Nursing Investigation Results -

Pennsylvania Department of Health
NORRITON SQUARE NURSING AND REHABILITATION CENTER
Patient Care Inspection Results

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NORRITON SQUARE NURSING AND REHABILITATION CENTER
Inspection Results For:

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NORRITON SQUARE NURSING AND REHABILITATION CENTER - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on a Medicare/Medicaid Recertification, State Licensure, Civil Rights Compliance Survey, and an Abbreviated Survey in response to one complaint completed on March 29, 2019, it was determined that Norriton Square Nursing and Rehabilitation Center 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:


483.10(g)(5)(i)(ii) REQUIREMENT Required Postings: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.
483.10(g)(5) The facility must post, in a form and manner accessible and understandable to residents, resident representatives:
(i) A list of names, addresses (mailing and email), and telephone numbers of all pertinent State agencies and advocacy groups, such as the State Survey Agency, the State licensure office, adult protective services where state law provides for jurisdiction in long-term care facilities, the Office of the State Long-Term Care Ombudsman program, the protection and advocacy network, home and community based service programs, and the Medicaid Fraud Control Unit; and
(ii) A statement that the resident may file a complaint with the State Survey Agency concerning any suspected violation of state or federal nursing facility regulation, including but not limited to resident abuse, neglect, exploitation, misappropriation of resident property in the facility, and non-compliance with the advanced directives requirements (42 CFR part 489 subpart I) and requests for information regarding returning to the community.
Observations:

Based on observation and staff interview it was determined that the facility failed to post, in a form and manner accessible and understandable to residents and resident representatives including in large accessible print, a list of names, addresses (mailing and email) and telephone numbers of the State Survey Agency, the State licensure office, adult protective services, the protection and advocacy network, home and community based programs and the Medicaid Fraud Control Unit and failed to post a statement that the resident may file a complaint with the State Survey Agency concerning any suspected violation of state or federal nursing facility regulation, including but not limited to resident abuse, neglect, exploitation, misappropriation of resident property in the facility, and non-compliance with the advanced directives and requests for information regarding returning to the community on both nursing units and the entrance to the facility.

Findings include:

Observation of the window case located on the first-floor of the facility in the entrance vestibule with the Nursing Home Administrator (NHA) on March 25, 2019, at 10:34 a.m. revealed a piece of paper with very small font (approximately 8- or 10-point font) and a heading called "Norristown, PA" with the telephone number for the local Pennsylvania Department of Health office telephone number printed underneath. The sign also listed a telephone number for the Medicaid Fraud Control Unit that when dialed presented callers with the opportunity to win a Caribbean cruise; it was not possible to reach the Medicaid Fraud Control Unit from this telephone number.

Further observation on the first-floor of the facility in the entrance vestibule with the NHA on March 25, 2019, at 10:34 a.m. revealed a facility corporate poster very high up the wall with a handwritten telephone number for the local Pennsylvania Department of Health office telephone number, not the correct 24-hour nursing care facility complaint hotline telephone number for the State Survey Agency.

Further observation on the second- and third-floors of the facility with the NHA on March 25, 2019, at 10:44 a.m. revealed that neither nursing unit had important contact information except for the ombudsman's telephone number. However, the ombudsman's telephone number was posted in a hallway leading to the nursing stations, not in resident accessible areas.

Interview with the NHA on March 25, 2019, at 10:44 a.m. revealed confirmation that the facility did not have the required postings and the information that was posted was misleading, not in large print and was not accessible to residents in wheelchairs.

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



 Plan of Correction - To be completed: 05/23/2019

Center Executive Director posted the required postings on each unit and corrected the posting in the 1st floor vestibule
Regional Vice President of Operations re-educated CED on the required postings on each unit.
Center Executive Director or designee will conduct a weekly audit x 3 months to ensure that postings remain in place on the nursing units and on the 1st floor vestibule.
Center Executive Director will review audit findings at the monthly QAPI meeting x 3 months

483.70(a)-(c) REQUIREMENT License/Comply w/ Fed/State/Locl Law/Prof Std: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.
483.70(a) Licensure.
A facility must be licensed under applicable State and local law.

483.70(b) Compliance with Federal, State, and Local Laws and Professional Standards.
The facility must operate and provide services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards and principles that apply to professionals providing services in such a facility.

483.70(c) Relationship to Other HHS Regulations.
In addition to compliance with the regulations set forth in this subpart, facilities are obliged to meet the applicable provisions of other HHS regulations, including but not limited to those pertaining to nondiscrimination on the basis of race, color, or national origin (45 CFR part 80); nondiscrimination on the basis of disability (45 CFR part 84); nondiscrimination on the basis of age (45 CFR part 91); nondiscrimination on the basis of race, color, national origin, sex, age, or disability (45 CFR part 92); protection of human subjects of research (45 CFR part 46); and fraud and abuse (42 CFR part 455) and protection of individually identifiable health information (45 CFR parts 160 and 164). Violations of such other provisions may result in a finding of non-compliance with this paragraph.
Observations:

Based on observation, facility documentation review and staff interview it was determined that the facility failed to have a three-day supply of emergency food in storage in the facility as is required by the Commonwealth of Pennsylvania Long-Term Care Facilities Licensure Regulations.

Findings include:

Observation on March 21, 2019, starting at 9:00 a.m. with the Food Service Director (FSD) and Regional FSD (RFSD) for comparison of the facility's emergency menu against the emergency stock revealed perishable cottage cheese on the non-perishable emergency menu and the facility did not have a supply of emergency cottage cheese.

Further observation on March 21, 2019, at 9:00 a.m. with the FSD and RFSD revealed the following items missing from the facility stock when compared to the emergency menu:
Canned ham;
Pureed canned ham;
Fruit punch;
Melba toast;
Milk powder;
Four cans of beef stew, and
1550 saltine cracker packets.

The facility failed to have a three-day supply of emergency food in storage in the facility.

28 Pa. Code 207.2(a) Administrator's responsibility
Previously cited 03/09/17

28 Pa. Code 211.6(b) Dietary services



 Plan of Correction - To be completed: 05/23/2019

The facility had the non-perishable emergency menu updated to remove cottage cheese from the menu.

The Dining Services Director ordered canned ham, pureed canned ham, fruit punch,
melba toast, milk powder, 4 cans of beef stew, and 1550 packets of saltine cracker
Packets.

Center Executive Director will re-educate the Dining Services Director on the policy to ensure a 3-day supply of emergency food is stored in the facility.

Dining Services Director will conduct a weekly audit x 3 months to ensure that all of the
items listed on the emergency menu are available in-house.

Center Executive Director will review audit findings at the monthly QAPI meeting x 3 months

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 observation, facility documentation and policy review and staff interview, it was determined that the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety for the main kitchen, both bistro kitchens located on the nursing units and the nourishment/resident food refrigerators on both nursing units.

Findings include:

Review of a facility policy titled Outside Cleaning and dated as revised on November 1, 2007, revealed the exterior of the building and surrounding grounds are policed for cleanliness and overall appearance.

Review of a facility policy titled Machine Warewashing and Sanitizing and dated as revised on June 15, 2018, revealed that employees clean and sanitize all dishware after each use/meal.

Review of a facility policy titled Refrigerate/Frozen Storage and dated as revised on June 15, 2018, revealed that all foods are labeled with the name of product and the use by date once opened, prepared foods are labeled and dated with the name of the product, date opened and use by day and refrigeration units are kept clean and organized.

Review of a facility policy titled Department Maintenance and dated as revised on June 15, 2018, revealed that the food and nutrition services department is maintained in a good physical condition with equipment in working order.

Review of a facility policy titled Ice Machine Cleaning/Inspection and dated as revised on June 1, 2007, revealed all ice machines are inspected and cleaned quarterly to ensure proper operation and minimize equipment failure.

Review of a facility policy titled Food Brought in for Patients/Residents and effective November 28, 2017, revealed food items that require refrigeration must be labeled with the resident's name and the date the food was brought in.

Observation of the main kitchen on March 20, 2019, starting at 10:36 a.m. with Employee E8, Food Service Director (FSD), revealed the following observations:

Observation of the kitchen's waste disposal area in the parking lot revealed:
One circular trash can without a lid next to the trash compactor filled with water, dirty clinical gloves and food debris, and dirty clinical gloves, food waste, cigarette butts and other miscellaneous trash scattered around the base of the trash compactor.

Observation of the kitchen's receiving door hallway revealed:
18 cardboard boxes were placed directly on the floor of the hallway.

Observation of the kitchen's dirty dish area revealed:
Two large wooden-handled plungers laying directly on the floor;
Hundreds of small elliptically shaped black/dark brown substances along the perimeters of the room;
The presence of flies around and under the counters;
Grouting missing between approximately 40 floor tiles where water was pooling;
Grouting missing between baseboard tiles around the perimeter of the room, and
Dishwasher temperature logs for the heat-sanitizing dishwasher revealed the FSD had been documenting parts per million chemical concentrations even though the dish washer sanitized by heat, not chemicals.

Observation of the cereal storage area (not the dry food storage room) in the central kitchen area revealed:
Open frosted flakes and raisin bran both dated 2/7/19 - the FSD identified these as expired, and
Four bowels of cereal with loose fitting lids and no preparation dates.

Observation of the ice cream box revealed:
Two large panes of stained glass that slide to allow access to ice cream, and
A variety of brown colored food debris caught in all the grooves and handles of the ice cream box.

Observation of the stand mixer revealed:
Brown, yellow and white substances dried and stuck in a variety of places on the machine, including in the grooves.

Observation of the large toaster machine revealed:
A large accumulation of burned bread debris throughout the machine - the FSD identified that the machine had been cleaned since breakfast;
The control knobs along the front of the machine were covered in yellow sticky substances, and
The dust vents along the front underside of the machine were completely clogged with dust.

Observation of the microwave unit revealed:
The top exterior surface of the microwave was coated in a layer of a greasy substance that was embedded with dust particulates.

Observation of the juice concentrate to diluted drinkable juice machine revealed:
Large quantities of food-like debris wedged between various components of the machine, and
Dust accumulation in the level surfaces of the machine components.

Observation of the ice machine revealed:
A pipe used for cleaning had been placed directly under the flow of waste water from the ice machine, causing contaminated waste water to spew onto the kitchen floor tiles instead of entering directly into the waste water system, and
A black substance was observed to be dangling from the waste water pipe from the ice machine.

Observation of the meat slicer machine and associated food preparation counter revealed:
Dark pink and yellow dried substances, identified by the FSD as dried meat and dried fat, were caught between various hard to reach surfaces of the meat slicer machine, and
A plastic container of food thickener open to the air behind the meat slicer that was undated and unlabeled.

Observation of the three-door frozen vegetable box and surrounding area revealed:
All three doors had broken rubber gaskets that were discolored with black and yellow substances;
A bag of frozen cookies was open to the air;
Under the unit on the floor was a large accumulation of food waste including broccoli and a bread roll, and
The trash can adjacent to the vegetable box was not lined with a bag and had loose raw foods and dirty food preparation gloves.

Observation of the single-door refrigerator unit and surrounding area revealed:
The ceiling tiles directly above the unit were stained with yellow and brown substances, and
The air vent above the unit was dusty with large strings of dust and spider webs hanging down from the vents - the FSD identified that ceiling vents in the kitchen are not on a cleaning schedule with the maintenance department.

Observation of the frozen meat box revealed:
A tray of unlabeled undated cauliflower;
Beef used for cheese steaks in a bag open to the air and was placed inside an open box.

Observation of the food preparation table opposite the frozen meat box revealed:
One large metal tray containing uncooked bread rolls with a partial covering of plastic wrap that was undated and unlabeled.

Observation of the bread rack revealed:
Open packets of bread rolls, not sealed, unlabeled and undated, and
A plastic container, open to the air, with a dried yellow substance adhered to the bottom.

Observation of the four food trucks (enclosed shelves on wheels for delivering food trays to the nursing units) revealed:
All four trucks contained food debris, stains, sticky substances and dust. The carts were identified by the FSD as having been cleaned after breakfast, ready for lunch.

Observation in the dry food storage room revealed:

Two boxes stored within 18-inches of the ceiling (12.5" and 13" away from ceiling), away from the wall and in direct line of blocking the spray from fire sprinklers - interview with the Director of Maintenance on March 20, 2019, at 11:54 a.m. confirmed there were boxes too high to the ceiling in the dry food storage room that posed a fire hazard;
Two bulging ceiling tiles and two other stained ceiling tiles;
One hole in the baseboard as you enter the room to the back-left corner - estimated by the FSD to be one inch in diameter;
Multiple holes in the wall to the back-right of the room behind a cart on wheels, and
Marshmallows open and undated.

Observation in the janitor's closet revealed:
Multiple cardboard boxes stored directly on the floor, and
An accumulation of dirty food preparation gloves mixed with bread slice off-cuts in the waste water ceramic bin.

Observation of the tray line for lunch preparation revealed:
Dietary staff were observed to be plating resident food onto plates with brown and yellow substances adhered to the eating surface;
Observation of all 12 plates in a stack of clean plates revealed that all the plates were discolored with yellow and/or brown substances stuck to the plate that could be chipped off with the FSD's fingernails;
Further observation of all 10 bowls in a stack of clean bowls revealed the same problem as with the plates;
Throughout the lunch service a tray of raw chicken was defrosting open to the air on the table adjacent to the sandwich preparation table, Employee E15, Cook, touched the inside of the raw chicken pan, wrapped it, carried the raw chicken into the refrigerator and then left carrying containers of blue cheese, ham and salami, without first having performed hand hygiene. Employee E15 touched numerous surfaces with contaminated hands.

Observation in the walk-in refrigerator revealed:
The door handle latch was broken/missing so the door could not create a tight seal;
One large plastic container of mandarins in juice with plastic wrap on top and dated February 26, 2019 with a thick layer of white, black, green and blue mold as identified by the FSD layered across the top surface of the mandarins;
One orange coated in a white fluffy substance;
Cesar dressing decanted from a larger container into a smaller container dated as prepared on March 9, 2019 - the FSD identified this as expired;
Cabbage in a sealed bag dated March 4, 2019 - the FSD identified this as expired;
Sour cream dated February 28, 2019 - the FSD identified this as expired;
Unlabeled, undated and partially unwrapped meat-like substance, cooked poultry-like substance, cooked ham-like substance, liver wsubstance, cheese-like substance, three trays of uncooked bread roll-like substances and five containers of fruit juice;
Ham dated as opened on March 22, 2019 (two days in the future) and labeled, covered in plastic wrap that was open to the air;
Eight sour cream, 13 tartar sauce, 14 parmesan cheese and 5 Italian dressing cups all exposed to the air;
One gallon of whole milk opened but undated, and
Dill pickles in vinegar opened with illegible open date written on the container.

Observation of the main nursing home kitchen on March 21, 2019, starting at 12:07 p.m. for a follow-up kitchen tour with Employee E8, Food Service Director (FSD), revealed the following observations in the walk-in refrigerator:
The door handle latch continued to be broken/missing so the door could not achieve a tight seal;
The moldy orange from the previous day had disintegrated over the other oranges in a mass of mold and moisture - the mold was identified by the FSD;
Two moldy apples, moldy cucumbers and zucchinis - the mold was identified by the RFSD;
Unlabeled, undated and partially or fully unwrapped three trays of uncooked bread roll-like substances (no change from previous day) and one container of fruit juice, and
One gallon of 2% milk opened but undated.

Observation of the second-floor bistro dining room on March 21, 2019, at 9:48 a.m. with the FSD revealed the following observations:
Undated and unlabeled open bread stored in the cupboards;
The microwave was soiled with yellow and brown sticky substances on the inside, and

Observation of the third-floor bistro dining room on March 21, 2019, at 9:58 a.m. with the FSD revealed the following observations:
The ice machine did not have an air gap between the waste-water outlet and the drainage pipe;
Undated and unlabeled open one-gallon whole milk, a cardboard lactose free milk and two bowls of cereal;
A lump of ice in the ice machine was contaminated with an unidentified yellow substance;
The cupboards were contaminated with brown substances, rust, food crumbs and the under cabinets were buckling and damaged on the inside;
The ice machine scoop was stored in water that was pooling in the wall mounted holder, and

Observation of the second-floor medication storage room nourishment refrigerator on March 22, 2019, at 9:58 a.m. with Employee E6, Registered Nurse (RN), Nurse Manager, revealed the following:
A large accumulation of discolored ice with purple and yellow colorations;
The thermometer was unreadable because it was frozen into the ice;
Sticky substances throughout the refrigerator;
Undated and unlabeled puddings, and
No refrigerator temperature logs.

Observation of the third-floor nourishment refrigerator for resident food on March 22, 2019, at 10:05 a.m. with the Director of Nursing revealed the following:

Unlabeled and undated two peanut butter cups, ice pops and ice cream containers, a moldy and malodorous food item belonging to Resident R69;
A lunch bag for Employee E16, licensed nurse;
A grey shopping bag that was undated and unlabeled containing a biohazard bag inside which were moldy crackers, cheese and pepperoni which smelled malodorous - the mold was identified by Employee E3, RN, Infection Control Nurse, and
Undated yoghurt and a baked breaded desert that was undated and unlabeled.

The facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety for the main kitchen, both bistro kitchens located on the nursing units and the nourishment/resident food refrigerators on both nursing units.

28 Pa. Code 207.2(a) Administrator's responsibility
Previously cited 03/09/17

28 Pa. Code 211.6(b) Dietary services




 Plan of Correction - To be completed: 05/23/2019

In the kitchen's waste disposal area in the parking lot, the circular trash can next to the compactor was emptied and the trash around the compactor was discarded.

In the kitchen's receiving door hallway, the 18 cardboard boxes were removed and Discarded.

In the kitchen's dish area, the 2 large wooden-handled plungers laying on the floor were discarded

The entire dish area was pressure washed. The drains were treated each night to reduce the presence of flies. Pest Control also treated the dish area.

The grouting will be replaced between 40 floor tiles and between baseboard tiles around the perimeter of the room.

The Dining Services Director is correctly documenting the dish-machine temperature logs.

The open frosted flakes cereal, raisin bran cereal, and 4 bowls of cereal with loose-fitting lids were discarded immediately.

On the ice cream box, the glass and grooves and handles of the box were cleaned to remove stains and debris

The standing mixer was cleaned to remove brown, yellow, and white substances.

The toaster, control knobs on the toaster, and the dust vents on the toaster were cleaned to remove bread debris and stains

The top exterior surface of the microwave was cleaned to remove the greasy substance.

The juice machine was cleaned to remove food-like debris and dust accumulation

The maintenance department repaired the ice machine in the kitchen so that the pipe has a 3" inch air gap from the drain

The waste water pipe from the ice machine was cleaned to remove the black substance.

The meat slicer was taken apart and cleared to remove the pink and yellow substances.

The plastic container of food thickener that was open to the air behind the meat slicer was discarded

On the 3-door frozen vegetable box, the maintenance department repaired the broken rubber gaskets.

In the 3-door frozen vegetable box, the bag of frozen cookies open to the air was discarded

Under the 3-door frozen vegetable box, the broccoli and bread roll were discarded

The trash can adjacent to the vegetable box was emptied, power washed, and a new liner was placed in the can

Above the single-door refrigerator unit, the ceiling tiles were replaced

The air vent above the single-door refrigerator unit was cleaned and added to a cleaning schedule

In the frozen meat box, the tray of unlabeled, undated cauliflower, the beef used for cheesesteaks open to the air, and the uncooked bread rolls that were unlabeled and undated were discarded

On the bread rack, the open packets of bread rolls were discarded

On the bread rack, the plastic container, open to the air was removed and cleaned to remove the dried yellow substance

All four food trucks were power washed to remove debris stains, sticky substances, and dust

In the dry food storage, the two boxes stored within 18-inches of the ceiling were removed and the maintenance department added an indicator on the wall to identify 18-inches from the ceiling

The 2 bulging ceiling tiles and two stained tiles in the dry storage area were replaced

The hole in the baseboard and multiple holes in the walls of the dry storage area were repaired and patched by the maintenance department

The marshmallows that were open and undated in the dry storage area were discarded

In the janitor's closet, multiple cardboard boxes stored directly on the floor were discarded

In the janitor's closet, the accumulation of dirty food preparation gloves mixed with bread slice cut-offs in the waste-water ceramic bin were discarded

The plates and bowls utilized for the tray line for lunch preparation were removed from the tray line, and cleaned and sanitized to remove stains and substances

The tray of raw chicken that was defrosting open to the air on the table adjacent to the sandwich preparation table, the blue cheese, ham, and salami were discarded

In the walk-in refrigerator, the door handle latch was repaired by the maintenance department so that it could properly create a tight seal

In the walk-in refrigerator, the one large plastic container of mandarin oranges, an orange coated in a white fluffy substance, caesar dressing that was expired, cabbage that was expired, the unlabeled, undated, and partially unwrapped meat-like substance, cooked poultry-like substance, cooked ham-like substance, liver substance, cheese-like substance, 3 trays of uncooked bread roll-like substances and five containers of fruit juice were discarded immediately

In the walk-in refrigerator, the ham the eight sour cream, 13 tartar sauce, 14 parmesan cheese, and 5 italian dressing cups that were open to the air were discarded

In the walk-in refrigerator, the gallon of whole milk undated and the dill pickles with illegible date were discarded

In the walk-in refrigerator, the 2 moldy apples, moldy zucchinis and moldy cucumbers were discarded

In the 2nd floor dining room, the undated and unlabeled bread stored in the cupboards was discarded

In the 2nd floor dining room, the microwave was cleaned to remove the yellow and brown substances

In the 3rd floor dining room, the maintenance department repaired the drainage pipe on the ice machine to create a 3-inch air gap between the waste-water outlet and the draining pipe

In the 3rd floor dining room, the undated and unlabeled one gallon of whole milk, lactose-free milk, and 2 bowls of cereal were discarded

In the 3rd floor dining room, the lump of ice with the yellow substance was removed as well as all of the ice, the ice machine was cleaned

In the 3rd floor dining room, the cupboards were cleaned and repaired of the damage

In the 3rd floor dining room, the ice machine scoop holder was replaced to ensure that water would not pool

In the 2nd floor medication room, the nourishment refrigerator was defrosted and cleaned to remove the large accumulation of ice and thaw the thermometer

In the nourishment refrigerator in the 2nd floor medication room, the undated and unlabeled puddings were discarded

Temperature logs were added to the nourishment refrigerator in the 2nd floor medication room

In the 3rd floor medication room, in the nourishment refrigerator, the unlabeled and undated peanut butter cups, ice pops, and ice cream containers, the grey shopping bag of unlabeled and undated employee food, and the undated yogurt and baked breaded dessert were discarded

Dining Services District Manager or designee to re-educate dining services staff on how to store, prepare, distribute, and serve food in accordance with professional standards for food service safety

Dining Services Director or designee to conduct weekly audits x 3 months to ensure that the dining services department is storing, preparing, distributing, and serving food in accordance with professional standards for food service safety

Center Executive Director will review audit findings at the monthly QAPI meeting x 3 months

483.45(g)(h)(1)(2) REQUIREMENT Label/Store Drugs and Biologicals: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.
483.45(g) Labeling of Drugs and Biologicals
Drugs and biologicals used in the facility must be labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable.

483.45(h) Storage of Drugs and Biologicals

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

483.45(h)(2) The facility must provide separately locked, permanently affixed compartments for storage of controlled drugs listed in Schedule II of the Comprehensive Drug Abuse Prevention and Control Act of 1976 and other drugs subject to abuse, except when the facility uses single unit package drug distribution systems in which the quantity stored is minimal and a missing dose can be readily detected.
Observations:
Based on observation, facility policy review, facility documentation review and staff interview, it was determined that the facility failed to store drugs and biologicals under proper temperature controls according to manufacturer guidelines and State and Federal laws for two of two medication refrigerators in the facility.

Findings include:

Review of facility medication refrigeration logs for January, February and March 2019 revealed instructions to nursing staff that the refrigerators must be 32 degrees Fahrenheit (F) to 40 F. 32 F (or 0 degrees Celsius [C]) is freezing point and 40 F is 4.4 C. Freezing point is damaging to medications that must be refrigerated at higher temperatures. The temperature logs revealed multiple occasions when the refrigerator temperatures were at freezing point of 32 F/0 C, as follows:
January 1, 24, 25 and 26, 2019;
February 19, 20, 21, 22, 23, 24, 25, 26, 27 and 28, 2019, and
March 20, 2019.

Observation of the facility's second-floor medication storage refrigerator on March 22, 2019, at 10:05 a.m. with Employee E6, Registered Nurse (RN), Nurse Manager for the unit, revealed the refrigerator was at 28 F/-2.2 C which was below freezing point. The refrigerator temperature logs for March 21 and 22, 2019, had not been completed by the time of the observation. A review of a random selection of medications from inside the refrigerator revealed the following:
Influenza vaccines, 10 vials per box, three boxes with instructions to store at 35-46 F (2-8 C);
Influenza quadrivalent vaccines, eight syringes with instructions to store at 36-46 F (2.2-7.8 C);
Prevnar 13, 0.5 ml disposable syringes, three syringes with instructions of "do not freeze";
Vancomycin hydrochloride for oral solution with instructions to store at 36-46 F (2.2-7.8 C);
Vancomycin hydrochloride 1.5 g in 500 ml of normal saline, two bags with instructions to "REFRIGERATE";
Azactam 1 g, three bags with instructions to "REFRIGERATE";
Lorazepam oral concentrate 2 mg/ml for two residents with instructions to store at 36-46 F (2.2-7.8 C);
Acidophilus NA/F starch/f capsules, 281 capsules with instructions to "REFRIGERATE";
Admelog MDV insulin with instructions to "REFRIGERATE UNTIL OPENED", and
Acetaminophen suppositories 650 mg, two boxes of house stock with instructions to store at room temperature of 59-86 F (15-30 C).

Interview with Employee E6, RN, Nurse Manager, on March 22, 2019, at 9:55 a.m. revealed confirmation that the medication storage refrigerator was below freezing point and that all the medications would need to be returned to pharmacy and reordered because frozen medications are damaged medications. Employee E6 also confirmed that medications stored at freezing point would be frozen. The interview also revealed that the facility routinely stored acetaminophen suppositories in medication storage refrigerators to make the suppositories easier for the nurses to insert into the residents' rectums even with the knowledge they must be stored at room temperature.

Observation of the facility's third-floor medication storage refrigerator on March 22, 2019, at 10:12 a.m. with the Director of Nursing and Employee E3, RN, Infection Control Nurse, revealed two acetaminophen suppository 650 mg boxes of house stock medications with instructions to store at room temperature of 59-86 F (15-30 C). The temperature of the refrigerator was 38 F/3.3 C.

Interview with the Director of Nursing on March 22, 2019, at 9:58 a.m. revealed confirmation that it was not acceptable for nursing staff to store the acetaminophen suppositories in the refrigerator because they needed to be stored at room temperature.

The facility failed to store drugs and biologicals under proper temperature controls according to manufacturer guidelines and State and Federal laws.

28 Pa. Code 201.14(a) Responsibility of licensee
Previously cited 12/06/18, 11/08/18, 05/16/18, 03/09/17

28 Pa. Code 201.18(a) Management

28 Pa. Code 201.18(b)(3) Management
Previously cited 12/06/18, 05/16/18, 03/09/17

28 Pa. Code 211.9(a)(1)(2)(i) Pharmacy services

28 Pa. Code 211.12(c) Nursing services

28 Pa. Code 211.12(d)(1) Nursing services
Previously cited 12/06/18, 05/16/18, 03/09/17

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

28 Pa. Code 211.12(d)(3) Nursing services
Previously cited 12/06/18, 11/08/18, 05/16/18

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



 Plan of Correction - To be completed: 05/23/2019

The following medications that were improperly stored in the refrigerator are as follows: Influenza vaccines, Influenza quadrivalent vaccines, Prevnar 13, Vancomycin hydrochloride oral solution, Vanccomycin hydrochloride 1.5g IV, Azactam 1g, Lorazepam oral concentrate, Acidophilus NA/F starch /f capsules, Admelog, and Acetaminophen suppositories were all disposed of as per policy and reordered from the pharmacy to be replaced at the time of discovery.
NPE/designee will re-inservice licensed nursing staff on medication and vaccine refrigerator/freezer temperatures policy.
The unit manager/designee will perform an initial audit of the medication refrigerators as well as vaccine refrigerators to ensure medications are stored at the proper temperature as per policy and acetaminophen suppositories are stored at room temperature.
The unit manager/designee will perform a weekly audit of the medication refrigerators as well as vaccine refrigerators to ensure medications are stored at the proper temperature as per policy and acetaminophen suppositories are stored at room temperature.
The DON/designee will review the results of the audits at the Facility's Monthly Quality Improvement Meeting x 3 months.

483.10(e)(3) REQUIREMENT Reasonable Accommodations Needs/Preferences:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
483.10(e)(3) The right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents.
Observations:

Based on review of facility policy and medical records and resident and staff interviews, it was determined that the facility failed to ensure resident preferences and needs were accommodated relating to religion and bathing for five of 19 residents reviewed (Resident R10, R56, R57, R59 and R79).

Findings include:

Interview with Resident R56 on March 21, 2019, at 10:10 a.m. revealed that the resident had received one shower since he was admitted into the facility. The resident reported that he has only been provided with bed baths and further stated that he should be allowed to take a shower. Review of Resident R56's clinical record revealed that the resident was admitted into the facility on December 21, 2018.

Review of Resident R56's Admission Minimum Data Set (MDS-periodic assessment of needs) dated December 31, 2018 revealed that the resident was cognitively intact and that he required the assistance of one person for the task of bathing.

Review of facility "Tasks" documentation for Resident R56 revealed that the resident was scheduled to receive two showers or baths a week. Continued review of Resident R56's task documentation for December 21 through 31, 2018 and the months of January 2019 and February 2019. review of the tasks documentation for March 1 through 22, 2019, revealed that the resident received two showers for the month. There was no documentation that the resident was offered, refused or received any additional showers or baths for the month of March 2019.

Review of Resident R10's Admission Minimum Data Set (MDS-periodic assessment of needs) dated February 1, 2019 revealed that the resident was cognitively impaired. Review of Resident R10's care plan revealed that the resident had impaired/decline in cognitive function related to conditions which included, adult failure to thrive. Review of the Resident R10's care plan revealed that the resident was dependent on staff for her Activities of Daily living, which included bathing, grooming and personal hygiene.

Review of the "Tasks" documentation for Resident R10 revealed that the resident was scheduled for two showers or baths a week. Continued review of the tasks documentation for Resident R10 revealed that there was no documentation that the resident was offered, refused, or received two showers or baths a week for the months of January, February and March 2019.

Review of Resident R79's Quarterly Minimum Data Set (MDS-periodic assessment of needs) dated February 28, 2019 revealed that the resident was cognitively intact and that he required the assistance of one person to assist him with the task of bathing.

Review of the "Resident Council Minutes" for January 15, 2019 revealed that Resident R79 reported that he was not always getting showers.

Review of the "Tasks" documentation for Resident R79 revealed that in November 2018 the resident was scheduled for two showers or baths a week, but there was no documentation indicating that the resident was offered, refused, or received two showers or baths a week for the month of November 2018. Further review of the tasks documentation for Resident R79 dated December 2018 revealed that the resident was documented as receiving one shower on December 22, 2018. There was no additional documentation indicating that Resident R79 was offered, refused, or received two showers or baths a week for any additional days during the month of December 2018.

Review of Resident R57's Admission Minimum Data Set (MDS-periodic assessment of needs) dated February 12, 2019 revealed that the resident was cognitively impaired and that he was totally dependent on staff for the task of bathing. Review of the clinical record also revealed that the resident was admitted into the facility on February 5, 2019.

Review of Resident R57's "Tasks" documentation revealed that the resident was scheduled to receive two showers or baths a week for February 2019. Further review of Resident R57's task documentation revealed there was no documentation indicating that the resident was offered, refused, or received two showers or baths a week for the month of February 2019 or from March 1, 2019 through March 22, 2019.

Interview with the Administrator on March 22, 2019 at approximately 3:05 p.m. it was reported that it is the facility's practice that residents are offered showers/bath two times a week. Additionally, the Administrator indicated during the interview that the facility did not have a formal policy regarding showers/baths.

Interview with Employee E11, Unit Manager, on March 25, 2019 at approximately 1:00 p.m. the above resident's shower schedules were reviewed, along with the tasks' documentation. The Unit Manger reported that residents are offered showers/baths two times a week. The Unit manager further indicated that she did not know why the documentation for the above residents did not reflect that they were being offered showers/baths. She confirmed during the interview that no additional documentation could be produced to show evidence that showers/baths were being offered to the residents, that the residents refused to take showers/baths, or that they received showers of baths for the above time periods.

The facility failed to accommodate four resident's needs for showering and/or bathing.

Review of Resident R59's medical records revealed that the resident was admitted to the facility on February 8, 2019, with diagnoses, including but not limited to, amyotrophic lateral sclerosis (ALS - also known as Lou Gehrig's disease, it is a disease which causes the death of neurons controlling voluntary muscles) and abnormal mobility. Further review of Resident R59's medical record revealed that the resident was receiving hospice services (end of life comfort and care).

Interview with Resident R59 on March 25, 2019, at 9:49 a.m. revealed that she practiced Christianity and at the time of her admission into the facility had requested the Recreation Director to contact her church pastor to inform him that she was now a resident in the nursing home. Resident R59 further indicated that she had wanted him to come and pray with her because she was dying. Resident R59 revealed that to date, she had not been contacted by her church and believed that the facility had not followed through on her request.

Review of medical records for Resident R59 revealed she had a Post Admission Preferences recreation comprehensive assessment dated February 11, 2019, that was completed by the Recreation Director. Sections in the assessment detailed the name of Resident R59's church and revealed a yes to whether Resident R59 wanted to stay in contact with the organization while being a resident at the nursing home. Further review of the recreation assessment revealed a note inserted by the Recreation Director that staff would try to look up the contact details of the church.

Interview with the Recreation Director on March 25, 2019, at 10:17 a.m. revealed that Resident R59 "hasn't expressed any interest to us about religion" and confirmed that upon review of progress notes there was no documented evidence of contact with religious organizations on behalf of Resident R59. Further interview with the Recreation Director revealed the information about religious needs for Resident R59 in the recreation comprehensive assessment from February 2019 was accurate.

Continued review of Resident R59's medical records, following the interview with the Recreation Director, revealed a new progress note for March 25, 2019, at 11:19 a.m. where the Recreation Director documented that she had now contacted the pastor for Resident R59, 42 days following the resident's request. The documentation further indicated that Resident R59's pastor would come and visit the resident on the following day.

The facility failed to ensure that one resident's religious preferences and needs were accommodated.

28 Pa. Code 211.12(d)(1) Nursing services
Previously cited 12/06/18, 05/16/18, 03/09/17

28 Pa. Code 211.12(d)(5) Nursing services
Previously cited 12/06/18, 11/08/18, 05/16/18, 03/09/17




 Plan of Correction - To be completed: 05/23/2019

Resident R56 receives his showers as scheduled and will be documented correctly in the Point Of Care tasks
Resident R10 receives her showers as scheduled and will be documented correctly in the Point of Care tasks
Resident R79 is no longer a resident at this facility.
Resident R57 receives his showers as scheduled and will be documented correctly in the Point Of Care tasks
Nurse Practice Educator or designee will re-educate the CNAs on the procedure of offering a resident a shower when it is scheduled and how to document it correctly in the Point of Care tasks.
Unit Managers or designee will conduct an initial audit to ensure that resident's showers are being offered and documented correctly
Unit Managers or designee will conduct 5 random weekly audits x 3 months to ensure that resident's showers are being offered and documented correctly
Center Executive Director will review audit findings at the monthly QAPI meeting x 3 months

Resident R59 was visited by her Pastor from her church on 3/26/19.
Center Executive Director re-educated Recreation department on the policy for meeting resident's religious preferences.
Recreation Director or designee will conduct initial audit to ensure that resident's religious preferences are being met
Recreation Director or designee will conduct random weekly audits x 3 months to ensure that resident's religious preferences are being met how many
Center Executive Director will review audit findings at the monthly QAPI meeting x 3 months

483.80(a)(3) REQUIREMENT Antibiotic Stewardship Program:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
483.80(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)(3) An antibiotic stewardship program that includes antibiotic use protocols and a system to monitor antibiotic use.
Observations:

Based on review of facility policy and staff interview, it was determined the facility failed to ensure that the antibiotic stewardship protocols were accurately updated annually and on an as needed basis.

Findings include:

Review of facility antibiotic stewardship protocols (algorithms) revealed the following algorithms and dates of corporate publication:
Algorithm for the Management of Acute Bronchitis - March 2017;
Algorithm for the Management of Bacterial Pneumonia in Patients of Long-Term Care - March 2017;
Algorithm for the Management of Cellulitis and Soft Tissue Infections (STI) - August 21, 2017;
Algorithm for the Management of Upper Respiratory Tract Infections in Older Adults - November 2017;
Catheter Associated Urinary Tract Infection (CAUTI) Algorithm with an Indwelling Catheter - October 2016;
Sepsis Algorithm for Adults - November 2016, and
UTI Algorithm - Patient Without an Indwelling Catheter - February 2017.

Interview with Employee E3, Registered Nurse (RN), Infection Control Nurse (ICN), on March 25, 2019, at 1:14 p.m. revealed that the most recent infection prevention and control program (IPCP) protocols, algorithms and policy review took place on February 4, 2019.

A request for the facility to identify whether there were updated corporate IPCP antibiotic stewardship algorithms revealed that the facility's corporate infection control division had published annual updates to the antibiotic stewardship algorithms and the most recent changes were published in December 2018. In the December 2018 revision, two new antibiotic stewardship algorithms were published in addition to those previously listed:
Algorithm for the Management of Clostridium Difficile Infection, and
Wound infection algorithm.

Interview with Employee E3, RN and ICN, on March 25, 2019, at 1:45 p.m. revealed that the Medical Director had been using the outdated antibiotic stewardship algorithms for residents who required antibiotics in the facility. The interview also revealed confirmation that the antibiotic stewardship algorithms had not been reviewed at the annual and as needed IPCP review meetings during the last 14 months.

The facility failed to accurately update the antibiotic stewardship protocols on an annual and as needed basis.

28 Pa. Code 201.14(a) Responsibility of licensee
Previously cited 12/06/18, 11/08/18, 05/16/18, 03/09/17









 Plan of Correction - To be completed: 05/23/2019

The facility updated the antibiotic stewardship protocols to the current version.
Center Executive Director re-educated Nurse Practice Educator on the procedure of updating the antibiotic stewardship protocol annually and as needed.
Nurse Practice Educator or designee will conduct a weekly audit x 3 months to ensure that the antibiotic stewardship protocol is updated annually and as needed
Center Nurse Executive will review audit findings at the monthly QAPI meeting x 3 months

483.10(a)(1)(2)(b)(1)(2) REQUIREMENT Resident Rights/Exercise of Rights: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(a) Resident Rights.
The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility, including those specified in this section.

483.10(a)(1) A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the resident.

483.10(a)(2) The facility must provide equal access to quality care regardless of diagnosis, severity of condition, or payment source. A facility must establish and maintain identical policies and practices regarding transfer, discharge, and the provision of services under the State plan for all residents regardless of payment source.

483.10(b) Exercise of Rights.
The resident has the right to exercise his or her rights as a resident of the facility and as a citizen or resident of the United States.

483.10(b)(1) The facility must ensure that the resident can exercise his or her rights without interference, coercion, discrimination, or reprisal from the facility.

483.10(b)(2) The resident has the right to be free of interference, coercion, discrimination, and reprisal from the facility in exercising his or her rights and to be supported by the facility in the exercise of his or her rights as required under this subpart.
Observations:

Based on medical record review, facility policy review and resident and staff interview, it was determined that the facility did not ensure residents were informed of their right to choose an attending physician for one of 19 residents reviewed (Resident R59).

Findings include:

Interview with Resident R59 on March 21, 2019, at 10:15 a.m. revealed the resident would like to have chosen her own physician in the facility but was assigned a physician by the facility. The resident did not know she had a right to choose her own physician and revealed that she not been informed of this right by the facility at admission.

Further interview with Resident R59 on March 26, 2019, at 9:39 a.m. revealed she had never seen the admissions packet before when shown a sample of the document.

Review of medical records for Resident R59 revealed that when the resident, who is her own responsible party, was admitted to the facility, she did not initial her admissions documentation to indicate that she had received a copy of the admissions packet that contained information about her right to choose an attending physician which indicates she had not been informed of her right to choose an attending physician.

Interview with the Nursing Home Administration (NHA) on March 25, 2019, at 9:06 a.m. revealed that residents have a choice in the facility and are not forced to do anything but that the facility assigns residents to physicians during the admissions process, before they go to the building. The NHA confirmed that the resident education for the right to choose an attending physician is contained within the admissions packet.

The facility failed to inform residents of their right to choose an attending physician.

28 Pa. Code 211.12(d)(1) Nursing services
Previously cited 12/06/18, 05/16/18, 03/09/17

28 Pa. Code 211.12(d)(5) Nursing services
Previously cited 12/06/18, 11/08/18, 05/16/18, 03/09/17




 Plan of Correction - To be completed: 05/23/2019

Resident R59 was offered a choice for her attending physician however declined changing her physician at time of meeting.
Center Executive Director re-educated Admissions Director on the sign-in process with Admission Packet and how to present choice of attending physician to new admissions.
Social Service Director or designee will conduct initial audit to ensure that residents understand that they have the right to choose an attending physician.
Social Service Director or designee to conduct 5 random weekly audits x 3 months to ensure that residents understand that they have the right to choose an attending physician.
Center Executive Director will review audit findings at the monthly QAPI meeting x 3 months

483.10(c)(6)(8)(g)(12)(i)-(v) REQUIREMENT Request/Refuse/Dscntnue Trmnt;Formlte Adv Dir:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.10(c)(6) The right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.

483.10(c)(8) Nothing in this paragraph should be construed as the right of the resident to receive the provision of medical treatment or medical services deemed medically unnecessary or inappropriate.

483.10(g)(12) The facility must comply with the requirements specified in 42 CFR part 489, subpart I (Advance Directives).
(i) These requirements include provisions to inform and provide written information to all adult residents concerning the right to accept or refuse medical or surgical treatment and, at the resident's option, formulate an advance directive.
(ii) This includes a written description of the facility's policies to implement advance directives and applicable State law.
(iii) Facilities are permitted to contract with other entities to furnish this information but are still legally responsible for ensuring that the requirements of this section are met.
(iv) If an adult individual is incapacitated at the time of admission and is unable to receive information or articulate whether or not he or she has executed an advance directive, the facility may give advance directive information to the individual's resident representative in accordance with State Law.
(v) The facility is not relieved of its obligation to provide this information to the individual once he or she is able to receive such information. Follow-up procedures must be in place to provide the information to the individual directly at the appropriate time.
Observations:

Based on medical record review, facility policy review and staff interview, it was determined that the facility failed to ensure resident's advanced directives were consistently documented throughout their medical records for three of 19 residents reviewed (Residents R10, R65 and R71).

Findings include:

Review of a facility policy titled Health Care Decision Making and dated as revised on January 1, 2013, revealed that one of the purposes of allowing residents to create advanced directives is to assure that residents' wishes concerning health care decisions are communicated to all staff so that residents' rights will be honored, and their wishes executed at the appropriate time.

Review of medical records for Resident R65 revealed the resident was most recently admitted to the facility in February 2019 with diagnoses including type 2 diabetes (results from insufficient production of insulin, causing high blood sugar), morbid obesity, difficulty swallowing, major depressive disorder and congestive heart failure (a progress disease that affects the pumping action of the heart muscles).

Further review of medical records for Resident R65 revealed a Physician Orders for Life-Sustaining Treatment (POLST) form dated March 30, 2018, at the front of Resident R65's paper chart for Do Not Resuscitate (DNR is a legal order written to withhold cardiopulmonary resuscitation [CPR] or advanced cardiac life support [ACLS], in respect of the wishes of a resident in case their heart were to stop or they were to stop breathing).

Further review of medical records for Resident R65 revealed no documented physician orders for DNR which means the resident is a full code (CPR and/or ACLS is administered in the event the resident's heart were to stop or they were to stop breathing).

Further review of medical records for Resident R65 revealed a physician's progress note dated February 5, 2019, at midnight, stating that the resident remained a full code with full medical intervention, which contradicted the POLST DNR order at the front of her paper chart.

Interview with Employee E6, Registered Nurse (RN), Nurse Manager, on March 22, 2019, at 11:45 a.m. revealed confirmation that the orders were inconsistent and could be confusing to employees in a life critical event.

Review of medical records for Resident R71 revealed diagnoses including type 2 diabetes, difficulty maintaining balance walking and right-hand pain. Review of the resident's POLST form at the front of the paper chart for quick and easy access was for a full code, however, the most up to date POLST form for DNR, Do Not Hospitalize (DNH) and Do Not Intubate (DNI means to not insert a breathing tube into the lungs to support breathing function) was located further back in the paper record in a section not related to advanced directives or somewhere easily accessible during an emergency situation. Review of the electronic health record on March 25, 2019, revealed the DNR, DNH and DNI orders had been entered into the computer on March 24, 2019.

Interview with Employee E17, Licensed Practical Nurse (LPN), on March 25, 2019, at 12:36 p.m. revealed confirmation that the most accessible POLST form at the very front of Resident R71's paper record was outdated and should have been replaced by the newer POLST that was hidden further back in the record.

Review of the clinical record for Resident R10 revealed diagnoses that included, but not limited to, Cerebral Infarctions (a stroke); End Stage Renal Disease (kidneys are no longer able to work as they should to meet the body's needs); Hypertension (high blood pressure); Depression (feelings of sadness) and Dysphagia (difficulty swallowing).

Review of the resident's chart revealed a POLST (Physician Orders for Life Sustaining Treatment) which stated DNR/Do not Attempt Resuscitation.

Review of the resident's physician orders for March 2019 did not have a code status listed on the physician's orders.

During an interview with the Administrator and the Director of Nursing on Friday, March 22, 2019 at approximately 3:00 p.m. it was confirmed that if there is no code status order listed on the physician orders for a resident, then the code status for the resident would be Full Code.

On March 25, 2019 at approximately 9:00 a.m. it was confirmed by the Administrator that the resident's Code Status was DNR and not Full Code.

The facility failed to ensure resident's advanced directives were consistently documented throughout their medical records.

28 Pa. Code 201.14(a) Responsibility of licensee
Previously cited 12/06/18, 11/08/18, 05/16/18, 03/09/17

28 Pa. Code 201.18(b)(1) Management
Previously cited 12/06/18,11/08/18, 05/16/18, 03/09/17

28 Pa. Code 201.18(b)(2) Management

28 Pa. Code 201.18(b)(3) Management
Previously cited 12/06/18, 05/16/18, 03/09/17

28 Pa. Code 201.18(e)(1) Management
Previously cited 12/06/18, 11/08/18

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

28 Pa. Code 211.5(f) Clinical records
Previously cited 12/06/18

28 Pa. Code 211.12(d)(1) Nursing services
Previously cited 12/06/18, 05/16/18, 03/09/17

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

28 Pa. Code 211.12(d)(3) Nursing services
Previously cited 12/06/18, 11/08/18, 05/16/18

28 Pa. Code 211.12(d)(5) Nursing services
Previously cited 12/06/18, 11/08/18, 05/16/18, 03/09/17

 Plan of Correction - To be completed: 05/23/2019

Resident R10 A physician order has been obtained for the code status.
Resident R65 Resident has been discharged from the facility.
Resident R71 A physician order has been obtained for the code status.
Nurse Practice Educator (NPE) or designee will re-in-service licensed nursing staff and social services to ensure a physician's order has been obtained for residents code status.
The unit manager or designee will complete an initial audit of current residents to ensure that a physician's order has been obtained for residents code status.
The unit manager or designee will complete 5 random weekly audits x 3 months of current residents to ensure that a physician's order has been obtained for residents code status.
The DON/designee will review the results of the audits at the Facility's Monthly Quality Improvement Meeting x 3 months.
483.12(a)(1) REQUIREMENT Free from Abuse and Neglect:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.12 Freedom from Abuse, Neglect, and Exploitation
The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms.

483.12(a) The facility must-

483.12(a)(1) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion;
Observations:

Based on review of clinical records, facility policies and procedures and facility documentation, and interviews with staff, it was determined that the facility failed to protect the rights of residents to be free from neglect by not providing the goods and services necessary to avoid physical harm, pain, mental anguish or emotional distress related to failure to provide proper and timely incontinent care, and failure to provide a safe and proper transfer for two of 19 records reviewed (Resident R15 and Resident R440).

Findings include:

Review of the facility's policy titled, Abuse Prohibition revised on July 1, 2018, states the facility will prohibit abuse, mistreatment, neglect, misappropriation of resident property, and exploitation for all resident through prevention, identification and investigation. It further states, neglect is defined as the failure of the facility, to provide goods and services to a patient that are necessary to avoid harm, pain, anguish or emotional distress. Actions to prevent neglect will include identifying, correcting and intervening in situations in which neglect occurred. Resident R15 was admitted to the facility on January 22, 2017 with diagnoses that included a stroke, abnormal gait and mobility and muscle weakness. Clinical notes revealed the resident was cognitively intact and incontinent of bowel and bladder.

Review of the information dated January 30, 2019 submitted by the facility, revealed Resident R15 waited approximately three hours for incontinence care. Review of the facility's investigation revealed "Around 11:45 a.m." Resident R15's assigned Nursing Assistant (NA), Employee E13, was moved to another unit prior to giving the resident her morning care. The NA Employee E9 that took over Employee E13's assignment indicated she (Employee E9) told the Charge Nurse, Employee E10 that Resident R15 needed to be changed and then went back to continue assisting another resident with their meal. During that time, the Charge Nurse did not provide Resident R15 with incontinence care but in turn told NA Employee E9, "To speak to the Unit Manager." Per the facility's investigation the NA never spoke to the Unit Manager and Resident R15 did not receive the incontinence care until a fifth employee, NA Employee E12 gave Resident R15 incontinence care at 2:30 p.m.

The facility failed to provide incontinence care in a timely manner.

Resident R440 had diagnoses that included stroke, dementia, dysphasia, aphasia, Diabetes, history of a right femur fracture, abnormal posture, gait and mobility, muscle weakness and repeated falls, confused and cognitively impaired.
Review of Resident R440's care plan revealed the resident was at risk for falls related to her impaired mobility, and stroke. The interventions dated July 2018, included utilizing proper footwear during transfers/ambulation and assisting the resident while getting in and out of the bed.

Review of the facility's documentation dated October 18, 2018 indicated NA, Employee E14 neglected to place proper footwear on Resident R440 prior to transferring the resident. The documentation indicated that the resident, "Attempted to plop backwards and ended up sliding." The NA guided her to the floor while holding her under her arms. After the fall the resident complained of right shoulder and arm pain.

During an interview on March 26, 2019 at 11:30 a.m. with Register Nurse Employee E3, revealed there was no documentation available for review during the survey that the facility took further actions to prevent and correct future unsafe transfers. The facility failed to reeducate the NA and staff the importance of using proper footwear with all transfers and failed to intervening when the neglect occurred.

28 Pa. Code 201.14(a) Responsibility of licensee
Previously cited 12/06/18, 11/08/18, 05/16/18, 03/09/17

28 Pa. Code 211.12(d)(1) Nursing services
Previously cited 12/06/18, 05/16/18, 03/09/17

28 Pa. Code 211.12(d)(3) Nursing services
Previously cited 12/06/18, 11/08/18, 05/16/18

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




 Plan of Correction - To be completed: 05/23/2019

A reportable incident had been submitted to the DOH and was accepted in regards to Resident R15.
The Nurse Practice Educator or designee will re-educate nursing staff on providing timely incontinence care
The Unit Manager or designee will conduct 5 random weekly audits x 3 months to ensure that incontinence care is provided timely
The Center Nurse Executive will report findings to the QAPI committee meeting monthly x 3.

A reportable incident will be submitted to the DOH in regards to Resident R440.
Nurse Practice Educator or designee will re-educate Employee E14 on the utilization of proper footwear with all transfers to ensure neglect does not occur.
Nurse Practice Educator or designee will re-educate nursing staff on the utilization of proper footwear with all transfers to ensure neglect does not occur.

Unit Manager or designee will conduct an initial audit of the past 5 days of resident incident reports related to falls to ensure that proper footwear was utilized with all transfers to ensure neglect does not occur.
Unit Manager or designee will conduct a weekly audit of resident incident reports related to falls to ensure that proper footwear was utilized with all transfers to ensure neglect does not occur.
Center Nurse Executive or designee will review audit findings at the monthly QAPI committee meeting monthly x 3.
483.12(c)(1)(4) REQUIREMENT Reporting of Alleged Violations:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must:

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

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


Based on review of clinical records, facility policies and procedures and facility documentation and interviews with staff, it was determined the facility failed to conduct an investigation for an elopement and report it to the state agency for of 19 resident records reviewed (Resident R14).

Findings include:

Review of medical records for Resident R14 revealed complex diagnoses including schizophrenia (a mental disorder characterized by delusions, hallucinations, disorganized speech and behavior), high blood pressure, chronic pain, constipation, weakness and difficulty maintaining balance when walking.

Interview with Resident R14 on March 21, 2019, at 11:12 a.m. revealed the resident expressed a desire to leave the facility and further probing questions revealed the resident self-identified as having eloped to the neighboring property "a few months ago".

Review of facility event reports to the Pennsylvania Department of Health revealed no elopement reports for Resident R14 during the last year.

Review of medical records for Resident R14 revealed that on November 1, 2018, at 3:50 a.m. the resident entered the elevator and stated he would be in the lobby. At 4:00 a.m. the resident was not seen in the lobby but was "found outside sitting on a bench" at the neighboring apartment block. The implication of the word found is that the resident was not with any facility employees at the neighboring apartment block.

Interview with the Nursing Home Administrator (NHA) on March 21, 2019, at 3:43 p.m. revealed the NHA had not been aware of the nursing progress notes that indicated a potential elopement to the neighboring property for Resident R14 on November 1, 2018, and for that reason the incident was not investigated.

The facility failed to conduct a complete and thorough investigation for an incident of neglect and failed to investigate a potential instance of elopement from the facility.

28 Pa. Code 201.14(a) Responsibility of licensee
Previously cited 12/06/18, 11/08/18, 05/16/18, 03/09/17

28 Pa. Code 201.18(b)(1) Management
Previously cited 12/06/18,11/08/18, 05/16/18, 03/09/17




 Plan of Correction - To be completed: 05/23/2019

CED investigated the potential elopement of Resident R14 and after investigation it was not deemed an elopement. The RN Nursing Supervisor who witnessed the event added a clarification to the charge nurse's progress note.
The Center Executive Director or designee will complete an initial audit of the past 5 days for current resident progress notes to ensure any potential elopement is investigated and reported to the Department of Health as indicated.
The Center Executive Director or designee will complete a weekly audit x 3 months of current resident progress notes to ensure any potential elopement is investigated and reported to the Department of Health as indicated.
The Nurse Practice Educator or designee will re-educate licensed nurses on documentation regarding elopement and notifying Administration on any potential elopement.
The Center Executive Director will report findings to the QAPI committee meeting monthly x 3.

483.12(c)(2)-(4) REQUIREMENT Investigate/Prevent/Correct Alleged Violation:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must:

483.12(c)(2) Have evidence that all alleged violations are thoroughly investigated.

483.12(c)(3) Prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress.

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

Based on review of clinical records, facility policies and procedures and facility documentation and interviews with staff, it was determined the facility failed to conduct a complete and thorough investigation for an incident of neglect related to not providing incontinence care in a timely manner for one out of 19 resident records reviewed (Resident R15).

Findings include:

Review of the facility's policy titled, Abuse Prohibition revised on July 1, 2018, states the facility will prohibit abuse, mistreatment, neglect, misappropriation of resident property, and exploitation for all residents through prevention, identification and investigation. It further states, neglect is defined as the failure of the facility, to provide goods and services to a resident that are necessary to avoid harm, pain, anguish or emotional distress. Actions to prevent neglect will include identifying, correcting and intervening in situations in which neglect occurred.

Resident R15 was admitted to the facility on January 22, 2017, with diagnoses that included a stroke, abnormal gait and mobility and muscle weakness. Clinical notes revealed the resident was cognitively intact and incontinent of bowel and bladder.

Review of event investigation information dated January 30, 2019, submitted by the facility, revealed that Resident R15 waited approximately three-hours for incontinence care. Review of the facility's investigation revealed "Around 11:45 a.m." Resident R15's assigned Nursing Assistant (NA), Employee E13, NA, was moved to another unit prior to giving the resident her morning care. Employee E9, NA, who took over Employee E13's assignment indicated that she (Employee E9) had told the Charge Nurse, Employee E10, that Resident R15 needed to be changed and then, went back to continue assisting another resident with their meal. During that time, the Charge Nurse did not provide Resident R15 with incontinence care but in turn told Employee E9, NA, "to speak to the Unit Manager". Per the facility's investigation the NA never spoke to the Unit Manager and Resident R15 did not receive the incontinence care until a fifth employee, Employee E12, NA, gave Resident R15 incontinence care at 2:30 p.m.

Further review of the facility's investigation revealed they failed to thoroughly conduct interviews and receive witness statements from all the available staff working on that unit, capable of providing incontinent care for the resident. Per the facility's staffing report for the third-floor unit that day, a Unit Manager, Charge Nurse, two Licensed Practical Nurses and three additional NAs were available to assist Resident R15 with incontinence care. The witness statement from Employee E10, Charge Nurse, was not thoroughly investigated, it lacked her reason as to why she did not perform incontinence care when her NA, Employee E9, informed her that Resident R15 needed it.

The facility failed to investigate why Employee E13, NA, did not provide care to Resident R15 before she was moved to another floor. Lastly, they failed to investigate why there was a breakdown in communication within the staff; the breakdown ultimately caused Resident R15 to wait three-hours for incontinence care.


28 Pa. Code 201.18(b)(3) Management
Previously cited 12/06/18, 05/16/18, 03/09/17

28 Pa. Code 201.18(e)(1) Management
Previously cited 12/06/18, 11/08/18

28 Pa. Code 201.29(a)(d) Resident Rights

28 Pa. Code 211.5(f) Clinical records
Previously cited 12/06/18






 Plan of Correction - To be completed: 05/23/2019

A reportable incident had been submitted to the DOH and was accepted in regards to Resident R15.
The Clinical Quality Specialist re-educated the CED to ensure neglect investigations are thorough.
The Center Executive Director or designee will complete an initial audit of neglect reportable files with the past 30 days to ensure the investigation was thorough.
The Center Executive Director or designee will complete a weekly audit x 3 months of neglect reportable files to ensure the investigation was thorough.
The Center Executive Director will report findings to the QAPI committee meeting monthly x 3.

483.45(f)(1) REQUIREMENT Free of Medication Error Rts 5 Prcnt or More:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.45(f) Medication Errors.
The facility must ensure that its-

483.45(f)(1) Medication error rates are not 5 percent or greater;
Observations:

Based on observations, medical record review and staff interview, it was determined that the facility failed to ensure that it was free of a medication error rate of five percent or greater.

Findings include:

Observation of medication administration completed on March 22 and 25, 2019, revealed 32 medication administration opportunities and four observed medication errors which yielded a medication error rate of 12.5%.

Review of medical records for Resident R392 revealed physician orders for the following medications:
Potassium chloride extended release 20 mEq tablet, two times a day for supplement, due at 8:00 a.m. and 8:00 p.m.;
Furosemide 80 mg tablet, two times a day for diuresis (increased urination), due at 8:00 a.m. and 8:00 p.m.;
Rivaroxaban 15 mg tablet, two times a day for 12 days to treat deep vein thromboses (DVT), due at 8:00 a.m. and 8:00 p.m., and
Cyclosporine emulsion 0.05%, one drop in each eye two times a day for dry eyes due to inflammation, due at 8:00 a.m. and 8:00 p.m.

Observation of medication administration for Resident R392 on March 25, 2019, at 12:03 p.m. with Employee E7, Licensed Practical Nurse (LPN), revealed the potassium chloride, furosemide, rivaroxaban and cyclosporine emulsion that were due at 8:00 a.m. were administered at 12:03 p.m.

Interview with Employee E3, Registered Nurse (RN), Infection Control Nurse, on March 26, 2019, at 10:50 a.m. revealed confirmation that Resident R392 received four of her 8:00 a.m. medications four-hours late on March 25, 2019.

The facility did not ensure that it was free of a medication error rate of five percent or greater.

28 Pa. Code 211.9(a)(1) Pharmacy services

28 Pa. Code 211.10(c) Resident care policies

28 Pa. Code 211.12(c) Nursing services

28 Pa. Code 211.12(d)(1) Nursing services
Previously cited 12/06/18, 05/16/18, 03/09/17

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



 Plan of Correction - To be completed: 05/23/2019

R389 Residents medication potassium chloride, furosemide, rivaroxaban, cyclosporine medication is being administered as per physicians order and resident suffered no ill effects from the occurance.
Employee E7 has been reeducated on administering medications in a timely manner and a medication competency has been completed.
Nurse Practice Educator/Designee will re-inservice licensed nursing staff on administering medication in a timely manner to prevent significant medication errors.
Nurse Practice Educator/designee will complete an initial medication competency on facility licensed nurses to ensure that medications are administered in a timely manner.
Nurse Practice Educator/designee will complete six random weekly medication competencies on facility licensed nurses to ensure that medications are administered in a timely manner.
The DON/designee will review the results of the audits at the Facility's Monthly Quality Improvement Meeting x 3 months

483.45(f)(2) REQUIREMENT Residents are Free of Significant Med Errors:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
The facility must ensure that its-
483.45(f)(2) Residents are free of any significant medication errors.
Observations:
Based on observation, medical record review and staff interview, it was determined that the facility failed to administer medications according to the prescriber's order resulting in one significant medication error that had the potential to jeopardize the resident's health and safety for one of 19 residents reviewed (Resident R392).

Findings include:

Review of medical records for Resident R392 revealed a physician order for the following medication:
Rivaroxaban 15 mg tablet, two times a day for 12 days to treat deep vein thromboses (DVT - blood clots), due at 8:00 a.m. and 8:00 p.m.

Observation of medication administration for Resident R392 on March 25, 2019, at 12:03 p.m. with Employee E7, Licensed Practical Nurse (LPN), revealed the rivaroxaban that was due at 8:00 a.m. was administered at 12:03 p.m. which was 8-hours before the next scheduled dose and 16-hours after the previously administered dose. The FDA approved patient labeling for rivaroxaban states to take the medication only as directed to prevent the risk of hemhorrage if taken too close together and prevent that risk of clots if taken too far apart.

Interview with Employee E3, Registered Nurse (RN), Infection Control Nurse, on March 26, 2019, at 10:50 a.m. revealed confirmation that Resident R392 received the 8:00 a.m. rivaroxaban four-hours late on March 25, 2019. Employee E3 confirmed that spacing rivaroxaban too close to the next dose could result in bleeding problems. Employee E3 confirmed that a delay in receiving rivaroxaban could result in blood clots.

The facility failed to administer medications in a safe and effective manner.

28 Pa. Code 211.10(c) Resident care policies

28 Pa. Code 211.12(d)(1) Nursing services
Previously cited 12/06/18, 05/16/18, 03/09/17

28 Pa. Code 211.12(d)(3) Nursing services
Previously cited 12/06/18, 11/08/18, 05/16/18

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


 Plan of Correction - To be completed: 05/23/2019

R389 Residents medication rivaroxaban, medication is being administered as per physicians order and resident suffered no ill effects from the occurrence.
Employee E7 has been reeducated on administering medications in a timely manner to prevent a significant medication error.
Nurse Practice Educator/Designee will re-inservice licensed nursing staff on administering medication in a timely manner to prevent significant medication errors.
Nurse Practice Educator/designee will complete an initial medication competency on facility licensed nurses to ensure that medications are administered in a timely manner to prevent a significant medication error.
Nurse Practice Educator/designee will complete six random weekly medication competencies to ensure that medications are administered in a timely manner to prevent a significant medication error.
The DON/designee will review the results of the audits at the Facility's Monthly Quality Improvement Meeting x 3 months.

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

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

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

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

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

483.70(i)(5) The medical record must contain-
(i) Sufficient information to identify the resident;
(ii) A record of the resident's assessments;
(iii) The comprehensive plan of care and services provided;
(iv) The results of any preadmission screening and resident review evaluations and determinations conducted by the State;
(v) Physician's, nurse's, and other licensed professional's progress notes; and
(vi) Laboratory, radiology and other diagnostic services reports as required under 483.50.
Observations:
Based on interviews with residents and facility staff and review of clinical documentation, facility policy review, it was determined that the facility failed to maintain complete, accurate and accessible medical records related to meal consumption, palliative care and medication administration for three of 19 resident records reviewed (R15, R59 and R440).

Findings include:

Review of the facility's policy titled, Palliative and/or End of Life Care revised on March 2018, reveals patients with advanced illness have the right to choose palliative care as the primary goal of treatment. The patient will receive a comprehensive assessment to provide direction for the development of the patient's care plan to address choices and preferences of the patient. A periodical review of the care plan addressing services and support to honor the patient's choices and rights.

Resident R15 was admitted to the facility on January 22, 2017 with diagnoses that included Viral Hepatitis C (a blood born virus), stroke, abnormal gait and mobility. Review of Resident R15's care plan revealed the resident was on palliative/comfort measures (the care focuses on providing relief from the symptoms, pain, physical and mental stress at any stage of illness) since December 6, 2018. Interventions included collaborating with the hospice (palliative) program to coordinate a plan of care and to provide the resident with sufficient information to make an informed decision related to her needs.

During an interview with Resident R15 on March 22, 2019 at approximately 11:30 a.m. the resident indicated that she does not receive palliative care from an outside service. The resident stated, "I'm not getting that! I better not be paying for it cause I don't get it!" Immediately afterwards, the Third floor Unit Manager, Registered Nurse (RN) Employee E4 could not provide evidence of nursing notes or documentation pertaining to the palliative care services that have been provided for Resident R15. The RN indicated that the facility should have progress notes collaborating with the Palliative Care service. On March 22, 2019 at approximately 1:00 p.m. the RN made a request to the Palliative Care service to fax documentation related to the care that was given to Resident R15.

Review of the medical record for Resident R440 revealed that the resident had diagnoses that included stroke, dementia, dysphasia, aphasia, Diabetes, history of a right femur fracture, abnormal posture, gait and mobility, muscle weakness and repeated falls. Review of R440 care plans revealed the resident was impaired and had a decline in cognition. The interventions included to monitor for conditions that may contribute to cognitive loss or dementia including psychiatric disorders and poor nutrition. The resident's care plan for the diagnosis of Diabetes included interventions to monitor meal consumption with each meal. Continuing with the care plans revealed the resident was a risk for significant weight loss due to the diagnoses of Diabetes with interventions that included alerting the dietician and physician to any significant weight loss.

Review of the facility's meal consumption record for Resident R 440 from February 6, 2019 to March 20, 2019 revealed numerous dates with missing meal consumption recordings. Interview with RN Unit Manager Employee E3 on March 26, 2019 at 1:00 p.m. verified that the meal consumption documentation for Resident R440 was incomplete.

Continuing with the review of Resident R440's care plans revealed the resident was on Palliative care for comfort measures, initiated on October 29, 2018. Third floor Unit Manager, Registered Nurse (RN) Employee E3 could not provide nursing notes or documentation pertaining to the palliative care services that have been provided for Resident R440. The RN indicated that the facility should have progress notes collaborating with the care given by Palliative Care service but indicated they were not found or accessible. On March 25, 2019 at approximately 11:30 p.m. the RN made a request to the Palliative Care service to fax their documentation related to the care and services that was provided to Resident R15.

Review of the medication administration record (MAR) for Resident R59 for the month of March 2019 on March 25, 2019, at 12:47 p.m. revealed no documentation for the following medications, dates and times to indicate whether the medications were given, held, refused or unable to be given due to the resident not being in the facility:
Baclofen (treats muscle spasms) tablet 20 mg for March 23, 2019, at 8:00 p.m.;
Enoxaparin sodium (prevents blood clots) solution 30 mg/0.3 ml on March 23, 2019, at 9:00 p.m.;
Florastor Capsule (probiotic) 250 mg on March 23, 2019, at 9:00 p.m.;
Heparin lock flush solution (prevents peripheral catheter clotting) 10 unit/ml on March 4, 5, 7, 15, 19 and 23, 2019;
House supplement (extra protein and calories for wound healing) on March 15 and 19, 2019, at 2:00 p.m.;
Lidocaine cream (treats knee pain) 4% on March 23, 2019, at 9:00 p.m.;
Miconazole Powder (treats rash) on March 23, 2019, at 9:00 p.m.;
Gabapentin capsule (treats nerve pain) 300 mg on March 23, 2019, at 9:00 p.m.;
Normal saline flushes (prevents peripheral catheter clotting) of 10 ml on March 4, 5, 7, 15, 19 and 23, 2019;
Nystatin-Triamcinolone Cream (treats fungal rash) on March 23, 2019, at 9:00 p.m.;
Oxycodone HCl (treats pain) tablet 5 mg at bedtime on March 23, 2019, at 9:00 p.m.;
Santyl Ointment (treats pressure ulcer areas) 250 unit/g on March 18 and 23, 2019;
Zoloft (treats depression) tablet 25 mg at March 23, 2019, at 9:00 p.m., and
Zosyn (treats bacterial infections) Solution 3-0.375 g/50 ml on March 3, 4, 5, 7, 15 and 19, 2019.

The facility failed to maintain complete, accurate and accessible records for three residents.

28 Pa. Code 211.2(a) Physician services

28 Pa. Code 211.5(f) Clinical records
Previously cited 12/06/18

28 Pa. Code 211.12(d)(1) Nursing services
Previously cited 12/06/18, 05/16/18, 03/09/17

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





 Plan of Correction - To be completed: 05/23/2019

R15 Palliative care notes have been received and are now in the residents chart.
R440 Palliative care notes have been received and are now on the residents chart. Meal consumption documentation is being completed.
R59 Baclofen, enoxaparin sodium, florastor, house supplement, lidocaine cream, miconazole powder, gabapentin, nystatin cream, oxycodone, santyl, and Zoloft are being documented as ordered. The heparin, normal saline flushes, and zosyn have been discontinued.
Nurse Practice educator/designee will re-inservice the licensed nursing staff on documentation of medication administration and obtaining and filing palliative care progress notes on the residents chart
Nurse Practice Educator/designee will re-inservice nursing staff on point click care meal consumption documentation.
The unit manager or designee will complete an initial audit of current resident's medication administration records to ensure documentation is completed for the last twenty four hours.
Unit Manager or designee will perform an initial audit to ensure residents who are receiving palliative care services notes are in their charts.
The Unit Manager or designee will conduct an initial audit for the past twenty four hours of meal consumption to ensure it is documented in point click care.
The Unit Manager or designee will complete ten weekly random audits of current resident's medication administration records to ensure documentation is completed.
The Unit Manager or designee will perform weekly audits of residents who are receiving palliative care services notes are in their charts.
The Unit Manager or designee will conduct ten random weekly audit of meal consumption to ensure it is documented in point click care
The DON/designee will review the results of the audits at the Facility's Monthly Quality Improvement Meeting x 3 months.

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

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

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

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

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

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

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

Based on observation, medical record review, facility policy review and staff interview, it was determined that the facility failed to maintain an effective infection prevention and control program related to wound care and eye drop administration for two of 19 residents reviewed (Resident R71 and R392).

Findings include:

Review of a facility policy titled Hand Hygiene and dated revised on November 28, 2017, revealed that employees are to perform hand hygiene before patient care to reduce the transmission of pathogenic microorganisms. Per facility policy, employees are instructed to rub their hands vigorously outside the stream of water for 20 seconds covering all surfaces of the hands and fingers during the hand washing with soap and water.

Review of the facility-approved bleach wipes for cleaning overbed tables prior to wound dressing changes revealed instructions for wet contact times of three minutes for complete bactericidal, tuberculocidal, fungicidal and virucidal activity.

Review of medical records for Resident R71 revealed the resident had a stage II pressure ulcer (characterized by partial-thickness skin loss into but no deeper than the dermis) on his sacrum (the triangular bone in the lower back, situated between the two hipbones of the pelvis).

Observation of wound care for Resident R71 with Employee E7, Licensed Practical Nurse (LPN), on March 25, 2019, at 10:57 a.m. revealed the nurse prepared the wound care supplies in the clinical care hallway without washing her hands first. The nurse entered the room to wash her hands prior to setting up in the room and rubbed her hand vigorously with soap outside of the stream of water for eight seconds before washing off the soap with water. The nurse used the facility-approved bleach wipes to wipe the top surface of the overbed table for five seconds before allowing the table to remain wet for 40 seconds before drying.

Further observation of wound care for Resident R71 with Employee E7, LPN, on March 25, 2019, at 11:20 a.m. revealed that after the nurse removed the wound dressing, she removed her gloves and performed hand hygiene by rubbing her hands vigorously with soap outside the stream of water for four seconds before washing off the soap with water. The nurse reapplied gloves and cleansed the wound with saline soaked gauze by wiping up from the anus, around the outside of the wound and ending in the middle of the wound which contaminated the wound by transferring anal bacteria up and into the center of the wound. The nurse then used dry gauze to wipe up from anus, around the outside of the wound and ending in the middle of the wound. The nurse removed her gloves and performed hand hygiene by rubbing her hands vigorously with soap outside the stream of water for three seconds before washing off the soap with water.

Further observation of wound care for Resident R71 with Employee E7, LPN, on March 25, 2019, at 11:23 a.m. revealed that at the end of the dressing change the nurse packed up the supplies, removed her gloves and performed hand hygiene by rubbing her hands vigorously with soap directly under the stream of water.

Observation of medication administration for Resident R392 on March 25, 2019, at 12:02 p.m. revealed Employee E7, LPN, touched a variety of surfaces while preparing medications with bare hands, then entered the resident's room and put on a pair of disposable clinical gloves without performing hand hygiene first. Employee E7, wearing the gloves that were put on with dirty hands, maneuvered the eyelids with her gloved-fingers to instill one eye drop in each eye for the resident which had the potential to introduce infection to the resident's eyes.

The facility failed to ensure employees vigorously rubbed their hands with soap for 20 seconds prior to washing off the soap, failed to follow manufacturer instructions for cleansing surfaces prior to wound care dressings and failed to administer eye drops with clean gloves.

28 Pa. Code 201.14(a) Responsibility of licensee
Previously cited 12/06/18, 11/08/18, 05/16/18, 03/09/17

28 Pa. Code 211.12(d)(1) Nursing services
Previously cited 12/06/18, 05/16/18, 03/09/17

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

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



 Plan of Correction - To be completed: 05/23/2019

Resident R71 resident is being provided wound care in aseptic manner and suffered no ill effects from the identified practice.
Resident R392 is being provided eye drops in a sanitary manner and suffered no ill effects from the identified practice.

Employee E7 will be re-inserviced on hand hygiene, facility approved bleach wipes, and aseptic wound care.
Employee E7 will also have medication pass competency conducted with focus on eye drop administration in a sanitary manner. Wound care competency with aseptic technique focus. Employee E7 will perform return demonstration of proper hand hygiene, aseptic wound technique, as well as competent medication pass with focus on administering eye drops in a sanitary manner.
Nurse Practice Educator/designee will in-service licensed nursing staff on hand hygiene, medication pass with focus on ensuring eye drops are administered utilizing sanitary technique, aseptic wound treatment and proper dwell time for facility approved bleach wipes.

Nurse Practice Educator/designee will complete an initial medication competency on facility licensed nurses to ensure that eye drops are administered in a sanitary manner.
Nurse Practice Educator/designee will complete an initial aseptic wound competency on facility licensed nurses to ensure that wound care is provided utilizing aseptic technique. Including adherence to the dwell time of the facility approved bleach wipes.
Nurse Practice Educator/designee will complete an initial hand hygiene competency on facility licensed nurses to ensure hands are cleansed as per policy.
Nurse Practice Educator/designee will complete six weekly medication competencies on facility licensed nurses to ensure that eye drops are administered in a sanitary manner.
Nurse Practice Educator/designee will complete six weekly aseptic wound competencies on facility licensed nurses to ensure that wound care is provided utilizing aseptic technique. Including adherence to the dwell time of the facility approved bleach wipes.
Nurse Practice Educator/designee will complete six weekly hand hygiene competencies on facility licensed nurses to ensure hands are cleansed as per policy.

The DON/designee will review the results of the audits at the Facility's Monthly Quality Improvement Meeting x 3 months.


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