Pennsylvania Department of Health
QUALITY LIFE SERVICES - CHICORA
Patient Care Inspection Results

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QUALITY LIFE SERVICES - CHICORA
Inspection Results For:

There are  108 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.
QUALITY LIFE SERVICES - CHICORA - 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 Abbreviated Survey related to two complaints completed on January 22, 2024, it was determined that Quality Life Services- Chicora was not in compliance with the following requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care and the 28 Pa. Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.


 Plan of Correction:


483.60(i)(1)(2) REQUIREMENT Food Procurement,Store/Prepare/Serve-Sanitary:This is a less serious (but not lowest level) deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents.  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(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, facility policy and staff interviews it was determined that the facility failed to maintain sanitary conditions in the Main Kitchen and one out of four unit refrigerators (Memory Lane) which created the potential for cross contamination and food-bourne illness.

Findings include:

During an observation on 1/17/24, at 9:30 a.m. it was revealed one ice machine in the main kitchen contained a brown substance inside the machine.

Review of work history report dated September 2023-July 2024, it was revealed the ice machine was last serviced 12/18/23.

Review of facility policy "Unit Nourishment Centers-CU3.17". Dated 1/6/23, indicated that food service staff will rotate stock and remove outdated items. Check the temperatures of the refrigerators/freezers in the units daily, document temperatures, and actions taken for any inappropriate temperatures.

During an observation on 1/18/24 at 10:10 a.m. the Memory Lane refrigerator revealed a jar of relish with open date of 4/15 no year or name fuzzy whitish substance growing on top. The freezer revealed two large plastic containers of vanilla ice cream no date opened. One large plastic container with sherbet no open date. One white paper container marked with a store type label as vanilla ice cream no name or date on it. One single Bargs root beer float tube with expiration of April 3, 2023. One unopened box of Bargs root beer float tubes with expiration date of April 3, 2023.
No refrigerator temperatures recorded for dates of 1/5/23, 1/6/23, 1/7/23, 1/8/23.

During an interview on 1/17/24, at 9:50 a.m. the Dietary Manager Employee E7 confirmed the brown substance in ice machine creating the potential for cross contamination.

During an interview on 1/18/24, 10:15 a.m., LPN Employee E5 confirmed that the facility failed to properly monitor food expiration date and confirmed that the facility failed to properly monitor food temperatures, and food expiration dates creating the potential for food-borne illness.


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

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

28 Pa. Code: 211.6(c) Dietary services.


 Plan of Correction - To be completed: 03/06/2024

1. Immediate action taken: Ice machine outside of the main kitchen was cleansed to remove calcium build up/residue and all expired and undated food was discarded from the refrigerator/freezer on Memory Lane on 1/18/24.
2. All unit refrigerators and freezers storing resident food will be reviewed for expired and undated items. All unit refrigerators will be checked to ensure temperatures are being logged. The ice machine outside the main kitchen area was cleaned by the maintenance department.
3. Dietary manager/designee will provide education to all dietary staff on the proper procedure for rotating stock and removing outdated items in facility refrigerators/freezers and monitoring temperatures. Ice machine outside of the main kitchen will have a monthly cleaning log posted and maintenance/housekeeping will sign off for completion.
4. Dietary manager/designee will conduct weekly audits x 4 weeks on unit refrigerators/freezers for residents to review stock and monitor for outdated/expired items. Weekly audits will be completed for a period of 4 weeks to ensure that refrigerator temperatures are being logged. Maintenance Director/designee will audit the ice machine outside of the main kitchen weekly for 4 weeks for cleaning/maintenance needs outside of the monthly cleaning schedule Compliance date March 6, 2024

483.10(i)(1)-(7) REQUIREMENT Safe/Clean/Comfortable/Homelike Environment: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(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 review of facility policy, observations, and staff interviews, it was determined that the facility failed to maintain a clean, safe, homelike environment for one out of four nursing units (Miller's Crossing).

Findings include:

The facility "Protocol: Value of Appearance" policy dated 1/6/23, indicated it is the facility policy to maintain a welcoming, clean, safe, and attractive home-like environment.

During a tour of the facility's nursing stations and shower rooms, the following was observed:
-At 12:41 p.m. on 1/18/24, during an observation of the nursing station on Miller's Crossing the ceiling tile was observed to be damaged with pieces of the ceiling observed on the floor.
-At 12:51 p.m. on 1/18/24, during an observation of the shower room on Miller's Crossing the ceiling was observed to be damaged with a piece of drywall screwed into the ceiling.

During an interview on 1/18/24, at 12:52 p.m. Nurse Aide, Employee E1 stated that there was a leak at the Miller's Crossing's nursing station and stated there was a hole in the ceiling in Miller's Crossing shower room that needs repaired.

Review of the facility's "Work History Report" dated 1/18/24, indicated regular maintenance and a safety inspection was completed on the roof by the Director of Maintenance, Employee E3.

During an interview on 1/18/24, at 1:35 p.m. the Director of Maintenance, Employee E3 confirmed the ceiling tile was damaged from a leak in the Miller's Crossing nursing station and shower room.

During an interview on 1/18/24, at 1:36 p.m. the Nursing Home Administrator indicated the facility is currently in the process of getting a new roof. It was indicated the leaking worsened in the last year.

During an interview on 1/18/24, at 1:40 p.m. the Nursing Home Administrator confirmed that the facility failed to maintain a clean, safe, homelike environment for one out of four nursing units (Miller's Crossing).

28 Pa. Code:207.2(a) Administrator's responsibility.

28 Pa. Code: 201.29(j) Resident rights.


 Plan of Correction - To be completed: 03/06/2024

1. The facility maintenance department completed temporary repairs to mitigate water leaks during the week of 1/8/24.
2. The facility had been in the process of obtaining estimates from roofing companies prior to the start of this licensure survey.
3. Education will be provided to the staff to continue to report any water leaks to the administration
4. The contracted roofing company has a tentative start date of February 12, 2024 for roof repairs pending weather conditions. The ceiling repairs in the Miller's Crossing shower room and Miller's crossing nurse's station will begin following the repair of the roof. Compliance date is March 6, 2024

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 facility policy and clinical record reviews and interview with staff, it was determined that the facility failed to implement, review, and revise a care plan after a fall for one of six residents (Resident R95).

Findings include:

A review of the facility policy "Care Plan and Interdisciplinary Care Conferences" dated 1/6/23, indicated the care plan is a working tool that is reviewed and revised at specific intervals and as needed to reflect response to care and changing needs and goals. It was indicated it's purpose is to structure and guide therapeutic interventions to meet resident's needs and achieve expected. The care plan is reviewed and updated at least quarterly and is based on ongoing assessment and evaluation of resident needs. It may be specifically reviewed and updated as the resident's condition changes.

A review of the clinical record indicated Resident R95 was admitted to the facility on 8/30/23, with diagnoses that included hypertension (high blood pressure), hyperlipidemia (high level of fat in the blood), Alzheimer ' s disease (brain disorder that causes memory loss, thinking problems, behavior changes).

A review of resident R95's progress notes 1/12/24, entered at 1:38 a.m. stated "Resident came walking down hallway with no clothes on as aide came out of a room and noticed blood on his fingers. Upon closer observation aide informed writer resident has blood coming from head. Writer assessed resident to noticed a small cut on residents right side of his head. Writer cleaned up the area and applied pressure until bleeding stopped. After further assessing resident writer observed an abrasion on residents lower right side. Resident did state that it hurt when touched".

A review of Resident R95's care dated 1/19/24, failed to include fall interventions.

During an interview on 1/22/24, at 10:54 a.m. the Director of Nursing confirmed the facility failed to implement, review, and revise a care plan after a fall for one of six residents. (Resident R95)

28 Pa. Code 211.11(d) Resident Care Plans.

28 Pa. Code 211.11(d) Resident care plan

28 Pa. Code 211.12(d)(3) Nursing services


 Plan of Correction - To be completed: 03/06/2024

1. R95's care plan was updated to reflect that resident is high risk for falls on 1/22/24 by the DON, interventions were also reviewed and revised at this time.
2. DON or designee will complete a facility audit to identify the care plan updates for resident care plans. Audit will be from January 15, 2024 thru January 31, 2024
3. DON or designee will educate the nurses on requirements for care plan reviews and revisions following any change in condition or resident event.
4. DON or designee will conduct weekly audits for care plan revision on residents who have experienced an incident/accident or a change in status for 4 weeks. Compliance date is March 6, 2024

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 clinical records and staff interview, it was determined that the facility failed to administer medications as prescribed by the physician for two of two residents (Resident R68 and R71) and failed to complete a Registered Nurse assessment on one of five residents following an injury (Resident R95).

Findings include:

Review of the facility's policy "Accidents and Incidents" dated 1/6/23, indicates when a resident incident/accident occurs the resident will be assessed by a Registered Nurse (RN).

Review of an undated Registered Nurse (RN) job description titled "Registered Nurse Position Responsibilities" indicated it is the RN's duty to ensure accurate documentation of all incidents/occurrences during the shift. Assist in assessing physical, mental psychosocial status of all residents.

A review of the clinical record indicated Resident R68 was admitted to the facility on 5/31/23, with diagnoses that included type 2 diabetes mellitus (metabolic disorder impacting organ function related to glucose levels in the human body), end stage renal disease and dependence on renal dialysis.

A review of Resident R68's quarterly MDS assessment(minimum data assessment: a periodic assessment of resident care needs) dated 12/8/23, indicated the diagnosis remained current.

A review of Resident R68's physician orders dated 11/21/23, indicated HumaLOG Injection Solution 100 UNIT/ML (Insulin Lispro)
Inject as per sliding scale:
if 151 - 200 = 1 unit;
201 - 250 = 2 unit;
251 - 300 = 3 units;
301 - 350 = 4 units;
351 - 400 = 5 units;
401 - 999 = 6 units,
subcutaneously four times a day for Type 2 Diabetes Mellitus.

A review of resident R68's medication administration record (MAR) dated November and December 2023, indicated a "1" on the following dates: 11/24/23, 11/29/23,12/1/23, 12/8/23, 12/22/23.

A review of progress notes on the above dates, indicated no issues.

During an interview on 1/22/24, at 10:55 a.m. the Director of Nursing (DON) confirmed the Resident R68 was out to dialysis, it was improper documentation.

A review of the clinical record indicated Resident R71 was admitted to the facility on 8/28/23, with diagnoses that included type 2 diabetes mellitus (metabolic disorder impacting organ function related to glucose levels in the human body), muscle weakness and abnormal bait and mobility.

A review of Resident R71's physician orders dated 12/6//23, indicated Admelog Injection Solution 100 UNIT/ML (Insulin Lispro)
Inject as per sliding scale:
if 141 - 180 = 1 unit;
181 - 220 = 2 units;
221 - 260 = 3 units;
261 - 300 = 4 units;
301 - 340 = 5 units;
341 - 999 = 6 units subcutaneously three times a day for type 2 diabetes mellitus

A review of resident R71's medication administration record (MAR) dated December 2023, indicated a "1" on the following dates: 12/6/23, 12/8/23, 12/13/23, 12/15/23, 12/18/23, 12/20/23, 12/29/23.

A review of progress notes on the above dates, indicated no provider notification.

During an interview on 1/22/24, at 10:55 a.m. the Director of Nursing confirmed the above findings and the facility failed to follow physician's orders for Resident's R68 and R71.

A review of the clinical record indicated Resident R95 was admitted to the facility on 8/30/23, with diagnoses that included hypertension (high blood pressure), hyperlipidemia (high level of fat in the blood), Alzheimer' s disease (brain disorder that causes memory loss, thinking problems, behavior changes).

A review of Resident' R95's progress notedated 1/12/24, entered at 1:38 a.m. stated "Resident came walking down hallway with no clothes on as aide came out of a room and noticed blood on his fingers. Upon closer observation aide informed writer resident has blood coming from head. Writer assessed resident to noticed a small cut on residents right side of his head. Writer cleaned up the area and applied pressure until bleeding stopped. After further assessing resident writer observed an abrasion on residents lower right side. Resident did state that it hurt when touched".

A review of Resident R95's progress note dated 1/12/24, failed to include an assessment completed by a RN.

During an interview on 1/22/24, at 10:54 a.m. the DON confirmed the above findings and the facility failed to complete an assessment/documentation by a RN of incident/occurrence for one of five residents following an injury (Resident R95).

28 Pa. Code: 211.12 (d)(1)(3)(5) Nursing services.

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

28 Pa. Code: 211.10(c)(d) Resident care policies



 Plan of Correction - To be completed: 03/06/2024

1. DON contacted IT/PCC specialist to identify documentation roadblocks for entering a blood glucose value for dialysis residents R68 & R71 are out of the building on 1/22/24. RN Assessment for R95 was documented late on 1/21/24 at 2033 within the facility incident report.
2. An initial audit for incidents from January 22, 2024 to January 31, 2024 have been reviewed to ensure an RN assessment occurred and was documented. An audit of dialysis residents who are diabetic with insulin coverage orders will be completed.
3. DON/designee will provide education to nurses on proper documentation for blood glucose monitoring for dialysis residents who are diabetic who are out of the building to change the times for blood glucose monitoring with coverage on dialysis days to be completed upon their return from dialysis. DON/designee will educate all facility RN's on the need for an RN assessment following any incident per facility policy.
4. DON/designee will conduct weekly audits x 4 weeks on all incidents to ensure RN assessments have occurred and are clearly documented. If an RN fails to provide an assessment the DON will provide education to the nurse and continue with progressive discipline. DON/designee will conduct weekly audits for a period of 4 weeks on resident's receiving dialysis that the blood glucose was performed per the physician order. Compliance date March 6, 2024
All audits results will be brought to the QAPI meeting for review and discussion

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 clinical records, and staff interviews, it was determined that the facility failed to make certain that appropriate treatments and services were provided for the removal of a urinary catheter as required for one of five residents (Resident R51).

Findings include:

Review of the facility "Cather: Use of-NU 10.11" policy dated 1/6/23, indicated in select situations, the use of an indwelling catheter (hollow tube inserted through the urethra or suprapubically into the bladder to drain urine) may be appropriate. This method of continence management will be provided when medically indicated by a physician order.

Review of the clinical record indicated that Resident R51 was admitted to the facility on 4/14/23, and readmitted on 10/19/23, with diagnoses that included muscle weakness, obstructive uropathy (blockage of urinary flow), and anemia (deficiency of healthy red blood cells in blood).

A review of Resident R51's Minimum Data Set Assessment (MDS, periodic assessment of resident care needs) dated 11/9/23, indicated the diagnosis were current.

A review of Resident R51's physician order dated 12/17/23, through 1/22/24, indicated the resident had a 16 fr 10cc indwelling foley catheter.

A review of Resident R51's physician order dated 12/17/23, through 1/22/24, indicated to change catheter as needed for pulling or clogging.

A review of Resident R51's progress note dated 1/9/24, stated the resident returned from a urology appointment and the foley catheter was left out. It was recommended to hydrate and monitor.

During an observation on 1/17/24, at 12:40 p.m. Resident R51 did not have a foley catheter present.

A review of Resident R51's physician orders dated 1/9/24, through 1/19/24, failed to indicate an order to monitor urinary output.

A review of Resident R51's Kardex dated 1/22/24, indicated the resident was continent of bladder.

During an interview on 1/22/24, at 8:55 a.m. Registered Nurse (RN), Employee E4 confirmed the facility failed to discontinue Resident R51's physician order for an indwelling foley catheter, and failed to update the clinical record to monitor the resident's urinary output. RN, Employee E4 confirmed the facility failed to make certain that appropriate treatments and services were provided for the removal of a urinary catheter as required for one of five residents (Resident R51).

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

28 Pa code: 211.10 (c)(d) Resident care policies.

28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.


 Plan of Correction - To be completed: 03/06/2024

1. R51's orders were updated to discontinue Foley catheter orders as ordered by urology provider.
2. DON or designee will conduct an audit of all residents with Foley catheter orders to ensure physician orders were accurate and up to date.
3. Education will be provided to nurses on order transcription for Foley catheter orders by DON/designee.
4. DON or designee will conduct weekly audits of all Foley catheter orders for a period of 4 weeks to ensure physician orders are accurate. Compliance date March 6, 2024
All audits results will be brought to the QAPI meeting for review and discussion

483.25(f) REQUIREMENT Colostomy, Urostomy, or Ileostomy 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(f) Colostomy, urostomy,, or ileostomy care.
The facility must ensure that residents who require colostomy, urostomy, or ileostomy services, receive such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences.
Observations:

Based on facility policy, clinical record review, resident, and staff interviews, it was determined that the facility failed to provide colostomy care and services consistent with professional standards of practice for one of two residents reviewed (Resident R17).

Findings include:

Review of facility policy "Ostomy Care" dated 1/6/23, indicated that supplies needed for ostomy (an artificial opening in an organ of the body, created during an operation) care included ostomy appliance, with appropriate size and type, and drainage pouch.

Review of the admission record indicated Resident R17 was admitted to the facility on 4/25/14, and readmitted on 11/6/19.

Review of Residents R17's Minimum Data Set (MDS - a periodic assessment of care needs) dated 12/21/23, indicated the diagnoses of COPD, (chronic obstructive pulmonary disease- a group of progressive lung disorders characterized by increasing breathlessness), high blood pressure and muscle weakness. Section H0100 indicated Resident R17 had an ostomy while a resident.

During an interview on 1/17/24, at 11:24 a.m. Resident R17 indicated that he had a recent operation where he received a colostomy (a surgical process that diverts bowel through an artificial opening in the abdomen wall).

Review of Resident R17's physician orders on 1/22/24, did not include an order that colostomy was to be changed, or how often it was to be changed, or the products required to change the colostomy device.

Review of Resident R17's care plan dated 12/15/23, failed to include the type of appliance, size of the appliance or wafer, and type of collection bag required for colostomy maintenance.

During an Interview on 1/22/24, at 11:06 a.m. the Clinical Service Specialist Employee E2 confirmed the facility failed to provide colostomy care and services consistent with professional standards of practice for one of two residents reviewed (Resident R17).

28 Pa. Code: 211.11 (a)(c)(d) Resident care plan

28 Pa. Code: 211.10(c) Resident care policies.

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


 Plan of Correction - To be completed: 03/06/2024

1. Orders obtained from facility CRNP for R17's colostomy and care plan updated to include colostomy interventions on 1/22/24.
2. DON or designee reviewed all residents in the facility with an ostomy to identify if physician orders were present for the care of the ostomy and care planned.
3. Education will be provided by the DON and/or designee to the nurses on the need for colostomy orders to include the size, appliance, and care orders and individualized care.
4. DON/designee will conduct weekly audits for a period of 4 weeks for residents with colostomy's to ensure there are orders for ostomy care and are care planned. Compliance date March 6, 2024

483.25(i) REQUIREMENT Respiratory/Tracheostomy Care and Suctioning: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(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 review of facility policy, observations, interviews, and clinical record review, it was determined that the facility failed to provide appropriate respiratory care for one of three residents (Residents R58).

Findings include:

Review of facility policy "Oxygen Concentrator" dated 1/6/23, indicated that water bottles used for oxygen concentrators should be labeled and dated, and changed weekly.

Review of facility policy "Oxygen Therapy Via Nasal Cannula", dated 1/6/23, indicated that nasal canula (a lightweight tube placed in the nostrils to deliver oxygen) should be labeled with resident's name and date. Nasal cannula should be replaced every seven days, dated, and store in plastic bag when not in use.

Review of the clinical record indicated that Resident R58 was admitted to the facility on 5/3/19.

Review of Residents R58's Minimum Data Set (MDS - a periodic assessment of care needs) dated 10/10/23, indicated the diagnoses of respiratory failure (not enough oxygen in the blood), COPD, (chronic obstructive pulmonary disease- a group of progressive lung disorders characterized by increasing breathlessness), shortness of breath. Section O0100 indicated Resident R58 used oxygen while a resident.

Review of a physician's order dated 5/12/23, indicated oxygen at 3 lpm (liter per minute) via nasal cannula continuously.

Review of physician's order dated 5/12/23, indicated to change oxygen tubing weekly.

Review of a physician's order dated 5/13/23, indicated to administer Albuterol Sulfate (an inhaled medication used to prevent wheezing and difficulty breathing) Solution 0.63 per three milliliters every three times per day for COPD via nebulizer.

During an observation on 1/11/24, at 2:10 p.m. Resident R58 was lying in bed with nasal cannula in place. It was noted that a nebulizer machine was present on a side table next to Resident R58 with the face mask and medication cup assembled while not in use. No name or date was noted on the tubing or facemask of the nebulizer setup and not in plastic bag. No name or date was noted on the nasal canula or the water bottle used for the oxygen concentrator.

During an interview on 1/11/24, at 2:20 p.m. Registered Nurse (RN) Employee E6 confirmed that no name or date was present on the nebulizer set up and that the supplies were not stored in plastic bag while not in use, and that the nasal cannula and water bottle used for the oxygen concentrator also had no date.

During an interview on 1/11/24, at 2: 40 p.m. the Director of Nursing confirmed that the facility failed to provide appropriate respiratory care for one of three residents.


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

28 Pa. Code 211.12(d)(1)(2)(5) Nursing services

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


 Plan of Correction - To be completed: 03/06/2024

1. Immediate action taken: R58's oxygen tubing, humidifier, and nebulizer were changed and dated. Oxygen equipment and nebulizer set up were provided a plastic bag for storage while not in use with resident's name.
2. DON or designee reviewed all residents with oxygen and nebulizers to ensure all tubing, humidifiers, and nebulizer equipment were properly dated and resident's name on the bag) and stored in plastic bags when not in use.
3. DON/designee will provide education to all staff on the need for weekly oxygen tubing and humidifier changes with proper dating, proper storage when equipment is not in use, and the name is on the storage bag.
4. Ongoing monitoring: DON/designee will conduct weekly audits for a period of 4 weeks to ensure all oxygen equipment is changed weekly and dated appropriately, audit will include review of all nebulizers for proper storage while not in use as well as ensuring the bag has the resident's name on it. Compliance date is March 6, 2024
All audits results will be brought to the QAPI meeting for review and discussion

§ 211.10(b) LICENSURE Resident care policies.:State only Deficiency.
(b) The policies shall be reviewed at least annually and updated as necessary.

Observations:

Based on a review of facility policies and procedures, and staff interview, it was determined that the facility failed to review policies at least annually.

Findings include:

Review of the facility's "Policy and Procedure Manual" dated 1/6/23, indicated the policy procedure manual is reviewed annually and updated as needed.

There was no documented evidence that the facility's policies were reviewed on an annual basis

Interview with the Director of Nursing on 1/22/24, at 11:58 a.m. confirmed that the facility failed to review and update the policies and procedures on an annual basis.

28 Pa. Code 211.10(b) Resident care policies


 Plan of Correction - To be completed: 03/06/2024

1. Facilities policy and procedure manual will be reviewed 2/9/2024 and updated as needed. Annual reviews will continue moving forward following this policy/procedure review.
2. In order to protect other residents at risk for being affected the annual review will be assigned on everyone's calendar as a reminder.
3. The DON and/or designee will provide education to the administrative staff of the need for policy and procedure annual review per the regulatory requirement.
4. An audit will be conducted of the review sheet to ensure policies are reviewed as required. Compliance date is March 6,2 024

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

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 nurse aide per 12 residents during the day shift, and one nurse aide per 20 residents on one of 14 days (1/12/24).

Findings include:

Review of facility census data indicated that on 1/12/24, the facility census was 98, which required 8.17 nurse aides (NAs) during the day shift and 4.90 NAs during the night shift.

Review of the nursing time schedules revealed 7.59 NAs provided care on the day shift and 4.00 NAs provided care on the night shift on 1/12/24. No additional excess higher-level staff were available to compensate this deficiency.

During an interview on 1/22/24, at 11:32 a.m., Director of Nursing confirmed that the facility administrative staff failed to provide a minimum of one nurse aide per 12 residents during the day shift, and during the night shift on one of 14 days (1/12/24).


 Plan of Correction - To be completed: 03/06/2024

1. The facility was unable to make corrective action for the nurse aide staffing for the identified day that have already passed. No residents were affective by the nurse aide staffing on the identified scheduled days.
2. DON and/or designee will re-educate the labor manager and the supervisors on the nurse aide ratio regulation for the state of PA including the revised staff ratio effective January 1, 2024.
3. The facility will conduct daily staffing meetings M-F to ensure all ratios are met throughout the day, the following day and the weekend staffing. Scheduler/Labor Manager or designee will contact all staffing agencies, in house staff, and nursing administration in the event of staff call offs to ensure nurse aide ratios are met on each shift.
4. Audits of all steps taken to fill any call-offs that could affect the ratio will be completed by the DON and/designee the day following for the previous day staffing. Audits will be completed 5 days a week and ongoing to ensure compliance with staffing ratios. Staffing ratios will be in compliance using the revised methodology. Results of the audits will be reviewed and recorded in the monthly QAPI meeting. Compliance date March 6, 2024


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