Pennsylvania Department of Health
 PENNKNOLL VILLAGE
Patient Care Inspection Results

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PENNKNOLL VILLAGE
Inspection Results For:

There are  137 surveys for this facility. Please select a date to view the survey results.

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PENNKNOLL VILLAGE - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on a Medicare/Medicaid Recertification survey, State Licensure survey,Civil Rights Compliance suvey, and a complaint survey completed on February 23, 2024, it was determined that Pennknoll Village was not in compliance with the following requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care Facilities and the 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.




 Plan of Correction:


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

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

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

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


Based on review of clinical records and grievance records, as well as resident and staff interviews, it was determined that the facility failed to make ongoing efforts to resolve a grievance regarding dietary complaints.

Findings include:

The facility's policy regarding complaint and grievances, dated February 13, 2024, indicated that residents should have reasonable expectations of care and services and the facility should address those expectations in a timely, reasonable, and consistent manner.

The grievance log from December 2023 revealed that there were three grievances from the resident council meeting on December 10, 2023, regarding residents not receiving food that they requested, receiving tiny portions of food, and hair found in the soup. Education was provided to dietary.

The grievance log from February 2024 revealed that the rice was undercooked, foods that were to be served cold were being served on the hot plates, the dietary department ignores resident requests, portions were small, food was not palatable and was terrible, poor food quality, and residents were served the wrong consistency. The dietary staff were re-educated about these concerns to resolve them.

A meeting with a group of residents on February 21, 2024, at 11:30 a.m. revealed that the residents continue to be dissatisfied with the quality and palatability of the food served at the facility. The group has made complaints to dietary regarding food services, but there have been no changes.

Interview with the Nursing Home Administrator on February 23, 2024, at 11:48 a.m. confirmed that there are many grievances regarding food and re-education has been ineffective to resolve food complaints.

28 Pa. Code 201.29(i) Resident Rights.

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




 Plan of Correction - To be completed: 03/28/2024

1. The residents identified from the December 2023 grievances were provided education regarding their option to receive a replacement meal or additional condiments if the food they are served is not agreeable to their individual taste.
2. Grievances in the last 30 days were reviewed by the Executive Director (ED) to ensure ongoing efforts to resolve grievances.
3. The ED reeducated the social services staff and Department Managers on the facility's grievance guidelines.
4. The ED/ designee to conduct Quality Improvement (QI) monitoring of regulation F 585 to ensure ongoing efforts to resolve grievances including dietary complaints. Monitor conducted via weekly grievance reviews times 4 weeks. The Dietary Manager/designee to conduct weekly meetings with the residents who choose to attend, to monitor the overall satisfaction of the food served weekly X 4 weeks, biweekly X 1 months, then monthly as needed. Findings reported to the Quality Improvement Performance Improvement committee and updated as indicated. Quality monitoring schedule modified based on findings.
483.60(d)(1)(2) REQUIREMENT Nutritive Value/Appear, Palatable/Prefer Temp: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(d) Food and drink
Each resident receives and the facility provides-

§483.60(d)(1) Food prepared by methods that conserve nutritive value, flavor, and appearance;

§483.60(d)(2) Food and drink that is palatable, attractive, and at a safe and appetizing temperature.
Observations:


Based on individual resident interviews and an interview with a group of residents, as well as a meal test tray, it was determined that the facility failed to serve food items that were palatable to residents.

Findings include:

Interview with Resident 7 on February 20, 2024, at 1:01 p.m. revealed that the food was awful and there was nothing good about it. Interview with Resident 11 on February 20, 2024, at 2:00 p.m. and Resident 93 during the initial tour on February 21, 2024, at 10:11 a.m. revealed that the food was bad. Interview with Resident 115 during the initial tour on February 20, 2023, at 11:03 a.m. revealed the food was not palatable as it did not taste good. Resident 115 would frequently order take out or have family bring in food. Interview with a group of residents on February 21, 2024, at 11:43 a.m. revealed that the food was bland, the vegetables were overcooked, and condiments do not come on the trays.

Observations of the lunch meal on February 22, 2024, at 12:23 p.m. revealed that food items on a test tray were not palatable to taste. The brussel sprouts were overcooked, mushy and bland. The pureed stuffing and chicken were bland and pasty, and the honey Dijon chicken was bland with no seasoning and not palatable to taste. Condiments were noted on top of the tray carts and were available on resident request per staff interviews.

Interview with the Dietary Manager on February 22, 2024, at the time of the test tray, revealed no response to observations of food tasting bland and vegetables being overcooked. Interview with the Dietary Manager and the corporate dietary consultant on February 22, 2024, at 4:30 p.m. revealed that the recipe is followed and the chicken was cooked then brushed with the seasonings then put back in the oven to finish cooking. The blandness of the honey Dijon chicken and pureed food and consistency of the brussel sprouts were addressed again with the Dietary Manager and she stated she could not speak to the individual tastes of the residents and that she seasons the food within the restrictions of the residents.

28 Pa. Code 211.6(b) Dietary Services.


 Plan of Correction - To be completed: 03/28/2024

1. The residents identified from the December 2023 grievances were provided education regarding their option to receive a replacement meal or additional condiments if the food they are served is not agreeable to their individual taste.
2. Residents receiving meals from the kitchen have the potential to be affected by this alleged deficient practice.
3. The Director of Dietary Services reeducated the dietary staff on following the recipes. The Executive Director, or designee, will reeducate the nursing staff on what options are available if a Resident is not satisfied with the meal they are served.
4. The Director of Dietary or designee to conduct Quality Improvement (QI) monitoring of regulation F 804 to ensure to serve food items that were palatable to residents. Quality Improvement monitoring conducted via weekly resident interviews for 4 weeks, then monthly as needed using a sample size of 5 residents. Findings reported to the Quality Improvement Performance Improvement (QAPI) committee and updated as indicated. QI monitoring schedule modified based on findings.

483.45(a)(b)(1)-(3) REQUIREMENT Pharmacy Srvcs/Procedures/Pharmacist/Records: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.
§483.45 Pharmacy Services
The facility must provide routine and emergency drugs and biologicals to its residents, or obtain them under an agreement described in §483.70(g). The facility may permit unlicensed personnel to administer drugs if State law permits, but only under the general supervision of a licensed nurse.

§483.45(a) Procedures. A facility must provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident.

§483.45(b) Service Consultation. The facility must employ or obtain the services of a licensed pharmacist who-

§483.45(b)(1) Provides consultation on all aspects of the provision of pharmacy services in the facility.

§483.45(b)(2) Establishes a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation; and

§483.45(b)(3) Determines that drug records are in order and that an account of all controlled drugs is maintained and periodically reconciled.
Observations:


Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure the accountability of controlled medications (drugs with the potential to be abused) for two of 51 residents reviewed (Residents 15, 29).

Findings include:

The facility's policy regarding controlled drug disposal, dated February 13, 2024, indicated that controlled drugs should be wasted using a commercial controlled drug disposal system signed by two nurses witnessing the destruction of the controlled drug.

The facility's policy regarding medication administration, dated February 13, 2024, indicated that the nurse will document on the Medication Administration Record (MAR) immediately prior to administration or immediately post administration based on the preferred individual practice of the nurse.

A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 15, dated December 28, 2023, revealed that the resident was cognitively intact, was dependent on staff for care needs, had constant pain, and was receiving controlled pain medication.

Physician's order for Resident 15, dated February 28, 2023, included an order for the resident to receive 5 milligrams (mg) of Oxycodone (a narcotic pain medication) by mouth every eight hours as needed for severe pain.

Review of Resident 15's controlled drug records for December 2023 and February 2024 revealed that a dose of Oxycodone was signed-out once on February 2, 2024, at 5:00 p.m. However, the resident's clinical record, including the MAR, contained no documented evidence that Oxycodone was actually administered.

Physician's orders for Resident 15, dated July 6, 2023, included an order for the resident to receive a 50 micrograms (mcg) Fentanyl (a narcotic pain patch) patch to be applied every three days for pain management and removed per schedule, and an order for a second nurse to witness the disposal of the patch every three days.

The MAR and a controlled drug count record for Resident 15, dated December 2023 and January and February 2024 revealed that a 50 mcg Fentanyl patch was applied to the resident on December 15 and 27, 2023; January 2, 2024; and February 4 and 22, 2024. There was no documented evidence that two licensed nurses signed that the old patch was destroyed after removal on that dates listed above.

Interview with the Director of Nursing on February 23, 2024, at 3:33 p.m. confirmed that the Oxycodone for Resident 15 was signed out on the narcotic sheet but was not documented as administered on the medication administration record, and confirmed that there was no documented evidence that two licensed personnel performed the destruction of Resident 15's Fentanyl patches as required.


A quarterly MDS assessment for Resident 29, dated February 3, 2024, revealed the resident was cognitively intact, required supervision to partial assist with care needs, had a surgical area, and was receiving controlled pain medication.

Physician's orders for Resident 29, dated January 3, 2024, included an order for the resident to receive 50 milligrams (mg) of Tramadol every six hours as needed for moderate to severe pain.

Review of the controlled drug record for Resident 29 for January 2024 revealed that a dose of Tramadol was signed out on January 7, 2024, at 8:55 p.m. and January 14, 2024, at 6:30 p.m.

Review of Resident 29's MAR and nursing notes revealed no documented evidence that the signed-out doses of Tramadol were administered to the resident on the above-mentioned dates and times.

Interview with the Director of Nursing on February 23, 2024, at 3:03 p.m. confirmed that there was no documented evidence in Resident 29's clinical records to indicate that the signed-out doses of Tramadol were administered to the resident on the above-mentioned dates and times.

28 Pa. Code 211.9(h) Pharmacy Services.

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



 Plan of Correction - To be completed: 03/28/2024

1. The physician for Resident 15 and 29 was notified of the missing entries on the medication administration record (MAR) on 3/18/24.
2. Residents receiving controlled medication were reviewed by a licensed nurse to ensure accountability of controlled medications. Follow up completed based on findings.
3. The Director of Nursing/Designee reeducated the licensed nursing staff on the facility's Fentanyl Removal and Medication Administration, Oral policies.
4. The Director of Nursing/Designee to conduct Quality Improvement monitoring of regulation F0755 to ensure the accountability of controlled medications. Quality Improvement monitoring conducted via medical record review weekly x 4 weeks, then monthly using a sample size of 5 random residents. Findings reported to the Quality Improvement Performance Improvement committee and updated as indicated. Quality monitoring schedule modified based on findings.

483.25(g)(1)-(3) REQUIREMENT Nutrition/Hydration Status Maintenance: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(g) Assisted nutrition and hydration.
(Includes naso-gastric and gastrostomy tubes, both percutaneous endoscopic gastrostomy and percutaneous endoscopic jejunostomy, and enteral fluids). Based on a resident's comprehensive assessment, the facility must ensure that a resident-

§483.25(g)(1) Maintains acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that this is not possible or resident preferences indicate otherwise;

§483.25(g)(2) Is offered sufficient fluid intake to maintain proper hydration and health;

§483.25(g)(3) Is offered a therapeutic diet when there is a nutritional problem and the health care provider orders a therapeutic diet.
Observations:


Based on review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that weights were obtained and documented as ordered for residents with weight loss for two of 51 residents reviewed (Residents 12, 42) and failed to ensure supplements were provided and documented as ordered for two of 51 residents reviewed (Residents 77, 97).

Findings include:

The facility's policy for weighing residents, dated February 13, 2024, indicated that weights will be completed as indicated and documented in the clinical record.

A significant change Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 12, dated December 13, 2023, revealed that the resident was moderately cognitively impaired, had diagnoses that included coronary (heart) artery disease and dysphagia (difficulty swallowing foods or liquids), required tube feedings for nutrition, and had weight loss that was not a physician-prescribed weight loss regimen. Current care plans indicated that the resident was at potential risk for altered nutritional status related to her dysphagia diagnosis.

Physician's orders for Resident 12, dated December 6, 2023, revealed that the resident was to be weighed every evening shift for three days (December 6, 7, 8, 2023), then every Wednesday on the evening shift for four weeks, (December 13, 20, 27, 2023, and January 3, 2024) then every evening shift, starting on the first and ending on the third of every month (February 1, 2 , 3, 2024).

A review of Resident 12's weight record for December 2023 and January and February 2024 revealed no documented evidence that the weights were completed on Friday, December 8, 2023; Wednesday, December 13, 2023; or Friday February 2, 2024, as ordered.

A significant correction MDS assessment for Resident 42, dated February 2, 2024, revealed that the resident was cognitively impaired, dependent for care needs, had pressure ulcers, and had a weight loss that was not a physician-prescribed weight loss regimen.

Physician's orders for Resident 42, dated January 16, 2024, included an order for 0.5 tablet of 15 milligrams (mg) of Remeron (an antidepressant used to stimulate appetite) at bedtime for weight loss.

Physician's orders for Resident 42, dated January 18, 2024, included an order for weekly weights for four weeks every day shift on Thursday to monitor weight due to weight loss.

A review of Resident 42's weight record and TAR for January and February 2024 revealed no documented evidence that the weekly weights were completed on Thursday, January 25, 2024, or Thursday, February 8, 2024, as ordered.

An interview with the Director of Nursing on February 22, 2024, at 11:26 a.m. confirmed that there was no documented evidence that the weights for Resident's 12 and 42 were completed as ordered on the above dates mentioned, and they should have been.

An admission MDS assessment for Resident 77, dated January 14, 2024, revealed that the resident was severely cognitively impaired (unable to make sound decisions), able to make himself understood, could understand others, had concerns with pocketing food, required an altered diet, and required staff assistance with meals.

Current physician's orders for Resident 77 revealed that the resident was to have a health shake or substitute with meals due to weight loss.

A review of the Medication Administration Records (MAR) and nursing notes for Resident 77 for December 2023 and January 2024 revealed that staff documented that the health shake was not available for administration.

A quarterly MDS assessment for Resident 97, dated January 20, 2024, revealed that the resident was cognitively intact, was able to make herself understood, could understand others, had weight loss while not on a physician-prescribed weight loss regimen, and had diagnoses that included anemia (problem of not having enough healthy red blood cells or hemoglobin to carry oxygen to the body's tissues) and kidney disease.

A nurse's note for Resident 97, dated January 17, 2024, revealed that the dietician recommended a health shake or substitute with meals four times a day and to add a yogurt at bedtime due to weight loss. The physician was made aware of the recommendation and an order was received for a health shake or substitute with meals and to add a yogurt at bedtime due to weight loss.

A review of the MAR and nursing notes for Resident 97 for December 2023 and January 2024 revealed that staff documented that the health shake was not available for administration.

Interview with Licensed Practical Nurse 2 on February 21, 2024, at 12:17 p.m. revealed that the kitchen provides the health shake, and if the health shake is unavailable, they will make a fortified pudding as a substitute.

Interview with the Director on Nursing on February 22, 2024, at 3:25 p.m. confirmed that Residents 77 and 97 did not receive the health shakes as ordered by the physician/dietician and should have received either a health shake or a substitute.

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


 Plan of Correction - To be completed: 03/28/2024

1. The physician was notified of the missing entries in the documentation for Resident 12, Resident 42, and Resident 77on 3/11/2024. Resident 97 no longer resides in the facility.
2. Residents with a significant weight loss were reviewed to ensure weights were obtained and supplements provided per physician's order. Follow up completed based on the findings.
3. The Director of Nursing/Designee reeducated the licensed nursing staff to follow physician's orders.
4. The Director of Nursing/designee to conduct Quality Improvement (QI) monitoring of regulation F0692 to ensure physician weight orders and physician supplement orders are followed. QI monitoring conducted via medical record weekly x 4 weeks, then monthly, as needed, using a sample size of 5 random residents. Findings reported to the Quality Improvement Performance Improvement (QAPI) committee and updated as indicated. Quality monitoring schedule modified based on findings.

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


Based on clinical record reviews, observations, and staff interviews, it was determined that the facility failed to provide reasonable accommodation of a resident's needs by failing to ensure that the call bell was within reach for one of 25 residents reviewed (Resident 31).

Findings include:

An annual Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 31, dated January 29, 2024, indicated that the resident was understood and could understand, and he required maximum assistance for transfers and toileting. The resident's current care plan indicated that the resident had decreased mobility and that staff were to ensure the call bell was within reach.

Observations of Resident 31 on February 20, 2024, at 1:05 p.m. revealed that the resident was lying in bed, and the call bell was hanging off the back of the bed onto the floor and was not within his reach.

Interview with Licensed Practical Nurse 1 at that time revealed that Resident 31 was capable of using his call bell and it should have been placed within his reach.

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




 Plan of Correction - To be completed: 03/28/2024

1. Resident 31's call bell was placed within reach.
2. In-house residents were observed by a member of the Interdisciplinary Team (IDT) that call bell system is within reach. Any issues identified were corrected immediately.
3. The Director of Clinical Services (DCS)/designee re-educated the nursing staff to place call bell within reach of the residents.
4. The DCS/designee to conduct Quality Improvement (QI) monitoring of the regulation F558 to ensure the call system is within reach of the residents. QI monitoring to be conducted randomly 3 times per week for 4 weeks using a sample size of ten residents. Findings to be reviewed via Quality Assurance Performance Improvement (QAPI) Committee Meeting and updated as indicated. QI schedule modified based on findings.

483.10(g)(14)(i)-(iv)(15) REQUIREMENT Notify of Changes (Injury/Decline/Room, etc.):This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
§483.10(g)(14) Notification of Changes.
(i) A facility must immediately inform the resident; consult with the resident's physician; and notify, consistent with his or her authority, the resident representative(s) when there is-
(A) An accident involving the resident which results in injury and has the potential for requiring physician intervention;
(B) A significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications);
(C) A need to alter treatment significantly (that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment); or
(D) A decision to transfer or discharge the resident from the facility as specified in §483.15(c)(1)(ii).
(ii) When making notification under paragraph (g)(14)(i) of this section, the facility must ensure that all pertinent information specified in §483.15(c)(2) is available and provided upon request to the physician.
(iii) The facility must also promptly notify the resident and the resident representative, if any, when there is-
(A) A change in room or roommate assignment as specified in §483.10(e)(6); or
(B) A change in resident rights under Federal or State law or regulations as specified in paragraph (e)(10) of this section.
(iv) The facility must record and periodically update the address (mailing and email) and phone number of the resident
representative(s).

§483.10(g)(15)
Admission to a composite distinct part. A facility that is a composite distinct part (as defined in §483.5) must disclose in its admission agreement its physical configuration, including the various locations that comprise the composite distinct part, and must specify the policies that apply to room changes between its different locations under §483.15(c)(9).
Observations:


Based on a review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that a resident's attending physician was notified about changes in weight for one of 51 residents reviewed (Resident 19), failed to notify the physician regarding an elevated blood sugar and change in skin condition for one of 51 residents reviewed (Resident 47), and failed to notify the physician of purulent drainage from a resident's nephrostomy tube for one of 51 residents reviewed (Resident 97) .

Findings include:

The facility's policy regarding weight monitoring, dated February 13, 2024, indicated to record weight and alert the nurse to any significant weight change. When there is a significant variance from the previous recorded weight, the scale should be rebalanced and the resident re-weighed and a licensed nurse is to validate. The nurse is responsible to notify the physician of any significant weight change and to consult with the Director of Dietary Services and/or the dietician.

A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 19, dated January 30, 2024, indicated that the resident had a weight loss, was not on a physician-prescribed weight loss program, and the resident had diagnoses that included congestive heart failure (the heart cannot pump blood as well as it should causing fluid to build up in the lungs and lower legs).

Physician's orders for Resident 19, dated January 23, 2024, included an order for 40 milligrams (mg) of Lasix (a medication used to treat fluid build-up) daily and 25 mg of Spironolactone (a medication used to treat fluid build-up) daily for 90 days (through April 23, 2024).

Physician's orders for Resident 19, dated January 30, 2024, included an order for weekly weights due to weight loss in the hospital.

A review of Resident 19's clinical record revealed that the resident's weight on January 8, 2024, (prior to her hospitalization on January 15, 2024) was 173.6 pounds. The resident's weight on readmission on January 23, 2024, was 164 pounds. Her weight on January 31, 2024, was 161.2 pounds; on February 8, 2024, her weight was 158 pounds; on February 14, 2024, her weight was 159 pounds; and on February 21, 2024, her weight was 169.6 pounds.

There was no documented evidence that the nurse was alerted to the weight changes, that the weight changes were validated by a re-weight, that the Dietary Director or dietician was consulted, or that the physician was notified about Resident 19's progressive weight loss from January 23, 2024, through February 8, 2024, and her significant weight increase from February 14, 2024, to February 21, 2024.

Interview with the Director of Nursing on February 23, 2024, at 1:49 p.m. confirmed that there was no documented evidence that the nurse was alerted to the weight changes, that the weight changes were validated by a re-weight, that the Dietary Director or dietician was consulted, or that the physician was notified about Resident 19's progressive weight loss from January 23, 2024, through February 8, 2024, and her significant weight increase from February 14, 2024, to February 21, 2024.

An annual MDS assessment for Resident 47, dated December 19, 2023, revealed that the resident was cognitively intact and required assistance with daily care tasks.

A nursing note for Resident 47, dated February 15, 2024, at 10:10 a.m., revealed that staff reported when turning the resident during daily care the nurse aide noticed a crack in the skin approximately 1.0 centimeter (cm) x 1.0 cm behind the right knee, and she notified the registered nurse.

There was no documented evidence that the physician was notified by the registered nurse about the change in skin condition for Resident 47.

Interview with the Director of Nursing on February 22, 2024, at 3:02 p.m. confirmed that there was no documented evidence in Resident 47's clinical record that the facility called the physician to notify him about the change in skin condition.

A nursing note for Resident 47, dated February 4, 2024, at 3:54 p.m. stated that resident's blood sugar was
411 milligrams/deciliter (mg/dL) and the resident was in bed eating a bag of chips when the blood sugar was taken. The registered nurse was updated and was to inform the physician when the resident's blood sugar was over 400 mg/dL.

There was no documented evidence in Resident 47's medical record that the physcian was notified of the resident's elevated blood sugar.

Interview with the Director of Nursing on February 22, 2024, at 3:03 p.m. confirmed that the physician was not notified of Resident 47's elevated blood sugar.

A quarterly MDS assessment for Resident 97, dated February 2, 2024, revealed that the resident was cognitively impaired, required assistance with daily care tasks, and had a diagnosis of neurogenic bladder (a lack of bladder control due to a brain, spinal cord, or nerve problem). Resident 97's care plan, dated April 28, 2023, indicated to monitor the nephrostomy site for signs and symptoms of infection during care.

A nursing note for Resident 97, dated February 12, 2024, revealed that the resident's nephrostomy site (a nephrostomy is a thin catheter that drains urine from the kidney into a bag) had drainage that was greenish and bloody, there was a distinct odor present, and the resident had complaints of pain. The registered nurse was notified of the change in condition of the resident.

There was no documented evidence the physician was notified about the change in condition to Resident 97's nephrostomy site.

Interview with the Director of Nursing on February 22, 2024, at 2:04 p.m. confirmed that there was no documented evidence that Resident 97's physician was notified about the change in condition of the resident's nephrostomy.

28 Pa. Code 211.12(d)(1)(3) Nursing Services.



 Plan of Correction - To be completed: 03/28/2024

1. Resident 19's physician was made aware on 3/11/24 of the change in condition. Resident 47's physician was made aware on 3/11/24 of the changes in condition. Resident 97 no longer resides at this facility.
2. Residents with a change in condition in the last 30 days were reviewed to ensure the physician was notified. Follow up was completed based on findings.
3. The Director of Nursing/designee reeducated the licensed staff on the facility's Change in Resident Condition policy and procedure.
4. The Director of Nursing/designee to conduct Quality Improvement (QI) monitoring of regulation F0580 to ensure proper physician notification of condition changes. Monitoring conducted via medical record weekly x 4 weeks using a sample size of 5 random residents. Findings reported to the Quality Improvement Performance Improvement committee and updated as indicated. Quality monitoring schedule modified based on findings.
483.21(b)(1)(3) 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.
§483.21(b)(3) The services provided or arranged by the facility, as outlined by the comprehensive care plan, must-
(iii) Be culturally-competent and trauma-informed.
Observations:


Based on review of facility policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to develop care plans for individualized resident care needs for three of 51 residents reviewed (Residents 7, 42, 68).

Findings include:

The facility's policy on care plans, dated February 13, 2024, indicated that a comprehensive, individualized, person-centered plan of care would be developed for each resident that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs that are identified in the comprehensive assessment.

A Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 7, dated December 29, 2023, indicated that the resident was cognitively intact, required moderate to substantial assistance with care needs, and was frequently incontinent of bowel and bladder.

An urology consult for Resident 7, dated January 4, 2024, indicated that the resident has a cystoscopy (a procedure to diagnose a treat urinary tract problems) to remove a urethral stent (a tiny tube that holds open the ureters-tubes that carry urine from the kidneys to the bladder).

Physician's orders for Resident 7, dated January 4, 2024, included an order for the resident to receive 250 milligrams (mg) of Keflex (an antibiotic) at bedtime, status post cystoscopy with stent removal for six months (through July 4, 2024).

There was no documented evidence that a care plan was developed to address Resident 7's need for long-term antibiotic therapy.

An interview with the Director of Nursing on February 23, 2024, at 9:28 a.m. confirmed that Resident 7 did not have a care plan for long-term antibiotic therapy and should have.

A significant correction MDS assessment for Resident 42, dated February 2, 2024, revealed that the resident was dependent for care needs, was cognitively impaired, and was incontinent of bowel.

Observations on February 20, 2024, at 11:33 a.m. revealed that Resident 42 was on contact precautions for Clostridium difficile (C. diff) (a highly contagious infection of the colon).

Progress notes for Resident 42, dated February 13, 2024, revealed that the resident's stool tested positive for C. diff. and the resident's room was changed with contact precautions initiated.

Physician's orders for Resident 42, dated February 13, 2024, included an order for the resident to receive 500 mg of Metronidazole (an antibiotic) three times a day for 10 days. There was no documented evidence that the resident had a care plan in place to address the C. diff infection with antibiotic and contact precautions.

Interview with the Director of Nursing on February 22, 2024, at 3:02 p.m. confirmed that there was no comprehensive care plan in place to address Resident 42's C. diff infection with antibiotic and contact precautions.

A quarterly MDS assessment for Resident 68, dated January 23, 2024, indicated the resident was cognitively impaired, required substantial assistance to dependent with care needs, used oxygen, and had a diagnosis of congestive heart failure (the heart cannot pump blood as well as it should) and respiratory failure (blood does not have enough oxygen and causes difficulty breathing).

Progress notes for Resident 68, dated December 13, 2023, revealed that the resident's pulse oximetry (measures blood oxygen levels) was 78 percent on room air (without supplemental oxygen). The respiratory therapist evaluated the resident and oxygen was applied at 3 liters per minute (LPM) via nasal cannula (a small tube that delivers oxygen through the nasal passages). The resident's pulse oximetry increased to 92 percent. The medical director and resident representative were notified.

Physician's orders for Resident 68, dated December 13, 2023, included an order for oxygen at 3 LPM via nasal cannula, change tubing, mask, and/or nasal cannula weekly and sooner as needed. Physician's orders, dated January 18, 2024, included an order for oxygen at 3 LPM continuously via nasal cannula with ear protectors on tubing. There was no documented evidence that the resident had a care plan in place to address his need for supplemental oxygen.

Interview with the Director of Nursing on February 22, 2024, at 4:02 p.m. confirmed that there was no comprehensive care plan in place to address Resident 68's need for supplemental oxygen.

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



 Plan of Correction - To be completed: 03/28/2024

1. Resident 7, Resident 42 and Resident 68's care plans were developed to individualized resident care needs on 3/12/2024.
2. Residents receiving antibiotics and residents receiving oxygen were reviewed by a licensed nurse to ensure care plan development. Follow up was completed based on findings.
3. The Director of Nursing (DON)/Designee reeducated the licensed staff on the facility's care plan policy.
4. The Minimum Data Set (MDS) nurse/designee to Quality Improvement (QI) conduct monitoring of regulation F0656 to ensure care plans developed for individualized resident care needs. QI monitoring conducted via medical record weekly x 4 weeks, then monthly as needed using a sample size of 5 random residents. Findings reported to the QAPI committee and updated as indicated. Quality monitoring schedule modified based on findings.

483.21(b)(2)(i)-(iii) REQUIREMENT Care Plan Timing and Revision:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
§483.21(b) Comprehensive Care Plans
§483.21(b)(2) A comprehensive care plan must be-
(i) Developed within 7 days after completion of the comprehensive assessment.
(ii) Prepared by an interdisciplinary team, that includes but is not limited to--
(A) The attending physician.
(B) A registered nurse with responsibility for the resident.
(C) A nurse aide with responsibility for the resident.
(D) A member of food and nutrition services staff.
(E) To the extent practicable, the participation of the resident and the resident's representative(s). An explanation must be included in a resident's medical record if the participation of the resident and their resident representative is determined not practicable for the development of the resident's care plan.
(F) Other appropriate staff or professionals in disciplines as determined by the resident's needs or as requested by the resident.
(iii)Reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments.
Observations:


Based on review of facility policy and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that care plans were updated to reflect changes in care needs for one of 51 residents reviewed (Resident 29).

Findings include:

The facility's policy on care plans, dated February 13, 2024, indicated that the comprehensive care plan will be reviewed, updated and/or revised based on changing goals, preferences and needs of the resident and in response to current interventions after the completion of each Omnibus Budget Reconciliation Act (OBRA) MDS assessment and as needed.

A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 29, dated February 3, 2024, revealed that the resident was cognitively intact and required supervision to partial assist with care needs.

Clinical record review for Resident 29 revealed that he had a care plan in place for heparin (an anticoagulant or blood thinning medication). The resident did not have an order for heparin or any other anticoagulant.

Interview with the Director of Nursing on February 22, 2024, at 4:01 p.m. confirmed the Resident 29's care plan for anticoagulant should have been resolved to reflect the resident was not on an anticoagulant.

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




 Plan of Correction - To be completed: 03/28/2024

1. Resident 29's care plan was revised to reflect the discontinuation of the anticoagulant therapy.
2. Residents receiving an anticoagulant in the last 30 days were reviewed by a licensed nurse to ensure the care was revised as indicated. Follow up was completed based on the findings.
3. The Director of Nursing/Designee reeducated the licensed staff on the facility's care plan policy.
4. The Minimum Data Set (MDS) nurse/designee to conduct Quality Improvement (QI) monitoring of regulation F0657 care plans were updated to reflect changes in care needs. QI monitoring conducted via medical record weekly x 4 weeks, then monthly as needed using a sample size of 5 random residents. Findings reported to the Quality Assurance Performance Improvement (QAPI) committee and updated as indicated. Quality monitoring schedule modified based on findings.

483.25 REQUIREMENT Quality of Care:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
§ 483.25 Quality of care
Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices.
Observations:


Based on clinical record reviews and staff interviews, it was determined that the facility failed to ensure that physician's orders were followed for one of 51 residents reviewed (Resident 33), and failed to prevent a delay in care for one of 51 residents reviewed (Resident 97) resulting in his hospitalization.

Findings include:

A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 33, dated February 2, 2024, revealed that the resident was cognitively impaired.

A nutritional note for Resident 33, dated December 12, 2023, revealed that the resident was to receive a health shake two times per day to meet her protein needs.

Physician's orders for Resident 33, dated December 13, 2023, included orders for the resident to receive a 4-ounce health shake two times per day.

Review of Resident 33's Medication Administration Records (MAR) and nursing notes for December 2023, as well as January and February 2024, revealed that staff had documented that the health shake was not available for administration.

Interview with the Director of Nursing on February 22, 2024, at 3:25 p.m. confirmed that Resident 33 did not receive the health shakes as ordered by the physician..


A quarterly MDS assessment for Resident 97, dated February 2, 2024, revealed that the resident was cognitively impaired, required assistance with daily care tasks, and has a diagnosis of neurogenic bladder (lack of bladder control due to a brain, spinal cord, or nerve problem).

A nursing note for Resident 97, dated October 8, 2023, at 3:05 p.m., revealed that the nephrostomy (a catheter that is inserted in the kidney through the abdomen and allows urine to drain) dressing was loose, there was blood in the drainage bag, and six centimeters of the tube was exposed from the site. The nurse sent a fax to the provider to notify them of the change in condition.

A nursing note for Resident 97, dated October 9, 2023, at 7:53 a.m., revealed that six centimeters of the nephrostomy tube was exposed from the site due to sutures being out, and a call was placed to the physician with orders to contact the urologist office.

A nursing note for Resident 97, dated October 9, 2023, at 3:23 p.m., indicated that the resident had 180 milliliter (ml) of frank (fresh) red blood in the nephrostomy tube and 100 ml of tea-colored urine in the catheter. A call was placed to the urologist's office and staff were waiting on a call back.

A nursing note for Resident 97, dated October 9, 2023, at 3:37 p.m., indicated that the resident needs to be sent to the emergency room due to the bleeding and inability to provide urology care.

A nursing note for Resident 97, dated October 9, 2023, at 4:19 p.m., revealed that the resident would need to be sent to Altoona UPMC instead of Bedford UPMC due to the possibility to staying overnight and needing to see a urologist. UPMC Bedford did not have a urologist available at that time.

Interview with the Director of Nursing on February 22, 2024, at 11:43 a.m. confirmed that the physician was not notified timely about Resident 97's changes in condition, which led to her hospitalization and treatment of a blood clot.

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






 Plan of Correction - To be completed: 03/28/2024

1. Resident 33's physician was notified on 3/11/2024. Resident 97 no longer resides at the facility.
2. Residents receiving health shakes were reviewed by a licensed nurse to ensure physician's orders were followed. Residents with a nephrostomy tube were reviewed by a licensed nurse to ensure changes in resident conditions were reported timely. Follow was completed based on findings.
3. The Director of Nursing (DON)/Designee reeducated the licensed staff on the facility's Notification of Change in Condition policy and procedure and to follow physician's orders.
4. The Director of Nursing/designee to conduct Quality Improvement (QI) monitoring of regulation F0684 to ensure consulting physician orders are addressed timely, physician's orders are followed, and physician notification of resident's change in condition. Monitoring conducted via medical records review weekly x 4 weeks, then monthly as needed using a sample size of 5 random residents. Findings reported to the Quality Improvement Performance Improvement committee and updated as indicated. Quality monitoring schedule modified based on findings.

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 review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that treatments for pressure ulcers were provided as ordered by the physician for one of 51 residents reviewed (Resident 42).

Findings include:

The facility's policy regarding dressing changes, dated February 13, 2024, indicated that all dressings were to be applied to wounds by a nurse, as ordered by the physician to promote healing, and then documented in the medical record.

A significant correction Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 42, dated February 2, 2024, revealed that the resident was dependent for care needs, was cognitively impaired, had an indwelling foley catheter, a Stage 2 pressure ulcer (pressure wound with skin loss), a Stage 3 pressure ulcer (pressure wound involving the fat layers beneath the skin), an unstageable pressure ulcer (full-thickness pressure injuries in which the base is obscured by slough and/or eschar), a venous ulcer (ulcers caused by problems with blood flow in the leg veins), and had diagnoses that included peripheral vascular disease and diabetes. The resident's care plan, revised on January 30, 2024, revealed that staff were to administer treatments as ordered and to monitor for effectiveness.

Physician's orders for Resident 42, dated November 12, 2023, included an order for the staff to cleanse the right great toe with betadine (an antiseptic solution used to treat and prevent infection) every day shift and may cover with a dry dressing as needed for drainage. A review of the resident's Treatment Administration Record (TAR) for January 2024 revealed that the resident did not receive the treatment on January 25, 2024, as ordered.

Physician's order for Resident 42, dated December 29, 2023, included an order for the staff to cleanse and dry the coccyx, apply exufiber AG (a dressing used on wounds with a high amount of drainage) to the wound bed, and cover with border foam daily. A review of the resident's TAR for January 2024 revealed that the resident did not receive this treatment on January 9, 2024, as ordered.

Physician's orders for Resident 42, dated January 6, 2024, included an order for the staff to cleanse the left hip with soap and water, dry well, apply optifoam gentle (a foam dressing) to the area daily and as needed for soilage and dislodgement. A review of the resident's TAR for January 2024 revealed that the resident did not receive this treatment on January 18, 2024, as ordered.

Physician's orders for Resident 42, dated January 18, 2024, included an order for staff to paint the resident's right heel with betadine and cover with foam dressing every day and evening shift. A review of the resident's TAR for January 2024 revealed that the resident did not receive this treatment on January 21 and 31, 2024, on the evening shift and on January 25, 2024, on the day shift as ordered.

Physician's orders for Resident 42, dated January 18, 2024, included an order for staff to cleanse and dry the coccyx, apply calcium AG (a dressing used to wounds with a high amount of drainage) to the wound bed, and cover with sacral foam daily. A review of the resident's TAR for January 2024 revealed that the resident did not receive this treatment on January 25 and 26, 2024, as ordered.

Physician's order for Resident 42, dated January 19, 2024, included an order for the staff to apply santyl (a wound debridement treatment) to the left hip every day shift. A review of the resident's TAR for January 2024 revealed that the resident did not receive this treatment on January 25, 2024, as ordered.

Physician's orders for Resident 42, dated January 27, 2024, included an order for staff to irrigate the coccyx with one-forth strength Dakins (a solution used to treat and prevent tissue infections), apply santyl to the wound bed, and cover with sacral foam daily. A review of the resident's TAR for February 2024 revealed that the resident did not receive this treatment on February 14, 2024, as ordered.

Interview with the Director of Nursing on February 22, 2024, at 11:26 a.m. confirmed there was no documented evidence that wound treatments were attempted or done to the areas listed above on dates listed above.

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



 Plan of Correction - To be completed: 03/28/2024

1. Resident 42's physician was notified of missing wound documentation on 3/11/2024.
2. Residents receiving wound care were reviewed by a licensed nurse to ensure that treatments for pressure ulcers were provided as ordered by the physician. Follow up completed based on findings.
3. The Director of Nursing/Designee reeducated the licensed nursing staff to follow the physician's orders and on the facility's dressing change policy with emphasis placed on documenting in the resident's medical record.
4. The Director of Nursing/designee to conduct Quality Improvement (QI) monitoring of regulation F0686 to ensure treatments for pressure ulcers were provided as ordered by the physician. Quality Improvement monitoring conducted via medical record weekly x 4 weeks, then monthly as needed using a sample size of 5 random residents. Findings reported to the Quality Improvement Performance Improvement (QAPI) committee and updated as indicated. Quality monitoring schedule modified based on findings.

483.25(e)(1)-(3) REQUIREMENT Bowel/Bladder Incontinence, Catheter, UTI:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
§483.25(e) Incontinence.
§483.25(e)(1) The facility must ensure that resident who is continent of bladder and bowel on admission receives services and assistance to maintain continence unless his or her clinical condition is or becomes such that continence is not possible to maintain.

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

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


Based on a review of clinical records, as well as staff interviews, it was determined that the facility failed to provide suprapubic urinary catheter changes as ordered by the physician for one of 51 residents reviewed (Resident 35).

Findings include:

An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 35, dated February 8, 2024, revealed that the resident was cognitively intact; was understood; could understand; required partial assistance with dressing, toilet use, and bathing; was independent with bed mobility and eating; had an indwelling catheter (a tube inserted into the bladder to drain urine); and had an active diagnosis of neurogenic bladder (bladder does not function properly due to disease or damage to the central nervous system).
A care plan for Resident 35's indwelling catheter, dated February 1, 2024, revealed that she had a suprapubic catheter due to a neurogenic bladder.

A nursing note for Resident 35, dated February 10, 2024, at 9:30 a.m., revealed that the consultant physician recommended the resident to have a suprapubic catheter change every two weeks while at the facility. Resident 35 must use a 24 French catheter size. The Medical Director was notified of the recommendation.

Physician's orders for Resident 35, dated February 10, 2024, included orders for staff to change the 24 French, 10-millimeter balloon catheter (indicates size of catheter) every two weeks. The catheter must be a 24 French suprapubic tube.

A review of Resident 35's Medication and Treatment Administration Records (MAR/TAR) for February 2024 revealed that the catheter was not changed on February 20, 2024, as scheduled.

A nursing note for Resident 35, dated February 20, 2024, at 7:00 a.m., revealed that staff were unable to change the catheter this shift and were awaiting delivery of correct size of the catheter per physician's order.

Interview with Director of Nursing on February 23, 2024, at 3:33 p.m. confirmed that the catheter was not changed as ordered, because central supply was not notified of the physician's order and the supplies were not ordered.

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



 Plan of Correction - To be completed: 03/28/2024

1. Resident 35 no longer resides at the facility.
2. Residents with catheter were reviewed to ensure availability of physician ordered catheter size.
3. The Director of Nursing/Designee reeducated the licensed nursing staff to notify the central supply clerk of supply orders.
New physician's orders reviewed during the morning clinical meeting to ensure supplies are ordered as needed.
4. The Director of Nursing/designee to conduct Quality Improvement (QI) monitoring of regulation F0690 to ensure catheter changes as ordered by the physician. Monitoring conducted via medical record weekly x 4 weeks, then monthly as needed of residents with indwelling catheters. Findings reported to the Quality Improvement Performance Improvement (QAPI) committee and updated as indicated. Quality monitoring schedule modified based on findings.

483.25(i) REQUIREMENT Respiratory/Tracheostomy Care and Suctioning:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
§ 483.25(i) Respiratory care, including tracheostomy care and tracheal suctioning.
The facility must ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals and preferences, and 483.65 of this subpart.
Observations:


Based on review of policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that residents received oxygen as ordered by the physician for one of 51 residents reviewed (Resident 95).

Findings include:

The facility's policy regarding oxygen therapy, dated December 13, 2023, indicated that oxygen was to be administered by licensed staff and in accordance with physician's orders.

A quarterly Minimum data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 95, dated February 16, 2024, revealed that the resident was cognitively intact and had diagnoses that included chronic respiratory failure with hypoxia (a serious condition that causes low blood oxygen). Resident 95's care plan, dated September 1, 2023, indicated that she had difficulty breathing related to respiratory failure.

Physician's orders for Resident 95, dated February 9, 2024, included an order for the resident to receive continuous oxygen at a flow rate of 4 liters per minute via nasal cannula (tubes that deliver oxygen into the nostrils).

Observations of Resident 95 on February 11, 2024, at 1:10 p.m., and February 12, 2023, at 12:28 p.m. and 3:35 p.m. revealed that the resident was in her room receiving oxygen from an oxygen concentrator (electrical machine that concentrates oxygen from the air) that was set between 3.0 and 3.5 liters per minute.

Interview with Licensed Practical Nurse 3 on February 22, 2024, at 3:35 p.m. confirmed that Resident 95's oxygen flow rate was set between 3.0 and 3.5 liters per minute, and not 4.0 liters per minute as ordered by the physician.

Interview with the Director of Nursing on February 22, 2024, at 9:30 a.m. confirmed that Resident 95's oxygen flow rate should be set at 4 liters per minute continuously as per physician order, and it was not.

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


 Plan of Correction - To be completed: 03/28/2024

1. Resident 95's physician was notified of the incorrect oxygen setting on 3/12/2024.
2. Residents receiving oxygen were reviewed by a licensed nurse to ensure residents received oxygen as ordered by the physician. Follow up completed based on the findings.
3. The Director of Nursing/Designee reeducated the licensed nursing staff on the facility's oxygen therapy policy.
4. The Director of Nursing/designee to conduct Quality Improvement (QI) monitoring of regulation F0695 to ensure residents received oxygen as ordered by the physician. QI monitoring conducted via observation and medical records review 5 days a week x 2 weeks, then weekly x 4 weeks, then monthly as needed, using a sample size of 5 random residents. Findings reported to the Quality Improvement Performance Improvement (QAPI) committee and updated as indicated. Quality monitoring schedule modified based on findings.

483.35(d)(4)-(6) REQUIREMENT Nurse Aide Registry Verification, Retraining: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.
§483.35(d)(4) Registry verification.
Before allowing an individual to serve as a nurse aide, a facility must receive registry verification that the individual has met competency evaluation requirements unless-
(i) The individual is a full-time employee in a training and competency evaluation program approved by the State; or
(ii)The individual can prove that he or she has recently successfully completed a training and competency evaluation program or competency evaluation program approved by the State and has not yet been included in the registry. Facilities must follow up to ensure that such an individual actually becomes registered.

§483.35(d)(5) Multi-State registry verification.
Before allowing an individual to serve as a nurse aide, a facility must seek information from every State registry established under sections 1819(e)(2)(A) or 1919(e)(2)(A) of the Act that the facility believes will include information on the individual.

§483.35(d)(6) Required retraining.
If, since an individual's most recent completion of a training and competency evaluation program, there has been a continuous period of 24 consecutive months during none of which the individual provided nursing or nursing-related services for monetary compensation, the individual must complete a new training and competency evaluation program or a new competency evaluation program.
Observations:


Based on review of personnel files, as well as staff interviews, it was determined that the facility failed to verify registry verification prior to allowing individuals to work as a nurse aide for one of five newly hired nurse aides reviewed (Nurse Aide 4).

Findings include:

The personnel file for Nurse Aide 4 revealed that she was hired by the facility on October 9, 2023. However, there was no documented evidence that the facility verified the nurse aide's standing with the state nurse aide registry until February 21, 2024.

Interview with the Nursing Home Administrator on February 22, 2024, at 11:21 a.m. confirmed that Nurse Aide 4 did not have a nurse aide registry check completed prior to her start date and that she should have.

28 Pa. Code 201.29 Personnel Policies and Procedures.


 Plan of Correction - To be completed: 03/28/2024

1. No residents were identified with this alleged deficient practice. The registry verification for Nurse Aide 4 was completed on 2/21/23.
2. Personnel files of Certified Nurse Aides (CNA) hired in the last 90 days were reviewed by The Human Resource Coordinator (HRC) /Designee to ensure registry verification prior to allowing individuals to work as a nurse aide. Follow up completed based on the findings.
3. The Executive Director (ED)/Designee reeducated the Human Resource Coordinator on the facility's personnel file maintenance policy.
4. The Human Resource Coordinator/Designee to conduct Quality Improvement (QI) monitoring of regulation F 729 to ensure registry verification prior to allowing individuals to work as a nurse aide. QI monitoring conducted via personnel file review of newly hired nurse's aides weekly for 8 weeks. Findings to be reported to the Quality Improvement Performance Improvement (QAPI) committee meeting and updated as indicated. QI monitoring schedule modified based on findings.

483.35(d)(7) REQUIREMENT Nurse Aide Peform Review-12 hr/yr In-Service:This is a less serious (but not lowest level) deficiency and 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.
§483.35(d)(7) Regular in-service education.
The facility must complete a performance review of every nurse aide at least once every 12 months, and must provide regular in-service education based on the outcome of these reviews. In-service training must comply with the requirements of §483.95(g).
Observations:


Based on review of personnel files, as well as staff interviews, it was determined that the facility failed to ensure that nurse aide performance evaluations were completed annually based on hire dates for four of five nurse aides reviewed (Nurse Aides 5, 6, 7, 8).

Findings include:

A list of nurse aides provided by the facility revealed that Nurse Aide 5 was hired on June 20, 2019, and that she was due for her annual performance evaluation in June 2023. Nurse Aide 6 was hired December 21, 2017, and was due for her annual performance evaluation in December 2023. Nurse Aide 7 was hired May 4, 2015, and was due for her annual performance evaluation in May 2023. Nurse Aide 8 was hired September 24, 2015, and was due for her annual performance evaluation in September 2023. There was no documented evidence that the annual performance evaluations were completed as required for Nurse Aides 5, 6, 7, and 8.

Interview with the Nursing Home Administrator on February 22, 2024, at 12:07 p.m. confirmed that he could not provide evidence that annual performance evaluations were completed as required for Nurse Aides 5, 6, 7, and 8.

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

28 Pa. Code 201.18(b)(1)(3)(e)(1) Management.

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





 Plan of Correction - To be completed: 03/28/2024

1. No residents were identified with this alleged deficient practice.
2. The Human Resource Coordinator (HRC) reviewed the employee files for Certified Nurse Aides (CNA) who have been employed for at least one year to ensure performance evaluations were completed annually. Follow up completed based on findings.
3. The Executive Director (ED) reeducated the HRC and the Director of Nursing (DON) on the facility's employee job performance evaluation policy. The HRC will notify the DON of upcoming performance evaluations so that the appropriate supervisor can ensure that they are completed in a timely manner.
4. The HRC/Designee to conduct Quality Improvement (QI) monitoring of regulation F 730 to ensure nurse aide performance evaluations were completed annually based on hire date. QI monitoring conducted via nurse aide personnel file review weekly for 8 weeks. Findings to be reported to the Quality Improvement Performance Improvement (QAPI) committee meeting and updated as indicated. QI schedule modified based on findings.

483.45(c)(1)(2)(4)(5) REQUIREMENT Drug Regimen Review, Report Irregular, Act On: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(c) Drug Regimen Review.
§483.45(c)(1) The drug regimen of each resident must be reviewed at least once a month by a licensed pharmacist.

§483.45(c)(2) This review must include a review of the resident's medical chart.

§483.45(c)(4) The pharmacist must report any irregularities to the attending physician and the facility's medical director and director of nursing, and these reports must be acted upon.
(i) Irregularities include, but are not limited to, any drug that meets the criteria set forth in paragraph (d) of this section for an unnecessary drug.
(ii) Any irregularities noted by the pharmacist during this review must be documented on a separate, written report that is sent to the attending physician and the facility's medical director and director of nursing and lists, at a minimum, the resident's name, the relevant drug, and the irregularity the pharmacist identified.
(iii) The attending physician must document in the resident's medical record that the identified irregularity has been reviewed and what, if any, action has been taken to address it. If there is to be no change in the medication, the attending physician should document his or her rationale in the resident's medical record.

§483.45(c)(5) The facility must develop and maintain policies and procedures for the monthly drug regimen review that include, but are not limited to, time frames for the different steps in the process and steps the pharmacist must take when he or she identifies an irregularity that requires urgent action to protect the resident.
Observations:


Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that the physician or designee responded timely to a pharmacy recommendation for one of 51 residents reviewed (Resident 15).

Findings include:

The facility's policy regarding Monthly Drug Regimen Reviews, dated February 13, 2024, indicated that consultant reports have one recommendation per page. The Director of Nursing or designee would contact the physician with any outstanding recommendations, if no response from the physician notify the medical director for further assistance 15-21 days after the reports are available. During the drug regimen review, routine recommendations were to be communicated to the Director of Nursing or the designee, attending physician, and the Medical Director for response and resolution, after the completion of the monthly medication review.

Physician's orders for Resident 15, dated April 11, 2023, included an order for the resident to receive one 20 milligram (mg) tablet of Omeprazole delayed release twice a day for gastro-esophageal reflux disease (GERD - heartburn) scheduled at 9:00 a.m. and 5:00 p.m.

A monthly pharmacy medication regimen review for Resident 15, dated January 10, 2024, revealed a recommendation for a change in the medication administration times. The medication should be given 30 to 60 minutes before food for optimal control of gastric acidity. There was no documented evidence that the recommendation was addressed by the physician or designee.

Interview with the Director of Nursing on February 22, 2024, at 4:45 p.m. confirmed that there was no documented evidence in Resident 15's clinical record to indicate that the physician or designee addressed the January 10, 2024, pharmacy recommendation to change the medication administration time for optimal effectiveness.

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


 Plan of Correction - To be completed: 03/28/2024

1. Resident 15's Omeprazole administration times were changed on 3/13/24.
2. Pharmacy recommendations for the last 30 days were reviewed by a licensed nurse to ensure that the physician or designee responded timely to a pharmacy recommendation.
3. The Director of Nursing/Designee reeducated the licensed nursing staff concerning the timing of implementation of pharmacy recommendations.
4. The Director of Nursing/Designee to conduct monitoring of regulation F0756 to ensure pharmacy recommendations are being acknowledged and implemented timely as ordered by the physician. Quality Improvement (QI) monitoring conducted via medical records review monthly x 2 months Findings reported to the Quality Improvement Performance Improvement committee and updated as indicated. QI monitoring schedule modified based on findings.

483.55(b)(1)-(5) REQUIREMENT Routine/Emergency Dental Srvcs in NFs: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.
§483.55 Dental Services
The facility must assist residents in obtaining routine and 24-hour emergency dental care.

§483.55(b) Nursing Facilities.
The facility-

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

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

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

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

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


Based on review of facility policy and clinical records, as well as observations and staff interviews, it was determined that the facility failed to offer routine dental services for one of 51 residents reviewed (Resident 91).

Findings include:

The facility's policy regarding dental services, dated February 13, 2024, revealed that routine and emergency dental services are available to meet the resident's oral health services in accordance with the resident's assessment and plan of care.

An annual Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 91, dated December 16, 2023, revealed that the resident was cognitively intact and was dependent on staff for daily care tasks including oral care.

An interview with Resident 91's family members on February 21, 2024, at 9:13 a.m. revealed that the resident and her family had requested that she see the dentist for a regular cleaning since she still had all of her own teeth. Observations of Resident 91 on February 21, 2024, at 9:13 a.m. revealed that the resident still had all of her own teeth and that they were in good condition.

However, there was no documented evidence that Resident 91 had seen a dentist or was scheduled for an appointment to see the dentist since her admission to the facility in January 2023.

Interview with the Director of Nursing on February 23, 2024, at 11:20 a.m. confirmed that Resident 91 had not seen a dentist or had a consult with a dentist since her admission.

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

28 Pa. Code 211.15(a) Dental Services.



 Plan of Correction - To be completed: 03/28/2024

1. Resident 91 was scheduled for dental services.
2. Long term care residents were reviewed by the social services staff to ensure routine dental services were offered. Follow up was completed based on findings.
3. The Executive Director (ED) ED reeducated the social service staff on the regulation F 791. The Director of Nursing/designee will educate nursing staff on the follow through process to confirm a dental appointment is scheduled when a referral or request for services is made.
4. The Social Service Director/designee to conduct Quality Improvement (QI) monitoring of regulation F0791 to ensure routine dental services are offered. QI monitoring conducted via medical records review weekly x 4 weeks, then monthly as needed using a sample size of 5 random residents. Findings reported to the Quality Improvement Performance Improvement committee and updated as indicated. QI monitoring schedule modified based on findings.

483.75(c)(d)(e)(g)(2)(i)(ii) REQUIREMENT QAPI/QAA Improvement Activities: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.
§483.75(c) Program feedback, data systems and monitoring.
A facility must establish and implement written policies and procedures for feedback, data collections systems, and monitoring, including adverse event monitoring. The policies and procedures must include, at a minimum, the following:

§483.75(c)(1) Facility maintenance of effective systems to obtain and use of feedback and input from direct care staff, other staff, residents, and resident representatives, including how such information will be used to identify problems that are high risk, high volume, or problem-prone, and opportunities for improvement.

§483.75(c)(2) Facility maintenance of effective systems to identify, collect, and use data and information from all departments, including but not limited to the facility assessment required at §483.70(e) and including how such information will be used to develop and monitor performance indicators.

§483.75(c)(3) Facility development, monitoring, and evaluation of performance indicators, including the methodology and frequency for such development, monitoring, and evaluation.

§483.75(c)(4) Facility adverse event monitoring, including the methods by which the facility will systematically identify, report, track, investigate, analyze and use data and information relating to adverse events in the facility, including how the facility will use the data to develop activities to prevent adverse events.

§483.75(d) Program systematic analysis and systemic action.

§483.75(d)(1) The facility must take actions aimed at performance improvement and, after implementing those actions, measure its success, and track performance to ensure that improvements are realized and sustained.

§483.75(d)(2) The facility will develop and implement policies addressing:
(i) How they will use a systematic approach to determine underlying causes of problems impacting larger systems;
(ii) How they will develop corrective actions that will be designed to effect change at the systems level to prevent quality of care, quality of life, or safety problems; and
(iii) How the facility will monitor the effectiveness of its performance improvement activities to ensure that improvements are sustained.

§483.75(e) Program activities.

§483.75(e)(1) The facility must set priorities for its performance improvement activities that focus on high-risk, high-volume, or problem-prone areas; consider the incidence, prevalence, and severity of problems in those areas; and affect health outcomes, resident safety, resident autonomy, resident choice, and quality of care.

§483.75(e)(2) Performance improvement activities must track medical errors and adverse resident events, analyze their causes, and implement preventive actions and mechanisms that include feedback and learning throughout the facility.

§483.75(e)(3) As part of their performance improvement activities, the facility must conduct distinct performance improvement projects. The number and frequency of improvement projects conducted by the facility must reflect the scope and complexity of the facility's services and available resources, as reflected in the facility assessment required at §483.70(e). Improvement projects must include at least annually a project that focuses on high risk or problem-prone areas identified through the data collection and analysis described in paragraphs (c) and (d) of this section.

§483.75(g) Quality assessment and assurance.

§483.75(g)(2) The quality assessment and assurance committee reports to the facility's governing body, or designated person(s) functioning as a governing body regarding its activities, including implementation of the QAPI program required under paragraphs (a) through (e) of this section. The committee must:

(ii) Develop and implement appropriate plans of action to correct identified quality deficiencies;
(iii) Regularly review and analyze data, including data collected under the QAPI program and data resulting from drug regimen reviews, and act on available data to make improvements.
Observations:


Based on review of the facility's plans of correction for previous surveys, and the results of the current survey, it was determined that the facility's Quality Assurance Performance Improvement (QAPI) committee failed to correct quality deficiencies and ensure that plans to improve the delivery of care and services effectively addressed recurring deficiencies.

Findings include:

The facility's deficiencies and plans of corrections for a State Survey and Certification (Department of Health) survey ending March 30, 2023, revealed that the facility developed plans of correction that included quality assurance systems to ensure that the facility maintained compliance with cited nursing home regulations. The results of the current survey, ending February 23, 2024, identified repeated deficiencies related to revision of residents' care plans, catheter care, regulations regarding nurse aide annual performance evaluations, and infection prevention and control.

The facility's plan of correction for a deficiency regarding revising residents' care plans, cited during the survey ending March 30, 2023, revealed that audits of care plans would be completed, and the results would be reported to the QAPI committee for review. The results of the current survey, cited under F657, revealed that the QAPI committee was ineffective in maintaining compliance with the regulation regarding revising residents' care plans.

The facility's plans of correction for deficiencies regarding, catheter care, cited during the survey ending on March 30, 2023, revealed that audits would be conducted and the results of the audits would be brought before the QAPI committee for further monitoring. The results of the current survey, cited under F690, revealed that the QAPI committee was ineffective in maintaining compliance with the regulation regarding catheter care.

The facility's plan of corrections for deficiencies regarding nurse aide annual performance evaluations, cited during the survey ending March 30, 2023, revealed that the facility would complete audits and report the results of the audits to the QAPI committee for review. The results of the current survey, cited under F730, revealed that the facility's QAPI committee failed to successfully implement their plan to ensure ongoing compliance with regulations regarding nurse aide annual performance evaluations.

The facility's plan of correction for a deficiency regarding infection prevention and control, cited during the survey ending March 30, 2023, revealed that infection prevention and control would be monitored by QAPI. The results of the current survey, cited under F880, revealed that the QAPI committee was ineffective in maintaining compliance with infection prevention and control.

Refer to F657, F690, F730, and F880.

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

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


 Plan of Correction - To be completed: 03/28/2024

1. Resident 29's care plan was revised to reflect the discontinuation of the anticoagulant therapy. Resident 35 no longer resides at the facility.
2. Residents receiving an anticoagulant in the last 30 days were reviewed by a licensed nurse to ensure the care was revised as indicated. Follow up was completed based on the findings. Residents with catheter were reviewed to ensure availability of physician ordered catheter size. The Human Resource Coordinator (HRC) reviewed the employee files for Certified Nurse Aides (CNA) who have been employed for at least one year to ensure performance evaluations were completed annually.
3. The Director of Nursing (DON)/Designee reeducated the licensed staff on the facility's care plan policy. The DON/Designee reeducated the licensed nursing staff to notify the central supply clerk of supply orders. New physician's orders reviewed during the morning clinical meeting to ensure supplies are ordered as needed. The Executive Director (ED) reeducated the HRC and the DON on the facility's employee job performance evaluation policy. The HRC will notify the DON of upcoming performance evaluations so that the appropriate supervisor can ensure that they are completed in a timely manner.
The ED reeducated the department managers on the facility's Quality Improvement Performance Improvement (QAPI) policy and on the 5 elements of QAPI.
4. The Director of Nursing/designee to conduct Quality Improvement monitoring of regulation F0686 to ensure treatments for pressure ulcers were provided as ordered by the physician. Quality Improvement monitoring conducted via medical record weekly x 4 weeks, then monthly as needed using a sample size of 5 random residents. The Director of Nursing/designee to conduct Quality Improvement monitoring of regulation F0690 to ensure catheter changes as ordered by the physician. Monitoring conducted via medical record weekly x 4 weeks, then monthly as needed of residents with indwelling catheters. The Human Resource Coordinator/Designee to conduct Quality Improvement monitoring of regulation F730 to ensure nurse aide performance evaluations were completed annually based on hire date. Quality Improvement monitoring conducted via nurse aide personnel file review weekly for 8 weeks.
Findings to be reported to the QAPI committee meeting and updated as indicated. Quality Improvement schedule modified based on findings.

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

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

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

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

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

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

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


Based on review of policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that proper infection control practices were followed while providing care for two of 51 residents reviewed (Residents 12, 109).

Findings include:

The facility's policy regarding catheter care, dated February 13, 2024, indicated that the catheter tubing and drainage bag were to be kept off the floor to prevent catheter-associated urinary tract infections.

A significant change Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 12, dated December 13, 2023, revealed that the resident was moderately cognitively impaired and had diagnoses that included acute kidney failure (a condition where the kidneys cannot filter waste from the blood) with dysfunction of the bladder. The resident's care plan, dated February 5, 2024, indicated the use of an indwelling catheter with interventions that included that the catheter tubing and bag should be kept off the floor.

Observations on February 20, 2024, at 1:13 p.m. and February 21, at 3:15 p.m. revealed that Resident 12's catheter drainage bag was touching the floor as it hung off the right side of her bed.

Interview with Nurse Aide 9 on February 21, 2024, at 3:15 p.m. confirmed that the catheter bag was touching the floor, and it should not have been.

Interview with the Director of Nursing on February 21, 2024, at 3:24 p.m. confirmed that Resident 12's catheter bag should not have been touching the floor.

The facility's policy regarding the hand washing and hand hygiene, dated February 13, 2024, indicated that alcohol-based hand rub containing at least 62 percent alcohol, or alternatively soap and water, was to be used before and after direct contact with residents, before and after handling clean or soiled dressings, before moving from a contaminated body site to clean body site during resident care, after handling used dressings and contaminated equipment, and after removing gloves.

An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 109, dated February 8, 2024, revealed that the resident was cognitively impaired; was dependent on staff for toileting, hygiene and transfers; and was at risk for pressure ulcers. The resident's care plan, dated February 11, 2024, indicated that she had a Stage II pressure injury on the gluteal cleft (butt crack) related to immobility and staff were to administer treatments as ordered.

Physician's orders for Resident 109, dated February 11, 2024, included an order for the gluteal cleft be cleansed, patted dry, peri protect applied to the area, and covered with optifoam.

Observations of Resident 109's wound care on February 22, 2024, at 12:46 p.m. revealed that there were two distinct open areas on her gluteal cleft. Licenced Practical Nurse (LPN) 10 removed a urine-soaked brief, provided incontinence care, and removed the soiled dressing. LPN 10 then washed her hands with soap and water and donned clean gloves before cleansing the pressure area with moistened wash clothes and soap. LPN 10 removed her gloves, donned a clean pair without performing hand hygiene, and applied the peri protect with a gloved hand. LPN 10 removed her gloves, donned a clean pair of gloves, applied the foam bordered dressing, and secured the clean brief.

Interview with the LPN 10 on February 22, 2024, at 1:15 p.m. confirmed that she did not wash her hands or perform hand hygiene between glove changes and dirty-to-clean tasks.

Interview with the Director of Nursing on February 22, 2024, at 3:45 p.m. confirmed that hand hygiene should have been completed between dirty and clean tasks and between glove changes.

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


 Plan of Correction - To be completed: 03/28/2024

1. The catheter bag for Resident 12 was removed from touching the floor and placed in an appropriate container. Resident 109 suffered no apparent harm from hand hygiene not performed. Licensed Practical Nurse (LPN) was reeducated on the facility's dressing change policy.
2. Residents with a catheter were observed to ensure proper infection control practices were followed while providing care.
3. The Director of Nursing and/or Designee re-educated the nursing staff on the proper placement and storage of catheter bags and on the facility's hand hygiene policy. The Director of Nursing/Designee reeducated the licensed nursing staff on the facility's dressing change policy.
4. The Director of Nursing/designee to conduct Quality Improvement (QI) monitoring of regulation F0880 to ensure proper infection control practices. QI monitoring conducted via observation and medical records review five times a week for 2 weeks, then weekly for 4 weeks, then monthly, as needed using a sample size of 5 residents. Findings reported to the Quality Improvement Performance Improvement (QAPI) committee and updated as indicated. QI monitoring schedule modified based on findings.

§ 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 Federal, State and local agencies responsible for the health and welfare of residents. This includes complying with all applicable Federal and State laws, and rules, regulations and orders issued by the Department and other Federal, State or local agencies.

Observations:


Based on review of Pennsylvania state law, policies, and attendance records for the facility's Infection Prevention Committee, as well as staff interviews, it was determined that the facility failed to ensure that the multi-disciplinary Infection Prevention Committee met at least quarterly.

Findings include:

The Act 52 Infection Control Plan, dated March 20, 2002, revealed that a health care facility should develop and implement an internal infection control plan that should be established for the purpose of improving the health and safety of residents and health care workers, and should include a multi-disciplinary committee and meet at least quarterly.

Interview with Director of Nursing on February 21, 2024, at 9:44 a.m. revealed that the facility's infection control committee was not part of its QAPI committee.

The facility's Infection Prevention committee meeting attendance records for 2023 revealed no documented evidence that quarterly meetings were held during the first and third quarter.

Interview with the Nursing Home Administrator on February 23, 2024, at 10:50 a.m. confirmed that there was no documented evidence that the infection control committee met for the first and third quarter of 2023.



 Plan of Correction - To be completed: 03/28/2024

1. No residents were identified related to this alleged deficiency.
2. Residents have the potential to be affected.
3. The Executive Director, the Director of Nursing and the Infection Preventionist were reeducated on the Act 52 Infection Control Plan.
4. The Executive Director will monitor to ensure quarterly Infection Control Meetings are held per regulation.

§ 211.10(a) LICENSURE Resident care policies.:State only Deficiency.
(a) Resident care policies shall be available to admitting physicians, sponsoring agencies, residents and the public and shall reflect an awareness of, and provision for, meeting the total medical, nursing, mental and psychosocial needs of residents.

Observations:


Based on clinical record reviews and staff interviews, it was determined that the facility failed to develop policies related to use of call bells.

Findings include:

Observations of Resident 31 on February 20, 2024, at 1:05 p.m. revealed that the resident was lying in bed with the call bell behind the resident's head and out of reach.

Review of the facility's care policies, most recently reviewed by the facility on February 13, 2024, revealed that there was no policy regarding use of call bells.

Interview with the Nursing Home Administrator on February 21, 2024, at 10:06 a.m. confirmed that there were no policies regarding use of call bells.



 Plan of Correction - To be completed: 03/28/2024

1. Resident 31's call bell was placed within reach by staff after it was brought to attention by the state surveying agency (SSA).
2. In-house residents were observed by a member of the Interdisciplinary Team (IDT) to ensure residents call bell was within reach.
3. The Director of Nursing (DON)/designee reeducated the nursing staff to place call bell within reach of resident and on the facility's call bell system policy.
4. The DON/designee to monitor resident call bells to ensure within reach of resident 5 times a week x 2 weeks, weekly x 2 weeks, then monthly.

§ 211.12(f.1)(2) LICENSURE Nursing services. :State only Deficiency.
(2) Effective July 1, 2023, a minimum of 1 nurse aide per 12 residents during the day, 1 nurse aide per 12 residents during the evening, and 1 nurse aide per 20 residents overnight.

Observations:


Based on review of nursing schedules, review of staffing information furnished by the facility, and staff interviews, it was determined that the facility failed to ensure a minimum of one nurse aide per 12 residents on the day shift for two of 21 days, failed to ensure a minimum of one nurse aide per 12 residents on the evening shift for 14 of 21 days, and failed to ensure a minimum of one nurse aide per 20 residents on the overnight shifts for 17 of 21 days (24-hour periods) reviewed.

Findings Include:

Review of facility census data indicated that on February 5, 2024, the facility census was 117, which required 9.75 (117 residents divided by 12) nurse aides during the evening shift. Review of the nursing time schedules revealed 9.40 nurse aides provided care on the evening shift on February 5, 2024. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on February 5, 2024, the facility census was 117, which required 5.85 nurse aides during the night shift. Review of the nursing time schedules revealed 5.50 nurse aides provided care on the night shift on February 5, 2024. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on February 6, 2024, the facility census was 118, which required 9.83 nurse aides during the evening shift. Review of the nursing time schedules revealed 8.90 nurse aides provided care on the evening shift on February 6, 2024. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on February 6, 2024, the facility census was 118, which required 5.90 nurse aides during the night shift. Review of the nursing time schedules revealed 5.00 nurse aides provided care on the night shift on February 6, 2024. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on February 7, 2024, the facility census was 117, which required 9.75 nurse aides during the evening shift. Review of the nursing time schedules revealed 9.10 nurse aides provided care on the evening shift on February 7, 2024. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on February 8, 2024, the facility census was 116, which required 9.67 nurse aides during the evening shift. Review of the nursing time schedules revealed 9.60 nurse aides provided care on the evening shift on February 8, 2024. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on February 8, 2024, the facility census was 116, which required 5.80 nurse aides during the night shift. Review of the nursing time schedules revealed 4.90 nurse aides provided care on the evening shift on February 8, 2024. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on February 9, 2024, the facility census was 116, which required 9.67 nurse aides during the evening shift. Review of the nursing time schedules revealed 9.40 nurse aides provided care on the evening shift on February 9, 2024. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on February 9, 2024, the facility census was 116, which required 5.80 nurse aides during the night shift. Review of the nursing time schedules revealed 4.40 nurse aides provided care on the night shift on February 9, 2024. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on February 10, 2024, the facility census was 114, which required 9.50 nurse aides during the evening shift. Review of the nursing time schedules revealed 9.40 nurse aides provided care on the evening shift on February 10, 2024. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on February 10, 2024, the facility census was 114, which required 5.70 nurse aides during the night shift. Review of the nursing time schedules revealed 5.60 nurse aides provided care on the night shift on February 10, 2024. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on February 11, 2024, the facility census was 114, which required 9.50 nurse aides during the day shift. Review of the nursing time schedules revealed 9.30 nurse aides provided care on the day shift on February 11, 2024. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on February 11, 2024, the facility census was 113, which required 9.42 nurse aides during the evening shift. Review of the nursing time schedules revealed 8.30 nurse aides provided care on the evening shift on February 11, 2024. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on February 11, 2024, the facility census was 113, which required 5.65 nurse aides during the night shift. Review of the nursing time schedules revealed 4.70 nurse aides provided care on the night shift on February 11, 2024. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on February 12, 2024, the facility census was 113, which required 5.65 nurse aides during the night shift. Review of the nursing time schedules revealed 4.90 nurse aides provided care on the night shift on February 12, 2024. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on February 13, 2024, the facility census was 113, which required 5.65 nurse aides during the night shift. Review of the nursing time schedules revealed 4.50 nurse aides provided care on the night shift on February 13, 2024. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on February 14, 2024, the facility census was 112, which required 5.60 nurse aides during the night shift. Review of the nursing time schedules revealed 5.00 nurse aides provided care on the night shift on February 14, 2024. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on February 15, 2024, the facility census was 110, which required 9.17 nurse aides during the evening shift. Review of the nursing time schedules revealed 8.30 nurse aides provided care on the evening shift on February 15, 2024. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on February 15, 2024, the facility census was 110, which required 5.50 nurse aides during the night shift. Review of the nursing time schedules revealed 5.10 nurse aides provided care on the night shift on February 15, 2024. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on February 16, 2024, the facility census was 110, which required 9.17 nurse aides nurse aides during the evening shift. Review of the nursing time schedules revealed 8.20 nurse aides provided care on the evening shift on February 16, 2024. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on February 16, 2024, the facility census was 110, which required 5.50 nurse aides during the night shift. Review of the nursing time schedules revealed 5.00 nurse aides provided care on the night shift on February 16, 2024. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on February 17, 2024, the facility census was 109, which required 5.45 nurse aides nurse aides during the night shift. Review of the nursing time schedules revealed 4.40 nurse aides provided care on the night shift on February 17, 2024. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on February 18, 2024, the facility census was 109, which required 9.08 nurse aides during the evening shift. Review of the nursing time schedules revealed 8.70 nurse aides provided care on the evening shift on February 18, 2024. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on February 18, 2024, the facility census was 109, which required 5.45 nurse aides during the night shift. Review of the nursing time schedules revealed 4.50 nurse aides provided care on the night shift on February 18, 2024. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on February 19, 2024, the facility census was 110, which required 9.17 nurse aides during the evening shift. Review of the nursing time schedules revealed 8.10 nurse aides provided care on the evening shift on February 19, 2024. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on February 19, 2024, the facility census was 110, which required 5.50 nurse aides during the night shift. Review of the nursing time schedules revealed 4.80 nurse aides provided care on the night shift on February 19, 2024. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on February 20, 2024, the facility census was 110, which required 5.50 nurse aides during the night shift. Review of the nursing time schedules revealed 4.50 provided care on the night shift on February 20, 2024. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on February 21, 2024, the facility census was 110, which required 9.17 nurse aides during the evening shift. Review of the nursing time schedules revealed 8.80 nurse aides provided care on the evening shift on February 21, 2024. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on February 21, 2024, the facility census was 110, which required 5.50 nurse aides during the night shift. Review of the nursing time schedules revealed 4.60 nurse aides provided care on the night shift on February 21, 2024. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on February 22, 2024, the facility census was 110, which required 9.17 nurse aides during the day shift. Review of the nursing time schedules revealed 8.00 nurse aides provided care on the day shift on February 22, 2024. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on February 22, 2024, the facility census was 110, which required 9.17 nurse aides during the evening shift. Review of the nursing time schedules revealed 9.10 nurse aides provided care on the evening shift on February 22, 2024. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on February 23, 2024, the facility census was 111, which required 9.25 nurse aides during the evening shift. Review of the nursing time schedules revealed 9.00 nurse aides provided care on the evening shift on February 23, 2024. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on February 23, 2024, the facility census was 111, which required 5.55 nurse aides during the night shift. Review of the nursing time schedules revealed 4.40 nurse aides provided care on the night shift on February 23, 2024. No additional excess higher-level staff were available to compensate this deficiency.

Interview with the Nursing Home Administrator on February 23, 2024, at 4:30 p.m. confirmed that the facility did not meet the required nurse aide-to-resident staffing ratios for the days listed above.


 Plan of Correction - To be completed: 03/28/2024

1. The facility cannot retroactively correct nursing staffing hours and ratios.
2. The facility is focusing on the retention of existing nursing staff and recruiting new staff through the efforts of the staffing committee and human resource department.
3. The Executive Director (ED) re-educated the scheduler and nursing supervisors on the staffing ratios and hours per patient day (HPPD). Staffing meetings to review the calculations for nursing staff ratios and HPPD for accuracy.
4. The ED or Designees to conduct Quality Improvement (QI) monitoring of daily schedules to ensure the ratio of care/minimum PPD will be met. QI monitoring conducted via OnShift Daily Schedules reviewed weekly x 4 weeks, then once a month as needed. Findings reported to the Quality Improvement Performance Improvement (QAPI) committee and updated as indicated. QI monitoring schedule modified based on findings.

§ 211.12(f.1)(4) LICENSURE Nursing services. :State only Deficiency.
(4) Effective July 1, 2023, a minimum of 1 LPN per 25 residents during the day, 1 LPN per 30 residents during the evening, and 1 LPN per 40 residents overnight.
Observations:


Based on review of nursing schedules, review of staffing information furnished by the facility, and staff interviews, it was determined that the facility failed to ensure a minimum of one licensed practical nurse LPN per 25 residents during the day shift for seven of 21 days, failed to ensure a minimum of one LPN per 30 residents on the evening shift for one of 21 days, and failed to ensure a minimum of one LPN per 40 residents on the night shift for 18 of 21 days reviewed.

Findings Include:

Review of facility census data indicated that on February 3, 2024, the facility census was 117, which required 2.93 LPN's during the night shift.

Review of the nursing time schedules revealed 2.50 LPN's worked on the night shift on February 3,2024. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on February 4, 2024, the facility census was 117, which required 2.93 LPN's during the night shift.

Review of the nursing time schedules revealed 2.30 LPN's worked on the night shift on February 4, 2024. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on February 5, 2024, the facility census was 117, which required 2.93 LPN's during the night shift.

Review of the nursing time schedules revealed 1.90 LPN's worked on the night shift on February 5, 2024. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on February 6, 2024, the facility census was 118, which required 2.95 LPN's during the night shift.

Review of the nursing time schedules revealed 2.00 LPN's worked on the night shift on February 6, 2024. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on February 8, 2024, the facility census was 116, which required 2.90 LPN's during the night shift.

Review of the nursing time schedules revealed 1.90 LPN's worked on the night on February 8, 2024. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on February 9, 2024, the facility census was 116, which required 2.90 LPN's during the night shift.

Review of the nursing time schedules revealed 2.00 LPN's worked on the night shift on February 9, 2024. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on February 10, 2024, the facility census was 114, which required 2.85 LPN's during the night shift.

Review of the nursing time schedules revealed 1.90 LPN's worked on the night shift on February 10, 2024. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on February 11, 2024, the facility census was 113, which required 2.83 LPN's during the night shift.

Review of the nursing time schedules revealed 2.40 LPN's worked on the night shift on February 11, 2024. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on February 12, 2024, the facility census was 113, which required 2.83 LPN's during the night shift.

Review of the nursing time schedules revealed 2.00 LPN's worked on the night shift on February 12, 2024. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on February 13, 2024, the facility census was 113, which required 2.83 LPN's during the night shift.

Review of the nursing time schedules revealed 2.50 LPN's worked on the night shift on February 13, 2024. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on February 14, 2024, the facility census was 112, which required 2.80 LPN's during the night shift.

Review of the nursing time schedules revealed 2.00 LPN's worked on the night shift on February 14, 2024. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on February 15, 2024, the facility census was 110, which required 2.75 LPN's during the night shift.

Review of the nursing time schedules revealed 2.40 LPN's worked on the night shift on February 15, 2024. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on February 17, 2024, the facility census was 110, which required 4.40 LPN's during the day shift.

Review of the nursing time schedules revealed 4.00 LPN's worked on the day shift on February 17, 2024. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on February 17, 2024, the facility census was 109, which required 3.63 LPN's during the evening shift.

Review of the nursing time schedules revealed 3.60 LPN's worked on the evening shift on February 17, 2024. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on February 17, 2024, the facility census was 109, which required 2.73 LPN's during the night shift.

Review of the nursing time schedules revealed 2.50 LPN's worked on the night shift on February 17, 2024. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on February 18, 2024, the facility census was 109, which required 4.36 LPN's during the day shift.

Review of the nursing time schedules revealed 4.00 LPN's worked on the day shift on February 18, 2024. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on February 18, 2024, the facility census was 109, which required 2.73 LPN's during the night shift.

Review of the nursing time schedules revealed 2.50 LPN's worked on the night shift on February 18, 2024. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on February 19, 2024, the facility census was 109, which required 4.36 LPN's during the day shift.

Review of the nursing time schedules revealed 4.00 LPN's worked on the day shift on February 19, 2024. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on February 19, 2024, the facility census was 110, which required 2.75 LPN's during the night shift.

Review of the nursing time schedules revealed 2.50 LPN's worked on the night shift on February 19, 2024. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on February 20, 2024, the facility census was 110, which required 4.40 LPN's during the day shift.

Review of the nursing time schedules revealed 4.00 LPN's worked on the day shift on February 20, 2024. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on February 20, 2024, the facility census was 110, which required 2.75 LPN's during the night shift.

Review of the nursing time schedules revealed 2.00 LPN's worked on the night shift on February 20, 2024. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on February 21, 2024, the facility census was 110, which required 4.40 LPN's during the day shift.

Review of the nursing time schedules revealed 4.00 LPN's worked on the day shift on February 21, 2024. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on February 22, 2024, the facility census was 110, which required 4.40 LPN's during the day shift.

Review of the nursing time schedules revealed 4.00 LPN's worked on the day shift on February 22, 2024. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on February 22, 2024, the facility census was 110, which required 2.75 LPN's during the night shift.

Review of the nursing time schedules revealed 1.90 LPN's worked on the night shift on February 22, 2024. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on February 23, 2024, the facility census was 110, which required 4.40 LPN's during the day shift.

Review of the nursing time schedules revealed 4.00 LPN's worked on the day shift on February 23, 2024. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on February 23, 2024, the facility census was 111, which required 2.78 LPN's during the night shift.

Review of the nursing time schedules revealed 2.50 LPN's worked on the night shift on February 23, 2024. No additional excess higher-level staff were available to compensate this deficiency.

Interview with the Nursing Home Administrator on February 23, 2024, at 4:30 p.m. confirmed that the facility did not meet the required Licensed Practical Nurse-to-resident staffing ratios for the days listed above.



 Plan of Correction - To be completed: 03/28/2024

1. The facility cannot retroactively correct nursing staffing hours and ratios.
2. The facility is focusing on the retention of existing nursing staff and recruiting new staff through the efforts of the staffing committee and human resource department.
3. The Executive Director (ED) re-educated the scheduler and nursing supervisors on the staffing ratios and hours per patient day (HPPD). Staffing meetings to review the calculations for nursing staff ratios and HPPD for accuracy.
4. The ED or Designees to conduct Quality Improvement (QI) monitoring of daily schedules to ensure the ratio of care/minimum PPD will be met. QI monitoring conducted via OnShift Daily Schedules reviewed weekly x 4 weeks, then once a month as needed. Findings reported to the Quality Improvement Performance Improvement (QAPI) committee and updated as indicated. QI monitoring schedule modified based on findings.

§ 211.12(i)(1) LICENSURE Nursing services.:State only Deficiency.
(1) Effective July 1, 2023, the total number of hours of general nursing care provided in each 24-hour period shall, when totaled for the entire facility, be a minimum of 2.87 hours of direct resident care for each resident.

Observations:


Based on review of nursing schedules and staff interviews, it was determined that the facility failed to provide 2.87 hours of direct resident care for each resident for 14 of 21 days (24-hour periods) reviewed.

Findings include:

Nursing time schedules provided by the facility for the days of February 3 through February 23, 2024, revealed that the facility provided only 2.75 hours of direct care for each resident on February 5, 2024; 2.72 hours of direct care for each resident on February 8, 2024; 2.72 hours of direct care for each resident on February 9, 2024; 2.79 hours of direct care for each resident on February 10, 2024; 2.66 hours of direct care for each resident on February 11, 2024; 2.86 hours of direct care for each resident on February 12, 2024; 2.69 hours of direct care for each resident on February 15, 2024; 2.83 hours of direct care for each resident on February 16, 2024; 2.71 hours of direct care for each resident on February 17, 2024; 2.81 hours of direct care for each resident on February 18, 2024; 2.60 hours of direct care for each resident on February 19, 2024; 2.62 hours of direct care for each resident on February 22, 2024; and 2.71 hours of direct care for each resident on February 23, 2024.

Interview with the Nursing Home Administrator on February 23, 2024, at 4:30 p.m. confirmed that the facility did not meet the required daily PPD on the days listed above.




 Plan of Correction - To be completed: 03/28/2024

1. The facility cannot retroactively correct nursing staffing hours and ratios.
2. The facility is focusing on the retention of existing nursing staff and recruiting new staff through the efforts of the staffing committee and human resource department.
3. The Executive Director (ED) re-educated the scheduler and nursing supervisors on the staffing ratios and hours per patient day (HPPD). Staffing meetings to review the calculations for nursing staff ratios and HPPD for accuracy.
4. The ED or Designees to conduct Quality Improvement (QI) monitoring of daily schedules to ensure the ratio of care/minimum PPD will be met. QI monitoring conducted via OnShift Daily Schedules reviewed weekly x 4 weeks, then once a month as needed. Findings reported to the Quality Improvement Performance Improvement (QAPI) committee and updated as indicated. QI monitoring schedule modified based on findings.


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