Nursing Investigation Results -

Pennsylvania Department of Health
JUNIPER VILLAGE AT BROOKLINE-REHABILITATION AND SKILLED CARE
Patient Care Inspection Results

Note: If you need to change the font size, click the "View" menu at the top of the page, place the mouse over the "Text Size" menu item, and select the desired font size.

Severity Designations

Click here for definitions Click here for definitions Click here for definitions Click here for definitions
Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
JUNIPER VILLAGE AT BROOKLINE-REHABILITATION AND SKILLED CARE
Inspection Results For:

There are  46 surveys for this facility. Please select a date to view the survey results.

Surveys don't appear on this website until at least 41 days have elapsed since the exit date of the survey.
JUNIPER VILLAGE AT BROOKLINE-REHABILITATION AND SKILLED CARE - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on a Medicare Recertification Survey, State Licensure Survey, and Civil Rights Compliance Survey, completed on February13, 2019, it was determined that Juniper Village at Brookline-Rehabilitation and Skilled Care 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(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 observations, resident, staff, and family interviews, and review of select policy and procedures, it was determined that the facility failed to accommodate resident needs regarding call bells on two of two Nursing Units
(Second and Third Floor, Resident 45, 5, and 13).

Findings include:

Review of the facility's policy entitled "Call Light, Use Of," last reviewed without changes on January 8, 2019, indicated that staff is to answer all call lights within five minutes whether or not they are assigned to the resident. The call bell is to be conveniently positioned within reach of the resident.

An interview with Resident 45 on February 10, 2019, at 10:56 AM revealed that staff are unable to hear her hand bell (an alternate bell provided to her for safety reasons). She stated, "I shake that bell and shake it and they just don't come. If I have to go to the bathroom and my tube feeding is running I have to disconnect it myself, go to the bathroom and then reconnect it. Other times I have to walk out to the desk to get someone's attention."

During the same interview, Resident 45 rang the hand bell three times and no staff responded. She stated, "See I told you and I have told them too."

An interview with Resident 5's daughter on February 10, 2019, at 1:53 PM revealed that she visits every day and frequently her mother's call bell is not within her reach. She indicated that she has reported this to staff many times, but it continues to happen.

The surveyor conducted a group interview with four residents attending on February 11, 2019, at 10:30 AM. The residents stated that staff response to call bells is not always timely. The residents indicated they have had to wait 20 to 30 minutes for staff to meet their needs.

Observation of Resident 5 on February 11, 2019, at 9:30 AM revealed her call bell was not within her reach.

Observation of Resident 13 on February 10, 2019 at 11:24 AM revealed his call bell was wrapped around the head of his bed, not within his reach.

The above information was brought to the attention of the Nursing Home Administrator and Director of Nursing on February 11, 2019, at 2:30 PM.

483.10(e)(3) Reasonable Accommodations Needs/Preferences
Previously cited deficiency 1/19/18

28 Pa. Code 211.12(d)(5) Nursing services
Previously cited 3/14/18 and 1/19/18


 Plan of Correction - To be completed: 04/01/2019

Residents 45, 5, and 13 were not harmed based on this deficient practice. Upon learning that call bells were out of reach for residents, staff placed call bells within reach. Tap bell replaced with regular corded call bell for resident 45.
Associates will be educated on proper call bell placement when entering/exiting a room as it relates to "Call Light, Use of" policy and appropriate call response time.
A weekly audit will be conducted for 10% sample to ensure proper placement of call bell and response time. This weekly audit will be conducted for a period of 12 weeks.
Results of the audit will be forwarded to the quality assurance committee for recommendations and discussion. The director of nursing, or designee, will oversee this process.

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

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

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

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

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

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

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







Based on review of the facility's infection control data collection and staff interview, it was determined that the facility failed to maintain a system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents and staff.

Findings include:

Review of the facility's infection control plan revealed the facility failed to maintain an ongoing system of surveillance designed to identify possible communicable diseases or infections within the facility from October 1, 2018 through January 30, 2019.

Interview with the Director of Nursing and Employee 4, registered nurse, confirmed these findings on February 13, 2019, at 11:30 AM.

42 CFR 483.80(a)(1)(2)(4)(e)(f) Infection Prevention and Control

Previously cited 01/09/18

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

Previously cited 03/14/18 and 01/09/18


 Plan of Correction - To be completed: 04/01/2019

No residents were harmed based on this deficient practice. Infection control plan reviewed.Infection control plan reviewed with Infection Control Nurse and log line listing implemented immediately to be tracked beginning 2/1/2019.
Any resident that has documented s/s of infection has the potential to be affected by this deficient practice. In order to prevent this from occurring, log line listing will be used for tracking and trending infections. Infection Control Nurse educated on facility's infection control plan including but not limited to, log line listing, tracking/trending, and reporting.
A weekly audit will be conducted for all residents showing s/s of infection that meets the criteria of a reportable disease. This weekly audit will be conducted for a period of 12 weeks.
Results of the audit will be forwarded to the quality assurance committee for recommendations and discussion. The director of nursing, or designee, will oversee this process.

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

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

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

Based on observations and staff interview, it was determined that the facility failed to store and serve food in a manner to prevent the potential spread of food borne illness in the main kitchen.

Findings included:

Observation during the initial tour of the kitchen on February 10, 2019, at 9:46 AM revealed caked-on debris on the inside seal of the microwave door and dusty build-up on the back panel and tubing of the ice machine.

Additional observation during the initial tour of the kitchen revealed, Employee 6, dietary aide, labeling a tray of plated dishes of pudding covered in plastic wrap in the refrigerator with a prepared date of February 9, 2019. Concurrent interview with Employee 6, dietary aide, revealed the pudding was prepared last evening and the date came off. Also, in the refrigerator, was a container of sour cream labeled with a "best by" date of February 6, 2019.

Further observation during the initial tour of the kitchen revealed a tray of plated dishes of mandarin oranges in the walk-in cooler that did not have a prepared date and juice was spilled onto the tray. Concurrent interview with Employee 5, cook, revealed the paper indicating the date was dissolved from the fruit juice that spilled on the tray. Also, in the walk-in cooler was a bowl of shredded carrots labeled with a "use by" date of February 8, 2019.

The findings were discussed in an interview with the Nursing Home Administrator on February 11, 2019, at 2:21 PM.

42 CFR 483.60(i) (1)-(2) Food Procurement, Store/Prepare/Serve-Sanitary
Previously cited 01/19/18

28 Pa. Code 211.6 (c) Dietary services
Previously cited 01/09/18


 Plan of Correction - To be completed: 04/01/2019

No residents were harmed based on this deficient practice.
All residents have the potential to be affected by this deficient practice, and routine checks will ensure procurement, store/prepare/serve-sanitary guidelines are maintained.
Dining staff will receive education on to ensure products are regularly checked to maintain sanitary guidelines regarding microwave and ice machine debris, labeling, and 'best by' and 'use by' dates.
Cleaning of the microwave has been added to the daily routine checklist. To compliment this daily cleaning, a weekly cleaning routine which requires an aide or cook to remove all plastic seals/coverings prior to scrubbing the appliance thoroughly. Cleaning the inside of the ice machine is a component of the weekly cleaning tasks and includes both the outside and inside of the machine with a focus on the exposed paneling and tubing. Labeling education will include foods that should be dished in bowls rather than plated to better contain the juices that dissolved the label observed by the surveyor. Daily routine checks by cooks now include to check food labels and relevant 'use by' and 'best by' dates before departure for the day, to dispose of foods that have reached that date.
Daily and weekly checklists for aides and cooks will be signed by Dining Services Director at the end of each week to ensure all food labeling/inspection tasks have been properly completed. Checklists will be maintained in the kitchen.
Dining Services Director or designee will oversee this process.

483.25(d)(1)(2) REQUIREMENT Free of Accident Hazards/Supervision/Devices:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
483.25(d) Accidents.
The facility must ensure that -
483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and

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

Based on review of select facility policies and procedures, clinical record review, observation, and staff interview, it was determined that the facility failed to implement interventions to prevent the potential for resident accidents for two of seven residents reviewed for fall concerns (Residents 29 and 50) and one of one residents reviewed for suicidal ideation concerns (Resident 45), and for one of one residents reviewed for skin integrity related to accidents (Resident 66).

Findings include:

The facility policy entitled, "Fall Management," last reviewed without changes on January 8, 2019, revealed that residents will have a fall prevention plan. When a resident falls, the interdisciplinary team will review the fall within 24 to 72 hours and update the fall care plan. The interdisciplinary team will identify appropriate interventions to reduce the risk of falls. If falling recurs despite initial interventions, staff will implement additional or different interventions, or indicate why the current approach remains relevant. Staff will try various interventions based on the assessment of the nature or category of falling until falling is reduced or stopped; or until the reason for the continuation of the falling is identified as unavoidable.

Clinical record review for Resident 29 revealed nursing documentation dated January 10, 2019, at 2:57 PM indicating that Resident 29's roommate's husband alerted staff that Resident 29 was on the floor. Resident 29 dropped a piece of paper and was leaning to pick it up when the fall occurred. The documentation stipulated that staff sent a screen request to the skilled physical therapy department.

Nursing documentation dated January 11, 2019, at 9:06 AM (18 hours after the above documentation), reiterated that Resident 29 fell out of her wheelchair when attempting to pick up a dropped piece of paper. The documentation stipulated that staff sent a screen request to the skilled occupational therapy department.

Interview with the Nursing Home Administrator and Director of Nursing on February 13, 2019, at 1:40 PM revealed that the Therapy Screen/Referral Form initiated by staff on January 10, 2019, failed to stipulate if the request was for physical or occupational therapy. The signature on the form indicated that only occupational therapy performed a screening evaluation for Resident 29. The facility had no evidence that skilled physical therapy screened Resident 29 following this incident.

Nursing documentation dated February 2, 2019, at 4:25 AM revealed that staff again found Resident 29 on the floor. Resident 29 stated that she fell attempting to reach her call bell that fell to the floor.

Review of Resident 50's clinical record and incident investigations for the four months from October 12, 2018, through February 7, 2019, revealed that Resident 50 sustained at least 46 falls during the period.

Clinical record review of nursing documentation dated October 12, 2018, at 9:22 PM revealed that the licensed practical nurse reported Resident 50 was sitting on the floor in her room.

Review of the facility's investigation of Resident 50's fall on October 12, 2018, at 8:50 PM included an interdisciplinary review note dated October 25, 2018 (13 days later) that stipulated an interdisciplinary meeting held on October 23, 2018 (11 days after the fall) discussed Resident 50's multiple falls that month and potential new interventions. The investigation did not include evidence that the facility implemented any new interventions in response to this fall. Resident 50 sustained six additional falls after October 12, 2018, and before the October 23, 2018, multidisciplinary meeting.

Nursing documentation dated October 13, 2018, at 11:29 PM revealed that staff noted Resident 50 on the floor at the bottom of her bed. The documentation indicated that the facility would continue current safety measures.

Review of a fall investigation dated October 13, 2018, at 9:50 PM relating to the above documentation entered at 11:29 PM revealed no new post fall interventions.

Nursing documentation dated October 19, 2018, at 4:03 PM revealed that staff noted Resident 50 on the floor at the end of the Third Floor nursing unit west hallway. Resident 50's walker was tilted on its side; tangled in a chair at the end of the hallway. Staff assessed an "incision (laceration, skin wound)" to Resident 50's head measuring 2 cm (centimeters).

Review of the facility's investigation dated October 19, 2018, at 2:00 PM confirmed that the post fall intervention to prevent potential recurrence of falls was to "temporarily" remove the chair from the end of the hallway.

Nursing documentation created on October 22, 2018 (almost three days later), at 7:29 AM, for the October 19, 2018, incident confirmed that Resident 50's walker was sitting on top of a chair at the end of the Third Floor nursing unit west hallway. This nurse described Resident 50's injury as a skin tear to the left side of her head with a moderate amount of bleeding. The staff noted that the facility would remove the chair from the end of the Third Floor nursing unit west hallway.

Nursing documentation dated November 17, 2018, at 6:50 PM revealed that while evaluating Resident 50's fall in a resident room located near the end of the Third Floor nursing unit west hallway, staff noted Resident 50's walker at the end of the hall by the chair.

Observation of the Third Floor nursing unit west hallway on February 13, 2019, at 7:31 AM revealed a chair located at the end of the hallway.

Nursing documentation dated October 19, 2018, at 10:39 PM indicated that staff observed Resident 50 on the floor in the lounge located on the Third Floor nursing unit west hallway. The documentation indicated that the facility would continue current safety measures. The writer stipulated he/she obtained a statement and that staff stated that Resident 50 "sat herself on the floor."

Review of the facility's investigation dated October 19, 2018, at 9:50 PM revealed no statements obtained from staff who stated that Resident 50 sat herself on the floor; and that no witnesses were found. The report failed to identify any new interventions implemented in an effort to prevent future falls. The multidisciplinary review dated October 30, 2018 (11 days later) confirmed that Resident 50 had multiple falls from October 19 through 21, 2018 (Resident 50 fell twice on October 20, 2018, and once on October 21, 2018). The review indicated that an interdisciplinary meeting held October 23, 2018, determined the need for a "psych" (psychiatric or psychological) evaluation to provide any additional behavioral recommendations.

Interview with the Director of Nursing on February 13, 2019, at 12:28 PM confirmed that the psych evaluation did not occur until November 6, 2018 (18 days after the October 19, 2018, fall). Resident 50 sustained six additional falls after October 19, 2018, and before November 6, 2018.

Nursing documentation dated October 20, 2018, at 2:44 PM revealed that Resident 50 sustained a fall in the "alcove" (common area with a television by the nurses' station). Review of the facility's investigation dated October 20, 2018, at 2:29 PM revealed no new fall prevention interventions.

Nursing documentation dated October 20, 2018, at 3:52 PM revealed that Resident 50 sustained a fall again in the alcove area within an hour of the previous fall.

A facility investigation dated October 20, 2018, at 3:30 PM reiterated the information from the multidisciplinary review dated October 30, 2018 (10 days later) regarding the interdisciplinary meeting held on October 23, 2018.

Nursing documentation dated October 21, 2018, at 9:44 PM revealed that staff noted Resident 50 lying on the floor in her room. The documentation indicated that the facility would continue current safety measures.

Review of the facility's investigation dated October 21, 2018, at 9:15 PM revealed no new post fall prevention interventions.

Nursing documentation dated October 23, 2018, at 12:55 PM revealed that the leadership team reviewed Resident 50's recent fall history. The documentation indicated that the activities department was involved to keep Resident 50 engaged.

Review of Resident 50's activity attendance records dated October 2018 through January 2019 revealed the following:

October 2018, Resident 50 attended only nine activities during the month.
November 2018, Resident 50 attended only three activities during the month.
December 2018, Resident 50 attended only two activities during the month.
January 2019, Resident 50 attended only one activity during the month.

The activity records revealed no activity provided after 4:00 PM although 23 of Resident 50's 46 falls (50 percent) occurred between the hours of 4:00 PM and 10:00 PM.

Observation of Resident 50 on February 13, 2019, at 10:30 AM revealed she was in the alcove area.

Review of the activities calendar posted on the Third Floor nursing unit indicated a manicure activity scheduled on the Second Floor nursing unit at 10:30 AM.

Interview with Employee 3 (care plan coordinator) on February 13, 2019, at 10:30 AM revealed that staff would take residents from the Third Floor nursing unit to the Second Floor nursing unit for the manicure activity.

Observation of Resident 50 on February 13, 2019, at 10:37 AM with Employee 2 (registered nurse) and Employee 1 (licensed practical nurse), revealed Resident 50 was not transported to the Second Floor nursing unit for the manicure activity. During the interview with Employees 1 and 2, Resident 50 ambulated through the area behind the nurse's station, bumping into chairs with her walker.

Nursing documentation dated October 27, 2018, at 9:57 PM revealed that staff notified the writer that Resident 50 was on the floor in her room.

Review of the facility's investigation dated October 27, 2018, at 9:00 PM revealed no new post incident fall prevention interventions. The multidisciplinary notation dated November 2, 2018 (Resident 50 fell twice again before this documentation), referred to the interdisciplinary team meeting held "earlier in the month" when the team requested a psych evaluation and the family to schedule an eye doctor appointment.

Interview with the Director of Nursing on February 13, 2019, at 12:28 PM revealed that Resident 50 never went to an eye doctor appointment; that Resident 50's family cancelled the scheduled appointment. The interview confirmed that the facility failed to implement any interventions in lieu of this intervention to address the visual deficits potentially predisposing Resident 50 to falls.

Nursing documentation dated October 30, 2018, at 5:10 PM revealed that the licensed practical nurse observed Resident 50 stumble and fall back onto her "bottom" in the television room (alcove).

Review of the facility's investigation dated October 30, 2018, at 5:10 PM revealed no new post incident fall prevention interventions. The multidisciplinary notation dated November 6, 2018 (seven days later, Resident 50 fell once again before this date) reiterated that Resident 50's eye doctor and psych evaluation were still pending.

Nursing documentation dated November 1, 2018, at 1:21 PM revealed that staff determined Resident 50 was sitting in a recliner in the (Willow) Third Floor nursing unit west hall lounge. A nurse aide walking by the lounge noted Resident 50 was laying on her back in front of the recliner.

Review of the facility's investigation dated November 1, 2018, at 11:11 AM revealed no new post incident fall prevention interventions in response to this fall from the recliner in the lounge.

Nursing documentation dated November 7, 2018, at 11:25 AM revealed that staff found Resident 50 on the floor in the "core area" (area outside dining room nearing nurse's station).

Review of the facility's investigation dated November 7, 2018, at 11:00 AM noted the completion of a psych evaluation on November 6, 2018, resulted in medication adjustments to address increased hallucinations, which contributed to increased restlessness and falls.

Interview with the Director of Nursing on February 13, 2019, at 12:28 PM while reviewing the documentation of the November 6, 2018, psych evaluation, confirmed that the documentation indicated the only change in Resident 50's medication regime was to increase the antidepressant, Lexapro, from 7.5 milligrams (mg) every morning to 10 mg every morning. The practitioner noted Resident 50 described her mood as anxious and depressed, described seeing children (possible visible hallucinations), and had limited concentration, judgment, impulse control, and attention span.

Nursing documentation dated November 12, 2018, at 2:45 PM revealed that staff observed Resident 50 on the floor in another resident's room.

Review of the facility's investigation dated November 12, 2018, at 2:45 PM revealed a multidisciplinary team notation dated November 26, 2018 (14 days later) reiterating that medication adjustments resulted from a psych evaluation. The investigation did not indicate any new post incident fall prevention interventions.

Nursing documentation dated November 13, 2018, at 10:32 PM revealed that staff found Resident 50 laying supine in the dining room. The documentation indicated that the facility would continue current interventions. The documentation did not suggest the implementation of any new interventions.

Review of the facility's investigation dated November 13, 2018, at 7:44 PM reiterated that the facility would continue current interventions. The documentation did not suggest the implementation of any new interventions.

Nursing documentation dated November 14, 2018, at 1:01 PM revealed that staff found Resident 50 on the floor in her room.

Review of the facility's investigation dated November 14, 2018, at 9:20 AM revealed no new post incident fall prevention interventions.

Nursing documentation dated November 16, 2018, at 4:00 PM revealed that staff observed Resident 50 grimacing in what was believed to be pain in her right hip and leg. Resident 50 reached for the nurse from behind and began to fall. The nurse then lowered Resident 50 to the floor on top of her walker. Staff obtained stat (immediate) physician orders to obtain x-rays of Resident 50's right hip, knee, and ankle.

Review of the facility's investigation dated November 16, 2018, at 3:00 PM noted the new post incident intervention was testing to evaluate Resident 50's complaints of pain before her fall. Nursing documentation dated November 24, 2018, at 7:11 PM (eight days after the fall), indicated that the physician's assistant did not review the findings of the stat x-rays until November 19, 2018 (three days after the fall). Resident 50 sustained another fall during that time on November 17, 2018.

Nursing documentation dated November 17, 2018, at 6:50 PM revealed that another resident's caregiver summoned facility nursing staff. The registered nurse noted Resident 50 on the floor in this other resident's room. Resident 50's walker was at the end of Third Floor nursing unit west hall by the arm chair.

Review of the facility's investigation dated November 17, 2018, at 4:25 PM revealed no new post incident fall prevention interventions.

Nursing documentation dated November 27, 2018, at 3:07 AM revealed that staff reported to the nurse that Resident 50 was on the floor. Resident 50 verbalized that, "there were men and women, a lot of them, I see their souls and I was going with them." The documentation indicated that the facility would continue current safety measures.

Review of the facility's investigation dated November 27, 2018, at 2:00 AM revealed that the multidisciplinary team review of this fall did not occur until February 10, 2019 (on the first day of the annual survey, more than two months after this fall). The review did not indicate the initiation of any new fall prevention interventions in response to this fall.

Nursing documentation dated November 30, 2018, at 12:37 PM revealed that staff reported Resident 50 was on the floor in her room. The documentation indicated that staff placed Dycem (sticky material meant to reduce sliding from the surface) on Resident 50's red chair.

The incident investigation dated November 30, 2018, at 12:31 PM reiterated that the immediate corrective action following the fall was to place Dycem on the red chair. The investigation of the circumstances of the fall did not identify other seating surfaces in the resident's room that would pose a fall risk.

Nursing documentation dated December 1, 2018, at 6:38 PM revealed that the staff found Resident 50 sitting on the floor in front of a chair in her room. This documentation indicated that staff again applied Dycem on the chair to prevent slipping.

Review of the facility's investigation dated December 1, 2018, at 4:49 PM again reiterated that the immediate corrective action after the fall was to place Dycem on the chair (no color or description included). The multidisciplinary team notation dated February 10, 2019 (more than two months following the fall) clarified that the, "Dycem added to other chair beside bed to prevent resident from sliding out of chair." The facility failed to ensure a multidisciplinary review of Resident 50's falls timely; and failed to identify all potential seating surface risks in her room after the fall on November 30, 2018.

Nursing documentation dated November 2, 2018, at 4:34 PM revealed that staff observed Resident 50 on her buttocks in front of the red chair in her room. The documentation indicated that staff applied Dycem to a red chair in the resident's room. The documentation did not indicate that this entry was related to the falls on either November 30, 2018, or December 1, 2018.

Interview with the Director of Nursing on February 13, 2019, at 12:28 PM revealed that the facility had no evidence of an investigation relating to a fall for Resident 50 on November 2, 2018.

Observation of Resident 50's room on February 13, 2019, at 10:37 AM with Employee 1 and Employee 2, revealed no Dycem on a green (second) chair at Resident 50's bedside. Interview at the time of the observation confirmed that there was the potential that Resident 50 would sit in this green chair.

Nursing documentation dated December 3, 2018, at 1:53 AM revealed that the staff found Resident 50 on the floor in her room. Resident 50 presented with a reddened area to her lower right back. The documentation indicated that the facility would continue current interventions. Nursing documentation dated December 9, 2018, at 10:04 PM revealed that Resident 50's right buttock area now presented with deep red and purple bruising that measured 30 centimeters (cm) by 10 cm.

Review of the fall incident investigation dated December 3, 2018, at 12:30 AM revealed a multidisciplinary notation dated February 10, 2019 (on first day of the survey, more than two months later) that the team reviewed the incident and that the only intervention was staff brought Resident 50 to the alcove for closer supervision and redirection. The documentation did not quantify the closer supervision (e.g. 15-minute checks or line-of-sight at all times) nor the length of time staff maintained the heightened supervision.

Nursing documentation dated December 9, 2018, at 11:48 AM revealed staff found Resident 50 on the floor in the Third Floor nursing unit east hall library (corner room).

Review of the facility's investigation dated December 9, 2018, at 11:42 AM noted that, "Resident often sits on the very edge of chairs. Trying to encourage resident to sit back further on the chairs." Given Resident 50's known cognitive deficits, history of non-compliance, and inability to comprehend or retain simple instructions, the facility would have no reasonable expectation that this intervention would reduce Resident 50's fall risk. The multidisciplinary team notation dated February 10, 2019 (following the surveyor's request for all of Resident 50's fall investigations on the first day of the survey, more than two months later) indicated the only approach to reduce Resident 50's fall potential was redirection out of the lounge for closer supervision at the time of the incident. The facility had no evidence of changes to Resident 50's fall risk plan of care.

Nursing documentation dated December 13, 2018, at 2:33 PM revealed that staff again observed Resident 50 sitting on her buttocks, on the floor, in the corner room.

Review of the facility's investigation dated December 13, 2018, at 12:00 PM included the multidisciplinary team notation dated February 10, 2019 (almost two months later) that staff assessed and redirected Resident 50 out of the room.

Nursing documentation dated December 13, 2018, at 3:22 PM revealed that staff again observed Resident 50 sitting on her buttocks, on the floor, in the corner room.

Review of the facility's investigation dated December 13, 2018, at 4:15 PM stipulated that staff observed Resident 50 laying on the floor, on her back, in the corner room. The multidisciplinary notation dated February 10, 2019, (almost two months later) noted staff provided one-to-one redirection to the nurse's station for a snack. The notation did not indicate the length of time staff provided this heightened supervision.

The facility failed to implement appropriate interventions to prevent Resident 50's repeated falls in the corner room area.

Observation of the Third Floor nursing unit east hall corner room on February 13, 2019, at 10:24 AM revealed the door was open with nursing students documenting at tables in the room. There were no signs to alert staff and/or visitors to keep the doors shut (to limit Resident 50's wandering into this area).

Nursing documentation dated December 15, 2018, at 11:11 PM revealed that staff noted Resident 50 sitting on the floor on the left side of her bed. The documentation indicated that the facility would continue current safety measures.

Review of the facility's investigation dated December 15, 2018, at 10:30 PM included a multidisciplinary team notation dated February 10, 2019 (almost two months later) that current interventions were in place. The investigation had no evidence of any new fall prevention interventions.

Nursing documentation dated December 16, 2018, at 7:31 PM revealed that the nurse walked into the Grandview dining room and saw Resident 50 laying on the floor with her walker beside her.

Review of the facility's investigation dated December 16, 2018, at 7:27 PM included a multidisciplinary team notation dated February 10, 2019 (eight weeks later) that staff redirected Resident 50 out of the dining room, provided toileting care, and then redirected Resident 50 to the alcove area for closer supervision. The documentation did not quantify the closer supervision, nor the length of time staff maintained the heightened supervision. The investigation provided no evidence that the facility made permanent changes to Resident 50's fall prevention plan of care in response to this fall.

Nursing documentation dated December 17, 2018, at 6:00 PM revealed that staff found Resident 50 on the floor. Resident 50 presented with two lacerations: one to the left temple/eye measuring 2.0 cm by 0.25 cm, and one to the back of her left hand measuring 3.0 cm by 0.25 cm. Resident 50 also presented with bruising on her left temple/eye area measuring 7.0 cm by 3.0 cm and bruising to the back of her left hand measuring 6.0 cm by 5.0cm. Staff applied four steri-strips (thin adhesive bandages used to pull/keep wound edges together) to Resident 50's left hand and three steri-strips to her left eye. The facility transported Resident 50 to the hospital for evaluation of the lacerations.

Nursing documentation dated December 17, 2018, at 9:28 PM revealed that Resident 50 returned from the hospital with four stitches on the back of her left hand.

Review of the facility's investigation dated December 17, 2018, at 6:00 PM indicated that staff found Resident 50 laying on the floor in the Third Floor nursing unit west hall lounge. The investigation indicated that the facility revised the document on February 10, 2019, at 9:12 PM; however, did not stipulate what information the facility revised.

Nursing documentation dated December 18, 2018, at 9:59 PM revealed that staff saw Resident 50 laying on the floor in her room. The documentation indicated that the facility would continue current interventions.

Review of the facility's investigation dated December 18, 2018, at 8:54 PM revealed the multidisciplinary notation dated February 10, 2019 (almost eight weeks later) revealed that staff redirected Resident 50 back to bed to sleep. The documentation did not provide any evidence of any new fall prevention interventions.

Nursing documentation dated December 23, 2018, at 5:23 PM revealed that staff found Resident 50 sitting on the floor in the alcove area. The documentation indicated that the facility would continue current interventions.

Review of the facility's investigation dated December 23, 2018, at 5:04 PM revealed the multidisciplinary notation dated February 10, 2019 (seven weeks later) that reiterated that the facility would continue current interventions. The documentation did not provide any evidence that the facility revised Resident 50's fall prevention plan of care.

Nursing documentation dated December 30, 2018, at 7:00 PM revealed that a nurse aide alerted the nurse that Resident 50 was laying on the floor in the hallway. The staff assessed a "bump" on the back of Resident 50's head.

Nursing documentation dated December 30, 2018, at 7:00 PM noted that the staff received the report that Resident 50 was found on the floor at the end of the Third Floor nursing unit east hallway. Resident 50 stated that she hit her head on the wooden railing. The assessment noted a "bump" on the occipital (back) area. The documentation did not include an assessment of the size of the "bump." The documentation indicated that the facility would continue with current safety measures.

Review of the facility's investigation dated December 30, 2018, at 7:00 PM noted, "no injuries observed," although staff identified a "bump" on the occipital area. The investigation did not indicate any new plan of care changes.

Nursing documentation dated December 31, 2018, at 12:23 PM revealed that staff reported that Resident 50 was sitting on her buttocks, on the floor, in her room, in front of a red chair, at 12:10 PM.

Review of the facility's investigation dated December 31, 2018, at 12:18 PM revealed no indication of any new plan of care changes.

Nursing documentation dated January 2, 2019, at 3:43 PM revealed that the nurse walked into the dining room and found Resident 50 on the floor.

Review of the facility's investigation dated January 2, 2019, at 3:43 PM noted that the facility would, "Continue current interventions. Staff continue to provide safety cues for resident and redirection." The investigation did not indicate any new plan of care changes.

Nursing documentation dated January 4, 2019, at 6:30 PM revealed that staff found Resident 50 on the floor in another resident's room. The documentation noted that the facility would continue with current interventions.

Review of the facility's investigation dated January 4, 2019, at 6:25 PM revealed the same documentation entered into the clinical record by the nursing staff. The documentation provided no evidence of changes in Resident 50's fall prevention plan of care.

Nursing documentation created on January 11, 2019, at 7:48 PM for an incident with an effective date of January 4, 2019, at 10:43 PM (a week later, following nursing documentation dated January 7, 2019, at 6:33 PM, that indicated nursing staff noted two bruises on Resident 50's back left shoulder), revealed that staff notified the writer that Resident 50 was again on the floor in another resident's room (within four hours of the previous fall). Resident 50 left the room to "rest in the TV (television) area to the side of the nurse's station (alcove)." The documentation indicated that the facility would continue with current interventions.

Review of the facility's investigation dated January 4, 2019, at 10:22 PM revealed that staff assessed bruising to Resident 50's left shoulder and back: lateral side measured 4 cm by 3 cm and the left measured 6 cm by 2.5 cm.

Nursing documentation dated January 8, 2019, at 12:42 PM revealed that staff reported that Resident 50 was on the floor in her room.

Review of the facility's investigation dated January 8, 2019, at 12:29 PM revealed that the multidisciplinary team reviewed the incident on January 20, 2019 (12 days later, following four additional falls). The investigation determined that staff would continue to provide safety cues and redirection. The investigation provided no evidence of changes in Resident 50's fall prevention plan of care.

Nursing documentation dated January 10, 2019, at 5:38 PM revealed that staff observed Resident 50 lean to the left while sitting in the dining chair and fall to the side. Staff assessed and returned Resident 50 to the chair.

Review of the facility's investigation dated January 10, 2019, at 6:02 PM revealed that the facility would not allow Resident 50 to sit in a chair with wheels in the dining room for safety.

Interview with the Director of Nursing on February 13, 2019, at 12:28 PM revealed that the facility did not remove all chairs with wheels from the dining room. The facility did not implement measures from preventing Resident 50 from entering the dining room unattended and sitting in any of the wheeled chairs during hours between meals.

Nursing documentation dated January 13, 2019, at 1:43 PM revealed that Resident 50 walked into the registered nurse's office and fell backwards into the copy machine, hitting her head.

Review of the facility's investigation dated January 13, 2019, at 1:38 PM indicated that staff would continue to redirect Resident 50 and provide cues for safety, "interdisciplinary team to discuss."

Interview with the Director of Nursing on February 13, 2019, at 12:28 PM revealed the facility had no evidence of a discussion by the interdisciplinary team regarding Resident 50's fall on January 13, 2019.

Nursing documentation dated January 15, 2019, at 7:10 PM revealed that staff noted Resident 50 laying on the floor in the Grandview dining room, under a table.

Review of the facility's investigation dated January 15, 2019, at 7:10 PM noted, "Will continue current interventions." The investigation provided no evidence of changes in Resident 50's fall prevention plan of care.

Nursing documentation dated January 22, 2019, at 4:35 PM revealed that staff observed Resident 50 laying on the floor in the dining room.

Review of the facility's investigation dated January 22, 2019, at 4:35 PM revealed that the staff documented, "Closing of the dining room doors when meals are over will be discussed with IDT (interdisciplinary team)." Resident 50 sustained a subsequent fall on February 3, 2019, when staff found Resident 50 on the floor in the Grandview dining room.

Nursing documentation dated January 25, 2019, at 2:45 PM revealed that staff found Resident 50 sitting on the floor "in the library."

Nursing documentation dated January 25, 2019, at 3:39 PM reiterated that staff found Resident 50 sitting on the floor "in the library." The documentation indicated that staff will keep the library door closed to discourage wandering.

Review of the facility's investigation dated January 25, 2019, at 2:45 PM revealed a multidisciplinary team notation dated February 10, 2019 (more than two weeks later), that reiterated that staff would keep the lounge door closed to deter Resident 50 from wandering in the room.

Observation on February 10, 2019, at 10:46 AM revealed the Willow lounge doors open.

Observation on February 13, 2019, at 7:31 AM, 10:24 AM, and 10:37 AM, revealed the Willow lounge and corner room lounge doors open.

Nursing documentation dated January 25, 2019, at 7:15 PM revealed staff found Resident 50 laying on the floor in the television room.

Nursing documentation created on January 26, 2019, at 8:05 PM (more than 24 hours later), noted that the facility would continue current safety measures.

Review of the facility's investigation dated January 25, 2019, at 7:15 PM revealed a multidisciplinary team notation dated February 10, 2019 (more than two weeks later) indicating that staff redirected Resident 50 to bed at the time of the incident; however, there was no evidence of revising the interventions in Resident 50's fall prevention plan of care.

Nursing documentation dated February 3, 2019, at 11:37 AM revealed that Connections (entity outside the facility) staff reported at 10:15 AM that Resident 50 was on the floor in the Grandview dining room.

Review of the facility's investigation dated February 3, 2019, at 11:24 AM noted that there were no witnesses to the fall; but that staff heard someone calling for help in the Grandview dining room. The responder found Resident 50 on the floor. The investigation included no actions taken to determine if staff ensured that the dining room doors were shut as directed following Resident 50's fall on January 22, 2019. No staff statement attested to verifying the condition of the dining room doors between the breakfast and lunch meals. The investigation only noted, "Current interventions in place at time of incident." There was no evidence that the facility evaluated or revised the interventions in Resident 50's fall prevention plan of care.

Nursing documentation dated February 7, 2019, at 6:07 PM revealed that staff observed Resident 50 seated on a fall mat in another resident's room.

Review of the facility's investigation dated February 7, 2019, at 5:58 PM revealed that staff's immediate action was to assist Resident 50 to the nurse's station and offer a snack; however, Resident 50 declined and continued to wander. There was no evidence that the facility evaluated or revised the interventions in Resident 50's fall prevention plan of care.

Review of the dates and times of Resident 50's repeated falls in the month between January 10, 2019, and February 10, 2019, revealed that eight of nine occurrences (88.8 percent) of the incidents occurred in a less than six-hour window between 1:30 PM and 7:15 PM. The facility was unable to provide evidence of individualized interventions to address Resident 50's heightened fall risk during this window of time.

Interview with the Director of Nursing on February 13, 2019, at 12:28 PM reviewed the above findings regarding Resident 50's repeated falls. The interview revealed that the facility could provide no evidence of the ongoing implementation, or review, of individualized fall prevention interventions to increase Resident 50's individualized supervision (e.g. maintain within staff sight, silent or audible alarms, specific alarms activated by Resident 50's wanderguard device on the doors of lounges, dining rooms, and areas not readily visible to staff); to deter unassisted/unsupervised ambulation (e.g. chair prevents rising, scoop or perimeter mattresses); to decrease restlessness and continuous wandering (e.g. scheduled/supervised restorative walking program several times a day, medication adjustments, or ensure she is maintained in an activity while awake); or to increase resident safety or balance if allowed to independently ambulate (e.g. skilled therapy or restorative nursing). The interview confirmed that current physician's orders allowed Resident 50 to ambulate independently on the nursing unit using a wheeled walker despite her proven inability to do so safely.

Review of the facility's policy entitled "Suicide Threats," last reviewed without changes on January 8, 2019, revealed that all resident suicide threats must be taken seriously and immediately reported to the nurse supervisor/charge nurse. The nurse supervisor/charge nurse will immediately notify the resident's attending physician, Director of Nursing, and the power of attorney. A staff member will remain with the resident until the nurse supervisor/charge nurse arrives to assess the resident. The nurse supervisor/charge nurse will notify the resident's attending physician and report his/her findings and seek further medical instructions from the physician. Nursing service personnel will be informed of the suicide threat and to report changes in the resident's behavior immediately. Residents may be temporarily secluded if there is a potential of danger to him/herself or to others. An assessment of the resident's behavior will be made by the interdisciplinary care plan team within 24-48 hours of such incident to determine interventions that may be necessary to prevent the recurrence of such threats. Documentation of the incident will be recorded in the resident's medical record.

Clinical record review for Resident 45 revealed a social service note dated February 2, 2019, at 5:34 PM indicating that the social worker met with the resident's daughter-in-law at her request to discuss the resident staying permanently at the facility and her family starting to clear out the resident's apartment and pairing down on the resident's belongings. The social worker saw the resident's daughter-in-law later in the day and she mentioned that she had been talking with the resident about closing her apartment and the resident stated that she had been thinking about suicide all day. The social worker met with the resident along with the registered nurse supervisor. The resident stated that she did not remember saying that. She did say that she was depressed but not suicidal and denied having a plan. The resident was followed by a psychiatrist and psychologist. The social worker would ask them to follow up with her next week. The social worker will monitor and note changes in the progress notes.

The next documentation regarding Resident 45's suicidal ideation was on February 4, 2019, at 2:34 PM by the social worker indicating that she met with this resident to follow up on comments that she had made this past weekend. The resident again stated that she did not remember saying that, but she is depressed not suicidal and does not have a plan for suicide. The resident did state that she was having a difficult time adjusting to the changes in her lifestyle and the need for long term care. The social worker indicated that 15 minute checks were initiated, her call bell was removed and replaced with a tap bell, and her silverware was replaced with plastic silverware.

An interview with the Director of Nursing on February 13, at 9:30 AM confirmed the above regarding Resident 45. She indicated that the facility failed to follow their policy regarding suicidal ideation. There was no documented evidence that staff were monitoring this resident from Friday until Monday when the social worker indicated that 15 minute checks were initiated as well as her call bell replaced, and her silverware replaced with plastic utensils.

The facility failed to immediately implement interventions to ensure Resident 45's safety after she reported that she was depressed and having thoughts of suicide all day.

Resident 66's care plan that was initiated on May 25, 2018, revealed the resident was to be transferred using a gait belt, rolling walker, and assistance of two staff members.

Clinical record review of Resident 66's progress note dated October 27, 2018, by Employee 8, registered nurse, revealed the resident sustained three skin tears on the left elbow measuring 1.5 cm x 0.5 cm (centimeters), and 1 cm x 0.3 cm, and 1 cm x 0.5 cm during transfer from the wheelchair to the bed. The investigation revealed the resident became combative during the transfer and he was transferred from the wheelchair to the bed with assistance of one staff member.

The above information was confirmed with the Nursing Home Administrator on February 13, 2019, at 12:30 PM.

483.25(d) Accidents
Previously cited deficiency 1/19/18

28 Pa. Code 211.11(d) Resident care plan
Previously cited 1/19/18

28 Pa. Code 211.12(d)(1)(5) Nursing services
Previously cited 3/14/18 and 1/19/18

28 Pa. Code 211.12(d)(3) Nursing services
Previously cited 1/19/18




 Plan of Correction - To be completed: 04/01/2019

Care plans reviewed for residents 29, 50, 45, and 66 are and being updated as appropriate for each individual. Facility "Suicide threats" policy was reviewed on 2/4/2019 with associates.
Any resident that has an injury/accident has the potential to be affected by this deficient practice. In order to prevent this from occurring, incident/accident reports will be reviewed by IDT team within 72 hours for appropriate interventions, plan of care to be reviewed, and monitored by nursing staff to ensure interventions are in place. Nursing staff will be educated on "Fall Management" policy.
A weekly audit will be conducted for all incident/accident reports to ensure they are reviewed within 72 hours. This weekly audit will be conducted for a period of 12 weeks.
Results of the audit will be forwarded to the quality assurance committee for recommendations and discussion. The director of nursing, or designee, will oversee this process.

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

Based on observation, clinical record review, select facility policy review, and staff interview, it was determined that the facility failed to develop a comprehensive individualized care plan for one of 18 residents reviewed (Resident 40).

Findings include:

Review of Resident 40's skin and wound evaluation record revealed the resident was admitted with a pressure ulcer and it was currently a healing Stage IV (full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer) measuring 10.7 cm x 4 cm x 3.6 cm (centimeters) with light exudate (drainage).

Resident 40's physician orders dated February 4, 2019, revealed the resident is to be in bed, positioned side to side, except for therapy and meals. Resident 40's physician orders from the wound care center dated December 12, 2018, revealed the resident was to be repositioned side to side every two hours.

Resident 40's MDS (Minimum Data Set, an assessment tool completed at specific intervals to determine resident care needs) dated January 4, and February 7, 2019, revealed Resident 40 required extensive assistance of two staff for bed mobility.

Observation of Resident 40 on February 10, 2019, from 11:16 AM to 12:12 PM revealed the resident was lying on his back in bed with his heels touching the surface of the bed.

Observation of Resident 40 on February 11, 2019, from 9:54 AM to 11:31 AM, revealed the resident was lying on his back in bed with his heels touching the surface of the bed and no staff entering the room to offer to reposition him. At 11:31 AM, the surveyor stood outside Resident 40's room and summoned staff to report that the resident was reaching for something and there was a concern he may fall. Staff entered his room to meet his needs. He was repositioned on his right side during his sacral wound dressing change.

Review of Resident 40's pressure ulcer care plan did not include the above measures for repositioning off the sacral ulcer.

An interview with the Director of Nursing on January 13, 2019, at 9:05 AM confirmed that the above.

28 Pa. Code 211.12(d)(5) Nursing services
Previously cited 03/14/18 and 01/09/18


 Plan of Correction - To be completed: 04/01/2019

Resident 40's care plan for pressure ulcer was reviewed with IDT team, including medical director. Orders reviewed and care plan updated to reflect current interventions are appropriate at this time.
All residents with pressure areas are at risk for this deficient practice. In order to prevent this from occurring, nursing staff will be educated on updating care plans with new orders.
A weekly audit will be conducted for all residents with skin integrity issues, to ensure proper care plans are in place. This weekly audit will be conducted for a period of 12 weeks.
Results of the audit will be forwarded to the quality assurance committee for recommendations and discussion.
The director of nursing, or designee, will oversee this process.

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 observation, clinical record review, and staff and resident interview, it was determined that the facility failed to ensure a medication error rate less than five percent (Residents 78 and 75).

Findings include:

The facility's medication error rate was 8.88 percent based on 34 medication opportunities with two medication errors.

Observation of a medication administration pass on February 13, 2019, at 7:48 AM revealed Employee 1 (licensed practical nurse), administered one drop of Trusopt Plus (two percent, contains only dorzolamide, medication used to reduce abnormally high pressure/fluid in the eye) solution in each of Resident 78's eyes.

Clinical record review for Resident 78 revealed the current physician's order instructed staff to administer one drop of Dorzolamide HCl-Timolol Mal Solution (common brand name Cosopt, contains two drugs used to treat high pressure inside the eye by decreasing the amount of fluid within the eye) in each of Resident 78's eyes every morning and at bedtime.

Interview with Employee 1 on February 13, 2019, at 10:18 AM, verified that she administered Trusopt, not Cosopt, to Resident 78.

Interview with Employee 1 and Employee 2 (registered nurse) on February 13, 2019, at 10:41 AM, revealed that the physician discontinued Resident 78's Trusopt, and started the Cosopt, on February 10, 2019; however, staff did not remove the eye drop from the medication cart. Employee 1 incorrectly obtained the Trusopt medication that remained in the medication cart.

Continued observation of the medication administration pass on February 13, 2019, at 8:14 AM revealed Employee 1 prepared medications for Resident 75. Employee 1 arranged Resident 75's medication in two medication cups; one cup with chewable medications and one cup for medications meant to be swallowed whole. Employee 1 placed Resident 75's Centrum Silver Ultra (vitamin supplement) 300-600 micrograms in the cup of medications meant to be swallowed whole. The labeling on the packaging noted, "Chew Med Before Swallowing."

After Employee 1 secured the medication cart and approached Resident 75's room door for medication administration on February 13, 2019, at 8:25 AM, the surveyor questioned the decision to not include the Centrum Silver Ultra with the chewable medications. Employee 1 stated that Resident 75 indicated that he could not chew the tablet.

Interview with Resident 75 as he received his medications on February 13, 2019, at 8:28 AM revealed that he could not recall any issues with chewing the Centrum Silver Ultra.

Interview with Employee 1 on February 13, 2019, at 8:29 AM revealed that there was no evidence that nursing staff attempted to get clarification (either from the contracted pharmacy provider or a physician) regarding the form (chewable) of Centrum Silver Ultra provided for Resident 75. Nursing staff administered the medication whole despite the labeling that indicated that the resident should chew the tablet before swallowing.

28 Pa. Code 211.12(d)(1) Nursing services
Previously cited 3/14/18 and 1/19/18

28 Pa. Code 211.12(d)(3) Nursing services
Previously cited 1/19/18


 Plan of Correction - To be completed: 04/01/2019

Residents 75 & 78 were not harmed based on this deficient practice.
Employee 1 (Licensed Practical Nurse) education provided on 6 Medication Rights and the importance of following the labeling on medication packages.
Licensed staff will be educated on medication administration to avoid further medication errors.
Random medication administration audits will be conducted with licensed practical nurse staff to ensure medication error rate not to exceed 5%. Five audits will be conducted weekly x 4 weekly; then 3 audits will be conducted weekly x 4 weekly; then 5 audits a month x2 months. Results of these audits will be taken to QAPI committee for discussion and recommendation.
The Staff Development Coordinator or designee will be responsible for audits.

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

Based on clinical record review and staff and resident interview it was determined that the facility failed to ensure procedures for management of an emergency for residents requiring dialysis services for two of three residents reviewed (Residents 13 and 41).

Findings include:

The facility did not provide a policy for emergency management procedures for a resident receiving dialysis.

Clinical record review revealed the facility admitted Resident 13 on November 28, 2018. Review of Resident 13's physician orders revealed diagnoses including End Stage Renal Disease (the last stage of long-term kidney disease when your kidneys can no longer support your body's needs).

Further review of Resident 13's physician orders revealed an order for hemodialysis (process of removing waste products and excess water from the body) with an outside provider on Tuesday, Thursday, and Saturdays each week.

Review of Resident 13's plan of care revealed he had a fistula (surgically created connection between the artery and vein, placed in an arm or a leg) and nursing staff were to check for thrill (the vibration felt over the chest wall by using one's hand) and bruit (an abnormal swishing sound heard with a stethoscope over a blood vessel), every shift. The plan of care did not address any procedures for emergencies, including bleeding from Resident 13's fistula.

Review of Resident 41's care plan revealed he receives dialysis treatment three times weekly.

Interview with Resident 41 on February 10, 2019, at 11:22 AM revealed he receives dialysis through a fistula in his right arm and staff check his fistula routinely and there is no medical emergency equipment in his room.

Interview with the Director of Nursing on February 13, 2019, at 12:59 PM confirmed these findings. There was no evidence that staff were educated on emergency procedures for Resident 13's fistula.

28 Pa. Code 211.5(f) Clinical records
Previously cited 1/9/18

28 Pa. Code 211.5(g)(h) Clinical records

28 Pa. Code 211.10(d) Resident care policies
Previously cited 3/14/18 and 1/9/18

28 Pa. Code 211.12(d)(1)(5) Nursing services
Previously cited 3/14/18 and 1/9/18

28 Pa. Code 211.12(d)(3) Nursing services
Previously cited 1/9/18


 Plan of Correction - To be completed: 04/01/2019

Residents 13 and 41 dialysis plan of care reviewed with IDT team. Neither resident had any harm from this deficient practice. Policy to be created to include emergency management procedures for residents receiving dialysis.
Any resident that is receiving dialysis has the potential to be affected by this deficient practice. In order to prevent this from occurring, a policy will be created to define emergency procedures r/t dialysis. Care plans will be updated as appropriate for each individual. Nursing staff will be educated on emergency policy for dialysis.
A weekly audit will be conducted for all residents receiving dialysis to ensure proper plan of care. This weekly audit will be conducted for a period of 12 weeks.
Results of the audit will be forwarded to the quality assurance committee for recommendations and discussion. The director of nursing, or designee, will oversee this process.

483.25(c)(1)-(3) REQUIREMENT Increase/Prevent Decrease in ROM/Mobility:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.25(c) Mobility.
483.25(c)(1) The facility must ensure that a resident who enters the facility without limited range of motion does not experience reduction in range of motion unless the resident's clinical condition demonstrates that a reduction in range of motion is unavoidable; and

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

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

Based on clinical record review, and resident and staff interview, it was determined that the facility failed to implement services to prevent a decline in mobility for one of four residents reviewed (Resident 53).

Findings include:

Interview with Resident 53 on February 11, 2019, at 9:42 AM revealed that his core strength is weaker because he does not receive assistance with walking because the staff do not have time to walk with him.

Clinical record review for Resident 53 revealed a care plan that indicated the resident is to be provided a restorative nursing program for ambulation up to 120-175 feet as tolerated three to five times weekly.

With the ambulation program being ordered three to five times weekly, the resident had the opportunity to receive the program 12 to 20 times monthly. Documentation for the ambulation nursing program indicated that Resident 53 received the ambulation program as follows:

November 2018, provided zero times
December 2018, provided six times
January 2019, provided three times
February 1 to 11, 2019, provided one time

These findings were reviewed during an interview Nursing Home Administrator on February 13, 2019, at 10:00 AM.

483.25(c)(1)(2)(3) Increase/Prevent Decrease in ROM/Mobility
Previously cited 01/09/18

28 Pa. Code 211.12(d)(1)(5) Nursing services
Previously cited 03/14/18 and 01/09/18


 Plan of Correction - To be completed: 04/01/2019

Resident 53's plan of care/restorative nursing orders reviewed with IDT team. Resident did not have any additional harm based on this deficient practice. Review of clinical record shows that resident is ambulating with restorative nursing program per order.
Any resident with decreased mobility is at risk based on this deficient practice. In order to prevent this from occurring, nursing staff and restorative nurses will be educated on Restorative Program Policies including but not limited to "Ambulation/Locomotion/Falls".
A weekly audit will be conducted for all residents on a restorative nursing program, to ensure programs are completed per order. This weekly audit will be conducted for a period of 12 weeks.
Results of the audit will be forwarded to the quality assurance committee for recommendations and discussion. The director of nursing, or designee, will oversee this process.

483.25(b)(1)(i)(ii) REQUIREMENT Treatment/Svcs to Prevent/Heal Pressure Ulcer:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.25(b) Skin Integrity
483.25(b)(1) Pressure ulcers.
Based on the comprehensive assessment of a resident, the facility must ensure that-
(i) A resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable; and
(ii) A resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing.
Observations:

Based on observation and staff interview, it was determined that the facility failed to implement interventions to promote wound healing and prevent infection for one of 18 residents reviewed (Resident 40).

Findings include:

The facility policy entitled, "Wound Care" last reviewed on January 8, 2019, revealed during a dressing change, the nurse is to wash their hands and dry them thoroughly, apply gloves, and remove the dressing. Then the nurse is to wash and dry the hands thoroughly prior to applying new gloves to redress the wound. The policy does not refer to using a washcloth for cleansing an open wound during wound care.

The facility policies entitled, "Isolation Precautions and Infection Control Program Overview" last reviewed on January 8, 2019, revealed contact precautions (measures intended to prevent transmission of infectious agencies, which are spread by direct or indirect contact with the resident or resident's environment) are recommended in settings with evidence of ongoing transmission, acute care settings with increased risk for transmission, or wounds that cannot be contained by dressings.

Clinical record review for Resident 40 revealed he was admitted to the nursing facility on November 5, 2018, with an unstageable (full thickness tissue loss in which the base of the ulcer is covered by slough and or eschar in the wound bed) pressure area of the sacrum (bottom of the spine) measuring 8 cm x 7.5 cm (centimeters). The skin and wound evaluation record revealed measurements taken on February 4, 2019, indicated the pressure ulcer is a healing Stage IV (full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage, or bone in the ulcer) measuring 10.7 cm x 4 cm x 3.6 cm with light exudate (drainage).

Clinical record review of Resident 40's physician orders dated February 4, 2019, revealed the resident is to be in bed, positioned side to side, except for therapy and meals. Resident 40's physician orders from the wound care center dated December 12, 2018, revealed the resident is to be repositioned side to side every two hours.

Nursing documentation dated January 22, 2019, revealed that the resident had been taking Doxycycline (antibiotic) 100 milligrams (mg) orally, twice daily since November 16, 2018, for a sacral wound infection of MRSA (Methicillin Resistant Staphylococcus Aureus, bacteria that causes difficult to treat infections due to its resistance to many antibiotics). The wound was in the healing stages and drainage was contained in the Wound VAC. Employee 4 indicated that she checked the CDC (Center for Disease Control) recommendations for contact precautions and discussed them with the provider. A verbal physician's order was received to discontinue contact precautions due to two months of antibiotic precautions and drainage containment.

Physician order's dated February 4, 2019, revealed Resident 40 was reordered Doxycycline, 100 mg orally, every morning and bedtime for one month, continued through March 4, 2019, for MRSA of the sacral wound.

Clinical record review of Resident 40's MDS (Minimum Data Set, an assessment tool completed at specific intervals to determine resident care needs) dated January 4, and February 7, 2019, revealed Resident 40 required extensive assistance of two staff for bed mobility.

Observation of Resident 40 on February 10, 2019, from 11:16 AM to 12:12 PM revealed the resident was lying on his back in bed with his heels touching the surface of the bed and a Wound VAC (a device using negative pressure vacuum-assisted therapy to help wounds heal; the device decreases air pressure on the wound, which may help the wound heal more quickly) attached to his body with drainage in the tubing.

Observation of Resident 40 on February 11, 2019, from 9:54 AM to 11:31 AM, revealed the resident was lying on his back in bed with his heels touching the surface of the bed and no staff entering the room to offer to reposition him. The Wound VAC was draining fluids. At 11:31 AM, the surveyor stood outside Resident 40's room and summoned staff to report the resident was reaching for something and there was a concern he may fall. Staff entered his room to meet his needs.

Observation of Resident 40's sacral dressing change by Employee 4, registered nurse, on February 11, 2019, from 11:37 AM to 12:10 PM revealed the following breaks in the infection control process. Employee 4, registered nurse, removed the dressing and used a washcloth to cleanse the resident's draining sacral wound infected with MRSA. After removing her soiled gloves, the registered nurse did not cleanse her hands prior to applying clean gloves. Employee 4 laid her forearms on Resident 40's bed during the dressing change.

Concurrent interview with Employee 4 revealed that the resident did not require contact precautions due to being on long term antibiotics, therefore, the washcloth would go in general laundry, and she should have washed her hands after removing the dirty gloves.

Observation of Resident 40 on February 11, 2019, at 12:15 PM revealed he was transferred to a wheelchair and taken to the dining room. Concurrently, the surveyor mentioned to Employee 4 that the resident has been observed lying on his back with his heels touching the surface of the mattress since the surveyor's arrival to the resident's hallway at 9:54 AM.

The above findings of the resident not being repositioned off his sacral area and the breaks in the infection control process were confirmed with the Director of Nursing on February 13, 2109, at 9:05 AM.

28 Pa. Code 211.12(d)(1)(5) Nursing services
Previously cited 03/14/18 and 01/09/18


 Plan of Correction - To be completed: 04/01/2019

Resident 40's orders reviewed with IDT team, including medical director. Resident did not have any harm based on this deficient practice. Orders reviewed and updated to reflect current plan of care are appropriate at this time.
All residents with pressure areas and communicable infections are at risk for this deficient practice. In order to prevent this from occurring, nursing staff will be educated on the "Wound Care" and "Isolation precautions and Infection Control Program Overview" policies.
A weekly audit will be conducted for all residents with wounds and/or communicable infections to ensure proper wound care procedures are being followed. This weekly audit will be conducted for a period of 12 weeks.
Results of the audit will be forwarded to the quality assurance committee for recommendations and discussion. The director of nursing, or designee, will oversee this process.

483.24(a)(2) REQUIREMENT ADL Care Provided for Dependent Residents:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.24(a)(2) A resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene;
Observations:

Based on observation, clinical record review, and resident and staff interview, it was determined that the facility failed to provide bathing assistance for a resident dependent on staff assistance for one of one residents reviewed for bathing issues (Resident 43).

Findings include:

Clinical record review revealed the facility admitted Resident 43 on October 10, 2018. Review of Resident 43's admission Minimum Data Set (MDS, an assessment tool completed at specific intervals to determine care needs) dated October 17, 2018, revealed she requires physical help in part of her bath, with one-person physical assistance.

Interview and observation of Resident 43 on February 11, 2019, at 9:51 AM revealed Resident 43's hair appeared greasy. Resident 43 stated that she ran out of shampoo and the staff have been using a 3 in 1 (shampoo/conditioner/body wash) in her hair and she doesn't like it and she refuses a shower at times.

Review of Resident 43's clinical record revealed task documentation (ADL, activities of daily living charting) dated January 2019, noting she only received three bath/showers and refused on six occasions.

Review of Resident 43's plan of care revealed documentation that she was resistant toward showers when she first moved in to the facility. Nursing staff were instructed to provide reassurance during the bathing process and offer different shower dates/times with refusals.

There was no documentation that nursing staff offered Resident 43 alternate shower dates/times or attempted any interventions to ensure Resident 43 received a bath/shower. Interview with the Director of Nursing on February 13, 2109, at 1:05 PM confirmed these findings.

28 Pa. Code 211.12 (d)(1)(5) Nursing services
Previously cited 3/14/18

28 Pa. Code 211.12 (d)(2)(3) Nursing services
Previously cited 3/14/18 and 1/9/18


 Plan of Correction - To be completed: 04/01/2019

Resident 43's shower schedule reviewed with IDT team. Documentation noted that resident refused shower but no further documentation noted that resident received bed bath or other means of bathing at other times to ensure resident received a shower. Resident discharged from facility 2/13/2019.
All residents are at risk for this deficient practice who require assistance with showering and completing bathing tasks. Nursing staff will be educated on completing showers per facility protocol/policy. Tasks have been updated for all residents to include PRN shower documentation as well as offering bed baths.
A weekly audit will be conducted for all residents to ensure showers are completed. This weekly audit will be conducted for a period of 12 weeks.
Results of the audit will be forwarded to the quality assurance committee for recommendations and discussion. The director of nursing, or designee, will oversee this process.

483.24(a)(1)(b)(1)-(5)(i)-(iii) REQUIREMENT Activities Daily Living (ADLs)/Mntn Abilities:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.24(a) Based on the comprehensive assessment of a resident and consistent with the resident's needs and choices, the facility must provide the necessary care and services to ensure that a resident's abilities in activities of daily living do not diminish unless circumstances of the individual's clinical condition demonstrate that such diminution was unavoidable. This includes the facility ensuring that:

483.24(a)(1) A resident is given the appropriate treatment and services to maintain or improve his or her ability to carry out the activities of daily living, including those specified in paragraph (b) of this section ...

483.24(b) Activities of daily living.
The facility must provide care and services in accordance with paragraph (a) for the following activities of daily living:

483.24(b)(1) Hygiene -bathing, dressing, grooming, and oral care,

483.24(b)(2) Mobility-transfer and ambulation, including walking,

483.24(b)(3) Elimination-toileting,

483.24(b)(4) Dining-eating, including meals and snacks,

483.24(b)(5) Communication, including
(i) Speech,
(ii) Language,
(iii) Other functional communication systems.
Observations:

Based on clinical record review and staff interview, it was determined that the facility failed to provide care and services to maintain the ability to transfer for one of five residents reviewed for a decline in activities of daily living (Resident 50).

Findings include:

Clinical record review for Resident 50 revealed an annual MDS (Minimum Data Set, an assessment tool completed at specific intervals to determine resident care needs) dated August 8, 2018, and a quarterly MDS assessment dated October 24, 2018, that indicated Resident 50 required only supervision (no physical help from staff) for transfers.

A quarterly MDS assessment dated January 17, 2019, assessed a decline in Resident 50's condition to now requiring the extensive physical assistance of two staff for transferring.

A physician's order dated January 24, 2019, indicated an evaluation for physical therapy services only.

Resident 50's clinical record contained no evidence of ongoing skilled physical therapy or restorative nursing programs to address her decline in safe transfers.

Interview with the Director of Nursing on February 13, 2019, at 12:40 PM revealed that the facility did not develop a treatment plan (skilled therapy or restorative nursing treatment) in an effort to restore Resident 50's ability to transfer without staff assistance.

28 Pa. Code 211.12(d)(1)(5) Nursing services
Previously cited 3/14/18 and 1/19/18

28 Pa. Code 211.12(d)(3) Nursing services
Previously cited 1/19/18


 Plan of Correction - To be completed: 04/01/2019

Resident 50's MDS showed decline showed physical decline in ADL status from prior MDS assessment to current MDS assessment. Resident was not harmed based on this deficient practice. PT eval was completed and did not indicate need for therapy services. Will have PT eval for a appropriateness of restorative program.
Residents that show change in assistance required for completing ADLs from prior MDS assessment to current MDS assessment have the potential to be affected by this deficient practice. In order to prevent this from occurring, declines noted in ADL status on MDS assessments will be forwarded to therapy for further evaluation and recommendation.
A weekly audit will be conducted for all MDSs that trigger for decline in ADLs. This weekly audit will be conducted for a period of 12 weeks.
Results of the audit will be forwarded to the quality assurance committee for recommendations and discussion. The director of nursing, or designee, will oversee this process.

483.20(f)(1)-(4) REQUIREMENT Encoding/Transmitting Resident Assessments:Least serious deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency has the potential for causing no more than a minor negative impact on the resident.
483.20(f) Automated data processing requirement-
483.20(f)(1) Encoding data. Within 7 days after a facility completes a resident's assessment, a facility must encode the following information for each resident in the facility:
(i) Admission assessment.
(ii) Annual assessment updates.
(iii) Significant change in status assessments.
(iv) Quarterly review assessments.
(v) A subset of items upon a resident's transfer, reentry, discharge, and death.
(vi) Background (face-sheet) information, if there is no admission assessment.

483.20(f)(2) Transmitting data. Within 7 days after a facility completes a resident's assessment, a facility must be capable of transmitting to the CMS System information for each resident contained in the MDS in a format that conforms to standard record layouts and data dictionaries, and that passes standardized edits defined by CMS and the State.

483.20(f)(3) Transmittal requirements. Within 14 days after a facility completes a resident's assessment, a facility must electronically transmit encoded, accurate, and complete MDS data to the CMS System, including the following:
(i)Admission assessment.
(ii) Annual assessment.
(iii) Significant change in status assessment.
(iv) Significant correction of prior full assessment.
(v) Significant correction of prior quarterly assessment.
(vi) Quarterly review.
(vii) A subset of items upon a resident's transfer, reentry, discharge, and death.
(viii) Background (face-sheet) information, for an initial transmission of MDS data on resident that does not have an admission assessment.

483.20(f)(4) Data format. The facility must transmit data in the format specified by CMS or, for a State which has an alternate RAI approved by CMS, in the format specified by the State and approved by CMS.
Observations:

Based on clinical record review and staff interview, it was determined that the facility failed to ensure completion of a Minimum Data Set Assessment (MDS) for the one resident reviewed (Resident 2).

Findings include:

Clinical record review for Resident 2 revealed that the facility discharged him on September 1, 2018.

An interview with Employee 3 (care plan coordinator) on February 13, 2019, at 11:35 AM revealed that a discharge
Minimum Data Assessment (MDS, an assessment tool completed at specific intervals to determine resident care needs) was not completed for Resident 2.

The facility failed to ensure that staff completed the discharge MDS according to the Resident Assessment Instrument User's Manual (reference used to complete an MDS).

28 Pa. Code 211.5(f) Clinical record





 Plan of Correction - To be completed: 04/01/2019

I hereby acknowledge the CMS 2567-A, issued to JUNIPER VILLAGE AT BROOKLINE-REHABILITATION AND SKILLED CARE for the survey ending 02/13/2019, AND attest that all deficiencies listed on the form will be corrected in a timely manner.
201.14(a) LICENSURE Responsibility of licensee.:State only Deficiency.
(a) The licensee is responsible for meeting the minimum standards for the operation of a facility as set forth by the Department and by other State and local agencies responsible for the health and welfare of residents.
Observations:

Based on review of select facility policies and staff interviews, it was determined that the facility was not in compliance with the requirements of the Act 52 Infection Control Plan.

Findings include:

The Act 52 Infection Control Plan, states that a health care facility shall develop and implement an internal infection control plan that shall be established for the purpose of improving the health and safety of residents and health care workers and shall include a multidisciplinary committee including a representative from each of the following, if applicable to the specific health care facility:

(i) Medical staff that could include the chief medical officer or the nursing home medical director
(ii) Administration representatives that could include the chief executive officer, the chief financial officer, or the nursing home administrator
(iii) Laboratory personnel
(iv) Nursing staff that could include a director of nursing or a nursing supervisor
(v) Pharmacy staff that could include the chief of pharmacy
(vi) Physical plant personnel
(vii) A patient safety officer
(viii) Members from the infection control team, which could include an epidemiologist.
(ix) The community, except that these representatives may not be an agent, employee or contractor of the health care facility

Interview on February 13, 2019, at 11:30 AM with the Director of Nursing and Employee 4 (registered nurse) revealed that she is responsible for infection control. Employee 4 confirmed that the following disciplines were absent from the quarterly Infection Control meetings on July 26, and October 30, 2018: physical plant personnel and patient safety officer. The pharmacist was absent from the October 30, 2018, quarterly Infection Control meeting.

Interview with the Nursing Home Administrator on February 13, 2019, at 11:45 AM confirmed that the facility was not in compliance with the requirements of Act 52 infection control plan.


 Plan of Correction - To be completed: 04/01/2019

No residents were harmed based on this deficient practice.
No residents have the potential to be affected by this deficient practice. In order to prevent this from occurring, Infection Control Nurse educated on requirements of Act 52 including but not limited to quarterly multidisciplinary committee meetings with all required members present.
A quarterly audit will be conducted for all Infection Control Meetings. This audit will be conducted for a period of 2 quarters (April and July) to ensure all required members are present.
Results of the audit will be forwarded to the quality assurance committee for recommendations and discussion. The director of nursing, or designee, will oversee this process.

201.19 LICENSURE Personnel policies and procedures.:State only Deficiency.
Personnel records shall be kept current and available for each employe and contain sufficient information to support placement in the position to which assigned.
Observations:

Based on employee personnel file review and staff interview, it was determined that the facility failed to ensure personnel records included verification of employees' health status for five of five employees reviewed (Employees 9, 10, 11, 12, and 13).

Findings include:

Review of Employee 9's (registered nurse) personnel file revealed that the facility hired him on January 14, 2019. The facility never obtained verification of Employee 9's health status.

Review of Employee 10's (registered nurse) personnel file revealed that the facility hired her on January 2, 2019. The facility never obtained verification of Employee 9's health status.

Review of Employee 11's (dining) personnel file revealed that the facility hired her on November 29, 2018. The facility never obtained verification of Employee 11's health status.

Review of Employee 12's (nurse aide) personnel file revealed that the facility hired her on November 19, 2018. The facility never obtained verification of Employee 12's health status.

Review of Employee 13's (licensed practical nurse) personnel file revealed that the facility hired her on November 19, 2018. The facility never obtained verification of Employee 11's health status.

Interview with the Nursing Home Administrator, and Employee 7 (human resources) on February 13, 2019, at 1:00 PM confirmed these findings.


 Plan of Correction - To be completed: 04/01/2019

Employee 9, 10, 11, 12, 13 were not harmed based on this deficient practice.
Employee 9, 10, 11, 12, 13 were contacted by Human Resources Director to obtain verification of health status documentation.
All current employee files were audited for compliance with health status documentation. Health status documentation to be part of pre-employment check list prior to first day of employment.
All new employee files will be audited x 3 months; then half of new employee files will be audited x2 months, then random sample will be audited x2 months. Results of these audits will be taken to QAPI committee for discussion and recommendation.
The Human Resources Director or designee will be responsible for audits.


Back to County Map


  
Home : Press Releases : Administration
Health Planning and Assessment : Office of the Secretary
Health Promotion and Disease Prevention : Quality Assurance



Copyright 2001 Commonwealth of Pennsylvania. All Rights Reserved.
Commonwealth of PA Privacy Statement

Visit the PA Power Port