Pennsylvania Department of Health
ARBUTUS PARK MANOR
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

ARBUTUS PARK MANOR
Inspection Results For:

There are 92 surveys for this facility. Please select a date to view the survey results.

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ARBUTUS PARK MANOR - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:
Based on a Medicare/Medicaid Recertification survey, State Licensure survey, Civil Rights Compliance survey, and a complaint survey completed on September 19, 2024, it was determined that Arbutus 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(i)(1)-(7) REQUIREMENT Safe/Clean/Comfortable/Homelike Environment:

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(i) Safe Environment.
The resident has a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

The facility must provide-
§483.10(i)(1) A safe, clean, comfortable, and homelike environment, allowing the resident to use his or her personal belongings to the extent possible.
(i) This includes ensuring that the resident can receive care and services safely and that the physical layout of the facility maximizes resident independence and does not pose a safety risk.
(ii) The facility shall exercise reasonable care for the protection of the resident's property from loss or theft.

§483.10(i)(2) Housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior;

§483.10(i)(3) Clean bed and bath linens that are in good condition;

§483.10(i)(4) Private closet space in each resident room, as specified in §483.90 (e)(2)(iv);

§483.10(i)(5) Adequate and comfortable lighting levels in all areas;

§483.10(i)(6) Comfortable and safe temperature levels. Facilities initially certified after October 1, 1990 must maintain a temperature range of 71 to 81°F; and

§483.10(i)(7) For the maintenance of comfortable sound levels.

Observations:

Based on observations and staff interviews, it was determined that the facility failed to ensure that residents had a clean and homelike environment on one of three nursing units (secured unit).

Findings include:

Observations on September 16, 2024, at 8:17 p.m. revealed that the carpet in the hallway on the 400 side of the secured unit was stained and dirty. There was duct tape on the carpet of the threshold between the hallway and room 408 and between the hallway and room 410.

Interview with the Director of Maintenance on September 18, 2024, revealed that the carpet in the secured unit was to be scrubbed nightly and that it was in need of being replaced. He stated that the duct tape on the floor between the hallway and rooms 408 and 410 was there because the strip that was there was a trip hazard. He stated that the duct tape made a smooth transition between the hallway and the resident rooms.

Interview with the Director of Nursing on September 18, 2024, at 1:24 p.m. confirmed that the carpeting in the secured unit needed replaced and that duct tape should not have been placed on the threshold between the hallway and the resident rooms.

28 Pa. Code 201.29(j) Resident Rights.

28 Pa. Code 207.2(a) Administrator's Responsibility.

Plan of Correction - To be completed: 11/08/2024

The carpet on the secured unit is in poor repair with stains because of the age of the carpet as well as the need for professional cleaning. The transition strips have been removed to accommodate a safety concern between the room and hallway of 2 doorways and instead of repairing to accommodate for safety concern the tape was placed.
The carpet is to be professionally cleaned and then checked daily and spot scrubbed by housekeeping in the evening twice weekly and as needed. The transition strips between rooms 408 and 410 will be placed. Following the professional cleaning of the carpet and the spot cleaning twice weekly, the need for replacement will be re-evaluated and if identified to need replaced, we will initiate the process of flooring replacement.
Education regarding the regulation and plan of correction will be provided to maintenance and housekeeping staff by the Director of Nursing. The housekeeping Supervisor will be instructed how to identify concerns associated with environmental issues and the process to be taken to address concerns that are identified and follow up on completion of tasks assigned to address cleanliness and homelike appearance of the resident areas by the Director of Nursing.
For Quality Assurance Purposes environmental rounds will be completed weekly to address spot cleaning needs as well as environmental appearance issues identified by the housekeeping supervisor. The concerns will be assigned to the specified department to address. The identified concerns and interventions to address the concerns will be addressed in the Quality Assurance and Performance improvement meetings that are held every other week with all department leaders on an ongoing basis.

483.60(i)(1)(2) REQUIREMENT Food Procurement,Store/Prepare/Serve-Sanitary:

§483.60(i) Food safety requirements.
The facility must -

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

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

Observations:

Based on facility policies, observations, and staff interviews, it was determined that the facility failed to store food in accordance with professional standards for food service safety.

Findings include:

The facility's policy regarding labeling and dating food, dated January 10, 2024, revealed that food was to be discarded on or immediately after the expiration/use by date.

Observations in the kitchen on September 16, 2024, at 6:15 p.m. revealed that there were two gallons of chocolate ice cream mix that expired July 17, 2024, and one gallon of vanilla ice cream mix that expired July 15, 2024, in the cooler. Observations in the freezer at that time revealed two bags of frozen chicken breasts that were open and exposed to air. The freezer also had opened ice cream cup containers and food container debris lying on the floor under the shelves. Observations on September 16, 2024, in the dry storage room revealed food crumbs and debris on the floor and the floor was sticky.

Observations in the kitchen on September 18, 2024, at 10:05 a.m. revealed that a fan with a large accumulation of dust blowing on to the food prep area, and there was food, dirt, and debris on the floor in the freezer and on the floor in the dry storage room.

Interview with the Food Service Director on September 18, 2024, 10:09 a.m. confirmed that the ice cream mix and frozen chicken breasts should have been discarded, and that the freezer and dry storage rooms should have been clean.

28 Pa. Code 211.6(f) Dietary Services.

Plan of Correction - To be completed: 11/08/2024

The expired food items and exposed chicken were disposed of immediately. The floors have also been cleaned in the freezers and dry storage area. The fan was removed and cleaned.
The Kitchen area was deep cleaned by the kitchen personnel.
The dietary and housekeeping / maintenance staff will be educated on the regulation as well as the plan of correction associated with the deficiency by the Kitchen Supervisor and the Director of Nursing.
There will be a specific preventative cleaning and maintenance schedule established for the kitchen for sanitation and cleanliness maintenance for routine cleaning to be accomplished in the kitchen area. This schedule will be posted in the kitchen area.
When the food delivery arrives on a weekly basis and the new items are restocked, the items remaining on the shelves will be checked for proper storage as well as any expired items disposed of prior to the addition of new inventory.
The kitchen will be inspected twice weekly to assure completion of the scheduled cleaning and proper storage is addressed as applicable for 4 weeks. This inspection will be done by the Director of Nursing, Administrator or the Assistant Administrator.
For Continued Quality assurance purposes, the kitchen will be inspected randomly to assure that the schedule is being followed for the same purposes and any identified concerns will be addressed immediately as well as discussed in the Quality Assurance and Improvement Meetings every other week to discuss further need of intervention implementation.
Education and plan of correction will be implemented by 11/8/2024.

483.10(c)(7) REQUIREMENT Resident Self-Admin Meds-Clinically Approp:

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

§483.10(c)(7) The right to self-administer medications if the interdisciplinary team, as defined by §483.21(b)(2)(ii), has determined that this practice is clinically appropriate.

Observations:

Based on review of facility policies and clinical records, as well as observations and staff interviews, it was determined that facility failed to determine if a resident was safe to self-administer medications for one of 31 residents reviewed (Resident 99).

Findings include:

The facility's medication policy, dated January 10, 2024, indicated that self-administration was permitted when specifically authorized by the physician. Control and supervision are the responsibility of the faculty.

Review of the clinical record for Resident 99 revealed that she was admitted to the facility on September 11, 2024, and had diagnoses that included diabetes.

Physician's orders for Resident 99, dated September 11, 2024, included an order that the resident could use her insulin pump (a wearable medical device that supplies a continuous flow of insulin underneath the skin) as set by her endocrinologist (doctor who specializes in the diagnosis and treatment of hormone-related diseases and conditions, including diabetes) with 100 unit per milliliter of basal Novolog (insulin used to keep your blood glucose levels stable during periods of fasting) at a rate of 0.55 units per hour.

Physician's orders for Resident 99, dated September 12, 2024, included an order that the resident could manage her insulin bolus (dose of insulin taken to handle a rise in blood glucose) as set up in her insulin pump by her endocrinologist, before meals and at bedtime, making sure she notifies staff prior to self-administering each bolus.

There was no documented evidence in Resident 99's clinical record to indicate that an assessment was completed to determine if she was safe to self-administer her medication.

A nurse's note for Resident 99, dated September 13, 2024, at 4:10 a.m. revealed that the resident appeared to be anxious and confused at times and that she continued to manage her diabetes with a continuous glucose machine.

Observations of Resident 99 on September 17, 2024, at 2:30 p.m. revealed that the resident had an insulin pump attached to her right abdomen, which she reported at the time of the observation to be functioning properly.

Interview with the Director of Nursing on September 18, 2024, at 2:39 p.m. confirmed that an assessment to determine if Resident 99 was safe to self-administer her medications was not completed.

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

Plan of Correction - To be completed: 11/08/2024

There was no medication self administration assessment completed on resident 99 to determine if she was capable of self administration prior to the resident being permitted to do such.
Education will consist of the regulation, the reason we were cited and the plan of correction associated with the deficiency.
All registered nurses will be educated on how to complete the medication self administration assessment for residents wishing to self administer medications. The medication administration policy will be updated to include when an assessment should be completed to include with admission, resident request to self administer medications and also with annual comprehensive assessment completion or with change in condition. All licensed nurses will also be educated on need to notify a Registered nurse if a resident is requesting any self administration. Education and update on protocol will be completed by the Director of Nursing.
All residents requesting self-administration of any medication will have an assessment completed and care plan updated to include their ability to self administer what they were deemed capable of doing or if there are limitations associated with self administration.
For Quality Assurance purposes, All new licensed nurses will be educated on the medication administration policy to include how to identify the need to complete and how to complete the self administration assessment. Moving forward, any resident who wishes to self administer will be identified through 24 hour report and an assessment completed prior to permitting resident to self administer to assure the resident is safe and capable of doing so.
A weekly check with direct care staff nurses will be completed to assure that everyone who self administers medications is identified and reassessed with Annual and significant change comprehensive assessments during safety risk meetings by the interdisciplinary care team.

Education and plan of correction will be completed by November 8, 2024.

483.10(j)(1)-(4) REQUIREMENT Grievances:

§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 policies, as well as interviews with residents and staff, it was determined that the facility failed to ensure that residents and/or their representatives could file a grievance/concern anonymously by failing to ensure that information on how to file a grievance or complaint was available to residents or their representatives without asking.

Findings include:

The facility's "Grievance Process" policy, dated January 10, 2024, indicated that anyone may file a grievance anonymously if they chose to do so.

During an interview with a group of residents on September 17, 2024, at 10:34 a.m., the residents indicated that they did not know how to file a grievance anonymously.

Interview with the Director of Nursing on September 19, 2024, at 9:48 a.m. revealed that the facility's grievance forms were located behind each nursing station, and confirmed that nurses could give the forms to the residents; however, residents or their representatives could not access or file the grievance forms on their own.

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

28 Pa. Code 201.29(i) Resident Rights.

Plan of Correction - To be completed: 11/08/2024

There was no location identified for residents to file a grievances anonymously without requesting from the staff.
All facility staff will be educated on the processes established for residents to file a grievance and forms will be issued to residents at a special activity to reach the majority of the resident. The residents will be told where they can place anonymous grievances and also how they would file a grievance verbally if they choose.
They can write a grievance note on any piece of paper of their choosing or use the specific forms that will be available at both lock boxes to write their grievance and can drop in the locked box at any time of the day or night.
We will also make responsible parties aware of processes established in house so that they can also file a grievance as they see necessary. The message will also include the name, email address and telephone number of the grievance officer established in the facility. New residents will be given information on how to file a grievance during new resident orientation to the facility.
For Quality Assurance purposes we will discuss the grievance processes established with every residents council moving forward and hand out forms for filing and make them readily available throughout the facility at the elevator exits as well as the front desk. They will be checked daily and a plan developed to address the grievance and a written response maintained on record or provided to the resident as necessary. The box will be checked by the Grievance officer, Administrator or the Director of Nursing and Addressed with department necessary to address the concerns.
Education and plan of correction will be completed by 11/08/2024.

483.15(c)(3)-(6)(8) REQUIREMENT Notice Requirements Before Transfer/Discharge:

§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(k).

Observations:

Based on clinical record reviews and staff interviews, it was determined that the facility failed to notify the resident and legal guardian in writing regarding the reason for hospitalization for two of 31 residents reviewed (Residents 54, 83).

Findings include:

A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 54, dated July 25, 2024, revealed that the resident was understood, could understand others, and had a diagnosis that included a cerebral vascular accident (CVA - commonly known as a stroke) with hemiplegia (paralysis on one side of the body).

Nursing notes for Resident 54, dated July 11, 2024, revealed that the resident's foley catheter (a thin, flexible tube that drains urine from the bladder into a collection bag) was changed the previous night. A urine was obtained that morning, and the resident has not had any output since. The nurse removed water from the foley catheter balloon to change it thinking that it was blocked, but blood came out from around the resident's penis and the catheter would not come out. When the nurse tried to advance the foley, blood came out. The resident had a temperature the previous night that went down but went back up to 101.2 degrees Fahrenheit (F), and he was having dyspnea (shortness of breath). The resident was started on oxygen and was sent to the emergency room and admitted with a diagnosis of sepsis (a life-threatening condition that occurs when the body's immune system overreacts to an infection, damaging the body's own tissues and organs).

There was no documented evidence that a written notice of Resident 54's transfer to the hospital was provided to the resident and/or the resident's responsible party regarding the reason for transfer.

Interview with the Business Office Manager on September 18, 2024, at 1:03 p.m. confirmed that there was no documented evidence that a written notice of Resident 54's transfer to the hospital was provided to the resident and/or the resident's responsible party regarding the reason for transfer.

A quarterly MDS assessment for Resident 83, dated August 1, 2024, indicated that the resident was cognitively impaired, was dependent on staff for his daily care needs, and had diagnoses that included dementia.

A nurse's note for Resident 83, dated June 2, 2024, at 2:04 p.m., revealed that the resident had decreased urine output, his abdomen was distended, and he had abnormal drainage from his penis. The physician was notified, and orders were received to transport the resident to the emergency room for evaluation. A nurse's note at 8:14 p.m. revealed that the resident was admitted to the hospital.

A nurse's note for Resident 83, dated July 19, 2024, at 11:33 a.m., revealed that the physician reviewed the results of the resident's x-ray and recommended further testing be done at the hospital. The physician ordered the resident be transferred to the emergency room for evaluation. A nurse's note at 8:45 p.m. revealed that the resident was admitted to the hospital for further testing and treatment.

A nurse's note for Resident 83, dated August 8, 2024, at 3:00 a.m., revealed that the resident had a change in condition that included a fever and elevated heart rate and blood pressure. The family was notified and gave permission to transfer the resident to the emergency room for evaluation. A nurse's note at 6:06 a.m. revealed that the resident was admitted to hospital.

There was no documented evidence that a written notice of Resident 83's transfers to the hospital was provided to the resident's responsible party regarding the reason for transfer.

Interview with the Business Office Manager on August 18, 2024, at 1:05 p.m. confirmed that the facility was not providing written notices to the residents or their responsible parties that indicated the reason for transfer to the hospital when a resident was transferred to the hospital.

28 Pa. Code 201.25 Discharge Policy.

28 Pa. Code 201.29(f)(g) Resident Rights.

Plan of Correction - To be completed: 11/08/2024

The nursing staff and business office staff will be educated on the regulation and well as the plan of correction associated with the deficiency by the Director of Nursing.
The notice was not being sent to the residents on transfer to the hospital as required related to lack of knowledge associated with the regulation as the facilities practice to return residents to the facility following hospitalization is never in question and is always communicated in person or by phone to the responsible party by the nurse.
The education will include the policy regarding the notices and the form that will be utilized to accomplish the notice. The business office personnel will send the notice to the responsible party on the business day following the transfer as this type of transfer is urgent related to the medical needs of a resident and cannot be accomplished prior to the transfer. The nurse initiating the transfer will continue to notify the responsible party in person or by telephone when the need is established based on resident condition and physicians order. It written notice will be in writing and uploaded into the electronic health record under miscellaneous documents to maintain proof of notice.
For Quality Assurance Purposes the Director of Nursing will check the miscellaneous records the day following any resident transfer to assure it was completed as required.
The education and plan of correction will be implemented by 11/08/2024.

483.15(d)(1)(2) REQUIREMENT Notice of Bed Hold Policy Before/Upon Trnsfr:

§483.15(d) Notice of bed-hold policy and return-

§483.15(d)(1) Notice before transfer. Before a nursing facility transfers a resident to a hospital or the resident goes on therapeutic leave, the nursing facility must provide written information to the resident or resident representative that specifies-
(i) The duration of the state bed-hold policy, if any, during which the resident is permitted to return and resume residence in the nursing facility;
(ii) The reserve bed payment policy in the state plan, under § 447.40 of this chapter, if any;
(iii) The nursing facility's policies regarding bed-hold periods, which must be consistent with paragraph (e)(1) of this section, permitting a resident to return; and
(iv) The information specified in paragraph (e)(1) of this section.

§483.15(d)(2) Bed-hold notice upon transfer. At the time of transfer of a resident for hospitalization or therapeutic leave, a nursing facility must provide to the resident and the resident representative written notice which specifies the duration of the bed-hold policy described in paragraph (d)(1) of this section.

Observations:

Based on review of clinical records, as well as staff interviews, it was determined that the facility failed to issue a bed-hold notice at the time of an anticipated leave of absence from the facility for two of 31 residents reviewed (Resident 54, 83).

Findings include:

A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 54, dated July 25, 2024, revealed that the resident was understood, could understand others, and had a diagnosis that included a cerebral vascular accident (CVA - commonly known as a stroke) with hemiplegia (paralysis on one side of the body).

Nursing notes for Resident 54, dated July 11, 2024, revealed that the resident's foley catheter (a thin, flexible tube that drains urine from the bladder into a collection bag) was changed the previous night. A urine was obtained that morning, and the resident has not had any output since. The nurse removed water from the foley catheter balloon to change it thinking that it was blocked, but blood came out from around the resident's penis and the catheter would not come out. When the nurse tried to advance the foley, blood came out. The resident had a temperature the previous night that went down but went back up to 101.2 degrees Fahrenheit (F), and he was having dyspnea (shortness of breath). The resident was started on oxygen and was sent to the emergency room and admitted with a diagnosis of sepsis (a life-threatening condition that occurs when the body's immune system overreacts to an infection, damaging the body's own tissues and organs).

There was no documented evidence that a bed-hold notice was issued to Resident 54 or his responsible party at the time of his transfer to the hospital.

Interview with the Business Office Manager on September 18, 2024, at 1:03 p.m. confirmed that there was no documented evidence that a bed-hold notice was issued to Resident 54 or his responsible party at the time of his transfer to the hospital.

A quarterly MDS assessment for Resident 83, dated August 1, 2024, indicated that the resident was cognitively impaired, was dependent on staff for his daily care needs, and had diagnoses that included dementia.

A nurse's note for Resident 83, dated June 2, 2024, at 2:04 p.m., revealed that the resident had decreased urine output, his abdomen was distended, and he had abnormal drainage from his penis. The physician was notified, and orders were received to transport the resident to the emergency room for evaluation. A nurse's note at 8:14 p.m. revealed that the resident was admitted to the hospital.

A nurse's note for Resident 83, dated July 19, 2024, at 11:33 a.m., revealed that the physician reviewed the results of the resident's x-ray and recommended further testing be done at the hospital. The physician ordered the resident to be transferred to the emergency room for evaluation. A nurse's note at 8:45 p.m. revealed that the resident was admitted to the hospital for further testing and treatment.

A nurse's note for Resident 83, dated August 8, 2024, at 3:00 a.m., revealed that resident had a change in condition that included a fever and elevated heart rate and blood pressure. The family was notified and gave permission to transfer the resident to the emergency room for evaluation. A nurse's note at 6:06 a.m. revealed that the resident was admitted to hospital.

There was no documented evidence that a bed-hold notice was issued to Resident 83 or his responsible party at the time of his transfers to the hospital.

Interview with the Business Office Manager on August 18, 2024, at 1:05 p.m. confirmed that the facility was not providing written bed-hold notices to the residents or their responsible parties when a resident was transferred to the hospital.

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

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

Plan of Correction - To be completed: 11/08/2024

The nursing staff and business office staff will be educated on the regulation and well as the plan of correction associated with the deficiency by the Director of Nursing.
The notice was not being sent to the residents on transfer to the hospital as required related to lack of knowledge associated with the regulation and the facilities practice to return residents to the facility following hospitalization is never in question.
The education will include the policy regarding the notices and the form that will be utilized to accomplish the notice. The business office personnel will send the notice to the responsible party on the business day following the transfer as this type of transfer is urgent related to the medical needs of a resident and cannot be accomplished prior to the transfer. It will be in writing and uploaded into the electronic health record under miscellaneous documents to maintain proof of notice. The bed hold notice will include all necessary information as required in the regulation.
For Quality Assurance Purposes the Director of Nursing will check the miscellaneous records the day following any resident transfer to assure it was completed as required.
The education and plan of correction will be implemented by 11/08/2024.

483.21(b)(1)(3) REQUIREMENT Develop/Implement Comprehensive Care Plan:

§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 policies and clinical records, as well as staff interviews, it was determined that the facility failed to develop care plans to address individualized resident care needs for one of 31 residents reviewed (Resident 99).

Findings include:

The facility's policy regarding care plans, dated January 10, 2024, indicated that a resident care plan will be established within 24 hours of admission and will be reviewed and revised as indicated on readmission, significant change, and as needed for new or revised interventions. Resident care management is designed to ensure systemic comprehensive approach to assessing, planning, and meeting the resident's needs.

Review of the clinical record for Resident 99 revealed that she was admitted to the facility on September 11, 2024, and had diagnoses that included diabetes.

Physician's orders for Resident 99, dated September 11, 2024, included an order that the resident may use her insulin pump (a wearable medical device that supplies a continuous flow of insulin underneath the skin) as set by her endocrinologist (doctor who specializes in the diagnosis and treatment of hormone-related diseases and conditions, including diabetes) with 100 unit per milliliter of basal Novolog (insulin used to keep blood glucose levels stable during periods of fasting) at a rate of 0.55 units per hour.

Physician's orders for Resident 99, dated September 12, 2024, included an order that the resident may manage her insulin bolus (dose of insulin taken to handle a rise in blood glucose) as set up in her insulin pump by her endocrinologist, before meals and at bedtime, making sure she notifies staff prior to self-administering each bolus.

Observations of Resident 99 on September 17, 2024, at 2:30 p.m. revealed that the resident had an insulin pump attached to her right abdomen, which she reported at the time of the observation to be functioning properly.

As of August 16, 2024, there was no documented evidence that a care plan was developed to address Resident 99's individualized care needs related to her diabetes and self-administration of insulin using an insulin pump.

Interview with the Director of Nursing on September 18, 2024, at 2:39 p.m. confirmed that Resident 99 did not have a care plan in place to address the care and treatment required for her diagnosis of diabetes and self-administering insulin using an insulin pump.

28 Pa. Code 211.10(d) Resident Care Plans.

Plan of Correction - To be completed: 11/08/2024

All nursing staff and staff included in the interdisciplinary care plan implementation and revision process will be educated on the regulation as well as the plan of correction associate with the deficiency by the Director of Nursing.
The care plan for resident 99 in relation to her diabetes and self use of her pump was not initiated timely. R-99's care plan is presently in place regarding both management of diabetes as well as the self-administration of bolus's and was implemented on 9/28/2024.
An interim care plan should be implemented within 24 hours following admission and should address major concerns and issues on how to care for the individual.
The education will include the interim care plan development for a resident following admission and the need to update with significant changes and or concerns until the comprehensive assessment and care plan can be established.
For Quality Assurance purposes all newly admitted residents will have their interim care plan reviewed the day following admission to address their immediate concerns that are identified with admission diagnoses and conditions or concerns by the interdisciplinary care team in the morning clinical meetings that occur daily on an ongoing basis.
Education and plan of correction will be implemented by November 8, 2024.

483.21(b)(2)(i)-(iii) REQUIREMENT Care Plan Timing and Revision:

§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 policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that a resident's care plan was updated/revised to reflect the resident's specific care needs for one of 31 residents reviewed (Resident 41).

Findings include:

The facility's policy regarding care plans, dated January 10, 2024, indicated that a resident care plan will be established within 24 hours of admission and will be reviewed and revised as indicated on readmission, significant change, and as needed for new or revised interventions. Resident care management is designed to ensure systemic comprehensive approach to assessing, planning, and meeting the resident's needs.

A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 41, dated August 16, 2024, indicated that the resident was understood and could usually understand others, required assistance from staff for daily care needs, and had diagnoses that included dementia and Post Traumatic Stress Disorder (PTSD - a mental and behavioral disorder that develops related to a terrifying event).

A psychiatry consult note for Resident 41, dated June 16, 2024, revealed that the resident acknowledged experiencing PTSD symptoms as a result of his military service.

A review of Resident 41's plan of care revealed no documented evidence that his care plan was revised to address any triggers (stimulus that causes a painful memory to resurface) related to PTSD that could re-traumatize the resident.

Interview with the Director of Nursing on August 19, 2024, at 8:45 a.m. confirmed that the facility did not attempt to identify Resident 41's PTSD triggers and revise his care plan to include care related to possible PTSD triggers.

28 Pa. Code 201.24(e)(4) Admission Policy.

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

Plan of Correction - To be completed: 11/08/2024

There was no assessment completed or care plan established to address resident diagnoses of Post Traumatic Stress Disorder (PTSD) and how to care for this resident related to his possible triggers.
A trauma related event evaluation was created to be used for residents identified with potential traumatic events in their past medical or life history to identify and care plan appropriately to meet the needs of the individual related to potential triggers and how to care for that individual to avoid potential for re-traumatization. This was created by the Director of Nursing in coordination with Social Services.
Nursing staff and social services will be educated on the Trauma informed care and the importance of addressing care plan needs of residents that are identified with a history of a traumatic event to decrease the potential for re-traumatization related to their medical or personal history by the Director of Nursing and Social Services.
Resident 41 will have an assessment completed by Social Services to address his specific triggers and how to care for the individual to decrease the likelihood of re-traumatization. All residents with known trauma or diagnoses of PTSD will have this evaluation completed by Social Services and needs care planned appropriately. Staff caring for residents with identified needs will be educated on addressing the residents specific needs by Social Services.
For Quality Assurance Purposes diagnoses and resident history will be reviewed following each new admission and with change in condition in morning clinical meeting daily with the interdisciplinary care team. Any diagnoses change will also be reviewed for need to complete trauma assessment and care planning.
Education and plan of correction will be implemented by 11/08/2024.

483.25(m) REQUIREMENT Trauma Informed Care:

§483.25(m) Trauma-informed care
The facility must ensure that residents who are trauma survivors receive culturally competent, trauma-informed care in accordance with professional standards of practice and accounting for residents' experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization of the resident.

Observations:

Based on clinical record review and staff interview, it was determined that the facility failed to ensure that residents were assessed and received trauma-informed care to eliminate or mitigate triggers for residents with the diagnosis of Post Traumatic Stress Disorder (PTSD) (a mental and behavioral disorder that develops related to a terrifying event) for one of 31 residents reviewed (Resident 41).

Findings include:

A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 41, dated August 16, 2024, indicated that the resident was understood and could usually understand others, required assistance from staff for daily care needs, and had diagnoses that included dementia and PTSD.

Review of the care plan for Resident 41, dated January 22, 2024, indicated that the resident had a diagnosis of dementia and PTSD.

There was no documented evidence the facility identified Resident 41's specific triggers that could re-traumatize the resident or implement measures as to how facility staff could prevent or minimize triggers from occurring.

Interview with the Director of Nursing on August 19, 2024, at 8:45 a.m. confirmed that the facility did not complete a trauma informed care assessment on Resident 41.

28 Pa Code 201.24(e)(4) Admission Policy.

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

28 Pa. Code 211.16(a) Social Services.

Plan of Correction - To be completed: 11/08/2024

There was no evaluation for trauma related events previously established.
A trauma related event evaluation was created to be used for residents identified with potential traumatic events in their past medical or life history to identify and care plan appropriately to meet the needs of the individual related to potential triggers and how to care for that individual to avoid potential for re-traumatization. This was created by the Director of Nursing in coordination with Social Services.
Nursing staff and social services will be educated on the Trauma informed care and the importance of addressing care plan needs of residents that are identified with a history of a traumatic event to decrease the potential for re-traumatization related to their medical or personal history by the Director of Nursing and Social Services.
Trauma informed care education is currently in place as a part of all staff in-servicing that is to be completed on an annual basis for all employees including new hires.
Resident 41 will have an assessment completed by Social Services to address his specific triggers and how to care for the individual to decrease the likelihood of re-traumatization. All residents with known trauma or diagnoses of PTSD will have this evaluation completed by Social Services and needs care planned appropriately. Staff caring for residents with identified needs will be educated on addressing the residents specific needs by Social Services.
For Quality Assurance Purposes diagnoses and resident history will be reviewed following each new admission and with change in condition in morning clinical meeting daily with the interdisciplinary care team. Any diagnoses change will also be reviewed for need to complete trauma assessment and care planning.
Education and plan of correction will be implemented by 11/08/2024.

483.45(g)(h)(1)(2) REQUIREMENT Label/Store Drugs and Biologicals:

§483.45(g) Labeling of Drugs and Biologicals
Drugs and biologicals used in the facility must be labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable.

§483.45(h) Storage of Drugs and Biologicals

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

§483.45(h)(2) The facility must provide separately locked, permanently affixed compartments for storage of controlled drugs listed in Schedule II of the Comprehensive Drug Abuse Prevention and Control Act of 1976 and other drugs subject to abuse, except when the facility uses single unit package drug distribution systems in which the quantity stored is minimal and a missing dose can be readily detected.

Observations:

Based on review of policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that medications were properly labeled for one of 31 residents reviewed (Resident 36).

Findings include:

The facility's policy regarding medication, dated January 10, 2024, indicated that medications that a resident brings with him/her on admission to the facility from home or another facility will be used if they are properly labeled and ordered by the physician, and the dose is the ordered dose.

A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 36, dated July 17, 2024, revealed that the resident was understood, could understand others, and had a diagnosis which included multiple sclerosis (MS - a chronic autoimmune disease that affects the central nervous system).

Physician's orders for Resident 36, January 27, 2024, included orders for the resident to self-administer approximately sixty-one different over-the-counter biological and herbal supplements.

Observations of the West Hall medication refrigerator on September 19, 2024, at 11:07 a.m. revealed that on the bottom shelf of the door were eight plastic, sandwich-size, zip-lock baggies that were 1/4 full of multiple tablets and capsules. However, there was no labeling on the eight plastic sandwich-size, zip-lock baggies to indicate who they belonged to or what the contents were. Interview with Licensed Practical Nurse 1 at the time of observation revealed that the eight plastic, sandwich-size, zip-lock baggies containing the multiple tablets and capsules belonged to Resident 36 and were her biological and herbal supplements. She indicated that the resident's son prepares the supplements at home and then brings the zip-lock baggies into the facility. She confirmed that there was no name or labeling of what the contents of the zip-lock bags contained.

Interview with the Director of Nursing on September 19, 2024, at 11:55 a.m. confirmed that not having Resident 36's name on the zip lock baggies is a problem. She indicated that she maintains a list of the supplements that Resident 36 uses for the nursing staff that work on that unit.

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

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

Plan of Correction - To be completed: 11/08/2024

Resident 36 takes a substantial amount of biological and herbal supplements at her request and they are made up ahead of time for resident to self-administer as she requests different supplements at differing times of the day.
A meeting was held with the resident and her son regarding the supplements and the need to make up the packs and properly label. They verbalized understanding and we went over the supplement requests as requested by the resident.
Labels were established for the packages of supplements to be placed on the packages for the resident. They will be made up by a licensed nurse on a weekly basis with the bags labeled with the residents name and contents of each individual packet. They supplements will be purchased by the resident and delivered to the facility for purposes of packaging as requested by resident.
Self-administration of supplements was evaluated and resident does have knowledge and ability to self-administer and the physician has approved the supplement use and self-administration.
All licensed nurses will be educated on the process established specifically for this resident as well as the regulation of proper labeling and storing of drugs and biologicals.
For Quality Assurance Purposes drug and biological storage areas will be audited weekly for proper labeling and storage or items. Any identified concerns will be identified and addressed immediately and further corrective action implemented at the time of identification. Any identified concerns and additional interventions identified will also be discussed in the Quality Assurance and Performance Improvement meetings that are held every other week with all department leaders. The audits will be completed by the Nurse Supervisors of each location of storage.
Education and plan of correction will be implemented by 11/08/2024.

483.20(f)(5), 483.70(h)(1)-(5) REQUIREMENT Resident Records - Identifiable Information:

§483.20(f)(5) Resident-identifiable information.
(i) A facility may not release information that is resident-identifiable to the public.
(ii) The facility may release information that is resident-identifiable to an agent only in accordance with a contract under which the agent agrees not to use or disclose the information except to the extent the facility itself is permitted to do so.

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

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

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

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

§483.70(h)(5) The medical record must contain-
(i) Sufficient information to identify the resident;
(ii) A record of the resident's assessments;
(iii) The comprehensive plan of care and services provided;
(iv) The results of any preadmission screening and resident review evaluations and determinations conducted by the State;
(v) Physician's, nurse's, and other licensed professional's progress notes; and
(vi) Laboratory, radiology and other diagnostic services reports as required under §483.50.

Observations:

Based on review of clinical records, as well as resident and staff interviews, it was determined that the facility failed to maintain clinical records that were complete and accurately documented for one of 31 residents reviewed (Resident 99).

Findings include:

Review of the clinical record for Resident 99 revealed that she was admitted to the facility on September 11, 2024, and had diagnoses that included diabetes.

Physician's orders for Resident 99, dated September 12, 2024, included an order that the resident may manage her insulin bolus (dose of insulin taken to handle a rise in blood glucose) as set up in her insulin pump (a wearable medical device that supplies a continuous flow of insulin underneath the skin) by her endocrinologist (doctor who specializes in the diagnosis and treatment of hormone-related diseases and conditions, including diabetes), before meals and at bedtime, making sure she notifies staff prior to self-administering each bolus.

A nurse's note for Resident 99, dated September 15, 2024, at 10:05 a.m., revealed that the resident was nauseous and vomited. The nurse asked the resident if she gave herself a bolus of insulin, and she reported that she gave herself a small dose of less than three units.

Review of the Medication Administration Record (MAR) for Resident 99, dated September 2024, revealed no documented evidence of the amount of insulin the resident was self-administering with boluses using her insulin pump.

Interview with the Nursing Home Administrator on September 18, 2024, at 2:39 p.m. confirmed that there was no documented evidence of the amount of insulin the resident was self-administering with boluses using her insulin pump.

28 Pa. Code 211.5(f) Clinical Records

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

Plan of Correction - To be completed: 11/08/2024

Resident's order stated that the resident was to notify staff of administration of bolus insulin prior to administration. The nurses should have maintained record of medication that was self-administered.
Resident 99's Medication Administration Record was updated to include documentation of Bolus insulin verification to be completed every shift. Resident was educated by the Director of Nursing and a document given to the resident to self-record readings from her pump as well as notifying and writing down the insulin bolus amount that she is providing to herself.
Education will be provided to the nursing staff regarding the regulation and why we were cited and the plan of correction associated with the deficiency. Education will include the medication administration policy updates that include when a resident self-administers amounts of something that is not unit dosed and it is identified to be necessary as varying doses depending on circumstances it must be recorded to maintain the residents record complete and accurate.
Moving forward, any resident who wishes to self-administer medications or biologicals will be identified through 24 hour report in morning clinical meeting and an assessment completed prior to permitting resident to self administer. Medications that are given related to variables will have specific recordings necessitated in the residents medication or treatment administration records. This will occur on an ongoing basis.
Education and plan of correction will be implemented by 11/08/2024.

483.80(a)(1)(2)(4)(e)(f) REQUIREMENT Infection Prevention & Control:

§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 §483.71 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 established infection control guidelines, facility policy, and residents' clinical records, as well as observations and staff interviews, it was determined that the facility failed to follow infection control guidelines from the Centers for Medicare/Medicaid Services (CMS) and the Centers for Disease Control (CDC) to reduce the spread of infections and prevent cross-contamination for two of 31 residents reviewed (Residents 25, 37).

Findings include:

CDC guidance on isolation precautions and Implementation of Personal Protective Equipment (PPE) use in Nursing Homes to Prevent Spread of Multidrug-Resistant Organisms (MDRO's - bacteria that have become resistant to certain antibiotics, and these antibiotics can no longer be used to control or kill the bacteria), dated July 12, 2022, indicates that MDRO transmission is common in skilled nursing facilities, contributing to substantial resident morbidity and mortality and increased healthcare costs. Enhanced Barrier Precautions (EBP) are an infection control intervention designed to reduce transmission of resistant organisms that employs targeted gown and glove use during high contact resident care activities. CMS updated its infection prevention and control guidance effective April 1, 2024. The recommendations now include the use of EBP during high-contact care activities for residents with chronic wounds or indwelling medical devices, regardless of their MDRO status, in addition to residents who have an infection or colonization with a CDC-targeted or other epidemiologically important MDRO when contact precautions do not apply.

The facility's policy regarding EBP, dated January 10, 2024, indicated that the facility will prevent the spread of novel or targeted multidrug-resistant organisms (MDROs). The precautions refer to the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands. Enhanced barrier precautions apply to all residents with wounds and or indwelling medical devices (e.g. central line, urinary catheter, feeding tube, tracheostomy, or ventilator) regardless of MDRO colonization status.

An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 25, dated July 16, 2024, revealed that the resident was cognitively intact, required supervision with personal hygiene, had an indwelling urinary catheter (a flexible tube inserted into the bladder to collect urine into a drainage bag), and had diagnoses that included chronic kidney disease.

Physician's orders for Resident 25, dated August 15, 2024, included an order for the resident to have a size 16 French Coude (type of catheter with a curved tip used to empty urine from the bladder) catheter inserted.

Observations of Resident 25 on September 16, 2024, at 7:30 p.m. revealed that the resident was sitting in a recliner in his room with a catheter drainage bag in a basin on the floor to the left side of his feet. There was no signage or notification of the resident being on EBP posted at the resident's room, and there was no PPE observed in or around the resident's room.

Interview with Registered Nurse 2 on September 16, 2024, at 7:56 p.m. confirmed that Resident 25 did not have EBP in place and that the resident should have.

An admission MDS assessment for Resident 37, dated June 13, 2024, revealed that the resident was cognitively impaired, required assistance from staff for daily care needs, and had an indwelling urinary catheter (a soft, flexible plastic tube inserted in the bladder).

Physician's orders for Resident 37, dated June 6, 2024, included an order for an indwelling foley catheter, size 14 French with a 10 milliliter balloon.

Observations during the facility tour on September 16, 2024, at 7:55 p.m. revealed that Resident 37 was lying in bed with the indwelling catheter attached to the bed frame and visible from the doorway. There was no signage or notification of the resident being on EBP posted at the resident's room, and there was no PPE observed in or around the resident's room.

Interview with the Director of Nursing on September 16, 2024, at 8:50 p.m. confirmed that Resident's 25 and 37 did not have EBP precautions in place and they should have.

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

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

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

Plan of Correction - To be completed: 11/08/2024

There were no signs on the doors indicating to staff that enhanced barrier precautions were indicated for high contact activities in related to the use of an indwelling catheter for resident 25 and resident 37.
The signs were placed and the nursing staff re-educated on the need for enhanced barrier precautions related to indwelling medical devices even without active or colonized infection by the Director of Nursing.
Education will be provided to all facility staff related to the regulation as well as the plan of correction associated with the deficiency. The education will include the policy on enhanced barrier precautions and when there is a need for enhanced barrier precautions and how someone on precautions is identified and what care activities for the residents should include the use of enhanced barrier precautions. The education to be provided by the Director of Nursing.
For Quality Assurance purposes, all new residents will have a record review prior to admission to see if Enhanced Barrier Precautions are applicable and will have the posting implemented prior to their arrival and reevaluated with and change in condition. In clinical meetings we will discuss any acute changes in resident status and if there is an identified need of further transmission based precautions identified for anyone. This will include review of all lab results involving culture and sensitivity testing or needs that are symptom based to prevent further potential spread of illness.

Plan of correction and in-servicing will be implemented by 11/08/2024.

483.90(i) REQUIREMENT Safe/Functional/Sanitary/Comfortable Environ:

§483.90(i) Other Environmental Conditions
The facility must provide a safe, functional, sanitary, and comfortable environment for residents, staff and the public.

Observations:

Based on observations and staff interviews, it was determined that the facility failed to ensure that the resident environment was maintained in a safe and sanitary environment in one of two shower rooms on the secured unit and in one resident's bathroom (Resident 49).

Findings include:

Observations in the shower room on the secured unit on September 16, 2024, at 8:17 p.m. and again on September 18, 2024, at 8:43 a.m. revealed that the toilet grab bars were loose and that the toilet had rust stains and a black, removable substance around it.

Observations in Resident 49's room on September 16, 2024, at 8:17 p.m. and again on September 18, 2024, at 8:43 a.m. revealed that the resident's toilet grab bars were loose and not tightly secured to the wall or floor.

Interview with the Director of Maintenance on September 18, 2024, at 8:43 a.m. confirmed that the shower room toilet grab bars should not be loose, there should not be rust or a black, removable substance around the toilet, and that Resident 49's toilet grab bars should not be loose.

28 Pa. Code 207.2(a) Administrator's Responsibility.

Plan of Correction - To be completed: 11/08/2024

The bars surrounding the tub room toilet were repaired to restore security with use and the bars were also restored in the bathroom of resident 49. They are currently stable and safe to use. The area of rust and removable substance were cleaned and removed.
All bathrooms of residents will be checked for same concerns of loose toilet grab bars or cleanliness issues and requests for cleaning or repairs will be made by the Director of Nursing and housekeeping supervisor.
All staff will be educated on the regulation as well as the plan of correction associated with the deficiency by the housekeeping supervisor and the Director of Nursing.

For Quality Assurance Purposes environmental rounds will be completed weekly for 4 weeks to address cleaning needs as well as environmental appearance issues by the housekeeping supervisor. Nursing Management will also complete environmental rounds for any safety issues that need to be addressed weekly X's 4 and then monthly following. The concerns will be assigned to the specified department to address. The identified concerns and interventions to address the concerns will be identified in the Quality Assurance and Performance improvement meetings that are held every other week with all department leaders on an ongoing basis.
Education and plan of correction will be implemented by 11/8/2024.

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