daily morning meetings with the Interdisciplinary team to review changes in resident condition and to ensure Registered nurse assessment is being completed for each condition change.
In order to maintain compliance with the above cited practice, the Interdisciplinary team will discuss all residents having change in condition daily. The documentation of residents having change in condition will be reviewed daily by the Director of Nursing, or her designee, to ensure that a Registered Nursing assessment was completed. The monitoring will continue indefinitely to ensure that Registered Nursing assessment remains compliant.


The above plan of correction, as noted in deficiency, will be completed by 3/30/2019.

Immediate corrective action as related to deficiency F-689 Includes:

All nursing staff members will receive in-service education on the Incident and Accident Prevention policy and procedure.
The Alternating Pressure Mattresses for all residents will be assessed for safety prior to and after application; and these mattresses will be assessed for safety and proper inflation following a fall of any resident from his/her bed.
A review of all Incident/Accident reports will occur every morning at the Interdisciplinary staff meeting. The Alternating Pressure mattresses for all residents using them will be assessed as possible contributing factors for falls from bed.
The Plan of Correction will be monitored as state in the deficiency F-689.
This Plan of correction will be completed as stated above, by 3/30/2019.

The Immediate Plan of correction related to deficiency F-758 - Unnecessary Medications.
All Licensed Nursing Staff members pharmacists and Physicians have received educational instruction of the compliance with Pharmacy recommendations for Gradual Dose reduction of Psychotropic medications.
The Interdisciplinary Quality Assessment/Process Improvement Committee related to Psychotropic medication reduction will continue to meet monthly to address the Pharmacy recommendations and review these with the Medical Director.
The interdisciplinary team will review all Psychotropic medications daily in the morning meeting to ensure that the Pharmacy recommendation are continually and properly addressed by Physicians.
The above Plan of Correction will be completed, as stated in the deficiency above, by 3/30/2019.

The immediate Plan of Correction for F-761 - Labeling and Storage of Drugs and Biologicals - All licensed nursing staff will receive on-going competency based education through hands on techniques and medication pass observations to ensure compliance with locking the medication cart drawers and never pre-filling medication syringes.
Routine monitoring of medication administration will be performed by the Clinical Education Coordinator, or her Designee to ensure future compliance with this cited practice.
The above deficiency, as noted earlier in this report, will be completed by 3/30/2019.

The immediate Plan of Correction for deficiency - F-812- Preparation of Food Under Sanitary Conditions - F- 812
The Food Service Department staff members have all received in-service education on the importance of following proper hand hygiene and glove
use. The educational instruction was provided by the Infection Control Practitioner and the Clinical Education Coordinator. Random Dietary Department audits will be performed by this Administrator, or her designee, to ensure that all staff members are practicing proper hand hygiene at all times.
The above plan of correction, as stated in the deficiency, will be complete by 3/30/2019.

Immediate Plan of action for Complete and Accurate Medical records - F- 842 - Al Nursing staff members received and will continue to receive on-going education on the importance of accurate clinical records and appropriate documentation in the clinical record.
The Director of Nursing, or her Designee will review documentation I the clinical record daily to ensure compliance with this requirement.
The date of completion for this Plan of Correction is, as listed In the original deficiency, 3/30/2019.

The immediate Plan of Correction for Deficiency- F-880 Includes:
All Licensed Nursing staff members received, and will continue to receive on-going education on the importance of practicing proper hang hygiene and glove use during medication administration. Random medication administration audits will be performed by the Assistant Director of Nursing and the Clinical Education Coordinator.
The date of completion for the above Plan of Correction, as indicated in the original deficiency, is 3/30/2019.

483.60(i)(1)(2) REQUIREMENT Food Procurement,Store/Prepare/Serve-Sanitary:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
483.60(i) Food safety requirements.
The facility must -

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

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


Based on review of policies, as well as observations and staff interviews, it was determined that the facility failed to ensure that staff used sanitary food handling techniques while preparing residents' food.

Findings include:

The facility's policy regarding glove use, dated January 2, 2019, indicated that employees handling food would change gloves when beginning each new task and before handling ready-to-eat foods.

Observations during the noon meal in the 500 hall dining room on January 28, 2019, at 12:25 p.m. revealed that Dietary Aide 13 walked away from the steam table to the refrigerator, touched the refrigerator door with her gloved hands, removed and opened a container of chicken salad, and with the same gloves on, handled two slices of bread and made and served a sandwich to a resident.

Interview with the Dietary Manager on January 28, 2019, at 12:40 p.m. revealed that staff should change their gloves and wash their hands after they touch items in the kitchen, such as the refrigerator handle, and prior to handling ready-to-eat foods such as sandwiches.

Interview with Dietary Aide 13 on January 28, 2019, at 12:45 p.m. confirmed that she touched the refrigerator door with her gloved hands and did not change her gloves and wash her hands prior to making a sandwich for a resident.

42 CFR 48360(i)(1)(2) Food Procurement, Store/Prepare/Serve-Sanitary.
Previously cited 2/15/18.

28 Pa. Code 211.6(f) Dietary services.
Previously cited 2/15/18.



 Plan of Correction - To be completed: 03/30/2019

The preparation and/or execution of the Plan of Correction does not constitute admission or agreement by the provider of truth of the facts or conclusions set forth in the statement of deficiencies. This Plan of Correction is prepared and/or executed solely because it is required by the provision of federal and state laws.

* No residents were adversely affected by the above cited practice.

All residents have the potential to be adversely affected by the cited practice.
Measures implemented to ensure that compliance is maintained within this requirement include:
Dietary staff member #13 has been counseled and will receive additional return demonstration Hand Hygiene and proper use of gloves educational instruction on Wednesday, February 13th, 2019. The Dietary Manager and the Infection Prevention/Control Practitioner will review proper handwashing techniques and glove changing expectations when working with food items. All Dietary staff members will receive the above training as well.
All staff members will receive educational instruction on the importance of proper hand hygiene and glove use on Wednesday, February 22nd, 2019.
The Administrator, Director of Nursing, Clinical Education Coordinator and the Infection Prevention/Control Practitioner will provide education and instruction to staff members regarding the importance of practicing proper hand hygiene and glove use among those who are providing services to residents.

* In order to maintain compliance with the above plan of correction, the Dietary Manager, or her Designee, will monitor proper sanitary practices during meal services via the utilization of a newly developed auditing tool.

* The Dietary Manager will observe the staff hand hygiene practice and glove use three times a week for three months.

* The above plan of correction will be completed by 3/30/2019.
483.35(a)(1)(2) REQUIREMENT Sufficient Nursing Staff:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
483.35(a) Sufficient Staff.
The facility must have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment required at 483.70(e).

483.35(a)(1) The facility must provide services by sufficient numbers of each of the following types of personnel on a 24-hour basis to provide nursing care to all residents in accordance with resident care plans:
(i) Except when waived under paragraph (e) of this section, licensed nurses; and
(ii) Other nursing personnel, including but not limited to nurse aides.

483.35(a)(2) Except when waived under paragraph (e) of this section, the facility must designate a licensed nurse to serve as a charge nurse on each tour of duty.
Observations:


Based on clinical record reviews, observations, and staff interviews, it was determined that the facility failed to ensure that there were sufficient staff to provide timely and appropriate assistance during meals, in accordance with residents' care plans, for 13 of 55 residents reviewed (Residents 5, 9, 19, 25, 27, 43, 44, 57, 60, 64, 66, 67, 74).

Findings include:

A significant change in status Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 66, dated January 8, 2019, revealed that the resident was severely cognitively impaired, had diagnoses that included dementia (brain disease or injury marked by issues with memory, personality changes, and impaired reasoning), and required extensive assistance from one staff for eating. The resident's care plan, dated January 10, 2019, revealed that staff were to provide set-up help with supervision to extensive assistance with meals, encourage the resident to feed herself and assist as needed, and provide intermittent cueing and supervision at meals.

A quarterly MDS assessment for Resident 67, dated January 8, 2019, revealed that the resident was severely cognitively impaired, had medical diagnoses that included Alzheimer's disease (a progressive loss of brain cells that leads to the loss of memory and other thinking skills) and dementia, and was totally dependent on staff for eating. The resident's care plan, dated January 23, 2019, revealed that staff were to provide total assistance for eating.

Observations during the lunch meal in the 300 unit dining room on January 29, 2019, at 12:07 p.m. revealed that staff were serving meals to residents; however, after they completed this task, Residents 66 and Resident 67 did not receive a meal at that time. At 12:44 p.m. Residents 66 and 67 were served their meals and staff sat down beside the residents to assist them to eat.

Interview with Registered Nurse 9 on January 29, 2019, at 1:01 p.m. revealed that they did not have enough staff to feed Resident 67 at the time they were serving other residents their meals because Resident 67 was dependent for eating. Although Resident 66 will feed herself at times, there were not enough staff available to assist her at the time that other residents were eating.


A significant change MDS assessment for Resident 5, dated November 5, 2018, revealed that the resident was usually understood and could usually understand, had diagnoses that included dementia, and required extensive assistance from staff for eating. The resident's care plan, dated November 6, 2018, included that staff were to provide extensive assistance with meals.

A significant change MDS assessment for Resident 9, dated January 22, 2019, revealed that the resident was sometimes understood and could usually understand, had diagnoses that included a stroke with hemiplegia (paralysis on one side of the body), and required limited assistance from staff for eating. The resident's care plan, dated January 30, 2019, included that staff were to provide set-up help and supervision to limited assistance with meals.

A quarterly MDS assessment for Resident 19, dated January 23, 2019, revealed that the resident was severely cognitively impaired, had diagnoses that included dementia and diabetes (a disease that interferes with blood sugar control), and was totally dependent on staff for eating. The resident's care plan, dated January 25, 2019, included that staff were to provide set-up help and supervision to total care with meals.

An annual MDS assessment for Resident 25, dated November 30, 2018, revealed that the resident was usually understood and could usually understand, had medical diagnoses that included diabetes, and required extensive assistance from staff for eating. The resident's care plan, dated December 3, 2018, included that staff were to provide set-up help and supervision to total care with meals.

A quarterly MDS assessment for Resident 27, dated December 4, 2018, revealed that the resident was sometimes understood and could usually understand, had medical diagnoses that included cerebral palsy (affects a person's ability to move and maintain balance and posture) and stroke, and was totally dependent on staff for eating. The resident's care plan, dated December 27, 2018, included that staff were to provide set-up help and supervision to total care with meals.

A quarterly MDS assessment for Resident 43, dated January 22, 2019, revealed that the resident was sometimes understood and could sometimes understand, had medical diagnoses that included dementia and diabetes, and required extensive assistance from staff for eating. The resident's care plan, dated January 24, 2019, included that staff were to provide extensive assistance with meals.

A significant change MDS assessment for Resident 44, dated December 17, 2018, revealed that the resident was usually understood and could usually understand, and required supervision from staff for eating. The resident's care plan, dated December 18, 2018, included that staff were to provide set-up help and supervision to limited assistance with meals.

A quarterly MDS assessment for Resident 57, dated January 1, 2019, revealed that the resident was severely cognitively impaired, had medical diagnoses that included dementia, and required extensive assistance from staff for eating. The resident's care plan, dated January 7, 2019, included that staff were to provide set-up help and supervision to total care with meals.

A quarterly MDS assessment Resident 60, dated January 1, 2019, revealed that the resident was sometimes understood and could sometimes understand, had medical diagnoses that included dementia and a stroke, and required extensive assistance from staff for eating. The resident's care plan, dated January 7, 2019, included that staff were to provide set-up help and supervision to extensive assistance with meals.

A quarterly MDS assessment for Resident 64, dated January 8, 2019, revealed that the resident was severely cognitively impaired, had medical diagnoses that included dementia, and required extensive assistance from staff for eating. The resident's care plan, dated January 14, 2019, included that staff were to provide set-up help and supervision to total assistance with meals.

An admission MDS assessment for Resident 74, dated January 1, 2019, revealed that the resident was usually understood and could usually understand, had medical diagnoses that included a stroke, and required limited assistance from staff for eating. The resident's care plan, dated December 26, 2018, included that staff were to provide assistance with meals.

Observations during the breakfast meal in the 300 unit dining room on January 30, 2019, at 8:05 a.m. revealed that Residents 9, 19, 25, 27, 57, 60, 64, 66, 67 and 74 were all seated in the dining room along with five other residents. At 8:13 a.m. staff served the five other residents who were all sitting at the same table, and staff sat down to assist four of the five residents and stopped feeding the other residents in the dining room. Resident 43 arrived in the dining room at 8:20 a.m., Resident 5 arrived at 8:21 a.m., and Resident 44 arrived at 8:24 a.m. At 8:26 a.m. two additional staff arrived and served Residents 66 and 67, who waited 13 minutes. At 8:29 a.m. Resident 5 was served his meal (8 minutes). At 8:32 a.m. staff finished assisting the initial residents who were served first and then served Residents 25 and 74, who waited 19 minutes, and Resident 43, who waited 12 minutes. At 8:36 a.m. Residents 19 and 57, who were seated in the private dining room connected to the main dining room, were served their meals after waiting 23 minutes. Resident 44 was served at 8:38 a.m. after waiting 13 minutes, and Residents 9, 27, 60 and 64 were served after waiting 25 minutes.

Interview with Restorative Licensed Practical Nurse 10 on January 30, 2019, at 9:50 a.m. revealed that the facility did not have enough staff to provide timely assistance to residents who required assistance to eat, and the number of residents who required assistance to eat had increased.

28 Pa. Code 211.14(a) Responsibility of licensee.
Previously cited 2/15/18.

28 Pa. Code 201.18(e)(1) Management.
Previously cited 2/15/18.

28 Pa. Code 211.12(a) Nursing services.




 Plan of Correction - To be completed: 03/30/2019

The preparation and/or execution of the Plan of Correction does not constitute admission or agreement by the provider of truth of the facts or conclusions set forth in the statement of deficiencies. This Plan of Correction is prepared and/or executed solely because it is required by the provision of federal and state laws.

* No negative out come was experienced by residents #5, #9, #19, #25, #27, #43, #44, #57, #60, #64, #66, #67,and/or #74.
All residents receiving Restorative Dining Services in the 200 and 300 Units were immediately separated into two separate dining groups. After the groups were divided, all residents at the tables received and consumed their meals at the same time. It was determined that the number of staff members is sufficient. However, the staff members were not evenly assigned/distributed to residents in the noted dining room areas during the breakfast and lunch time meals.

* All residents receiving Restorative Dining Services are at risk of being affected by the same cited practice.
Measures implemented to ensure future compliance with the requirement include:
All residents receiving Restorative Dining Services on both the 200 and 300 units were separated into two groups on each of the units. While one group of residents consumed their meal, the other group engaged in activities with the Life Enrichment personnel. The dining experience was effective and efficient once staff members and residents were redistributed.
All staff members will receive in-service education on the updated policy and procedure related to the Restorative Dining process. The in-service education will be conducted by the Administrator, Director of Nursing and the Clinical Education Coordinator on Wednesday, February 20th, 2019. Additional in-service education for the Nursing Staff members will occur on a specific date prior to the completion of this Plan of Correction. The in-service education will focus on the appropriate assigning/ distribution of staff members to residents during the meal time process to ensure that all residents are eating their meals together, and that no resident is waiting longer than any other (unless the resident chooses to do so).
Adequate assigning/distribution of nursing staff members, including licensed nursing staff/Nursing Management staff(as becomes necessary) to the Restorative Dining residents will ensure future compliance with the above cited requirement.
It was determined by the Interdisciplinary team decision that the number of staff members were sufficient when the groups of residents were divided because there was no longer an issue and staff members and residents indicated they were satisfied with the newly designed dining experience. If there are issues regarding staffing, the Director of Nursing and the Administrator assess and determine what the staffing needs and/or concerns are and address these.

* The above corrective action will be monitored via the utilization of a newly developed auditing tool. The Director of Nursing, or her Designee, will monitor the effectiveness of the redistribution/re-assignment of staff to residents in the Restorative Dining Program. Monitoring will occur daily for two weeks, weekly for six weeks, then monthly for three months.
Audit results will be referred to the Quality Assurance/Improvement Committee for review and recommendation.

* The above Plan of Correction will be completed by 3/30/2019.
483.10(f)(5)(i)-(iv)(6)(7) REQUIREMENT Resident/Family Group and Response:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
483.10(f)(5) The resident has a right to organize and participate in resident groups in the facility.
(i) The facility must provide a resident or family group, if one exists, with private space; and take reasonable steps, with the approval of the group, to make residents and family members aware of upcoming meetings in a timely manner.
(ii) Staff, visitors, or other guests may attend resident group or family group meetings only at the respective group's invitation.
(iii) The facility must provide a designated staff person who is approved by the resident or family group and the facility and who is responsible for providing assistance and responding to written requests that result from group meetings.
(iv) The facility must consider the views of a resident or family group and act promptly upon the grievances and recommendations of such groups concerning issues of resident care and life in the facility.
(A) The facility must be able to demonstrate their response and rationale for such response.
(B) This should not be construed to mean that the facility must implement as recommended every request of the resident or family group.

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

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


Based on review of Resident Council meeting minutes and residents' clinical records, as well as resident and staff interviews, it was determined that the facility failed to make ongoing efforts to promptly resolve the grievances of the Resident Council.

Findings include:

Resident Council meeting minutes, dated September 6, October 5, November 1 and December 6, 2018, and January 3, 2019, revealed that residents expressed concerns about the long wait time for staff to answer their call bells. Each month this concern was presented to the Director of Nursing or the Activity Director during the Resident Council meeting.

Interview with a group of residents on January 29, 2019, at 11:00 a.m. revealed that the residents stated that they wait too long for their call bell to be answered on the night shift, and they often have incontinent episodes (bladder of bowel accidents) because of the long wait times. They reported that the call bell wait times were worse on the night shift because of a lack of staff on each unit, and the nurse aides will enter the room, turn the call bell off, tell the resident that they will come right back, but then not return, forcing the resident to ring the bell again.

Interview with the Director of Nursing on January 13, 2019, at 2:53 p.m. revealed that she was aware that the residents were upset about the long wait times for their call bells to be answered and that she had been conducting call bell audits. She stated if a call bell alarms for more than five minutes it will beep in her office to alert her; however, she has never come in during the night shift to observe call bell wait times herself. The Director of Nursing was not able to provide documented evidence of prompt and ongoing efforts to address the concerns of the Resident Council regarding long call bell wait times.

28 Pa. Code 201.29(i) Resident rights.



 Plan of Correction - To be completed: 03/30/2019

The preparation and/or execution of the Plan of Correction does not constitute admission or agreement by the provider of truth of the facts or conclusions set forth in the statement of deficiencies. This Plan of Correction is prepared and/or executed solely because it is required by the provision of federal and state laws.

* Call bell audits were reviewed for better staff responsiveness and resident satisfaction. No negative outcomes were identified by the cited practice.

* all residents who verbalize grievances, complaints, and/or concerns during monthly Resident Council meetings are at risk for being affected by the same above cited practice.
Measures implemented to ensure future compliance with the cited requirement include:
In-service education will be provided by the Administrator, Director of Nursing and Clinical Education Coordinator on the facility policies, procedures and protocols on addressing, investigating and follow-up on resident grievances, complaints and/or concerns.
The Life Enrichment Coordinator will inform Department Managers in writing regarding any verbalized grievance, complaint and/or concerns verbalized by residents during resident council meetings. The appropriate Department Manager will complete and log the grievance and record any and all action taken, and document follow-up with resident(s) involved.
The above corrective actions will be monitored via the utilization of a newly developed auditing tool. The Administrator, or her Designee, will perform monthly audits on the grievance log to ensure that all resident grievances, complaints and/or concerns were addressed by the appropriate Department Manager, investigated and follow-up was provided and documented. The audits will be performed by the Administrator, or her Designee monthly following the Resident Council meeting for six months or until one hundred percent compliance is achieved.

* Results of the audits will be referred to the Quality Assurance/Improvement Committee for review and recommendation.

* The above Plan of Correction will be completed by 3/30/19.
483.10(c)(7) REQUIREMENT Resident Self-Admin Meds-Clinically Approp:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.10(c)(7) The right to self-administer medications if the interdisciplinary team, as defined by 483.21(b)(2)(ii), has determined that this practice is clinically appropriate.
Observations:


Based on review of policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that assessments were completed to determine if it was safe for a resident to self-administer medications for one of 55 residents reviewed (Resident 3).

Findings include:

The facility's policy regarding self-administration of medications, dated January 2, 2019, indicated that residents could keep medications at their bedsides and self-administer if they were able to demonstrate the ability to self-administer medications.

A significant change Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 3, dated November 2, 2018, indicated that the resident was alert and oriented and required the extensive assistance of two persons for daily care needs. A recapitulation of physician's orders for January 2019 included an order for Proctozone HC 2.5 percent cream (topical cream for hemorrhoids) to be applied three times daily for hemorrhoids.

Observations on January 28, 2019, at 11:30 a.m. revealed that Resident 3 had a tube of Proctozone HC 2.5 percent at bedside. Interview with Licensed Practical Nurse 2 on January 28, 2019, at 12:15 p.m. confirmed that the cream was present on Resident 3's nightstand and should not have been, and the nurse removed the cream from the resident's room.

Physician's orders, dated January 29, 2019, included an order for Proctozone HC 2.5 percent cream (topical cream for hemorrhoids) to be applied three times daily to hemorrhoids, and the cream could be kept at bedside. There was no documented evidence that an assessment was completed to determine if the resident was capable, and if it was safe for the resident to self-administer the hemorrhoid cream.

Interviews with Registered Nurses 11 and 12 on January 31, 2019, at 2:35 p.m. revealed that Resident 3 had been self-administering the hemorrhoid cream and requested that it be kept at bedside.

Interview with the Director of Nursing on January 31, 2019, at 5:10 p.m. confirmed that an assessment to determine if it was safe for Resident 3 to self-administer the hemorrhoid cream was not completed prior to permitting the resident to do so.

28 Pa. Code 211.10(c) Resident care policies

28 Pa. Code 211.12(d)(1) Nursing services.
Previously cited 2/15/18.

28 Pa. Code 211.12(d)(5) Nursing services.
Previously cited 5/17/18, 2/15/18.





 Plan of Correction - To be completed: 03/30/2019

The preparation and/or execution of the Plan of Correction does not constitute admission or agreement by the provider of truth of the facts or conclusions set forth in the statement of deficiencies. This Plan of Correction is prepared and/or executed solely because it is required by the provision of federal and state laws.

* Licensed Practical Nurse Immediately removed the cream from the bedside of resident #3 and secured it inside of the medication cart. Resident #3 suffered no adverse affects from the cited practice.

* All residents receiving medications are at risk for the cited requirement.


* Measures implemented to ensure future compliance with the cited requirement include:
The Self Administration of Medication policy and procedure has been reviewed and revised to include the addition of a Self Administration of medication assessment. The Self Administration of Medication Assessment was completed for resident #3.
All residents having medications stored at bedside will have orders reviewed, assessment completed and Physician notification of assessment appropriateness findings when appropriate.
All staff members will receive in-service education on the above cited requirement and the updated policy/procedure by the Administrator, Director of Nursing, Infection Control/Prevention Practitioner and Clinical Education Coordinator on Wednesday, February 20th.
Licensed Nursing staff members will receive additional in-service education by the Director of Nursing, or her Designee prior to the Plan of Correction completion date.
The Mental status assessment will be reviewed by the Director of Nursing, or her designee, for those residents who self administer medications to ensure appropriateness of self administration of medications.

* The above corrective action will be monitored via the utilization of a newly developed auditing tool. The Director of Nursing, or her designee will perform audits on the Physician's orders and self administration of medication assessments of all residents deemed appropriate to self administer medications to ensure maintained compliance. Compliance audits will be performed weekly for four weeks, then monthly for three months. Findings of the compliance audits will be forwarded to the Quality Assurance/Quality Improvement Committee for review and/or recommendation.

* The above Plan of Correction will be completed by 3/30/2019.
483.10(g)(17)(18)(i)-(v) REQUIREMENT Medicaid/Medicare Coverage/Liability Notice:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.10(g)(17) The facility must--
(i) Inform each Medicaid-eligible resident, in writing, at the time of admission to the nursing facility and when the resident becomes eligible for Medicaid of-
(A) The items and services that are included in nursing facility services under the State plan and for which the resident may not be charged;
(B) Those other items and services that the facility offers and for which the resident may be charged, and the amount of charges for those services; and
(ii) Inform each Medicaid-eligible resident when changes are made to the items and services specified in 483.10(g)(17)(i)(A) and (B) of this section.

483.10(g)(18) The facility must inform each resident before, or at the time of admission, and periodically during the resident's stay, of services available in the facility and of charges for those services, including any charges for services not covered under Medicare/ Medicaid or by the facility's per diem rate.
(i) Where changes in coverage are made to items and services covered by Medicare and/or by the Medicaid State plan, the facility must provide notice to residents of the change as soon as is reasonably possible.
(ii) Where changes are made to charges for other items and services that the facility offers, the facility must inform the resident in writing at least 60 days prior to implementation of the change.
(iii) If a resident dies or is hospitalized or is transferred and does not return to the facility, the facility must refund to the resident, resident representative, or estate, as applicable, any deposit or charges already paid, less the facility's per diem rate, for the days the resident actually resided or reserved or retained a bed in the facility, regardless of any minimum stay or discharge notice requirements.
(iv) The facility must refund to the resident or resident representative any and all refunds due the resident within 30 days from the resident's date of discharge from the facility.
(v) The terms of an admission contract by or on behalf of an individual seeking admission to the facility must not conflict with the requirements of these regulations.
Observations:


Based on clinical record reviews and staff interviews, it was determined that the facility failed to provide the required notice to the resident or the resident's representative following the end of their Medicare coverage for two of three residents reviewed (Residents 74, 75) who remained in the facility for long-term care.

Findings include:

A Skilled Nursing Facility (SNF) Beneficiary Protection Notification Review form, completed by the facility and dated January 13, 2019, revealed that Medicare coverage for Resident 74 started on December 25, 2018, and that her last covered day was January 13, 2019. The form indicated that the facility initiated discontinuation from Medicare Part A coverage and that the resident's benefit days were not exhausted. According to Resident 74's care plan, updated December 25, 2018, she remained in the facility to receive long-term care following the end of her Medicare coverage.

A Skilled Nursing Facility (SNF) Beneficiary Protection Notification Review form, completed by the facility and dated January 13, 2019, revealed that Medicare coverage for Resident 75 started on December 31, 2018, and that his last covered day was January 13, 2019. The form indicated that the facility initiated discontinuation from Medicare Part A coverage and that the resident's benefit days were not exhausted. According to Resident 75's care plan, updated December 31, 2018, he remained in the facility to receive long-term care following the end of his Medicare coverage.

There was no documented evidence that Residents 74 and 75 were provided with an Advance Beneficiary Notice of Noncoverage (ABN - a notice given to Medicare beneficiaries to convey that Medicare is not likely to provide coverage in a specific case).

Interview with the Director of Social Services on January 31, 2019, at 9:44 a.m. revealed that she was unaware that residents were to be issued an ABN if they were not appealing the end of their Medicare time and that she had not been issuing them to residents who did not appeal their Medicare denials.

28 Pa. Code 201.18(e)(1) Management.
Previously cited 2/15/18.


 Plan of Correction - To be completed: 03/30/2019

he preparation and/or execution of the Plan of Correction does not constitute admission or agreement by the provider of truth of the facts or conclusions set forth in the statement of deficiencies. This Plan of Correction is prepared and/or executed solely because it is required by the provision of federal and state laws.



* The Medicare Beneficiary Protection Notification Review Forms for resident's #74 and #75 have been completed and presented to these residents/responsible party's.

* All residents who experience a change in his/her Medicare coverage are at risk for being affected by the above cited practice. Measures implemented to ensure that the cited practice does not repeat include: The Director of Social Services has received educational instruction on the regulatory guidelines regarding timely presentation of the Beneficiary Protection Notification Review Form to all residents who experience changes in his/her Medicare coverage while remaining in the facility.
An educational in-service for all staff related to this plan of correction has ben scheduled for Wednesday, February 22nd, 2019.
A checklist has been originated and is being maintained by the Director of Social services. The Director of Social Services, or her Designee, will document on the checklist, the names of all residents who shall receive a Beneficiary Protection Notification Review Form. The resident's names will be checked as the forms are received.

* Compliance with the above corrective action will be monitored via the utilization of a newly developed auditing tool. The Director of Discharge Planning Services, or her Designee, will perform compliance audits on the list maintained by the Director of Social Services.
Compliance monitoring will compare the checklist with resident conversation to ensure the forms were received.
Audits will occur weekly for four weeks, then monthly for three months.

* The above Plan of Correction will be complete by 3/30/2019.
483.21(a)(1)-(3) REQUIREMENT Baseline Care Plan:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.21 Comprehensive Person-Centered Care Planning
483.21(a) Baseline Care Plans
483.21(a)(1) The facility must develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. The baseline care plan must-
(i) Be developed within 48 hours of a resident's admission.
(ii) Include the minimum healthcare information necessary to properly care for a resident including, but not limited to-
(A) Initial goals based on admission orders.
(B) Physician orders.
(C) Dietary orders.
(D) Therapy services.
(E) Social services.
(F) PASARR recommendation, if applicable.

483.21(a)(2) The facility may develop a comprehensive care plan in place of the baseline care plan if the comprehensive care plan-
(i) Is developed within 48 hours of the resident's admission.
(ii) Meets the requirements set forth in paragraph (b) of this section (excepting paragraph (b)(2)(i) of this section).

483.21(a)(3) The facility must provide the resident and their representative with a summary of the baseline care plan that includes but is not limited to:
(i) The initial goals of the resident.
(ii) A summary of the resident's medications and dietary instructions.
(iii) Any services and treatments to be administered by the facility and personnel acting on behalf of the facility.
(iv) Any updated information based on the details of the comprehensive care plan, as necessary.
Observations:


Based on clinical record reviews and staff interviews, it was determined that the facility failed to create baseline care plans that included residents' individualized care needs, and failed to provide a written summary of the baseline care plans to the resident and/or resident's representative for two of 55 residents reviewed (Residents 12, 185) who were new admissions.

Findings include:

An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 185, dated January 25, 2019, revealed that the resident was alert and oriented, required extensive assistance for care, did not ambulate (walk), and received dialysis treatments (a mechanical process that purifies the blood of a person whose kidneys are not working normally). A hospital discharge summary for Resident 185, dated January 18, 2019, revealed that the resident had diagnoses that included end-stage renal (kidney) disease requiring dialysis treatment.

There was no documented evidence that Resident 185's baseline care plan (includes the minimum healthcare information necessary to properly care for a resident) included information about the resident's dialysis treatment, and no documented evidence that the resident and/or the resident's representative was provided with a written summary of the baseline care plan.


An admission MDS assessment for Resident 12, dated November 12, 2018, revealed that the resident was alert and oriented, required limited to extensive assistance for care, and was receiving hospice (end-of-life) services. A nursing note for Resident 12, dated November 6, 2018, at 1:44 p.m. revealed that she arrived via wheelchair from home with her family, she was respite care (temporary care provided in the facility, to offer a break to the primary caregiver at home) and under hospice care.

There was no documented evidence that Resident 12's baseline care plan included information about the resident's hospice services, and no documented evidence that the resident and/or the resident's representative was provided with a written summary of the baseline care plan.

Interview with the Director of Nursing on January 31, 2019, at 3:28 p.m. confirmed that baseline care plans were not created for Resident 185's dialysis care and Resident 12's hospice care, and that the residents' and/or the residents' representatives were not provided with a written summary of the baseline care plans.

28 Pa. Code 211.11(e) Resident care plan.





 Plan of Correction - To be completed: 03/30/2019

The preparation and/or execution of the Plan of Correction does not constitute admission or agreement by the provider of truth of the facts or conclusions set forth in the statement of deficiencies. This Plan of Correction is prepared and/or executed solely because it is required by the provision of federal and state laws.

* The care plan for resident #12 was immediately updated to reflect Hospice Services.
The care plan for resident #185 was immediately updated to reflect Dialysis services.
No negative outcome was identified for either of the noted residents.

* All residents with orders for Dialysis and/or Hospice Services are at risk for being affected by this same cited practice. Measures implemented to ensure that the cited practice is not repeated include:
The plans of care for the residents named have been updated to reflect Hospice and Dialysis services provided.
The baseline plans of care for all applicable residents are in the process of review and will be updated to include residents' individualized care needs, and written summaries will be provided to the residents/responsible parties.
In-service education will be provided to all staff members regarding this plan of correction on Wednesday, February 20th, 2019. Educational instruction will be provided by the Administrator, Director of Nursing and Clinical Education Coordinator.
Additional educational instruction will be provided to Licensed Nursing Staff members, Interdisciplinary team members, Case Manager, Registered Nurse Assessment Coordinator and Social Service Director. This additional in-service education will occur at a time prior to the finalization of this plan of correction.
The admitting Registered Nurse will initiate the Baseline plan of care and review with resident/responsible party as applicable. The Admitting nurse will document that the baseline plan of care was completed on the 24 hour report sheet.

* Interdisciplinary team members and the Registered Nurse Assessment Coordinator will review and update plans of care to ensure that a baseline/comprehensive assessment for each applicable resident has been completed.

* The above Plan of Correction will be monitored via the utilization of a newly developed auditing tool. The Director of Nursing, or her designee, will perform audits on the care plans of 5 newly admitted residents (or otherwise) weekly for one month, then monthly for three months to ensure compliance with the cited requirement.

* Compliance audits will be referred to the Quality Assurance/Improvement Committee for review and recommendation.

* The above Plan of Correction will be completed by 3/30/2019.
483.21(b)(1) REQUIREMENT Develop/Implement Comprehensive Care Plan:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.21(b) Comprehensive Care Plans
483.21(b)(1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at 483.10(c)(2) and 483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following -
(i) The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under 483.24, 483.25 or 483.40; and
(ii) Any services that would otherwise be required under 483.24, 483.25 or 483.40 but are not provided due to the resident's exercise of rights under 483.10, including the right to refuse treatment under 483.10(c)(6).
(iii) Any specialized services or specialized rehabilitative services the nursing facility will provide as a result of PASARR recommendations. If a facility disagrees with the findings of the PASARR, it must indicate its rationale in the resident's medical record.
(iv)In consultation with the resident and the resident's representative(s)-
(A) The resident's goals for admission and desired outcomes.
(B) The resident's preference and potential for future discharge. Facilities must document whether the resident's desire to return to the community was assessed and any referrals to local contact agencies and/or other appropriate entities, for this purpose.
(C) Discharge plans in the comprehensive care plan, as appropriate, in accordance with the requirements set forth in paragraph (c) of this section.
Observations:


Based on clinical record reviews and staff interviews, it was determined that the facility failed to develop comprehensive care plans that included specific and individualized interventions to address residents' specific care needs for two of 55 residents reviewed (Residents 23, 43).

Findings include:

A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 23, dated November 28, 2018, revealed that the resident was able to be understood, required extensive assistance for care, and was incontinent of bowel and bladder. A nursing note for Resident 23, dated January 12, 2019, at 7:31 a.m. revealed that the resident was complaining about lower abdominal pain and chills, and on assessment she was having vomiting, diarrhea, and shortness of breath, and appeared pale and requested to go to the hospital. A nursing note dated January 14, 2019, revealed that the resident was readmitted to the facility from the hospital with a diagnosis of Clostridium difficile (C.diff - an infectious bacterium that causes diarrhea), and physician's orders dated January 14, 2019, included an order for the resident to receive Vancomycin (an antibiotic used to treat bacterial infections in the bowel) for C. diff.

There was no documented evidence that a care plan to address Resident 23's care needs related to C. diff infection was developed.

Interview with the Director of Nursing on January 31, 2019, at 3:02 p.m. confirmed that a care plan to address Resident 23's C. diff infection should have been created on January 14, 2019, when she was readmitted to the facility.


A significant change in status MDS assessment for Resident 43, dated December 17, 2018, indicated that the resident was sometimes understood and had an indwelling urinary catheter (tube placed and held in the bladder to drain urine). Physician's orders, dated July 3, 2018, included an order to change the indwelling urinary catheter every 30 days and as needed if it became dislodged or could not be irrigated successfully. Physician's orders dated January 1, 2019, included orders to monitor the resident's fluid intake and urinary output every shift, flush the indwelling urinary catheter as needed, monitor the placement of the indwelling urinary catheter tubing every shift, and document on the Treatment Administration Record (TAR).

Resident 43's care plan, dated January 24, 2019, included that staff were to provide assistance with the indwelling urinary catheter; however, there was no documented evidence that the care plan included specific and individualized interventions to address the resident's care needs regarding the indwelling urinary catheter.

Interview with Registered Nurse Assessment Coordinator 7 (RNAC - a registered nurse who is responsible for the completion of MDS assessments and who is often involved in the development of care plans) on January 31, 2019, at 2:45 p.m. revealed that he felt that the physician's orders on the resident's TAR were part of the care plan.

28 Pa. Code 211.11(d) Resident care plans.





 Plan of Correction - To be completed: 03/30/2019

The preparation and/or execution of the Plan of Correction does not constitute admission or agreement by the provider of truth of the facts or conclusions set forth in the statement of deficiencies. This Plan of Correction is prepared solely because it is required by the provision of federal and state laws.

* The plan of care for resident #23 has been updated to include specific care needs related to her history of Chlostridium Difficile.
The plan of care for resident #43 has been updated to reflect specific care needs related to an indwelling foley catheter.
The policy and Procedure related to comprehensive care plan completion and accuracy was not being followed.
No negative outcome was identified as a result of the above cited practice.

* All residents are at risk for being adversely affected by the above cited practice.
Measures implemented to ensure future compliance with the noted requirement include:
The Policy and Procedure regarding Comprehensive and Individualized plans of care has been updated and will be reviewed with all staff members at an in-service scheduled for Wednesday, 2/20/2019. In-service education will be provided by the Administrator, Director of Nursing and Clinical Education Coordinator.
The plans of care for all residents will be assessed for individualization and will be updated accordingly prior to the date of Plan of Correction completion.
The Interdisciplinary Care Team and the Registered Nurse Assessment Coordinator will review and update existing and newly developed plans of care. The Registered Nurse Assessment Coordinator will have the responsibility of ensuring that all care needs are documented on the plan of care. The residents chart is always included in the plan of care conference.

* The above Plan of Correction will be monitored via the utilization of a newly developed auditing too. care plans of five residents will be monitored by the Assistant Director of Nursing, or her Designee, weekly for one month, then monthly for three months.

Results of the above monitoring will be forwarded to the Quality Assurance/Improvement Committee for review and recommendation.

* The above Plan of Correction will be completed by 3/30/2019.
483.21(b)(3)(i) REQUIREMENT Services Provided Meet Professional Standards:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.21(b)(3) Comprehensive Care Plans
The services provided or arranged by the facility, as outlined by the comprehensive care plan, must-
(i) Meet professional standards of quality.
Observations:


Based on review of the Pennsylvania Nurse Practice Act and residents' clinical records, as well as staff interviews, it was determined that the facility failed to ensure that a professional (registered) nurse completed an assessment of a resident following a change in condition for one of 55 residents reviewed (Resident 11), and failed to ensure that physician's orders were clarified when needed for one of 55 residents reviewed (Resident 43).

Findings include:

The Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, 21.11 (a)(1)(2)(4) indicated that the registered nurse was to collect complete and ongoing data to determine nursing care needs, analyze the health status of individuals and compare the data with the norm when determining nursing care needs, and carry out nursing care actions that promote, maintain and restore the well-being of individuals.

An annual Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 11, dated November 12, 2018, indicated that the resident was confused and required extensive assistance from staff for transfers, bed mobility, hygiene and dressing. A nursing note, dated November 26, 2018, at 10:16 a.m. indicated that the resident had a witnessed fall in the dining room, hit her head on the floor, and was sent to the emergency room. A nursing note dated November 26, 2018, at 4:23 p.m. revealed that the resident returned from the emergency room at 4:00 p.m. after receiving staples to the back of her head. A nursing note dated November 26, 2018, at 6:06 p.m. revealed that Licensed Practical Nurse 14 was called to Resident 11's room after the resident was walking, became limp, her eyes rolled in her head, and she vomited. There was no documented evidence that a registered nurse completed an assessment of this change in the resident's condition.

Interview with the Director of Nursing on January 31, 2019, at 3:08 p.m. confirmed that a registered nurse should have assessed Resident 11's change of condition, especially because she had a head injury earlier that day.


A quarterly MDS assessment for Resident 43, dated December 17, 2018, indicated that the resident was sometimes understood and could sometimes understand, and had an indwelling urinary catheter (a tube inserted and held in the bladder to drain urine).

A nursing note for Resident 43, dated July 3, 2018, revealed that the resident was admitted to the facility with an intact 16 French (size) indwelling urinary catheter with a 10 cubic centimeter (cc) balloon (located on the bladder end of the catheter and filled with fluid to hold the catheter in place). Physician's orders, dated July 3, 2018, included orders to change the indwelling urinary catheter every 30 days and as needed if it became dislodged or if it could not be irrigated successfully. The physician's order did not include the size of the catheter to be used.

A nursing note for Resident 43, dated October 23, 2018, revealed that the resident returned from the emergency room and emergency room staff replaced the indwelling urinary catheter with a size 16 French. A nursing note dated October 29, 2018, revealed that multiple attempts to flush the resident's indwelling urinary were unsuccessful, and the catheter was removed and replaced with an 18 French catheter. A nursing note dated November 26, 2018, revealed that the indwelling urinary catheter was not draining, was changed, and an 18 French catheter with a 10 cc balloon was inserted. A nursing note dated November 30, 2018, revealed that the indwelling urinary catheter was not draining and could not be irrigated so it was changed and an 18 French catheter was inserted.

Physician's orders for Resident 43, dated January 1, 2019, included an order to maintain the indwelling urinary catheter. The physician's order did not include the size of the catheter to be used.

A nursing note for Resident 43, dated January 24, 2019, revealed that the resident's indwelling urinary catheter was not draining and could not be irrigated so it was changed and a 16 French catheter was inserted. A nursing note dated January 29, 2019, revealed that the indwelling urinary drainage bag was empty, an unsuccessful attempt to irrigate was made, and a new 16 French catheter was inserted.

There was no documented evidence that staff attempted to clarify the incomplete physician's order regarding the size of the catheter that Resident 43 was to use.

Interview with the Director of Nursing on January 31, 2019, at 5:40 p.m. confirmed that the July 3, 2018, physician's order to change Resident 43's indwelling urinary catheter did not include the size of catheter to be inserted, and that staff should have clarified the physician's orders to include the size of the catheter the resident was to use.

42 CFR 483.21(b)(3)(i) Services Provided Meet Professional Standards.
Previously cited 2/15/18.

28 Pa. Code 211.12(d)(1)(3) Nursing services.
Previously cited 2/15/18.

28 Pa. Code 211.12(d)(5) Nursing services.
Previously cited 5/17/18, 2/15/18.




 Plan of Correction - To be completed: 03/30/2019

The preparation and/or Plan of Correction does not constitute admission or agreement by the provider of truth of the facts or conclusions set forth in the statement of deficiencies. This Plan of Correction is prepared and/or executed solely because it is required by the provision of federal and state laws.

* The Licensed Practical Nurse was provided with educational instruction on the expectation that she notify the Registered Nurse for assessment on any resident exhibiting a change in condition.
An order was obtained from the Physician by the Registered Nurse, for the correct indwelling foley catheter size for resident # 43.

* All residents having any change in condition are at risk of being affected by this same cited practice.
Measures implemented to ensure future compliance with the cited requirement include:
All staff will receive in-service education related to this and other cited requirements on Wednesday, 2/20/2019. In-service education will be provided by the Administrator, Director Of Nursing and the Clinical Education Coordinator.
Additional in-service education to the Licensed Nurses will occur on a date prior to the Plan of Correction completion deadline. The education will focus on the importance and the requirement of Registered Nurse assessments in all condition change. The in-service educational material will be provided by The Director of Nursing Services and The Clinical Education Coordinator.

* The above Plan of Correction will be monitored via the utilization of a newly developed auditing tool.
The Director of Nursing, or her Designee, will review the change I condition report daily for any noted resident change (decline, falls, weight loss, etc.) Nursing progress notes will also be reviewed daily by the Director of Nursing, or her designee, to ensure that any change in resident condition/correct size of indwelling foley catheter was assessed and documented by a Licensed Registered Nurse.

* The above Plan of Correction will be monitored via the utilization of a newly developed auditing tool. The Nursing progress notes and change in condition sheet of residents will be reviewed weekly by the Director of Nursing or her Designee, to ensure compliance with Registered Nurse assessment with condition change/Indwelling foley catheter size. The progress notes and change in condition sheet of ten residents will be reviewed weekly for four weeks, then monthly for three months to ensure compliance with the cited requirement.

The protocol for possible head injury is to complete neurological assessments as per facility protocol. The Physicians and Registered Nurses were provided with education on proper order completion regarding foley catheter size documentation in the order. The root cause of nurses not clarifying the need to get clarification of the foley catheter size is being addressed with educational instruction.
* audit results will be forwarded to the Quality Assurance/Improvement Committee for review and recommendation.

* The above Plan of Correction will be completed by 3/30/2019.
483.25(d)(1)(2) REQUIREMENT Free of Accident Hazards/Supervision/Devices:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.25(d) Accidents.
The facility must ensure that -
483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and

483.25(d)(2)Each resident receives adequate supervision and assistance devices to prevent accidents.
Observations:


Based on review of clinical records and incident investigation reports, as well as observations and staff interviews, it was determined that the facility failed to ensure that air mattresses were assessed for potential safety hazards following a fall out of bed for one of 55 residents reviewed (Resident 53).

Findings include:

A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 53, dated December 26, 2018, indicated that the resident was cognitively impaired, required extensive assistance for daily care tasks, including transfers and bed mobility, and had diagnoses that included dementia (disease that affects thought processes, decision making, memory, and/or the ability to care for oneself). Physician's orders dated March 13, 2018, included an order for an air mattress on the resident's bed. The resident's care plan, updated January 19, 2019, indicated that the resident was at risk for falls and changes in skin integrity, and had an air mattress on his bed.

A nursing note and an incident investigation for Resident 53, dated October 28, 2018, revealed that the resident was found lying on a fall mat (mat placed on the floor near a resident's bed to prevent serious injuries from falls) on his stomach on the right side of his bed. No injuries were noted and the resident was assisted back into bed by two staff and a mechanical lift (device that uses hydraulic power to lift and transfer a resident from surface to surface).

Following the fall out of bed on October 28, 2018, there was no documented evidence that the incident investigation included an assessment of the air mattress as a potential contributing factor to the fall.

Interview with the Director of Nursing on January 31, 2019, at 5:10 p.m. confirmed that the air mattress was not assessed as a potential contributing factor to Resident 53's fall out of bed.

42 CFR 483.25(d)(1)(2) Free of Accident Hazards/Supervision/Devices.
Previously cited 2/15/18.

28 Pa. Code 211.12(d)(5) Nursing services.
Previously cited 5/17/18, 2/15/18.








 Plan of Correction - To be completed: 03/30/2019

The preparation and/or execution of the Plan of Correction does not constitute admission or agreement by the provider of truth of the facts or conclusions set forth in the statement of deficiencies. This Plan of Correction is prepared solely because it is required by the provision of federal and state laws.

* The Alternating Pressure Mattress on the bed of resident # 53 has been assessed for safety and poses no increased risk at this time.
There was no negative outcome as a result of the above cited action.
A safety assessment on every Alternating Pressure Mattress must be completed prior to application to a resident's bed. All Alternating Pressure Mattresses will be assessed for function, placement and inflation following every resident fall from bed to assess as to whether or not the mattress contributed to the fall.

* All residents having Alternating Pressure Mattresses are at risk for the same cited practice.
Measures implemented to ensure future compliance with the cited requirement include:
All Alternating Pressure Mattresses in the facility have been assessed to ensure that they are inflated properly and completely, and they pose no entrapment risk to residents.
All Alternating Pressure mattresses are being assessed after falls to indicate as to whether or not the mattress may have been a contributing factor. The potential for Alternating Pressure mattresses being responsible for falls has been investigated, however, the mattress assessment form had not been completed until this plan of corrective action was implemented.
All staff members will receive in-service education on the importance of ensuring that all Alternating Pressure Mattresses are assessed for function and safety. The in-service education will be provided by the Administrator, Director of Nursing and Clinical Education Coordinator on Wednesday, February 20th, 2019.
Additional in-service education will be provided to all nursing staff members on a specific date prior to completion of the Plan of Correction.

* The above corrective actions will be monitored via the utilization of a newly developed auditing tool.
The Alternating Pressure Mattresses of all residents who have had a fall out of bed, will be assessed to ensure safety, and confirm that a faulty mattress was not a contributing factor to the fall. Audits will be performed by the Director of Nursing, or her Designee, on all fall reports weekly for four weeks, then Monthly for three months. The audits will specifically target residents falling out of bed, and having an Alternating Pressure mattress on the bed.
Results of compliance audits will be referred to the Quality Assurance/Improvement Committee for review and recommendation.

* The above Plan of Correction will be completed by 3/30/2019.
483.25(k) REQUIREMENT Pain Management:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.25(k) Pain Management.
The facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences.
Observations:


Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that a resident's pain level was assessed prior to the administration of pain medications for two of 55 residents reviewed (Residents 25, 51).

Findings include:

The facility policy regarding pain assessment, dated January 2, 2019, indicated that nursing staff would assess pain during each medication administration, including the location, intensity, onset, duration, variation, and quality.

An annual Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 25, dated November 30, 2018, indicated that the resident was alert and oriented, was dependent on extensive assistance of two persons for activities of daily living (daily care needs), had pain, and received pain medications. Physician's orders, dated November 3, 2018, included an order for the resident to receive two 325 milligram (mg) tablets of Tylenol (an over-the-counter pain medication) every four hours as needed for a pain rating of 1-5.

Resident 25's Medication Administration Record (MAR) for January 2019 revealed that staff administered Tylenol to the resident on January 2, 4, 9, 12, 13, 17, 21, 23, 24, 26 and 27, 2019; however, there was no documented evidence on the MAR or the resident's clinical records that the resident's pain rating was assessed prior to administering the Tylenol.


A significant change MDS assessment for Resident 51, dated November 2, 2018, indicated that the resident was alert and oriented, required limited to extensive assistance from one person for daily care tasks, and received pain medications.

Physician's orders for the resident, dated December 17, 2018, included an order for the resident to receive two 325 mg tablets of Tylenol every four hours as needed for a pain rating of 1-5, and the resident's care plan regarding pain, dated December 24, 2018, indicated that the resident's pain would be monitored.

Resident 51's MAR for November and December 2018 and January 2019 revealed that staff administered Tylenol to the resident on November 16, 27 and 28, 2018; December 8, 24 and 29, 2018; and January 13, 14 and 15, 2019; however, there was no documented evidence on the MAR or the resident's clinical records that the resident's pain rating was assessed prior to administering the Tylenol.

Interview with Registered Nurse 11 on January 31, 2019, at 2:36 p.m. confirmed that Resident 25's and 51's pain rating assessments were not documented on the MAR's or in the residents' clinical records.

Interview with the Director of Nursing on January 31, 2019, at 4:15 p.m. confirmed that assessments of the residents' pain ratings should have been completed and recorded in the residents' clinical records.

28 Pa. Code 211.12(d)(5) Nursing services.
Previously cited 5/17/18, 2/15/18.







 Plan of Correction - To be completed: 03/30/2019

The preparation and/or execution of the Plan of Correction does not constitute admission or agreement by the provider of truth of the facts or conclusions set forth in the statement of deficiencies. This Plan of Correction is prepared and/or executed solely because it is required by the provision of federal and state laws.

* No negative outcomes were identified related to resident #25 and/or resident #51 as a result of the above cited practice. The Medication Administration records for resident #25 and resident #51 are currently reflecting pain level ratings reported by these individuals.

* All residents ordered pain level ratting assessments are at risk of being affected by the above cited practice.
Measures implemented to ensure future compliance with the cited requirement include:
All staff members will receive in-service education on the plan of correction and updated Pain Assessment and management Policy and Procedure related to pain assessment and management on Wednesday, February 20th, 2019. The in-service education will be provided by the Administrator, Director of Nursing and the Clinical Education Coordinator.
Addition educational instruction on pain assessment and management will be provided to the nursing staff members on a date prior to the plan of correction completion date. The Director of Nursing and Clinical Education Coordinator will provide the additional education.

The facility Pharmacist Consultant has updated the pain assessment portion of the Medication Administration records for all residents to include specific pain scale assessment requirements. Previously, there was not a specific area located on the Medication Administration Record to document the level of pain.
The Pharmacist Consultant will schedule in-service education for the Licensed Nursing staff members on the newly developed pain assessment tool before the Plan of Correction completion date.

* The above corrective actions will be monitored via the utilization of a newly developed auditing tool. The Medication Administration records of residents will be audited to ensure that appropriate pain assessment levels are recorded as ordered.
The Director of Nursing, or her Designee will monitor the Medication Administration Records of five residents weekly for four weeks, then monthly for three months.
Audit results will be forwarded to the Quality Assurance/Improvement Committee for review and/or recommendation.

* The above Plan of Correction will be completed by 3/30/2019.
483.25(l) REQUIREMENT Dialysis:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.25(l) Dialysis.
The facility must ensure that residents who require dialysis receive such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences.
Observations:


Based on clinical record reviews and staff interviews, it was determined that the facility failed to obtain a physician's order for dialysis services for one of 55 residents reviewed (Resident 185).

Findings include:

An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 185, dated January 25, 2019, revealed that the resident was able to make her needs known and had diagnoses that included kidney failure requiring dialysis (mechanical process that purifies the blood of a person whose kidneys are not working normally). Admission information revealed that the resident was admitted to the facility on January 18, 2019, and was being transported to a dialysis center for treatments every Monday, Wednesday and Friday.

As of January 31, 2019, there was no physician's order for the resident to receive dialysis treatments.

An interview with Registered Nurse 1 on January 31, 2019, at 11:30 a.m. confirmed that Resident 185 had received dialysis treatments three times per week since her admission and there was no physician's order for dialysis treatments.

An interview with the Director of Nursing on January 31, 2019, at 3:30 p.m. confirmed that Resident 185 did not have a physician's order for dialysis treatments, and an order should have been obtained upon admission on January 18, 2019.

28 Pa. Code 211.2(a) Physician services.

28 Pa. Code 211.12(d)(1)(3) Nursing services.
Previously cited 2/15/18.

28 Pa. Code 211.12(d)(5) Nursing services.
Previously cited 5/17/18, 2/15/18.




 Plan of Correction - To be completed: 03/30/2019

The preparation and/or execution of the Plan of Correction does not constitute admission or agreement by the provider of truth of the facts or conclusions set forth in the statement of deficiencies. This Plan of correction is prepared and/or executed solely because it is required by the provision of federal and state laws.

* The Dialysis order for resident # 185 has been written and transcribed as indicated.
No negative outcome was identified for this resident.

* All residents receiving Dialysis Treatment have the potential to be affected by this same practice.
Measures implemented to ensure future compliance with the cited requirement include:
All staff members will receive in-service education on the policy and procedure for obtaining and following physician orders for treatment and services. The in-service education will be provided by the Administrator, Director of nursing and Clinical Education Coordinator on Wednesday, February 20th, 2019.
All Licensed Nursing Staff members will receive additional in-service education on the importance and requirement of obtaining and following Physician orders for resident treatment and services. The Nursing in-service education will be provided on a date before the Plan of Correction completion, and will be conducted by the Director of Nursing and the Clinical Education Coordinator.
All residents using Dialysis services currently have appropriate orders for the service.

* The above Plan of Correction will be monitored via the utilization of a newly developed auditing tool. The Medical records of all newly admitted residents will be reviewed to ensure that all services provided to the resident are appropriately ordered, transcribed and carried out. The Assistant Director of Nursing, or her Designee, will perform audits on the medical records of all newly admitted residents weekly for one month, then monthly for three months to ensure the appropriateness of Physician orders and services (specifically, Dialysis).

Results of compliance audits will be forwarded to the QA/QAPI Committee for review and recommendation.

* The above Plan of Correction will be completed by 3/30/2019.
483.45(c)(3)(e)(1)-(5) REQUIREMENT Free from Unnec Psychotropic Meds/PRN Use:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.45(e) Psychotropic Drugs.
483.45(c)(3) A psychotropic drug is any drug that affects brain activities associated with mental processes and behavior. These drugs include, but are not limited to, drugs in the following categories:
(i) Anti-psychotic;
(ii) Anti-depressant;
(iii) Anti-anxiety; and
(iv) Hypnotic

Based on a comprehensive assessment of a resident, the facility must ensure that---

483.45(e)(1) Residents who have not used psychotropic drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record;

483.45(e)(2) Residents who use psychotropic drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs;

483.45(e)(3) Residents do not receive psychotropic drugs pursuant to a PRN order unless that medication is necessary to treat a diagnosed specific condition that is documented in the clinical record; and

483.45(e)(4) PRN orders for psychotropic drugs are limited to 14 days. Except as provided in 483.45(e)(5), if the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she should document their rationale in the resident's medical record and indicate the duration for the PRN order.

483.45(e)(5) PRN orders for anti-psychotic drugs are limited to 14 days and cannot be renewed unless the attending physician or prescribing practitioner evaluates the resident for the appropriateness of that medication.
Observations:


Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that a gradual dose reduction was attempted for an antianxiety medication for one of 55 residents (Resident 72).

Findings include:

The facility's policy regarding psychotropic medications (medications that affect brain activities associated with mental processes and behavior), dated January 2, 2019, indicated that residents on these medications would receive gradual dose reductions, with the intention to decrease or discontinue the use of the medications whenever safe and possible, unless clinically contraindicated.

Physician's orders for Resident 72, dated November 6, 2017, included orders for the resident to receive 0.5 milligrams (mg) of lorazepam (an anti-anxiety medication) every morning and 1.0 mg at bedtime.

A monthly pharmacy consultation form to Resident 72's attending physician, dated June 7, 2018, indicated that a recommendation was made to consider a gradual dose reduction of the anti-anxiety medication, and the physician made a notation on the pharmacy consultation form, dated June 15, 2018, which indicated, "in process of new psychiatrists, no change yet, I am actively working on it."

There was no documented evidence that the physician attempted a gradual dose reduction for Resident 72's lorazepam, and no documented reason that a gradual dose reduction was contraindicated for the resident. The resident's Medication Administration Records for January 1-31, 2019, revealed that the resident continued to receive 0.5 mg of lorazepam every morning and 1.0 mg at bedtime.

Interview with the Director of Nursing on January 31, 2019, at 5:10 p.m. confirmed that there was no documented evidence that a gradual dose reduction of Resident 72's lorazepam was attempted, as recommended by the pharmacy, and no documented evidence that a gradual dose reduction was contraindicated.

42 CFR 483.45(c)(3)(e)(1)-(5) Free from Unnecessary Psychotropic Meds/PRN Use.
Previously cited 2/15/18.

28 Pa. Code 211.12(d)(3) Nursing services.
Previously cited 2/15/18.

28 Pa. Code 211.12(d)(5) Nursing services.
Previously cited 5/17/18, 2/15/18.





 Plan of Correction - To be completed: 03/30/2019

The preparation and/or execution of the Plan of Correction does not constitute admission or agreement by the provider of truth or of the facts or conclusions set forth in the statement of deficiencies. This Plan of Correction is prepared and/or executed solely because it is required by the provision of federal and state laws.

* The Physician ordered a dose reduction on the Ativan for resident #72.
No negative outcomes were identified by the cited practice.

* All residents ordered Psychotropic medications are at risk of being affected by the same cited practice. Measures implemented to ensure future compliance with the cited requirement include:
The Pharmacy Gradual Dose reduction requests for all residents receiving Psychotropic medications have been reviewed and were addressed by the ordering Physicians in a timely manner.
All staff members will receive in-service education on the facility policy and procedure for the gradual dose reduction attempts to occur as per Pharmacy recommendation unless clinically contraindicated. In-service education will be provided by the Administrator, Director of Nursing and the Clinical Education Coordinator on Wednesday, February 20th, 2019.
Additional in-service education will be provided to all Licensed Nursing staff members related to the policy and procedure noted above. The nursing staff in-service will take place on a date prior to the date of completion for this Plan of Correction.

* The above corrective actions will be monitored via the utilization of a newly developed auditing tool.
The Director of Nursing, or her Designee, will monitor the monthly Pharmacy recommendation to physicians regarding Gradual Dose Reduction requests for residents receiving Psychotropic medications. Audits will occur on the recommendations of five residents psychotropic medication Gradual Dose Reduction requests(if applicable), weekly for four weeks, then monthly for three months.
Results of the audits will be referred to the Quality Assurance/Improvement Committee for review and recommendation.
The cause of this medication not being reduced as per Pharmacist recommendation, is because the Physician did not believe that resident should have the reduction at the time. The Physician has been educated on the regulation and has since made the reduction.

* The above Plan of Correction will be completed by 3/30/2019.
483.45(g)(h)(1)(2) REQUIREMENT Label/Store Drugs and Biologicals:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.45(g) Labeling of Drugs and Biologicals
Drugs and biologicals used in the facility must be labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable.

483.45(h) Storage of Drugs and Biologicals

483.45(h)(1) In accordance with State and Federal laws, the facility must store all drugs and biologicals in locked compartments under proper temperature controls, and permit only authorized personnel to have access to the keys.

483.45(h)(2) The facility must provide separately locked, permanently affixed compartments for storage of controlled drugs listed in Schedule II of the Comprehensive Drug Abuse Prevention and Control Act of 1976 and other drugs subject to abuse, except when the facility uses single unit package drug distribution systems in which the quantity stored is minimal and a missing dose can be readily detected.
Observations:


Based on review of policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that medications remained properly secured and labeled in the medication cart during medication administration.

Findings include:

The facility's policy regarding medication administration, dated January 2, 2019, indicated that all medication storage areas (carts, medication rooms, central supply) were to be locked at all times unless in use and under the direct observation of the medication nurse.

Observations of the 200 hall medication cart on January 28, 2019, at 12:25 p.m. revealed that the medication cart was parked outside of room 208 and was not locked. The licensed practical nurse was down the hall interacting with a resident and there were no staff around the medication cart. There were residents wandering the hall around the medication cart at that time.

Interview with Licensed Practical Nurse 5 on January 28, 2019, at 12:37 p.m. revealed that she walked away from the cart, leaving it unsecured, to attend to a resident, and she should have locked the cart before she walked away from it.


Observations during medication administration on January 30, 2019, at 3:20 p.m. revealed that Registered Nurse 6 prepared medications to administer to Resident 187, and without locking the medication cart, the nurse entered Resident 187's room and administered the medications. Registered Nurse 6 then moved the medication cart to Resident 189's room, prepared the resident's medication, and without locking the medication cart, entered Resident 189's room and administered the medications. Registered Nurse 6 then moved the medication cart to Resident 191's room, prepared the resident's medication, and without locking the medication cart, entered Resident 191's room and administered the medications. Registered Nurse 6 then moved the medication cart to Resident 186's room, prepared the resident's medication, and without locking the medication cart, entered Resident 186's room and administered the medications.

Interview with Registered Nurse 6 on January 30, 2019, at 3:56 p.m. revealed that she was not aware, and was never told, that she should have locked the medication cart when leaving it unattended.

Interview with the Director of Nursing on January 31, 2019, at 2:46 p.m. confirmed that medication carts were to be locked and secured at all times when not in use or within sight of the nurse.


Physician's orders for Resident 187, dated January 21, 2019, included an order for 0.1 cubic centimeters (cc's) of Aplisol (a serum used to test for tuberculosis, which is a serious bacterial lung infection) to be injected (just under the skin) in the left forearm. Observations during medication administration on January 30, 2019, at 3:20 p.m. revealed that Registered Nurse 6 arrived at Resident 187's room and opened the top drawer of the medication cart, which contained an unlabeled syringe with a clear fluid in it. Registered Nurse 6 indicated at the time of the observation that the syringe was Aplisol because the resident was due for her second tuberculosis test. She indicated that she knew the resident was due to be tested and she prepared the syringe of Aplisol earlier.

Physician's orders for Resident 191, dated January 21, 2019, included an order for 0.1 cc's of Aplisol to be injected (just under the skin) in the left forearm. Observations during medication administration on January 30, 2019, at 3:42 p.m. revealed that Registered Nurse 6 arrived at Resident 191's room and opened the top drawer of the medication cart, which contained an unlabeled syringe with a clear fluid in it. Registered Nurse 6 indicated at the time of the observation that the syringe was Aplisol because the resident was due for her second tuberculosis test. She indicated that she knew the resident was due to be tested and she prepared the syringe of Aplisol earlier.

Interview with the Director of Nursing on January 31, 2019, at 3:00 p.m. confirmed that Registered Nurse 6 should not have prepared the Aplisol solution prior to arriving at the residents' rooms.

42 CFR 483.45(g)(h)(1)(2) Label/Store Drugs and Biologicals.
Previously cited 2/15/18.

28 Pa. Code 211.9(a)(1) Pharmacy services.
Previously cited 2/15/18.

28 Pa. Code 211.12(d)(1) Nursing services.
Previously cited 2/15/18.





 Plan of Correction - To be completed: 03/30/2019

Licensed Practical Nurse #5 was counseled regarding the importance of securing the medication cart when leaving the immediate area. The nurse was attempting to assist another resident who was unsteady on his feet and wobbling. Because she was attempting to prevent a possible fall, the medication cart was left unattended.
An additional nursing staff member has been recruited to assist full time in the secured Dementia Unit to decrease the resident to staff ratio and allow for more individualized care.
No negative outcomes were identified by the above cited practice.
Registered Nurse #6 was counseled related to the facility policy and procedure indicating that medications are never to be pre-poured. The Registered Nurse indicated that she felt that it was okay just put syringes in the medication cart since she would be administering them shortly. Registered Nurse #6 indicated that she was unaware she left her medication cart unsecured.

*All residents are at risk for being affected by this above cited practice.
Measures implemented to ensure future compliance with the above cited practice include:
The Assistant Director of Nursing will perform medication administration audits this week with both Licensed Practical Nurse #5 and Registered Nurse #6 to ensure that they both are capable on the medication administration skills.

All Licensed Nursing staff members will receive in-service educational training on the importance of following the facility policy on Labeling and Storage of Drugs and Biologicals. The in-service education will be provided by the Administrator, Director of Nursing and Director of Clinical Education, and will take place on Wednesday, February 20th, 2019.
The above corrective actions will be monitored via the utilization of a newly developed auditing tool.
The Assistant Director of Nursing, or her Designee, will perform compliance audits on the medication carts to ensure that they are secure and that no medications have been pre-poured.
Compliance audits will occur on all of the medication carts weekly for four weeks then monthly for three months.
Results of the audits will be referred to the Quality Assurance/Improvement Committee for review and recommendation.

483.20(f)(5), 483.70(i)(1)-(5) REQUIREMENT Resident Records - Identifiable Information:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.20(f)(5) Resident-identifiable information.
(i) A facility may not release information that is resident-identifiable to the public.
(ii) The facility may release information that is resident-identifiable to an agent only in accordance with a contract under which the agent agrees not to use or disclose the information except to the extent the facility itself is permitted to do so.

483.70(i) Medical records.
483.70(i)(1) In accordance with accepted professional standards and practices, the facility must maintain medical records on each resident that are-
(i) Complete;
(ii) Accurately documented;
(iii) Readily accessible; and
(iv) Systematically organized

483.70(i)(2) The facility must keep confidential all information contained in the resident's records,
regardless of the form or storage method of the records, except when release is-
(i) To the individual, or their resident representative where permitted by applicable law;
(ii) Required by Law;
(iii) For treatment, payment, or health care operations, as permitted by and in compliance with 45 CFR 164.506;
(iv) For public health activities, reporting of abuse, neglect, or domestic violence, health oversight activities, judicial and administrative proceedings, law enforcement purposes, organ donation purposes, research purposes, or to coroners, medical examiners, funeral directors, and to avert a serious threat to health or safety as permitted by and in compliance with 45 CFR 164.512.

483.70(i)(3) The facility must safeguard medical record information against loss, destruction, or unauthorized use.

483.70(i)(4) Medical records must be retained for-
(i) The period of time required by State law; or
(ii) Five years from the date of discharge when there is no requirement in State law; or
(iii) For a minor, 3 years after a resident reaches legal age under State law.

483.70(i)(5) The medical record must contain-
(i) Sufficient information to identify the resident;
(ii) A record of the resident's assessments;
(iii) The comprehensive plan of care and services provided;
(iv) The results of any preadmission screening and resident review evaluations and determinations conducted by the State;
(v) Physician's, nurse's, and other licensed professional's progress notes; and
(vi) Laboratory, radiology and other diagnostic services reports as required under 483.50.
Observations:


Based on clinical record reviews and staff interviews, it was determined that the facilty failed to ensure that clinical records were complete and accurately documented for three of 55 residents reviewed (Residents 7, 37, 55).

Findings included:

A nursing note for Resident 31, dated December 7, 2018, revealed that Resident 31 was hovering over a male resident and attempting to kiss him on the lips. A nursing note dated December 7, 2018, revealed that Resident 31 was standing in a room with a male resident and when asked to come away from him she stated, "I just got him alone and away from everybody." A nursing note dated December 14, 2018, revealed that Resident 31 was redirected several times from trying to have a male resident follow her into different rooms. A nursing note dated December 15, 2018, revealed that Resident 31 required supervision and redirection for safety due to a behavior of entering other residents' rooms and wanting to have contact with a male resident. She was redirected to activities for safety as she was attempting to hold onto a male resident's arms. A nursing note dated December 17, 2018, revealed that Resident 31 continued with advancements toward a male resident and she stated that he was her husband. A nursing note dated December 23, 2018, revealed that Resident 31 was observed attempting to get into bed with a male resident and became aggressive when redirected out of his room. A nursing note dated December 24, 2018, revealed that Resident 31 was observed attempting to climb into bed with a male resident. A nursing note dated December 26, 2018, revealed that Resident 31 attempted to give a male resident her meal several times and then attempted to get the male resident to go into her room with her. A nursing note dated December 27, 2018, revealed that Resident 31 was attempting to get into bed with a male resident and when staff intervened she became combative. A nursing note dated December 28, 2018, revealed that Resident 31 was attempting to get into bed with a male resident. A nursing note dated December 31, 2018, revealed that Resident 31 continued to follow Resident 7 and get him to follow her, she was rubbing his neck and back, and trying to get him into a room with her. When staff intervened, Resident 31 stated that he was her husband and that even if he was not she wanted him anyway. A nursing note dated January 2, 2019, revealed that Resident 31 continued to hover over a male resident. A nursing note dated January 12, 2019, revealed that Resident 31 continued to seek the attention of male residents on the unit. A nursing note dated January 13, 2019, revealed that Resident 31 attempted to seek attention from a male resident on Janaury 12 and when staff attempted to redirect her she threw her glasses at them. A nursing note dated January 14, 2019, revealed that Resident 31 continued to seek male attention and affection and was noted to follow a male resident into the restroom, rub the male residents' backs, and attempt to kiss male residents. The resident approaches different male residents, but is especially attentive to Resident 7 and Resident 37. A nursing note, dated January 23, 2019, revealed that Resident 31 was observed in Resident 37's bed under the covers with Resident 37, both were fully clothed, and she was redirected out of his bed.

There was no documented evidence of any of these interactions with Resident 31 in the male residents' medical records.

Interview with the Director of Nursing on January 31, 2019, at 2:55 p.m. confirmed that there was no documented evidence in Resident 7, 37 or 55's medical records that Resident 31 was interfering or interacting with them in any way. The Director of Nursing stated that she was unaware that the incident should be documented in both residents' medical records. She knew that Resident 31 was following Residents 7, 37 and 55 because of the incident reports that the staff were completing; however, the incident reports were not considered part of the residents' clinical records.

42 CFR 483.20(f)(5), 483.70(i)(1)-(5) Resident Records - Identifiable Information.
Previously cited 5/17/18, 2/15/18.

28 Pa. Code 211.5(f) Clinical Records.
Previously cited 5/17/18, 2/15/18.



 Plan of Correction - To be completed: 03/30/2019

The preparation and/or execution of the Plan of Correction does not constitute admission or agreement by the provider of truth of the facts set forth in the statement of deficiencies. This Plan of Correction is prepared and/or executed solely because it is required by the provision of federal and state laws.

* The incidents documented within the medical record of resident #31, have also been added to the medical records of residents' #7, resident #37 and resident #55.
There were no negative outcomes identified by the above cited practice.

* All residents involve in interaction with other residents are at risk for this same cited practice.
Measures implemented to ensure future compliance with this requirement include:
All staff members will receive in-service education on the importance of complete and accurate documentation in the resident's medical record. The in-service education will be provided by the Administrator, Director of Nursing and the Clinical Education Coordinator on Wednesday, February 29th, 2019. The facility policy regarding documentation in the medical record has been updated to include documentation shall be present in the medical records of each resident involved in a specific interaction/altercation/incident.
In-service education for nursing staff members regarding specific documentation instruction will occur on a date prior to the Plan of Correction completion date. Education will focus on the policy and procedure updates noted above, and the importance of complete and accurate documentation must be present in the medical records of all residents involved in any altercations or incidents involving other residents.

* Compliance with the above requirement will be monitored via the utilization of a newly developed auditing tool.
The medical records of all residents noted to be involved in altercations/incidents with other residents shall be reviewed to ensure accurate and complete documentation in the records of all individuals involved.
The Director of Nursing, or her Designee, will complete audits on medical records of residents who are involved in altercations or incidents with one another to ensure that all records consist of complete and accurate documentation. Audits will occur of all incidents involving resident to resident altercation/incidents with one another.

* Compliance audits will be forwarded to the QA/QAPI Committee for review and recommendation.

* The above Plan of Correction will be completed by 3/30/2019.
483.80(a)(1)(2)(4)(e)(f) REQUIREMENT Infection Prevention & Control:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.80 Infection Control
The facility must establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections.

483.80(a) Infection prevention and control program.
The facility must establish an infection prevention and control program (IPCP) that must include, at a minimum, the following elements:

483.80(a)(1) A system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon the facility assessment conducted according to 483.70(e) and following accepted national standards;

483.80(a)(2) Written standards, policies, and procedures for the program, which must include, but are not limited to:
(i) A system of surveillance designed to identify possible communicable diseases or
infections before they can spread to other persons in the facility;
(ii) When and to whom possible incidents of communicable disease or infections should be reported;
(iii) Standard and transmission-based precautions to be followed to prevent spread of infections;
(iv)When and how isolation should be used for a resident; including but not limited to:
(A) The type and duration of the isolation, depending upon the infectious agent or organism involved, and
(B) A requirement that the isolation should be the least restrictive possible for the resident under the circumstances.
(v) The circumstances under which the facility must prohibit employees with a communicable disease or infected skin lesions from direct contact with residents or their food, if direct contact will transmit the disease; and
(vi)The hand hygiene procedures to be followed by staff involved in direct resident contact.

483.80(a)(4) A system for recording incidents identified under the facility's IPCP and the corrective actions taken by the facility.

483.80(e) Linens.
Personnel must handle, store, process, and transport linens so as to prevent the spread of infection.

483.80(f) Annual review.
The facility will conduct an annual review of its IPCP and update their program, as necessary.
Observations:


Based on clinical record reviews, observations and staff interviews, it was determined that the facility failed to ensure that proper infection control practices and techniques were followed during the administration of medications.

Findings include:

Physician's orders for Resident 10, dated January 1, 2019, included an order for the resident to receive 1.0 gram of Colestipol (a medication used to treat high cholesterol) twice a day.

Observations during medication administration on January 29, 2019, at 9:30 a.m. revealed that Licensed Practical Nurse 4 went to pop a Colestipol tablet out of a blister package (individual pills packaged in a clear plastic bubble on a foil and cardboard backing) into the souffle cup for Resident 10, when the tablet became stuck on the foil. Licensed Practical Nurse 4 used her bare hand to remove the Colestipol tablet from the foil and place it into the souffle cup.

Interview with Licensed Practical Nurse 4 on January 29, 2019, at 9:43 a.m. revealed that she should have put a glove on to remove the tablet from the foil.

Interview with the Director of Nursing on January 31, 2019, at 3:00 p.m. confirmed that Licensed Practical Nurse 4 should not have touched Resident 10's medication with her bare hand.

42 CFR 483.80(a)(1)(2)(4)(e)(f) Infection Prevention and Control.
Previously cited 2/15/18.

28 Pa. Code 211.12(d)(1) Nursing services.
Previously cited 2/15/18.





 Plan of Correction - To be completed: 03/30/2019

The preparation and/or execution of this Plan of Correction does not constitute admission or agreement by the provider of truth of the facts or conclusions set forth in the statement of deficiencies. This plan of correction is prepared and/or executed solely because it is required by the provision of federal and state laws.

* Resident #10 suffered no adverse effects from the above cited practice.

* All residents receiving medications are at risk for this same cited practice.
Measures implemented to ensure future compliance with the cited requirement include: Proper hand hygiene technique and glove use along with return demonstration was reviewed with Licensed Practical Nurse #4 on Monday, 2/4/19. A medication pass audit will be conducted with Licensed Practical Nurse #4 tomorrow, February 13th, 2019. The Infection Prevention and Control Registered Nurse will observe the medication pass of Licensed Nurse #4 to ensure that proper hand hygiene practices occur.
In-service education on the importance of following proper Infection/Prevention and Control guidelines will take place on Wednesday, February 20th, 2019. The Administrator, Director of Nursing, Infection Prevention and control Practitioner and the Clinical Education Coordinator will provide all staff members with education on proper hand hygiene protocols and standards.

* The above plan of correction will be monitored via the utilization of a newly developed auditing tool. The Infection/Prevention and Control Practitioner will perform audits on medication administration to ensure compliance is maintained regarding proper hand hygiene and glove use.
Medication administration audits will be performed twice weekly for six weeks then monthly for three months.

* This plan of correction will be completed by 3/30/2019.

201.14(a) LICENSURE Responsibility of licensee.:State only Deficiency.
(a) The licensee is responsible for meeting the minimum standards for the operation of a facility as set forth by the Department and by other State and local agencies responsible for the health and welfare of residents.
Observations:


Based on review of policies and attendance records for the facility's Infection Control Committee, as well as staff interviews, it was determined that the facility failed to ensure that a representative from the community attended Infection Control Committee meetings, and that written notices were sent to residents and/or their representatives when antibiotic treatment was initiated for specific infections.

Findings include:

The Act 52 Infection Control Plan, dated March 20, 2002, revealed that a health care facility should develop and implement an internal infection control plan that should be established for the purpose of improving the health and safety of residents and health care workers, and should include a multi-disciplinary committee including a representative from each of the following, if applicable to the specific health care facility. Applicable members included medical staff that could include the chief medical officer or the nursing home medical director, the nursing home administrator, laboratory personnel, nursing staff that could include the director of nursing or a nursing supervisor, pharmacy staff, physical plant personnel, a patient safety officer, and a community member that may not be an agent, employee or contractor of the facility.

Review of attendance records for quarterly meetings of the facility's Infection Control Committee revealed no documented evidence that a community member attended the meetings on March 29, June 29, September 28 and December 20, 2018.

Interview with the Infection Control Coordinator on January 30, 2019, at 2:51 p.m. confirmed the above.


Act 52 of 2007, The Pennsylvania Patient Safety Reporting System (PA-PSRS) requires notification in writing to the resident and/or the resident's representative when antibiotic treatment is initiated for infection. An interview with the Infection Control Coordinator on January 30, 2019, at 2:51 p.m. confirmed that she has not sent letters to any of the residents or their representatives because it is faster to call them. She also confirmed that there was no documented evidence of the notifications via telephone.




 Plan of Correction - To be completed: 03/30/2019

The letters to residents/responsible parties regarding infections and antibiotic therapies are being sent and documented as such.

An Infection Control Committee Member has been retained from the community , and is not an agent, employee or contractor of the facility.
The Community member will sign in on the attendance sheet for each meeting attended.

The Infection Prevention/Control Nurse is responsible to ensure that the Antibiotic letters are sent to the families.
A log will be maintained with documentation to show that the letters have been sent to families regarding the initiation of Antibiotic therapies.

Compliance with the above will be reviewed by the Quality Assurance/Improvement Committee to ensure that guidelines are met.



35 P. S. 448.809b LICENSURE Photo Id Reg:State only Deficiency.
(1) The photo identification tag shall include a recent photograph of the employee, the employee's name, the employee's title and the name of the health care facility or employment agency.

(2) The title of the employee shall be as large as possible in block type and shall occupy a one-half inch tall strip as close as practicable to the bottom edge of the badge.

(3) Titles shall be as follows:
(i) A Medical Doctor shall have the title " Physician. "
(ii) A Doctor of Osteopathy shall have the title " Physician. "
(iii) A Registered Nurse shall have the title " Registered Nurse. "
(iv) A Licensed Practical Nurse shall have the title " Licensed Practical Nurse. "
(v) Abbreviated titles may be used when the title indicates licensure or certification by a Commonwealth agency.


Observations:


Based on review of policies, as well as observations and staff interviews, it was determined that the facility failed to ensure that all staff displayed photo identification tags on their uniforms.

Findings include:

The facility's policy regarding identification badges, dated January 2, 2019, indicated that all personnel were required to wear photo identification tags or badges during their work shift.

Observations on January 28, 2019, at 10:00 a.m. and 2:45 p.m. revealed that Nurse Aide 2 was not wearing a photo identification tag. Interview with Nurse Aide 2 at 2:48 p.m. confirmed that she was not wearing her photo identification tag.

Observations on January 28, 2019, at 2:50 p.m. revealed that Licensed Practical Nurse 3 had a piece of tape on her uniform with her name and position on it, but she was not wearing a photo identification tag. Interview with Licensed Practical Nurse 3 at that time confirmed that she was not wearing a photo identification tag.

An interview with the Nursing Home Administrator on January 30, 2019, at 3:45 p.m. confirmed that all staff were required to wear a photo identification tag at all times when on duty in the facility.




 Plan of Correction - To be completed: 03/30/2019

The preparation and/or execution of the Plan of Correction does not constitute admission of agreement by the provider of truth of the facts or conclusions set forth in the statement of deficiencies. This Plan of Correction is prepared and/or executed solely because it is required by the provision of federal and state laws.

The two nursing staff members without
their photo name badges received replacement badges immediately.
No negative outcome was experienced as a result of this cited requirement.

All facility staff members are required to wear on their person, a photo identification badge at all times while on the company property. Should an employee lose or misplace hiss/her badge, the facility has obtained replacement badges for these employees.
In-service education to all staff members regarding the importance of wearing the photo identification badge. will occur on Wednesday, February 20th, 2019. In-service education will be presented by the Administrator and Clinical Education Coordinator. Staff will be instructed to report to the Administrative office for a replacement badge in the event that a badge has become lost or misplaced.
The Plan of Correction for this requirement is complete.

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