Nursing Investigation Results -

Pennsylvania Department of Health
CAMBRIA CARE CENTER
Patient Care Inspection Results

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CAMBRIA CARE CENTER
Inspection Results For:

There are  176 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.
CAMBRIA CARE CENTER - 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 complaint survey completed on April 25, 2019, it was determined that Cambria Care Center was not in compliance with the following requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care Facilities and the 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.




 Plan of Correction:


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


Based on review of the Resident Assessment Instrument User's Manual and clinical records, as well as staff interviews, it was determined that the facility failed to complete accurate comprehensive Minimum Data Set assessments for five of 89 residents reviewed (Residents 49, 142, 156, 201, 206).

Findings include:

The Resident Assessment Instrument (RAI) User's Manual, which gives instructions for completing Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2018, revealed that if the influenza (flu) vaccine was not received, Section O0250C (influenza vaccine) was to be coded with the reason the flu vaccine was not received. The section was to be coded with a one (1) if the resident was not in the facility during this year's influenza vaccination season; two (2) if the resident received the vaccination outside of the facility; three (3) if the resident was not eligible for the vaccine due to a medical contraindication; (4) if the vaccine was offered and declined; or (5) if the vaccine was not offered.

A quarterly MDS assessment for Resident 49, dated February 5, 2019, revealed that Section O0250C was coded with a five (5), indicating that the influenza vaccine was not offered to the resident. However, interview with Infection Control Registered Nurse 37 on April 25, 2019, at 12:27 p.m. revealed that Resident 49 received an influenza vaccine on October 29, 2018, while out of the facility at the hospital.

Interview with Registered Nurse Assessment Coordinator 32 (RNAC - a registered nurse who is responsible for the completion of MDS assessments) on April 25, 2019, at 12:40 p.m. confirmed that Resident 49 received the flu vaccine while at the hospital in October 2018, and Section O0250C of the quarterly MDS assessment of February 5, 2019, should have been coded with a two (2) because the vaccine was given outside the facility.


The RAI User's Manual, dated October 2018, revealed that Section M0210 (unhealed pressure ulcers) was to be coded based on the presence of any pressure ulcer/injury (regardless of stage) in the past seven days. The section was to be coded zero (0) No if the resident did not have a pressure ulcer/injury during the seven-day look-back period, or one (1) Yes if the resident had any pressure ulcer/injury (at any stage, or unstageable), and if the section was coded one (1) then Section M0300 (current number of unhealed pressure ulcers/injury at each stage) was to be completed.

A diagnosis list for Resident 142, dated November 9, 2018, revealed that the resident had diagnoses that included a sacral (area at the base of the spine) wound. The resident's physician's orders and Treatment Administration Records (TAR's) for March 2019 revealed that he received wound care to a sacral pressure ulcer every other day and as needed for soilage.

An annual MDS assessment for Resident 142, dated March 15, 2019, revealed that Section M0210 was coded zero (0), indicating that the resident had no unhealed pressure ulcers during the assessment period.

An interview with Registered Nurse 39 on April 24, 2019, at 1:38 p.m. confirmed that Resident 142 had a sacral pressure ulcer during the look-back period for the annual MDS assessment dated March 15, 2019, and Section M0210 should have been coded with a one (1).


The RAI User's Manual, dated October 2018, revealed that Section E0800 (rejection of care) was intended to determine if the resident rejected evaluation or care that was necessary to achieve the resident's goals for health and well being. Instructions for Section E0800 revealed that it was to be coded with a zero (0) if the behavior was not exhibited; one (1) if the behavior occurred 1 to 3 days (during the seven-day assessment period); two (2) if the behavior occurred 4 to 6 days; or three (3) if the behavior occurred daily.

Nursing notes for Resident 156, dated March 22, 2019, at 12:16 a.m. and 7:15 a.m. revealed that the resident refused to have her weight checked, and nursing notes dated March 22, 2019, at 8:00 a.m. and 9:59 a.m. revealed that the resident refused to take her medications.

However, an admission MDS assessment for Resident 156, dated March 28, 2019, revealed that Section E0800 was coded zero (0), indicating that the resident did not reject care during the assessment period.

An interview with Registered Nurse 39 on April 24, 2019, at 1:38 p.m. confirmed that Section E0800 of Resident 156's admission MDS assessment dated March 28, 2019, was incorrect and should have captured her rejection of care and medications.


The RAI User's Manual, dated October 2018, revealed that Section P (restraints and alarms) was to record the frequency that the resident was restrained by any of the listed devices or if an alarm was used at any time during the day or night during the seven-day look-back period.

Physician's orders for Resident 201, dated January 1, 2019, included an order for the resident to use padded bilateral assistive handrails for positioning, and the resident's care plan, dated January 3, 2019, indicated that the resident was at risk for falls and was to have padded bilateral assistive handrails for positioning. A bed safety evaluation, dated April 3, 2019, indicated that the resident benefited from the use of padded bilateral assistive handrails for positioning and to aid in bed mobility, and the resident was able to assist with turning and repositioning with the use of bilateral assistive handrails.

Section P0100A (bed rails used as a physical restraint) of a quarterly MDS assessment for Resident 201, dated April 3, 2019, was coded with a one (1), indicating that the resident was restrained by a bed rail less than daily.

Interview with RNAC 32 on April 25, 2019, at 8:45 a.m. revealed that Resident 201 was not restrained by the use of bed rails and had been restraint-free for some time now. Interview on April 25, 2019, at 9:00 a.m. with Restorative Nurse 33, who coded Section P of Resident 201's MDS assessment, confirmed that Section P0100A on the resident's quarterly MDS assessment was coded incorrectly because she hit the wrong button. She confirmed that the resident used bilateral handrails for assistance with bed mobility and not as a physical restraint.


The RAI User's Manual, dated October 2018, revealed that Section A2100 (discharge status) was to be coded to show where the resident was discharged to and included codes (01) through (09) and (99). Code (01) indicated that the resident was discharged to the community, and Code (03) indicated that the resident was discharged to an acute hospital.

Resident 206's clinical record revealed that the resident was admitted to the facility on December 19, 2018, and was discharged to home on February 1, 2019. However, an MDS discharge assessment, dated February 1, 2019, revealed that Section A2100 was coded (03), indicating that the resident was discharged to the hospital.

An interview with the Nursing Home Administrator on April 25, 2019, at 6:37 p.m. confirmed that Resident 206 was discharged to home and that Section A2100 of the MDS discharge assessment dated February 1, 2019, was inaccurately coded.

28 Pa. Code 211.5(f) Clinical records.
Previously cited 12/27/18, 4/20/18.





 Plan of Correction - To be completed: 06/04/2019

The following is submitted for plan of correction purposes only and should not be construed as an admission.


R49 has had their Quarterly MDs dated February 5, 2019 reviewed and modified to reflect the correction information in Section O regarding the administration of the Influenza Vaccine.

Assessments completed within the last 7 days will be audited by the Registered Nurse Assessment Coordinator to ensure accurate coding of the Influenza Vaccine in Section O0250.

Influenza Vaccine information will be uploaded into Point Click Care once completed, by the Infection Control Nurse.

The Registered Nurse Assessment Coordinators will be re-educated on federal regulation 641, to include Section O, Influenza Vaccine and accuracy of assessments.

Audits of ten (10) assessments, will be completed weekly for 2 months, by the Registered Nurse Assessment Coordinator to ensure accurate information is coded in Section O0250 regarding Influenza Vaccine Administration. Negative findings will result in a Quality Assurance and Performance Improvement meeting being conducted. All results will be reviewed by the Quality Assurance Committee until such time consistent substantial compliance has been achieved as determined by the committee.


R142 has had their Annual Assessment dated March 15, 2019 reviewed and modified to reflect the correct information in Section M0210 regarding presence of an unhealed pressure ulcer.

Residents with current unhealed pressure ulcers will have their most recent MDS audited by the Wound Nurse to ensure accurate coding of a pressure ulcer present in the 7 day look back.

The Wound Nurses will be re-educated on federal regulation 641, to include Section M, and accuracy of assessments.

Audits of ten (10) assessments, will be completed weekly for 2 months, by the Wound Nurse to ensure accurate information is coded in Section M0210 regarding presence of unhealed pressure ulcers . Negative findings will result in a Quality Assurance and Performance Improvement meeting being conducted. All results will be reviewed by the Quality Assurance Committee until such time consistent substantial compliance has been achieved as determined by the committee





R156 has had their Admission MDS, dated March 28, 2019 reviewed and modified to reflect the correct information in E0800 regarding rejection of care.

Assessments completed within the past 7 days will be reviewed by the Social Service Worker to ensure accurate coding of E0800 regarding refusal of care. Any discrepancies will be modified to reflect accurate coding.

The Social Worker will be re-educated on federal regulation 641, to include Section E, and accuracy of assessments.

Audits of ten (10)assessments, will be completed weekly for 2 months, by the Social Worker, to ensure accurate information is coded in Section E0800 regarding refusal of care in the look back period. Negative findings will result in a Quality Assurance and Performance Improvement meeting being conducted. All results will be reviewed by the Quality Assurance Committee until such time consistent substantial compliance has been achieved as determined by the committee


R201 has had their Quarterly assessment dated April 3, 2019 reviewed and modified to reflect the correct information in Section P regarding restraint use. Assessments completed within the last 7 days will be reviewed by the Restorative Nurse, comparing information with the Bed safety Evaluation, to ensure accurate coding of P0100A regarding restraint use. Any discrepancies will be reviewed and modified to reflect correct information in Section P0100A.

The Restorative Nurse will be re-educated on federal regulation 641, to include Section P, and accuracy of assessments.

Audits of ten (10) assessments will be completed weekly for 2 months, by the Restorative Nurse, to ensure accurate information is coded in Section P0100A, restraint use. Negative findings will result in a Quality Assurance and Performance Improvement meeting being conducted. All results will be reviewed by the Quality Assurance Committee until such time consistent substantial compliance has been achieved as determined by the committee.


R206 has had their Discharge Assessment, dated February 1, 2019 reviewed and modified to reflect the correct information in section A, regarding discharge destination.

Discharge Assessments completed within the last 7 days will be reviewed by the Registered Nurse Assessment Coordinator, to ensure correct information is coded in Section A2100. Any discrepancies will be reviewed and modified to reflect correct information in Section A2100.

The Registered Nurse Assessment Coordinator will be re-educated on federal regulation 641, to include Section A, and accuracy of assessments.

Audits of ten discharge assessments will be completed weekly for 2 months, by the Registered Nurse Assessment Coordinator, to ensure accurate information is coded in Section A2100, discharge destination. Negative findings will result in a Quality Assurance and Performance Improvement meeting being conducted. All results will be reviewed by the Quality Assurance Committee until such time consistent substantial compliance has been achieved as determined by the committee.



483.80(a)(1)(2)(4)(e)(f) REQUIREMENT Infection Prevention & Control: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.
483.80 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 review of policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to use proper infection control practices during incontinent care for four of 89 residents reviewed (Residents 2, 16, 27, 97).

Findings include:

The facility's policy regarding hand washing, dated March 12, 2019, revealed that whether or not gloves were worn, hands were to be washed after contact with blood or body fluids, mucous membranes, secretions, or excretions, and before and after going to the bathroom.

The facility's guidelines for perineal area and buttock care for a female resident, dated 2016, indicated that water and a small amount of soap should be used.

A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 2, dated Janaury 17, 2019, revealed that the resident was cognitively impaired, totally dependent on staff for bathing, and incontinent of urine.

Observations on April 24, 2019, at 9:18 a.m. revealed that Nurse Aides 6 and 7 provided a bed bath and incontinent care for Resident 2. When filling a basin of water, Nurse Aide 6 did not put soap in the water, used the water to wipe the resident's perineal area and buttocks, and then dried the area with a towel. Interview with Nurse Aide 6 at that time confirmed that she should have used soap when providing incontinent care for the resident.

Interviews with Registered Nurse 37 (the facility's Infection Control Nurse) and the Director of Nursing on April 24, 2019, at 10:09 a.m. and 10:35 a.m., respectively, confirmed that Nurse Aide 6 should have used soap for Resident 2's incontinent care.


A quarterly MDS assessment for Resident 16, dated January 30, 2019, revealed that the resident was cognitively impaired, required extensive assistance to total dependence for care, and was incontinent of urine.

Observations of Resident 16 on April 24, 2019, at 1:28 p.m. revealed that the resident had been incontinent of urine, and with gloves on, Nurse Aide 28 cleaned the resident. With the same gloves on, which were now contaminated, the nurse aide then applied a barrier cream to the resident's buttocks.

Interview with Nurse Aide 28 and Licensed Practical Nurse 29 on April 24, 2019, at 1:41 p.m confirmed that Nurse Aide 28 did not change his gloves and wash his hands after cleaning Resident 16 and was aware that he should have.


A quarterly MDS assessment for Resident 27, dated February 4, 2019, revealed that the resident was moderately cognitively impaired and required the extensive assisstance for toileting.

Observations on April 23, 2019, at 3:11 p.m. revealed that Licensed Practical Nurse 4 and Nurse Aide 5 used a sit-to-stand mechanical lift (a device that uses hydraulic power to lift and transfer a person while supported in a standing position) to place Resident 27 on the toilet. After the resident urinated and had a bowel movement, Licensed Practical Nurse 4 cleaned the resident with disposable wipes, and with the same gloves on she then pulled the resident's brief and pants up and used the sit-to-stand lift to put the resident into her chair.

Interview with Licensed Practical Nurse 4 on April 23, 2019, at 3:20 p.m. confirmed that she should have changed her gloves and washed her hands after cleaning the resident and before providing any further care.

Interview with Registered Nurse 37, the facility's Infection Control Nurse, on April 23, 2019, at 3:30 p.m. and with the Director of Nursing on April 24, 2019, at 10:33 a.m. confirmed that Licensed Practical Nurse 4 should have changed her gloves and washed their hands after cleaning the resident and before providing further care.


A quarterly MDS assessment for Resident 97, dated February 26, 2019, revealed that the resident was severely cognitively impaired and dependent for bathing.

Observations on April 23, 2019, at 12:45 p.m. revealed that Resident 97 had been incontinent of bowel and Nurse Aides 35 and 36 provided a bed bath and incontinent care using a basin of water. With gloves on, Nurse Aide 36 cleaned the stool from the resident's skin using incontinent wipes. Without removing the now contaminated gloves and washing her hands, the nurse aide dried the area and reached into a container of bath supplies and obtained a tube of incontinence barrier cream (a skin protectant cream), opened the cream, dispensed it onto her gloved hand, and applied the cream to the resident's buttocks. As Nurse Aide 36 took the basin of water away to empty, it was observed that the basin was labeled with Resident 97's roommate's name. Interview with Nurse Aide 36 at that time confirmed that the basin that was used for Resident 97's bed bath belonged to the resident's roommate, and they should have checked to ensure that they used the correct basin prior to bathing Resident 97. She also confirmed that she should have removed her gloves, washed her hands, and put on new gloves after cleaning stool from the resident's skin and prior to applying the skin protectant cream to the resident's buttocks.

Interview with Registered Nurse 37, the facility's Infection Control Nurse, on April 23, 2019, at 4:14 p.m. confirmed that the nurse aides should have ensured that they were using the proper wash basin prior to bathing Resident 97, and that Nurse Aide 36 should have removed her gloves, washed her hands and applied new gloves after cleaning the resident's skin and prior to applying cream to the resident's buttocks.

42 CFR 483.80(a)(1)(2)(4)(e)(f) Infection Prevention & Control.
Previously cited 4/20/18.

28 Pa. Code 211.12(d)(1) Nursing services.
Previously cited 4/20/18.

28 Pa. Code 211.12(d)(5) Nursing services.
Previously cited 1/17/19, 12/27/18, 11/21/18, 5/18/18, 4/20/18.




 Plan of Correction - To be completed: 06/04/2019

The following is submitted for plan of correction purposes only and should not be construed as an admission.

Resident 2 continues to reside at the facility. Resident 2 receives total assistance with bathing and incontinence activities in a manner that promotes and maintains infection prevention and control practices including adding soap to the water used for perianal care.

Resident 16 and Resident 27 continue to reside at the facility and receive extensive to total assistance with incontinence care in a manner that promotes and maintains infection prevention and control practices, including the proper wearing of gloves.
Resident 97 continues to reside at the facility and receives total assistance with bathing activities in a manner that promotes and maintains infection prevention and control practices, including using resident specific equipment.

The Director of Nursing/designee will complete education with nursing staff on facility guidelines for perianal and buttock care for residents, which includes using soap per facility guidelines, glove use, and not sharing resident equipment. Nursing staff will also be educated on the federal regulation F880. Nursing staff will complete hand hygiene competencies with the Infection Control Coordinator/designee.

The Director of Nursing/designee will audit staff members preforming incontinence care to ensure infection prevention measures and facility guidelines for perianal care, including the use of soap, glove use, and the use of resident specific equipment, are maintained. These audits will be completed on 5 residents daily for two weeks, weekly for two weeks, monthly for two months, and randomly thereafter. Results of these audits will be reviewed in the facility Quality Assurance Performance Improvement meeting for further recommendations for continued compliance.



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 plans of correction for previous surveys, 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 corrections for State Survey and Certification (Department of Health) surveys ending April 20, May 18 and December 27, 2018, and January 17, 2019, 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 April 25, 2019, identified repeated deficiencies related to providing reasonable accommodations, completing timely Minimum Data Set (MDS) assessments (mandated assessments of residents' abilities and care needs), developing and implementing comprehensive individualized care plans, revising residents' care plans to include current care needs, providing assisted care to dependent residents, providing quality care, maintaining a safe environment, management of feeding tubes, ensuring that there were no significant medication errors, proper storage and labeling of medications, and following proper infection control practices.

The facility's plan of correction for a deficiency regarding providing reasonable accommodations, cited during the survey ending April 20, 2018, revealed that the facility would conduct audits and forward the results of the audits to the QAPI committee meetings. The results of the current survey, cited under F558, revealed that the QAPI committee was ineffective in maintaining compliance with the regulations regarding accommodating residents' needs.

The facility's plans of correction for deficiencies regarding completing timely comprehensive and quarterly MDS assessments, cited during the survey ending April 20, 2018, revealed that the facility would complete audits and report the results of the audits to the QAPI committee for review. The results of the current survey, cited under F636 and F638, revealed that the facility's QAPI committee was ineffective in maintaining compliance with the regulations regarding completing timely MDS assessments.

The facility's plan of correction for a deficiency regarding developing and implementing a comprehensive and individualized care plan for each resident, cited during the survey ending and April 20, 2018, revealed that the facility would complete audits and report the results of the audits to the QAPI committee for review. The results of the current survey, cited under F656, revealed that the facility's QAPI committee was ineffective in maintaining compliance with the regulation regarding developing and implementing a comprehensive individualized care plan for each resident.

The facility's plans of correction for deficiencies regarding revising residents' care plans to include current interventions to address their care needs, cited during the surveys ending April 20 and May 18, 2018, revealed that the facility would complete audits and report the results of the audits to the QAPI committee for review. The results of the current survey, cited under F657, revealed that the facility's QAPI committee was ineffective in maintaining compliance with the regulation regarding revising residents' care plans to include current interventions.

The facility's plan of correction for a deficiency regarding providing care to dependent residents, cited during the surveys ending April 20 and December 27, 2018, revealed that the facility would complete audits and report the results of the audits to the QAPI committee for review. The results of the current survey, cited under F677, revealed that the facility's QAPI committee was ineffective in maintaining compliance with the regulation regarding providing care to dependent residents.

The facility's plan of correction for a deficiency regarding providing quality care, cited during the survey ending April 20, 2018, revealed that the facility would complete audits and report the results of the audits to the QAPI committee for review. The results of the current survey, cited under F684, revealed that the facility's QAPI committee was ineffective in maintaining compliance with the regulation regarding providing quality care.

The facility's plans of correction for deficiencies regarding failures to ensure that the resident environment was free from accident hazards, cited during the surveys ending April 20, 2018, and January 17, 2019, indicated that audits of documentation would be completed and the results of the audits would be presented at the QAPI committee. The results of the current survey, cited under F689, revealed that the QAPI committee was ineffective in maintaining compliance with the regulation regarding the resident environment being free from accident hazards.

The facility's plan of correction for a deficiency regarding the management of feeding tubes, cited during the survey ending April 20, 2018, revealed that the facility would complete audits and report the results of the audits to the QAPI committee for review. The results of the current survey, cited under F693, revealed that the facility's QAPI committee was ineffective in maintaining compliance with the regulation regarding the management of feeding tubes.

The facility's plan of correction for a deficiency regarding significant medication errors, cited during the survey ending and April 20, 2018, revealed that the facility would complete audits and report the results of the audits to the QAPI committee for review. The results of the current survey, cited under F760, revealed that the facility's QAPI committee was ineffective in maintaining compliance with the regulation regarding significant medication errors.

The facility's plan of correction for a deficiency regarding properly storing and labeling medications, cited during the survey ending and April 20, 2018, revealed that the facility would complete audits and report 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 was ineffective in maintaining compliance with the regulation regarding proper storage and labeling of medications.

The facility's plan of correction for deficiencies regarding following infection control practices, cited during the survey ending April 20, 2018, revealed that the facility would complete audits and report 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 was ineffective in maintaining compliance with the regulation regarding following infection control practices.

Refer to F558, F636, F638, F656, F657, F677, F684, F689, F693, F760, F761, F880.

28 Pa. Code 201.14(a) Responsibility of licensee.
Previously cited 11/21/18, 4/20/18.

28 Pa. Code 201.18(e)(1) Management.
Previously cited 4/20/18.





 Plan of Correction - To be completed: 06/04/2019

The following is submitted for plan of correction purposes only and should not be construed as an admission.



The Quality Assurance Committee will meet to review the repeat deficiencies: F558, F636, F638, F656, F657, F677, F677, F684, F689, F693, F760, F761, and F880. A facility Quality Assurance Performance Improvement Plan will be developed for these repeat federal deficiencies. To ensure sustained compliance, these areas will continue to be audited, with outcomes presented at the monthly Quality Assurance Committee meetings for review and recommendations.

The Quality Assurance Committee will be educated by the Nursing Home Administrator or Designee, on Federal Regulation 867. The Quality Assurance Committee will then review the facility's current Quality Assurance Performance Improvement Process to ensure that a systemic approach is being utilized to determine underlying causes of non-compliance in order to prevent repeat deficiencies and that corrective action plans address any changes at the systems level. The Committee will also reevaluate how the effectiveness of its performance improvement efforts is currently being monitored. After this review of the facility's Quality Assurance Improvement Process, the Committee will make any necessary revisions to the process that will better ensure improvements are sustained and repeat deficiencies are avoided.

An outside Consultant will randomly attend Quality Assurance Performance Improvement Committee Meetings to monitor the effectiveness of the Quality Assurance Improvement Process, including, if compliance with the federal regulations that received repeat deficiencies is being sustained.

The interdisciplinary team and licensed nursing staff will be in-serviced by the Director of Nursing or Designee on the facility's Quality Assurance Improvement Process, including any revisions, as well as on Federal Regulations: F558, F636, F638, F656, F657, F677, F684, F689, F693, F760, F761 and F880.







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 food packaging was labeled with the date it was opened and was discarded by the "use by" date in three of four nursing unit pantries (first, second and fourth floors).

Findings include:

The facility's policy regarding labeling foods, dated June 1, 2018, revealed that all foods items were to be dated when they were opened, and large cartons of beverages were to be discarded seven days after they were opened (unless the manufacturer's recommended date was shorter).

Observations of the refrigerator in the first floor nursing unit pantry on April 24, 2019, at 10:47 a.m. revealed that one 46-ounce container each of apple juice, orange juice, and nectar-thickened orange juice were previously opened but were not labeled with the date they were opened. Interview with the Dietary Director on April 24, 2019, at 10:49 a.m. confirmed that the above containers were opened but were not labeled with the date they were opened and should have been.

Observations of the refrigerator in the second floor nursing unit pantry on April 24, 2019, at 10:29 a.m. revealed that one 46-ounce container each of honey-thickened, lemon-flavored water and nectar-consistency thickened water were previously opened but were not labeled with the date they were opened. Interview with the Dietary Director on April 24, 2019, at 10:32 a.m. confirmed that the containers of thickened water were not labeled with the date they were opened and should have been.

Observations of the freezer compartment of the refrigerator in the fourth floor nursing unit pantry on April 24, 2019, at 10:54 a.m. revealed a one-quart container of orange sherbet that was opened and dated December 15, 2018. The container was approximately three fourths full and there was a thick build up of frost covering the container. In the refrigerator compartment there was a 46-ounce container of honey-thickened water that was opened but not dated, and a 46-ounce container of orange juice that was labeled as opened on April 15, 2019.

Interview with the Dietary Director on April 24, 2019, at 11:00 a.m. confirmed that the containers of orange sherbet and orange juice should have been discarded, and the honey thickened water should have been labeled with the date it was opened.

28 Pa. Code 211.6(f) Dietary services.





 Plan of Correction - To be completed: 06/04/2019

The following is submitted for plan of correction purposes only and should not be construed as an admission.

Food items stored in the unit pantries were inspected to ensure that the food packaging was labeled with the date it was opened, as well as, to ensure food items were discarded by the "use by" date, per policy. Food items that did not meet these requirements were discarded.

Residents are receiving food items from the unit pantries that are labeled/dated properly per policy.
A dietary staff member will check refrigerators and freezers daily for compliance and initial a log that this was done.

The Director of Nursing/Designee will in-service the dietary and nursing staff on food safety requirements. The education will include a review of the facility's policy on labeling and dating food items, as well as, a review of federal regulation F812.

The Director of Nursing/Designee
will perform audits to ensure food items are properly labeled and dated according to policy: daily X 2 weeks, then weekly X 2 months, then monthly X 2 months. Results of the audits will be forwarded to the QAPI Committee for review and recommendations.


483.35(d)(7) REQUIREMENT Nurse Aide Peform Review-12 hr/yr In-Service: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(d)(7) Regular in-service education.
The facility must complete a performance review of every nurse aide at least once every 12 months, and must provide regular in-service education based on the outcome of these reviews. In-service training must comply with the requirements of 483.95(g).
Observations:


Based on review of a list of nurse aides provided by the facility and the nurse aides' personnel files, as well as staff interviews, it was determined that the facility failed to ensure that nurse aide performance evaluations were completed annually based on hire dates for 13 of 26 nurse aides reviewed (Nurse Aides 7 through 19).

Findings include:

A list of nurse aides provided by the facility revealed that based on their months and days of hire, annual performance evaluations were due between January 1, 2018, and March 23, 2019, However, there was no documented evidence that annual performance evaluations were completed as required for Nurse Aides 7 through 19.

Interview with the Director of Nursing on April 24, 2019, at 2:20 p.m. confirmed that she could provide no evidence that annual performance evaluations were completed as required for the above nurse aides.

28 Pa. Code 201.14(a) Responsibility of licensee.
Previously cited 11/21/18, 4/20/18.

28 Pa. Code 201.18(b)(1) Management.
Previously cited 4/20/18.

28 Pa. Code 201.18(b)(3) Management.

28 Pa. Code 201.18(e)(1) Management.
Previously cited 4/20/18.

28 Pa. Code 201.20(a)(c) Staff development.




 Plan of Correction - To be completed: 06/04/2019

The following is submitted for plan of correction purposes only and should not be construed as an admission.

Nurse Aides seven through nineteen have had performance evaluations completed and will receive performance evaluations annually.

Current Nurse Aides will be reviewed to ensure that they have performance evaluations completed per regulation.
The Nursing Home Administrator will designate an employee to oversee the annual evaluation process to ensure that evaluations are completed in a timely manner. Designated employee will ensure compliance of timely evaluations by utilizing a system/form that will record staff hire dates, along with annual evaluations due dates and evaluation completion date.
The Nursing Home Administrator will educate this designated employee, the Director of Nursing, the Assistant Director of Nursing, and the Staff Development Coordinator on Federal Regulation 730 and importance of completing nurse aide evaluations per regulation.

The Nursing Home Administrator/Designee will audit that Nurse Aide performance evaluations are completed at least annually. These audits will be completed monthly for four months then annually thereafter.

Results of these audits will be reviewed in the facility's Quality Assurance Performance Improvement meetings for further suggestions for sustained compliance.





483.25(d)(1)(2) REQUIREMENT Free of Accident Hazards/Supervision/Devices: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.
483.25(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 clinical record reviews, observations and staff interviews, it was determined that the facility failed to ensure resident safety during transportation in a wheelchair without leg rests for two of 89 residents reviewed (Residents 75, 196), and failed to ensure that physician-ordered safety measures were in place for three of 89 residents reviewed (Residents 21, 58, 59).

Findings include:

A quarterly Minimal Data Set (MDS) assessment (a federally-mandated assessment of a resident's abilities and care needs) for Resident 75, dated February 21, 2019, revealed that the resident was usually understood and could usually understand, required extensive assistance with daily care tasks, used a walker and wheelchair for mobility, used oxygen, had two falls without injury since her last assessment, and had diagnoses that included respiratory failure, difficulty walking, muscle weakness, primary generalized arthritis, anxiety, depression, manic disorder and schizophrenia. The resident's care plan, dated October 7, 2018, included that bilateral leg rests were to be used when the resident was being transported in a wheelchair.

Observations on April 25, 2019, at 4:20 p.m. revealed that Licensed Practical Nurse 27 pushed Resident 75 briskly down the hallway in a wheelchair toward the dining area. During the transport, the wheelchair was not equipped with leg rests and the resident held her feet in the air. Half way down the hallway the nurse turned the resident over to a nurse aide who encouraged the resident to propel herself down the hallway, which the resident did without issue.

An interview with Licensed Practical Nurse 27 on April 25, 2019, at 4:36 p.m. confirmed that she pushed Resident 75 down the hall in a wheelchair, but the nurse did not remember if there were leg rests on the wheelchair or if the resident needed leg rests for transport. The nurse admitted to being in a hurry to get the resident to the dining room.

An interview with the Director of Nursing on April 25, 2019, at 4:45 p.m. confirmed that Resident 75's wheelchair should have had leg rests in place when she was being transported by Licensed Practical Nurse 27.


A quarterly MDS assessment for Resident 196, dated April 9, 2019, revealed that the resident was alert and oriented, required the extensive assistance of two persons for transfers, used a wheelchair for mobility, and had hemiplegia (paralysis on one side of the body) following a stroke. The resident's care plan, dated December 20, 2018, included that the resident was at risk for falls related to right-sided weakness, and she was to use a wheelchair with a leg rest on the right side at all times and a leg rest on the left side for transport only.

Observations on April 22, 2019, at 2:32 p.m. revealed that Nurse Aide 30 pushed Resident 196 in her wheelchair from the beginning of the hallway into her bedroom, which was located at the end of the hallway. The resident's wheelchair was not equipped with a leg rest on the left side, and during the transport, the resident's left foot was sliding on the floor.

Interview with Nurse Aide 30 on April 22, 2019, at 2:39 p.m. revealed that she should have put a leg rest on the left side of the wheelchair prior to transporting Resident 196.

Interview with the Director of Nursing on April 22, 2019, at 3:12 p.m. confirmed that staff should be using leg rests when transporting residents in wheelchairs.


A quarterly MDS assessment for Resident 21, dated January 30, 2019, indicated that the resident was severely cognitively impaired and required the extensive assistance of two staff for bed mobility and transfers. Physician's orders dated April 10, 2019, and the resident's care plan dated September 25, 2018, included an order for the resident to have foam and lamb's wool padding to both assistive handrails (small side rails on the bed), including the middle horizontal bars.

Observations of Resident 21 on April 22, 2019, at 10:48 a.m. and April 24, 2019, at 9:11 a.m. and 9:35 a.m. revealed that the resident was in bed and both assistive handrails had black padding but did not have lamb's wool in place.

Interviews with Nurse Aide 34 and the Director of Nursing on April 24, 2019, at 9:35 a.m. and 2:20 p.m., respectively, confirmed that Resident 21 was to have lamb's wool on both assistive handrails.


A quarterly MDS assessment for Resident 58, dated February 13, 2019, revealed that the resident was cognitively impaired, dependent for care, and had diagnoses that included chronic pain. Physician orders, dated April 5, 2019, included an order for the resident to use a specialty (air) mattress with padded pump hooks (the pump is usually hooked to the foot board of the resident's bed). The resident's care plan, dated October 31, 2018, included interventions for padded pump hooks and a padded bedside table to be within reach.

Observations of Resident 58 on April 24, 2019, at 8:56 a.m. revealed that the hooks of the air mattress pump at the foot of the resident's bed were not padded, and the resident's bedside table was also not padded.

Interview with Nurse Aide 21 on April 24, 2019, at 9:28 a.m. confirmed that neither the pump hooks nor the bedside table were padded for Resident 58, and she did not remember ever seeing padding on them.

An interview with the Director of Nursing on April 24, 2019, at 4:44 p.m. confirmed that Resident 58's pump hooks and bedside table should have been padded as ordered and care planned.


A quarterly MDS assessment for Resident 59, dated February 13, 2019, revealed that the resident was severely cognitively impaired. Physician orders, dated July 23, 2018, included an order for the resident to wear geri-sleeves (skin protecting sleeves) to both arms at all times when out of bed. The resident's care plan, dated September 18, 2018, indicated that she was at risk for alterations in skin integrity, had fragile skin, and was to wear geri-sleeves at all times when out of bed.

Observations during the lunch meal on April 22, 2019, at 11:30 a.m. revealed that Resident 59 was sitting at a table in the dining room being fed by Nurse Aide 35. The resident did not have geri-sleeves on.

Interview with Nurse Aide 35 on April 22, 2019, at 12:25 p.m. confirmed that Resident 59 was wear geri-sleeves at all times and did not have them on.

Interview with Licensed Practical Nurse 38 on April 22, 2019, at 12:25 p.m. confirmed that Resident 59 was to wear geri-sleeves as ordered by the physician and as care planned.

42 CFR 483.25(d)(1)(2) Free of Accident Hazards/Supervision/Devices.
Previously cited 1/17/19, 4/20/18.

28 Pa. Code 211.12(d)(3) Nursing services.
Previously cited 5/18/18, 4/20/18.

28 Pa. Code 211.12(d)(5) Nursing services.
Previously cited 1/17/19, 12/27/18, 11/21/18, 5/18/18, 4/20/18.






 Plan of Correction - To be completed: 06/04/2019

The following is submitted for plan of correction purposes only and should not be construed as an admission.


Resident R75 continues to reside in this facility. This resident's leg rests are utilized per physician's order and plan of care.
Resident R196 continues to reside in this facility. This resident's leg rests are utilized per physician's order and plan of care.

Resident R21 continues to reside in this facility. This resident's bilateral handrails are padded with black foam and sheep skin padding.
Resident R58 continues to reside in this facility. This resident's hooks of the air mattress pump and the bedside table are padded.

Resident R59 continues to reside in this facility. This resident's Geri-sleeves are applied per physician's order.

Current residents with leg rests will be reviewed to ensure that the leg rests are being utilized per physician's order and plan of care.
Current residents with padded air mattress pump hooks and bedside tables will be reviewed to ensure these items are padded per physician's order and plan of care.

Current residents with Geri-sleeves will be reviewed to ensure Geri-sleeves are applied per physician's order and plan of care.

Physician ordered/care planned assistive and safety devices, including padding, are now on the Nurse Aide Activities of Daily Living/Care sheets to ensure compliance.

The Director of Nursing/Designee will educate nursing staff and facility staff responsible for transporting residents in their chair with leg rests on Federal Regulation 689 and the importance of ensuring leg rests are utilized per physician's order and plan of care, bedside tables and air mattress pump hooks are padded per physician's order and plan of care, and Geri-sleeves are applied per physician's order and plan of care.

The Director of Nursing/Designee will audit compliance with leg rests being utilized per physician's order and plan of care, bedside tables and air mattress pump hooks being padded per physician's order and plan of care, and Geri-sleeves being applied per physician's order and plan of care. These audits will be completed on five residents daily for two weeks, weekly for two weeks, monthly for two months, then randomly thereafter.

Results of these audits will be reviewed in the facility's Quality Assurance Performance Improvement meetings for further suggestions to achieve sustained compliance.


483.10(e)(2) REQUIREMENT Respect, Dignity/Right to have Prsnl Property: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(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 care in a manner that maintained dignity for one of 89 residents reviewed (Resident 58).

Findings include:

A quarterly Minimum Data Set (MDS) assessment (a federally-mandated assessment of a resident's abilities and care needs) for Resident 58, dated February 13, 2019, revealed that the resident was cognitively impaired, totally dependent for care, was on a pain regimen, and had diagnoses that included anxiety and chronic pain. Resident 58's care plan, dated October 17, 2018, revealed that the resident was to receive a shower during the day shift (7:00 a.m. to 3:00 p.m.) on Monday and Thursday and that two staff members were needed for her shower.

Observations on April 22, 2019, at 9:28 a.m. revealed that Nurse Aides 7 and 20 transferred Resident 58 from bed to a shower litter using a mechanical lift (device that uses hydraulic power to lift and move a person from surface to surface while supported and suspended in a heavy-duty fabric sling). As the resident was being lowered onto the litter, her head rested on the top frame of the litter, which was plastic and unpadded. The resident was transported to the shower room by Nurse Aide 20, and was then rolled side-to-side while being undressed, which caused her head to come off the frame of the litter and be unsupported. The resident was sleeping and did not wake up while being undressed. Nurse Aide 7 checked the water temperature using the spray hose from the adjacent tub, the hose was not long enough to reach the resident, so the shower litter was repositioned closer to the tub. Nurse Aide 7 began to spray water onto Resident 58 while she was sleeping, and the resident awakened and her eyes were wide. While showering her, the two nurse aides did not speak to the resident, whose head remained unsupported. When asked if support was available for the resident's head, such as a shower pillow, Nurse Aide 7 replied that the shower litter was new and a pillow was not available.

Throughout the shower and after Resident 58's hair and body were washed and rinsed, the resident had goosebumps on her arms, chest and legs. When the shower was finished, there was water pooling on the litter under the resident, and the nurse aides attempted to push it out the drain at the bottom of the litter mat and place a towel down to absorb the rest. The resident was dried, the nurse aides changed their gloves and applied lotion to her body and cream to her buttocks area, and then the resident was dressed and transferred into a chair.

The facility's competency checklists for assisting a resident with a shower or whirlpool bath for Nurse Aide 20, dated February 25, 2019, and Nurse Aide 7, dated January 31, 2019, revealed that when a resident was finished with a shower, a towel was to be placed over the resident's shoulders to prevent chilling.

The observations of the shower provided to Resident 58 revealed that Nurse Aides 7 and 20 did not place a towel on the resident's shoulders after the shower was finished.

An interview with the Nurse Aide Curriculum Coordinator on April 23, 2019, at 3:33 p.m. revealed that she does not teach litter showers as this was not a requirement of the core curriculum for nurse aide training. She indicated that a pillow should have been placed under Resident 58's head during the shower, and the nurse aides should have covered the resident after the shower.

An interview with the Nursing Home Administrator and the Director of Nursing on April 24, 2019, at 3:16 p.m. confirmed that the shower litters were newer, that shower pillows were not available, that training was not in place for staff using the shower litters for resident showers, and that they did not feel that it was inappropriate for Resident 58 to remain uncovered after the shower, even though she exhibited signs of being cold.

28 Pa. Code 201.29(j) Resident rights.
Previously cited 4/20/18.






 Plan of Correction - To be completed: 06/04/2019


The following is submitted for plan of correction purposes only and should not be construed as an admission.



Resident 58 continues to reside in this facility and is receiving showers using the proper procedure.

Current residents receiving showers utilizing litters will be reviewed to ensure that showers are being given using proper procedures.

The competency and policy and procedure for showers will be reviewed and revised as deemed appropriate.

The Director of Nursing / Designee will provide education on Federal Regulation 557 and the importance of providing showers using proper procedures to maintain resident dignity.

The Director of Nursing / Designee will audit compliance with showers. These audits will be on 5 residents daily for two weeks, weekly for two weeks, monthly for two months, then randomly thereafter.

Results of these audits will be reviewed in the facility's Quality Assurance Performance Improvement meetings for further suggestions for sustained compliance.

483.10(e)(3) REQUIREMENT Reasonable Accommodations Needs/Preferences: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(e)(3) The right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents.
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 call bells were in reach at all times for one of 89 residents reviewed (Resident 121).

Findings include:

The facility's policy regarding call bells, dated March 12, 2019, revealed that staff were to respond to residents' needs through a call light system and it was the responsibility of all facility staff to respond to residents' call lights.

A significant change Minimum Data Set (MDS) assessment (a federally-mandated assessment of a resident's abilities and care needs) for Resident 121, dated February 2, 2019, revealed that the resident was understood and could understand; required extensive assistance from staff for care, including toileting, transfers and bed mobility; was occasionally incontinent of bladder; and always incontinent of bowel. A medical diagnosis list, dated April 1, 2019, revealed that the resident had diagnoses that included cerebral vascular accident (CVA - commonly known as a stroke) with left-sided hemiplegia (paralysis on one side of the body). The resident's care plan, dated August 18, 2018, indicated that the resident had a self-care performance deficit and staff were to encourage the resident to use the bell to call for assistance.

Observations during an interview with Resident 121 on April 22, 2019, at 9:24 a.m. revealed that the resident was lying in bed and the resident's call bell was lying on the floor to the right side of the resident's bed. During the interview, the resident indicated that his bed was wet with urine.

Interview with Nurse Aide 31 on April 22, 2019, at 9:32 a.m. revealed that he changed Resident 121 about an hour ago, that the resident's pad and top sheet were wet, that the resident was capable of using the call bell, but the call bell was on the floor and out of the resident's reach.

Interview with the Director of Nursing on April 24, 2019, at 2:20 p.m. confirmed that staff should ensure that Resident 121's call bell was within his reach.

42 CFR 483.10(e)(3) Reasonable Accommodations Needs/Preferences.
Previously cited 4/20/18.

28 Pa. Code 211.12(d)(5) Nursing services.
Previously cited 1/17/19, 12/27/18, 11/21/18, 5/18/18, 4/20/18.




 Plan of Correction - To be completed: 06/04/2019

The following is submitted for plan of correction purposes only and should not be construed as an admission.

Resident 121 continues to reside in this facility and is provided his call bell within reach.
Current residents will be reviewed to ensure they have their call bells within reach.

The call bell policy will be reviewed and revised as deemed appropriate.
Licensed nursing staff will document on the resident's Treatment Administration Record that call bell is within reach. Nursing staff will be educated to verify that it is within reach at change of shift rounds, with toileting/incontinence care, repositioning, medication pass, tray pass, and with every resident interaction.

The Director of Nursing/ Designee will educate nursing staff on federal regulation 0558 and the importance of ensuring resident's call bell is within reach at all times.

The Director of Nursing/ Designee will audit that call bells are within resident's reach. These audits will be completed on five residents per unit daily for two weeks, weekly for two weeks, monthly for two months, then randomly thereafter.

Results of these audits will be reviewed during the facility's Quality Assurance Performance Improvement committee for further recommendations to ensure sustained compliance.





483.10(j)(1)-(4) REQUIREMENT Grievances: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(j) Grievances.
483.10(j)(1) The resident has the right to voice grievances to the facility or other agency or entity that hears grievances without discrimination or reprisal and without fear of discrimination or reprisal. Such grievances include those with respect to care and treatment which has been furnished as well as that which has not been furnished, the behavior of staff and of other residents, and other concerns regarding their LTC facility stay.

483.10(j)(2) The resident has the right to and the facility must make prompt efforts by the facility to resolve grievances the resident may have, in accordance with this paragraph.

483.10(j)(3) The facility must make information on how to file a grievance or complaint available to the resident.

483.10(j)(4) The facility must establish a grievance policy to ensure the prompt resolution of all grievances regarding the residents' rights contained in this paragraph. Upon request, the provider must give a copy of the grievance policy to the resident. The grievance policy must include:
(i) Notifying resident individually or through postings in prominent locations throughout the facility of the right to file grievances orally (meaning spoken) or in writing; the right to file grievances anonymously; the contact information of the grievance official with whom a grievance can be filed, that is, his or her name, business address (mailing and email) and business phone number; a reasonable expected time frame for completing the review of the grievance; the right to obtain a written decision regarding his or her grievance; and the contact information of independent entities with whom grievances may be filed, that is, the pertinent State agency, Quality Improvement Organization, State Survey Agency and State Long-Term Care Ombudsman program or protection and advocacy system;
(ii) Identifying a Grievance Official who is responsible for overseeing the grievance process, receiving and tracking grievances through to their conclusions; leading any necessary investigations by the facility; maintaining the confidentiality of all information associated with grievances, for example, the identity of the resident for those grievances submitted anonymously, issuing written grievance decisions to the resident; and coordinating with state and federal agencies as necessary in light of specific allegations;
(iii) As necessary, taking immediate action to prevent further potential violations of any resident right while the alleged violation is being investigated;
(iv) Consistent with 483.12(c)(1), immediately reporting all alleged violations involving neglect, abuse, including injuries of unknown source, and/or misappropriation of resident property, by anyone furnishing services on behalf of the provider, to the administrator of the provider; and as required by State law;
(v) Ensuring that all written grievance decisions include the date the grievance was received, a summary statement of the resident's grievance, the steps taken to investigate the grievance, a summary of the pertinent findings or conclusions regarding the resident's concerns(s), a statement as to whether the grievance was confirmed or not confirmed, any corrective action taken or to be taken by the facility as a result of the grievance, and the date the written decision was issued;
(vi) Taking appropriate corrective action in accordance with State law if the alleged violation of the residents' rights is confirmed by the facility or if an outside entity having jurisdiction, such as the State Survey Agency, Quality Improvement Organization, or local law enforcement agency confirms a violation for any of these residents' rights within its area of responsibility; and
(vii) Maintaining evidence demonstrating the result of all grievances for a period of no less than 3 years from the issuance of the grievance decision.
Observations:


Based on review of policies, clinical records, and facility grievance forms, as well as staff interviews, it was determined that the facility failed to make ongoing efforts to resolve the grievances of residents and/or their legal representatives, and failed to ensure that the resident or responsible party was provided with a written grievance decision for one of 89 residents reviewed (Resident 16).

Findings include:

The facility's grievance policy, revised October 19, 2018, indicated that the facility would investigate all resident and family grievances and make prompt efforts to resolve them. The Grievance Official would provide a written decision on the grievance to the resident or representative upon request, and the written grievance decision would include the date the grievance was received, the steps taken to investigate the grievance, a summary of the pertinent findings or conclusions regarding the resident's concerns(s), a statement as to whether the grievance was confirmed or not confirmed, any corrective action taken or to be taken by the facility as a result of the grievance, and the date the written decision was issued. The Grievance Officer or designee would keep the resident appropriately apprised of progress toward the resolution of grievances, and evidence demonstrating the results of all grievances would be kept for a period of no less than three years from the issuance of the grievance decision.

A quarterly Minimum Data Set (MDS) assessment (a federally-mandated assessment of a resident's abilities and care needs) for Resident 16, dated January 30, 2019, revealed that the resident was confused, required extensive to total dependence on staff for care, was incontinent of urine, and had diagnoses that included Alzheimer's dementia (brain disorder that causes problems with memory, thinking and behavior).

A grievance form for Resident 16, dated February 21, 2019, revealed that Resident Family Member 16 had concerns regarding care being performed for Resident 16 after supper on February 20, 2019; consistent caregivers; wanting no agency staff to care for Resident 16; and only staff members that he requests to take care of the resident.
There was no documented evidence that the resident's complaint/grievance was thoroughly investigated, including interviews and/or written statements from the staff who worked during the shift in question, and whether or not there was proper care provided at that time. There was also no documented evidence regarding efforts that were made to resolve Resident Family Member 16's concerns regarding consistent caregivers, not wanting agency staff to care for the resident, and only staff members that he requested to take care of Resident 16.

A grievance form for Resident 16, dated February 25, 2019, revealed that Resident Family Member 16 had concerns that he did not want two specific nurse aides providing care to Resident 16 and preferred to have two other nurse aides provide care for the resident. He was concerned that the two nurse aides did not understand Resident 16's needs when she cried out. There was no documented evidence that efforts were made to resolve Resident Family Member 16's concerns.

A grievance form for Resident 16, dated March 21, 2019, revealed that Resident Family Member 16 had a concern that the pantry doors were now being locked and he was not able to get Resident 16 a snack and drink when he visited. He was assured that staff would be attentive to his requests for pantry items, but there was no documented evidence that the complaint/grievance was thoroughly investigated or that the complaint/grievance was resolved.

A grievance form for Resident 16, dated March 25, 2019, revealed that Resident Family Member 16 believed the resident received poor care from an agency staff member. There was no documented evidence that the resident's complaint/grievance was thoroughly investigated, including interviews and/or written statements from the staff who worked during the shift in question, and whether or not proper care was provided at that time.

There was also no documented evidence that a copy of the grievance decision/resolutions were provided to Resident Family Member 16.

Interview with the Director of Nursing on April 25, 2019, at 4:17 p.m. confirmed that there was no documented evidence that Resident Family Member 16's grievances were logged for the past three months. She confirmed that there were no interviews conducted with staff regarding the care Resident 16 was provided, and she confirmed that there was no evidence that Resident Family Member 16 received copies of the grievance resolution.

28 Pa. Code 201.29(i) Resident rights.




 Plan of Correction - To be completed: 06/04/2019

The following is submitted for plan of correction purposes only and should not be construed as an admission.

Resident 16 continues to reside in this facility and the complaint/grievances from the resident/resident representative are being addressed appropriately and in a timely manner including offering a copy of the grievance/resolutions to the resident representative.

Current residents/resident representatives that have voiced a complaint/grievance over the past 30 days will be reviewed to ensure a thorough investigation has been completed, statements are obtained, resolution has been made, and a copy has been provided to the resident/resident representative.
Resident grievances and notification of resolutions will be reviewed by the Interdisciplinary/ management team daily in facility "stand-up"/morning meeting.

The Director of Nursing / Designee will provide education on Federal Regulation 0585 and the importance of completing a thorough investigation, obtaining statements, resolution has been made, and a copy of the grievance decision/resolutions has been provided to the resident /resident responsible party.

The Director of Nursing / Designee will audit compliance with grievances. Audits will be completed on grievances for one month, then randomly thereafter.

Results of these audits will be reviewed in the facility's Quality Assurance Performance Improvement meetings for further suggestions for sustained compliance.



483.12(c)(1)(4) REQUIREMENT Reporting of Alleged Violations: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.
483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must:

483.12(c)(1) Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures.

483.12(c)(4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken.
Observations:


Based on review of policies and clinical records, as well as resident and staff interviews, it was determined that the facility failed to report an allegation of neglect for one of 89 residents reviewed (Resident 118).

Findings include:

The facility abuse policy, dated March 12, 2019, revealed that all allegations of abuse and neglect were to be reported immediately to the Nursing Home Administrator and Director of Nursing, and to appropriate authorities within 24 hours.

An admission Minimum Data Set (MDS) assessment (a federally-mandated assessment of a resident's abilities and care needs) for Resident 118, dated March 14, 2019, revealed that the resident was alert and able to make her needs known, did not ambulate (walk), and required extensive assistance for care. The resident's care plan, dated March 20, 2019, revealed that the resident required assistance with care due to limited physical mobility.

During an interview with Resident 118 on April 22, 2019, at 9:15 a.m. the resident stated that on April 14, 2019, she was placed on the bedpan around 11:15 a.m. and left there for over three hours, resulting in a big indentation on her buttocks. Resident 118 also stated that it was staff from the next shift who took her off the bedpan, and she reported this to a registered nurse the same day that it occurred.

An interview with the Nursing Home Administrator on April 22, 2019, at 1:59 p.m. revealed that she was not aware of the incident involving Resident 118 and she would look into it.

Interview with the Nursing Home Administrator on April 24, 2019, at 4:00 p.m. revealed that she confirmed that Resident 118 reported the incident to Registered Nurse 32 on the day that it occurred, and Registered Nurse 32 did not report the incident to the Nursing Home Administrator as required, but should have reported it immediately so that an investigation could have been started immediately.







 Plan of Correction - To be completed: 06/04/2019

The following is submitted for plan of correction purposes only and should not be construed as an admission.
Resident 118 continues to reside in this facility and allegation of neglect was reported to the Administrator, Director of Nursing, and appropriate authorities with appropriate follow through.

Resident concerns/complaints will be immediately documented on a grievance form and reported immediately to the nursing supervisor who will immediately inform the Nursing Home Administrator. On weekends, holidays, and off hours the Nursing Supervisor will notify the Director of Nursing or the Assistant Director of Nursing. Grievances will be reviewed by the Interdisciplinary/ Management team daily in "stand-up"/morning meeting.

The policy on abuse was reviewed and remains appropriate.
The Director of Nursing/ Designee will educate nursing staff on federal regulation 0609 and the importance of ensuring allegations of neglect are reported immediately to the Administrator, Director of Nursing, and appropriate authorities.
The Director of Nursing/ Designee will audit that any allegation of neglect, for any resident, will be reported immediately to the Nursing Home Administrator and Director of nursing, and to appropriate authorities within twenty four hours for one month, then random audits will be completed monthly thereafter.

Results of these audits will be reviewed during the facility's Quality Assurance Performance Improvement committee for further recommendations to ensure sustained compliance.




483.20(b)(1)(2)(i)(iii) REQUIREMENT Comprehensive Assessments & Timing:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.20 Resident Assessment
The facility must conduct initially and periodically a comprehensive, accurate, standardized reproducible assessment of each resident's functional capacity.

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

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


Based on review of the Resident Assessment Instrument User's Manual and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that comprehensive admission Minimum Data Set assessments were completed in the required time frame for two of 89 residents reviewed (Residents 308, 310).

Findings include:

The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which provides instructions and guidelines for completing required Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2018, indicated that an admission MDS assessment was to be completed no later than 14 days following admission.

An comprehensive admission MDS assessment for Resident 308 revealed that the resident was admitted on January 3, 2019, and the resident's admission MDS assessment was dated as completed on January 27, 2019, which was 24 days after admission.

An comprehensive admission MDS assessment for Resident 310 revealed that the resident was admitted on January 10, 2019, and the resident's admission MDS assessment was dated as completed on January 25, 2019, which was 15 days after admission.

An interview with the Nursing Home Administrator on April 24, 2019, at 2:43 p.m. confirmed that the admission MDS assessments for Residents 308 and 310 were not completed within the required time frame.

42 CFR 483.20(b)(1)(2)(i)(iii) Comprehensive Assessments and Timing.
Previously cited 4/20/18.




 Plan of Correction - To be completed: 06/04/2019


The following is submitted for plan of correction purposes only and should not be construed as an admission.

Current residents with admission assessments completed in the last 14 days will be reviewed by the Registered Nurse Assessment Coordinator, to ensure they have been completed within the 14 day time frame.

The Registered Nurse Assessment Coordinators and the Case Manager, will meet daily, to discuss assessments due for the week, and current day.
They will then be reviewed for timeliness the following day.
The Registered Nurse Assessment Coordinators will be re-educated on federal regulation 636 and the need for timely completion of admission assessments within the 14 day time frame.

Audits of all admission assessments will be completed weekly for two months, to ensure that admission assessments have been completed within the 14 day time frame.

Audit results will be reviewed by the Quality Assurance Committee until such time consistent substantial compliance has been achieved as determined by the committee. Negative findings will result in a Quality Assurance and Performance Improvement meeting being conducted.

483.20(c) REQUIREMENT Qrtly Assessment at Least Every 3 Months: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(c) Quarterly Review Assessment
A facility must assess a resident using the quarterly review instrument specified by the State and approved by CMS not less frequently than once every 3 months.
Observations:


Based on review of the Resident Assessment Instrument Manual and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that quarterly Minimum Data Set assessments were completed within the required time frame for two of 89 residents reviewed (Residents 113, 204).

Findings include:

The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which provides instructions and guidelines for completing Minimum Data Set (MDS) assessments (federally-mandated assessments of a resident's abilities and care needs), dated October 2018, indicated that the assessment reference date (ARD - the last day of the assessment's look-back period) of a quarterly MDS assessment must be no more than 92 days after the ARD of the most recent assessment of any type, and the assessment was to be completed no later than the ARD plus 14 calendar days.

A quarterly MDS assessment for Resident 113, with an ARD of January 22, 2019, was due to be completed by February 5, 2019, but was not signed as completed until February 18, 2019, which was 27 days from the ARD until completion.

A quarterly MDS assessment for Resident 204, with an ARD of January 10, 2019, was due to be completed by January 24, 2019, but was not signed as completed until February 3, 2019, which was 24 days from the ARD until completion.

An interview with the Nursing Home Administrator on April 24, 2019, at 2:43 p.m. confirmed that the quarterly MDS assessments for Residents 113 and 204 were not completed within the required time frame.

42 CFR 483.20(c) Quarterly Assessment at Least Every 3 Months.
Previously cited 4/20/18.




 Plan of Correction - To be completed: 06/04/2019

The following is submitted for plan of correction purposes only and should not be construed as an admission.


Current residents will be reviewed, by the Registered Nurse Assessment Coordinator, to ensure the assessment reference date has been scheduled no more than 92 days from the last assessment reference date.

The Registered Nurse Assessment Coordinator will schedule quarterly assessments no more than 92 days from the last assessment reference date.
The Registered Nurse Assessment Coordinators and the Case Manager, will meet daily to discuss assessments due for the week, and day.
Assessments will then be reviewed for timeliness the following day.
The Registered Nurse Assessment Coordinators will be re-educated on federal regulation 638 and the need for timely completion of quarterly within 14 days of the assessment reference date.

Audits of 20 residents will be completed, weekly for two months to ensure that quarterly assessments have been scheduled no more than 92 days from the last assessment reference date and completed within 14 days of the assessment reference date. Negative findings will result in a Quality Assurance and Performance Improvement meeting being conducted. All results will be reviewed by the Quality Assurance Committee until such time consistent substantial compliance has been achieved as determined by the committee


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 review of policies and clinical records, as well as staff interviews and observations, it was determined that the facility failed to develop care plans to address individualized resident care needs for three of 89 residents reviewed (Residents 16, 49, 129).

Findings include:

A quarterly Minimum Data Set (MDS) assessment (a federally-mandated assessment of a resident's abilities and care needs) for Resident 16, dated January 30, 2019, indicated that the resident was confused and received intravenous therapy (IV therapy - medications administered directly into a vein). Physician's orders, dated January 12, 2019, included an order for the resident to receive 500 milligrams (mg) of Imipenem-Cilastatin (an antibiotic) intravenously every eight hours for seven days for a urinary tract infection. A nursing note, dated January 24, 2019, at 4:30 p.m. revealed that the resident had a peripherally inserted central catheter (PICC line - a type of IV catheter that is inserted into a peripheral vein and used for long-term administration of medications and/or fluids)

There was no documented evidence that a care plan was developed to address Resident 16's care needs related to the PICC line.

Interview with the Director of Nursing and Nursing Home Administrator on April 25, 2019, at 12:50 p.m. confirmed that a care plan was not developed to address Resident 16's care needs related to the PICC line.


A quarterly MDS assessment for Resident 49, dated February 5, 2019, revealed that the resident was severely cognitively impaired and required extensive assistance from staff for care. Physician's orders, dated October 29, 2018, included an order for the resident to receive a 500 milligram (mg) tablet of valacyclovir (an antiviral drug used to treat herpes infections in adults) twice daily by mouth. The resident's current diagnosis list, dated April 22, 2019, revealed that the resident had a diagnoses of herpes zoster (shingles) of the eye.

There was no documented evidence that a care plan was developed to address Resident 49's care needs related to herpes of the eye.

Interview with the Director of Nursing on April 25, 2019, at 1:00 p.m. confirmed that a care plan was not developed to address Resident 49's care needs related to herpes of the eye.


An admission MDS assessment for Resident 129, dated February 12, 2019, revealed that the resident was alert and able to make her needs known, required extensive assistance for care, and had a gastrostomy tube (the surgical insertion of a tube through the abdomen and into the stomach for nutritional support).

There was no documented evidence in Resident 129's clinical record that a care plan was developed to address the resident's care needs related to the gastrostomy tube.

An interview with Registered Nurse Assessment Coordinator 32 (RNAC - a registered nurse who is often involved in developing care plans) on April 25, 2019, at 12:21 p.m. confirmed that a care plan to address Resident 129's care needs related to the gastrostomy tube was not developed and should have been developed on admission.

42 CFR 483.21(b)(1) Develop/Implement Comprehensive Care Plans.
Previously cited 4/20/18.

28 Pa. Code 211.11(d) Resident care plan.
Previously cited 5/18/18, 4/20/18.

28 Pa. Code 211.12(d)(5) Nursing services.
Previously cited 1/17/19, 12/27/18, 11/21/18, 5/18/18, 4/20/18.






 Plan of Correction - To be completed: 06/04/2019

The following is submitted for plan of correction purposes only and should not be construed as an admission.

R16 has had their care plan reviewed and updated to meet their current needs. The resident no longer has a PICC line.
R49 has had their care plan reviewed and updated to meet their current needs including Herpes Zoster infection care needs.
R129 has had their care plan reviewed an updated to meet their current needs including Gastrostomy tube care.

Current residents utilizing a PICC Line will have their care plan reviewed, by the Registered Nurse Assessment Coordinator, to ensure that a care plan has been developed to address care needs related to the PICC line. Current residents with Herpes Zoster infection will have their care plan reviewed by the Infection Control Nurse, to ensure that a care plan has been developed to address care needs related to Herpes Zoster infection. Current residents with a Gastrostomy Tube will have their care plan reviewed by the Registered Nurse Assessment Coordinator to ensure that a care plan has been developed to address care needs related to the Gastrostomy tube.

The interdisciplinary care plan team members responsible for the development of care plans will review physician's orders for any new orders and facility 24 hour report daily for any changes in resident condition in order to update the care plan to ensure that the care plan reflects the current status of the resident. Residents will be reviewed by the Registered Nurse Assessment Coordinator on admission, quarterly, and with any change in status to ensure the development of a comprehensive care plan.

Interdisciplinary care plan team members responsible for the development of care plans will be re-educated on developing comprehensive care plans.
Audits of twenty resident care plans will be completed to ensure development of a comprehensive care plan. These audits will be completed weekly for two months, by the DON or designee. Negative findings will result in a Quality Assurance and Performance Improvement meeting being conducted. All results will be reviewed by the Quality Assurance Committee until such time consistent substantial compliance has been achieved as determined by the committee.



483.21(b)(2)(i)-(iii) REQUIREMENT Care Plan Timing and Revision: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)(2) A comprehensive care plan must be-
(i) Developed within 7 days after completion of the comprehensive assessment.
(ii) Prepared by an interdisciplinary team, that includes but is not limited to--
(A) The attending physician.
(B) A registered nurse with responsibility for the resident.
(C) A nurse aide with responsibility for the resident.
(D) A member of food and nutrition services staff.
(E) To the extent practicable, the participation of the resident and the resident's representative(s). An explanation must be included in a resident's medical record if the participation of the resident and their resident representative is determined not practicable for the development of the resident's care plan.
(F) Other appropriate staff or professionals in disciplines as determined by the resident's needs or as requested by the resident.
(iii)Reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments.
Observations:


Based on review of policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to review and revise care plans with individualized interventions to address residents' care needs for two of 89 residents reviewed (Residents 2, 58).

Findings include:

The facility's policy regarding care plans, dated November 28, 2018, revealed that care plans were to be updated when a change in condition occurred, and care plans that no longer reflected the resident's current status were to be discontinued.

A care plan that was initiated on November 30, 2019, and revised on April 17, 2019, indicated that Resident 2 had the potential for mood problems, increased restlessness, and psychosocial well-being problems due to diagnoses of anxiety and dementia. A quarterly Minimum Data Set (MDS) assessment (a federally-mandated assessment of a resident's abilities and care needs) for Resident 2, dated January 17, 2019, indicated that the resident was cognitively impaired and dependent on staff for care, including hygiene and bathing.

Observations on April 22, 2019, at 10:39 a.m. revealed that Nurse Aides 7 and 20 provided morning care to Resident 2, and throughout the care, the resident yelled out statements such as, "Ouch, it hurts!" and, "My leg, my leg!"

Interview with Nurse Aide 7 on April 22, 2019, at 11:14 a.m. revealed the Resident 2 yells out all the time, including when you walk into her room. Interview with Registered Nurse 3 on April 22, 2019, at 1:04 p.m. revealed that Resident 2 resists care all the time.

There was no documented evidence that Resident 2's care plan was revised to include ongoing behaviors of yelling out and resisting care.

Interview with the Director of Nursing and Assistant Director of Nursing on April 22, 2019, at 3:10 p.m. confirmed that Resident 2's care plan was not revised to include that she screams and yells during care, and the care plan should have been revised.


A quarterly MDS assessment for Resident 58, dated February 13, 2019, indicated that the resident was cognitively impaired, dependent for care, incontinent of bowel and bladder, at risk for developing pressure ulcers (skin breakdown caused by prolonged, unrelieved pressure), and had diagnoses that included chronic pain and anorexia. The resident's care plan, dated November 30, 2018, included an intervention that green wedges were to be in place on each side of the resident while she was in bed, under the fitted sheet, from the top of the shoulders down, and to check their placement every shift.

Physician's orders for Resident 58, dated February 12, 2019, included an order for the resident to use green wedges along both sides of her body while in bed, from the top of the shoulders down. There was no documented evidence that Resident 58's care plan was updated following this order to reflect that the green wedges were to be beside the resident and not under the fitted sheet.

Observations of Resident 58 on April 24, 2019, at 8:56 a.m. revealed that two green wedges were in place on each side of the resident while she was in bed, and the wedges were not under the fitted sheet.

Resident 58's care plan, dated October 17 and November, 2018, included that a soft-touch gray call bell was to be within reach at all times.

Observations of Resident 58 on April 24, 2019, at 8:56 a.m. revealed that the resident was in bed with a regular button-style call bell on the right side of her pillow. Interview with Nurse Aide 21 on April 24, 2019, at 9:00 a.m. revealed that Resident 58 was not capable of using a call bell due to dementia.

There was no documented evidence that Resident 58's care plan was updated to reflect that the resident was not capable of using a call bell.

Physician's orders for Resident 58, dated July 24, 2018, included an order for the resident to utilize orthopedic shoes, put on at lunch, and taken off at dinner, and the resident's care plan, dated October 31, 2018, reflected the physician's order for the resident to wear orthopedic shoes on at lunch and off at dinner.

Observations of Resident 58 on April 22, 2019, at 10:20 a.m. and April 24, 2019, at 9:25 a.m. revealed that the resident was dressed and had orthopedic shoes on. Interview with Nurse Aide 21 on April 24, 2019, at 9:28 a.m. revealed that Resident 58 always gets her shoes on when she gets dressed and out of bed.

There was no documented evidence that Resident 58's care plan was updated to reflect that she wore orthopedic shoes as soon as she was dressed and out of bed.

Interview with Registered Nurse Assessment Coordinator 23 on April 24, 2019, at 10:00 a.m. confirmed that the care plans in place regarding Resident 58's green wedges, call bell use, and orthopedic shoes were not updated to reflect the resident's current care needs.

Physician orders for Resident 58, dated July 24 and November 13, 2018, and the resident's care plan dated November 30, 2018, included orders/interventions for the resident to wear heel protectors (white) to both knees, on in the morning and off in the evening, and for a contour pillow under both ankles while in bed (to keep the heels off the bed).

Observations of Resident 58 while in bed on April 24, 2019, at 8:56 a.m. revealed that the resident did not have heel protectors on her knees nor a contour pillow under her ankles. An interview with Nurse Aides 21 and 26 on April 24, 2019, at 9:20 a.m. revealed that they have never seen heel protectors for Resident 58's knees and that the contour pillow was discontinued yesterday.

There was no documented evidence that Resident 58's care plan was revised to reflect her current care needs related to the use of heel protectors on her knees and a contour pillow under her heels.

An interview with Registered Nurse Assessment Coordinator 23 on April 24, 2019, at 10:00 a.m. confirmed that Resident 58's care plan regarding the use of heel protectors and a contour pillow was not updated.

42 CFR 483.21(b)(2)(i)-(iii) Care Plan Timing and Revision.
Previously cited 4/20/18.

28 Pa. Code 211.11(d) Resident care plan.
Previously cited 5/18/18, 4/20/18.

28 Pa. Code 211.12(d)(5) Nursing services.
Previously cited 1/17/19, 12/27/18, 11/21/18, 5/18/18, 4/20/18.



 Plan of Correction - To be completed: 06/04/2019

The following is submitted for plan of correction purposes only and should not be construed as an admission.


R2 care plan has been reviewed and updated to reflect the resident's current needs related to behaviors of yelling out and resisting care.
R58 care plan has been reviewed and updated to reflect the correct use of current positioning equipment, orthopedic shoes, cognitive needs and the ability to use call bell.
The interdisciplinary care plan team members responsible for the development of care plans will review physician's order for any new orders and facility 24 hour report daily for any changes in resident condition in order to update the care plan to ensure that the care plan reflects the current status of the resident. Current residents care plans will be reviewed by the Registered Nurse Assessment Coordinator on admission, quarterly, and with any change in status to ensure that care plans are updated to reflect changes in residents' care needs.

The Registered Nurse Assessment Coordinator and the interdisciplinary team responsible for updating care plans will be re-educated on updating and revising care plans per the Resident Assessment Instrument guidelines.

Audits of ten (10) resident care plans will be completed weekly for four months, by the DON or Designee, to ensure that care plans have been updated to reflect any changes in resident care needs. Negative findings will result in a Quality Assurance and Performance Improvement meeting being conducted. All results will be reviewed by the Quality Assurance Committee until such time consistent substantial compliance has been achieved as determined by the committee.

483.24(a)(2) REQUIREMENT ADL Care Provided for Dependent Residents: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.
483.24(a)(2) A resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene;
Observations:


Based on clinical record reviews, observations and staff interviews, it was determined that the facility failed to provide the necessary services to maintain good nutrition and oral hygiene for two of 89 residents reviewed (Residents 59, 199).

Findings include:

A quarterly Minimum Data Set (MDS) assessment (a federally-mandated assessment of a resident's abilities and care needs) for Resident 59, dated February 13, 2019, revealed that the resident was severely cognitively impaired and required extensive assistance from staff for daily care tasks, including eating. The resident's care plan, dated September 18, 2018, revealed that the resident wore an upper denture.

A quarterly MDS assessment for Resident 199, dated April 3, 2019, revealed that the resident was severely cognitively impaired and required extensive assistance from staff for care, including eating. The resident's care plan, dated August 15, 2018, revealed that the resident wore an upper denture.

Observations during the lunch meal on April 22, 2019, at 11:30 a.m. revealed that Residents 59 and 199 were sitting at a table in the dining room and were being fed by Nurse Aide 35. Neither Resident 59 nor Resident 199 had an upper denture in place during the meal.

Interview with Nurse Aide 35 on April 22, 2019, at 12:25 p.m. confirmed that neither Resident 59 nor Resident 199 had their upper denture in place during the lunch meal.

Interview with Licensed Practical Nurse 38 on April 22, 2019, at 12:35 p.m. revealed that neither Resident 59 nor Resident 199 had a history of refusing to wear their upper denture, and she confirmed that Residents 59 and 199 should have had their dentures in place prior to being fed lunch.

42 CFR 483.24(a)(2) ADL Care Provided for Dependent Residents.
Previously cited 4/20/18.

28 Pa. Code 211.12(d)(1) Nursing services.
Previously cited 4/20/18.

28 Pa. Code 211.12(d)(5) Nursing services.
Previously cited 1/17/19, 12/27/18, 11/21/18, 5/18/18, 4/20/18.



 Plan of Correction - To be completed: 06/04/2019

The following is submitted for plan of correction purposes only and should not be construed as an admission.

Residents 59 and 199 continue to reside in this facility and are being provided their dentures for every meal.
Current residents who wear dentures will be reviewed to ensure that they are wearing their dentures for meals and snacks.

Resident dentures have been added to the Nurse Aide Activities of Daily Living/Care sheets so they know which residents wear dentures.
The Director of Nursing/Designee will educate nursing staff on federal regulation 677 and the importance of providing residents' dentures to them to promote and maintain good nutrition and oral hygiene.

The Director of Nursing/Designee will audit that dentures are being worn as appropriate. These audits will be on five residents per unit daily for two weeks, weekly for two weeks, monthly for two months, then randomly thereafter.

Results of these audits will be reviewed during the facility's Quality Assurance Performance Improvement committee for further recommendations to ensure sustained compliance.

483.25 REQUIREMENT Quality of Care: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 Quality of care
Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices.
Observations:


Based on review of policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to provide proper positioning for two of 89 residents reviewed (Residents 21, 58), and failed to assess and monitor wounds for one of 89 residents reviewed (Resident 9).

Findings include:

A quarterly Minimum Data Set (MDS) assessment (a federally-mandated assessment of a resident's abilities and care needs) for Resident 21, dated January 30, 2019, indicated the resident was severely cognitively impaired, required the extensive assistance of two staff for bed mobility and transfers, and had diagnoses that included Alzheimer's dementia (brain disorder that causes problems with memory, thinking and behavior). Physician's orders, dated April 10, 2019, and the resident's care plan dated February 5, 2019, included an order/intervention for the resident to have a bed pillow placed vertically along the resident's left side from the shoulder down while lying in bed.

Observations of Resident 21 on April 22, 2019, at 10:48 a.m. and April 24, 2019, at 9:11 a.m. and 9:35 a.m. revealed that the resident was in bed and his upper body was leaning to the far left. The resident did not have a pillow placed vertically along his left side.

Interviews with Nurse Aide 34 and the Director of Nursing on April 24, 2019, at 9:35 a.m. and 2:20 p.m., respectively, confirmed that Resident 21 was to have a pillow on his left side while in bed.


A quarterly MDS assessment for Resident 58, dated February 13, 2019, revealed that the resident was cognitively impaired, totally dependent for care, had limited range of motion of all extremities, was on a pain regimen, and had diagnoses that included anxiety and chronic pain. Resident 58's care plan, dated October 31, 2018, included interventions for staff to anticipate and meet the resident's needs and to provide supportive care assistance with mobility as needed.

Observations on April 22, 2019, at 9:28 a.m. to 10:00 a.m. revealed that Nurse Aides 7 and 20 transferred Resident 58 from bed to a shower litter using a mechanical lift (device that uses hydraulic power to lift and move a person from surface to surface while supported and suspended in a heavy-duty fabric sling). As the resident was being lowered onto the litter, her head rested on the top frame of the litter, which was plastic and unpadded. The resident was transported to the shower room by Nurse Aide 20 and was then rolled side-to-side while being undressed, which caused her head to come off the frame of the litter and be unsupported. During the shower, the resident's head remained unsupported. When asked if support was available for the resident's head, such as a shower pillow, Nurse Aide 7 replied that the shower litter was new and a pillow was not available.

An interview with the Nursing Home Administrator and the Director of Nursing on April 24, 2019, at 3:16 p.m. confirmed that the shower litters were newer, that shower pillows were not available, and that the resident should not have been placed with her head resting on the frame of the shower litter and should have had her head supported during the shower.


The facility's policy regarding wound care, dated March 12, 2019, revealed that all wounds and/or changes in skin condition were to be assessed by a registered nurse and communicated to the physician for appropriate treatment. The facility's Wound Care Coordinator or designee was to be responsible for completing weekly evaluations, measurements and descriptive information on wounds, and documenting the information.

A quarterly MDS assessment for Resident 9, dated January 31, 2019, revealed that the resident was severely cognitively impaired, required extensive assistance from staff for care, was frequently incontinent of bowel and bladder, and was at risk for skin breakdown.

A nursing note for Resident 9, dated March 27, 2019, at 5:58 a.m. revealed that Licensed Practical Nurse 40 noted a small "open area" on the resident's sacrum (the large triangular bone at the base of the spine), the registered nurse was notified, and a "Wound Communication" was sent. A nursing note authored by Registered Nurse 41 on March 27, 2019, at 6:00 a.m. revealed that Resident 9 had a "small open area to the sacrum." The skin around the wound was pink and blanchable with no drainage, the physician was notified, and new orders were received. A skin/wound note for Resident 9, dated March 27, 2019, at 7:57 a.m. and authored by Registered Nurse 39 (one of the facility's designated wound nurses) revealed that the resident was seen at the bedside related to a wound communication concerning a small superficial open area to the sacrum and that an appropriate treatment was in place.

Resident 9's care plan, updated March 29, 2019, indicated that the resident was at risk for altered skin integrity due to incontinence, limited mobility and fragile skin, and staff were to apply Hydrogel (a cooling, moisturizing gel that promotes wound healing and provides pain relief) to an open area on the resident's sacrum and cover with adhesive foam (an absorbent dressing) twice daily and as needed for soilage or displacement. The resident's Treatment Administration Records (TAR's) for March and April 2019 revealed that staff applied Hydrogel and an adhesive foam dressing twice daily from March 27 to April 25, 2019; however, there was no documented evidence that the wound was initially measured or that any ongoing weekly evaluations or measurements were completed.

Interview with Registered Nurses 39 and 42 on April 25, 2019, at 7:31 p.m. confirmed that there were no documented measurements of Resident 9's sacral wound and no documented evidence that the wound was evaluated for changes weekly from March 27 to April 25, 2019. They confirmed that the resident's wound should have been evaluated weekly.

42 CFR 483.25 Quality of Care
Previously cited 4/20/18.

28 Pa. Code 211.12(d)(1) Nursing services.
Previously cited 4/20/18.

28 Pa. Code 211.12(d)(3) Nursing services.
Previously cited 5/18/18, 4/20/18.

28 Pa. Code 211.12(d)(5) Nursing services.
Previously cited 1/17/19, 12/27/18, 11/21/18, 5/18/18, 4/20/18.




 Plan of Correction - To be completed: 06/04/2019

The following is submitted for plan of correction purposes only and should not be construed as an admission.


Resident 21 continues to reside in this facility and is using positioning pillows per physician's order.
Resident 58 continues to reside in this facility and is being positioned properly on the shower litter.
Resident 9 continues to reside in this facility and the identified small open area is now resolved.

Current residents receiving physician orders for positioning pillows will be reviewed to ensure that pillows are being used per order.
Current residents receiving showers utilizing litters will be reviewed to ensure proper positioning.
Current residents with identified opened areas will be reviewed to ensure that they are being monitored and assessed by a Licensed Nurse. Newly identified areas will be assessed by the registered Nurse Wound Coordinator who will continue to assess at least every seven days. In the absence of the wound nurse, a registered nurse will assess. Wound rounds are made with the Certified Registered Nurse Practitioner (CRNP) certified in wound care at least every seven days on residents with areas.

The Director of Nursing / Designee will provide education to nursing staff on Federal Regulation 684 and on the importance of providing proper positioning and assessments of open areas to maintain quality of care.

The Director of Nursing / Designee will audit compliance with positioning pillows. These audits will be on 5 residents daily for two weeks, weekly for two weeks, monthly for two months, then randomly thereafter.
The Director of Nursing / Designee will audit compliance with proper positioning on shower litters. These audits will be on 5 residents daily for two weeks, weekly for two weeks, monthly for two months, then randomly thereafter.
The Director of Nursing / Designee will audit compliance with monitoring identified skin areas. These audits will be on 5 residents daily for two weeks, weekly for two weeks, monthly for two months, then randomly thereafter.


Results of these audits will be reviewed in the facility's Quality Assurance Performance Improvement meetings for further suggestions for sustained compliance.






483.25(e)(1)-(3) REQUIREMENT Bowel/Bladder Incontinence, Catheter, UTI: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(e) Incontinence.
483.25(e)(1) The facility must ensure that resident who is continent of bladder and bowel on admission receives services and assistance to maintain continence unless his or her clinical condition is or becomes such that continence is not possible to maintain.

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

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


Based on review of policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that appropriate procedures to prevent urinary infections were used during care for two of 89 residents reviewed who had an indwelling urinary catheter (Residents 121, 142), and failed to ensure that toileting/incontinent care was provided as scheduled for one of 89 residents reviewed (Resident 16).

Findings include:

A significant change Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 121, dated February 2, 2019, revealed that the resident was understood and could understand, and required extensive assistance from staff for care, including toileting, transfers and bed mobility. A medical diagnosis list, dated April 1, 2019, revealed that the resident had diagnoses that included a stroke with left-sided hemiplegia (paralysis on one side of the body). The resident's care plan, dated September 14, 2018, revealed that the resident had a suprapubic catheter (a tube surgically inserted through the lower abdomen into the bladder to drain urine), and staff were to keep the catheter tubing and drainage bag off the floor.

Observations on April 22, 2019, at 9:24 a.m. during an interview with Resident 121 revealed that the resident was lying in bed and the catheter drainage bag was touching the fall mat on the floor to the left of the resident's bed.

Interview with Licensed Practical Nurse 25 on April 22, 2019, at 9:39 a.m. confirmed that Resident 121's drainage bag was touching the fall mat on the floor and that it should not have been. Interview with the Director of Nursing on April 24, 2019, at 2:20 p.m. confirmed that Resident 121's drainage bag should not touch the fall mat on the floor.


The facility's policy regarding indwelling catheters (tube inserted and held in the bladder to drain urine), dated March 12, 2019, revealed that when emptying the urine collection bag, staff were to cleanse the end of the drainage tubing with an alcohol wipe before reclamping.

An annual MDS assessment for Resident 142, dated March 15, 2019, revealed that the resident was able to make his needs known, was dependent for care, had an indwelling urinary catheter, and had diagnoses that included Guillain-Barre syndrome (a rare disorder in which the body's immune system attacks the nerves, eventually paralyzing the whole body) resulting in quadriplegia (total loss of the use of all four limbs). The resident's care plan, dated August 9, 2018, indicated that he had an indwelling urinary catheter due to a sacral pressure ulcer (skin breakdown caused by prolonged, unrelieved pressure).

Observations of catheter care on April 23, 2019, at 8:15 a.m. revealed that Registered Nurse 39 emptied Resident 142's urine drainage bag into a graduated cylinder and did not clean the end of the drainage tube when she was done emptying the bag.

Interview with the Director of Nursing on April 23, 2019, at 10:30 a.m. confirmed that Registered Nurse 39 should have cleansed the end of Resident 142's catheter drainage tubing with an alcohol wipe when she was finished emptying the bag.


A quarterly MDS assessment for Resident 16, dated January 30, 2019, revealed that the resident was cognitively impaired, required extensive assistance with care, and was incontinent of urine. The resident's care plan, dated January 11, 2019, revealed that staff were to toilet the resident after breakfast, after lunch, at the overlap between the day shift (7:00 a.m. to 3:00 p.m.) and evening shift (3:00 p.m. to 11:00 p.m.), after supper, at bedtime, at the last check on the evening shift, and the first, second and third check during the night shift (11:00 p.m. to 7:00 a.m.).

Bowel and bladder records for February and March 2019 revealed that staff provided "incontinent care" to Resident 16 on February 24 at 9:22 p.m. and there was no documented evidence that toileting and/or incontinent care was provided again until 3:28 a.m. (over six hours). "Incontinent care" was provided on March 13 at 3:46 p.m. and there was no documented evidence that toileting and/or incontinent care was provided again until 8:33 p.m. (4 hours and 47 minutes). "Incontinent care" was provided on March 24 at 5:50 a.m. and there was no documented evidence that the resident was provided toileting and/or incontinent care again until 2:39 p.m. (8 hours and 49 minutes).

Interview with the Nursing Home Administrator on April 25, 2019, at 3:36 p.m. confirmed that there was no documented evidence that Resident 16 was toileted according to the scheduled toileting plan.

28 Pa. Code 211.12(d)(3) Nursing services.
Previously cited 5/18/18, 4/20/18.

28 Pa. Code 211.12(d)(5) Nursing services.
Previously cited 1/17/19, 12/27/18, 11/21/18, 5/18/18, 4/20/18.




 Plan of Correction - To be completed: 06/04/2019

The following is submitted for plan of correction purposes only and should not be construed as an admission.

Resident R121 continues to reside in this facility and the catheter drainage bag is being positioned so that it is not touching the fall mat or floor.
Resident R142 continues to reside in this facility; staff are emptying the urinary drainage bag using appropriate technique.

Resident R16 continues to reside in this facility and is being toileted/ receiving incontinent care according to the care plan.

Current residents with indwelling catheters will be reviewed to ensure that the urinary drainage bags are positioned correctly (off the floor/floor mat) and are being emptied using the correct procedure.
Nursing staff will be educated on verifying correct positioning of indwelling catheter drainage bags and tubing with every resident interaction. Verification of proper positioning will be documented by the licensed nurses every shift on the electronic Treatment Sheet.

Current residents with care plans for toileting/incontinent care at specific times will be reviewed for compliance with the care plans. To achieve this, one week of documentation will be reviewed.

The Director of Nursing/Designee will educate nursing staff on Federal Regulation 690 and the importance of proper positioning and emptying of urinary drainage bags and also the importance of compliance with care planned toileting schedules.

The Director of Nursing/Designee will audit compliance with positioning and emptying of urinary drainage bags and also compliance with care planned toileting schedules. These audits will be on five residents daily for two weeks, weekly for two weeks, monthly for two months, then randomly thereafter.

Results of these audits will be reviewed in the facility's Quality Assurance Performance Improvement meetings for further suggestions to achieve sustained compliance.


483.25(g)(4)(5) REQUIREMENT Tube Feeding Mgmt/Restore Eating Skills: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(g)(4)-(5) Enteral Nutrition
(Includes naso-gastric and gastrostomy tubes, both percutaneous endoscopic gastrostomy and percutaneous endoscopic jejunostomy, and enteral fluids). Based on a resident's comprehensive assessment, the facility must ensure that a resident-

483.25(g)(4) A resident who has been able to eat enough alone or with assistance is not fed by enteral methods unless the resident's clinical condition demonstrates that enteral feeding was clinically indicated and consented to by the resident; and

483.25(g)(5) A resident who is fed by enteral means receives the appropriate treatment and services to restore, if possible, oral eating skills and to prevent complications of enteral feeding including but not limited to aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, and nasal-pharyngeal ulcers.
Observations:


Based on review of policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that a tube feeding formula was dated and a feeding syringe was clean for one of 89 residents reviewed (Resident 124) who received nutrition via a gastrostomy tube.

Findings include:

The facility's policies regarding tube feedings (nutrition and fluids administered via a tube that has been surgically inserted through the abdomen into the stomach), dated March 12, 2019, indicated that after use, the plunger of the feeding syringe was to be removed from the barrel and thoroughly rinsed of any feeding formula or medication residue, dried thoroughly, and stored in a bag until the next use. Feeding syringes were to be replaced every 24 hours.

A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 124 dated March 6, 2019, revealed that the resident was cognitively impaired and totally dependent on staff for bed mobility, transfers, hygiene, eating and bathing. Physician's orders dated April 18, 2019, included an order for the resident to receive Jevity 1.2 (a tube feeding formula) at 55 milliliters (ml) per hour for 22 hours, to provide 1210 ml per day.

Observations on April 22, 2019, at 9:34 a.m. revealed of Resident 124's container of tube feeding formula, Jevity 1.2, was opened and was being administered. The container was not labeled with the date the tube feeding was started.

Interview with Licensed Practical Nurse 1 on April 22, 2019, at 9:41 a.m. confirmed that Resident 124's container of tube feeding formula was not dated when it was hung and it should have been. Interview with the Director of Nursing on April 22, 2019, at 1:45 p.m. confirmed that the tube feeding container should have had a sticker that was labeled with the date it was started.

Observations of a feeding syringe in Resident 124's room on April 23, 2019, at 10:01 a.m. revealed that the syringe was in a clear plastic bag that was hanging next to his tube feeding, and there was an orange-colored fluid on the tip of the syringe and on the plunger of the syringe.

Interview with Licensed Practical Nurse 2 on April 23, 2019, at 10:05 a.m. confirmed that Resident 124's feeding syringe had an orange fluid on it and was not clean.

Interview with Registered Nurse Manager 3 on April 23, 2019, at 10:29 a.m. and with the Director of Nursing on April 24, 2019, at 11:36 a.m. confirmed that Resident 124's feeding syringe should have been cleaned after use.

42 CFR 483.25(g)(4)(5) Tube Feeding Management/Restore Eating Skills.
Previously cited 4/20/18.

28 Pa. Code 211.12(d)(5) Nursing services.
Previously cited 1/17/19, 12/27/18, 11/21/18, 5/18/18, 4/20/18.



 Plan of Correction - To be completed: 06/04/2019

The following is submitted for plan of correction purposes only and should not be construed as an admission.


Resident R124 continues to reside in this facility and tube feedings are being labeled correctly with date, time, and initials and tube feeding syringes are cleaned and stored per policy.
Current residents receiving enteral feedings will be reviewed to ensure that the tube feedings are labeled per policy including date, time, and initials and also that the tube feeding syringes are cleaned and stored per policy.
The Night Shift Registered Nurse Supervisor will now be responsible for ensuring that new enteral feeding syringes are dispensed to residents will enteral feeding tubes that are dated and also verify that enteral feedings are dated.
The Director of Nursing/Designee will educate licensed nursing staff on Federal Regulation 693 and the importance of dating tube feeding s and also cleaning tube feeding syringes.

The Director of Nursing/Designee will audit that tube feedings are dated and syringes are cleaned and stored correctly. These audits will be done on five residents daily for two weeks, weekly for two weeks, monthly for two months, then randomly.

Results of the audits will be reviewed in the facility's Quality Assurance Performance Improvement meeting for further recommendations for sustained compliance.



483.45(f)(2) REQUIREMENT Residents are Free of Significant Med Errors: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.
The facility must ensure that its-
483.45(f)(2) Residents are free of any significant medication errors.
Observations:


Based on clinical record reviews and staff interviews, it was determined that the facility failed to ensure that residents were free from significant medication errors for one of 89 residents reviewed (Resident 16).

Findings include:

A quarterly Minimum Data Set (MDS) assessment (a federally-mandated assessment of a resident's abilities and care needs) for Resident 16, dated January 30, 2019, indicated that the resident was confused and received intravenous therapy (IV therapy - medications administered directly into a vein). Physician's orders, dated January 11, 2019, included an order for the resident to receive 500 milligrams (mg) of Imipenem-Cilastatin (an antibiotic) intravenously every eight hours for seven days for a urinary tract infection. A nursing note, dated January 24, 2019, at 4:30 p.m. revealed that the resident had a peripherally inserted central catheter (PICC line - a catheter that is inserted in a peripheral vein and used for long-term administration of medications and/or fluids)

Resident's 16's Medication Administration Record (MAR) for January 2019 revealed that Imipenem-Cilastatin was not administered on January 13, 2019, at 6:00 a.m. and January 15, 2019, at 6:00 a.m. and 2:00 p.m.

Interview with the Director of Nursing on April 25, 2019, at 12:50 p.m. confirmed that Imipenem-Cilastatin was not administered to Resident 16 as ordered by the physician due to the loss of IV access and the medication should have been extended for another three doses but was not.

42 CFR 483.45(f)(2) Residents Are Free of Significant Med Errors.
Previously cited 4/20/18.

28 Pa. Code 211.12(d)(5) Nursing services.
Previously cited 1/17/19, 12/27/18, 11/21/18, 5/18/18, 4/20/18.



 Plan of Correction - To be completed: 06/04/2019

The following is submitted for plan of correction purposes only and should not be construed as an admission.


Resident R16 continues to reside in this facility. A medication error report was generated regarding the missed doses of antibiotics. Resident R16 is currently free of infections.

Current residents ordered antibiotics to be delivered for a specified time/duration of administration will be reviewed to ensure that the ordered doses were administered as ordered.

Ordered antibiotic therapy will be communicated at change of shift report to ensure completion as ordered. Physicians will be notified if ordered doses are not able to be administered for further interventions.

The Director of Nursing/Designee will educate licensed nurses on Federal regulation 760 and the importance of administering medications as ordered. Education will also include notification of the physician for any factor that would impact administering the antibiotic, including loss of intravenous access.

The Director of Nursing/Designee will audit that antibiotics ordered for a specified time/duration are administered as ordered. These audits will be on residents ordered antibiotics weekly for six weeks, monthly for two months, then randomly thereafter.

Results of these audits will be reviewed in the facility's Quality Assurance Performance Improvement meeting for further suggestions for sustained compliance.

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 clinical record reviews, 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, failed to label a bottle of testing solution when it was opened for one of four medication room refrigerators reviewed (first floor med room), and failed to discard expired medication/equipment in one of nine medication carts reviewed (first floor bariatric cart).

Findings include:

Physician's orders for Resident 17, dated August 3, 2018, included an order for the resident to receive 5 milligrams (mg) of Valium (a medication used to treat anxiety) two times per day for muscle spasms.

Observations during medication administration on April 23, 2019, at 8:35 a.m. revealed that Licensed Practical Nurse 29 prepared to give medication to Resident 17 by removing an unmarked medication cup from the medication cart. The cup contained a round yellow tablet. Interview with Licensed Practical Nurse 29 at that time revealed that the cup contained Resident 17's dose of Valium.

Interview with Licensed Practical Nurse 29 on April 23, 2019, at 9:04 a.m. revealed that she prepared Resident 17's dose of Valium prior to moving the medication cart from the previous resident's room to Resident 17's room.

Interview with the Director of Nursing on April 24, 2019, at 2:20 p.m. confirmed that the medications were to remain secured in the medication cart in their original packages until the time of administration, and that medications were not to be pre-poured because the nurse should ensure that the resident is available to receive their medication prior to preparing it.


The facility's policies regarding medication administration, dated June 1, 2018, revealed that when opening a multi-dose container, the date the container was opened and the initials of the first person to use the multi-dose container were to be recorded on the accessory label affixed for that purpose.

The facility's policy regarding medication storage, dated June 1, 2018, revealed that outdated, contaminated or deteriorated medication were to be immediately removed, disposed of according to procedures for medication disposal, and reordered from the pharmacy if a current order exists.

The manufacturer's instructions for Aplisol (a solution injected under the skin to test for tuberculosis - a lung infection) revealed that vials in use more than 30 days should be discarded due to possible oxidation (exposure to oxygen causing it to lose its properties) and degradation (breakdown of the substance causing it to lose its quality) which may affect potency.

Observations of the first floor medication room refrigerator on April 25, 2019, at 5:50 p.m. revealed that a multidose vial of Aplisol was opened and was not labeled with the date it was opened.

Observations of the first floor bariatric medication cart on April 25, 2019, at 5:50 p.m. revealed that a bottle of 0.65 percent saline spray nasal for Resident 40 was currently in use and was labeled that it was opened March 23 and expired on April 23. A bottle of 0.65 percent saline spray nasal for Resident 191 was labeled that it was opened January 30, 2019, and expired on March 30, 2019, and there was no current order for this medication. There were also three sets of intravenous (IV) tubing extension sets (add on tubing for intravenous administration) with an expiration date of June 2017.

An interview with Licensed Practical Nurse 22 on April 25, 2019, at 5:50 p.m. confirmed that the opened bottle of Aplisol was not dated, the IV sets were expired, and the saline nasal sprays appeared to be expired.

An interview with the Director of Nursing on April 25, 2019, at 7:50 p.m. confirmed that the Aplisol vial should have been dated when it was opened, the saline nasal sprays were expired and should have been discarded, and the IV sets were expired and should not have been available for use.

42 CFR 483.45(g)(h)(1)(2) Label/Store Drugs and Biologicals.
Previously cited 4/20/18.

28 Pa. Code 211.9(a)(1) Pharmacy services.
Previously cited 4/20/18.

28 Pa. Code 211.12(d)(1) Nursing services.
Previously cited 4/20/18.




 Plan of Correction - To be completed: 06/04/2019

The following is submitted for plan of correction purposes only and should not be construed as an admission.


Resident R17 continues to reside in this facility and is receiving physician ordered medications per policy and standards of care.
The Aplisol from the first floor medication room that was not dated was discarded and replaced with a new vial that was dated on opening.
The saline nasal spray for resident R40 was discarded and replaced with a new bottle.
The saline nasal spray for resident R191 was discarded.
The expired intravenous equipment was discarded.

Current medication storage areas, including medication carts will be reviewed to ensure that all products, including intravenous equipment, are labeled correctly when opened and also not expired.

Current licensed nurses will be randomly evaluated during a medication pass to ensure that medications are not pre-poured and unlabeled in the carts.
The night shift nursing staff will now be responsible for checking the storage areas to ensure that medications are labeled and stored properly.

A Pharmacy Consultant will also review medication storage areas for regulatory compliance at least quarterly.
The Director of Nursing/Designee will educate licensed nursing staff on Federal Regulation 761 and the importance of labeling and storing drugs and biologicals appropriately.
The Director of Nursing/Designee will audit that medications and biologicals are labeled appropriately and stored correctly. Audits will also be done to ensure that medications are not pre-poured and unlabeled during a medication pass. These audits will be completed daily for two weeks, weekly for two weeks, monthly for two months, then randomly. Results of the audits will be reviewed in the facility Quality Assurance Performance Improvement meetings for recommendations for sustained compliance.


483.60(g) REQUIREMENT Assistive Devices - Eating Equipment/Utensils: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.
483.60(g) Assistive devices
The facility must provide special eating equipment and utensils for residents who need them and appropriate assistance to ensure that the resident can use the assistive devices when consuming meals and snacks.
Observations:


Based on clinical record reviews, observations, and staff interviews, it was determined that the facility failed to provide adaptive eating equipment as ordered by the physician for one of 89 residents reviewed (Resident 97).

Findings include:

A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 97, dated February 26, 2019, indicated that the resident was severely cognitively impaired and required limited assistance from staff to eat. Physician's orders, dated January 7, 2019, included an order for the resident to be provided with a maroon spoon (a special plastic spoon) for meals.

Observations during the lunch meal on April 23, 2019, at 11:47 a.m. revealed that Resident 97 was attempting to eat pureed meat out of a bowl and thickened milk out of a small glass with a regular metal fork. A maroon spoon was not provided to Resident 97.

Interview with Nurse Aide 35 on April 23, 2019, at 12:00 p.m. revealed that she was not aware that Resident 97 should have been provided with a maroon spoon during the meal, and she confirmed that one was not provided with the lunch meal and it should have been placed on the resident's meal tray by the kitchen staff.

Interview with the Dietary Director on April 24, 2019, at 11:50 a.m. confirmed that Resident 97 had a physician's order to receive a maroon spoon with her meals; however, this order was not communicated to the Dietary Department.

28 Pa. Code 211.12(d)(3) Nursing services.
Previously cited 5/18/18, 4/20/18.

28 Pa. Code 211.12(d)(5) Nursing services.
Previously cited 1/17/19, 12/27/18, 11/21/18, 5/18/18, 4/20/18.



 Plan of Correction - To be completed: 06/04/2019

The following is submitted for plan of correction purposes only and should not be construed as an admission.

Resident 97 continues to reside in this facility and Maroon spoon is provided during all meals per physician's order.
Current residents who are ordered a maroon spoon will be reviewed to ensure that they are provided a maroon spoon for all meals.

Dining assistive devices will be present on the activity of daily living nurse aide sheets.

The Director of Nursing/Designee will educate nursing staff on federal regulation 810 and the importance of providing residents' maroon spoon per physician's order during all meals.
The Director of Nursing/Designee will audit that dining assistive devices, including maroon spoons, are provided per physician's order for all meals. These audits will be on five residents daily for two weeks, weekly for two weeks, monthly for two months, then randomly thereafter.

Results of these audits will be reviewed during the facility's Quality Assurance Performance Improvement committee for further recommendations to ensure sustained compliance.

211.10(d) LICENSURE Resident care policies.:State only Deficiency.
(d) The policies shall be designed and implemented to ensure that the resident receives proper care to prevent pressure sores and deformities; that the resident is kept comfortable, clean and well-groomed; that the resident is protected from accident, injury and infection; and that the resident is encouraged, assisted and trained in self-care and group activities.
Observations:


Based on clinical record reviews, observations and staff interviews, it was determined that the facility failed to ensure that there was a policy in place for the care of indwelling urinary catheters.

Findings include:

A care plan for Resident 121, dated September 14, 2018, revealed that the resident had a suprapubic catheter (a tube inserted through the lower abdomen into the bladder to drain urine) and staff were to keep the tubing and drainage bag off the floor. Observations on April 22, 2019, at 9:24 a.m. during a interview with Resident 121 revealed that the resident was lying in bed and the catheter drainage bag was touching the fall mat on the floor to the left of the resident's bed.

Interview with the Director of Nursing on April 24, 2019, at 2:20 p.m. revealed that the facility used the Lippincott Manual (a reference book of nursing procedures) for guidance on the care of indwelling catheters, and there were no facility-specific care policies regarding the care of indwelling urinary catheters

Previously cited 4/20/18.




 Plan of Correction - To be completed: 06/04/2019

The following is submitted for plan of correction purposes only and should not be construed as an admission.

Resident R121 still resides in this facility and the resident's catheter drainage bag and tubing is positioned off the floor.

The policy for indwelling urinary catheters has been reviewed and revised to include facility specific care of these catheters.

The Director of Nursing/designee will educate nursing staff on State Regulation 1925 and the newly revised Indwelling Catheter Care policy.
The facility's Quality Assurance Performance Improvement Committee will review and revise as needed this policy at least annually.


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