Pennsylvania Department of Health
CHAPEL MANOR
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

CHAPEL MANOR
Inspection Results For:

There are 166 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.


CHAPEL MANOR - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:
Based on a Medicare/Medicaid Recertification Survey, Civil Rights Compliance Survey, State Licensure Survey and an Abbreviated survey in response to three complaints, completed on March 6, 2024, it was determined that Chapel Manor, was not in compliance with the 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 related to the health portion of the survey process.

Plan of Correction:

483.10(i)(1)-(7) REQUIREMENT Safe/Clean/Comfortable/Homelike Environment:

This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.

§483.10(i) Safe Environment.
The resident has a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

The facility must provide-
§483.10(i)(1) A safe, clean, comfortable, and homelike environment, allowing the resident to use his or her personal belongings to the extent possible.
(i) This includes ensuring that the resident can receive care and services safely and that the physical layout of the facility maximizes resident independence and does not pose a safety risk.
(ii) The facility shall exercise reasonable care for the protection of the resident's property from loss or theft.

§483.10(i)(2) Housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior;

§483.10(i)(3) Clean bed and bath linens that are in good condition;

§483.10(i)(4) Private closet space in each resident room, as specified in §483.90 (e)(2)(iv);

§483.10(i)(5) Adequate and comfortable lighting levels in all areas;

§483.10(i)(6) Comfortable and safe temperature levels. Facilities initially certified after October 1, 1990 must maintain a temperature range of 71 to 81°F; and

§483.10(i)(7) For the maintenance of comfortable sound levels.

Observations:

Based on observations and interviews with staff, it was determined that the facility failed to ensure a safe, clean, comfortable, homelike environment for two of three floors observed. (First Floor and Second Floor)

Findings Include:

Observation of the First floor B on unit March 6, 2024, at 11:02 a.m., revealed that there was an open linen cart in the hall way. Inside the cart there was disposible razors.

Interview with Registered Nurse on March 6, 2024, at 12:34 p.m. confirmed that the razors were unsecured and she removed the razors from the cart.

Observation of the First floor A wing pantry on March 1, 2024 at 10:44 a.m. revealed the door would not close shut for the small storage refrigerator behind the nurses station.

Observation on March 1, 2024 at 10:02 of Room 131-B revealed medication cups on the floor, paper trash on the floor, and a "flush slowly" sign on the toilet. Interview with Resident R77 revealed the toilet water does take a long time to go down and it often gets clogged.

Observation on March 1, 2024 at 10:10 a.m. of Room 135-B revealed a trash can with no liner with gloves inside that were disposed of.

Observation on March 1, 2024 at 10:22 a.m. of Room 129-C revealed paper trash on the floor, a trash can with no liner and gloves that were disposed of inside. In the bathroom there was a toilet paper bar that was broken off.

Interview on March 1, 2024 at 11:04 a.m. with Resident R109 in room 200-C revealed a complaint of staff not cleaning. Resident R109 revealed that staff will come into the room and look around but will never do a throughout mop of the floors.

Observation on March 1, 2024 at 1:10 p.m. of Room 204-B revealed the top drawer of her dresser had a broken handle.

28 Pa. Code 201.14 (a) Responsibility of licensee

Plan of Correction - To be completed: 04/09/2024

1. Linen cart covers in place, razors were removed from the cart.
2. DON/IP/designee to educate nursing staff on a safe, clean, comfortable and homelike environment including linen carts covered, and razors stored in appropriate area.
3. DON/IP/designee will complete an initial audit of linen carts on all units to ensure linen carts are kept clean and safe. DON/Designee will conduct weekly audits X 3 then monthly audits x3 to ensure linen carts are kept safe and clean.
4. DON/IP will report findings monthly to the QAPI committee.

1. A wing pantry refrigerator door has been repaired.
2. DON/NPE/designee to educate nursing staff regarding reporting need for refrigerator repairs to maintenance staff.
3. Maintenance Director/designee will complete an initial audit on all pantry refrigerators to ensure refrigerators are not in need of repair. Maintenance Director/Designee will then conduct audits of all pantry refrigerators for working condition weekly X 3 weeks, then monthly X 3 months.
4. Maintenance Director will report findings monthly to the QAPI committee.

1. Room 131B floor has been cleaned. Sign above the toilet was removed and the toilet has been repaired by maintenance staff.
2. NHA/Designee to re-educate Environmental and maintenance staff on the importance of a clean environment and repair of toilets.
3. Environmental Services Director/ Maintenance Director to perform random weekly audits X 3, then monthly X 3 on floor cleanliness in resident rooms and toilet repair.
4. Environmental Services Director and Maintenance Director will report findings monthly to the QAPI committee.

1. Room 135B and Room 129C gloves removed from trash can and liner in place.
2. NHA/Designee to re-educate Environmental staff on ensuring trash cans have appropriate liners.
3. Environmental Services Director to perform random weekly audits X 3, then monthly X 3 on trash cans to assure appropriate liners are in place.
4. Environmental Services Director will report findings monthly to the QAPI committee.

1. Room 129 C toilet paper bar has been repaired. Room 204B dresser drawer handle repaired.
2. NHA/Designee to re-educate Maintenance staff on timely room repairs.
3. Maintenance Director to complete an initial audit to identify toilet paper bars and dresser drawer handles which need repair. Maintenance Director/Designee to conduct weekly audits X 3 then monthly X 3 to ensure toilet paper bars and dresser drawer handles needing repair are identified.
4. Maintenance Director will report findings monthly to the QAPI committee.

1. Room 220C has been cleaned and floor mopped.
2. Environmental staff have been re-educated on the importance of a clean environment.
3. Environmental Services Director to perform random weekly audits X 3, then monthly X3 on room and floor cleanliness.
4. Environmental Services Director will report findings monthly to the QAPI committee.

483.60(i)(1)(2) REQUIREMENT Food Procurement,Store/Prepare/Serve-Sanitary:

§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 observations, interviews with staff, and review of facility policies and documentation, it was determined that the facility failed to ensure that food was stored, prepared, distributed, and served in accordance with professional standards for food service safety.

Findings Include:

Review of facility policy titled, "Food and Nutrition Services Policies and Procedures" dated May 1, 2023 states, "Food stored under refrigeration/freezer storage is maintained in a safe and sanitary manner". "1.4 All foods are labeled with the name of product and the date received and "use by" date once opened. Manufacturers "use by" dates are used until opened." "2.5 Food are kept in their original containers. If removed from the original container, foods are completely covered and labeled with the name of product and "use by" date."

Observation of the A wing pantry on March 1, 2024 at 11:44 a.m. revealed in the pantry an opened jar of peanut butter unlabeled, with a manufacturers expiration date that read June 11, 2023. In the drawer of the pantry was a plate with packets of spilled honey open and spilled all over the plate and drawer. The refrigerator used to store food for resident consumption had no temperature log and no thermometer. In the refrigerator was Popeyes labeled with room 117-b. A sandwich wrapped in saran labeled room 109 with no date. A container of food unlabeled food in plastic. Unlabeled wawa coffee cup full of liquid.

An interview with Licensed nurse, Employee E12 on March 1, 2024 at 11:48 a.m. confirmed that there was thermometer in the refrigerator and confirmed contents of refrigerator.

Observation of the B wing pantry on March 1, 2024 at 10:51 a.m. revealed the refrigerator was dirty. The refrigerator had no temperature log. In the pantry area were two individual cups of cheerios unlabeled and undated.

Observation of the C wing pantry on March 1, 2024 at 11:33 p.m. revealed the pantry had a box of rice Krispie cereal unwrapped with a manufactures expiration date of December 16, 2022. In the pantry was also a bottle of mouth wash with a manufacturer's expiration date of April 2019.

In the refrigerator there was a thickened lemon flavor water opened with a manufacturer's expiration date of February 28, 2024. The refrigerator was dirty and there was no current temperature log. On the front of the refrigerator was a temperature log that was not fully completed which was from December of 2023. Licensed nurse Employee E8 confirmed the findings of the C wing pantry at 11:38 a.m.

Observation of the D wing pantry on March 1, 2024 at 12:01 p.m. revealed no temperature log present at the refrigerator. In the pantry were five individual cups of rice Krispies cereal unlabeled and undated.

28 Pa. Code 201.14(a) Responsibility of licensee

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

Plan of Correction - To be completed: 04/09/2024

1. All pantry refrigerators in the facility were cleaned, all expired, undated and unlabeled items have been discarded, temperature logs and thermometers in place.
2. DON/NPE/Environmental Services Director to re-educate nursing staff and environmental services regarding pantry refrigerators containing expired, undated and unlabeled items, temperature logs and thermometers in place and cleaning of refrigerators.
3. DON/NPE or Environmental Services to conduct an initial audit of all pantry refrigerators for cleanliness, expired, undated, unlabeled food items, temperature logs and thermometers in place. DON/NPE to conduct weekly audits X 3, then monthly X 3 to ensure refrigerator are clean, and all expired, undated and unlabeled items have been discarded and temperature logs in place and completed.
4. DON/Environmental Services Director will report findings to the monthly QAPI committee.

483.35(a)(3)(4)(c) REQUIREMENT Competent Nursing Staff:

§483.35 Nursing Services
The facility must have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment required at §483.70(e).

§483.35(a)(3) The facility must ensure that licensed nurses have the specific competencies and skill sets necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care.

§483.35(a)(4) Providing care includes but is not limited to assessing, evaluating, planning and implementing resident care plans and responding to resident's needs.

§483.35(c) Proficiency of nurse aides.
The facility must ensure that nurse aides are able to demonstrate competency in skills and techniques necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care.

Observations:

Based on review of facility provided documentation and interview with staff, it was determined that the facility did not provide requested evidence of competency trainings for five of five licensed nursing staff. (Employee E15, E16, E17 E18 and E19)

Findings include:

An initial request was made to the Nursing Home Administrator, Employee E1 for competency training of Registered nurse, Employee E15, Nurse aide, Employee E16, Licensed practical nurse, Employee E17, Licensed practical nurse, Employee E18, licensed practical nurse, Employee E19 on March 5, 2024 at 2:49 p.m.

This information was again requested via e-mail from Nursing Home, Employee E1 on Wednesday, March 6, 2024 at 1:28 pm and again at 1:38 pm.

At conclusion of survey on Wednesday, March 6, 2024 at 2:30 p.m. the facility had not provided the required documentation.

28 Pa Code 211.12(d)(1) Nursing services

28 Pa Code 211.12(d)(5) Nursing services

Plan of Correction - To be completed: 04/09/2024

1. Employee E15, E16, E17, E18 and E19 are completing their mandatory competency trainings.
2. DON/designee to re-educate facility NPE to ensure nursing staff complete mandatory competency trainings.
3. DON/designee to perform initial audit of nursing staff for up-to-date competencies, weekly audits X 3, then monthly X 3 for new nursing staff hires and annual compliance.
4. DON will report findings to the monthly QAPI committee.

483.10(g)(10)(11) REQUIREMENT Right to Survey Results/Advocate Agency Info:

This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.

§483.10(g)(10) The resident has the right to-
(i) Examine the results of the most recent survey of the facility conducted by Federal or State surveyors and any plan of correction in effect with respect to the facility; and
(ii) Receive information from agencies acting as client advocates, and be afforded the opportunity to contact these agencies.

§483.10(g)(11) The facility must--
(i) Post in a place readily accessible to residents, and family members and legal representatives of residents, the results of the most recent survey of the facility.
(ii) Have reports with respect to any surveys, certifications, and complaint investigations made respecting the facility during the 3 preceding years, and any plan of correction in effect with respect to the facility, available for any individual to review upon request; and
(iii) Post notice of the availability of such reports in areas of the facility that are prominent and accessible to the public.
(iv) The facility shall not make available identifying information about complainants or residents.

Observations:

Based on observation and an interview with staff, it was determined that the facility failed to ensure that the most recent Department of Health Survey results were readily accessible to residents and visitors on two of two floors. (1st and 2nd Floor)

Findings Include:

Observation on March 1, 2024 at 10:38 a.m. revealed the survey binder was located in the main lobby. Further observation with the Regional Social Worker, Employee E4 revealed the survey results in the binder had not been updated since the survey from November 7, 2022.

Interview on March 1, 2024 at 10:40 a.m. with Regional Social Worker, Employee E4 confirmed the state survey results were not kept up to date for resident, families, and visitors to review.

28 Pa. Code 201.14 (a) Responsibility of licensee

Plan of Correction - To be completed: 04/09/2024

1.Most recent Department of Health Survey results are updated and readily accessible to residents and visitors on 1st and 2nd floors.
2.NHA and Social Services Director have been educated on the regulation of ensuring survey results are updated and accessible to residents and visitors.
3.Survey result binders will be audited weekly X 3, then monthly X 3 by NHA/Designee to ensure compliance.
4.NHA/Social Services Director will report findings monthly to the QAPI committee.

483.10(h)(1)-(3)(i)(ii) REQUIREMENT Personal Privacy/Confidentiality of Records:

§483.10(h) Privacy and Confidentiality.
The resident has a right to personal privacy and confidentiality of his or her personal and medical records.

§483.10(h)(l) Personal privacy includes accommodations, medical treatment, written and telephone communications, personal care, visits, and meetings of family and resident groups, but this does not require the facility to provide a private room for each resident.

§483.10(h)(2) The facility must respect the residents right to personal privacy, including the right to privacy in his or her oral (that is, spoken), written, and electronic communications, including the right to send and promptly receive unopened mail and other letters, packages and other materials delivered to the facility for the resident, including those delivered through a means other than a postal service.

§483.10(h)(3) The resident has a right to secure and confidential personal and medical records.
(i) The resident has the right to refuse the release of personal and medical records except as provided at §483.70(i)(2) or other applicable federal or state laws.
(ii) The facility must allow representatives of the Office of the State Long-Term Care Ombudsman to examine a resident's medical, social, and administrative records in accordance with State law.

Observations:

Based on the review of facility policy, observation and interviews with staff and resident, it was determined that the facility failed to ensure the privacy and confidentiality of resident's medical and personal care needs for one of four nursing units reviewed. (B wing nursing unit).

Findings Include:

Observation of resident room 101 A on the B unit revealed that there was information posted next to the name tag in the hallway about resident's transfer status use of Hoyer lift (mechanicl lift device). The label indicated "total lift, full body, medium and purple" (indicating the color of the lift pads).

Observation of resident room 101 B on the B unit revealed that there was information posted next to the name tag in the hallway about resident's transfer status and use of Hoyer lift. The label indicated "total lift, divided leg, small navy" (indicating the color of the lift pads).

Observation of resident room 103 on the B unit revealed that there was information posted next to the name tag in the hallway about resident's transfer status and use of Hoyer lift. The label indicated "total lift, divided leg, small navy" (indicating the color of the lift pads).

Further observation of the B unit revealed that there were other resident rooms had similar information posted.
Interview with Director of Nursing on March 6, 2024, at 11:02 a.m. confirmed that the residents transfer information was posted next to the name outside resident room in the hall which was accessible to residents, family, and visitors.

28 Pa. Code: 211.5(b) Clinical records

28 Pa. Code:210.29(i) Resident Rights

28 Pa. Code:211.12 (d)(3) Nursing Services

Plan of Correction - To be completed: 04/09/2024

1. Resident 101A,101B and 103B on B unit transfer status labels were removed immediately upon notice. All other transfer status labels on unit B have been removed.
2. DON/NPE/designee to provide education to nursing staff regarding privacy and confidentiality of resident's care needs.
3. NPE/designee to perform an initial audit of all residents to ensure transfer status labels are not visible outside the room.
4. NPE/Designee to conduct weekly audits X 3 weeks, then monthly X 3 months to ensure transfer status labels are not visible on the outside of the door.
5. DON/NPE will report findings monthly to the QAPI committee.

483.20(k)(1)-(3) REQUIREMENT PASARR Screening for MD & ID:

§483.20(k) Preadmission Screening for individuals with a mental disorder and individuals with intellectual disability.

§483.20(k)(1) A nursing facility must not admit, on or after January 1, 1989, any new residents with:
(i) Mental disorder as defined in paragraph (k)(3)(i) of this section, unless the State mental health authority has determined, based on an independent physical and mental evaluation performed by a person or entity other than the State mental health authority, prior to admission,
(A) That, because of the physical and mental condition of the individual, the individual requires the level of services provided by a nursing facility; and
(B) If the individual requires such level of services, whether the individual requires specialized services; or
(ii) Intellectual disability, as defined in paragraph (k)(3)(ii) of this section, unless the State intellectual disability or developmental disability authority has determined prior to admission-
(A) That, because of the physical and mental condition of the individual, the individual requires the level of services provided by a nursing facility; and
(B) If the individual requires such level of services, whether the individual requires specialized services for intellectual disability.

§483.20(k)(2) Exceptions. For purposes of this section-
(i)The preadmission screening program under paragraph(k)(1) of this section need not provide for determinations in the case of the readmission to a nursing facility of an individual who, after being admitted to the nursing facility, was transferred for care in a hospital.
(ii) The State may choose not to apply the preadmission screening program under paragraph (k)(1) of this section to the admission to a nursing facility of an individual-
(A) Who is admitted to the facility directly from a hospital after receiving acute inpatient care at the hospital,
(B) Who requires nursing facility services for the condition for which the individual received care in the hospital, and
(C) Whose attending physician has certified, before admission to the facility that the individual is likely to require less than 30 days of nursing facility services.

§483.20(k)(3) Definition. For purposes of this section-
(i) An individual is considered to have a mental disorder if the individual has a serious mental disorder defined in 483.102(b)(1).
(ii) An individual is considered to have an intellectual disability if the individual has an intellectual disability as defined in §483.102(b)(3) or is a person with a related condition as described in 435.1010 of this chapter.

Observations:

Based on clinical record review, review of facility policies and staff interview, it was determined that the PASRR (Preadmission Screening and Resident Review) was not appropriately completed according to the resident assessment for two of two residents reviewed (Residents R107 and R70).

Findings include:

The PASRR (Preadmission Screening Resident Review) was created in 1987 through language in the Omnibus Budget Reconciliation Act (OBRA) and it has three goals: to identify individuals with mental illness and/or intellectual disability, to ensure they are placed appropriately, whether in the community or in a nursing facility, and to ensure they receive the services they require for their mental illness or intellectual disability.

The PASRR Level 1 must be completed on all persons who are considering admission to a Medicaid certified nursing facility. A Level II PASRR evaluation must be completed if the Level 1 PASRR determined that the person is a targeted person with mental illness or an intellectual disability. The Level II PASRR would determine if placement or continued stay in the requested or current nursing facility is appropriate.

Clinical record review for Resident R107 revealed that she was admitted to the facility on January 10, 2019 and had diagnoses of schizophrenia and major depressive disorder (mood disorder characterized by low mood, a feeling of sadness, and a general loss of interest in things).

Review of Resident R107's PASRR Level I revealed that the facility completed it on January 10, 2019, and indicated that Resident R107 did not have a serious mental illness diagnosis (such as schizophrenia and depressive disorder).

Continued review revealed Quarterly Minimun Data Set (MDS- assesment of resident care needs), dated December 24, 2023, indicated that the resident had a diagnosis of depressive disorder and schizophrenia.

Review of Resident R70's clinical records revealed diagnosis of bipolar disorder, severe with psychotic features, narcissistic personality disorder, major depressive disorder.

Review of PASRR level I completed on December 17, 2015 due to change in condition; alcohol abuse with target diagnosis "quadriplegia, after 22, depression."

Review of R70's MDS completed on August 2, 2023 revealed that Resident R70 has not been evaluated by Level II PASRR to determine if he has a serious mental illness and/or mental retardation or related condition. Further review revealed blank and unaddressed areas for A1550. Conditions Related to MR/DD Status (PASRR).

28 Pa Code 201.8(b)(1)Management

28 Pa Code 201.8(e)(1)Management

Plan of Correction - To be completed: 04/09/2024

1. The facility has immediately initiated the completion of the Level II PASRR evaluations for Residents R107 and R70 to determine the appropriateness of their placement and ensure they receive the necessary services for their mental health conditions.
2. NHA to re-educate Social services staff responsible for completing PASRR assessments on the importance of thorough and accurate documentation in accordance with regulatory requirements.
3. Social Services Director/Designee will conduct an initial audit of residents admitted to the facility in the past 30 days for PASRR assessment documentation to ensure timely completion and accuracy for all new admissions and residents requiring reassessment.
4. Social Services Director/Designee will conduct weekly audits x 3 then monthly X 3 of all new admission to ensure PASRR assessment documentation is completed timely and accurately.

483.25(b)(1)(i)(ii) REQUIREMENT Treatment/Svcs to Prevent/Heal Pressure Ulcer:

§483.25(b) Skin Integrity
§483.25(b)(1) Pressure ulcers.
Based on the comprehensive assessment of a resident, the facility must ensure that-
(i) A resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable; and
(ii) A resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing.

Observations:

Based on the review of clinical records, staff interviews, it was determined that the facility failed to ensure that a physician's wound care recommendations to promote the healing of pressure ulcers (injury to skin and underlying tissue resulting from prolonged pressure on the skin) were followed as ordered for one of one resident with pressure ulcer reviewed. (Resident R199).

Findings Include:

Review of wound care physician's recommendation for Resident R199 dated February 29, 2024 revealed a wound care recommendations for sacral chronic stage 4 pressure ulcer to clean with normal saline and pack with vashe (a wound cleanser) moistened kling and cover with border dressing daily and as needed. Further review of the wound care recommendation revealed that the plan of care was discussed with facility staff.

Review of Resident R199's active physician orders revealed an order dated December 24, 2024, for wound care to the sacrum to cleanse with normal saline and pack with iodoform strip and cover with border foam dressing daily.

Further review of the physician order revealed no documented evidence that the wound care physician's recommendation of February 29, 2024, was implemented.

Review of the clinical record revealed no documented reason for not implementing the wound care physician's recommendation of February 29, 2024.

Interview with Director of Nursing, Employee E2, on November 13, 2023, at 2:00 p.m. confirmed that the wound care physician's recommendation of February 29, 2024, was not addressed and implemented.

28 Pa. Code 211.10(c) Resident care policies

28 Pa. Code 211.12(d)(1) Nursing services

28 Pa. Code 211.12(d)(5) Nursing services

Plan of Correction - To be completed: 04/09/2024

1. Resident R199 wound care treatment has been updated to reflect the current treatment recommendations as approved by the attending physician.
2. DON/NPE/designee to re-educate professional nurses on communication of wound care recommendations to primary physician for approval or declination of recommendation.
3. DON/NPE/designee to perform an initial audit of wound care physician recommendations for the last 30 days to ensure compliance. DON/NPE/Designee will continue with weekly audits X 3, then monthly X 3 to ensure wound care practitioner recommendations are consistent with physician orders.
4. DON/NPE will report findings monthly to the QAPI committee.

483.25(c)(1)-(3) REQUIREMENT Increase/Prevent Decrease in ROM/Mobility:

§483.25(c) Mobility.
§483.25(c)(1) The facility must ensure that a resident who enters the facility without limited range of motion does not experience reduction in range of motion unless the resident's clinical condition demonstrates that a reduction in range of motion is unavoidable; and

§483.25(c)(2) A resident with limited range of motion receives appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion.

§483.25(c)(3) A resident with limited mobility receives appropriate services, equipment, and assistance to maintain or improve mobility with the maximum practicable independence unless a reduction in mobility is demonstrably unavoidable.

Observations:

Based on observations, clinical record reviews, review of facility policy and staff interviews, it was determined that the facility failed to ensure that a resident with limited range of motion received appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion for two of two residents reviewed. (Resident R43 and Resident R148).

Findings include:

Observation of Resident R43 on March 1, 2024, at 11:30 a.m., revealed that Resident R43 had contracture (permanent shortening of muscle or tendon, producing a deformity) to left upper hand. The resident was observed not wearing a splint or devices to the left hand.

Further observation of the resident room revealed that there was a splint on the windowsill.

Observation of Resident R43 on March 5, 2024, at 1:07 p.m., revealed that the splint was on the dresser.

Observation of Resident R43 on March 6, 2024, at 11:09 a.m., revealed that the splint was on the dresser.

Interview with the Occupational therapist on March 6, 2024, on 11:19 a.m., stated that Resident R43 should have a restorative program or a physician order for wearing split. Employee E21 confirmed that the resident had contracture to the left hand and should be receiving services to prevent worsening of contracture.

Review of Occupational Therapy discharge summary dated March 6, 2023, revealed that a restorative nursing program was established with splinting/orthotic schedule.

Review of clinical record for Resident R43 revealed no evidence that a splinting schedule for left hand or a physician order for splinting was ordered.

Observation of Resident R148 conducted during the tour of the First Floor B wing unit on March 4, 2024 at 10:58 am revealed that Resident R148 was in bed sleeping. Further, Resident R148's left arm was observed limp.

Review of Resident R148's clinical record reveled that Resident R148 was admitted to the facility on November 3, 2023 with diagnoses of Anoxic Brain Damage (a damage to the brain caused by lack of oxygen), Acute and Chronic Respiratory Failure, Hemiplegia (paralysis of one side of the body) affecting left non-dominant side, contracture of the right knee.

Review of Resident R1458's admission MDS ( minimum data set- a federally required resident assessment completed at a specific interval) revealed that section C0500 BIMS (brief interview for mental status)Summary Score revealed a score of 12 suggesting that resident was moderately impaired in cognition. GG0115. Functional Limitation in Range of Motion A. Upper extremity (shoulder, elbow, wrist, hand) was coded 2 (indicating resident had limitation on both sides) B. Lower extremity (hip, knee, ankle, foot) was coded 2 (indicating resident had limitation on both sides) O0500. Restorative Nursing Programs A. Range of motion (passive) was coded "0", B. Range of motion (active) was coded "0", C. Splint or brace assistance was coded "0".

Review of Physical Therapy documentation revealed that resident was discharged from Physical Therapy on January 31, 2024 with discharge recommendations for Restorative Nursing Program. Further Resident R148's prognosis was documented as good with consistent staff follow-through.

Review of Resident R148's care plan inititiated on January 9, 2024 revealed that Resident R148 exhibits or is at risk for alterations in functional mobility related to contracture deformity. The goals were for Resident R148 not to have an increase in contractures, and a decrease in ROM (range of motion). The interventions were to assist with established therapeutic exercise program,

Review of Resident R148's clinical record revealed that there was no documented evidence that resident was placed on a Restorative Nursing Program or on any exercise program to prevent further deterioration of resident's condition.

28 Pa. Code 211.10(d) Resident care policy

28 Pa. Code 211.10(b) Resident care plans

Plan of Correction - To be completed: 04/09/2024

1. Resident R43 and R148 have been re-evaluated by therapy for appropriate treatment and services.
2. DON/NPE/designee to re-educate nursing staff regarding the Restorative Nursing Program and splinting/contracture management.
3. DON/NPE/designee to perform an initial audit of residents referred for a Restorative Nursing Program for splinting/contracture management to ensure the Restorative program is being followed . DON/NPE/Designee will continue with weekly audits X 3, then monthly X 3 for residents referred by therapy for RNP splinting/contracture management to ensure the program is being followed.
4. DON/NPE will report findings monthly to the QAPI committee.

483.25(d)(1)(2) REQUIREMENT Free of Accident Hazards/Supervision/Devices:

§483.25(d) Accidents.
The facility must ensure that -
§483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and

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

Observations:

Based on review of clinical records, review of facility documentation, review of facility policies and interviews with staff, it was determined that the facility failed conduct smoking assessment to ensure the safety of a resident who smokes for one of one resident reviewed for smoking safety. (Resident R101)

Findings include:

Review of facility policy titled "Smoking " dated, August 7, 2023, revealed " For Centers that allow smoking, smoking (including the use of e-cigarettes) will be permitted in designated areas only. Patients/Residents (hereinafter "patient") will be assessed on admission, quarterly, and with change in condition for the ability to smoke safely and, if necessary, will be supervised. The admitting nurse will perform a Smoking Evaluation on each patient who chooses to smoke. 2.3.1 Patients will be re-evaluated quarterly and with a change in condition. "

Review of facility documentation revealed that the Resident R101 was a smoker. Resident was added to smoking list with smoking privileges.

Interview with Resident R101 on March 1, 2024, at 10:15 a.m. stated she smoked at least two or more cigarettes every day.

Review of clinical record revealed that the resident had a smoking assessment completed on November 24, 2023.

Review of clinical records for Resident R101 did not reveal any evidence that facility conducted a quarterly evaluation to ensure the ability of the resident to smoke safely with or without supervision.

Interview with assistant Director of Nursing, Employee E2, on March 6, 2024, 12:09 p.m. confirmed that Resident R101 clinical record contained no evidence that the facility conducted a smoking reevaluation or a quarterly smoking safety evaluation for Resident R213.

28 Pa Code 201.14(a) Responsibility of licensee

28 Pa Code 211.12(d)(1) Nursing services

28 Pa Code 211.12(d)(5) Nursing services

Plan of Correction - To be completed: 04/09/2024

1. Resident R101 smoking evaluation has been completed.
2. DON/NPE/designee to re-educate professional nurses regarding Smoking assessment completion quarterly.
3. DON/NPE/designee to perform an initial audit to ensure residents who smoke have an up-to-date quarterly assessment. DON/Designee will continue with weekly audits X 3, then monthly X 3 for timely completion of smoking assessments.
4. DON/NPE will report findings monthly to the QAPI committee.

483.25(i) REQUIREMENT Respiratory/Tracheostomy Care and Suctioning:

§ 483.25(i) Respiratory care, including tracheostomy care and tracheal suctioning.
The facility must ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals and preferences, and 483.65 of this subpart.

Observations:

Based on observation, review of clinical record and staff interview, it was determined at the facility failed to provide appropriate respiratory care and services for one of one residents reviewed on oxygen therapy (Resident R7).

Findings include:

Review of facility Policy entitled Oxygen : Nasal Canula #3. Gather supplies: 3.1 Oxygen source per table above, 3.2 Nasal cannula labeled with date of initial set-up (high flow cannula if using a 10-liter
concentrator) #11. If humidifier is used: 11.1 Label with date;

Review of Resident R7's clinical record revealed that Resident R7 was admitted to the facility on November 3, 2023 with diagnoses of Acute and Chronic Respiratory Failure, Anoxic Brain Damage ( a brain damage caused by lack of oxygen), History of Pulmonary Embolism, Contracture of the Right Knee.

Review of physician's orders revealed an order dated March 13, 2021 for oxygen tubing change weekly, label each component with date and initials, every night shift every Friday, label each component with date and initials.

Observation of Resident R7 conducted on March 4, 2024 at 9:05 a.m. revealed that Resident R7 was on oxygen concentrator at 2 liters/ minute.

Further observation revealed that the humidification bottle was dated February 24, 2024 and the oxygen tubing and nasal cannula tubing were not dated.

Follow-up observation conducted on March 5, 2024 at 1:00 pm revealed that Resident R7's oxygen tubing did not have a date affixed to it.

Interview with resident conducted at the time of the observation revealed that she could not remember when her oxygen tubing was last changed.

28 Pa. Code 211.12(d)(5) Nursing services

Plan of Correction - To be completed: 04/09/2024

1. Oxygen tubing for R7 has been labeled and dated.
2. DON/NPE/designee will conduct an initial audit of residents receiving oxygen therapy to ensure the tubing is dated and labeled.
3. NPE/designee will re-educate licensed nursing staff on dating and changing oxygen tubing.
4. DON/Designee will conduct a weekly random audit x 3 weeks, then monthly x 3 of 5 residents receiving respiratory care to ensure oxygen tubing is labeled and dated as per policy.
5. DON/designee will review findings of audits monthly during the Quality Improvement Committee meeting.

483.55(b)(1)-(5) REQUIREMENT Routine/Emergency Dental Srvcs in NFs:

§483.55 Dental Services
The facility must assist residents in obtaining routine and 24-hour emergency dental care.

§483.55(b) Nursing Facilities.
The facility-

§483.55(b)(1) Must provide or obtain from an outside resource, in accordance with §483.70(g) of this part, the following dental services to meet the needs of each resident:
(i) Routine dental services (to the extent covered under the State plan); and
(ii) Emergency dental services;

§483.55(b)(2) Must, if necessary or if requested, assist the resident-
(i) In making appointments; and
(ii) By arranging for transportation to and from the dental services locations;

§483.55(b)(3) Must promptly, within 3 days, refer residents with lost or damaged dentures for dental services. If a referral does not occur within 3 days, the facility must provide documentation of what they did to ensure the resident could still eat and drink adequately while awaiting dental services and the extenuating circumstances that led to the delay;

§483.55(b)(4) Must have a policy identifying those circumstances when the loss or damage of dentures is the facility's responsibility and may not charge a resident for the loss or damage of dentures determined in accordance with facility policy to be the facility's responsibility; and

§483.55(b)(5) Must assist residents who are eligible and wish to participate to apply for reimbursement of dental services as an incurred medical expense under the State plan.

Observations:

Based on review of facility policy and clinical records, as well as observations and staff interviews, it was determined that the facility failed to offer routine dental services for one of 36 residents reviewed (Resident 101).

Findings include:

Review of facility policy titled "Dental Services " dated, September 1, 2022, revealed that "Centers will provide or obtain from an outside resource routine and emergency dental services, including 24-hour emergency dental care, to meet the needs of each patient,

Routine dental services means an annual inspection of the oral cavity for signs of disease, diagnosis of dental disease, dental radiographs as needed, dental cleaning, fillings (new and repairs), minor partial or full denture adjustments, smoothing of broken teeth, and limited prosthodontic procedures, e.g., taking impressions for dentures and fitting dentures.

If a patient's dentures are lost or damaged, staff must implement and document a care plan to maximize the patient's nutrition and ability to consume foods while replacement dentures are pursued. Patients with lost or damaged dentures must be referred for dental services within three (3) days. If a referral does not occur within three days, the Center must provide documentation of what was done to ensure the patient could still eat and drink adequately while awaiting dental services and the extenuating circumstances that led to the delay.

An quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 101, dated January 5, 2024, revealed that the resident was cognitively intact. Review of admission MDS assessment dated July 6, 2023 revealed that the resident had no natural teeth or tooth fragments.

An interview with Resident R101on March 1, 2024, at 10:33 a.m., stated she did not have any natural teeth and she had not seen a dentist since admission to the facility in June 2023. She stated her dentures were loose and she gave it back to the dentist who provided her dentures in the community. Resident stated after that she became hospitalized and admitted to the facility.

However, there was no documented evidence that Resident 101 had seen a dentist or was scheduled for an appointment to see the dentist since her admission to the facility in June 2023. There was no evidence that the facility contacted the dentist to obtain the dentures for the resident.

28 Pa. Code 211.12(c)(d)(3)(5) Nursing Services

28 Pa. Code 211.15(a) Dental Services.

Plan of Correction - To be completed: 04/09/2024

1. Resident R101 has been seen and evaluated by the dentist.
2. DON/NPE/designee to re-educate nursing staff regarding submitting referrals to the dentist for dentures and routine care.
3. DON/NPE to complete an Initial audit to ensure residents who require or request dentures are submitted for dental services, weekly audits X 3, then monthly X 3 for new admissions requiring dentures.
4. DON/NPE will report findings to the monthly QAPI committee.

483.75(a)(1)-(4)(b)(1)-(4)(f)(1)-(6)(h)(i) REQUIREMENT QAPI Prgm/Plan, Disclosure/Good Faith Attmpt:

§483.75(a) Quality assurance and performance improvement (QAPI) program.
Each LTC facility, including a facility that is part of a multiunit chain, must develop, implement, and maintain an effective, comprehensive, data-driven QAPI program that focuses on indicators of the outcomes of care and quality of life. The facility must:

§483.75(a)(1) Maintain documentation and demonstrate evidence of its ongoing QAPI program that meets the requirements of this section. This may include but is not limited to systems and reports demonstrating systematic identification, reporting, investigation, analysis, and prevention of adverse events; and documentation demonstrating the development, implementation, and evaluation of corrective actions or performance improvement activities;

§483.75(a)(2) Present its QAPI plan to the State Survey Agency no later than 1 year after the promulgation of this regulation;

§483.75(a)(3) Present its QAPI plan to a State Survey Agency or Federal surveyor at each annual recertification survey and upon request during any other survey and to CMS upon request; and

§483.75(a)(4) Present documentation and evidence of its ongoing QAPI program's implementation and the facility's compliance with requirements to a State Survey Agency, Federal surveyor or CMS upon request.

§483.75(b) Program design and scope.
A facility must design its QAPI program to be ongoing, comprehensive, and to address the full range of care and services provided by the facility. It must:

§483.75(b)(1) Address all systems of care and management practices;

§483.75(b)(2) Include clinical care, quality of life, and resident choice;

§483.75(b)(3) Utilize the best available evidence to define and measure indicators of quality and facility goals that reflect processes of care and facility operations that have been shown to be predictive of desired outcomes for residents of a SNF or NF.

§483.75(b) (4) Reflect the complexities, unique care, and services that the facility provides.

§483.75(f) Governance and leadership.
The governing body and/or executive leadership (or organized group or individual who assumes full legal authority and responsibility for operation of the facility) is responsible and accountable for ensuring that:

§483.75(f)(1) An ongoing QAPI program is defined, implemented, and maintained and addresses identified priorities.

§483.75(f)(2) The QAPI program is sustained during transitions in leadership and staffing;
§483.75(f)(3) The QAPI program is adequately resourced, including ensuring staff time, equipment, and technical training as needed;

§483.75(f)(4) The QAPI program identifies and prioritizes problems and opportunities that reflect organizational process, functions, and services provided to residents based on performance indicator data, and resident and staff input, and other information.

§483.75(f)(5) Corrective actions address gaps in systems, and are evaluated for effectiveness; and

§483.75(f)(6) Clear expectations are set around safety, quality, rights, choice, and respect.

§483.75(h) Disclosure of information.
A State or the Secretary may not require disclosure of the records of such committee except in so far as such disclosure is related to the compliance of such committee with the requirements of this section.

§483.75(i) Sanctions.
Good faith attempts by the committee to identify and correct quality deficiencies will not be used as a basis for sanctions.

Observations:

Based on review of facility documentation and interviews with staff, it was determined that the facility failed to maintain an effective, comprehensive, data-driven quality assurance and performance improvement program (QAPI) that focuses on indicators of the outcomes of care and quality of life as required.

Findings Include:

During interview held on March 6, 2024 at 11:10 a.m. with the Nursing Home Administrator, Employee E1 and the Director of Nursing Employee, E2 documentation was requested related to the implementation of the QAPI. The Nursing Home Administrator, Employee E1 confirmed there was no Performance Improvement Plan being discussed from September 2023 till December 2023.

The Nursing Home Administrator, Employee E1 provided the meeting minutes and sign in sheet from the month of December 2023.

The facility Nursing Home Administrator Employee E1 was not able to produce the QAPI documentation to present for review by the time of the conclusion of the survey.

28 Pa. Code 201.14 (a) Responsibility of licensee

28 Pa. Code 201.18 (b)(1) Management

Plan of Correction - To be completed: 04/09/2024

1. QAPI meeting is scheduled for every last Tuesday of every month with regulatory members to ensure QAPI plans meet residents' needs.
2. Regional clinical director will educate NHA, ANHA on facility policy and regulatory requirements for QAPI.
3. Regional clinical director will Conduct monthly audits x3 of QAPI documentation to ensure continued compliance with regulatory requirements.

483.80(a)(1)(2)(4)(e)(f) REQUIREMENT Infection Prevention & Control:

§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 facility policy, observations and staff interviewed, it was determined that the facility failed to follow acceptable infection control practices related to medication administration for one of two residents observed (Resident R205).

Findings include:

Review facility policy on Infection Control with review date of March 1, 2024, revealed that under section Policy: the infection preventionist will conduct regular Process Surveillance to review the practices directly related to patient care. Example of this type of surveillance include monitoring of compliance with transmission-based precaution, proper hand hygiene, the use and disposal of gloves and observation of environment. Under section Purpose: To identify whether the practices comply with established prevention and control procedures and policies based on recognized standards.

Medication administration observation conducted on March 5, 2024 at 9:17 a.m. with Licensed Nurse, Employee E13 on the first floor A wing revealed that during medication pass Employee E13 did not wash hands, use hand sanitizer or disinfecting the cart during medication administration.

Further observation revealed that while preparing medications for Resident R205 one tablet of aspirin and one tablet of Flouxetine fell out of the medication cup on to the medication cart.

Further observation revealed Employee E13 proceeded to pick up the one tablet of Aspirin and one tablet of Flouxetine with bare hand and puts the tablets back into the medication cup and continued placing medications into the same medication cup where the she placed the Aspirin and Flouxetine tablets that had fallen onto the medication cart. Further, Employee E13 proceeded to give the medication to Resident R205

Interview with Employee E13 conducted at the time of the observation revealed that Employee E13 confirmed that she picked up spilled meds, puts them back into the medication cup and proceeded to continue with the medication prep and eventally have Resident R205 medications inclujding the ones that had fallen out of the medication cup.

28 Pa. Code 201.14(a) Responsibility of licensee.

Plan of Correction - To be completed: 04/09/2024

1. Employee E13 and all nursing staff are re-educated on proper infection control practices, including hand hygiene, medication handling, and environmental cleaning.
2. ADON/Designee will conduct an initial audit of medication administration practices of licensed nurses to identify any similar deficiencies.
3. NPE/ ADON will conduct weekly audits x 3 then monthly x 3 to assess staff adherence to proper hand hygiene and medication handling procedures.
4. NPE and ADON will report findings of audits to QAPI monthly.

483.95(c)(1)-(3) REQUIREMENT Abuse, Neglect, and Exploitation Training:

§483.95(c) Abuse, neglect, and exploitation.
In addition to the freedom from abuse, neglect, and exploitation requirements in § 483.12, facilities must also provide training to their staff that at a minimum educates staff on-

§483.95(c)(1) Activities that constitute abuse, neglect, exploitation, and misappropriation of resident property as set forth at § 483.12.

§483.95(c)(2) Procedures for reporting incidents of abuse, neglect, exploitation, or the misappropriation of resident property

§483.95(c)(3) Dementia management and resident abuse prevention.

Observations:

Based on review of facility documentation and employee files, it was determined that the facility failed to provide training on abuse, neglect, and exploitation for one of five staff reviewed. (Employee E14)

Findings Include:

Review of employee file on March 6, 2024 for Licensed nurse, Employee E14 revealed a hire date of December 11, 2023.

Review of the employee file revealed abuse training was not completed until March 5, 2024. Further review of the employee file showed no documentation that training on abuse, neglect, and exploitation took place prior to March 5, 2024.

28 Pa Code: 201.14 (a) Responsibility of licensee

28 Pa Code: 201.18 (b) (1) Management

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

Plan of Correction - To be completed: 04/09/2024

1. All staff members, including Employee E14, have completed training on abuse, neglect, and exploitation.
2. Payroll staff have been educated on the importance of timely onboarding education.
3. Payroll staff/Designee will conduct an initial audit of all employee files to verify that staff have received abuse and neglect training within the required timeframe.
4. ANHA will conduct monthly audits of employee files and training records to verify compliance with training requirements.
5. Findings of audits to be reviewed monthly at QAPI

§ 211.12(f.1)(2) LICENSURE Nursing services. :

(2) Effective July 1, 2023, a minimum of 1 nurse aide per 12 residents during the day, 1 nurse aide per 12 residents during the evening, and 1 nurse aide per 20 residents overnight.

Plan of Correction - To be completed: 04/09/2024

1. There were no adverse effects to the residents in the center as a result of the CNA ratios for the night shift staffing during the months of November and December 2023.

2. Chapel Manor will continue to use recruiters, our website, recruitment websites and social media to advertise our current open positions and interview immediately. Staffing meetings are held two times a day Monday-Friday to review staffing ratios from the previous day, the current day, and the upcoming week to ensure appropriate staffing levels. Staff has been educated on the attendance policy.

3. The Scheduling Coordinator, Nursing Supervisors and Director of Nursing were re-educated on maintaining a CNA ratio of one CNA per 12 residents on day shift, 12 residents on evening shift, and 20 residents on night shift.

4. Administrator or designee to audit CNA ratios weekly for 3 weeks, then monthly x 3.

5. Findings will be reviewed in QAPI.

§ 211.12(f.1)(4) LICENSURE Nursing services. :

(4) Effective July 1, 2023, a minimum of 1 LPN per 25 residents during the day, 1 LPN per 30 residents during the evening, and 1 LPN per 40 residents overnight.

Plan of Correction - To be completed: 04/09/2024

1. There were no adverse effects to the residents in the center as a result of the Licensed Practical Nurse ratios for the night shift staffing during the months of November and December 2023.
2. Chapel Manor will continue to use recruiters, our website, recruitment websites and social media to advertise our current open positions and interview immediately. Staffing meetings are held two times a day Monday-Friday to review staffing ratios from the previous day, the current day, and the upcoming week to ensure appropriate staffing levels. Staff has been educated on the attendance policy.
3. The Scheduling Coordinator, Nursing Supervisors and Director of Nursing were re-educated on maintaining a licensed Practical nurse ratio of one licensed nurse per 25 residents on day shift, 30 residents on evening shift, and 40 residents on night shift.
4. Administrator or designee to audit Licensed Practical Nurse ratios weekly for 3 weeks, then monthly x 3.
5. Findings will be reviewed in QAPI.

§ 211.12(f.1)(5) LICENSURE Nursing services. :

(5) Effective July 1, 2023, a minimum of 1 RN per 250 residents during all shifts.

Observations:

Based on review of nursing time schedules and staff interviews, it was determined that the facility administrative staff failed to provide a minimum of one registered nurse (RN) per 250 residents during the evening shift, on one of 15 days reviewed (12/23/23)

Findings include:

Review of facility census data indicated that on 12/23/23, the facility census was 199, which required 1 RN during the evening shift.

Review of the nursing time schedules revealed 0 RN's provided care on the evening shift on 12/23/23. No additional excess higher-level staff were available to compensate this deficiency.

Phone interview on March 7, 2024 at 8:58 am with the Nursing Home Administrator confirmed that the required staffing ratios for RN's was not met on the above dates.

Plan of Correction - To be completed: 04/09/2024

1. There were no adverse effects to the residents in the center as a result of the Registered Nurse ratios for the night shift staffing during the months of December 2023.
2. Chapel Manor will continue to use recruiters, our website, recruitment websites and social media to advertise our current open positions and interview immediately. Staffing meetings are held two times a day Monday-Friday to review staffing ratios from the previous day, the current day, and the upcoming week to ensure appropriate staffing levels. Staff has been educated on the attendance policy.
3. The Scheduling Coordinator, Nursing Supervisors and Director of Nursing were re-educated on maintaining a registered nurse 24 hrs per day 7 days a week.
4. Administrator or designee to audit weekly schedule to ensure Registered Nurse coverage on all shifts for 3 weeks, then monthly x3.
5. Findings will be reviewed in QAPI.

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