Pennsylvania Department of Health
 BRIGHTON REHABILITATION AND WELLNESS CENTER
Patient Care Inspection Results

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BRIGHTON REHABILITATION AND WELLNESS CENTER
Inspection Results For:

There are  309 surveys for this facility. Please select a date to view the survey results.

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BRIGHTON REHABILITATION AND WELLNESS CENTER - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on a Medicare/Medicaid Recertification Survey, Civil Rights Compliance Survey, State Licensure Survey, and an abbreviated survey related to six complaints completed on March 13, 2024, it was determined that Brighton Rehabilitation and Wellness Center, was not in compliance with the requirements of 42 CFR part 483, Subpart B, Requirements for Long Term Nursing and Rehab Center Term Care Facilities and the 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations related to the health portion of the survey process.


 Plan of Correction:


483.24(a)(3) REQUIREMENT Cardio-Pulmonary Resuscitation (CPR):This is the most serious deficiency and 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 which places the resident in immediate jeopardy as it has caused (or is likely to cause) serious injury, harm, impairment, or death to a resident receiving care in the facility. Immediate corrective action is necessary when this deficiency is identified.
§483.24(a)(3) Personnel provide basic life support, including CPR, to a resident requiring such emergency care prior to the arrival of emergency medical personnel and subject to related physician orders and the resident's advance directives.
Observations:

Based on a review of the Amercian Heart Association (AHA) Guidelines, clinical records, facility policies, and staff interviews it was determined that the facility failed to ensure consistent care by ensuring resident desire for CPR was consistent, clear and able to easily be determined by staff for one of three Residents (Resident R468), which placed 467 of 467 residents, in immediate jeopardy to their health and safety with the potential for death because of a similar occurrence.

Findings include:

The Pennsylvania Code Title 49. Professional and Vocational Standards through the Department of State indicates under the Responsibilities of the Registered Nurse 21.11 General functions (a) The registered nurse assesses human responses and plans, implements, and evaluates nursing care for individuals or families for whom the nurse is responsible. In carrying out this responsibility, the nurse performs all the following functions: (4) Carries out nursing care actions which promote, maintain, and restore the well-being of individuals.

Review of the AHA Guidelines dated 2020, indicated if a person is not breathing and has no pulse for more than 10 seconds, start CPR.

The facility's CPR policy titled "Emergency Response Guideline" reviewed 10/1/23, indicated the following guidelines are available and are to be utilized in the event of a resident emergency. First, determine resident's unresponsiveness, then notify or leave another staff member and immediately notify a licensed nurse. It was indicated to active emergency in house emergency communication system, verify the resident's code status, call 911, and if necessary, initiate cardiopulmonary resuscitation (CPR). It was indicated to chart completely all events leading up to the situation, what transpired during the situation, and the events that followed. All information along with the date, time, and the nurse's signature should be documented in the nurse's notes.

Resident R468's clinical record revealed an admission date of 12/1/23, with diagnoses that included heart failure (progressive heart disease that affects pumping action of the heart muscles), high blood pressure, and bipolar disorder (mental illness characterized by extreme mood swings.)

Review of Resident R468's Minimum Data Set (MDS- a periodic assessment of care needs) dated 12/7/23, indicated the diagnoses were current.

Review of Resident R468's physician order dated 12/1/23, through 12/25/23, indicated Resident R468 was a full code (allows for all interventions needed to restore breathing or heart functioning). The order was discontinued on 12/25/23, and in the notes section it was indicated the resident ceased to breathe on 12/25/23, at 9:50 p.m. Review of Resident R468's physician order dated 12/26/23, through 2/29/24, (after the resident ' s death) entered by Registered Nurse (RN), Employee E11 indicated do not resuscitate.

Review of Resident R468's closed record revealed a POLST form dated 12/4/23, indicated if the resident has no pulse and is not breathing, do not attempt resuscitation (DNR). The form was signed by Nurse Practitioner, Employee E12 and it was indicated a verbal consent was provided from Resident R468's brother who was listed as an emergency contact.

Review of Resident R468's care plan dated 12/4/23, indicated the resident was a full code. Interventions indicated CPR will be performed as ordered.

Review of Resident R468's progress note dated 12/25/23, at 9:50 p.m. entered by Licensed Practical Nurse (LPN) Employee E2, indicated she and RN Supervisor Employee E3, were called to the unit due to the residents absent vital signs. It was indicated the resident ceased to breathe at that time. The resident's emergency contact and provider were notified. There was no documentation that CPR was administered as ordered.

During an interview on 2/29/24, at 10:12 a.m. the Director of Nursing (DON) and Unit Manager RN, Employee E11 confirmed CPR was not initiated for Resident R468 on 12/25/23, because the facility staff referred to her POLST and it indicated to DNR. The DON stated she contacted the nurse practitioner who completed the POLST on 12/4/23, and confirmed the order to Do-Not-Resuscitate was not entered in Resident R468's electronic clinical record. The DON stated the nurse practitioner's notes are supposed to transfer to point click care, and it does not always do that. The DON confirmed the resident's DNR order on her POLST should have been reflective in her electronic record. Unit Manager RN Employee E11 stated when she came back to work the following day, she reviewed Resident R468's death, and discovered the order to not resuscitate wasn't transcribed and she entered an order to Do-Not-Resuscitate on 12/26/23, after the resident was dead. The resident's POLST form did not align with the code status on electronic record, placing all residents at risk if they became unresponsive and pulseless, which resulted in an Immediate Jeopardy situation.

On 2/29/24, at 2:19 p.m. the Director of Nursing was notified that an immediate jeopardy was identified and was provided a copy of the completed IJ template, and a written IJ removal plan was requested at 2:20 p.m.

On 2/29/24, at 6:23 p.m. an Immediate Action Plan was accepted with the following actions:
Immediate Action:

-All residents were reviewed for code status, including orders, POLST, and care plan are accurate by 3/1/24, by the Director of Nursing or Designee.

-All nursing staff must be educated on ensuring code status is implemented as ordered by Director of Nursing or Designee prior to the next scheduled shift.

-CPR policy will be reviewed and revised by 3/1/24.

-The Director of Nursing or Designee will conduct audits of residents code status to ensure accuracy and repot findings to Quality Assurance and Performance Improvement (QAPI) meetings.

The facility's CPR policy titled "Emergency Response Guideline" was revised and reviewed on 2/29/24, and indicated to first determine unresponsiveness, notify, or have another staff member immediately notify a licensed nurse, then verify the resident's code status, activate in-house emergency communication system if required, call 911, and initiate CPR if necessary.

467 of 467 residents code status, including orders, POLST and care plan were reviewed and accurate as of 3/2/24.

On 3/2/24, at 10:20 a.m. 207 of 207 nursing staff verified they were educated prior to start of their shift via signature sheet. All nursing staff in facility on 3/2/24, were interviewed and confirmed training and understanding. All nursing staff were educated on what to do in an event of an emergency. Staff must determine unresponsiveness, notify a license nurse immediately, verify resident's code status. If an emergency response required, activate in-house emergency communication system, and call 911. If necessary, initiate cardiopulmonary resuscitation (CPR) and chart completely all events up to situation, what transpired during situation, and the events that followed. The physician and responsible must be notified. The facility will continue to educate all nursing staff prior to the start of the shift.

The Director of Nursing or designee will conduct audits to ensure policy is being followed and findings will be reported in upcoming QAPI meetings.

On 3/2/24, the Immediate Jeopardy was lifted at 1:34 p.m. after ensuring the Immediate Plan of Correction had been implemented.

During an interview on 3/12/24, at 10:46 a.m. LPN, Employee E16 stated if a resident is not breathing, she would check the resident's POLST. LPN, Employee E16 stated the order on the POLST form must be "carried over to the resident's clinical record immediately". It was indicated staff can check a resident's code status on the electronic record or their paper chart depending on their preference.

During an interview on 3/12/24, at 10:40 a.m. LPN, Employee E18 stated if a resident ceases to breathe, the resident's code status is checked in the resident's paper chart, It was indicated the orders must be updated in the resident's electronic chart.

During an interview on 3/12/24, at 10:49 a.m. LPN, Employee E8 stated if she needs to check a resident's code status, she always uses the electronic record and looks at the physician order. LPN, Employee E8 stated it is quicker to check a resident's code status in the electronic record. "Us floor nurses would look in the electronic record rather than the paper chart."

During an interview on 3/12/24, at 12:01 p.m. LPN, Employee E2 indicated to check a resident's code status, staff can look at computer or paper chart. It was stated if a POLST was completed or updated, it must "instantly be changed in the electronic record."

During an interview on 3/12/24, at 12:45 p.m. Registered Nurse Supervisor, Employee E44 stated staff can find a resident's code status either in the computer or in their paper chart. RN, Supervisor stated, "I am going to go with the one that is currently up to date" and "It definitely creates a delay" trying to find which one is more up to date, "time is of the essence." It was indicated on 12/25/23, RN Supervisor Employee E44 was called to Resident 468's room and stated her medical chart was in the room and her POLST indicated she was a DNR. It was indicated the resident was warm to touch, her time of death was confirmed by him and LPN, Employee E2. The resident did not have a blood pressure or apical pulse (a pulse point on your chest at the bottom tip of your heart). RN, Supervisor, Employee E44 stated LPN, Employee E2 documented everything regarding Resident R468.

During an interview on 3/12/24, at 1:13 p.m. LPN, Employee E2 stated when she was called to Resident R468's room, the first question she asked was, what was her code status, and stated LPN, Employee E48 had her paper chart pulled. It was verified she was a DNR by her POLST, and CPR was not adminstered.

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

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

28 Pa. Code: 201.29(d)(j) Resident rights.

28 Pa. Code 211.10(c) Resident care policies.


 Plan of Correction - To be completed: 05/08/2024

0678
1. The Facility is unable to retroactively correct deficiency as it relates to R468.
2. The consultant vendor reviewed the policy and procedure with the Director of Nurses and NHA and revised as necessary. An house audit was conducted to ensure all resident orders/care plans/POLST are consistent with residents wishes forCPR/DNR, no additional issues were identified.
3. A directed in-service will be held to re in-service staff by a CoreTactics HealthCare Consulting representative, Marianne Sherlock, on site, April 23-25 2024, on ensuring code status orders are accurate and being followed.
4. The Director of nursing/designee will audit 5 charts 3 times weekly for 2 weeks, 5 charts weekly for 2 weeks, then 5 charts monthly for 2 months to ensure orders/care plan /POLST are consistent with residents wishes for CPR/DNR. Audit finding will be shared with QAPI committee.
483.25(d)(1)(2) REQUIREMENT Free of Accident Hazards/Supervision/Devices:This is the most serious deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one which places the resident in immediate jeopardy as it has caused (or is likely to cause) serious injury, harm, impairment, or death to a resident receiving care in the facility. Immediate corrective action is necessary when this deficiency is identified. This deficiency was not found to be throughout this facility.
§483.25(d) Accidents.
The facility must ensure that -
§483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and

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

Based on review of facility policy, observations, clinical records, and staff interviews it was determined that the facility failed to make certain residents received adequate supervision to smoke safely for five of six residents observed (Residents R21, R116, R425, R448, and R464), failed to complete safe smoking assessments, to obtain physician orders for smoking, to have/implement care plans reflective of residents' smoking needs, and to have adaptive equipment needs for smoking safely. This created an Immediate Jeopardy situation for 74 of 74 residents that smoked. The facility failed to make certain residents were free from accidents and hazards related to smoking resulting in actual harm of a burn for one of six residents (Resident R384).

Findings include:

Review of the facility policy "Smoking Policy", dated 10/1/23, indicated the facility is a smoke free facility. Designated smoking areas have been established outside the building for those residents, staff or visitors who choose to smoke.
-Upon admission, residents who smoke will be reviewed for safety with independence in smoking.
-Licensed staff will be responsible for completion of the resident smoking review upon admission.
-Residents who are assessed to be unsafe to smoke independently will be supervised.
-Residents who require supervision will be reviewed by the interdisciplinary team to determine appropriate interventions to allow them to smoke in the safest manner possible.
-Interventions will be individualized based on the needs of the resident.
-These interventions will include but not be limited to wearing a smoking apron (prevent burns in clothing and keep hot ashes from burning the skin), smoking only when supervised by staff or a responsible party, etc.
-Smokers will be assessed for safety on admission, quarterly, and as needed based on individual circumstances and changes in the resident's condition.
-To ensure the safety of all residents, smoking supplies for residents who require supervised smoking will be kept locked in the smoking cart and provided to the resident upon request.

Review of the facility policy, "Incident and Accident Reports" dated 10/1/23, indicated the facility will document all unusual occurrences and events, including injuries of unknown origin. The following occurrences warrant an incident report: Changes in skin integrity, including burns.

Resident R21 was admitted to the facility on 2/10/17. The Minimum Data Set (MDS- a periodic assessment of care needs) dated 2/25/24, indicated the diagnoses of diabetes (a long-term condition in which the body has trouble controlling blood sugar), seizures (sudden uncontrolled movements), and bilateral amputations (surgical removal of a limb) above the knee.

Resident R21's Nursing Smoking Safety Screening V1 dated 7/7/23, revealed the following:
-Resident smokes 5-10 cigarettes a day.
-Likes to smoke in the morning, afternoon, evenings, and nights.
-Resident needs adaptive equipment of a smoking apron and supervision.
-Resident is aware that the facility needs to store lighter and cigarettes - Yes.
-Plan of care is used to assure resident is safe while smoking - Yes.

Review Resident R21's care plan dated 1/2/24, indicated at risk for smoking related injury related to:
-History of smoking incidents - smoking in non-designated areas.
-Does not follow facility smoking policy.
-Assist to and from Designated Smoking area
-Observe patient for unsafe smoking behaviors or attempts to obtain smoking material from outside sources, and immediately inform facility management.
-Patient not to have cigarettes or smoking material on person.
-Review smoking policy with patient.
-Storage of smoking materials per facility policy.

Review of Resident R21's physician orders as of 2/26/24, at 11:00 a.m. failed to include orders for smoking, and adaptive equipment needed for smoking safely.

During an observation on 2/27/24, at 9:54 a.m., Resident R21 was observed in a wheelchair, lighting a cigarette, and stated, "This is all we have here." Resident R21 failed to have a smoking apron on and had cigarettes and a lighter in his hand. No staff were present.

Resident R116 was admitted to the facility on 8/1/19. The MDS dated 1/9/24, indicated the diagnoses of diabetes, high blood pressure, and stroke.

Resident R116's Nursing Smoking Safety Screening V1 dated 4/11/22 (22 months prior), at 2:26 p.m. and revealed the following:
-Resident smokes 2-5 cigarettes a day.
-Likes to smoke in the morning, afternoon, evenings, and nights.
-Resident needs adaptive equipment of a smoking apron.
-Resident is aware that the facility needs to store lighter and cigarettes - Yes.
-Plan of care is used to assure resident is safe while smoking - Yes.

Review Resident R116's care plan dated 5/15/23, indicated potential for safety hazard, injury related to smoking:
-History of smoking incidents - in CafMocha by computer and in room.
-Resident will exhibit safe smoking habits and follow facility safe smoking practices set up by staff.
-Activities to keep all smoking materials in cart per policy.
-Provide a copy of facility smoking policy.
-Smoking allowed only in designated area.
-Smoking apron to be worn at all times while smoking.
-While smoking, will have direct supervision by staff or family member.

Review of Resident R116's physician orders as of 2/27/24, at 11:05 a.m. failed to include orders for smoking need, and adaptive equipment needed for smoking safely.

During an observation on 2/27/24, at 9:45 a.m., Resident R116 was observed in a wheelchair, with a lit cigarette in his hand. His hand was resting on the oversized crouch area of his pants. Resident R116 failed to have a smoking apron and had a cigarette and lighter on his person. No staff were present.

Resident R425 was admitted to the facility on 9/13/23. The MDS dated 1/31/24, indicated the diagnoses of diabetes, high blood pressure, anemia (the blood doesn't have enough healthy red blood cells), and hepatitis (inflammation of the liver).

Resident R425's Nursing Smoking Safety Screening V1 dated, 9/5/23 (16 months prior) revealed the following:
-Resident smokes 2-5 cigarettes a day.
-Likes to smoke in the morning, and afternoon.
-Resident needs adaptive equipment of a smoking apron.
-Resident is aware that the facility needs to store lighter and cigarettes - Yes.
-Plan of care is used to assure resident is safe while smoking - Yes.
-Safe to smoke with direct supervision.

Review Resident R425's care plan dated 9/25/23, indicated:
-risk for side effects/injury from smoking extremity range of motion limitations.
-Resident will exhibit safe smoking habits and follow facility safe smoking practices set up by staff.
-Complete safe smoking assessment per facility policy.
-Resident's cigarettes and lighter will be provided by staff at appropriate times.
-Resident will smoke in designated area.

Review of Resident R425's physician orders as of 2/27/24, at 11:07 a.m. failed to include orders for smoking, and adaptive equipment needed for smoking safely.

During an observation on 2/27/24, at 9:45 a.m., Resident R425 was observed standing in the far corner of the area with a lit cigarette in his hand. No staff were present.

Resident R448 was admitted to the facility on 1/5/24. The MDS dated 1/11/24, indicated the diagnoses of high blood pressure, seizures, and ulcerative colitis (chronic inflammatory bowel disease of the digestive tract).

Review of Resident 448's clinical record on 2/27/24, failed to include a Nursing Smoking Safety Screening V1.

Review Resident R448's care plan dated 1/4/23, failed to include a care plan that reflected the resident's smoking needs, and adaptive equipment needs for smoking safely.

Review of Resident R448's physician orders as of 2/27/24, at 11:38 a.m. failed to include orders for smoking.

During an observation on 2/27/24, at 9:45 a.m., Resident R448 was observed standing in the area and lit a cigarette with a lighter from his pocket and indicated "This place is run like a prison". No staff were present.

Resident R464 was admitted to the facility on 2/1/24. The MDS dated 2/8/24, indicated the diagnoses of stroke, hemiparesis (weakness/paralysis on one side of the body), and high blood pressure.

Review of Resident R464's Nursing Smoking Safety Screening V1 dated 2/5/24, revealed the following:
-Does the resident have cognitive loss? - Yes
-Does the resident have visual deficit? - Yes
-Resident smokes 1-2 cigarettes a day.
-Likes to smoke in the evenings.
-Resident needs adaptive equipment of supervision.
-Resident is aware that the facility needs to store lighter and cigarettes - Yes.
-Plan of care is used to assure resident is safe while smoking - Yes.
-Supervised smoking per policy.

Review Resident R464's care plan dated 2/5/24, indicated:
-resident has a history of smoking.
-Resident is at risk for side effects/injury from smoking.
-Resident will not smoke while utilizing nicotine patch.
-Resident will exhibit safe smoking habits and follow safe smoking practices set up by staff.
-Do smoking assessment if resident requests to smoke for safety of smoking.
-Encourage resident not to smoke related to recent stroke and health reasons.
-Resident's cigarettes and lighter will be provided by staff at appropriate times.
-Resident will smoke in designated area.

During an observation on 2/27/24, at 9:45 a.m., Resident R464 was observed in a wheelchair with a lit cigarette in his hand. Resident had cigarettes on his lap. No staff were present.

During an observation of the lobby to the outside pavilion area (designated smoking area) on 2/26/24, at 8:45 a.m., revealed a sign that stated "Smoking Times: 9:15 a.m., 11:30 a.m., 1:30 p.m., 3:45 p.m., and 7:45 p.m.

During an observation on 2/26/24, at 10:00 a.m., revealed residents freely coming in and out of the door to the smoking area from the unlocked door outside of Unit 2 West.

During an observation on 2/26/24, at 12:00 p.m., revealed residents freely coming in and out of the door to the smoking area from the unlocked door outside of Unit 2 West.

During an observation on 2/26/24, at 2:10 p.m., revealed residents freely coming in and out of the door to the smoking area from the unlocked door outside of Unit 2 West.

During an interview on 2/26/24, at 2:10 p.m. Nurse Aide (NA) Employee 43, indicated residents are in and out all-day smoking in between the scheduled smoking times that are supervised with the Activities Department.

During an interview on 2/26/24, at 2:30 p.m., Resident R205 indicated "Oh, they just let us go. We're out here all day with or without the staff".

During an interview on 3/12/24, at 10:36 a.m., Unit Manager RN Employee E11 indicated we have no smokers currently. When asked how residents were able to be outside unsupervised and smoke, she indicated the alert and oriented smokers would come at the tail end and then just stay out there after the supervised session was over.

During an interview on 3/12/24, at 10:46 a.m., LPN Employee E16 indicated the door to the smoking area has been unlocked for a while now so the residents can go in and out as they wish.

During an interview on 3/12/24, at 11:45 a.m., NA Employee E20 indicated she's worked there since January 2024, and they go out on their own to smoke and others just go out for fresh air and to be outside. When asked where the residents got the cigarettes and lighters, she indicated "they have them on them all the time."

During an interview on 3/12/24, at 11:49 a.m., LPN Employee E8 indicated "I've been here ten years, originally there was a smoking room inside just for the smokers. It was all cement blocks. When Covid-19 first hit, they moved it outside to the 2-West pavilion area. Later, the Covid-19 got so bad, nobody smoked at all. They made the original cement smoking room into a recreation room for the residents. It was always scheduled times and Activities Staff would take them out. At one point, the pavilion was unlocked because of all the alert and oriented residents that smoked out there all day by themselves."

During an interview on 3/12/24, at 1:52 p.m., Activity Assistant Employee E46 indicated "the residents who smoke have gone back and forth from supervised to unsupervised over the years. There was a cement block room inside at one time. Covid-19 hit, and nobody smoked. They opened 2-West pavilion area, it was locked, supervised times, smoking aprons, and the medication cart to hold the cigarettes."

During an interview on 3/12/24, at 1:53 p.m., Activity Assistant Employee E47 indicated "supervised smoking all stopped because the facility had too many alert and oriented smokers and it got out of control. There were only a few smokers who were compliant."

During an interview with the Director of Nursing (DON) on 2/26/24, at 3:00 p.m., indicated "the process for smoking is supervised by the Activity's Department at the scheduled times of 9:15 a.m., 11:30 a.m., 1:30 p.m., 3:45 p.m., and 7:45 p.m. They have an old medication cart that has all the smokers' cigarettes and lighters inside it, and they distribute them to each individual during the supervised times."

During an observation on 2/27/24, at 9:54 a.m., the smoking area outside of the Unit 2-West, five residents (Residents R21, R116, R425, R448 and R464) were outside smoking without staff presence and supervision. The observations and resident interviews revealed that the residents were outside smoking for 23 minutes without staff supervision.

Resident R384 was admitted to the facility on 11/20/22. The MDS dated 1/8/24, indicated the diagnoses of high blood pressure, diabetes, and peripheral vascular disease (a condition in which narrowed blood vessels reduce blood flow to the limbs).

Review of Resident R384's Nursing-
Smoking Safety Screening revealed it was last completed on 11/23/22 (16 months prior), at 3:27 p.m. revealed the following:
-Resident smokes 5-10 cigarettes a day.
-Likes to smoke in the morning, afternoon, and evenings.
-Resident needs adaptive equipment of a smoking apron and supervision.
-Due to elopement (resident exits to an unsupervised or unauthorized area without the facility's knowledge) risk, Resident R384 is to have a staff member from the unit to accompany at all breaks.
-Resident is aware that the facility needs to store lighter and cigarettes - Yes.
-Plan of care is used to assure resident is safe while smoking - Yes.

Review Resident R384's care plan dated 10/12/23, indicated resident is at risk for side effects/injury from smoking.
-Injury on 10/12/23. Resident educated to not sit so close to other residents at smoke times.
-Resident will exhibit safe smoking habits and follow safe smoking practices set up by staff.
-Complete safe smoking assessment per facility policy.
-Resident's cigarettes and lighter will be provided by staff at appropriate times.
-Observe resident for unsafe smoking behaviors. Report to supervisor if noted.
-Report any injuries to staff.
-Resident's cigarettes and lighter will be provided by staff at appropriate times.
-Resident deemed unsafe with standard supervised smoke break. For safety will be supervised at all times by unit staff, to during, and from smoke break, dated 11/23/22.

Review of Resident R384's physician orders dated 5/3/23, indicated ok to smoke at designated smoking times. Must wear appropriate footwear.

Review of incident and accident logs indicated on 10/11/23, at 7:54 a.m., Resident R384 was out smoking on last smoke break and another resident flicked the ashes of their cigarette, and an ember hit his ankle and burned him.

Review of Resident R384's incident report "smoking injury" dated 10/12/23, indicated that resident has a blister to left inner ankle with measurements of 3.5 centimeters (cm) x 4 cm. Resident R384 indicated he was out smoking at last smoke break on 10/11/23, and another resident flicked the ashes of their cigarette and an ember hit his ankle and burned him.

Review of Resident R384's progress note dated 10/12/23, at 8:11 a.m. indicated the resident has a blister to left inner ankle. Resident R384 stated he was out smoking on last smoke break on 10/11/23, and another resident flicked the ashes of their cigarette and an ember hit his ankle and burned him.

During an interview on 3/12/24, at 12:10 p.m., NA Employee E49 indicated she was caring for Resident R384 on 10/11/23, when the burn occurred; however, the resident never mentioned he was burned. We all take turns to escort residents who require it to smoking and have to stay with them at all times. NA Employee E49 did recall Resident R384 requiring a dressing from the nurses on that leg.

Review of the Nurse Practitioner Employee E10's wound note dated 10/12/23, at 8:47 a.m., indicated, Resident R384 was seen for a left ankle blister/burn for ongoing treatment and recommendations, and evaluation. Resident stated he was sharing a cigarette with another resident outside when a hot ash dropped on his ankle causing a burn/blister. The resident indicated he's not aware it's there until he looks at it. Integumentary (hair/skin/nails): left ankle burn. Fluid filled blister with brownish discoloration.

During an interview with the DON on 2/27/24, at 12:00 p.m., confirmed Resident R384 acquired a blister/burn while out smoking and the facility failed to keep residents free from accidents and hazards related to smoking resulting in actual harm of a burn for one of six residents (Resident R384).

During an interview on 2/27/24, at 1:00 p.m., the DON indicated the facility failed to make certain residents received adequate supervision, for five of six residents observed smoking (Residents R21, R116, R425, R448, and R464), and failed to complete safe smoking assessments, obtain physician orders for smoking, have/implement care plans reflective of residents' smoking needs, and adaptive equipment needs for smoking safely. This created an Immediate Jeopardy situation for 74 of 74 residents that smoke.

On 2/27/24, at 4:12 p.m., the Nursing Home Administrator (NHA) was made aware that Immediate Jeopardy (IJ) existed and was provided the IJ Template at that time and a corrective action plan was requested.

During an interview on 2/27/24, at 5:54 p.m. the NHA stated he was implementing education for his Corrective Action Plan with the department heads. Survey Agency (SA) informed the NHA the Corrective Action Plan had to be approved prior to implementation. He verbalized understanding.

On 2/27/24, at 6:16 p.m. the facility handed in a Corrective Action Plan.

On 2/27/24, at 6:20 p.m. the NHA was informed that the Corrective Action Plan handed in was not accepted.

On 2/27/24, at 7:53 p.m. an acceptable Corrective Action Plan was received which included the following interventions:

Upon identification from the survey team 2/27/24, at 4:12PM the following items shall be implemented.
1. All other resident smokers will be assessed for injuries related to smoking 2/28/24.
2. The smoking policy will be reviewed immediately and updated as of 2/27/24.
3. All resident smokers will have updated smoking assessments as of 2/28/24.
4. All resident smokers will have obtained orders for supervised smoking as of 2/28/24.
5. All resident smokers will have care plan reviewed and updated as of 2/28/24.
6. All resident smokers will be educated on the changes to the smoking policy as of 2/28/24.
7. All employees working in the building at the time of issuance will be re in serviced by director of nurses or designee on the changes to the smoking policy as of 2/27/24.
a. All remaining employees will be educated on the changes to the smoking policy prior to the start of their next scheduled shift.
b. Policy addition - resident smoking area will be closed and alarmed during none smoking times.
c. Policy addition - Added Residents will not have the code?
d. Policy addition - If residents are observed using the code maintenance will be informed to change the code immediately upon identification?
8. Resident smokers will be allowed to smoke in the designated smoking areas at designated smoking times, under supervision, with flame retardant equipment.
a. Residents will be offered smoking cessation materials in the interim.
b. Activities staff will be re in-serviced on ensuring resident smokers are wearing appropriate flame-retardant equipment prior to being permitted to smoke within the smoking area as of 2/28/24.
9. The smoking area shall be audited for supervision daily.
10. Resident outdoor smoking area was locked and alarmed as of 2/27/24, and code for door was changed to ensure residents do not have access to the designated smoking area unsupervised.
a. Activities staff will be re-inserviced by the Nursing Home Administrator (NHA) on not providing the code to residents as of 2/28/24.
11. The Director of Nursing (DON) and NHA/designee shall monitor the progress of this corrective action. This corrective action shall be reviewed at QA (Quality Assurance) to monitor compliance.

During an observation on 2/28/24, at 11:32 a.m,. the supervised smoking was observed. Activities staff were present with medication cart containing cigarettes, lighters, and smoking aprons.

During an interview on 2/28/24, at 11:34 a.m., Activity Director Employee E36 indicated all residents were to wear protective aprons per the education they received.

During an observation on 2/28/24, at 11:35 a.m., 14 residents observed outside smoking with three activities staff members. Adaptive equipment of 18 aprons and six fire retardant blankets were being utilized.

A review of the facility's Corrective Action Plan audit on 2/28/24, indicated that all residents who smoke were listed as unsafe and made to wear aprons regardless of if they required one for safety. The review indicated that seven of the 73 smokers did not have a new Smoking Assessment completed as indicated in the plan, and that the assessments and care plans initiated were not resident specific or individualized. All education, assessments, care plans, and physician orders would have to be re-conducted.

Review of facility's immediate action plan was verified and completed on 2/29/24, at 5:44 p.m. as follows:
1. All other resident smokers will be assessed for injuries related to smoking 2/28/24.
Verified 73 of 73 smokers were reassessed 2/29/24.
2. The smoking policy will be reviewed immediately and updated as of 2/27/24.
Completed 2/28/24.
3. All resident smokers will have updated smoking assessments as of 2/28/24.
Verified 73 of 73 smoking assessments completed as of 2/29/24.
4. All resident smokers will have obtained orders for supervised smoking as of 2/28/24.
Verified 73 of 73 smokers have physician orders for smoking as of 2/29/24.
5. All resident smokers will have care plan reviewed and updated as of 2/28/24.
Verified 73 of 73 resident smoking care plans were updated as of 2/29/24.
6. All resident smokers will be educated on the changes to the smoking policy as of 2/28/24.
Verified 73 of 73 smokers were educated.
7. All employees working in the building at the time of issuance will be re in-serviced by director of nurses or designee on the changes to the smoking policy as of 2/27/24.
a. All remaining employees will be educated on the changes to the smoking policy prior to the start of their next scheduled shift.
b. Policy addition - resident smoking area will be closed and alarmed during non-smoking times.
Observation on 2/28/24, at 9:00 a.m. revealed a secure keypad on the entrance to the smoking area that was locked and alarmed with a secured keypad.
c. Policy addition - Added Residents will not have the code for the secured keypad smoking entrance.
d. Policy addition - If residents are observed using the code maintenance will be informed to change the code immediately upon identification?
All staff education verified via signature sheets 207 of 207, and all nursing staff in facility on 2/29/24, were interviewed 113 of 113, and confirmed training and understanding.
8. Resident smokers will be allowed to smoke in the designated smoking areas at designated smoking times, under supervision, with flame retardant equipment.
Verified via observations of supervised smoking times on three of four occasions without issues.
a. Residents will be offered smoking cessation materials in the interim.
Verified this was completed 2/29/24.
b. Activities staff will be re in-serviced on ensuring resident smokers are wearing appropriate flame-retardant equipment prior to being permitted to smoke within the smoking area as of 2/28/24.
Verified 2/29/24.
9. The smoking area shall be audited for supervision daily.
Verified as complete 2/29/24.
10. Resident outdoor smoking area was locked and alarmed as of 2/27/24, and code for door was changed to ensure residents do not have access to the designated smoking area unsupervised.
Observed and confirmed 2/29/24.
a. Activities staff will be re-inserviced by NHA on not providing the code to residents as of 2/28/24.
Verified education and interviewed activities staff. Observed interactions during smoking sessions twice on 2/29/24.
11. The DON and NHA/designee shall monitor the progress of this corrective action. This corrective action shall be reviewed at QA to monitor compliance.

The IJ was lifted on 2/29/24, at 5:44 p.m.


28 Pa Code 211.5(f) Clinical records

28 Pa Code 211.12(c)(d)(1)(2)(5) Nursing services

28 Pa. Code: 211.10 (c)(d) Resident care policies

28 Pa Code 201.14(a) Responsibility of licensee.

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

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


 Plan of Correction - To be completed: 05/08/2024

0689
1. R384 received skin care and treatment for blister.
2. The consultant vendor reviewed the policy and procedure with the Director of Nurses and NHA and revised as necessary. An audit was done of facility smokers on 2/28/2024 to assess for injury related to smoking. No further issues identified.
3. A directed in-service will be provided by Core Tactics on Free from accidents/hazards and supervision April 23-25 2024 to re in-service the staff on ensuring residents are provided the safest environment possible for supervised smoking.
4. The consultant vendor and NHA/designee will observe supervised smoking 3 times weekly for 2 weeks, then 2 times weekly for 2 weeks, then 3 times monthly for 2 months to ensure adequate supervision is provided for resident smoking. NHA/designee will audit new admissions for smoking status to ensure order, assessment and care plan is completed weekly for 3 weeks, then monthly for 3 months.
483.25 REQUIREMENT Quality of Care:This is the most serious deficiency although it is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one which places the resident in immediate jeopardy as it has caused (or is likely to cause) serious injury, harm, impairment, or death to a resident receiving care in the facility. Immediate corrective action is necessary when this deficiency is identified.
§ 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 review of facility policy, clinical records, and staff interviews it was determined that the facility failed to follow physician orders for two of two residents who were at risk for aspiration (Resident R318 and Resident R406). The facility failed to assess, monitor, and follow physician orders as required after a resident fell, resulting in death for one of five residents (Resident R468). This failure resulted in death and placed two of five residents at risk for injury and death if they had a fall and required post fall monitoring, which resulted in an Immediate Jeopardy situation.

Findings include:

The Pennsylvania Code Title 49. Professional and Vocational Standards through the Department of State indicates under the Responsibilities of the Registered Nurse 21.11 General functions (a) The registered nurse assesses human responses and plans, implements, and evaluates nursing care for individuals or families for whom the nurse is responsible. In carrying out this responsibility, the nurse performs all of the following functions: (4) Carries out nursing care actions which promote, maintain and restore the well-being of individuals.

The facility's "Fall Protocols" policy dated 9/2014, last reviewed 10/1/23, indicated after a resident has a fall an immediate assessment will be conducted my nursing, and medical attention will be obtained as needed. It was indicated post fall monitoring shall be documented in the medical record. The resident's cognitive status (confused, lethargic, disoriented, aggressive, combative, acute change in status) will be monitored for any change in condition related to a possible or confirmed head injury.

Review of the facility "Nursing Department Staff" policy last reviewed 10/1/23, indicated the nurse supervisor or charge nurse must record in the resident's medical record information relative to changes in the resident's medical or mental condition or status. "to ensure the safety and well-being of residents, a resident check will be made at least every two hours throughout each 24-hour shift by nursing service personnel. "Changes in the resident's condition and medical needs that cannot be performed by the person conducting the routine check must be reported to the nurse supervisor or charge nurse at once." "The nurse supervisor or charge nurse must maintain documentation supporting the time, identity of person making the check, and outcome of each check."

Review of the facility's "Supervision of Resident Nutrition" policy dated 10/1/23, indicated each resident shall receive proper nutrition in accordance with the resident's assessment, care plan, and physician orders. It was indicated residents needing assistance in eating must be promptly assisted upon being served.

Review of the facility policy "Flow of Care" dated 10/1/23, stated care will be provided to residents, as needed 24-hours a day to attain and maintain the highest level of functioning. It was indicated staff must be aware of special precautions, such as aspiration precautions (a condition in which foods, stomach contents, or fluids are breathed into the lungs through the wind pipe.) Staff must follow the dining instructions on the tray card and care plan.

Review of Resident R318's clinical record revealed an admission date of 3/14/23, with diagnoses that included dementia (A group of symptoms that affects memory, thinking and interferes with daily life), high blood pressure, and Gastroesophageal Reflux Disease (GERD-a common condition in which the stomach contents move up into the esophagus.)

Review of Resident R318's Minimum Data Set (MDS - a periodic assessment of care needs) dated 2/8/24, indicated the diagnoses were current.

Review of Resident R318's care plan dated 3/14/23, indicated the resident had GERD and to maintain aspiration precautions.

Review of Resident R318's physician order dated 11/3/23, indicated for the resident to be upright 90 degrees for meals for safety.

During an observation on 2/27/24, at 1:26 p.m. Resident R318 was observed being fed by NA, Employee E20. The resident was not positioned at 90 degrees.

Review of Resident R406's clinical record indicated an admission date of 4/13/23, with diagnoses that included Alzheimer's Disease (a type of brain disorder that causes problems with memory, thinking and behavior) high blood pressure, and Gastroesophageal Reflux Disease (GERD-a common condition in which the stomach contents move up into the esophagus.)

Review of Resident R406's MDS, dated 2/3/24, indicated the diagnoses were current.

Review of Resident R406's care plan dated 3/14/23, indicated the resident had GERD and to maintain aspiration precautions.

Review of Resident R406's physician order dated 1/26/24, indicated the resident was a one-to-one feed with strict aspiration precautions. It was indicated the resident must be in an upright 90 degrees or head of bed elevated to 90 degrees for all meals and for more than 30 minutes after.

During an observation on 2/27/24, at 1:42 p.m. Resident R406 was observed being fed by NA, Employee E20 and was not in an upright 90-degree position. The resident started coughing after being fed.

Review of Resident R406 progress note dated 2/27/24, entered by Unit Manager, RN, Employee E18 stated it was reported that resident coughed during lunch feeding, educated CNA to raise HOB to 90 degrees during feedings. It was indicated the resident was assessed and no adverse outcomes occurred.

During an interview on 2/27/24, at 1:48 p.m. Unit Manager, RN, Employee E18 confirmed the facility failed to follow physician orders for two of two residents who were at risk for aspiration (Resident R318 and Resident R406).

Resident R468's clinical record revealed an admission date of 12/1/23, with diagnoses that included heart failure (progressive heart disease that affects pumping action of the heart muscles), high blood pressure, and bipolar disorder (mental illness characterized by extreme mood swing).

Review of Resident R468's Minimum Data Set (MDS - a periodic assessment of care needs) dated 12/7/23, indicated the diagnoses were current.

Review of Resident R468's fall assessment titled "NSG-MORSE FALL SCALE (PCC)" dated 12/2/23, indicated the resident was a moderate risk for falling.

Review of Resident R468's care plan initiated 12/4/23, and revised 12/21/23, indicated the resident had a potential for falls related to anxiety, depression, incontinence, medications, muscle weakness, and pain. It was indicated the resident had a fall on 12/10/23, and 12/20/23. Interventions included: complete fall risk assessment per facility protocol, ensure resident is not leaning forward while sitting in wheelchair, and monitor toilet needs.

Review of Resident R468's progress note dated 12/10/23, indicated the resident had a fall and hit her head. The resident's right eye was bruised. Neurological checks (exam consists of a physical examination to identify signs of disorders affecting your brain, spinal cord and nerves) were intiated. Family and physician were notified.

Review of Resident R468's progress note dated 12/20/23, indciated the resident was leaning forward in her wheelchair and fell. Resident hit her head, neurological checks were initiated. Family and physician were notified.

Review of Resident R468's clinical record failed to include a fall assessment that was completed as per the facility's policy after the resident fell on 12/10/23 and 12/20/23.

Review of Resident progress note dated 12/25/23, at 1:38 p.m., Licensed Practical Nurse (LPN) Employee E14 stated "patient was seen throwing herself on the floor in front of the nurse's station and twice down the hallway." The resident leans herself forward and dives down to the floor. "No injures noted with each event." "They were approximately 5 minutes apart from each other." It was indicated the physician and family were notified.

Review of Resident R468's physician order dated 12/25/23, indicated, starting at 3:00 p.m. to monitor the resident for nine shifts post fall for a decreased in activities of daily living, change in vitals, pain, range of motion decrease, lethargy, decrease in appetite, any new ecchymosis (bruising) or swelling, and neuro checks if resident sustained a head injury. The order was discontinued on 12/25/23, at 10:38 p.m., the resident ceased to breathe at 9:50 p.m.

Review of Resident R468's December 2023 Treatment Administration Record (TAR), failed to include documentation of the resident's vital signs that were ordered on 12/25/23, at 3:00 p.m. It was left blank, and not signed off for completion.

Review of Resident R468's clinical record and closed record failed to include documentation of the resident's post fall monitoring and vital signs on 12/25/23.

Review of Resident R468's progress note dated 12/25/23, at 9:50 p.m. entered by LPN Employee E2 indicated she and RN Supervisor Employee E3 were called to the unit due to the resident's absent vital signs. It was indicated the resident ceased to breathe at that time.

During an interview on 2/29/24, at 10:03 a.m. the Director of Nursing (DON) confirmed the facility failed to assess, monitor, and follow physician orders after a resident fell, resulting in death, for one of five residents (Resident R468). This failure placed residents at a high risk for injury and death if they had a fall and required post fall monitoring, which resulted in an Immediate Jeopardy situation.

During an interview on 3/12/24, at 11:42 a.m., LPN Employee E53 stated she worked 7:00 a.m. to 11:00 p.m. on 12/25/24, and Resident R468 "was a handful, she kept throwing herself on the ground." It was indicated it was witnessed three times. She notified the physician of the behaviors and ordered a one-time dose of Risperdal. She indicated she then called downstairs and told the scheduler she wanted moved. "I was done" with the unit, "I was the only nurse up there", "It was not a good time." LPN, Employee E53 stated. It was indicated she went somewhere else at 3:00 p.m. and does not recall who she gave report to. LPN, Employee E53 stated since the three falls were within five minutes, she completed one lump assessment. LPN, Employee E53 stated "it should all be in the computer."

During an interview on 3/12/24, at 12:01 p.m. LPN, Employee E2 indicated "I do remember someone said she fell, they were supposed to do the risk" assessment. She stated she entered the order for fall monitoring every shift of the next nine shifts. It was expected at 3:00 p.m. the nurse completed an assessment and documented vital signs in the clinical record. It was indicated after a resident falls, the nurse needs to complete a head-to-toe assessment, then once safe obtain vitals and call and update the supervisors. LPN, Employee E2 stated RN, Employee E50 was expected to obtain vitals for Resident R468 on 12/25/23, at 3:00 p.m. and monitoring for the next nine shifts is required each shift if a resident falls regardless of a head injury.

During an interview on 3/12/24, at 12:11 p.m. Nurse Aide, Employee E52 stated she doesn't recall Resident R468 having a fall on 12/25/23, but she had a history of placing herself on the ground. She indicated the last time seen Resident R468 on 12/25/23, was around 2:00 p.m. or 2:30 p.m. and she cleaned her up and put oxygen on her.

During an interview on 3/12/24, at 1:19 p.m. Employee E51, confirmed RN, Employee E50 worked from 3:00 p.m. to 7:00 p.m. on 12/25/23, on the unit Resident R468 resided.

During a phone interview on 3/13/24, at 10:56 a.m. RN, Employee E50 stated if a resident falls, an assessment, and their vital signs are documented in the resident's clinical record. RN, Employee E49 stated if a resident had a witnessed fall, an order is entered to complete an assessment and vital signs every shift for the next three days. RN, Employee E49 stated she works agency, and confirmed she worked Christmas. She indicated she does not remember Resident R468, and when she works at the facility she is often moved to another floor after four hours.

On 2/29/24, at 2:19 p.m. the Director of Nursing was notified that an immediate jeopardy was identified and was provided the IJ template, and a written IJ removal plan was requested at 2:20 p.m.

On 2/29/24, at 6:23 p.m. an Immediate Action Plan was accepted with the following actions:
Immediate Action:
-All residents will have a fall assessment completed by 3/1/24.

-An audit will be conducted of all physician orders to ensure accuracy and implementation will be done by 3/1/24.

-Fall policy will be reviewed and revised by 3/1/24.

-Fall care plans for all residents will be reviewed and revised as appropriate by 3/1/24.

-All nursing staff will be educated to ensure all residents are assessed for fall risks upon admission, readmission, quarterly, and with a significant change in medical condition. In the event of an actual fall, an attempt will be made to eliminate casual factors and prevent further falls. A fall risk assessment must be completed post fall if the resident was not previously identified as a high risk for falls. Once a resident falls, they are considered a high risk for falls. Staff will be educated to ensure the resident's plan of care is individualized and developed based on the fall assessment and cause of previous falls. The education is to be completed by the Director of Nursing or Designee prior to the nursing staff's next scheduled shift.

-The Director of Nursing or Designee will conduct audits of residents falls to ensure accuracy and repot findings to Quality Assurance and Performance Improvement (QAPI) meetings.

The facility's "Fall Protocols" policy was revised and reviewed on 2/29/24, to ensure all residents are assessed for fall risk upon admission, readmission, quarterly, and with a significant change in medical condition. In the event of an actual fall, an attempt will be made to eliminate casual factors and prevent further falls. It was indicated a fall risk assessment is completed post fall only if the resident was not previously identified as a high risk for falls. Once a resident has had a fall, they are considered a high risk for falls. It was indicated the resident's plan of care will be individualized and developed based on fall assessment and root cause analysis of any subsequent falls. A post fall investigation will be completed in the next clinical meeting following each fall to determine root cause and appropriate intervention. Following a fall, nursing will complete a head to toe assessment for injury, including vital signs. Neurological checks will be initiated if the resident struck their head or if the fall was unwitnessed. All assessment data will be documented in the medical record. The medical provider and responsible party will be notified of the fall and notifications documented in the medical record.

467 of 467 residents fall assessments were completed as of 3/1/24.

An audit of 467 resident's physician orders were reviewed. It was indicted nine of nine residents had a fall, and required neurological assessments and vital signs post fall. It was confirmed nine of nine residents who had physician orders for post fall monitoring were being followed as ordered.

467 of 467 residents care plans were reviewed and revised on 3/2/24, to include the resident's fall risk and interventions.

On 3/1/24, at 1:18 p.m. it was verified 113 of 115 nursing staff confirmed they were educated prior to start of their shift and was verified via signature sheet. All nursing staff were educated to conduct a fall assessment upon admission, quarterly, and with a significant change in the resident's status. Residents who were not previously identified as a high fall risk prior to fall must have a fall risk assessment completed. The care plans must be individualized and developed based on fall assessment and root cause analysis of any subsequent falls. An investigation must be conducted following a fall. Following a fall, nursing will complete a head to toe assessments, including vital signs. Neurological checks will be initiated if the resident struck their head or if the fall was unwitnessed. All assessment data will be documented in clinical record and medical provider and responsible party will be notified of fall and documented in medic al record.

Director of Nursing and designee will conduct audits to ensure policy is being followed and findings will be reported to QAPI.

On 3/2/24, at 12:37 p.m., the Immediate Jeopardy was lifted after ensuring the Immediate Plan of Correction had been implemented.

28 Pa. Code: 211.10(c)(d) Resident care policies.

28 Pa. Code: 211.12(d)(1)(2)(3)(5) Nursing services.


 Plan of Correction - To be completed: 05/08/2024

0684
1. R318 and R406 were assessed for ill effects related to not being positioned at 90 degrees for feeding, no ill effects identified. The Facility cannot retroactively correct deficiency as it relates to R468.
2. The consultant vendor reviewed the policy and procedure with the Director of Nurses and NHA and revised as necessary. An audit was conducted of all residents with recent falls on 3/1/24 to ensure residents received appropriate assessment and monitoring post fall. An audit was conducted of residents with orders to be upright for meals to ensure orders are being followed.
3. A directed in-service will be held to re in-service the staff, by Core Tactics April 23-25 2024, on providing care according to resident's care plan and physician orders.
4. The consultant vendor and Director of nursing/designee will audit residents with falls twice weekly for 2 weeks, weekly for 2 weeks and monthly for 2 months to ensure appropriate post fall monitoring. Director of nursing/designee will audit 3 residents with orders for feeding twice weekly for 2 weeks, then 3 residents with feeding orders weekly for 2 weeks, then 3 residents with feeding orders for 2 months to ensure orders are being followed. Audit findings will be shared with QAPI committee.
483.60(i)(1)(2) REQUIREMENT Food Procurement,Store/Prepare/Serve-Sanitary:This is a less serious (but not lowest level) deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
§483.60(i) Food safety requirements.
The facility must -

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

§483.60(i)(2) - Store, prepare, distribute and serve food in accordance with professional standards for food service safety.
Observations:
Based on a review of policy, observation and staff interview, it was determined that the facility failed to properly maintain kitchen equipment in a sanitary condition creating the potential for cross contamination in the main kitchen of the facility.

Findings include:

A review of facility policy "Sanitation" dated 10/1/23, indicated the food service area shall be maintained in a clean and sanitary manner. All equipment shall be kept clean, maintained in good repair and shall be free from breaks, corrosions, open seams, cracks, and chipper areas.

During an observation on 2/26/24, at 9:30 a.m., of the walk-in cooler #3 in the main kitchen, conducted with Food Service Director (FSD) Employee E1, revealed that the cold air condenser fan covers and the ceiling immediately forward of these cooler fans had a build-up of dust, grime, and debris. FSD Employee E1 confirmed observation by surveyor when viewed.

During an interview on 2/26/24, at 9:45 a.m., FSD Employee E1 confirmed that the facility failed to properly maintain kitchen equipment, walk-in cooler #3, in a sanitary condition creating the potential for cross contamination in the main kitchen of the facility.

28 Pa. Code: 201.14(a) Responsibility of licensee.

28 Pa. Code: 201.18(b)(1) Management.




 Plan of Correction - To be completed: 05/01/2024

0812
1. The walk-in cooler number 3 had the cold air condenser and ceiling immediately following the entrance to the walk-in cooler # 3 cleaned and removed of dust and debris.
2. The Food Service Director was re in-serviced by the NHA to properly maintain kitchen equipment per facility policy and procedure.
3. The Food Service Director / designee will audit the walk-in cooler monthly ongoing to ensure to maintain kitchen equipment per facility policy. Audit findings will be shared with QAPI committee.

483.70(e)(1)-(3) REQUIREMENT Facility 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.
§483.70(e) Facility assessment.
The facility must conduct and document a facility-wide assessment to determine what resources are necessary to care for its residents competently during both day-to-day operations and emergencies. The facility must review and update that assessment, as necessary, and at least annually. The facility must also review and update this assessment whenever there is, or the facility plans for, any change that would require a substantial modification to any part of this assessment. The facility assessment must address or include:

§483.70(e)(1) The facility's resident population, including, but not limited to,
(i) Both the number of residents and the facility's resident capacity;
(ii) The care required by the resident population considering the types of diseases, conditions, physical and cognitive disabilities, overall acuity, and other pertinent facts that are present within that population;
(iii) The staff competencies that are necessary to provide the level and types of care needed for the resident population;
(iv) The physical environment, equipment, services, and other physical plant considerations that are necessary to care for this population; and
(v) Any ethnic, cultural, or religious factors that may potentially affect the care provided by the facility, including, but not limited to, activities and food and nutrition services.

§483.70(e)(2) The facility's resources, including but not limited to,
(i) All buildings and/or other physical structures and vehicles;
(ii) Equipment (medical and non- medical);
(iii) Services provided, such as physical therapy, pharmacy, and specific rehabilitation therapies;
(iv) All personnel, including managers, staff (both employees and those who provide services under contract), and volunteers, as well as their education and/or training and any competencies related to resident care;
(v) Contracts, memorandums of understanding, or other agreements with third parties to provide services or equipment to the facility during both normal operations and emergencies; and
(vi) Health information technology resources, such as systems for electronically managing patient records and electronically sharing information with other organizations.

§483.70(e)(3) A facility-based and community-based risk assessment, utilizing an all-hazards approach.
Observations:

Based on staff interviews and a review of the facility's assessment and resident census and condition it was determined that the facility failed to implement and document a complete facility wide assessment, which identified the specific resources necessary to care for its specific resident population.

Findings include:

Facility assessment.
The facility must conduct and document a facility-wide assessment to determine what resources are necessary to care for its residents competently during both day-to-day operations and emergencies. The facility must review and update that assessment, as necessary, and at least annually. The facility must also review and update this assessment whenever there is, or the facility plans for, any change that would require a substantial modification to any part of this assessment. The facility assessment must address or include:

The facility's resident population, including, but not limited to,
(i) Both the number of residents and the facility's resident capacity;
(ii) The care required by the resident population considering the types of diseases, conditions, physical and cognitive disabilities, overall acuity, and other pertinent facts that are present within that population;
(iii) The staff competencies that are necessary to provide the level and types of care needed for the resident population;

Review of the Facility Assessment dated December 2023, indicated the following:
The care required by the resident population considering the types of diseases, conditions, physical and cognitive disabilities, overall acuity, and other pertinent facts that are present within that population.

Diseases/Conditions & Physical/Cognitive Disabilities for Which We Provide Care: failed to include smoking residents, polysubstance abuse, drug abuse, alcohol abuse, and negative pressure wound therapy (wound vac).

Interview on 3/4/24, at 10:22 a.m. the Director of nursing confirmed the facility failed to implement its Facility Assessment as described above to care for its specific resident population.

28 Pa Code 201.14(a) Responsibility of licensee.

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


 Plan of Correction - To be completed: 05/01/2024

0838
1. Although the skilled nursing facility is not a substance abuse center, the NHA reviewed the facility assessment and updated it to include "Smoking" and Wound vacuums" as well as to assist residents as practicable as possible in the event they actively require support for "poly-substance abuse," "drug use," "alcohol abuse."
2. The Director of Nurses and Assistant Administrator were re in-serviced by the NHA on ensuring the facility assessment is up to date and includes and addresses the resident population to ensure the facility assessment identifies specific resources utilized by the facility to properly care for the resident population.
3. The NHA will audit the facility assessment quarterly to ensure the facility assessment is up to date and includes and addresses the resident population to ensure the facility assessment identifies specific resources utilized by the facility to properly care for the resident population. Audit findings will be shared with QAPI committee.
483.70(d)(1)(2) REQUIREMENT Governing Body:This is a less serious (but not lowest level) deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
§483.70(d) Governing body.
§483.70(d)(1) The facility must have a governing body, or designated persons functioning as a governing body, that is legally responsible for establishing and implementing policies regarding the management and operation of the facility; and

§483.70(d)(2) The governing body appoints the administrator who is-
(i) Licensed by the State, where licensing is required;
(ii) Responsible for management of the facility; and
(iii) Reports to and is accountable to the governing body.
Observations:
Based on a review of 28 PA Code Commonwealth of Pennsylvania Long Term Care Licensure Regulations, subsection 201.18(e)(3), facility policy, and staff interviews, it was determined that the facility failed to meet with its governing body that is legally responsible for establishing and implementing policies regarding the management and operation of the facility as required.

Findings include:

28 PA Code Commonwealth of Pennsylvania Long Term Care Licensure Regulations, subsection 201.18(e)(3), dated 7/1/23, indicated management must maintain ongoing relationship with the governing body, medical and nursing staff and other professional and supervisory staff through meetings and reports, occurring as often as necessary, but at least on a monthly basis.

Review of the "Adminstrator" policy last reviewed 10/1/23, indicated the nursing home adminstrator is responsible for serving as a liason to the governing board.

During an interview on 3/4/24, at 1:03 p.m. the Director of Nursing stated the facility does "not routinely meet" with the governing body. The DON confirmed the facility failed to meet with the govering body at least monthly as required by 28 PA Code Commonwealth of Pennsylvania Long Term Care Licensure Regulations, subsection 201.18(e)(3).

During an interview on 3/4/24, at 2:20 p.m. when asked how frequently the Nursing Home Administrator (NHA) meets with its governing body, the NHA stated he is unsure who the governing body is, and "I got to get in touch with former NHA, unsure if we have one, haven't been in touch with any one from governing body." The NHA state he has been in this position since 10/16/23.

28 Pa. Code 201.14(g) Responsibility of licensee.
28 Pa. Code 201.18(e)(1)(2) Management.



 Plan of Correction - To be completed: 05/01/2024

0837
1.The NHA contacted and contracted with the corporate compliance consultant to ensure a review of policies and governing body meetings are held.
2. The NHA was re in-serviced by the corporate compliance consultant to ensure they maintain a regularly scheduled governing body meeting to ensure and maintain an ongoing relationship with the governing body.
3. The NHA/designee shall audit ongoing to ensure a governing body meeting is held at least monthly to ensure and maintain an ongoing relationship with the governing body. Audit findings will be shared with QAPI committee.
483.70 REQUIREMENT Administration:This is a less serious (but not lowest level) deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
§483.70 Administration.
A facility must be administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident.
Observations:
Based on a review of job descriptions, facility and clinical records, and staff interviews, it was determined that the Nursing Home Administrator (NHA) and the Director of Nursing (DON) did not effectively manage the facility to make certain that proper supervision and assessments were provided for smoking residents as required, make certain that staff initiate Cardiopulmonary Resuscitation (CPR-an emergency life-saving procedure that is done when breathing or a heartbeat has stopped and when performed immediately can double or triple chances of survival after cardiac arrest) in accordance with Pennsylvania Code Title 49 Professional and Vocational Standards as required, and make certain that staff assess, monitor, and follow physician orders after a resident fall, resulting in death as required which all resulted in three separate immediate jeopardy situations.

Findings include:

Review of the policy "Administrator" dated 10/1/23, indicated the facility shall operate under the direction of a nursing home administrator (NHA) licensed by the Pennsylvania Board of Examiners for nursing home administrators. The licensed nursing home administrator will operate the facility consistent with laws, regulations, and standards of practice recognized in the field of health care administration.

The job description for the NHA specified the primary purpose of the job position is to manage the Facility in accordance with current applicable federal, state, and local standards, guidelines, and regulations that govern long-term care facilities. To follow all facility policies and apply them uniformly to all employees. To ensure the highest degree of quality care is provided to our residents at all times.

The job description for the Director of Nursing specified the primary purpose of the job position was to plan, organize, develop, and direct the overall operation of the nursing service department in accordance with current federal, state and local standards, guidelines and regulations that govern the facility to ensure that the highest degree of quality of care is maintained at all times.

Based on the findings in this report that identified that the facility failed to effectively manage the facility to make certain that proper supervision and assessments were provided for smoking residents as required, failed to make certain that staff initiate Cardiopulmonary Resuscitation in accordance with Pennsylvania Code Title 49 Professional and Vocational Standards as required, and failed to make certain that staff assess, monitor, and follow physician orders after a resident fall, resulting in a death as required which all resulted in three separate immediate jeopardy situations. The facility failed to provide fundamental principal that applies to treatment and care provided to facility residents. The facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice, facility policies, physician orders, and the comprehensive person- centered policy.

28 Pa Code 201.14(a) Responsibility of licensee.

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


 Plan of Correction - To be completed: 05/01/2024

0835
1. Supervision and assessments for resident smoker's assessments and physician's orders were updated and confirmed. Clinical care staff were re in-serviced on following physician orders for CPR administration per MD orders. Clinical care staff were in serviced on following physician orders post resident fall.
2. The NHA and Director of Nurses were re in-serviced by CoreTactics Consulting firm representative Marianne Sherlock on each of the three identified immediate jeopardy citations and their job descriptions to ensure resident smokers assessments and physicians orders were updated and confirmed. And to follow CPR administration per provider orders. And following provider orders post resident fall.
NHA and Director of Nursing will establish a safety committee to meet monthly to review potential hazards and safety concerns within the facility.
3. The NHA and Director of Nursing shall meet with the consulting firm monthly for 3 months to ensure QA compliance and reviews of each. Audit findings will be shared with QAPI committee.
NHA/designee will make walking rounds daily to assess physical structure and provision of services to ensure safe practice daily for 2 weeks, weekly for 2 weeks, then monthly for 2 months. Audit findings will be shared with QAPI committee.
483.60(i)(4) REQUIREMENT Dispose Garbage and Refuse Properly:This is a less serious (but not lowest level) deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
§483.60(i)(4)- Dispose of garbage and refuse properly.
Observations:
Based on a review of facility policies, observations and staff interviews, it was determined that the facility failed to properly dispose of refuse, and failed to prevent the potential for rodent and insect infestation by maintaining a clean and sanitary outside refuse area.

Findings include:

A review of facility policy "Sanitation" dated 10/1/23, indicated the food service area shall be maintained in a clean and sanitary manner. All kitchens, kitchen areas, and dining areas shall be kept clean, free from litter and rubbish and protected from rodents, roaches, flies, and other insects.

During an observation on 2/26/24, at 9:40 a.m., of the facilities refuse/dumpster area, conducted with Food Service Director (FSD) Employee E1, revealed that dock area aligned with the refuse dumpsters contained varied items of debris and garbage, and immediately in front of and besides/between the dumpsters on the ground, there were multiple plastic bags full of garbage with piles of debris scattered. FSD Employee E1 confirmed observation by surveyor when viewed. FSD Employee E1 confirmed that this dumpster area is used by multiple facility departments for refuse removal.

During an interview on 2/26/24, at 9:45 a.m., FSD Employee E1 confirmed that the facility failed to properly dispose of refuse, and failed to prevent the potential for rodent and insect infestation by maintaining a clean and sanitary outside refuse area.

28 Pa. Code: 201.14 (a) Responsibility of licensee.

28 Pa. Code: 201.18 (b)(1) Management.

28 Pa. Code: 201.18 (e)(2.1) Management.


 Plan of Correction - To be completed: 05/01/2024

814
1. The area surrounding the main facility dumpster and dock area was cleaned.
2. The Environmental Director and Food Service Director and Plant-Ops Director were re in-serviced by the NHA to ensure the area by the dock and dumpster are clean per the sanitation policy.
3. The NHA / designee will audit the dumpster and dock area weekly for 4 weeks and monthly ongoing to ensure the area is orderly and sanitary. Audit findings will be shared with QAPI committee.

483.10(f)(5)(i)-(iv)(6)(7) REQUIREMENT Resident/Family Group and Response: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(f)(5) The resident has a right to organize and participate in resident groups in the facility.
(i) The facility must provide a resident or family group, if one exists, with private space; and take reasonable steps, with the approval of the group, to make residents and family members aware of upcoming meetings in a timely manner.
(ii) Staff, visitors, or other guests may attend resident group or family group meetings only at the respective group's invitation.
(iii) The facility must provide a designated staff person who is approved by the resident or family group and the facility and who is responsible for providing assistance and responding to written requests that result from group meetings.
(iv) The facility must consider the views of a resident or family group and act promptly upon the grievances and recommendations of such groups concerning issues of resident care and life in the facility.
(A) The facility must be able to demonstrate their response and rationale for such response.
(B) This should not be construed to mean that the facility must implement as recommended every request of the resident or family group.

§483.10(f)(6) The resident has a right to participate in family groups.

§483.10(f)(7) The resident has a right to have family member(s) or other resident representative(s) meet in the facility with the families or resident representative(s) of other residents in the facility.
Observations:

Based on review of facility documents, and staff and resident interviews it was determined that the facility failed to ensure that residents received timely resolution to Resident Council concerns and provide evidence that the Resident Council invited facility administration staff to attend the meetings, and that there were multiple members of the facility administration present at each meeting for 13 of 13 Resident Council meetings (February 2023, to February 2024).

Findings include:

Review of Resident Council meeting minutes revealed no evidence that administration was invited to attend council meetings, council concerns were forwarded to the appropriate department, and resolutions to previous documented concerns were addressed and/or discussed with Resident Council members.

- February 9, 2023 (14 residents/10 administration staff): staff talking on personal phones/using airbus; water temperatures; TV channels not working; lack of linens; poor condition of linens; labeling personal laundry; and facility cleanliness.
Residents were told to file grievances, and that staff would be educated. No evidence that resident concerns were referred to appropriate department for follow-up.

- March 9, 2023 (10 residents/15 administration staff): clothing and linens not being returned to residents.
Residents were told to file grievances. No evidence that resident concerns were referred to appropriate department for follow-up.

- April 13, 2023 (20 residents/14 administration staff): staff continuing to wear ear buds and talking on their phones during resident care and HIPPA violations; vaping and smoking marijuana; and staffing levels/medication errors.
Residents were told to files grievances. No evidence that resident concerns were referred to appropriate department for follow-up.

- May 11, 2023 (17 residents/14 administration staff): staff continuing to wear ear buds; smelling marijuana; and facility cleanliness.
No evidence that resident concerns were referred to appropriate department for follow-up.

- June 9, 2023 (14 residents/17 administration staff): medication administration times; rude staff; staff cursing at residents; lack of nightgowns on the units; and facility cleanliness.
Residents were told to report incidents when they happen, and that staff would be educated on the issues. No evidence that resident concerns were referred to appropriate department for follow-up.

- July 13, 2023 (17 residents/15 administration staff): staff cursing at residents; facility cleanliness; residents asking how to file a grievance after the 'big shots' leave for the day; and access to computers in the cafwere told to file grievances and that staff would be educated on the issues. No evidence that resident concerns were referred to appropriate department for follow-up.

- August 10, 2023 (11 residents/17 administration staff): staff wearing ear buds and being on their phones while caring for residents; resident identification prior to administering medications.
Resident were told to file grievances, staff will be educated, and that concerns will be investigated. No evidence that resident concerns were referred to appropriate department for follow-up.

- September 14, 2023 (three residents/15 administration staff): not seeing the doctor and having medications decreased without consultation with residents.
Residents were told that staff will talk to the physician involved. No evidence that resident concerns were referred to appropriate department for follow-up.

- October 12, 2023 (six residents/16 administration staff): orienting staff on their phones instead of paying attention while touring facility; wheelchair maintenance.
No evidence that resident concerns were referred to appropriate department for follow-up.

- November 9, 2023 (14 residents/16 administration staff): staff continues to be on cell phones all the time; new staff not introducing themselves when they enter resident rooms; staff talking each other during resident care; smelling marijuana; staff attitudes; losing TV channels; no hot water in resident room; wheelchair repairs; facility cleanliness; residents' ability to do laundry.
Residents were told administration is working on the cell phone issue and to report it to the supervisor immediately. No evidence that resident concerns were referred to appropriate department for follow-up.

- December 14, 2023 (seven residents/14 administration staff): staff taking breaks in the resident rec room; when residents report nursing concerns as told to do, nothing gets done and no one comes down to talk to him/her; staff continue to be on their cell phones; toilet not working for 10 weeks; no hot water on Grove 1 unit; cigarette butts in the hallway; and facility cleanliness. Residents were told that staff will be disciplined and educated. No evidence that resident concerns were referred to appropriate department for follow-up.

- January 11, 2024 (eight residents/15 administration staff): residents wandering into other resident's rooms; 2 West Unit doors are too hard to open; and requested a tarp around the 2 West pavilion.
Residents were told that the wandering residents will be addressed. No evidence that resident concerns were referred to appropriate department for follow-up.

- February 8, 2024 (eight residents/12 administration staff): residents requested sandwiches for the vending machine and push buttons to help them get through the 2 West doors.
Residents were told that the facility could not provide sandwiches in the vending machine, and administrator will investigate push buttons for 2 West doors. No evidence that resident concerns were referred to appropriate department for follow-up.

The concerns reported in the monthly Resident Council meetings continued to be reported throughout the year and there was no evidence that the facility reported to the Resident Council how the facility was going to monitor the facility response. The employee education provided to staff was not specific to concerns reported from the Resident Council and there was no evidence that the facility reported how they resolved the issue.

Interviews on 2/28/24, between 11:00 a.m. and 12:15 p.m. Resident Council members confirmed that the council believed administration had to be at the meetings so the council concerns would get to the right person, and that the council does not receive information on how the facility addressed their concerns or how those concerns were resolved.

Interview on 2/29/24, at 12:04 p.m. Activities Employee E36 confirmed there was no evidence that administration was invited to Resident Council meetings, Resident Council concerns were assigned to the appropriate department, facility responses to Resident Council concerns, and how the facility resolved the Resident Council concerns.

Interview on 2/29/24, at 12:45 p.m. the Administrator and Director of Nursing confirmed there was no evidence that administration was invited to Resident Council meetings, Resident Council concerns were assigned to the appropriate department, facility responses to Resident Council concerns, and how the facility resolved the Resident Council concerns.

28 Pa. Code 201.14 (a) Responsibility of licensee
28 Pa. Code 201.18(b)(1)(3) Management
28 Pa. Code 201.18 (e)(1)(4) Management
28 Pa. Code 201.29(j) Resident rights


 Plan of Correction - To be completed: 05/01/2024

0565
1. The Resident Council concerns that were brought in Feb 2023 to Feb 2024 will be reviewed to determine outstanding concerns not previously resolved.
The activities director approved by the Resident Council met with Resident Council to approve invitees for the April Resident Council meeting.
2. Activities director and NHA reviewed and updated the policy and procedures for Resident/Family group meetings to include approval of invitees to the resident council meeting and review of resident council concerns to ensure timely resolution, and grievance process.
3. The activities director was re-inserviced by the Administrator on the updated policy and procedure to ensure approval of invitees to the upcoming resident council meeting and review of resident council concerns to ensure timely resolution, and following grievance process for individual concerns not confirmed by resident council.
4. The activities director/designee will audit the Resident Council Meeting minutes for 3 months to ensure approval of invitees to the upcoming resident council meetings and review of resident council concerns to ensure timely resolution in addition to grievance logs to ensure follow up of grievance concerns brought up in council meetings Audit findings will be shared with QAPI committee.

483.45(c)(1)(2)(4)(5) REQUIREMENT Drug Regimen Review, Report Irregular, Act On:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
§483.45(c) Drug Regimen Review.
§483.45(c)(1) The drug regimen of each resident must be reviewed at least once a month by a licensed pharmacist.

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

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

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

Based on review of facility policy, documents, and clinical records and staff interviews it was determined that the facility failed to provide evidence that resident's medications were reviewed monthly for irregularities for four of five residents reviewed (Residents R46, R54, R251, R280).

Findings include:

A facility policy entitled, "Pharmacy Services" dated 10/01/23, stated that a licensed pharmacist will review the drug regimen of each resident at least once a month and that the pharmacist will report any irregularities to the attending physician and the director of nursing.

Resident R46's clinical record revealed an admission date of 1/06/23, with diagnoses including chronic obstructive pulmonary disease (COPD- a group of diseases that cause airflow blockage and breathing-related problems), irregular heartbeat, dementia, and heart failure, and lacked evidence that a review of his/her medications was conducted monthly by a licensed pharmacist.

Resident R54's clinical record revealed an admission date of 7/21/22, with diagnoses including schizophrenia (serious mental illness that affects how a person thinks, feels, and behaves), paranoid personality disorder (characterized by a pattern of unwarranted distrust and suspicion of others that involves interpreting their motives as malicious), and catatonic disorder (state in which someone is awake but does not seem to respond to other people and their environment), and lacked evidence that a review of his/her medications was conducted monthly by a licensed pharmacist.

Resident R251's clinical record revealed an admission date of 2/28/22, with diagnoses including lung cancer with metastasis to the spine, high blood pressure, and dementia, and lacked evidence that a review of his/her medications was conducted monthly by a licensed pharmacist.

Resident R280's clinical record revealed an admission date of 2/24/20, with diagnoses including psychotic disorder (severe mental health disorders that cause abnormal thinking and perceptions), anxiety, and non-Alzheimer's dementia (loss of memory and other intellectual functions).and lacked evidence that a review of his/her medications was conducted monthly by a licensed pharmacist.

Interview on 3/01/24, at 9:14 a.m. the Director of Nursing confirmed that the facility was unable to locate evidence of monthly pharmacy reviews.


28 Pa. Code 211.5(f) Clinical records
28 Pa. Code 211.12(d)(1)(3)(5) Nursing services



 Plan of Correction - To be completed: 05/01/2024

F0756
1. The Facility confirmed the residents had a regularly scheduled medication regimen review as required per regulation and the dept. of health had access to this information during the survey as relates to R46, R54, R251 and R280.
2. The NHA and DON met with consultant pharmacist to review regulation and medication regimen review policy and confirmed a house audit shows medication regimen was complete.
3. The NHA will re in-service consultant pharmacist and facility medical providers on regulatory requirements for documentation of medication regimen reviews.
4. The Director of nursing/designee will audit 5 residents twice weekly for 2 weeks, 5 residents weekly for 2 weeks, then 5 residents monthly for 2 months to ensure evidence of medication regimen review is present. Audit findings will be shared with QAPI committee.

483.35(a)(1)(2) REQUIREMENT Sufficient Nursing Staff: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.
§483.35(a) Sufficient Staff.
The facility must have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment required at §483.70(e).

§483.35(a)(1) The facility must provide services by sufficient numbers of each of the following types of personnel on a 24-hour basis to provide nursing care to all residents in accordance with resident care plans:
(i) Except when waived under paragraph (e) of this section, licensed nurses; and
(ii) Other nursing personnel, including but not limited to nurse aides.

§483.35(a)(2) Except when waived under paragraph (e) of this section, the facility must designate a licensed nurse to serve as a charge nurse on each tour of duty.
Observations:

Based on review of facility policies, observations, clinical record review, resident and staff interviews, it was determined that the facility failed to have sufficient nursing staff to provide nursing and related services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of six of ten residents (Resident R280, R330, R318, R129, R406, R2).

Findings Include:

Review of the facility policy "Flow of Care" dated 10/1/23, stated care will be provided to residents, as needed 24-hours a day to attain and maintain the highest level of functioning.

Review of the facility policy "Supervision of Resident Nutrition" dated 10/1/23, indicated each resident shall receive proper nutrition in accordance with the resident's assessment, care plan, and physician orders. It was indicated residents needing assistance in eating must be promptly assisted upon being served.

Review of Nursing Assistant (NA) job description indicated NA's are responsible for assisting residents with preparing for meals, serve food trays, assist with feeding as indicated, and assist residents with identifying food arrangements.

During an observation on 2/27/24, at 9:23 a.m. Resident R280 was observed in the dining room being assisted by a staff member with eating.

During an observation on 2/27/24, at 9:36 a.m. Resident R280 was left unattended, sitting in the dining room, with his breakfast tray in front of him. Resident R280 proceeded to get up out of his chair and attempt to put his breakfast tray back onto the cart. Resident R280 started urinating on the floor in front of the breakfast cart. Resident R280 then walked over and started reaching out to Resident R434, and Resident R434 yelled out NA, Employee E55's name to get her attention and assistance. NA, Employee E55 responded at 9:38 a.m. and removed the resident and took him back to his room.

During an interview on 2/27/24, at 9:38 a.m. Resident R434 stated "this happens often."

During an observation on 2/27/24, at 12:56 p.m. the lunch cart arrived on the unit.

During an observation on 2/27/24, at 1:07 p.m. a paper titled "List of Feeds" was observed at the nursing station on the wall. Resident R330, R318, R129, R406, R2 names were listed as residents who required assistance from staff with meals.

During an observation on 2/27/24, at 1:08 p.m. the nurse aides finished passing meal trays in the dining room, and started delivering meal trays to resident rooms.

During an observation on 2/27/24, at 1:18 p.m. Nurse Aide (NA), Employee E20 was observed assisting Resident R330 with her lunch in her room. A total of 22 minutes passed since the cart arrived on the unit.

During an observation on 2/27/24, at 1:24 p.m. Resident R318 was observed sleeping in bed with her lunch tray left on her bedside table. NA, Employee E20 was observed assisting her roommate Resident R330.

During an observation on 2/27/24, at 1:25 p.m.Resident R129, R2, and R406's lunch tray were observed sitting in the cart. A total of 29 minutes passed since the cart arrived on the unit.

During an observation on 2/27/24, at 1:27 p.m. NA, Employee E20 was observed assisting Resident R318 with lunch in her room. A total of 32 minutes passed since the cart arrived on the unit

During an observation on 2/27/24, at 1:34 p.m. Resident R330 was observed eating in her room with no supervision or assistance.

During an observation on 2/27/24, at 1:35 p.m. NA, Employee E20 was observed assisting and feeding Resident R129 lunch.

During an observation on 2/27/24, at 1:38 p.m. staff were observed picking up resident's lunch trays from their room.

During an observation on 2/27/24, at 1:42 p.m. NA, Employee E20 was observed entering Resident R406's room to assist her with lunch. A total of 48 minutes passed since the cart arrived on the unit

During an observation and interview on 2/27/24, at 1:46 p.m. LPN, Employee E18 confirmed Resident R318's and Resident R330's lunch tray were left unattended, and within reach on the bedside table. LPN, Employee E18 confirmed the facility failed to timely pass meal trays for lunch and proper supervision. LPN, Employee E18 stated "some days are better than others" when it comes to staffing.

During an observation and interview on 2/27/24, at 1:48 p.m. NA, Employee E20 was observed entering Resident R2's room with her lunch tray. A total of 52 minutes passed since the cart arrived on the unit. LPN, Employee E18 confirmed the facility failed to have sufficient nursing staff to provide assistance and supervision with meals in a timely manner for (Resident R330, R318, R129, R406, R2).

During an interview on 3/4/24, at 2:58 p.m., the Director of Nursing confirmed that the facility failed to have sufficient nursing staff to provide nursing and related services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of six of ten residents (Resident R280, R330, R318, R129, R406, and R2).

28 Pa. Code: 211.10(c)(d) Resident care policies.

28 Pa. Code: 211.12(d)(1)(2)(3)(5) Nursing services.

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

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




 Plan of Correction - To be completed: 05/01/2024

0725
1. The Facility is unable to retroactively correct deficiency as it relates to R280, R330, R318, R129, R406 and R2.
2. The NHA will conduct an audit of staffing levels on the affected unit. Ancillary staff will be identified to assist with tray pass to allow more time for nursing staff to assist with feeding. NHA will complete an audit of all units to ensure residents are being fed timely.
3. The Nursing schedulers and nursing administration will be re in-serviced by NHA to monitor acuity and utilize scheduled staff accordingly.
4. The NHA/designee will monitor meal times on 3 units twice weekly for 2 weeks, 3 units weekly for 2 weeks, then 3 units monthly for 2 months to ensure adequate staff are available to assist with meal times. Audit findings will be shared with QAPI committee.
483.25(i) REQUIREMENT Respiratory/Tracheostomy Care and Suctioning:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
§ 483.25(i) Respiratory care, including tracheostomy care and tracheal suctioning.
The facility must ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals and preferences, and 483.65 of this subpart.
Observations:

Based on facility policy review, observations, and staff interviews, it was determined that the facility failed to maintain sanitary conditions of respiratory equipment for six of eight residents reviewed (Resident R65, R94, R96, R264, R345, and R209).

Findings include:

Review of the facility policy "Oxygen Administration", last reviewed on 10/1/23, indicated oxygen therapy will be provided when a resident needs oxygen at a concentration greater than room air to treat hypoxia, and decreased pulmonary and myocardial work. Oxygen therapy will be ordered as appropriate using one of the following delivery systems:
- Manual resuscitator.
- Nasal Canula.
- Simple mask.
- Non-rebreathing mask.
- Aerosol mask, tracheostomy collar, or T-tube.
Procedure including but not limited to changing complete oxygen systems including humidification bottle, tubing, neb equipment and bad at least weekly and label with date.

Review of the facility policy "Cleaning and Disinfecting of BIPAP/CPAP Equipment" (machines that use air pressure to keep breathing airways open during sleep) dated 10/1/23, indicated the following steps for cleaning the devices in accordance with professional standards:
-The outside of the device will be wiped down with a damp cloth or alcohol wipe to remove dust weekly and as needed.
-The tubing hoses and humidifier reservoir will be soaked in a solution of one part vinegar to three parts hot water for 30 minutes, then allowed to air dry weekly.
-It is recommended the tubing hoses, mask, and non-disposable filter will be changed every six months or as needed, or more often if damaged or leaking.
-The disposable filter will be changed monthly.
-The non-disposable filters will be cleaned weekly by washing with hot soapy water, rinsing with hot water, and allowing to air dry.
-The headband will be washed with the mask in hot soapy water or can be placed in a washing machine as needed.

Review of resident R96's Minimum Data Set (MDS - periodic assessment of care needs) dated 11/2/23, indicated reentry to facility on 5/26/17, with diagnosis of coronary artery disease (heart disease where arteries cannot deliver enough oxygen to the heart), hypertension (high blood pressure), chronic obstructive pulmonary disease (COPD-makes it hard to breathe). MDS Section O is coded for oxygen use.

Review of Resident R96's physician orders 2/23/23, indicate oxygen via nasal cannula continuous at 4 liters/min for COPD.

Review of Resident R96's physician orders dated 7/25/23, indicate the change O2 tubing, change humidification bottle, cleanse O2 filter, inspect easy foam wraps (replace if soiled or missing) weekly.

During an observation 02/26/24, 9:54 a.m. revealed resident R96's oxygen tubing wrapped around the wall tree with no date/time the oxygen was on, set on 4 lpm. Resident R96 observed self-propelling in hallway with portable oxygen tank to chair, nasal canula on, not labeled with date and time.

Interview on 2/26/24, 10:07 a.m. LPN Employee E5 confirmed Resident R96's oxygen tubing in the room was on, no date/time on tubing. Resident R96's oxygen tubing that was on his chair was not labeled with date time.

Review of resident R94's MDS dated 12/30/24, indicated reentry to facility on 3/27/15, with diagnosis of anemia (low red blood cells), hypertension, COPD. MDS Section O is coded for oxygen use.

Review of Residents R94's physician orders dated 9/20/21, indicate oxygen via nasal cannula at 2 liters a min PRN (as needed) for COPD.

Review of physician orders dated 3/17/20, change oxygen tubing, change humidification bottle, storage bag, inspect easy foam wraps (replace if soiled of missing) every night shift every Tue for maintenance of oxygen equipment.

During resident observation 2/26/24, 10:32 a.m. Resident R94's nasal canula oxygen tubing was not labeled with date/time.

During an interview 2/26/24, 10:49 a.m. LPN Employee E8 confirmed that Resident R94's nasal cannula was not labeled with the date/time.

Review of resident R264's MDS dated 11/30/23, indicated reentry to facility on 10/20/23, with diagnosis of anemia , hypertension, COPD. MDS Section O is coded for oxygen use.

Review of R264's physician orders 10/20/23, indicated to inhale 3ml of Ipratropium-Albuterol Inhalation Solution 0.5-2.5 (3 MG/3ML) orally every 8 hours as needed for shortness of breath and wheezing. Further review of physician orders indicated oxygen was not a current order.

During an observation 2/26/24, 10:44 a.m. resident R264 was in her bed, oxygen on via nasal canula not labeled or dated, a nebulizer was noted to be sitting on top of dresser with a date of 2/7/24.

Interview 2/26/24, 10:50 a.m. LPN Employee E8 confirmed that Resident R264's nasal canula was not labeled with date/time and confirmed nebulizer was dated with the date of 2/7/24 and not changed. LPN Employee E8 also stated that tubing and nebulizers are changed weekly on the night shift.

Interview 2/29/24, 11:20 a.m. RN Employee E13 confirmed no orders were in place for Resident R264's oxygen.

Review of Resident R65's MDS dated 2/13/24, indicated reentry to facility on 1/6/24, with diagnosis of coronary artery disease, hypertension, COPD. MDS Section O is coded for oxygen use.

Review of Resident R65's physician order 2/8/2024, indicate supplement Oxygen 3 LPM titrate to 5 LPM for Pox under 88% every shift for shortness of breath.

During resident observation 2/26/24, 11:02 a.m. Resident R65's nasal canula oxygen tubing was not labeled with date/time.

During an interview 2/26/24, 11:02 a.m., Licensed Practical Nurse (LPN) Employee E5 confirmed that Resident R65' s nasal cannula was not labeled with the date/time.

Review of resident R345's MDS dated 2/13/24, indicated admission to facility on 9/18/23, with Atrial fibrillation (irregular heartbeat), shortness of breath, chronic pain syndrome. MDS Section O is coded for oxygen use.

Review of Resident R345's physician orders 9/19/23, indicate Oxygen via nasal cannula at 2 liters/min. PRN. Change O2 tubing, change humidification bottle, cleanse O2 filter, inspect easy foam wraps (replace if soiled or missing) weekly, every night shift every Tuesday.

During an observation 2/26/24, 11:06 a.m. resident R345 was in bed, oxygen tubing was on, not labeled or dated.

Interview 2/26/24, 11:06 a.m. LPN Employee E5 confirmed that the oxygen tubing was not labeled with date/time.

Review of the admission record indicated Resident R209 admitted to the facility on 11/17/21.

Review of Resident R209's MDS dated 1/11/24, indicated the diagnoses of obstructive sleep apnea (intermittent periods of not breathing during sleep), morbid obesity (100 pounds over your ideal body weight), and atrial fibrillation (irregular heart rhythm).

Review of Resident R209's physician order dated 9/1/22, indicated CPAP apply at bedtime. Settings of Fi02 21% (fraction of inspired oxygen) with PEEP 8 (positive end-expiratory pressure), every night shift for sleep apnea. Make sure utilizing bi-pap. If resident refuses must chart.

Review of Resident R209's Treatment Administration Record (TAR) dated February 2023, indicated the resident received the CPAP at bedtime every night shift as ordered.

Review of Resident R209's care plan dated 8/31/23, indicated the resident has altered respiratory status, difficulty breathing related to sleep apnea. Interventions indicated BIPAP/CPAP/VPAP Settings: (My, the residents, [PREFERRED NAME]'s),(Specify: CPAP/BIPAP) settings are- Titrated presssure: (X)cmH2O via (nasal pillow,nose mask or full-face mask) (FREQ).

Observation on 2/26/24, at 10:59 a.m. Resident R209 was in his room with a CPAP machine on the bedside stand.

Interview with Resident R209 on 2/26/24, at 11:00 a.m. indicated that "nobody has cleaned the CPAP since the Respiratory Department left".

Interview on 2/27/24, at 11:00 a.m. the Director of Nursing confirmed the physician orders did not include cleaning instructions and care of the CPAP machine, and that the care plan was not individualized to Resident R209's specification in the physician orders, failed to include cleaning instructions and care of the CPAP machine, and that the facility failed to maintain sanitary conditions of respiratory equipment for six of eight residents reviewed (Resident R65, R94, R96, R264, R345, and R209).

28 Pa. Code 211.12(c) Nursing services

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

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


 Plan of Correction - To be completed: 05/01/2024

0695
1. The oxygen tubing was changed and dated for R96, R94, R345 and R65. R264 oxygen orders were updated and tubing was changed and dated. R209 electronic record was updated to include cleaning instructions. CPAP was cleaned.
2. An audit will be completed of residents in facility with orders for oxygen equipment to ensure coinciding orders for care and changings are included.
3. The licensed staff will be re in-serviced on changing oxygen equipment per physician order and bipap/cpap cleaning.
4. The Director of nursing/designee will audit 3 residents with oxygen orders twice weekly for 2 weeks, then 3 residents weekly for 2 weeks, then 3 residents monthly for 2 months to ensure oxygen equipment and cpaps are being maintained per physician order. Audit findings will be shared with QAPI committee.
483.12 REQUIREMENT Free from Misappropriation/Exploitation: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.
§483.12
The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms.
Observations:

Based on review of clinical records and facility investigative documents, and staff interviews, it was determined that the facility failed to ensure that residents were free from misappropriation (the act of stealing something that you have been trusted to care for and using it for yourself) of medications for four of four residents reviewed (Residents R11, R152, R251, and R418).

Findings include:

Review of facility policy "Abuse: Protection from Abuse" dated 10/1/23, indicated the resident has a right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, involuntary seclusion, neglect, and misappropriation of property.

Review of facility policy "Controlled Medications" dated 10/1/23, indicated medications included in the Drug Enforcement Administration (DEA) classification as controlled substances, and medications classified as controlled substances by state law, are subject to special handling, storage, ordering, receipt, disposal, and recordkeeping requirements in the long-term care facility. The purpose of these regulations is: to assure controlled substances are handled, stored, and disposed of properly.

Review of admission record indicated Resident R11 was admitted to the facility on 1/19/24.

Review of Resident R11's Minimum Data Set (MDS- a periodic assessment of care needs) dated 2/8/24, indicated the diagnoses of high blood pressure, peripheral vascular disease (a condition in which narrowed blood vessels reduce blood flow to the limbs), and viral hepatitis (inflammation of the liver). Section C - Brief Interview for Mental Status ("BIMS", a screening test that aides in detecting cognitive impairment) indicated a score of 13 - cognitively intact.

Review of Resident R11's physician order dated 1/19/24, indicated oxycodone (narcotic pain medication) 5mg (milligrams) every 24 hours as needed for pain.

Review of Resident R11's January 2024, Medication Administration Record (MAR) indicated he received the medication twice on 1/29/24 and 1/31/24.

Review of Resident R11's February 2024, MAR indicated he received the medication zero times.

Review of Resident R11's controlled drug record dispense date was 1/23/24. Upon evaluation of the record, it was noted that the resident was admitted to the facility on 1/19/24, and there were narcotics signed out on the form from 1/14/24 -1/19/24 before the resident arrived.

Review of facility investigation dated 1/23/24, indicated Resident R11 received a card of 28 Oxycodone delivered by pharmacy. Noted ten doses signed out on dates 1/14/24 -1/23/24. The resident did not admit until 1/19/24. Doses were also signed out by the same person 1/25/24 -1/27/24. Dates are out of order and repeated. (Dose was only ordered every day). Comparison with the MAR did not coincide with the count sheet. Total of 18 doses suspicious.

Review of the admission record indicated Resident R152 admitted to the facility on 4/13/21.

Review of Resident R152's MDS dated 2/21/24, indicated the diagnoses of high blood pressure, diabetes (a long-term condition in which the body has trouble controlling blood sugar and using it for energy), and peripheral vascular disease. Section C BIMS score indicated 15 - cognitively intact.

Review of Resident R152's physician order dated 11/27/23, indicated oxycodone 5mg every six hours as needed for moderate pain.

Review of facility investigation dated 2/13/24, indicated Resident R152 received oxycodone from pharmacy and secured in the locked medication cart. It was noted doses signed for 2/12/24 on new card (Card 2) that was delivered on 2/13/23. Registered Nurse (RN) Employee E31 had card 1 signed out appropriately up to dose 2/16/24, at 4:15 a.m. Ten doses in question as signed out in duplicate. On 2/16/24, one dose suspicious due to signed as "too early, wasted" without a witness as required. RN Employee E31 worked this cart on 2/16/24.

Review of the admission record indicated Resident R251 admitted to the facility on 2/28/22.

Review of Resident R251's MDS dated 2/25/24, indicated the diagnoses of lung cancer with metastasis to the spine, high blood pressure, and dementia.

Review of Resident R251's physician order dated 10/11/23, indicated Oxycodone 5mg four times daily routinely.

Review of facility investigation dated 2/16/24, indicated Resident R251 had 120 tablets in two cards of 60 oxycodone delivered, signed in and locked in the medication cart. RN Employee E32 noted that ten doses were signed out with dates ranging from 2/13/24 - 2/25/24, (dates prior to the delivery of the card). The doses signed out on 2/14/24, exceed the daily amount ordered. There were five pills signed out for 2/14/24. RN Employee E31 was the only nurse that had access to this card from the time delivered on 2/16/24, after lunch to the time it was noted by RN Employee E32 on 3-11 shift that it appeared to be suspicious activity.

Further review of the investigation indicated on 2/22/24, the facility noted that it appeared that 13 doses from 2/13/24 -2/16/24, were not accounted for on the narcotic control log. Pharmacy was called and indicated another card of 30 tablets were sent on 2/12/24. On shift count sheet it was noted card was delivered. Currently, the facility does not have the count sheet for that card. Potentially 17 doses from the card delivered on 2/12/24 are unaccounted for.

Review of the admission record indicated Resident R418 admitted to the facility on 1/27/24.

Review of Resident R418's MDS dated 2/8/24, indicated the diagnoses of peripheral vascular disease, high blood pressure, and osteomyelitis of the spine (bone infection). Section C BIMS score indicated 12 - moderately impaired cognition.

Review of Resident R418's physician order dated 1/27/24, indicated Oxycodone 5mg every six hours and a decrease in order on 2/19/24, to Oxycodone 5mg every 12 hours.

Review of facility investigation dated 1/27/24, indicated Resident R418 received a card of 26 Oxycodone. Eleven doses suspicious. Not signed out on the MAR. Four doses were completely scribbled out on count sheet 1/29/24.

Interviews with the residents involved indicated they experienced no increase in levels of pain.

Interview on 3/4/24, at 9:58 a.m. Assistant Director of Nursing (ADON) Employee E35 confirmed a total of 65 tablets were not accounted for Resident R11 - 18 doses, Resident R152 - 11 doses, Resident R251 - 27 doses, and Resident R418 - 9 doses.

Interview with the ADON Employee E35 on 3/4/24, at 10:00 a.m. confirmed that the facility failed to ensure that residents were free from misappropriation of medications for four of four residents reviewed (Residents R11, R152, R251, and R418).

28 Pa Code 211.12(c)(d)(1)(2)(5) Nursing services

28 Pa. Code: 211.10 (c)(d) Resident Care Policies

28 Pa Code 201.14(a) Responsibility of licensee.

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

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


 Plan of Correction - To be completed: 05/01/2024

0602
1. The Medications were replaced for R11, R152, R251 and R418.
2. The NHA reviewed facility abuse prevention policy was up to date and confirmed E31 is no longer employed by facility or present through a clinical agency. An audit was done at time of reporting/investigation to ascertain scope of diversion, see event ID 989119.
3. The Staff will be educated on the facility abuse prevention policy, which includes the right to be free from misappropriation, including narcotics inventory.
4. The Director of nursing/designee will interview 5 residents twice weekly for 2 weeks, then 5 residents weekly for 2 weeks, then 5 residents monthly for 2 months to ensure residents are free from misappropriation. Director of nursing/designee will audit 3 med carts twice weekly for 2 weeks, 3 med carts weekly for 2 weeks, then 3 med carts monthly for 2 months to ensure inventory process for narcotics is being followed. Audit findings will be shared with QAPI committee.
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 review of facility policy and documentation, observations, grievance logs, council minutes, and staff, and resident interviews it was determined that the facility failed to provide a clean, safe, comfortable, and homelike environment for four of eight residents (R19, R211, R217, and R415).

Findings include:

Review of the facility policy "Resident Environment" dated 10/1/23, indicated the facility will provide an environment that is safe, clean, comfortable, and homelike.

Resident R19's clinical record revealed an admission date of 10/02/19, with diagnoses including schizoaffective disorder (mental health disorder that is marked by a combination of schizophrenia symptoms, such as hallucinations or delusions, and mood disorder symptoms, such as depression or mania), Type 2 Diabetes (affects how the body uses glucose (sugar), pseudobulbar affect (episodes of sudden uncontrollable and inappropriate laughing or crying), low level personal hygiene, and high blood pressure.

Observation on 2/27/24, at 10:13 a.m. Resident R19's personal sink failed to expel water into the basin when the cold and hot faucets were turned on.

Interview on 2/28/24, at 2:45 p.m. Licensed Practical Nurse (LPN) Employee E34 confirmed that there was no running water in Resident R19's sink when the cold and hot faucets were turned on.

Observation on 2/29/24, at 1:35 p.m. Resident R19's personal sink continued with no running water when the cold and hot faucets were turned on.

Review of admission record indicated Resident R211 admitted to the facility on 7/10/23.

Review of the Minimum Data Set (MDS- a periodic assessment of care needs) dated 1/31/24, indicated the diagnoses of pneumonia (lung infection), diabetes (a long-term condition in which the body has trouble controlling blood sugar and using it for energy), and high blood pressure. Section C - Brief Interview for Mental Status (BIMS - a screening test that aides in detecting cognitive impairment) indicated a score of 15 - cognitively intact.

Interview on 2/26/24, at 10:13 a.m. Resident R211 indicated she doesn't get showers because there is no hot water in the sink or the shower.

Review of the admission record indicated Resident R217 admitted to the facility on 7/16/21.

Review of R217's MDS dated 2/16/24, indicated the diagnoses of traumatic brain injury (TBI - brain dysfunction caused by an outside force, usually a violent blow to the head), pain, and polyneuropathy (the malfunction of peripheral nerves throughout the body). Section C - BIMS indicated a score of 15 - cognitively intact.

Interview on 2/26/24, at 12:04 p.m. Resident R217 indicated his toilet was corroded under the raised toilet seat and that he was tired of cleaning it himself.

Observation and interview on 2/26/24, at 12:10 p.m. Housekeeping Manager Employee E21 removed the raised seat from the commode and confirmed the toilet was corroded under the raised toilet seat with a brown substance.

Review of the admission record indicated Resident R415 admitted to the facility on 7/3/23.

Review of Resident R415's Minimum Data Set (MDS - a periodic assessment of care needs) dated 2/20/24, indicated the diagnoses seizure disorder (a person experiences abnormal behavior, symptoms, and sensations, sometimes including loss of consciousness), TBI, and anxiety. Section C -Brief Interview for Mental Status (BIMS -a screening test that aides in detecting cognitive impairment) indicated a score of 14 - cognitively intact.

Interview on 2/26/24, at 11:14 a.m. Resident R415 indicated there is never any hot water to shower in.

Facility tour on 3/1/24, at 10:42 a.m. Maintenance Director Employee E19 tested the temperature of Resident R211's sink and shower water. The sink tested at 83.6 degrees Fahrenheit (F) and the shower tested at 73 degrees F and after running for several minutes only reached a temperature of 77 degrees F.

Facility tour on 3/1/24, at 10:52 a.m. Maintenance Director Employee E19 tested the temperature of Resident R415's sink and shower water. The sink tested at 71 degrees F and the shower tested at 78 degrees F.

Review of council meeting minutes, facility grievance and complaint logs, and a random sample of maintenance work orders indicated unresolved concerns with water temperatures.

Interviews on 2/28/24, between 11:00 a.m. and 12:15 p.m. nine resident council members confirmed that there is an ongoing issue with sporadic lack of hot water on all units in the facility and that the water temperatures continue to be cold.

Interview on 2/29/24, at 12:04 p.m. the Director of Maintenance Employee E19 confirmed that the facility cannot provide documentation that the water temperature concerns were addressed in response to repeated resident council concerns.

Interview on 3/1/24, at 10:53 a.m. the Maintenance Director Employee E19 confirmed the facility failed to provide a clean, safe, comfortable, and homelike environment for three of eight residents (R211, R217, and R415).

28 Pa Code 201.14(a) Responsibility of licensee.

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

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


 Plan of Correction - To be completed: 05/01/2024

F0584
1. The sink was repaired for R19 to match care plan, water was always available but had been turned off due to resident care plan, the water temp was checked and adjusted for R211, the toilet riser was removed and toilet cleaned for R217, shower temps were reviewed and adjusted as needed for R415's unit. Resident council concerns for hot water were addressed and continue to be monitored and reported back to resident council.
2. The Director of Maintenance reviewed outstanding work orders to ensure completion.
3. The Director of maintenance was educated by NHA on providing a safe clean and comfortable homelike environment. Staff were re inserviced on how to update maintenance work orders.
4. The Maintenance Director/designee will audit, 10 work orders weekly, then 10 work orders monthly for 1 month to ensure completion. The maintenance Director/designee will audit water temps on 1 unit weekly until all (13) units have been audited and are within compliant ranges. Audit findings will be shared will QAPI committee.

483.10(c)(1)(4)(5) REQUIREMENT Right to be Informed/Make Treatment Decisions: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) Planning and Implementing Care.
The resident has the right to be informed of, and participate in, his or her treatment, including:

§483.10(c)(1) The right to be fully informed in language that he or she can understand of his or her total health status, including but not limited to, his or her medical condition.

§483.10(c)(4) The right to be informed, in advance, of the care to be furnished and the type of care giver or professional that will furnish care.

§483.10(c)(5) The right to be informed in advance, by the physician or other practitioner or professional, of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options and to choose the alternative or option he or she prefers.
Observations:

Based on facility policies, clinical record review and staff interviews, it was determined that the facility failed to ensure a resident's right to be informed of their total health status and participate in treatment decisions for one out of three sampled (Resident R468).

Findings include:

Review of the facility "Admission and Referral Process" policy last reviewed 10/1/23, indicated the Admission Department is responsible for coordinating all information and referral requests. The Admission date and time will be arranged and the Responsible Party/ Resident will complete all required documentation.

Review of the facility "Resident Rights" policy last reviewed 10/1/23, indicated all residents have the right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility. The facility will promote the exercise of rights for each resident, including any who face barriers (such as communication problems, hearing problems and cognition limits) in the assert these rights based on his or her degree of capability.

Clinical record review revealed that Resident R468 was admitted to the facility on 12/1/23, with diagnoses that included heart failure (progressive heart disease that affects pumping action of the heart muscles), high blood pressure, and bipolar disorder (mental illness characterized by extreme mood swings.)

Review of Resident R468's MDS dated 12/7/23, indicated the diagnoses were current. Section C: Cognitive Patterns indicated that the resident was severely cognitively impaired with a Brief Interview for Mental Status (BIMS) score of 3.

Review of the resident's admission record indicated Resident R468 was responsible for her own decision making.

Review of Resident R468's clinical record from 12/1/23, through 12/25/23, failed to include documented evidence that the facility fully informed Resident R468 of the treatment decisions proposed of their total health status and participation in treatment decisions. The resident failed to have a signed admission agreement.

During an interview on 2/29/24, at 11:32 a.m., the Admission Clerk, Employee E54 confirmed the facility was unable to locate a signed admission agreement that was completed for Resident R468.

During an interview on 3/5/24, at 9:54 a.m., the Director of Nursing confirmed the facility failed to provide evidence that Resident 468 was afforded the right to fully participate in treatment, including making healthcare decisions.

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

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


 Plan of Correction - To be completed: 05/01/2024

0552
1. The Facility is unable to correct the cited deficiency as it relates to R468 as she is no longer in the facility.
2. The Facility policy on admissions and referral process was reviewed by NHA to ensure the process in is line with resident/responsible party right to be informed of treatment to be provided.
3. The Admissions staff were re in-serviced by the NHA on ensuring admission agreements are signed by resident or responsible party per policy.
4. The NHA/designee will audit admission agreements for weekly for 2 weeks, monthly for 2 months to ensure they have been reviewed with resident/responsible party. Audit findings will be shared with QAPI committee.

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

Based on facility policy, clinical record review, observation, resident, and staff interview, it was determined that the facility failed to accommodate appropriate adaptive equipment to attain and maintain the highest level of functioning for hygiene needs of one of five residents interviewed (Resident R415).

Findings include:

Review of facility policy "Flow of Care" dated 10/1/23, indicated care will be provided to residents, as needed 24-hours a day to attain and maintain the highest level of functioning. Any concerns are to be addressed by the charge nurse responsible for that resident.

Review of the admission record indicated Resident R415 admitted to the facility on 7/3/23.

Review of Resident R415's Minimum Data Set (MDS - a periodic assessment of care needs) dated 2/20/24, indicated the diagnoses seizure disorder (a person experiences abnormal behavior, symptoms, and sensations, sometimes including loss of consciousness), traumatic brain injury (TBI- brain dysfunction caused by an outside force, usually a violent blow to the head), and anxiety. Section C - Brief Interview for Mental Status (BIMS - a screening test that aides in detecting cognitive impairment) indicated a score of 14 - cognitively intact.

Interview with Resident R415 on 2/26/24, at 11:10 a.m. indicated he requested a shower chair for the shower in his resident bathroom and hasn't received it. Indicated he fell in the shower a handful of times because his balance is bad when he tries to wash his feet due to dizziness related to his TBI. He indicated he banged his head, and his hip was sore. Now, he has to wear a helmet in his shower because they haven't gotten him a shower chair for his room.

Review of Resident R415's physician order dated 7/5/23, indicated helmet at all times when out of bed.

Review of Resident R415's care plan dated 7/20/23, indicated at risk for falls. Fall in shower room on 7/20/24. To wear helmet when out of bed.

Review of Resident R415's incident report dated 7/20/23, at 11:30 a.m. indicated resident reported to staff that he fell in the shower room. Resident educated not to remove shower shoes.

Observation on 2/26/24, at 11:10 a.m. of Resident R415's shower in his resident bathroom failed to have a shower chair present. A shower chair was not present in the resident room either. A helmet was observed on top of his closet area.

Interview with Rehab Director Employee E15 on 3/1/24, at 11:14 a.m. indicated the requisition was placed on 2/6/24, through central supply.

Review of facility email document dated 2/6/24, at 8:38 a.m. indicated an inquiry to central supply "Shower chair - do we have any in house?".

Review of Resident R415's progress notes dated 2/26/24, at 3:24 p.m. Rehab Director Employee E15 indicated per resident request, order placed this date for standard shower chair. To be provided on delivery.

Interview 2/26/24, at 11:00 a.m. Licensed Practical Nurse (LPN) Employee E16 confirmed that the facility failed to accommodate appropriate adaptive equipment to attain and maintain the highest level of functioning for hygiene needs of one of five residents interviewed (Resident R415).

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

28 Pa Code 211.12(c)(d)(1)(2)(5) Nursing services

28 Pa Code 211.5(f) Clinical records


 Plan of Correction - To be completed: 05/01/2024

0558
1. R415 was provided a shower chair. Order for helmet was discontinued due to no longer being needed.
2. The Director of Rehab will conduct a house audit to ensure all needed adaptive equipment per orders were received.
3. The Director of Rehab was re in-serviced by the NHA to ensure needed equipment is provided to the resident in a timely manner upon order.
4. The Director of rehab/designee will audit 3 residents requiring adaptive equipment weekly for 3 weeks, then monthly for 3 months to ensure adaptive equipment is ordered timely. Audit findings will be shared with QAPI committee.

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

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

Based on facility policy and clinical record review and staff interview, it was determined the facility failed to notify the physician of a change in condition for two of four residents (Resident R21 and R101).

Findings include:

Review of the facility policy "Notification of Condition Change: Physician" dated 10/1/23, indicated a change in a resident's condition will be reported to the physician in a timely manner. Licensed professional nurses are responsible to provide timely and complete communication to physician when there is a change in resident's condition.

Review of the facility policy "Nursing Care of the Diabetic Resident" dated 10/1/23, indicated obtain physician orders finger stick blood sugar testing including parameters for intervention. Document notification to physician of unstable and/or significant variances from baseline.

Review of the facility policy "Hypoglycemia Protocol" dated 10/1/23, indicated low blood glucose less than 70 or physician ordered low parameter.
-Hold all diabetic medications.
-Administer rapidly absorbed simple carbohydrate such as juice, regular soda pop, or tube of glucose gel.
-Recheck blood glucose in 10 -15 minutes.
-If below 70, repeat juice and blood glucose measurement times one. If no improvement, notify physician.

Review of admission record indicated Resident R21 was admitted to the facility on 2/10/17.

Review of Resident R21's Minimum Data Set (MDS- a period assessment of care needs) dated 2/25/24, indicated the diagnoses of diabetes (a long-term condition in which the body has trouble controlling blood sugar and using it for energy), seizures (sudden uncontrolled movements), and bilateral amputations (surgical removal of a limb) above the knee.

Review of Resident R21's physician order dated 8/1/23, indicated accucheck (finger stick to check glucose) two times a day.

Review of Resident R21's care plan dated 1/2/24, indicated to monitor for signs and symptoms of hypo/hyperglycemia (low/high blood sugar).

Review of Resident R21's glucose log indicated the following abnormal glucose results:
2/12/24, at 4:53 p.m. glucose high at 464.
2/20/24, at 5:34 p.m. glucose high at 445.
2/21/24, at 5:57 a.m. glucose high at 473.
2/21/24, at 5:26 p.m. glucose high at 508.

Review of Resident R21's progress notes failed to include documentation of physician notification for each of the abnormally high glucose levels and failed to include recheck glucose testing being performed.

Interview on 3/5/24, at 9:11 a.m. the Director of Nursing confirmed that the physician was not notified of abnormal glucose levels.

Review of admission record indicated Resident R101 was admitted to the facility on 7/24/21.

Review of Resident R101's MDS dated 1/31/24, indicated the diagnoses of diabetes, renal failure (kidney failure), legally blind, and osteomyelitis of left heel (infection of bone).

Review of Resident R101's physician order dated 1/24/24, indicated Lispro (a short acting, manmade version of human insulin), Inject as per sliding scale: if 151 - 200 = 1 unit; 201 - 250 = 2 units; 251 - 300 = 3 units; 301 - 350 = 4 units; 351 - 400 = 5 units; 401+ = 10 units give 10 units and call physician, subcutaneously (fatty tissue just beneath the skin) before meals.

Review of Resident R101's care plan dated 2/5/24, indicated patient's blood glucose will be well-managed with current regimen. Ensure patient has a treatment plan prescribed by provider if hypo/hyperglycemia occurs.

Review of Resident R101's glucose log indicated the following abnormal results:
12/29/23, at 1:44 p.m. glucose low at 66.
1/3/24, at 6:43 p.m. glucose low at 52.
2/3/24, at 5:54 a.m. glucose high at 460.
2/14/24, at 12:08 p.m. glucose low at 61.
2/23/24, at 6:18 a.m. glucose high at 450.

Review of Resident R101's progress notes failed to include documentation of physician notification for each of the abnormally high/low glucose levels and failed to include recheck glucose testing being performed.

Interview on 3/4/24, at 11:28 a.m. Assistant Director of Nursing (ADON) Employee E17 confirmed Resident R101's progress notes failed to include documentation of physician notification for each of the abnormally high/low glucose levels and failed to include recheck glucose testing being performed.

Interview on 3/5/24, at 3:00 p.m. The Director of Nursing confirmed the facility failed to notify the physician of a change in condition for two of four residents (Resident R21 and R101).

28 Pa Code 211.12(c)(d)(1)(2)(5) Nursing services

28 Pa. Code: 211.10 (c)(d) Resident Care Policies

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


 Plan of Correction - To be completed: 05/01/2024

0580
1. Providers were notified of elevated blood sugars for R21 and R101. R21 and R101 had parameters ordered by the Medical Provider for when to call the physician during a hypo/hyper glycemic event.
2. A house audit was conducted of diabetic residents to ensure orders with parameters on when to notify the physician of an abnormal blood sugar was done, no additional issues identified.
3. The Director of Nursing/designee will re in-service licensed staff on notifying the physician when a blood sugar result is outside the ordered parameters.
4. The Director of nursing/designee will audit 3 diabetic residents twice weekly for 2 weeks, then 3 residents weekly for 2 weeks, then 3 residents monthly for 2 months to ensure physician notifications are made. Audit findings will be shared with QAPI committee.
483.12(a)(1) REQUIREMENT Free from Abuse and Neglect:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
§483.12 Freedom from Abuse, Neglect, and Exploitation
The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms.

§483.12(a) The facility must-

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

Based on review of facility policies, facility documents, clinical records, and resident and staff interviews, it was determined that the facility failed to make certain residents were free from abuse and neglect for two of eight residents (Resident R284 and R403).

Findings include:

Review of facility policy "Abuse: Protection from Abuse" dated 10/1/23, indicated the resident has a right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, involuntary seclusion, neglect, and misappropriation of property. Residents must not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends, or other individuals. Abuse includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial wellbeing.

Review of the facility policy "Flow of Care" dated 10/1/23, stated care will be provided to residents, as needed 24-hours a day to attain and maintain the highest level of functioning.

Review of facility policy "Nursing Department Staff" dated 10/1/23, indicated to ensure the safety and well-being of residents, a resident check will be made at least every two hours through each 24-hour shift by nursing service personnel. Routine checks involve entering resident's rooms to determine if the resident needs are being met, if there has been a change in the resident's condition, and if the residents needs toileting assistance. It was indicated documentation must be maintained supporting the tome, identity of person making check, and outcome of check.

Review of admission record indicated Resident R284 was admitted to the facility on 11/11/22.

Review of Resident R284's Minimum Data Set (MDS- periodic assessment of care needs), dated 10/10/23, indicated the diagnoses of dementia (a group of symptoms that affects memory, thinking and interferes with daily life), high blood pressure, and malnutrition (condition that results from lack of sufficient nutrients in the body.) Section GG (Functional Abilities and Goals) indicated the resident required substantial and maximal assistance with toileting hygiene. Section H (Bowel and Bladder) indicated the resident is frequently incontinent (loss of bladder control.)

Resident R284's care plan initiated 11/11/22, indicated the resident is at risk for urinary incontinence and needs assistance for toileting. Interventions indicated to assist the resident to toilet as needed.

Review of Nurse Aide (NA), Employee E57's "Agency Orientation Checklist" dated 10/16/23, indicated Na, Employee E57 was educated on abuse and neglect.

Review of Resident R284's progress note dated 10/20/23, at 9:15 p.m. entered by LPN, Employee E56 indicated she was down the hall passing medications when she head Nurse Aide (NA), Employee E57 yell down and stated Resident R284 was on the floor. Upon entering the room, the resident was on his buttocks with his bilateral hands on the floor pressing himself. The resident stated "I fell out of bed." On assessment the "resident's bed was fully soaked of urine and his brief was falling apart." After changing his bed, resident was placed back into bed and washed up. No injuries noted on assessment. Resident stated that he did not hit his head.

Review of Resident R284's "Documentation Survey Report-v2 Oct-23" failed to reveal documentation of toilet use on the day and evening shift on 10/20/23. It was left blank and not completed.

Review of LPN, Employee E56's witness statement dated 10/20/23, indicated NA, Employee E57 "was caught sleeping in the front nurse's station." It stated she was informed of her assignment change. Resident R284 was found on the floor with his "brief was falling apart" and full of a bowel movement. It was indicated NA, Employee E57 left the unit for two hours and did not finish her evening care for her assignment.

Review of NA, Employee E26's witness statement dated 10/20/23, indicated NA, Employee E57 continually disappeared throughout the shift, and kept falling asleep. "All of the residents was full beds so the nurse changed the beds and her residents. Left the floor after 9 p.m. and never came back."

Review of NA, Employee E58's Witness Statement dated 10/20/23, indicated NA, Employee E57 was missing almost the whole shift. It was indicated NA, Employee E57 left the floor and never came back.

Review of NA, Employee E57's witness statement dated 10/20/23, indicated she went on break at 9:45 p.m. and when she came back she was told her residents were never changed. NA, Employee E57 confirmed Resident R284 was a part of her assignment. NA, Employee E57 stated Resident R284 fell and was wet, and she just changed him at 8:15 p.m. It was indicated the Resident R284 was the only resident she received assistance with due to him falling, and she was going to do his room next but the nurse already changed him.

During an interview on 3/5/24 9:54 a.m. the Director of Nursing confirmed the facility failed to protect Resident R284 from neglect.

During an interview on 3/12/23, at 10:29 a.m. NA, Employee E59 stated she check and changes the residents she is responsible for "three times a shift, if you see it sagging, and as needed." It was indicated every time a resident is changed, it is documented in the electronic record.

During an interview on 3/12/23, at 10:38 a.m. NA, Employee E60 stated it is expected to check and change residents every two hours and it's documented in the electronic clinical record.

During an interview on 3/12/23, at 10:40 a.m. LPN, Employee E18 indicated it is expected nurse aides check and change residents a minimum of every two hours and document in the electronic record.

During a phone interview on 3/12/24, at 11:56 a.m. LPN, Employee E56 indicated she was unsure who was assigned Resident 284 on 10/20/23, however when she found him "dirty" and his brief was "saturated". She indicated she remembers trying to figure out who his aide was, and she did make the comment that "she needs to start doing her rounds." It was indicated she started checking other residents and told her all the people that were wet. LPN, Employee E56 stated "I don't think she was doing rounds." It was indicated Resident R284 sheets were soaked with urine. LPN, Employee E56 stated it's expected to check on a residents a minimum of two hours, and if they are a heavy wetter, at least hourly.

During a phone interview on 3/12/23, at 12:52 p.m. NA, Employee E57 stated on 10/20/23, she checked everybody at 3:00 p.m., and Resident R284 used the bathroom a lot. She indicated she changed him in bed and repositioned him and he was dry. She indicated on her 2nd round the nurse said he was on the floor and he was really wet. She stated she was assisting someone else at the time. NA, Employee E57 stated she thinks it's retaliation because she was left on the floor cause a resident fell and if she'd been on the hall she wouldn't have fallen. She indicated her and two other staff members disappeared for like an hour. She indicated she did her care and did not leave anybody wet.

Review of admission record indicated Resident R403 was admitted to the facility on 6/7/23.

Review of Resident R403's MDS, dated 8/24/23, indicated the diagnoses of seizure disorder (a person experiences abnormal behavior, symptoms, and sensations, sometimes including loss of consciousness), traumatic brain injury (TBI- brain dysfunction caused by an outside force, usually a violent blow to the head), and high blood pressure. Section G Functional Status indicated bed mobility -how resident moves to and from lying position, turns side to side, and positions body while in bed required total dependence (full staff performance) of two person physical assist.

Review of care plan dated 6/8/23, indicated that Resident R403 had an activity of daily living self-care deficit related to TBI, and required total dependence on staff for bathing, bed mobility, and repositioning/turning in bed, and dressing.

Review of Resident R403's Kardex (summary of care needs) indicated two staff at all times for care and bed mobility.

Review of facility document event details dated 9/9/23, at 10:09 a.m. the nursing supervisor was notified that Resident R403 had rolled out of bed onto the floor. Resident was transferred to the emergency room for evaluation related to anticoagulant (blood thinner) use and possible head injury. Nurse Aide (NA) Employee E22 caring for the resident reported that she was changing the resident. While rolling resident he began to slide from the bed. NA Employee E22 left the room to get help. Resident was on the floor when staff returned to the room.

Review of PB-22 Report Form for Investigation of Alleged Abuse, Neglect, Misappropriation of Property document dated 9/12/23, at 10:00 a.m. indicated the findings of the facility investigation indicated NA Employee E22 stated that she was changing the resident in bed, and he started to slide out of bed, so she left the room to get help. She indicated this occurred when the resident was facing away from her. Review of Resident R403's care plan indicated he is to be assist of two for mobility. NA Employee E22 indicated she did not have a second person assisting her with resident's care.

Further review of the PB-22 indicated on 9/11/24, the Director of Nursing (DON) called NA Employee E22 to review her statement. NA Employee E22 indicated on the phone that she was aware that she should have had another person in the room to provide care and was unable to give an answer to why she did not seek assistance from another staff member. DON asked why she did not call out or use the call light to ring for help and she replied she didn't think anyone would hear her. DON asked if she was aware to never roll a fully dependent resident away from her during care, she stated she was aware. Conclusion - facility investigation concludes that neglect is substantiated.

Review of NA Employee E22's Witness Statement dated 9/9/23, indicated "I was changing and bathing the resident and he began to roll out of the bed while he was turned away from me. I ran out to get help and he was on the floor when I got back to him".

Review of Licensed Practical Nurse (LPN) Employee E5's witness statement dated 9/9/23, indicated she was the nursing station when NA Employee E22 came to the desk stating that "he fell out of bed" and she ran down the south hall. Upon entering room 217 I observed the feeding pump laying overtop of the bed with no one in it. On the other side of the bed by the window/wall, Resident R403 was lying in a supine (lying on the back) position with nothing on and the feeding tube wrapped behind him. The bed was in a high position since care was being done prior to the incident.

Interview on 3/12/24, at 8:47 a.m. Unit Manager Registered Nurse (RN) Employee E13 indicated "That's my unit, and it was my weekend to work. It was a little after 10:00 a.m. and Unit Director, LPN Employee E45 and I got a call that Resident R403 was on the floor. He was on the floor between the bed and the window with a brief on, that was opened, we assessed him, and he was at baseline. We asked NA Employee E22 to tell us exactly what happened, and she indicated she rolled the resident away from her, she was giving care by herself, and she physically left the resident's bedside to get help instead of using call bell and staying with the resident".

Interview on 3/12/24, at 10:12 a.m. NA Employee E25 indicated "I remember the fall, because he doesn't move anything but his head and a hand now and then and he's never fallen. I wanted to beat her up, I was crying I was so upset, I told her more than once. I gave report for her section when you do him, please come get me. NA Employee E22 came out as normally as we're talking and said Resident R403 is on the floor".

Interviews with facility staff - asked how do you know or where do you look for how much assistance a resident requires? How do you roll a resident in bed towards you or away from you?
-3/5/24, at 8:42 a.m. NA Employee E25 indicated it's in Point of Care (POC electronic health record) and we also have resident sheets with all the residents on the floor. Roll towards me.
-3/5/24, at 8:48 a.m. NA Employee E26 indicated either in the charts or ask therapy when they are new. We have papers that we use, how often are they updated daily. Call the nurse if no aid available towards me.
-3/5/24, at 8:58 a.m. NA Employee E27 indicated it's under the POC and also on paper with assignments.
-3/5/24, at 9:05 a.m. NA Employee E28 indicated it's on the NA sheet and computer, get someone to help. Roll towards me.
-3/5/24, at 9:25 a.m. NA Employee E29 indicated it's in POC tasks. I would get help. Roll towards you always.
-3/5/24, at 9:30 a.m. NA Employee E30 indicated on chart in POC assignment sheets, frequently, find help towards me.

Telephonic interview on 3/12/24, at 10:51 a.m. NA Employee E22 indicated "I don't remember his name, he was young in his late 20's. I was giving him a bed bath and changing his sheets. He fell out of bed when I turned him on his side. I was doing him myself as I have in the past. I called for help and let them know what was going on. I did take responsibility for the situation because I should have had a helper with me".

Interview on 3/4/24, at 11:00 a.m. the Director of Nursing confirmed that the facility failed to make certain residents were free from abuse and neglect for two of eight residents (Resident R284 and R403).

28 Pa Code 211.12(c)(d)(1)(2)(5) Nursing services

28 Pa. Code: 211.10 (c)(d) Resident Care Policies

28 Pa Code 201.14(a) Responsibility of licensee.

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

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



 Plan of Correction - To be completed: 05/01/2024

0600
1. The Facility cannot retroactively correct the deficiency as it relates to R284 and R403. Skin checks were completed on remaining residents in employee E57 assignment to ensure no skin breakdown related to incontinence. R403 was only resident involved in transfer error in employee E22's assignment.
2. The NHA reviewed facility abuse prevention policy was up to date and confirmed E22 and E57 are no longer employed by facility or present through a clinical agency.
3. The Staff will be educated on facility abuse prevention policy, education will include timely provision of care and following bed mobility orders.
4. The Director of nursing/designee will interview 5 residents twice weekly for 2 weeks, then 5 residents weekly for 2 weeks, then 5 residents monthly for 2 months to ensure residents are free from abuse and neglect. Audit findings will be shared with QAPI committee.
483.12(b)(1)-(5)(ii)(iii) REQUIREMENT Develop/Implement Abuse/Neglect Policies:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
§483.12(b) The facility must develop and implement written policies and procedures that:

§483.12(b)(1) Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property,

§483.12(b)(2) Establish policies and procedures to investigate any such allegations, and

§483.12(b)(3) Include training as required at paragraph §483.95,

§483.12(b)(4) Establish coordination with the QAPI program required under §483.75.

§483.12(b)(5) Ensure reporting of crimes occurring in federally-funded long-term care facilities in accordance with section 1150B of the Act. The policies and procedures must include but are not limited to the following elements.

§483.12(b)(5)(ii) Posting a conspicuous notice of employee rights, as defined at section 1150B(d)(3) of the Act.

§483.12(b)(5)(iii) Prohibiting and preventing retaliation, as defined at section 1150B(d)(1) and (2) of the Act.
Observations:

Based on review of facility policy and clinical records and staff interview, it was determined that the facility failed to implement written policies and procedures to prohibit and prevent abuse, neglect, and exploitation of residents for one of eight incidents reviewed (Resident R384).

Findings include:

Review of facility policy "Abuse: Protection from Abuse" dated 10/1/23, indicated the Facility shall have processes in place to include screening, training, prevention, identification, protection, investigation, reporting and response to allegations of potential or actual abuse and neglect.

Review of the admission record indicated Resident R384 was admitted to the facility on 11/20/22.

Review of Resident R384's MDS dated 1/8/24, indicated the diagnoses of high blood pressure, diabetes (a long-term condition in which the body has trouble controlling blood sugar and using it for energy), and peripheral vascular disease (a condition in which narrowed blood vessels reduce blood flow to the limbs).

Review of Resident R384's Nursing-Smoking Safety Screening revealed it was last completed on 11/23/22, at 3:27 p.m. Revealed the following:
-Resident smokes 5-10 cigarettes a day.
-Likes to smoke in the morning, afternoon, and evenings.
-Resident needs adaptive equipment of a smoking apron and supervision.
-Due to elopement (wander to an unsafe area unsupervised) risk Resident R384 is to have a staff member from the unit to accompany o all breaks.
-Resident is aware that the facility needs to store lighter and cigarettes - Yes.
-Plan of care is used to assure resident is safe while smoking - Yes.

Review Resident R384's care plan dated 10/12/23, indicated resident is at risk for side effects/injury from smoking.
-Injury on 10/12/23. Resident educated to not sit so close to other residents at smoke times.
-Resident will exhibit safe smoking habits and follow safe smoking practices set up by staff.
-Complete safe smoking assessment per facility policy.
-Resident's cigarettes and lighter will be provided by staff at appropriate times.
-Observe resident for unsafe smoking behaviors. Report to supervisor if noted.
-Report any injuries to staff.
-Resident's cigarettes and lighter will be provided by staff at appropriate times.
-Resident deemed unsafe with standard supervised smoke break. For safety will be supervised at all times by unit staff, to during, and from smoke break, dated 11/23/22.

Review of Resident R384's incident report "smoking injury" dated 10/12/23, indicated that resident has a blister to left inner ankle with measurements of 3.5 cm (centimeters) x 4cm. Resident R384 indicated he was out smoking at last smoke break on 10/11/23, and another resident flicked the ashes of their cigarette and an ember hit his ankle and
burned him.

Interview with the Director of Nursing on 2/27/24, at 5:12 p.m. indicated the resident burn was not thought of as a potential neglect situation.

Interview on 2/27/24, at 5:12 p.m. the Director of Nursing confirmed that the facility failed to implement written policies and procedures to prohibit and prevent abuse, neglect, and exploitation of residents for one of eight incidents reviewed (Resident R384).

28 Pa Code 211.12(c)(d)(1)(2)(5) Nursing services

28 Pa. Code: 211.10 (c)(d) Resident Care Policies

28 Pa Code 201.14(a) Responsibility of licensee.

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

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








 Plan of Correction - To be completed: 05/01/2024

0607
1. The R384 had received skin care and treatment for blister at time of incident October 2023 until resolved. R384 had an updated smoking safety assessment completed.
2. An audit was completed of all resident smokers to ensure their orders and care plans were appropriate for each respective resident. All residents smokers were re-evaluated for smoking safety.
3. The NHA re in-serviced the Director of Nursing on procedure for investigating injuries for potential abuse or neglect. Activities staff will be educated to ensure residents are spaced appropriately to minimize the risk of injury from other smokers.
4. The NHA/designee will audit incident reports twice weekly for 2 weeks, then 3 incident reports weekly for 2 weeks, then 3 incident reports monthly for 2 months to ensure appropriate investigation to rule out abuse or neglect. Audit finding will be shared with QAPI committee.
483.12(b)(5)(i)(A)(B)(c)(1)(4) REQUIREMENT Reporting of Alleged Violations:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
§483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must:

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

§483.12(c)(4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken.
Observations:
Based on review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to make certain that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property are reported to the administrator of the facility and to other officials for one of eight residents. (Resident R384).

Findings include:

Review of the facility policy "Abuse Reporting and Investigation" dated 10/1/23, indicated all reports of alleged or suspected abuse must be reported to the Administrator immediately.
-The Department of Health will be notified of the alleged event by the Administrator or designee via the Electronic Event Reporting System per regulation. Additional notification to the Area Agency on Aging (Protective Services) and local authorities will be completed as appropriate based on the allegation.

Review of the admission record indicated Resident R384 was admitted to the facility on 11/20/22.

Review of Resident R384's MDS dated 1/8/24, indicated the diagnoses of high blood pressure, diabetes (a long-term condition in which the body has trouble controlling blood sugar and using it for energy), and peripheral vascular disease (a condition in which narrowed blood vessels reduce blood flow to the limbs).

Review Resident R384's care plan dated 10/12/23, indicated resident is at risk for side effects/injury from smoking.
-Injury on 10/12/23. Resident educated to not sit so close to other residents at smoke times.
-Resident will exhibit safe smoking habits and follow safe smoking practices set up by staff.
-Complete safe smoking assessment per facility policy.
-Resident's cigarettes and lighter will be provided by staff at appropriate times.
-Observe resident for unsafe smoking behaviors. Report to supervisor if noted.
-Report any injuries to staff.
-Resident's cigarettes and lighter will be provided by staff at appropriate times.
-Resident deemed unsafe with standard supervised smoke break. For safety will be supervised at all times by unit staff, to during, and from smoke break, dated 11/23/22.

Review of Resident R384's incident report "smoking injury" dated 10/12/23, indicated that resident has a blister to left inner ankle with measurements of 3.5 cm (centimeters) x 4cm. Resident R384 indicated he was out smoking at last smoke break on 10/11/23, and another resident flicked the ashes of their cigarette and an ember hit his ankle and burned him.

Review of the facility's reportable events as of 2/27/24, at 5:12 p.m. did not include the above incident.

Interview on 2/27/24, at 5:15 p.m., the Director of Nursing confirmed the facility failed to make certain that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source, and misappropriation of resident property, are investigated, and reported to the administrator of the facility and to other officials for one of eight residents. (Resident R384).

28 Pa Code 211.12(c)(d)(1)(2)(5) Nursing services

28 Pa. Code: 211.10 (c)(d) Resident Care Policies

28 Pa Code 201.14(a) Responsibility of licensee.

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

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






 Plan of Correction - To be completed: 05/01/2024

0609
1. Investigation of smoking injury was completed.
2. A house audit of wounds was conducted to ensure any additional injuries were reported appropriately. No other issues were identified. A late submission ERS will be submitted.
3. The NHA will re in-service the Director of Nursing on the Facility procedure for reporting potential abuse or neglect timely.
4. The NHA/designee will audit incident reports twice weekly for 2 weeks, then 3 incident reports weekly for 2 weeks, then 3 incident reports monthly for 2 months to ensure appropriate investigation to rule out abuse or neglect. Audit finding will be shared with QAPI committee.
483.12(c)(2)-(4) REQUIREMENT Investigate/Prevent/Correct Alleged Violation:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
§483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must:

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

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

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

Based on review of facility policy, clinical records, facility documents, and staff interview, it was determined that the facility failed to fully investigate a potential allegation of abuse/neglect for a resident burn for one of eight residents (Resident R384).

Findings include:

Review of the facility policy "Abuse Reporting and Investigation" dated 10/1/23, indicated all reports of alleged or suspected abuse must be reported to the Administrator immediately. Identification of occurrences and patterns of potential mistreatment/abuse. Investigation - timely and thorough investigations of all reports and allegations of abuse.

Review of the admission record indicated Resident R384 was admitted to the facility on 11/20/22.

Review of Resident R384's MDS dated 1/8/24, indicated the diagnoses of high blood pressure, diabetes (a long-term condition in which the body has trouble controlling blood sugar and using it for energy), and peripheral vascular disease (a condition in which narrowed blood vessels reduce blood flow to the limbs).

Review of Resident R384's incident report "smoking injury" dated 10/12/23, indicated that resident has a blister to left inner ankle with measurements of 3.5 cm (centimeters) x 4cm. Resident R384 indicated he was out smoking at last smoke break on 10/11/23, and another resident flicked the ashes of their cigarette and an ember hit his ankle and burned him.

Interview on 2/27/24, at 5:15 p.m., the Director of Nursing indicated she did not have an investigation into the resident burn.

Interview on 2/27/24, at 5:16 p.m., the Director of Nursing confirmed the facility failed to fully investigate a potential allegation of abuse/neglect for a resident burn for one of eight residents (Resident R384).

28 Pa Code 211.12(c)(d)(1)(2)(5) Nursing services

28 Pa. Code: 211.10 (c)(d) Resident Care Policies

28 Pa Code 201.14(a) Responsibility of licensee.

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

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








 Plan of Correction - To be completed: 05/01/2024

0610
1. R384 received skin care and treatment for blister. R384 was interviewed by staff at time burn being discovered, R384 was able to verbalize how burn occurred.
2. An audit was done of facility smokers on 2/28/2024 to assess for injury related to smoking. No further issues identified. Full investigation of burn injury was completed, late submission ERS of investigation will be submitted.
3. The NHA re in-serviced the Director of Nursing on procedure for fully investigating injuries for potential abuse or neglect.
4. The NHA/designee will audit incident reports twice weekly for 2 weeks, then 3 incident reports weekly for 2 weeks, then 3 incident reports monthly for 2 months to ensure appropriate investigation to rule out abuse or neglect. Audit finding will be shared with QAPI committee.
483.15(d)(1)(2) REQUIREMENT Notice of Bed Hold Policy Before/Upon Trnsfr: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(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 facility policy, clinical records, and staff interviews it was determined that the facility failed to provide the resident and/or resident representative with a written notice of the facility bed-hold policy (explanation of how long a bed can be held during a leave of absence and the cost per day) upon or within twenty-four hours of transfer for two of 56 residents (Residents R124 and R383).

Findings include:

A facility policy entitled, "Bed Hold Policy and Procedure" dated 10/01/23, stated: "that upon discharge from the facility and admission to a hospital, the Social Services department or designee will contact, by telephone and in writing, the resident/agent to inform them that the resident was discharged to the hospital and of the 15-day bed hold, and that a call will inform the family to expect the bed hold letter within the next few days, and that the bed hold letter and bed hold reservation will be mailed on the date of discharge to the hospital for all residents, regardless of payor source."

Resident R124's clinical record revealed an admission date of 9/16/23, with diagnoses including irregular heartbeat, blood clots, high blood pressure, renal failure, and Type 2 Diabetes (affects how the body uses glucose (sugar)), panic disorder, rectal bleed, and anemia.

Departmental progress notes revealed that Resident R124 was discharged to the hospital on 10/20/23 (direct admission from dialysis), 12/06/23 (wound infection), and 1/19/24 (leaking nephrostomy tube- small tube that helps drain urine from your kidney) and lacked evidence that a written notification of the facility bed hold policy was provided to the resident/agent upon transfer.

Resident R383's clinical record revealed an admission date of 11/17/22, with diagnoses including schizoaffective disorder (mental health disorder that is marked by a combination of schizophrenia symptoms, such as hallucinations or delusions, and mood disorder symptoms, such as depression or mania), Type 2 Diabetes, panic disorder, rectal bleed, and anemia.

A departmental progress note dated 10/03/23, reveled that Resident R383 was discharged to the hospital for treatment of critical lab values, and lacked evidence that a written notification of the facility bed hold policy was provided to the resident/agent upon transfer.

Interview on 2/28/24, at 3:04 p.m. the Director of Nursing confirmed that there was no evidence that a written notification of the facility bed hold policy was provided to the resident/agent upon discharge.

28 Pa. Code 201.18(e)(1) Management
28 Pa. Code 201.29(f) Resident rights


 Plan of Correction - To be completed: 05/01/2024

0625
1. R124 and R383 were notified of bed hold policy.
2. The NHA reviewed the Facility policy and procedure for bedhold to ensure up to date and provided the staff with ancillary assessment to ensure residents and/or responsible parties are notified of facility bed hold procedure.
3.The Director of Nursing will re in-service the nursing management and supervisors on bed hold procedure when transferring residents out of facility.
4. The Director of nursing/designee will audit 3 hospital transfers 2 times weekly for 2 weeks, then 3 transfers weekly for 2 weeks, then 3 hospital transfers monthly for 2 months to ensure compliance with bed hold policy. Audit findings will be shared with QAPI committee.
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 review of The Centers for Medicare & Medicaid Services' Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual Effective October 1, 2023, clinical records, and staff interviews, it was determined that the facility failed to accurately code the Minimum Data Set (MDS-periodic assessment of resident care needs) for two of 56 residents reviewed (Resident R280 and R383).

Findings include:

RAI coding instructions for Section P0100 (Restraints) indicated: identify all physical restraints that were used at any time (day or night) during the 7-day lookback period and to code "1" (used less than daily) if the item met the definition and was used less than daily during the observation period.

RAI coding instructions for Section N0450 (Antipsychotic Medication Review) indicated: Did the resident receive antipsychotic medications since admission/entry or reentry or the prior assessment, whichever is more recent?

Review of Resident 280's clinical record indicated the resident was admitted to the facility on 2/24/20, with diagnoses that included psychotic disorder (severe mental health disorders that cause abnormal thinking and perceptions), anxiety, and non-Alzheimer's dementia (loss of memory and other intellectual functions).

Review of Resident R280's physician orders dated 12/15/23, indicated the resident was taking Seroquel (antipsychotic medication used to treat certain mental and mood disorders) 250 milligram (mg) by mouth in the evening related to psychosis (a collection of symptoms, including delusions, and hallucinations).

Review of Resident R280's physician order dated 12/15/23, indicated to administer 2mg of 2mg/ml Haldol (antipsychotic medication that decreased excitement in the brain, used to treat psychotic disorders) by mouth every four hours as needed (PRN) for agitation related to dementia.

Review of Resident R280's December Medication Administration Record (MAR), indicated the resident received both a PRN and routine antipsychotic on 12/25/23.

Review of Resident R280's Quarterly MDS (MDS - a periodic assessment of care needs) with the ARD (assessment reference date) of 12/27/23, Section N0450 (Antipsychotic Medication Review) was coded as the resident received antipsychotics on a PRN (as needed) basis only.

Resident R383's clinical record revealed an admission date of 11/17/22, with diagnoses including schizoaffective disorder (mental health disorder that is marked by a combination of schizophrenia symptoms, such as hallucinations or delusions, and mood disorder symptoms, such as depression or mania), Type 2 Diabetes, panic disorder, rectal bleed, and anemia.

During an interview on 3/4/24, at 12:25 p.m. Registered Nurse Assessment Coordinator, Employee E7 confirmed Resident R280's MDS dated 12/27/23, was coded inaccurately for antipsychotic medication review.

Resident R383's physician's orders lacked evidence that a restraint was ordered, and a Quarterly MDS with the ARD of 2/06/25, Section P0100H (other restraint) was coded as being used less than daily.

Interview on 2/29/24, 2:00 p.m. Registered Nurse (RN) Employee E7 confirmed that Resident R383's Quarterly MDS dated 2/06/24, was incorrectly coded for the use of other restraints used less than daily.

28 Pa. Code 201.14(a) Responsibility of licensee

28 Pa. Code 211.5(f) Clinical Records


 Plan of Correction - To be completed: 05/01/2024

0641
1. R280's MDS was corrected to accurately code that "antipsychotics were received on a routine and PRN basis" for N0450A on the MDS.R383's MDS was corrected to accurately code that other restraint was "Not Used" on P0100H on the MDS.
2. MDS nurses will audit the last MDS of all in house residents who are on an antipsychotic medication to verify N0450A was coded accurately. MDS Nurses will audit the last MDS of all in house residents to confirm restraint use was coded accurately.
3. MDS nurses will be re-educated by the Regional MDS Consultant on accurately completing Section N (Medications) and Section P (Restraints and Alarms) of the MDS per the RAI manual.
4. Assistant Director of UR or Regional MDS consultant will audit five resident MDS weekly for four weeks and monthly for three months to ensure N0450A and P0100H of the MDS is accurately completed. Results of audits will be presented to the Quality Assurance Performance Improvement Committee Meeting for tracking and trending.
483.21(b)(2)(i)-(iii) REQUIREMENT Care Plan Timing and Revision:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
§483.21(b) Comprehensive Care Plans
§483.21(b)(2) A comprehensive care plan must be-
(i) Developed within 7 days after completion of the comprehensive assessment.
(ii) Prepared by an interdisciplinary team, that includes but is not limited to--
(A) The attending physician.
(B) A registered nurse with responsibility for the resident.
(C) A nurse aide with responsibility for the resident.
(D) A member of food and nutrition services staff.
(E) To the extent practicable, the participation of the resident and the resident's representative(s). An explanation must be included in a resident's medical record if the participation of the resident and their resident representative is determined not practicable for the development of the resident's care plan.
(F) Other appropriate staff or professionals in disciplines as determined by the resident's needs or as requested by the resident.
(iii)Reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments.
Observations:
Based on a review of facility policy, resident clinical record review, and staff interview, it was determined the facility failed to ensure that a resident's care plan was updated and revised to reflect the resident's specific care needs for two of 28 residents (Resident R227, and R384).

Findings include:

Review of the facility policy "MDS/RAI/Care Planning" last reviewed 10/1/23, indicate to develop a written plan of care individualized for each resident, which identifies through an assessment process his/her strength, problems and needs.

Review of the facility policy "Side Rails Proper Use" last reviewed 10/1/23, indicate the use of quarter or half-side rails, as an assistive device will be addressed in the resident care plan.

Review of Resident R227's clinical record indicates an admission date of 3/7/23, with diagnosis of hypertension (high blood pressure), cerebrovascular accident (loss of blood flow to the brain), hemiplegia (one sided weakness or paralysis).

Review of Resident R227's physician orders 1/19/24, indicate bilateral bed enablers to increase independence with bed positioning with dx of hemiplegia affecting R dominant side.

Observation 2/29/24, 10:30 a.m. Resident R227's bed with bilateral enabler bars.

Review of Resident R227's care plan did not indicate bilateral enabler bars.

Interview 2/29/24, 10:58 a.m. RN Employee E6 confirmed the facility failed to initiate care plans for Resident R227's bilateral enabler bars.

Review of the admission record indicated Resident R384 was admitted to the facility on 11/20/22.

Review of Resident R384's MDS dated 1/8/24, indicated the diagnoses of high blood pressure, diabetes, and peripheral vascular disease (a condition in which narrowed blood vessels reduce blood flow to the limbs). Section N indicated anticoagulant use (blood thinner).

Review of Resident 384's physician order dated 11/22/22, indicated Apixaban (blood thinner) 5mg (milligrams) every day and evening.

Review of Resident 384's Medication Administration Record dated February 2024, indicated he received the Apixaban twice daily as ordered.

Review of Resident R384's care plan on 2/28/24, at 2:00 p.m. failed to include a plan of care for the Apixaban and risks associated with anticoagulant use.

Interview on 3/5/24, at 3:00 p.m. the Director of Nursing confirmed the facility failed to ensure that a resident's care plan was updated and revised to reflect the resident's specific care needs for two of 28 residents (Resident R227, and R384).

28 Pa. Code 211.11(a) Resident care plan.

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




 Plan of Correction - To be completed: 05/01/2024

0657
1. R384 care plan was updated to include anticoagulant usage. R227s care plan was updated to reflect enabler bar usage.
2. An audit will be conducted of residents ordered anticoagulation and enabler bars to ensure care plan is up to date.
3. The Director of Utilization Review/designee will educate MDS nurses on updating care plan with new orders.
4. The Director of Utilization Review/designee will audit orders for 3 residents twice weekly for 2 weeks, 3 residents weekly for 2 weeks, then 3 residents monthly for 2 months to ensure physician orders are care planned appropriately. Audit findings will be shared with QAPI committee.
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 review of resident clinical records and staff interviews it was determined that the facility failed to make certain that appropriate treatment and services were ordered and/or provided for one of five residents with a urinary catheter (Resident R431).

Findings include:

Review of the facility policy "Catheter Care" last reviewed 10/1/23, indicate ensure drainage bag is covered for privacy.

Review of the facility policy "Catheter Insertion Procedure" last reviewed 10/1/23, equipment: indicate the appropriate size and type of catheter.

Review of the facility policy "MDS/RAI/Care Planning" last reviewed 10/1/23, indicate to develop a written plan of care individualized for each resident, which identifies through an assessment process his/her strength, problems and needs.

Review of resident R431's Minimum Data Set (MDS - periodic assessment of care needs) indicated reentry to facility on 12/29/23, diagnosis of anemia (low iron in blood), pressure ulcer sacral area (bottom of spine) stage four (deep wound that impacts muscle, tendon, and bone).Section H indicated indwelling catheter.

Review of physician order 12/29/23, indicated insert/change fr foley catheter with cc (cubic centimeter) balloon. The order did not include the size of catheter or amount for balloon size/inflation.

Review of resident R431's care plan initiated on 11/10/23, with revision on 2/27/24, failed to include size of catheter, and amount for balloon size/inflation.

During an observation on 2/27/24, 9:12 a.m. Resident R431 was in bed his urinary drainage bag was hanging on bed frame, no privacy cover.

During an interview on 2/27/24, 9:15 a.m. Licensed Practical Nurse (LPN) Employee E4 confirmed the catheter bag failed to have a privacy cover.

During an interview 2/29/24, 11:00 a.m. Registered Nurse (RN) Employee E6 confirmed Resident R431's physician orders failed to include foley catheter and balloon size/inflation.

During an interview on 2/29/24, 11:04 a.m. RN Employee E7 confirmed the facility failed to document the foley catheter and balloon size/inflation in Residents R431's care plan.

28 Pa Code: 201.14 (a) Responsibility of licensee.

28 Pa code: 211.10 (c)(d) Resident care policies.

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


 Plan of Correction - To be completed: 05/01/2024

0690
1. R431 order was updated to reflect catheter size, privacy bag was placed.
2. A house audit was done of all residents with catheter orders to ensure catheter and balloon size are included and privacy covers are present, no additional issues identified.
3. The Director of nursing/designee will re in-service nursing staff on ensuring completeness of physician orders for foley catheters and privacy covers are used at all times.
4. The Director of nursing/designee will audit 1 resident with foley catheter orders twice weekly for 2 weeks, 1 resident weekly for 2 weeks and 3 residents monthly for 2 months to ensure completeness of catheter orders and presence of privacy covers. Audit findings will be shared with QAPI committee.
483.25(g)(1)-(3) REQUIREMENT Nutrition/Hydration Status Maintenance: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(g) Assisted nutrition and hydration.
(Includes naso-gastric and gastrostomy tubes, both percutaneous endoscopic gastrostomy and percutaneous endoscopic jejunostomy, and enteral fluids). Based on a resident's comprehensive assessment, the facility must ensure that a resident-

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

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

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

Based on review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to develop an individualized care plan to address the resident's specific nutritional concerns and preferences for one of four (Resident R108) records reviewed.

Findings include:

Review of facility policy "MDS/RAI/Care Planning", dated 10/1/23, indicated that residents will have a comprehensive assessment completed by day 14 of stay and a comprehensive care plan completed and reviewed within 7 days of the completion date of the MDS (Minimum Data Set assessment - a mandated assessment of a resident's abilities and care needs). The resident will then be assessed at least quarterly and care plan reviewed by the interdisciplinary team according to OBRA scheduled and more often if required for Medicare reimbursement. Policy further indicated that the facility will develop a written plan of care individualized for each resident, which identifies through an assessment process his/her strengths, problems and needs.

Review of facility policy "Nutritional Care Planning Process", dated 10/1/23, indicated an MDS and Initial Nutritional assessment and Quarterly MDS and Quarterly Nutritional assessment are completed to establish a Dietary Plan of Care. Each resident is nutritionally reassessed on a quarterly basis, with problems, goals, and approaches reassessed as well. Care plan will be revised as needed based on identified interventions.

Review of clinical Admission record indicated that Resident R108 was admitted to the facility 1/11/24.

Review of Resident R108's MDS assessment dated 2/9/24, indicated diagnosis anoxic brain damage (damage to the brain due to a lack of oxygen supply), dysphagia (a condition with difficulty in swallowing food or fluid) and seizure disorder (sudden, uncontrolled electrical disturbance in the brain which can cause changes in behavior, movements, feelings, and consciousness). Section K0520B: Nutritional Approaches, Feeding Tube, indicated that while a resident within the last 7 days, Resident R108 received this approach. Section K0520C: Nutritional Approaches, Mechanically Altered Diet (require change in texture of food or fluid), indicated that while a resident within the last 7 days, Resident R108 received this approach.

Review of active physician orders for Resident R108, initiated 2/8/24, indicated a Regular diet mechanical soft texture, Thin consistency, for NO STRAWS, 100% assistance with meals, small bites/sips. Further review also indicated an active physician order initiated on 2/8/24, Enteral Feed Order every evening and night shift Jevity 1.2 at 65ml/hr (milliliters per hour) with autoflush 25ml/hr H2O (water) 6p-6a.

Review of Resident R108's recapitalization of physician orders since admission, indicated that on 1/29/24, physician order initiated 1/12/24, NPO - Nothing by Mouth diet NPO texture, was discontinued. Further review of Resident 108's recapitalization of physician orders since admission, indicated that on 1/29/24, a Regular diet Pureed texture, Thin consistency, NO STRAWS; 100% assistance with meals, small bites/sips, allow adequate time between each bite and sip for pt to swallow/reswallow, upright 90 degrees for meals and 30 minutes after, was ordered and then discontinued on 2/5/24. Recapitalization of physician orders indicate that on 2/5/24, Resident R108 was ordered a Regular diet Mechanical Soft with Pureed Fruits/Veggies texture, Thin consistency, NO STRAWS; 100% assistance with meals, small bites/sips, which was then discontinue on 2/8/24, when current active physician order dated 2/8/24 was initiated for a Regular diet mechanical soft texture, Thin consistency, for NO STRAWS, 100% assistance with meals, small bites/sips.

Review of Resident R108's clinical progress note, dated 2/9/24, "Q Nutrition Assessment MDS/ARD 2/9/24" indicated that a diet of "regular, mechanical soft, thin liquids + Jevity 1.2 @ 65ml/hr, 6 pm to 6 am x 12 hrs (hours) via TF (tube feeding)". Clinical progress note further indicated to "Continue TF and PO (oral) diet per order. Encourage PO intake > 75%of meals. Maintain stable weight near IBW (Ideal Body Weight) range. Adjust nutrition POC (Plan of Care) as needed."

Review of Resident 108's current plan of care, failed to include an updated, individualized care plan to address the resident's specific nutritional concerns and preferences. The care plan failed to identify resident's current oral intake of a Regular diet, with mechanical soft textures and discontinuation of her NPO status, resulting in failure to update personal goals and preferences, identify resident-specific interventions, and a time frame and parameters for monitoring.

During an interview on 2/29/24, at 11:52 a.m., Registered Dietitian Director (RDD) Employee E9 confirmed that the facility failed to develop an individualized care plan to address the resident's specific nutritional concerns and preferences for one of four (Resident R108) records reviewed.

28 Pa. Code: 201.18(b)(1)(e)(1) Management.
28 Pa. Code: 211.12(d)(1) Nursing services.
28 Pa. Code: 211.12(d)(3) Nursing services.
28 Pa. Code: 211.12(d)(5) Nursing services.


 Plan of Correction - To be completed: 05/01/2024

0692
1. R108 care plan was updated to include oral diet.
2. An audit will be completed of all admissions within the last 30 days (3/1/24-4/1/24) to ensure nutritional care plan is individualized for the needs of the resident.
3. The NHA will re in-service the facility dietitians on ensuring each resident's nutritional care plan is individualized to that resident's nutritional needs and physician order is accurate.
4. The Dietitian/designee will audit 5 residents twice weekly for 2 weeks, 5 residents weekly for 2 weeks, then 5 residents monthly for 2 months to ensure nutritional care plans are individualized to the needs of the resident and physician order is accurate. Audit findings will be shared with QAPI committee.
483.40(b)(3) REQUIREMENT Treatment/Service for Dementia: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.
§483.40(b)(3) A resident who displays or is diagnosed with dementia, receives the appropriate treatment and services to attain or maintain his or her highest practicable physical, mental, and psychosocial well-being.
Observations:

Based on a review of clinical records and staff interview, it was determined that the facility failed to ensure a resident with dementia receives the appropriate treatment and services to attain or maintain his highest practicable physical, mental, and psychosocial well-being for one of four residents reviewed (Resident R280).

Findings include:

Review of the facility "Guidelines for Caregiver Interaction with Dementia" policy last reviewed 10/1/23, stated staff must change their thinking from trying to control behavior to understanding and changing the reason behind the behavior.

Review of the facility "Antipsychotic Drugs" policy last reviewed 10/1/23, indicated antipsychotic drugs should not be used unless medical causes such as pain, constipation, fever, or infection have been ruled out.

Review of Resident 280's clinical record indicated the resident was admitted to the facility on 2/24/20, with diagnoses that included psychotic disorder (severe mental health disorders that cause abnormal thinking and perceptions), anxiety, and non-Alzheimer's dementia (loss of memory and other intellectual functions).

A Minimum Data Set Assessment (MDS, a form completed at specific intervals to determine care needs) dated 1/11/24, indicated the diagnoses were current.

Revie of Resident R280's care plan dated 1/17/24, indicated the resident has impaired thought process due to dementia, and has behavioral disturbances, and impaired decision making. Interventions included to administer medications as ordered. Resident R380's care plan also indicated he has some bladder incontinence (loss of bladder control). Interventions included to encourage fluids during the day to promote prompted voiding response.

Review of Resident R280's progress note dated 2/6/24, indicated the resident had behaviors and went into another resident's room and flipped over a resident's TV and stand. It was documented the resident pulled another resident's hair.

Review of Resident R280's physician order dated 2/6/24, through 2/13/24, indicated to inject 0.5ml of 5mg/ml Haldol (an antipsychotic drug that is used to treat psychosis as well as symptoms of agitation, irritability, and delirium) intramuscularly every eight hours as needed for aggressive and combative behavior.

Review of Resident 280's February Medication Administration Record (MAR), indicated the resident was administered 2.5mg Haldol on the following dates:
-2/6/24, at 5:30 p.m.
-2/10/24, at 4:34 p.m.
-2/11/24, 2:41 p.m.
-2/12/24, 7:36 p.m.
-2/13/24 11:28 a.m.

Review of Resident R280's progress note dated 2/13/24, entered by Nurse Practitioner, Employee E37 stated the patient is experiencing increased agitation during the afternoon hours. "Will increase Zyprexa (antipsychotic medication used to trat severe agitation associated with certain mental and mood conditions)." Staff was instructed to notify the practitioner with any increase or worsening in behaviors.

Review of Resident R280's physician order dated 2/13/24, indicated to administered 2.5 mg Zyprexa three times a day for dementia with behavioral disturbance.

Review of Resident R280's physician order dated 2/13/24, indicated to inject 0.5ml of 5mg/ml Haldol intramuscularly every eight hours as needed for aggressive and combative behavior.

Review of Resident 280's February Medication Administration Record (MAR), indicated the resident was administered 2.5mg Haldol on the following dates:
-2/13/24, 6:53 p.m.
-2/15/24, 7:40 p.m.

Review of Resident R280's progress note dated 2/15/24, stated the resident was having increased behaviors and new orders for antibiotics were obtained for suspected urinary tract infection (UTI).

Review of Resident 280's physician order dated 2/15/24, ordered by Nurse Practitioner, Employee E38 indicated to administer 100 mg of Macrobid (antibiotic used to trat bladder infections) two times a day for a suspected urinary tract infection for five days.

Review of Resident R280's clinical record from 2/6/24, through 2/14/24, revealed the facility failed to identify the root cause of Resident R280's behaviors prior to administering Haldol for behaviors and increasing the resident's Zyprexa. Resident R280 was administered Haldol for behaviors, a total of seven times prior to the facility determining a urinary tract infection was the root cause.

Review of Resident R280's clinical record from 2/16/24, through 2/29/24, failed to indicate the resident displayed behaviors after starting Macrobid for a suspected UTI.

Review of Resident R280's care plan from 2/15/24, through 3/4/24, failed to reveal a focus or interventions to address the resident's risk for UTIs.

During an interview on 3/4/24, Registered Nurse Assessment Coordinator (RNAC), Employee E7 confirmed the facility failed to update Resident R280's care plan for his risk of UTIs.

During an interview on 3/4/24, at 10:20 a.m. Nurse Practitioner, Employee E37 stated Resident R280 "can be very difficult to get a urine." Nurse Practitioner, Employee E37 stated "In my experience it is very odd for a man to have a UTI," and confirmed she is able to order labs for suspected UTIs.

During an interview on 3/4/24, at 10:42 a.m. the Director of Nursing confirmed the facility failed to
ensure a resident with dementia receives the appropriate treatment and services to attain or maintain his highest practicable physical, mental, and psychosocial well-being for one of four residents reviewed (Resident R280).

During an interview on 3/4/24, at 2:00 p.m. Nurse Practitioner, Employee E39 confirmed she did see Resident R280 on 2/13/24, and stated "I know I would have not increased Zyprexa, he fell that day." Employee E38 stated if a resident who has dementia has increased behaviors, he would check to see if there has been a change in vital signs, and see what else the resident is complaining of, then once he sees them he would complete a full body exam. Nurse Practitioner, Employee E38 stated he would recommend a routine order for a urinalysis to rule out UTI. Nurse Practitioner, Employee E38 stated he seen Resident R280 on 2/15/24, and suspected there was a "good chance his change was related to a urinary tract infection." It was indicated a broad spectrum antibiotic was ordered because it was difficult obtaining a urine from him. Nurse Partitioner, Employee E38 confirmed treatment was delayed for Resident R280's UTI.

28 Pa Code 211.12 (d)(1)(2)(3)(5) Nursing services




 Plan of Correction - To be completed: 05/01/2024

0744
1. R280 was treated for suspected UTI. PRN medications for behaviors were discontinued. Care plan was updated to reflect risk for UTI.
2. A house audit will be conducted of current orders for prn psychotropic medications to ensure medical causative factors have been excluded.
3. Facility providers will be re in-serviced by medical director on recognizing atypical medical symptoms in the dementia population.
4. The Director of nursing/designee will audit 3 residents with prn or new orders for psychotropics twice weekly for 2 weeks, then 3 residents weekly for 2 weeks, then 3 residents monthly for 2 months to ensure evidence that medical factors were excluded is present. Audit findings will be shared with QAPI committee.
483.45(c)(3)(e)(1)-(5) REQUIREMENT Free from Unnec Psychotropic Meds/PRN Use: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(e) Psychotropic Drugs.
§483.45(c)(3) A psychotropic drug is any drug that affects brain activities associated with mental processes and behavior. These drugs include, but are not limited to, drugs in the following categories:
(i) Anti-psychotic;
(ii) Anti-depressant;
(iii) Anti-anxiety; and
(iv) Hypnotic

Based on a comprehensive assessment of a resident, the facility must ensure that---

§483.45(e)(1) Residents who have not used psychotropic drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record;

§483.45(e)(2) Residents who use psychotropic drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs;

§483.45(e)(3) Residents do not receive psychotropic drugs pursuant to a PRN order unless that medication is necessary to treat a diagnosed specific condition that is documented in the clinical record; and

§483.45(e)(4) PRN orders for psychotropic drugs are limited to 14 days. Except as provided in §483.45(e)(5), if the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she should document their rationale in the resident's medical record and indicate the duration for the PRN order.

§483.45(e)(5) PRN orders for anti-psychotic drugs are limited to 14 days and cannot be renewed unless the attending physician or prescribing practitioner evaluates the resident for the appropriateness of that medication.
Observations:
Based on a review of facility policy, clinical records and staff interviews, it was determined that the facility failed to limit as needed antipsychotic drugs to 14 days for one of four residents (Resident 280).

Findings include:

Review of the facility "Antipsychotic Drugs" policy last reviewed 10/1/23, indicated antipsychotic drugs should not be used unless medical causes such as pain, constipation, fever, or infection have been ruled out. Residents who use antipsychotic drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in effort to discontinue these drugs. As needed (PRN) antipsychotics must have a 14 day limit. "Orders may not extend beyond 14 day limit."

Review of Resident 280's clinical record indicated the resident was admitted to the facility on 2/24/20, with diagnoses that included psychotic disorder (severe mental health disorders that cause abnormal thinking and perceptions), anxiety, and non-Alzheimer's dementia (loss of memory and other intellectual functions).

A Minimum Data Set Assessment (MDS, a form completed at specific intervals to determine care needs) dated 1/11/24, indicated the diagnoses were current.

Review of Resident R280's care plan initiated 3/5/20, last revised 1/7/22, indicated the resident has impaired thought process due to dementia, and has behavioral disturbances, and impaired decision making. Interventions included to administer medications as ordered.

Review of Resident R280's physician order dated 7/19/23, through 12/15/23, ordered by Physician, Employee E40 indicated to inject 0.5 milliliters (ml) of milligram (mg)/ml Haldol (an antipsychotic drug that is used to treat psychosis as well as symptoms of agitation, irritability, and delirium) intramuscularly every eight hours as needed for aggressive and combative behavior.

Review of Resident R280's progress note dated 7/21/23, entered by LPN, Employee E41 documented the resident was discharged from hospice.

Review of Resident R380's physician orders indicated he was discharged from hospice on 7/21/23.

Review of the progress note dated 8/3/23, stated the resident was on hospice and the patient's episodes of agitation and aggression have decreased. "PRN medications as being ordered by hospice. Continue current medications as prescribed."

Review of the progress note dated 12/28/23, entered by Nurse practitioner Employee E37, indicated the resident was on hospice. It was indicated the end was added to the PRN Haldol.

During an interview on 3/4/24, at 10:20 a.m. Nurse Practitioner, Employee E37 stated PRN antipsychotics must have an end date, note exceeding more than 14 days. The resident must be assessed every 14 days and renewed if needed. Nurse Practitioner, Employee E37 stated Resident R280 was "on hospice" and "when I bill I put a specific identifier that he is on hospice," and "I have a nurse that does all medication checks in clinical record." Nurse Practitioner, Employee E37 confirmed Resident R280's PRN Haldol order that was active from 2/13/24, through 12/15/23, should have been renewed every 14 days.

During an interview on 3/4/24, at 12:40 p.m. the Director of Nursing confirmed the facility failed to limit as needed antipsychotic drugs to 14 days as required for one of four residents (Resident R280).

28 Pa Code 211.12 (d)(1)(2)(3)(5) Nursing services


 Plan of Correction - To be completed: 05/01/2024

0758
1. R280 is no longer receiving prn haldol.
2. A house audit will be conducted of residents receiving prn antipsychotic medications to ensure appropriate prescribing timeframes are in place.
3. The Director of Nursing will re in-service medical and psych providers on the regulatory requirement for use of prn antipsychotic drugs.
4. The Director of nursing/designee will audit 3 residents receiving prn antipsychotic medications twice weekly for 2 weeks, then 3 residents weekly for 2 weeks, then 3 residents monthly for 2 months to ensure that order contains a 14 day stop date or a rationale for continued usage is clearly documented in the resident's medical record. Audit findings will be shared with QAPI committee.
483.80(a)(1)(2)(4)(e)(f) REQUIREMENT Infection Prevention & Control:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
§483.80 Infection Control
The facility must establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections.

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

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

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

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

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

§483.80(f) Annual review.
The facility will conduct an annual review of its IPCP and update their program, as necessary.
Observations:
Based on a facility tour, review of facility policies, staff interviews, and review of Centers for Disease Control (CDC) guidelines, it was determined that the facility failed to maintain infection control practices to prevent the potential for contamination for one of three resident wounds (Resident R101), and one of two photocopy/mail room (Administration hallway).

Findings include:

Review of facility policy "Infection Control Plan, Program and Committee" dated 10/1/23, indicated a comprehensive process that addresses detection, prevention, and control of infections. The facility is committed to preventing adverse outcomes such as health care associated infections and their related events, improving resident care by supporting staff in all areas of the facility, minimizing occupational hazards associated with the delivery of healthcare, and fostering evidence-based decision making.

Review of admission record indicated Resident R101 was admitted to the facility on 7/24/21.

Review of Resident R101's MDS dated 1/31/24, indicated the diagnoses of diabetes, renal failure (kidney failure), legally blind, and osteomyelitis of left heel (infection of bone).

Review of Resident R101' physician order dated 1/24/24, indicated to apply Dakins 1/4 strength (wound cleanser) to left heel topically daily, every other day for wound care. Cleanse with Dakins solution, pack with Dakins moistened gauze, abdominal pad (ABD), and kerlix (gauze wrap) daily. Secure with ace wrap.

Review of Resident R101's Treatment Administration Record (TAR) dated January 2023, indicated this was administered on 1/24/24, 1/26/24, and 1/28/24.

Review of Resident R101's progress note dated 1/29/24, at 9:19 p.m. indicated while nurse was doing treatments, it was noted that the left heel dressing was dated 1/26/24. Current treatment is clean with Dakins solution, pack with Dakins gauze, ABD, and kerlix every other day.

Tour of facility on 2/27/24, at 9:39 a.m. an observation of the photocopy/mail room beside the Director of Nursing's office contained two centrifuge machines (used to spin blood vials) and a refrigerator.

Interview with Director of Nursing on 2/27/24, at 11:24 a.m. indicated they kept the lab supplies and centrifuges in there, and confirmed the potential for blood borne pathogens exposure, and the equipment should be kept in a soiled utility room with a sink available for hand washing available.

Interview on 3/6/24, at 3:00 p.m. the Director of Nursing confirmed the facility failed to maintain infection control practices to prevent the potential for contamination for one of three resident wounds (Resident R101), and one of two photocopy/mail rooms (Administration hallway).

28 Pa. Code: 211.10(c)(d) Resident care policies.

28 Pa. Code: 211.12(d)(1)(2)(3)(5) Nursing services.


 Plan of Correction - To be completed: 05/01/2024

0880 -
1. Lab centrifuge was moved to the soiled utility room on 2 main. The specimen refrigerator will be moved to 2 main soiled utility room. R101 was assessed by wound care for ill effects related to missed dressing change. No ill effects identified.
2. An audit was conducted of residents requiring dressing changes to ensure completion per physician orders.
3. Licensed staff will be educated by director of nursing/designee on completing dressing changes as ordered.
4. Director of nursing/designee will audit 3 residents requiring wound care twice weekly for 2 weeks, then 3 residents weekly for 2 weeks, then 3 residents monthly for 2 months to ensure completion of dressing changes as ordered. NHA/designee will audit mail room weekly for 3 weeks, then monthly for 3 months to ensure specimen refrigerator and centrifuge remain in soiled utility room on 2 main. Audit findings will be shared with QAPI committee.
§ 201.14(a) LICENSURE Responsibility of licensee.:State only Deficiency.
(a) The licensee is responsible for meeting the minimum standards for the operation of a facility as set forth by the Department and by other Federal, State and local agencies responsible for the health and welfare of residents. This includes complying with all applicable Federal and State laws, and rules, regulations and orders issued by the Department and other Federal, State or local agencies.

Observations:
Based on state regulations, staff interview, and review of the facility's Infection Control Committee Meeting attendance records, it was determined that the facility failed to ensure that Infection Control meetings occurred and that all of the required nine multidisciplinary members were present at the Infection Prevention Subcommittee meetings (a laboratory personnel, and a member from the community) for three of four quarters of 2023, and one quarter of 2024.

Findings include:

Review of Act 52 (The Act of March 20, 2002, P.L. 154, No. 13), known as the Medical Care Availability and Reduction of Error (MCARE) Act, Chapter 4, Section 403(1) Infection Control plan states, "A health care facility... shall develop and implement an internal infection control plan that shall include... a multidisciplinary committee including representatives from each of the following if applicable to that specific health care facility." A review of the applicable members at infection control meetings include medical staff, administration, laboratory personnel, nursing staff, pharmacy staff, physical plant personnel, patient safety officer, a community member, and a member of the infection control team.

Review of the facility's Infection Control Meeting attendance sheet dated 1/25/24, failed to reveal that laboratory staff, and a community member were in attendance.

Review of the facility's Infection Control Meeting attendance sheet dated 10/26/23, failed to reveal that laboratory staff, and a community member were in attendance.

Review of the facility's Infection Control Meeting attendance sheet dated 7/27/23, failed to reveal that laboratory staff, and a community member were in attendance.

Review of the facility's Infection Control Meeting attendance sheet dated 4/27/23, failed to reveal that laboratory staff were in attendance.

Interview on 3/4/24, at 1:00 p.m. the Director of Nursing confirmed failed to ensure that Infection Control meetings occurred and that all of the required nine multidisciplinary members were present at the Infection Prevention Subcommittee meetings (a laboratory personnel, and a member from the community) for three of four quarters of 2023, and one quarter of 2024.




 Plan of Correction - To be completed: 05/01/2024

1020
1. The Facility cannot retroactively correct the deficiency as it relates to absent community member and laboratory personnel.
2. The NHA reviewed the policy and procedure for infection control committee meeting attendance to ensure all committee members are identified.
3. The NHA will request an invitation to a lab designee and community member designee for all QA meetings.
4. The NHA/designee will audit attendance form quarterly, for infection control committee meeting, to ensure required committee members' participation. Audit findings will be shared with QAPI committee.
§ 211.12(f.1)(4) LICENSURE Nursing services. :State only Deficiency.
(4) Effective July 1, 2023, a minimum of 1 LPN per 25 residents during the day, 1 LPN per 30 residents during the evening, and 1 LPN per 40 residents overnight.
Observations:
Based on review of nursing time schedules and staff interviews it was determined that the facility administrative staff failed to provide a minimum of one Licensed Practical Nurse (LPN) per 40 residents during the midnight shift on two of 21 days reviewed (2/12/24, and 2/16/24).

Findings include:

Review of facility census data indicated that on 2/12/24, the census was 462, which required 11.55 LPN's during the midnight shift.

Review of nursing time schedules and deployment sheets revealed only 11.13 LPN's provided care.

Review of facility census data indicated that on 2/16/24, the census was 463, which required 11.58 LPN's during the midnight shift.

Review of nursing time schedules and deployment sheets revealed only 11.13 LPN's provided care.

Interview on 3/6/24, at 11:42 a.m. the Nursing Home Administrator and Director of Nursing confirmed the facility administrative staff failed to provide a minimum of one Licensed Practical Nurse (LPN) per 40 residents during the midnight shift on two of 21 days reviewed (2/12/24, and 2/16/24).


 Plan of Correction - To be completed: 05/01/2024

5530
1. The NHA reviewed the staffing structure, ratios, and PPD's in accordance with the newly implemented state regulation, and confirmed the nursing facility met the minimum for PPD but did not meet the newly implemented ratios by; 0.42, 0.45, respectively on two shifts of 21 days.
2. The licensed Administrator re-in serviced the schedulers on the policy, procedure, and regulation for ensuring meeting a staffing ratio.
3. The licensed Administrator will audit staffing weekly for one month to ensure continued compliance.
4. The licensed Administrator or designee will report findings to QAPI.
§ 211.12(i)(1) LICENSURE Nursing services.:State only Deficiency.
(1) Effective July 1, 2023, the total number of hours of general nursing care provided in each 24-hour period shall, when totaled for the entire facility, be a minimum of 2.87 hours of direct resident care for each resident.

Observations:
Based on review of nursing time schedules and staff interviews it was determined that the facility administrative staff failed to provide the minimum number of general nursing hours (2.87) to each resident in a 24-hour period on one of 21 days (2/25/24).

Findings include:

Nursing time schedules for the time period of 2/1/24, through 2/25/24, revealed that the facility failed to maintain 2.87 hours of general nursing care to each resident in a 24-hour period on 2/25/24.

Review of nursing time schedules indicated that on 2/25/24, the general hours of nursing care was 2.81.

During an interview on 3/6/24, at 11:42 a.m. the Nursing Home Administrator and Director of Nursing confirmed the facility failed to meet nursing hours requirements on one of 21 days (2/25/24).


 Plan of Correction - To be completed: 05/01/2024

5630
1. The NHA reviewed the staffing structure, ratios, and PPD's in accordance with the state regulation, and confirmed the nursing facility did not meet the minimum staffing PPD, by 0.06, on one of 21 days.
2. The NHA re-in serviced the schedulers on the policy, procedure, and regulation for ensuring meeting a staffing ratio.
3. The NHA will audit staffing weekly for one month to ensure continued compliance.
4. The NHA or designee will report findings to QAPI.

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