Pennsylvania Department of Health
THE WATERMARK AT BELLINGHAM PARK LANE
Patient Care Inspection Results

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
THE WATERMARK AT BELLINGHAM PARK LANE
Inspection Results For:

There are  111 surveys for this facility. Please select a date to view the survey results.

Surveys don't appear on this website until at least 41 days have elapsed since the exit date of the survey.
THE WATERMARK AT BELLINGHAM PARK LANE - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:
Based on a Medicare/Medicaid Recertification survey, State Licensure survey and Civil Rights Compliance survey completed April 19, 2024, it was determined that The Watermark at Bellingham Parklane was not in compliance with the following requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care and the 28 Pa. Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations as they relate to the Health portion of the survey.


 Plan of Correction:


483.20(h)-(j) REQUIREMENT Coordination/Certification of Assessment:This is a less serious (but not lowest level) deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents.  This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.20(h) Coordination.
A registered nurse must conduct or coordinate each assessment with the appropriate participation of health professionals.

483.20(i) Certification.
483.20(i)(1) A registered nurse must sign and certify that the assessment is completed.

483.20(i)(2) Each individual who completes a portion of the assessment must sign and certify the accuracy of that portion of the assessment.

483.20(j) Penalty for Falsification.
483.20(j)(1)Under Medicare and Medicaid, an individual who willfully and knowingly-
(i) Certifies a material and false statement in a resident assessment is subject to a civil money penalty of not more than $1,000 for each assessment; or
(ii) Causes another individual to certify a material and false statement in a resident assessment is subject to a civil money penalty or not more than $5,000 for each assessment.

483.20(j)(2) Clinical disagreement does not constitute a material and false statement.
Observations:

Based on review of clinical records and Minimum Data Set (MDS-mandated assessments of a resident's abilities and care needs) assessments, and a staff interview, it was determined that the facility failed to timely certify the completion of the MDS assessments for nine of nine sampled residents (Residents 6, 40, 42, 50, 57, 65, 76, 77, and Resident 99).

Findings include:

The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which provides instructions and guidelines for completing required MDS assessments, dated October 2019, indicated that the MDS Completion Date must be no later than 14 days after the Assessment Reference Date.

Review of Resident 6's progress note of September 23, 2023, revealed that resident was discharged to home. Review of Resident 6's clinical record revealed that a discharge MDS assessment dated September 23, 2023, was not completed and was listed as "in progress". Review of progress note of January 8, 2024, revealed that orders were received to discharge the resident home. Further review of the clinical record revealed that a discharge MDS assessment dated January 8, 2024, was not completed and was listed as "in progress".

Review of Resident 40's progress note of November 10, 2023, revealed that resident was discharged. Review of the clinical record revealed that a discharge MDS assessment dated November 10, 2023, was not completed and was listed as "in progress".

Review of Resident 42's progress note of January 10, 2024, revealed that the resident was discharged home. Review of the clinical record revealed that a discharge MDS assessment dated January 10, 2024, was not completed and was listed as "in progress".

Review of Resident 50's progress note of December 15, 2023, revealed that the resident was admitted to the hospital. Further review of the clinical record revealed that a discharge MDS assessment was not completed.

Review of Resident 57's progress note of December 22, 2023, revealed that resident was discharged home. Review of the clinical record revealed that a discharge MDS assessment dated December 22, 2023, was not completed and was listed as "in progress".

Review of Resident 65's clinical record revealed Resident 65 was discharged to the community on February 1, 2024.

Review of Resident 65's clinical record revealed Resident 65's discharge MDS was listed as "in progress".

Review of Resident 76's progress note of January 12, 2024, revealed resident was admitted to the hospital. Further review of the clinical record failed to reveal evidence that a discharge MDS assessment was completed.

Review of Resident 77's progress note of November 16, 2023, revealed that the resident was discharged home. Review of the clinical record revealed that a discharge MDS assessment dated November 16, 2023, was not completed and was listed as "in progress".

Review of Resident 99's progress note dated February 14, 2024 revealed Resident 99 expired in the facility.

Review of Resident 99's clinical record revealed Resident 99's Death in Facility MDS was listed as "in progress".

28 Pa. Code: 211.12 (d)(1)(5) Nursing services.
Previously cited 6/23/23



 Plan of Correction - To be completed: 05/26/2024

The following Coordination/Certification Assessments were completed:
Resident 6 MDS with ARD 9/23/23 was submitted on 4/23/34 and the MDS with ARD 1/8/24 was submitted on 4/24/24.
Resident 40 MDS with ARD 11/10/23 was submitted on 4/28/24.
Resident 42 MDS with ARD 1/10/24 was submitted on 4/28/24.
Resident 50 MDS with ARD 12/15/23 was submitted on 3/1/24.
Resident 57 MDS with ARD 12/22/23 was submitted on 4/30/24.
Resident 65 MDS with ARD 2/1/24 was submitted on 5/1/24.
Resident 76 MDS with ARD 1/12/24 was submitted on 4/28/24.
Resident 77 MDS with ARD 11/16/23 was submitted on 4/30/24.
Resident 99 MDS with ARD 2/14/24 was submitted on 5/1/24.

MDS staff received education on MDS scheduling, completion and following RAI guidelines.

A house MDS audit was completed for residents to ensure the deficient MDS assessments were completed and submitted. 82 additional residents were identified to have had an incomplete or in progress assessment. Those residents identified have had a MDS modified and submitted on 5/4/2024.

Weekly random audits of MDS timely scheduling and timely completion will be completed by the NHA, DON or designee X 3 months. Findings will be reported to QAPI for review and recommendations as appropriate.

483.80(a)(1)(2)(4)(e)(f) REQUIREMENT Infection Prevention & Control:This is a less serious (but not lowest level) deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents.  This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.80 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 upon review of facility policy and procedure, observation, and clinical record review, it was determined the facility failed to ensure enhanced barrier precautions were in place for residents requiring enhanced barrier precautions for three of three reviewed (Residents 50, 212, and 213).

Findings include:

Review of facility policy and procedure titled Enhanced Barrier Precautions, revised March 26, 2024, revealed "Enhanced Barrier Precautions (EBP) expands the use of PPE beyond situations in which exposure to blood and body fluids is anticipated, refers to the use of gown and gloves during high contact resident care activities that provide opportunities for transfer of multidrug resistant organism (MDROs) to staff hands and clothing."

Further review of facility policy and procedure revealed "EBP are indicated for residents with any of the following and should be used: infection or colonization with a CDC-targeted MDRO when Contact Precautions do otherwise apply; or wounds and/or indwelling medical devices even if the resident is not known to be infected or colonized with a MDRO; wounds in this policy refer generally to chronic wounds, not shorter lasting wounds such as skin breaks or tears covered with adhesive bandage or similar dressing. Examples of chronic wounds include but are not limited to pressure injuries, diabetic foot ulcers, unhealed surgical wounds, and venous stasis ulcers; indwelling medical device examples include central lines, urinary catheters, feeding tubes and tracheotomies. A peripheral intravenous line (not a peripherally inserted central catheter/PICC) is not considered an indwelling medical device for this policy."

Further review of this policy revealed "Examples of high contact resident care activities requiring gown and gloves for Enhanced Barrier Precautions include dressing, bathing/showering, transferring, providing hygiene, changing liens, changing briefs or assisting with toileting, device care or use, wound care - any skin opening requiring a dressing, contact during therapy in gyms, and transfers in shower rooms/bathing areas."

Further review of this policy revealed "Post EBP signage to communicate with associates the need for gown and gloves as applicable."

Review of Resident 50's admission MDS (Minimum Data Set - periodic assessment of resident needs) dated December 25, 2023, revealed that the resident had an in-dwelling catheter (a flexible tube inserted into the bladder for removing fluid).

Observations of Resident 50's room on the first three days of the survey failed to reveal evidence of EBP signage or PPE.

Review of Resident 212's admission diagnosis list revealed a diagnosis of osteomyelitis of the left foot with MRSA (an MDRO).

Observation of Resident 212's room on the first three days of the survey failed to reveal evidence of EBP signage or PPE.

Review of Resident 213's admission diagnosis list indicated Resident 213 had a colostomy.

Observation of Resident 213's room on the first three days of the survey failed to reveal evidence of EBP signage and failed to reveal evidence of PPE.

Observation of the First-Floor nursing unit on the first three day of the survey failed to reveal evidence of any EBP signage on any resident room that required same. No PPE was present in resident rooms or hallways. Multiple observations of staff entering and exiting rooms requiring EBP failed to reveal evidence of any PPE in use.

28 Pa. Code 211.5(f) Clinical records
Previously cited 6/23/23

28 Pa. Code: 211.12(d)(1)(5) Nursing services
Previously cited 6/23/23


 Plan of Correction - To be completed: 05/26/2024

The following Infection Prevention & Control practices were implemented:

Resident 50 Enhanced Barrier Precautions have been implemented.
Resident 212 Enhanced Barrier Precautions have been implemented.
Resident 213 Enhanced Barrier Precautions were implemented.

Nursing staff received education on Enhanced Barrier Precautions and implementation.

All residents were reviewed to ensure Enhanced Barrier Precautions have been implemented according to policy.

Weekly random audits of residents will be completed by DON or designee, to ensure Enhanced Barrier Precautions are in place per policy X 3 months or until substantial compliance is maintained. Audit findings will be reported to QAPI for review and recommendations as applicable.
483.20(b)(1)(2)(i)(iii) REQUIREMENT Comprehensive Assessments & Timing: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.
483.20 Resident Assessment
The facility must conduct initially and periodically a comprehensive, accurate, standardized reproducible assessment of each resident's functional capacity.

483.20(b) Comprehensive Assessments
483.20(b)(1) Resident Assessment Instrument. A facility must make a comprehensive assessment of a resident's needs, strengths, goals, life history and preferences, using the resident assessment instrument (RAI) specified by CMS. The assessment must include at least the following:
(i) Identification and demographic information
(ii) Customary routine.
(iii) Cognitive patterns.
(iv) Communication.
(v) Vision.
(vi) Mood and behavior patterns.
(vii) Psychological well-being.
(viii) Physical functioning and structural problems.
(ix) Continence.
(x) Disease diagnosis and health conditions.
(xi) Dental and nutritional status.
(xii) Skin Conditions.
(xiii) Activity pursuit.
(xiv) Medications.
(xv) Special treatments and procedures.
(xvi) Discharge planning.
(xvii) Documentation of summary information regarding the additional assessment performed on the care areas triggered by the completion of the Minimum Data Set (MDS).
(xviii) Documentation of participation in assessment. The assessment process must include direct observation and communication with the resident, as well as communication with licensed and nonlicensed direct care staff members on all shifts.

483.20(b)(2) When required. Subject to the timeframes prescribed in 413.343(b) of this chapter, a facility must conduct a comprehensive assessment of a resident in accordance with the timeframes specified in paragraphs (b)(2)(i) through (iii) of this section. The timeframes prescribed in 413.343(b) of this chapter do not apply to CAHs.
(i) Within 14 calendar days after admission, excluding readmissions in which there is no significant change in the resident's physical or mental condition. (For purposes of this section, "readmission" means a return to the facility following a temporary absence for hospitalization or therapeutic leave.)
(iii)Not less than once every 12 months.
Observations:


Based on review of the Resident Assessment Instrument User's Manual, clinical record review and staff interview, it was determined that the facility failed to ensure that the comprehensive Minimum Data Set assessments were completed in the required time frame for five of 12 residents reviewed (Residents 27, 166, 212, 214, 262)

Findings include:

The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which provides instructions and guidelines for completing required Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2019, indicated that a comprehensive admission MDS assessment was to be completed no later than 14 days following admission and an annual assessment not less than once every 12 months.

Review of Resident 27's clinical record revealed that an admission MDS assessment with an ARD (assessment reference date - last day of the assessment's look-back period) of April 17, 2023. The MDS is not completed and is listed as "in progress".

Review of Resident 166's clinical record revealed an admission MDS assessment dated February 13, 2024, was not completed and was listed as "in progress".

Review of Resident 212's clinical record revealed an admission MDS assessment with an ARD of April 11, 2024 was not initiated or submitted.

Review of Resident 214's clinical record revealed an admission MDS assessment with an ARD of April 16, 2024 was not completed and was listed as "in progress".

Review of Resident 262's clinical records revealed that an annual assessment with an ARD of November 3, 2023, was not completed and was listed as "in progress".

28 Pa Code 201.18(b)(1) Management
Previously cited 6/23/23

28 Pa. Code 211.5(f) Clinical records.
Previously cited 6/23/23


 Plan of Correction - To be completed: 05/26/2024


The following Comprehensive Assessments were completed:
Resident 27 MDS with ARD 4/17/23 (4/17/24) was completed and submitted on 4/25/24.
Resident 166 MDS with ARD 2/13/24 and was completed and submitted on 5/1/24.
Resident 212 MDS with ARD 4/2/24 was completed and submitted late on 4/19/24.
Resident 214 MDS with ARD 4/16/24 per the POC and instead set for 4/13/24 and was completed and submitted on 5/2/24.
Resident 262 MDS with ARD 11/3/23 was completed and submitted on 4/23/24.

MDS staff received education on MDS scheduling, completion and following RAI guidelines.

A house MDS audit was completed on 4/30/24. Nine additional residents were identified to have had an incomplete or in progress MDS out of compliance for comprehensive assessments. Those residents affected by this deficient practice have had an MDS completed and submitted on 5/3/24.

Weekly random audits of MDS timely scheduling and timely completion will be completed by the NHA, DON or designee X 3 months. Findings will be reported to QAPI for review and recommendations as appropriate.



483.20(c) REQUIREMENT Qrtly Assessment at Least Every 3 Months: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.
483.20(c) Quarterly Review Assessment
A facility must assess a resident using the quarterly review instrument specified by the State and approved by CMS not less frequently than once every 3 months.
Observations:

Based on review of the Resident Assessment Instrument User's Manual and clinical records, and staff interviews, it was determined that the facility failed to complete a quarterly Minimum Data Set assessments timely for four of 12 residents reviewed (Residentsv 5, 22, 50, and 211 ).

Findings include:

The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which provides instructions for completing Minimum Data Set (MDS- assessments (mandated assessments of residents' abilities and care needs), dated October 2019, indicated that a quarterly assessment was to be completed within 92 days of the previous assessment's (any type) reference date.


Review of Resident 5's clinical record revealed a quarterly assessment with an ARD (assessment reference date - last day of the assessment's look back period) of March 15, 2024. The assessment was not completed and is listed as "in progress".

Review of Resident 22's clinical record revealed a quarterly assessment with an ARD of March 6, 2024. The assessment was not completed.

Review of Resident 50's clinical record revealed a quarterly assessment with an ARD of March 22, 2024. The assessment was not completed and is listed as "in progress".

Review of Resident 211's clinical record revealed a quarterly assessment with an ARD of November 14, 2023 was not completed and is listed as "in progress".

28 Pa. Code: 211.12(d)(1)(5) Nursing services
Previously cited 6/23/23


 Plan of Correction - To be completed: 05/26/2024

The following Quarterly Assessments were completed:
Resident 5 in progress MDS with ARD 3/15/24 was completed and submitted on 5/2/24.
Resident 22 in progress MDS with ARD 3/6/24 was completed and submitted on 4/26/24.
Resident 50 in progress MDS with ARD 3/22/24 was completed and submitted on 5/2/24.
Resident 211 in progress MDS with ARD 11/14/23 as indicated in the POC was actually set for 11/9/23 was completed and submitted on 4/21/24.

MDS staff received education on MDS scheduling, completion and following RAI guidelines.

A house MDS audit was completed on 4/30/24. Three additional residents were identified to have a missed quarterly MDS. Those residents affected by this deficient practice have had a MDS completed and submitted on 5/2/24.

Weekly random audits of MDS timely scheduling and timely completion will be completed by the NHA, DON or designee X 3 months. Findings will be reported to QAPI for review and recommendations as appropriate.

483.15(c)(3)-(6)(8) REQUIREMENT Notice Requirements Before Transfer/Discharge: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.
483.15(c)(3) Notice before transfer.
Before a facility transfers or discharges a resident, the facility must-
(i) Notify the resident and the resident's representative(s) of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand. The facility must send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman.
(ii) Record the reasons for the transfer or discharge in the resident's medical record in accordance with paragraph (c)(2) of this section; and
(iii) Include in the notice the items described in paragraph (c)(5) of this section.

483.15(c)(4) Timing of the notice.
(i) Except as specified in paragraphs (c)(4)(ii) and (c)(8) of this section, the notice of transfer or discharge required under this section must be made by the facility at least 30 days before the resident is transferred or discharged.
(ii) Notice must be made as soon as practicable before transfer or discharge when-
(A) The safety of individuals in the facility would be endangered under paragraph (c)(1)(i)(C) of this section;
(B) The health of individuals in the facility would be endangered, under paragraph (c)(1)(i)(D) of this section;
(C) The resident's health improves sufficiently to allow a more immediate transfer or discharge, under paragraph (c)(1)(i)(B) of this section;
(D) An immediate transfer or discharge is required by the resident's urgent medical needs, under paragraph (c)(1)(i)(A) of this section; or
(E) A resident has not resided in the facility for 30 days.

483.15(c)(5) Contents of the notice. The written notice specified in paragraph (c)(3) of this section must include the following:
(i) The reason for transfer or discharge;
(ii) The effective date of transfer or discharge;
(iii) The location to which the resident is transferred or discharged;
(iv) A statement of the resident's appeal rights, including the name, address (mailing and email), and telephone number of the entity which receives such requests; and information on how to obtain an appeal form and assistance in completing the form and submitting the appeal hearing request;
(v) The name, address (mailing and email) and telephone number of the Office of the State Long-Term Care Ombudsman;
(vi) For nursing facility residents with intellectual and developmental disabilities or related disabilities, the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with developmental disabilities established under Part C of the Developmental Disabilities Assistance and Bill of Rights Act of 2000 (Pub. L. 106-402, codified at 42 U.S.C. 15001 et seq.); and
(vii) For nursing facility residents with a mental disorder or related disabilities, the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with a mental disorder established under the Protection and Advocacy for Mentally Ill Individuals Act.

483.15(c)(6) Changes to the notice.
If the information in the notice changes prior to effecting the transfer or discharge, the facility must update the recipients of the notice as soon as practicable once the updated information becomes available.

483.15(c)(8) Notice in advance of facility closure
In the case of facility closure, the individual who is the administrator of the facility must provide written notification prior to the impending closure to the State Survey Agency, the Office of the State Long-Term Care Ombudsman, residents of the facility, and the resident representatives, as well as the plan for the transfer and adequate relocation of the residents, as required at 483.70(l).
Observations:


Based on clinical record review and interview with staff, it was determined that the facility failed to notify the State Long-Term Care (LTC) Ombudsman's office of residents transferred or discharged for three of three residents reviewed (Residents 50, 64, and 76).

Findings include:

Review of Resident 50's clinical record revealed a nursing progress note dated December 15, 2023, revealed that the resident had a new order to be sent to the hospital to be evaluated due to bilateral lower extremity pain.

Further review of Resident 50's clinical record failed to reveal documented evidence that the State Ombudsman's office was notified of Resident 50's transfers from the facility to the hospital.

Review of Resident 64's nursing progress notes dated March 17, 2024, at 10:14 p.m., revealed resident was sent back to the hospital for further treatment (right knee infection).

Review of Resident 64's clinical record failed to reveal the State Ombudsman's office was notified of Resident 64's transfers from the facility to the hospital.

Review of Resident 76's clinical progress notes dated January 12, 2024 revealed Resident 76 was sent to the hospital and admitted as a result of a urinary tract infection.

Further review of Resident 76's clinical record failed to reveal evidence that the State Ombudsman's office was notified of the transfer to the hospital.

Interview with the Nursing Home Administrator on April 19, 2024, at 10:40 a.m. confirmed that the facility did not notify the State Ombudsman's office when residents were transferred or discharged.

28 Pa. Code 201.14(a) Responsibility of licensee

28 Pa. Code 201.18(a) Management

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

28 Pa. Code 201.29(a) Resident rights


 Plan of Correction - To be completed: 05/26/2024

The State Long-Term Care Ombudsman's office was immediately notified of transfer or discharge for R50, R64 and R76.

Director of Social Services received education on proper notification to State Long-Term Care Ombudsman of any resident transfer or discharge.

The State Long-Term care Ombudsman was notified of any resident transfer or discharge that took place since January 1, 2024.

Weekly audits will be completed by Social Services X 3 months or until substantial compliance is maintained. Findings will be reported to QAPI for review and recommendations as applicable.

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


Based on clinical record review and staff interview, it was determined that the facility failed to ensure MDS assessments accurately reflected the resident's status for two of 12 residents reviewed (Residents 50 and 212).

Findings include:

Review of Resident 50's hospital readmission skin assessment dated December 21, 2023, indicated resident had a left medial ankle venous stasis ulcer (slow healing sores on the legs caused by poor circulation). Review of the admission MDS assessment (Minimum Data Set - periodic assessment of resident needs) dated December 25, 2023, section M1030 Number of Venous and Arterial Ulcers indicated that Resident 50 did not have any venous or arterial ulcers.

Interview with the Director of Nursing, on April 19, 2024, at 1:30 p.m. confirmed that Resident 50 was admitted with the venous ulcer and the the assessment did not accurately reflect the resident's status.

Review of Resident 212's clinical progress note dated March 29, 2024 revealed "Patient was admitted to Room [number] via stretcher accompanied by two attendees on March 29, 2024 at 1630 [4:30 p.m.] with DX [diagnosis] of left foot infection MRSA [methicillin resistant staph aureus]. Patient oriented to room medications discussed denies pain/discomfort at this time. VSS [vital signs stable] safety measures in place."

Review of Resident 212's Admission/5 day MDS failed to reveal the diagnosis of MRSA to Resident 212's left foot.

Interview with the Director of Nursing and Nursing Home Administrator on April 19, 2024 at 1:30 p.m. confirmed that Resident 212's admission MDS did not accurately reflect Resident 212's status.

483.20 Accuracy of Assessments
Previously cited 6/23/23

28 Pa. Code 211.5(f) Clinical records
Previously cited 6/23/23

28 Pa. Code: 211.12(d)(1)(5) Nursing services
Previously cited 6/23/23


 Plan of Correction - To be completed: 05/26/2024

The following Assessments were completed for accuracy:
Resident 50 MDS with ARD 12/25/23 was modified on 5/1/24 and submitted on 5/2/24.
Resident 212 MDS with ARD 4/2/24 was modified on 5/2/24 and submitted on 5/3/24.

MDS staff received education on MDS scheduling, completion, accuracy and RAI guidelines.

A house MDS audit was completed for residents with infection and/or wounds on 5/1/24. No additional residents were identified to have an inaccurately coded MDS with an infection and/or wound.

Weekly random audits of MDS accuracy will be completed by the NHA, DON or designee X 3 months. Findings will be reported to QAPI for review and recommendations as appropriate.

483.21(a)(1)-(3) REQUIREMENT Baseline 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 Comprehensive Person-Centered Care Planning
483.21(a) Baseline Care Plans
483.21(a)(1) The facility must develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. The baseline care plan must-
(i) Be developed within 48 hours of a resident's admission.
(ii) Include the minimum healthcare information necessary to properly care for a resident including, but not limited to-
(A) Initial goals based on admission orders.
(B) Physician orders.
(C) Dietary orders.
(D) Therapy services.
(E) Social services.
(F) PASARR recommendation, if applicable.

483.21(a)(2) The facility may develop a comprehensive care plan in place of the baseline care plan if the comprehensive care plan-
(i) Is developed within 48 hours of the resident's admission.
(ii) Meets the requirements set forth in paragraph (b) of this section (excepting paragraph (b)(2)(i) of this section).

483.21(a)(3) The facility must provide the resident and their representative with a summary of the baseline care plan that includes but is not limited to:
(i) The initial goals of the resident.
(ii) A summary of the resident's medications and dietary instructions.
(iii) Any services and treatments to be administered by the facility and personnel acting on behalf of the facility.
(iv) Any updated information based on the details of the comprehensive care plan, as necessary.
Observations:


Based upon review of clinical records, it was determined the facility failed to ensure baseline care plans were completed upon admission for three of 18 residents reviewed (Residents 93, 212 and 213).

Findings include:

Clinical records review revealed Resident 93 was admitted to the facility on April 12, 2024, with a PICC (Peripherally Inserted Central Catheter) line to the right upper arm.

Review of Resident 93's physician order dated April 12, 2024, revealed an order for Micafungin Sodium (Anti-fungal medication) Intravenous Solution 100mg one time a day for post abdominal surgery for ten days.

Review of Resident 93's current care plan revealed that a care plan for the Resident's presence of PICC line and IV Anti-Fungal medication administration was not developed.

Interview with the Director of Nursing on April 19, 2024, at 1:00 p.m., confirmed a baseline care plan for the presence of PICC line and IV anti-fungal medication was not developed for Resident 93.

Review of Resident 212's clinical record revealed Resident 212 was admitted with a diagnosis of MRSA [methicillin resistant staph aureus - multi-drug resistant organism] of the left foot.

Review of Resident 212's baseline care plan failed to reveal evidence that the MRSA of the left foot was included in the baseline care plan.

Review of Resident 213's clinical record revealed Resident 213 was admitted to the facility on March 30, 2024, with a colostomy.

Review of Resident 213's baseline care plan failed to reveal evidence of the presence of a colostomy on admission.

Interview with the Nursing Home Administrator and Director of Nursing on April 19, 2024, at 1:45 p.m. confirmed there was no baseline care plans initiated for Resident 212's MRSA and Resident 213's colostomy.

28 Pa. Code 211.5(f) Clinical records
Previously cited 6/23/23

28 Pa. Code 211.11(a)(d) Resident care plans

28 Pa. Code: 211.12(d)(1)(5) Nursing services
Previously cited 6/23/23


 Plan of Correction - To be completed: 05/26/2024

The following Baseline Care Plans were completed:
Resident 93 Care Plan was implemented for PICC line and antifungal medication.
Resident 212 Care Plan was implemented for MRSA.
Resident 213 Care Plan was implemented for colostomy.

Licensed nurses received education on the policy for Baseline Care Plan implementation.

Audit was completed on residents admitted within the past 30 days to ensure Baseline Care Plans were initiated timely. No additional residents will PICC line, antifungal medications, MRSA or colostomies have been identified at this time.

Weekly random audits of new admission Baseline Care Plans will be completed by DON or designee, to ensure timely implementation X 3 months or until substantial compliance is maintained. Findings will be reported to QAPI for review and recommendations as applicable.


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 clinical records and staff interview, it was determined that the facility failed to develop a comprehensive care plan for one of 12 residents reviewed (Resident 50).

Findings include:

Review of Resident 50's physician's orders included an order dated December 22, 2023, for Heparin Sodium (anticoagulant - blood thinner) Injection 5000 units subcutaneously (under the skin) every 12 hours. Review of Resident 50's current active care plan revealed no care plan or interventions for anticoagulant medication.

Review of Resident 50's wound assessment dated April 2, 2024, revealed resident had arterial wounds (wounds caused by poor circulation) of the right and left ankles, the left first MTP (metatarsophalangeal - joints connecting bones of the foot to the toes), right medial foot, right lateral ankle, and left and right heels. Resident 50 also had a venous ulcer (slow healing sore caused by weak blood circulation) of the left calf and pressure ulcers (areas of damaged skin and tissue caused by sustained pressure) to the right and left buttocks.

Review of Resident 50's current active care plan revealed no care plan or interventions addressing the wounds.

Interview with the Director of Nursing on April 19, 2024, at 1:30 confirmed that Resident 50 did not have a care plan to address the anticoagulant or wounds.

28 Pa. Code 211.5(f) Clinical records
Previously cited 6/23/23

28 Pa. Code 211.12(d)(1)(5) Nursing services
Previously cited 6/23/23


 Plan of Correction - To be completed: 05/26/2024

The following Comprehensive Care Plan was completed:
Resident 50 Comprehensive Care Plan for wounds and anticoagulation medication were initiated.

Licensed nurses received education on the policy for Comprehensive Care Plan implementation for wounds and anticoagulation medications.

Residents with wounds were reviewed for timely implementation of Comprehensive Care Plan related to wounds. No additional residents were identified at this time.
Residents receiving anticoagulation medications were reviewed for timely implementation of Comprehensive Care Plan related to anticoagulation medications. No other residents were identified at this time.

Weekly random audits of Comprehensive Care Plans related to wounds and anticoagulation medications will be completed by DON or designee, to ensure timely implementation X 3 months or until substantial compliance is maintained. Findings will be reported to QAPI for review and recommendations as applicable.

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 a review of the facility's policy, clinical records review, and staff interviews, it was determined that the facility failed to follow the physician's weight monitoring order for two of the 12 residents reviewed (Resident 64 and 263).

Findings include:

A review of the facility's policy titled "Weights Policy", dated August 1, 2023, revealed residents will be weighed as directed by the physician, federal/state regulations, or standards of practice.

Clinical records review revealed Resident 64 was re-admitted to the facility on March 26, 2024, with the following diagnoses: Lymphedema (A swelling that generally occurs in an arm or leg caused by lymphatic system blockage), and right knee infection.

A review of Resident 64's physician's order sheet (POS) dated March 26, 2024, revealed an order for daily weights times three every day shift for monitoring for three days.

Review of Resident 64's March 2024, Treatment Administration Record (TAR) revealed resident's weight was not done on March 27, and 28, 2024.

Review of Resident 64's nursing progress notes dated March 27, 2024, revealed "Hoyer lift was broken..."

Review of Resident 64's nursing progress notes dated March 28, 2024, revealed weight was unable to complete.

Review of clinical record of Resident 263 revealed Residnets was admitted to the facility on April 8, 2024, with a feeding tube (medical device used to provide nutrition to people who cannot obtain nutrition by mouth) due to a diagnosis of Cerebrovascular Accident (stroke).

Review of Resident 263's physician order sheet dated April 8, 2024, revealed an order for daily weights times three every day shift for monitoring for three days.

Review of Resident 263's April 2024, TAR, revealed a weight of 158 pounds (from the hospital) on April 9, 2024. No weight was taken on April 10, 2024.

Interview with the dietitian, Employee E3 conducted on April 19, 2024, at 11:00 a.m., was conducted. Employee E3 reported that upon admission, the resident's weight should have been taken to get a baseline weight. Employee E3 confirmed that hospital weight should have not been used as a baseline weight when the resident was admitted to the facility. Employee E3 was unable to provide an answer as to why the physician's order regarding admission weight monitoring was not followed.

The facility failed to ensure Resident 64 and 263's admission physician weight monitoring order was followed.

28 Pa. Code 201.18(b)(1) Management
Previously cited 6/23/23

28 Pa. Code 211.5(f) Clinical records
Previously cited 6/23/23

28 Pa. Code 211.12(d)(1)(3)(5) Nursing services
Previously cited 6/23/23


 Plan of Correction - To be completed: 05/26/2024

The following weights were obtained:
Resident 64 weight was obtained and moving forward will be obtained per Weight Policy
Resident 263 weight was obtained and moving forward will be obtained per Weight Policy.

Registered Dietician and Licensed Staff received education on Weight Policy.

All current residents were audited to ensure weights are obtained per Weight Policy.

All new admission weights will be audited weekly by RD or designee, to ensure Weight Policy is followed X 3 months or until substantial compliance is maintained. Findings will be reported to QAPI for review and recommendations as applicable.

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 observations, clinical record reviews, as well as resident and staff interviews, it was determined that the facility failed to follow a physician's order and the wound specialist recommendation for one of four residents reviewed (Resident 262).

Findings include:

Review of Resident 262's clinical record revealed Resident 262 was admitted to the facility with a Stage 4 Pressure Ulcer (Full-thickness skin and tissue loss) to the sacrum.

Review of Resident 262's physician's order dated January 19, 2024, revealed a wound treatment to clean the sacral wound with an acetic wash, pat dry, and apply Medihoney (A dressing that aids and supports debridement and a moist wound healing environment in acute and chronic wounds and burns) with calcium alginate and cover with foam dressing.

Review of Resident 262's wound consult dated March 12, 2024, revealed improving the stage four wound to the sacrum, treatment recommendation was to cleanse the wound with saline solution (changed from Acetic wash), apply Medihoney with calcium alginate, and cover it with foam dressing.

Review of Resident 262's clinical record including, March 2024 and April 2024 Treatment Administration Record failed to reveal that the wound specialist recommendation made on March 12, 2024, to change acetic to normal saline was followed.

Observation of Resident 262's wound treatment with licensed nurse Employee E4 was conducted on April 19, 2024, at 11:00 a.m. During the wound observation, Employee E4 was observed cleaning the wound with an Acetic Solution.

Interview with the Director of Nursing conducted on April 19, 2024, revealed that any wound treatment recommendation from the wound specialist needed approval from the resident's primary physician.

Further review of Resident 262's clinical record failed to reveal that the primary physician was notified of the new wound treatment recommendation from the wound specialist on March 12, 2024.

The facility was unable to provide documentation and an answer as to why the recommendation from the wound specialist was not followed.

Review of the Resident 262's physician order dated August 30, 2023, revealed an order for the resident to be out of bed to a wheelchair for two hours in the room for lunch then put the resident back to bed after lunch (maximum of two hours out of bed) one time a day.

Observation conducted on April 17, 2024, at 1:00 p.m., revealed Resident 262 was in bed.

Observation conducted on April 18, 2024, at 1:38 p.m., revealed Resident 262 was in bed.

Interview was conducted with Resident 262 on April 18, 2024, at 1:40 p.m. The resident reported that no one had asked her/him to be out of bed. The resident reported that she/he was informed by the wound doctor that she/he needed to be out of bed for a few hours during lunch, but the staff would tell her/him that if she gets out of bed during lunch, that she/he might not get back to bed until after dinner. The resident verbalized wanting to be out of bed for a few hours, but this has not been happening for almost a month now.

Interview was conducted with Nursing Assistant Employee E4 on April 18, 2024, at 2:00 p.m. Employee E4 reported that she/he was an agency staff. Employee E4 reported that Resident 262 was not offered to be out of bed because she/he was given a report that the resident does not get out of bed.

The above information was conveyed to the Director of Nursing on April 19, 2024.

The facility failed to ensure Resident 262's physician order and wound specialist wound treatment recommendations were followed.

28 Pa. Code 201.18(b)(1) Management
Previously cited 6/23/23

28 Pa. Code 211.5(f) Clinical records
Previously cited 6/23/23

28 Pa. Code 211.12(d)(1)(3)(5) Nursing services
Previously cited 6/23/23



 Plan of Correction - To be completed: 05/26/2024

The following Treatment/Services to Prevent/Heal Pressure Ulcer were initiated:

Resident 262 Physician order was updated to most recent recommendation made by wound care NP.

Consulting wound care NP received education to review any new orders with DON or designee prior to leaving the building after the completion of weekly wound rounds.

All residents being followed by consulting wound care NP were reviewed to ensure recommendations made by consulting wound care NP were addressed appropriately.

Weekly random audits of consulting wound care NP recommendations will be completed by DON or designee, to ensure all recommendations made are addressed appropriately X 3 months or until substantial compliance is maintained. Findings will be reported to QAPI for review and recommendations as applicable.

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 the facility's policy, clinical records review, and staff interview, it was determined that the facility failed to provide treatment and services to maintain/restore bladder continence of one of the 12 residents reviewed (Resident 64).

Findings include:

Review of the facility's policy titled "Bowel and Bladder - Continence", dated October 15, 2018, revealed that the facility has a standard in place for all residents related to bowel and bladder management and continence care. The procedure includes the following: Begin with a two-hour daytime voiding schedule; Approach the resident at the scheduled time; Wait five seconds to allow an opportunity to self-initiate toileting; Prompt the resident with verbal cueing if needed; Assist the resident with the toileting needs; Adjust the schedule up or down as needed, do not exceed four-hour intervals; and consult with therapy and nursing regarding changes/concerns.

Review of Resident 64's Admission Minimum Data Set (MDS- A standardized assessment tool that measures health status in long-term care residents) dated March 17, 2024, revealed resident was cognitively impaired and dependent on toileting. The same MDS revealed that Resident 64 bladder continence was always continent.

Review of Resident 64's clinical record revealed resident was hospitalized and was re-admitted to the facility on March 26, 2024.

Review of Resident 64's MDS dated March 30, 2024, revealed resident was frequently incontinent with urine, which was a change from the March 17, 2024, MDS assessment.

Review of Resident 64's clinical record failed to reveal a comprehensive bladder continence assessment was completed after identifying a change in the resident's urinary continence.

The facility was unable to provide documentation of a treatment or services provided to monitor, restore/maintain Resident 64's urinary status.

Interview conducted with the Director of Nursing on April 19, 2024, at 12:30 p.m., confirmed that the facility failed to comprehensively assess Resident 64's urinary continence upon identifying a change and failed to implement treatment/services to restore and or maintain the resident's urinary status.

28 Pa. Code 201.18(b)(1) Management
Previously cited 6/23/23

28 Pa. Code 211.5(f) Clinical records
Previously cited 6/23/23

28 Pa. Code 211.12(d)(1)(3)(5) Nursing services
Previously cited 6/23/23

28 Pa. Code 211.10 (a)(d) Resident care policies


 Plan of Correction - To be completed: 05/26/2024

Resident 64 did not have a change in urinary continence. He remains continent.

The following MDS coding errors were corrected:
Resident 64 MDS dated 3/30/24 was corrected and resubmitted on 5/1/24.

MDS staff received education on MDS scheduling, completion and following RAI guidelines.

A house MDS audit of residents with MDS submitted was completed. No additional residents were identified as being affected by this deficient practice.

Weekly random audits of MDS accuracy will be completed by the NHA, DON or designee X 3 months. Findings will be reported to QAPI for review and recommendations as appropriate.

483.45(a)(b)(1)-(3) REQUIREMENT Pharmacy Srvcs/Procedures/Pharmacist/Records: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 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 clinical record reviews and staff interview, it was determined that the facility failed to ensure medications were made available for one of the 12 residents reviewed (Resident 93).

Findings include:

Review of Resident 93's diagnosis list includes hypertension (Elevated blood pressure), and Atherosclerotic Heart Disease (ASHD-heart condition in which an accumulation of fatty substances results in the narrowing of arteries and causing restriction in the flowing of blood).

Review of Resident 93's physician order dated April 12, 2024, revealed an order for Verapamil HCL ER 240 mg(miligram) given one tablet daily by mouth at bedtime for hypertension.

Review of Resident 93's April 2024, Medication Administration Record revealed Verapamil medication was not administered to the resident until April 16, 2024, four days after it was ordered.

Review of Resident 93's nursing progress notes dated April 12, 2024, at 9:46 p.m., revealed medication on route from the pharmacy.

Review of Resident 93's nursing progress notes dated April 14, 2024, at 8:07 p.m., revealed "waiting for pharmacy to drop off" (medication).

Review of Resident 93's nursing progress notes dated April 15, 2024, at 10:58 p.m., revealed: "called the pharmacy and is coming tonight."

Review of Resident 93's pharmacy records revealed that Verapamil medication was not delivered from the pharmacy until April 15, 2024, at 11:12 p.m.

Review of the facility's emergency medication available list does not include the medication Verapamil.

The above information was discussed with the Director of Nursing on April 19, 2024, at 11:30 a.m.

The facility failed to ensure Verapamil medication was available for Resident 93.

28 Pa. Code 211.12(d)(1)(3)(5) Nursing services
Previously cited 6/23/23

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



 Plan of Correction - To be completed: 05/26/2024

The following Pharmacy Services/Procedures/Pharmacist/Records have been completed:
Resident 93 Verapamil HCL ER 240mg was obtained from the pharmacy. Physician is aware and no adverse effects related to delay were documented.

Licensed nurses received education on physician notification of delay in pharmacy availability.

All residents receiving Verapamil HCL ER 240mg were audited to ensure timely availability of medication. No additional residents were identified.

Weekly random audits of residents receiving Verapamil HCL ER 240mg will be completed by DON or designee, to ensure timely availability of medication X 3 months or until substantial compliance is maintained. Findings will be reported to QAPI for review and recommendations as applicable.

201.22(a) LICENSURE Prevention, control and surveillance of tuber:State only Deficiency.
(a) The facility shall have a written TB infection control plan with established protocols which address risk assessment and management, screening and surveillance methods, identification, evaluation, and treatment of residents and employees who have a possible TB infection or active TB.

Observations:


Based on personnel record review and staff interview it was determined the facility failed to screen an employee for Tuberculosis (TB) prior to hiring for one of five employee records reviewed. (Employees E6)

Findings Include:

Review of Employee Personnel Files for new hires revealed that Employee E6 was not tested for tuberculosis prior to hire.

Interview with the Nursing Home Administrator on April 19, 2024, at 1:00 p.m., confirmed Employee E6 was not tested for tuberculosis prior to hire.



 Plan of Correction - To be completed: 05/26/2024

Employee 6 One step tuberculosis test has been completed.

Human Resource received education on TB Testing for Associates policy.

New hires from January 1, 2024 have been audited for acceptable pre-hire TB testing per policy and corrections made as warranted.

Weekly audits of all new hire TB testing will be completed by Human Resources to ensure TB Testing for Associates policy was followed X 3 months or until substantial compliance is maintained. Findings will be reported to QAPI for review and recommendations as applicable.



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