Pennsylvania Department of Health
BELAIR HEALTHCARE AND REHABILITATION CENTER
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

BELAIR HEALTHCARE AND REHABILITATION CENTER
Inspection Results For:

There are 151 surveys for this facility. Please select a date to view the survey results.

Surveys don't appear on this website until at least 41 days have elapsed since the exit date of the survey.


BELAIR HEALTHCARE AND REHABILITATION CENTER - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:

Based on a Medicare/Medicaid Recertification, State Licensure, and Civil Rights Compliance Survey completed on May 17,2024, it was determined that Belair Healthcare and Rehabilitation was not in compliance with the following requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care and the 28 Pa. Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.

Plan of Correction:

483.60(a)(1)(2) REQUIREMENT Qualified Dietary Staff:

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(a) Staffing
The facility must employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, taking into consideration resident assessments, individual plans of care and the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment required at §483.70(e)

This includes:
§483.60(a)(1) A qualified dietitian or other clinically qualified nutrition professional either full-time, part-time, or on a consultant basis. A qualified dietitian or other clinically qualified nutrition professional is one who-
(i) Holds a bachelor's or higher degree granted by a regionally accredited college or university in the United States (or an equivalent foreign degree) with completion of the academic requirements of a program in nutrition or dietetics accredited by an appropriate national accreditation organization recognized for this purpose.
(ii) Has completed at least 900 hours of supervised dietetics practice under the supervision of a registered dietitian or nutrition professional.
(iii) Is licensed or certified as a dietitian or nutrition professional by the State in which the services are performed. In a State that does not provide for licensure or certification, the individual will be deemed to have met this requirement if he or she is recognized as a "registered dietitian" by the Commission on Dietetic Registration or its successor organization, or meets the requirements of paragraphs (a)(1)(i) and (ii) of this section.
(iv) For dietitians hired or contracted with prior to November 28, 2016, meets these requirements no later than 5 years after November 28, 2016 or as required by state law.

§483.60(a)(2) If a qualified dietitian or other clinically qualified nutrition professional is not employed full-time, the facility must designate a person to serve as the director of food and nutrition services.
(i) The director of food and nutrition services must at a minimum meet one of the following qualifications-
(A) A certified dietary manager; or
(B) A certified food service manager; or
(C) Has similar national certification for food service management and safety from a national certifying body; or
D) Has an associate's or higher degree in food service management or in hospitality, if the course study includes food service or restaurant management, from an accredited institution of higher learning; or
(E) Has 2 or more years of experience in the position of director of food and nutrition services in a nursing facility setting and has completed a course of study in food safety and management, by no later than October 1, 2023, that includes topics integral to managing dietary operations including, but not limited to, foodborne illness, sanitation procedures, and food purchasing/receiving; and
(ii) In States that have established standards for food service managers or dietary managers, meets State requirements for food service managers or dietary managers, and
(iii) Receives frequently scheduled consultations from a qualified dietitian or other clinically qualified nutrition professional.

Observations:

Based on a review of facility documents, and staff interviews, it was determined that the facility failed to employ staff with the required skills and competencies to carry out the daily functions of the Dietary Department (Food Service Director Employee E9) for six of twelve months.

Findings include:

A review of facility document "Dietary Supervisor Job Description" indicated that a qualified candidate must have successful completion of a reputable course in food service operation, or a college degree in culinary arts management.

During an interview on 5/13/24, at 9:45 a.m. Food Service Director Employee E9 stated that he started at the facility in November 2023, and did not possess qualifications of a certified dietary manger or have any related degrees.

During an interview on 5/13/23, at 3:00 p.m. Nursing Home Administrator (NHA) confirmed that Food Service Director Employee E9 failed to meet the state agency requirements for a food service director.

28Pa. Code: 211.6(c)(d) Dietary services.

Plan of Correction - To be completed: 07/16/2024

The facility NHA will contract a qualified dietician which is currently in discussion.

It is expected that the contract will be in place within the next three weeks.

Former RD has been available PRN for interim needs until new RD and contract is in place.

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

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

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

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

Observations:

Based on review of facility policies, observations and staff interview, it was determined the facility failed to properly date and store food products, and maintain clean equipment in a manner to prevent foodborne illness in the main kitchen.

Findings include:

Review of facility policy "Food Receiving and Storage" dated 3/4/24, indicated foods shall be received and stored in a manner that complies with safe food handling practices.

Review of facility policy "Sanitization", dated 3/4/24, indicated that the food service area is maintained in a clean and sanitary manner.

During observation and interview in the dry storage room on 5/13/24, at 9:58 a.m. opened packages of macaroni, spaghetti, and egg noodles were noted to have not been dated. Food Service Director (FSD) Employee E9 confirmed that the facility failed to properly label and date opened food packages to prevent foodborne illness.

During observation on 5/14/24, at 11:17 a.m. a fan that was pointed towards the tray line, was covered in a gray, fuzzy substance.

During an interview on 5/14/24, at 11:20 a.m. FSD Employee E9 confirmed that the facility failed to maintain clean equipment to prevent foodborne illness.

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

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

28 Pa. Code: 211.6(c) Dietary services.

Plan of Correction - To be completed: 07/16/2024

Fan identified during survey was removed immediately from the wall and will not be replaced. Undated items identified during survey were immediately removed.

Dietary Manager will in-service dietary staff on the facility "Sanitization" and "Food Receiving and Storage" policy and procedure to ensure the facility remains in compliance with all regulatory requirements.

Dietary Manager audited kitchen during survey to ensure that any undated items were removed from the kitchen to ensure compliance

NHA, or designee, will monitor the kitchen bi-weekly x2, weekly x 2 and monthly thereafter, utilizing the Kitchen Food Service Observation form provided.

All in-services, audits and monitoring will be reported to the QAPI committee at the next scheduled meeting

483.15(c)(1)(i)(ii)(2)(i)-(iii) REQUIREMENT Transfer and Discharge Requirements:

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.

§483.15(c) Transfer and discharge-
§483.15(c)(1) Facility requirements-
(i) The facility must permit each resident to remain in the facility, and not transfer or discharge the resident from the facility unless-
(A) The transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in the facility;
(B) The transfer or discharge is appropriate because the resident's health has improved sufficiently so the resident no longer needs the services provided by the facility;
(C) The safety of individuals in the facility is endangered due to the clinical or behavioral status of the resident;
(D) The health of individuals in the facility would otherwise be endangered;
(E) The resident has failed, after reasonable and appropriate notice, to pay for (or to have paid under Medicare or Medicaid) a stay at the facility. Nonpayment applies if the resident does not submit the necessary paperwork for third party payment or after the third party, including Medicare or Medicaid, denies the claim and the resident refuses to pay for his or her stay. For a resident who becomes eligible for Medicaid after admission to a facility, the facility may charge a resident only allowable charges under Medicaid; or
(F) The facility ceases to operate.
(ii) The facility may not transfer or discharge the resident while the appeal is pending, pursuant to § 431.230 of this chapter, when a resident exercises his or her right to appeal a transfer or discharge notice from the facility pursuant to § 431.220(a)(3) of this chapter, unless the failure to discharge or transfer would endanger the health or safety of the resident or other individuals in the facility. The facility must document the danger that failure to transfer or discharge would pose.

§483.15(c)(2) Documentation.
When the facility transfers or discharges a resident under any of the circumstances specified in paragraphs (c)(1)(i)(A) through (F) of this section, the facility must ensure that the transfer or discharge is documented in the resident's medical record and appropriate information is communicated to the receiving health care institution or provider.
(i) Documentation in the resident's medical record must include:
(A) The basis for the transfer per paragraph (c)(1)(i) of this section.
(B) In the case of paragraph (c)(1)(i)(A) of this section, the specific resident need(s) that cannot be met, facility attempts to meet the resident needs, and the service available at the receiving facility to meet the need(s).
(ii) The documentation required by paragraph (c)(2)(i) of this section must be made by-
(A) The resident's physician when transfer or discharge is necessary under paragraph (c) (1) (A) or (B) of this section; and
(B) A physician when transfer or discharge is necessary under paragraph (c)(1)(i)(C) or (D) of this section.
(iii) Information provided to the receiving provider must include a minimum of the following:
(A) Contact information of the practitioner responsible for the care of the resident.
(B) Resident representative information including contact information
(C) Advance Directive information
(D) All special instructions or precautions for ongoing care, as appropriate.
(E) Comprehensive care plan goals;
(F) All other necessary information, including a copy of the resident's discharge summary, consistent with §483.21(c)(2) as applicable, and any other documentation, as applicable, to ensure a safe and effective transition of care.

Observations:

Based on clinical record review and staff interview, it was determined that the facility failed to make certain that the necessary resident information was communicated to the receiving health care provider for three out of five residents sampled with facility-initiated transfers (Residents R16, R24, and, R212).

The findings include:

Review of Resident R16's clinical record indicated the resident was admitted to the facility on 7/24/23, and readmitted on 10/14/23, with diagnoses of COPD, (chronic obstructive pulmonary disease- a group of progressive lung disorders characterized by increasing breathlessness), high blood pressure, and heart failure (a progressive heart disease that affects pumping action of the heart muscles. This causes fatigue, shortness of breath.)

Review of Resident R16's clinical record revealed that the resident was transferred to the hospital on 10/11/23, and returned to the facility on 10/14/24.

Review of Resident R16's clinical record revealed no documented evidence that the facility had communicated specific information to the receiving health care provider for the residents transferred and expected to return, which included the resident's care plan goals, advanced directive information, specific instructions for ongoing care, resident representative information, and all information necessary to meet the resident's specific needs at the receiving facility.

Review of Resident R24's clinical record indicated the resident was admitted to the facility on 3/4/22.

Review of Resident R24's MDS (Minimum Data Set, periodic assessment of resident care needs) dated 4/1/24, indicated diagnoses heart failure (a progressive heart disease that affects pumping action of the heart muscles), diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time) and, multiple sclerosis (a disease that affects central nervous system).

Review of Resident R24's clinical record revealed that the resident was transferred to the hospital on 3/22/24 and returned to the facility on 3/25/24.

Review of Resident R24's clinical record revealed no documented evidence that the facility had communicated specific information to the receiving health care provider for the residents transferred and expected to return, which included the resident's care plan goals, advanced directive information, specific instructions for ongoing care, resident representative information, and all information necessary to meet the resident's specific needs at the receiving facility.

Review of the clinical record indicated Resident R212 was admitted to the facility on 5/7/24.

Review of Resident R212's MDS dated 5/13/24, indicated diagnoses of high blood pressure, seizure disorder, and pneumonia (lung inflammation caused by bacteria or viral infection).

Review of Resident R212's clinical record indicated the resident was transferred to the hospital on 4/22/24, and returned to the facility on 5/7/24.

Review of Resident R212's clinical record failed to reveal a physician order to transfer the resident to the hospital on 4/22/24.

During an interview on 5/17/24, at 10:22 a.m. the Director of Nursing (DON) confirmed that the facility failed to obtain and document a physician order to send Resident R212 to the hospital on 4/22/24.

Review of Resident R212's clinical record revealed no documented evidence that the facility had communicated specific information to the receiving health care provider for the residents transferred and expected to return, which included the resident's care plan goals, advanced directive information, specific instructions for ongoing care, resident representative information, and all information necessary to meet the resident's specific needs at the receiving facility.

During an interview on 5/15/24, at 11:13 a.m. the DON stated, "We send the information with them but we do not have it documented."

During an interview on 5/15/24, at 11:15 a.m. the DON confirmed that the facility failed to make certain that the necessary resident information was communicated to the receiving health care provider for three out of five residents sampled with facility-initiated transfers (Residents R16, R24, and, 212).

28 Pa. Code 201.29 (a)(c.3)(2) Resident rights.

Plan of Correction - To be completed: 07/16/2024

DON, or designee, will in-service all RN's/LPN's to the facility policy and procedure for transfer or discharge documentation to ensure accuracy with documentation in resident charts.

DON, or designee, will audit all resident transfer/discharge documentation for the last 30 days to ensure all transfer/discharge documentation has been captured per policy and procedure.

DON, or designee, will monitor resident transfer documentation bi-weekly x 2 weeks, weekly x 4 weeks and monthly thereafter to ensure that all resident transfers contain the required documentation.

All in-service, audits and monitoring will be reported to the QAPI team at the next scheduled meeting.

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

§483.21(b) Comprehensive Care Plans
§483.21(b)(1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at §483.10(c)(2) and §483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following -
(i) The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under §483.24, §483.25 or §483.40; and
(ii) Any services that would otherwise be required under §483.24, §483.25 or §483.40 but are not provided due to the resident's exercise of rights under §483.10, including the right to refuse treatment under §483.10(c)(6).
(iii) Any specialized services or specialized rehabilitative services the nursing facility will provide as a result of PASARR recommendations. If a facility disagrees with the findings of the PASARR, it must indicate its rationale in the resident's medical record.
(iv)In consultation with the resident and the resident's representative(s)-
(A) The resident's goals for admission and desired outcomes.
(B) The resident's preference and potential for future discharge. Facilities must document whether the resident's desire to return to the community was assessed and any referrals to local contact agencies and/or other appropriate entities, for this purpose.
(C) Discharge plans in the comprehensive care plan, as appropriate, in accordance with the requirements set forth in paragraph (c) of this section.
§483.21(b)(3) The services provided or arranged by the facility, as outlined by the comprehensive care plan, must-
(iii) Be culturally-competent and trauma-informed.

Plan of Correction - To be completed: 07/16/2024

NHA, or designee, will in-service IDT team on the facility "Care Planning – Interdisciplinary Team" and "Care Plans, Comprehensive Person-Centered" Policy and procedure to ensure accurate completion of Individualized comprehensive care plan completion for all residents.

DON, or designee, will in-service all RN's/LPN's on "Antipsychotic Medication Use" and "Behavior and Side Effect Tracking Guide" to ensure that all resident side effects and behaviors are properly documented per the facility policy and procedure.

NHA, or designee, will audit all current resident care plans to ensure they accurately capture all measurable objectives and timetables for each resident.

NHA, or designee, will monitor new admission comprehensive care plans to ensure they accurately capture all measurable objective and timetables for each resident within the 7 day timeframe bi-weekly x 2, weekly x2 and monthly thereafter to ensure accurate completion.

DON, or designee, will audit all current residents to ensure all residents that are appropriate have an enabled behavior and side effect tracker added to their care profile, anyone without one will immediately have one entered.

DON, or designee, will monitor all residents with a behavior and side effect tracker bi-weekly x 2, weekly x 2 and monthly thereafter to ensure all behaviors and side effects are captured per policy and procedure.

TRAUMA INFORMED CARE

All in-services, audits, monitoring will be reported to the QAPI team at the next scheduled meeting.

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

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

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

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

Plan of Correction - To be completed: 07/16/2024

NHA, or designee, will be in-service direct care staff, social services director and business office on the facility "leave Day- Bed Hold Policy" and the Bed-Hold Notification to ensure residents are provided notification per policy.

DON, or designee, will audit resident transfer/discharge bed-hold documentation for resident's transfer/discharged in the last 30 days for accurate bed-hold documentation.

DON, or designee, will monitor documentation of bed-hold notifications given upon transfers to resident/responsible party bi-weekly x 2, weekly x 4 and month thereafter to ensure that all resident/legal representatives a receiving notification of the bed hold information.

All in-services, audits and monitors will be reported to the QAPI team at the next scheduled meeting.

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

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

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

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

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

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

Observations:

Based on review of resident clinical records, and staff interviews, it was determined that the facility failed to provide a transfer notice to a representative of the Office of the Long-Term Care Ombudsman Division for three of four residents (Resident R16, R24, and R212).

Findings Include:

A review of the facility policy "Transfer and Discharge-30 day" reviewed 3/4/24, indicated that the a copy of the transfer and discharge notice will be sent to the Office of the State Long-Term Care Ombudsman.

Review of Resident R16's clinical record indicated the resident was admitted to the facility on 7/24/23, and readmitted on 10/14/23, with diagnoses of COPD, (chronic obstructive pulmonary disease- a group of progressive lung disorders characterized by increasing breathlessness), high blood pressure, and heart failure (a progressive heart disease that affects pumping action of the heart muscles. This causes fatigue, shortness of breath.)

Review of Resident R16's clinical record revealed that the resident was transferred to the hospital on 10/11/23, and returned to the facility on 10/14/23.

Review of Resident R16's clinical record indicated the facility failed to include documented evidence that the facility provided a written transportation notification to the Office of Long-Term Care Ombudsman for the hospitalization on 10/11/23.

Review of Resident R24's clinical record indicated the resident was admitted to the facility on 3/4/22.

Review of Resident R24's MDS (Minimum Data Set, periodic assessment of resident care needs) dated 4/1/24, indicated diagnoses heart failure (a progressive heart disease that affects pumping action of the heart muscles), diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time) and, multiple sclerosis (a disease that affects central nervous system).

Review of Resident R24's clinical record revealed that the resident was transferred to the hospital on 3/22/24, and returned to the facility on 3/25/24.

Review of Resident R24's clinical record indicated the facility failed to include documented evidence that the facility provided a written transportation notification to the Office of Long-Term Care Ombudsman for the hospitalization on 3/22/24.

Review of the clinical record indicated Resident R212 was admitted to the facility on 5/7/24.

Review of Resident R212's MDS dated 5/13/24, indicated diagnoses of high blood pressure, seizure disorder, and pneumonia (lung inflammation caused by bacteria or viral infection).

Review of Resident R212's clinical record indicated the resident was transferred to the hospital on 4/22/24, and returned to the facility on 5/7/24.

Review of Resident R212's clinical record indicated the facility failed to include documented evidence that the facility provided a written transportation notification to the Office of Long-Term Care Ombudsman for the hospitalization on 4/22/24.

During an interview on 5/15/24, at 11:50 a.m. the Director of Nursing (DON) stated, "We do not send anything to the Ombudsman's Office".

During an interview on 5/15/24, at 11:54 a.m. the DON confirmed that the facility failed to provide a transfer notice to a representative of the Office of the Long-Term Care Ombudsman Division for three of four residents (Resident R16, R24, and R212).

28 Pa. Code 201.29 (a) (c.3) (2) Resident rights.

Plan of Correction - To be completed: 07/16/2024

NHA, or designee, will in-service social services director on the Federal Requirements for Providing LTC Ombudsman Programs with Notice of Resident Transfer or Discharge to ensure that all regulatory notifications are made to the State Ombudsmans Office monthly.

DON began an ongoing list at Survey for notification to the Ombudsmans Office, copy is contained in the POC book.

NHA, or designee, will monitor list of resident discharges / transfers weekly to ensure all residents are accurately captured for notification to the ombudsmans Office at the end of each month x 3 months.

All in-services, audits and monitoring will be reported to the QAPI team at the next scheduled meeting.

483.10(g)(17)(18)(i)-(v) REQUIREMENT Medicaid/Medicare Coverage/Liability Notice:

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)(17) The facility must--
(i) Inform each Medicaid-eligible resident, in writing, at the time of admission to the nursing facility and when the resident becomes eligible for Medicaid of-
(A) The items and services that are included in nursing facility services under the State plan and for which the resident may not be charged;
(B) Those other items and services that the facility offers and for which the resident may be charged, and the amount of charges for those services; and
(ii) Inform each Medicaid-eligible resident when changes are made to the items and services specified in §483.10(g)(17)(i)(A) and (B) of this section.

§483.10(g)(18) The facility must inform each resident before, or at the time of admission, and periodically during the resident's stay, of services available in the facility and of charges for those services, including any charges for services not covered under Medicare/ Medicaid or by the facility's per diem rate.
(i) Where changes in coverage are made to items and services covered by Medicare and/or by the Medicaid State plan, the facility must provide notice to residents of the change as soon as is reasonably possible.
(ii) Where changes are made to charges for other items and services that the facility offers, the facility must inform the resident in writing at least 60 days prior to implementation of the change.
(iii) If a resident dies or is hospitalized or is transferred and does not return to the facility, the facility must refund to the resident, resident representative, or estate, as applicable, any deposit or charges already paid, less the facility's per diem rate, for the days the resident actually resided or reserved or retained a bed in the facility, regardless of any minimum stay or discharge notice requirements.
(iv) The facility must refund to the resident or resident representative any and all refunds due the resident within 30 days from the resident's date of discharge from the facility.
(v) The terms of an admission contract by or on behalf of an individual seeking admission to the facility must not conflict with the requirements of these regulations.

Observations:

Based on a review of facility provided documentation and staff interview, it was determined the facility failed to issue an accurate Skilled Nursing Facility Advanced Beneficiary Notice form (SNF ABN CMS-10055) for one of three residents (Resident R163).

Findings include:

Review of the Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN CMS-10055) form provides information to residents/resident representatives that skilled nursing services may not be paid by Medicare and so that the resident/resident representative can decide if they wish to continue receiving skilled nursing services and assume financial responsibility.

Review of Resident R163's clinical record documented the resident was admitted to the facility on 1/9/24, and readmitted 2/4/24, and remained in the facility until 3/14/24.

Review of the facility provided Beneficiary Notice list, which includes residents who were discharged from Medicare Part A with benefit days remaining, and remained in the facility indicated Resident R163's last covered day was 2/29/24.

Review of Resident R163's record revealed a SNF ABN CMS-10055 form signed on 2/27/24, failed to include the accurate cost for Skilled Nursing Services. It was indicated it was $361.00 per day not including ancillary charges.

Review of Resident R163's statement dated 3/1/24, indicated the total amount due for the month of March was $11,815.00. It was indicated room and board charged were $379.00 per day.

During an interview with Social Worker, Employee E2 confirmed the costs listed on the SNF ABN CMS-10055 were incorrect.

During an interview on 5/15/24, at 10:22 a.m. the Nursing Home Administrator confirmed the facility failed to issue an accurate Skilled Nursing Facility Advanced Beneficiary Notice form (SNF ABN CMS-10055) for one of three residents (Resident R163).

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

Plan of Correction - To be completed: 07/16/2024

NHA, or designee, will in-service the social services director and business office on the form instructions for the Advance Beneficiary Notice of Non-Coverage to ensure accuracy with completion going forward.

Social Services Director will audit all current residents with existing ABN's for accuracy. Any errors identified are to be addressed and corrected immediately. Results of this audit are to be reported to the QAPI team at the next scheduled meeting.

NHA, or designee, will monitor all newly issued ABN's bi-weekly x 2, weekly x 2 and monthly thereafter to ensure accurate completion per regulation. All findings are to be reported to the QAPI team at the next regularly scheduled meeting.

The identified resident had already been discharged from the facility when identified by DOH during annual survey.

The in-service info, audits and monitors will be reported to the QAPI team at the next scheduled meeting.

483.12(a)(1) REQUIREMENT Free from Abuse and Neglect:

§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 neglect for one of eight residents (Resident R49).

Findings include:

Review of facility policy "Identifying Types of Abuse" dated 3/4/24, indicated neglect is the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary. It was indicated neglect occurs when the facility is aware of, or should have been aware of goods and services that a resident requires, but the facility fails to provide them.

Review of the facility policy "Resident Rights" dated 3/4/24, stated residents will be free from neglect.

Review of admission record indicated Resident R49 was admitted to the facility on 10/2/23.

Resident R49's care plan initiated 10/2/22, indicated the resident is at risk for alteration in skin integrity. Interventions indicated to observe for changes in skin condition and report abnormalities and administer treatment per physician orders.

Review of Resident R49's Minimum Data Set (MDS- periodic assessment of care needs), dated 4/29/24, indicated the diagnoses of dementia (a group of symptoms that affects memory, thinking and interferes with daily life), high blood pressure, and anxiety.

Review of Resident R49's physician order dated 5/12/24, indicated to cleanse right hand with normal saline (wound cleanser), pat dry, apply TAO (Triple Antibiotic Ointment) and cover with bordered gauze every shift for skin tear.

Review of Resident R49's May 2024 Treatment Administration Record (TAR) indicated the dressing was changed on 5/12/24, for day and night shift.

During an observation and interview on 5/13/24, at 12:06 p.m. Licensed Practical Nurse (LPN), Employee E6 confirmed Resident R49's right hand dressing was dated 5/11/24.

During an interview on 5/13/24 12:12 p.m. the Director of Nursing confirmed the facility failed to protect Resident R49 from neglect.

During an interview on 5/15/24, at 11:05 a.m. LPN, Employee E6 stated a treatment is not signed off in the TAR until it is completed.

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: 07/16/2024

DON, or designee, will in-service all staff on "Identifying Types of Abuse" and "Resident Rights" to ensure that all staff is aware of the policies and procedures and follow them accurately.

DON, or designee, will in-service the RN's/LPN's on the facility policy and procedure for "Medication and Treatment Orders" to ensure all nursing staff is accurately addressing all wound care dressings.

DON, or designee, audited all current resident treatment dressings to ensure that they were completed per the physician's order during survey.

DON, or designee, will monitor current resident treatments bi-weekly x 3, weekly x 2 and monthly thereafter to ensure they are being completed according to the physician's order. Results of the monitoring will be reported to the QAPI committee at their next scheduled meeting.

The resident identified during the survey had his dressing immediately changed with no repercussions to his wound.

All in-services, audits and monitoring will be reported to the QAPI team at the next scheduled meeting.

483.12 REQUIREMENT Free from Misappropriation/Exploitation:

§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.

Plan of Correction - To be completed: 07/16/2024

NHA, or designee, will in-service the IDT team on the facility playbook on "Conducting and Investigation" to ensure that the IDT team knows how to properly conduct an investigation in the event of any future incidents.

DON, or designee, will in-service all staff on "Resident Rights" and "Misappropriation of a Resident's Property" to ensure all staff are able to accurately follow each policy in the event of missing items.

DON, or designee, will in-service all RN's/LPN's on the facility playbook "Medication Management", the facility policy and procedure for controlled substances, the controlled drug emergency kit record, the change of shift controlled substance count sheet and the change of shift controlled drug emergency kit audit to ensure that all controlled substances are being accurately monitored and accounted for.

DON, or designee, will audit existing controlled substances to ensure accuracy and accounts are being completed per policy and procedures.

New controlled substance binders will be added to each nurses station.

DON, or designee, will monitor the facility-controlled substances by completing a controlled substances accountability monitor bi-weekly x 2 weeks, weekly x 2 weeks and monthly thereafter to ensure accuracy and accountability with e-kit and controlled substance counts.

All in-services, audits and monitors will be reported to the QAPI team at the next scheduled meeting.

483.12(b)(1)-(5)(ii)(iii) REQUIREMENT Develop/Implement Abuse/Neglect Policies:

§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, newly hired personnel records and staff interviews it was determined that the facility failed to conduct a current FBI (Federal Bureau of Investigation) background check on an employee prior to her date of hire for one out of five personnel records (Licensed Practical Nurse Employee E3).

Findings include:

The facility "Abuse Prevention Program" policy dated 3/4/24, indicated that the resident has the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms.

The facility " Background Check Procedures" policy dated 3/4/24, indicated that facility conducts employment background screening checks on all applicants, to include current employees as needed, in compliance with Federal and State requirements and regulations. All offers of employment are contingent upon clear results of a thorough criminal background check. All background checks must be completed; results received; reviewed and determination made before beginning employment.

Review of Licensed Practical Nurse Employee E3's personnel record indicated she was hired on 5/3/24.

Review of Licensed Practical Nurse Employee E3's personnel record revealed resident has not lived in Pennsylvania for 2 consecutive years and indicated a home address that was out of the state.

Review of Licensed Practical Nurse Employee E3's personnel record did not reveal that a current FBI background check was completed prior to her start date of employment.

During an interview on 5/15/24, at 8:50 a.m. Human Resource Employee E4 stated, "It was an oversight on my part".

During an interview on 5/15/24, at 1:06 p.m. the Director of Nursing confirmed that the facility failed to conduct a current FBI background check on an employee prior to her date of hire for one out of five personnel records (Licensed Practical Nurse Employee E3) as required.

28 Pa Code: 201.14(a) (c)(d)(e) Responsibility of licensee

28 Pa Code: 201.19 Personnel policies and procedures

28 Pa Code: 201.20 (a)(b)(c)(d) Staff development

28 Pa Code: 201.29 (d) Resident Rights

28 Pa Code 201.18(b)(1)(2)(e)(1) Management

Plan of Correction - To be completed: 07/16/2024

NHA, or designee, will in-service all staff on the facility abuse prevention program to ensure staff accountability with the knowledge of this policy.

NHA, or designee, will in-service the Human Resources Director on the facility policy background check policy to ensure all background checks are completed per the facility policy and stare/federal regulations.

NHA, or designee, will audit the last 3 months of new hires files to ensure they are in compliance with the facility background check procedure policy.

NHA, or designee, will monitor new hire files weekly x 3 weeks and monthly thereafter to ensure they are in compliance with the facility background check procedure policy.

All in-services, audits and monitoring will be reported to QAPI at the next scheduled meeting.

483.20(g) REQUIREMENT Accuracy of Assessments:

§483.20(g) Accuracy of Assessments.
The assessment must accurately reflect the resident's status.

Observations:

Based on a review of Resident Assessment Instrument (RAI) User's Manual, clinical records, and staff interviews, it was determined that the facility failed to ensure that MDS assessments accurately reflected the resident's status for one of six residents (Resident R25).

Findings include:

The Resident Assessment Instrument (RAI) User's Manual, which gives instructions for completing Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2023, indicated the following instructions:

-Observation (Look-Back, Assessment) Period is the time period over which the resident's condition or status is captured by the MDS assessment. Most MDS items themselves require an observation period, such as 7 or 14 days, depending on the item. Since a day begins at 12:00 a.m. and ends at 11:59 p.m., the observation period must also cover this time period. A standard 7-day look-back period counts back from and includes the Assessment Reference Date (ARD+6 previous days).

Review of the admission record indicated Resident R25 was admitted to the facility on 4/24/24.

Review of Resident R25's progress note dated 4/24/24, indicated the resident was very combative with care. It was indicated the resident tries to physically swing at the nurse aides during care.

Review of Resident R25's progress note dated 4/25/24, indicated the resident is still "a little combative with aides when doing care."

Review of Resident R25's MDS dated 4/30/24, included diagnoses of high blood pressure, altered mental status, and urinary tract infection. Review of Section E-Behavior, Question E0200 indicated that Resident R25 did not exhibit physical behavioral symptoms directed toward others.

During an interview on 5/17/24, at 9:58 a.m. the Director of Nursing confirmed the facility failed to ensure that MDS assessments accurately reflected the resident's status for one of six residents (Resident R25).

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

Plan of Correction - To be completed: 07/16/2024

MDS will be modified for correction of E0200

RNAC will provide education to the Social Service Director on MDS Section E0200 using the RAI Manual

Social Service Director will complete Relias Training – MDS 3.0 Section E
RNAC/and or designee will audit 2 MDSs per week for 3 weeks for coding accuracy of Section E0200,

If errors are noted, additional education will be completed and audit will continue until no errors are noted for 3 weeks.

All in-services, audits and monitors will be reported to the QUAPI team at the next scheduled meeting

483.21(a)(1)-(3) REQUIREMENT Baseline Care Plan:

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

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

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

Observations:

Based on review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to ensure that a resident and a resident's representative was provided a summary of their completed baseline care plan for two of six residents (Resident R21 and R33).

Findings include:

Review of the facility policy " Careplans-Baseline", last reviewed 4/3/24, indicated that a baseline plan of care to meet the resident's immediate needs shall be developed for each resident within forty-eight hours of admission. The resident and their representative will be provided a summary of the baseline care plan.

Review of Resident R21's clinical record indicated the resident was admitted to the facility on 4/12/24.

Review of Resident R21's MDS (Minimum Data Set, periodic assessment of resident care needs) dated 4/18/24, indicated diagnoses of depression, dysphasia (difficulty swallowing), and schizoaffective disorder (a mental disorder in which a person experiences a combination of schizophrenia and mood disorder symptoms).

Review of Resident R21's clinical record failed to produce documentation that a resident and resident representative was provided with a summary of the baseline care plan.

Review of Resident R33's clinical record indicated the resident was admitted to the facility on 4/19/24.

Review of Resident R33's MDS dated 4/25/24, indicated diagnoses of heart failure (a progressive heart disease that affects pumping action of the heart muscles, hypertension, and diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time).

Review of Resident R 33's clinical record failed to produce documentation that a resident and resident representative was provided with a summary of the baseline care plan.

During an interview on 5/16/24, at 1:48 p.m. the Nursing Home Administrator confirmed that the facility failed to ensure that a resident and a resident representitive was provided a summary of their completed baseline care plan for two of six residents (Resident R21 and R33).

28 Pa. Code: 211.11 (a)(c)(d) Resident care plan

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

Plan of Correction - To be completed: 07/16/2024

DON, or designee will in-service all RN's/LPN's on the facility "Care Plans- Baseline" policy and procedure and the step by step guide to completion within PCC for accurate completion upon admission.

DON, or designee, will audit all current residents to ensure that all residents have an accurately completed baseline careplan.

DON, or designee, will monitor all new admissions weekly x 2 weeks, bi-weekly x 2 and monthly thereafter to ensure accurate completion of the baseline careplan.

All in-services, audits and monitoring will be reported to the QAPI committee at the next scheduled meeting.

483.25 REQUIREMENT Quality of Care:

§ 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 clinical records, observation, and staff interviews, it was determined that the facility failed to follow physician orders for one of eight residents (Resident R49).

Findings include:

Review of admission record indicated Resident R49 was admitted to the facility on 10/2/23.

Resident R49's care plan initiated 10/2/22, indicated the resident is at risk for alteration in skin integrity. Interventions indicated to observe for changes in skin condition and report abnormalities and administer treatment per physician orders.

Review of Resident R49's Minimum Data Set (MDS- periodic assessment of care needs), dated 4/29/24, indicated the diagnoses of dementia (a group of symptoms that affects memory, thinking and interferes with daily life), high blood pressure, and anxiety.

Review of Resident R49's physician order dated 5/12/24, indicated to cleanse right hand with normal saline (wound cleanser), pat dry, apply TAO (Triple Antibiotic Ointment) and cover with bordered gauze every shift for skin tear.

During an observation and interview on 5/13/24, at 12:06 p.m. Licensed Practical Nurse, Employee E5 confirmed Resident R49's right hand dressing was dated 5/11/24. The dressing was not completed as ordered on 5/12/24, or 5/13/24, day shift.

During an interview on 5/13/24 12:12 p.m. the Director of Nursing confirmed the facility failed to follow physician orders for one of eight residents (Resident R49).

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

28 Pa. Code 201.29(a) Resident rights.

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

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

483.25(e)(1)-(3) REQUIREMENT Bowel/Bladder Incontinence, Catheter, UTI:

§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 clinical records and staff interviews, it was determined that the facility failed to change an indwelling catheter (insertion of a tube into the bladder to drain urine) as ordered for one of three residents (Resident R14), and failed to obtain a valid medical diagnosis for an indwelling urinary catheter and develop and implement a comprehensive plan of care related to urinary catheter usage for one of three residents (Resident R52).

Findings include:

Review of Title 42 Code of Federal Regulations (CFR) Incontinence indicated if the facility provides care for a resident with an indwelling catheter, in collaboration with the medical director and director of nurses, and based upon current professional standards of practice, resident care policies and procedures must be developed and implemented that address catheter care and services, including but not limited to: timely and appropriate assessments related to the indication for use of an indwelling catheter; identification and documentation of clinical indications for the use of a catheter; as well as criteria for the discontinuance of the catheter when the indication for use is no longer present; insertion, ongoing care and catheter removal protocols that adhere to professional standards of practice and infection prevention and control procedures; response of the resident during the use of the catheter; and ongoing monitoring for changes in condition related to potential CAUTI's (catheter-associated infections) and recognizing, reporting and addressing such changes.

Review of the clinical record indicated that Resident R14 was admitted to the facility on 6/14/21.

Review of Resident R14's Minimum Data Set (MDS - a periodic assessment of care needs) dated 5/2/24, indicated diagnoses of high blood pressure, paraplegia (paralysis on lower half of the body), and obstructive uropathy (occurs when urine can't flow either partially or completely, resulting in swelling and damage to kidneys). Section H-Bowel Bladder and Bowel indicated the resident had an indwelling catheter.

Review of Resident R14's physician order dated 2/19/24, indicated foley catheter 20 French with 30 cc (milliliter) balloon to be changed every thirty days and as needed for dislodgement for obstructive uropathy.

Review of Resident R14's care plan dated 6/24/21, indicated the resident required the use of indwelling urinary catheter. Interventions indicated to change the catheter as per physician order.

Review of Resident R14's March 2024 Treatment Administration Record (TAR) revealed the order to change the foley catheter every thirty days was left blank and not signed off for completion.

Review of Resident R14's April 2024 TAR revealed the order to change the foley catheter every thirty days was left blank and not signed off for completion.

Review of Resident R14's clinical record from 3/1/24, through 4/31/24, failed to indicate the resident's catheter was changed as ordered.

During an interview on 5/15/24, at 2:19 p.m. the Director of Nursing confirmed the facility failed to change a foley catheter as ordered for one of three residents (Resident R14).

Review of the clinical record indicated that Resident R52 was admitted to the facility on 4/6/24.

Review of Resident R52's MDS dated 4/10/24, indicated diagnoses of high blood pressure, hemiplegia (paralysis on one side of the body), and muscle weakness.

Review of a physician order dated 5/6/24, indicated foley catheter 16 French with 10 cc (milliliter) balloon to straight bag gravity drainage.

Review of Resident R52's care plan failed to reveal goals and interventions related to use of an indwelling urinary catheter.

During an interview on 5/17/24, at 10:22 a.m. the Director of Nursing confirmed that the facility failed to obtain a valid medical diagnosis for an indwelling urinary catheter and failed to develop and implement a comprehensive plan of care related to urinary catheter usage for Resident R52.

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

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

28 Pa. Code 211.11(d) Resident care policies.

Plan of Correction - To be completed: 07/16/2024

DON, or designee, will in-service all RN's/LPN's and IDT Team on the facility "Catheter Care- Urinary" policy and procedure to ensure all residents have the appropriate diagnosis, care plan and physicians order for their catheter.

DON, or designee, will audit all existing residents with catheters to ensure they have a proper diagnosis, careplan and physicians order.

DON, or designee, will monitor all new resident's who admit with Catheters to ensure there is an appropriate diagnosis, careplan and physicians order with each new admission x 1 week, bi weekly x 2 and monthly thereafter.

All in-services, audits and monitoring will be reported to the QAPI team at the next scheduled meeting.

483.25(i) REQUIREMENT Respiratory/Tracheostomy Care and Suctioning:

§ 483.25(i) Respiratory care, including tracheostomy care and tracheal suctioning.
The facility must ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals and preferences, and 483.65 of this subpart.

Observations:

Based on review of facility policy, observations, interviews, and clinical record review, it was determined that the facility failed to provide appropriate respiratory care for one of four residents (Residents R16).

Findings include:

Review of facility policy "Oxygen Administration" dated 3/4/24, indicated to check the mask, tank, and humidifying jar to be sure they are in good working order. "Be sure there is water in the humidifying jar and that the water level is high enough that the water bubbles as oxygen flows through." "Periodically re-check the water level in humidifying jar."

Review of the clinical record indicated that Resident R16 was admitted to the facility on 7/24/23, with diagnosis of COPD, (chronic obstructive pulmonary disease- a group of progressive lung disorders characterized by increasing breathlessness), high blood pressure, and heart failure (a progressive heart disease that affects pumping action of the heart muscles. This causes fatigue, shortness of breath.)

Review of Resident R16's physician's order dated 10/14/23, indicated to administer oxygen at 4 lpm (liter per minute) via nasal cannula continuously.

Review of Resident R16's physician's order dated 10/14/23, indicated to change oxygen tubing and canister every night shift every Saturday.

Review of Resident R16's care plan revised 4/26/24, indicated to administer oxygen at 4 l/m and to administer treatment and medications per order.

During an observation on 5/13/24, at 1:21 p.m. Resident R16 was receiving 4 l/m of oxygen via nasal cannula. The resident's humidification canister was observed to be empty.

During an interview on 5/13/24, at 11:20 a.m. Licensed Practical Nurse Employee E8 confirmed Resident R16's humidification canister was empty, and confirmed the facility failed to provide appropriate respiratory care for one of four residents (Residents R16).

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

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

Plan of Correction - To be completed: 07/16/2024

DON, or designee, will in-service all direct care staff on the facility "Oxygen Administration" policy and procedure to ensure all staff is aware of the oxygen administration policies.

DON, or designee, will audit all residents with oxygen to ensure their humidification cannisters are filled and maintained per policy.

DON, or designee, will monitor all residents with oxygen orders bi-weekly x 2 weeks, weekly x 2 weeks and monthly thereafter to ensure all humidification cannisters are filled and maintained per policy.

All in-services, audits and monitoring will be reported to the QAPI team at the next scheduled meeting.

483.25(m) REQUIREMENT Trauma Informed Care:

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

Observations:

Based on review of facility policy, resident record review, and staff interviews, it was determined that the facility failed to provide a trauma survivor with trauma informed care to eliminate or mitigate triggers that may cause re-traumatization of the resident for one of two residents (Resident R34).

Findings include:

Review of facility policy "Trauma Informed Care" dated 3/4/24, indicated the facility will deliver care and services which, in addition to meeting professional standards, are delivered using approaches which are culturally-competent and account for experiences and preferences, and address the needs of trauma survivors by minimizing triggers and/or re-traumatization. Facilities should use a multi-pronged approach to identifying a resident's history of trauma, this would include asking the resident about triggers that may be stressors or may prompt recall of a previous traumatic event. Facilities must identify triggers which may re-traumatize residents with a history of trauma. The facility should collaborate with resident trauma survivors, and as appropriate, resident's family, friends, and any other health care professionals to develop and implement individualized interventions.

Review of the clinical record indicated Resident R34 was admitted to the facility on 7/19/23.

Review of Resident R34's Minimum Data Set (MDS - a periodic assessment of care needs) dated 3/19/24, indicated diagnoses of high blood pressure, anxiety (a feeling of worry, nervousness, or unease), and Post Traumatic Stress Disorder (PTSD - a disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event and may have triggers that can bring back memories of trauma accompanied by intense emotional and physical reactions).

Review of Resident R34's care plan dated 10/11/23, indicated the resident was a survivor of abuse and that the facility should encourage discussing individual triggers, but failed to identify what the triggers were and how to avoid them.

During an interview on 5/17/24, at 10:57 a.m. Social Worker Employee E2 confirmed that the facility failed to identify PTSD triggers for Resident R34 in order to eliminate or mitigate any triggers that may cause re-traumatization for Resident R34.

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

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

Plan of Correction - To be completed: 07/16/2024

NHA, or designee, will in-service the IDT Team on the facility "Trauma Informed Care" policy and procedure to ensure that all residents with trauma careplans have any and all triggers are careplanned.

Social Services, or designee, will audit all current residents with trauma informed careplans meet the facility "trauma informed care" policy and procedure, listing all triggers for the residents trauma.

Social Services, or designee, will monitor all new residents to ensure that all residents that meet criteria for a trauma informed care plan, have one added to their comprehensive care plan with triggers for that resident with each new admission weekly x 2 weeks, bi-weekly x 2 weeks then monthly thereafter.

All in-services, audits and monitoring will be reported to the QAPI team at the next scheduled meeting.

483.40(b)(3) REQUIREMENT Treatment/Service for Dementia:

§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.

Plan of Correction - To be completed: 07/16/2024

NHA, or designee, will inservice the IDT Team on the facility "Dementia-Clinical Protocol" to ensure all residents with a dementia diagnosis receive the appropriate treatment and services to attain or maintain their highest practicable physical, mental and psychosocial well-being per the facility policy.

DON, or designee, will audit all existing residents with a dementia diagnosis to ensure accurate care planning to ensure they receive the appropriate treatments per the facility policy and regulatory requirements.

DON, or designee, will monitor all new residents with a dementia diagnosis to ensure accurate care planning to ensure they receive the appropriate treatments per the facility policy and regulatory requirements.

All in-services, audits and monitoring will be reported to the QAPI team at the next scheduled meeting.

483.45(c)(1)(2)(4)(5) REQUIREMENT Drug Regimen Review, Report Irregular, Act On:

§483.45(c) Drug Regimen Review.
§483.45(c)(1) The drug regimen of each resident must be reviewed at least once a month by a licensed pharmacist.

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

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

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

Observations:

Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that the physician responded timely pharmacy medication recommendations for one out of five sampled residents (Resident R49).

Findings include:

The facility "Medication Regimen Review" policy dated 8/17/23, indicated the consultant pharmacist will conduct Medication Regimen Review (MRR) and will make recommendations based on the information available in the resident's health record. If an irregularity does not require urgent action, it should be addressed before the consultant pharmacist's next monthly MRR. The facility should alert the Medical Director when MRR's are not addressed by the attending physician in a timely manner.

Review of admission record indicated Resident R49 was admitted to the facility on 10/2/23.

Review of Resident R49's Minimum Data Set (MDS- periodic assessment of care needs), dated 4/29/24, indicated the diagnoses of dementia (a group of symptoms that affects memory, thinking and interferes with daily life), high blood pressure, and anxiety.

Review Resident R49's Medication Regimen Review Recommendations dated 3/7/24, indicated the resident was on Risperdal (antipsychotic medication used to treat certain mental/mood disorders) and recommended that due to the potential for antipsychotic to cause extrapyramidal (involuntary and uncontrollable movement disorders caused by certain drugs) side effects, it is important to monitor for potential of involuntary muscle movements to assess for the presence or worsening of these symptoms. It was recommended that nursing perform an AIMS (Abnormal Involuntary Movement Scale) test now and then every six months and report to the physician immediately if any signs or symptoms are noted or worsening. It was indicated a note was written to the physician.

Review of Resident R49's clinical record on 5/15/24, failed to indicate an AIMS test was performed as recommended.

During an interview on 5/16/24, at 1:19 p.m. the Director of Nursing confirmed the facility failed to ensure that the physician responded timely pharmacy medication recommendations for one out of five sampled residents (Resident R49).

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

28 Pa. Code 211.5(f) Clinical records.

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

Plan of Correction - To be completed: 07/16/2024

NHA, or designee, will in-service the Medical Director on the facility "Medication Regimen Review" policy and procedure to ensure that all resident MRR's are addressed in accordance with this policy.

DON, or designee, will audit all current residents MRR's to ensure that they have been addressed properly and in accordance with the facility policy and procedure for the Medication Regimen Review.

DON, or designee, will monitor all new MRR's to ensure they are completed timely and accurately in line with the "Medication Regimen Review" policy weekly x 3 and monthly thereafter. (MRR's are issued monthly from pharmacy).

All in-services, audits and monitoring will be reported to the QAPI team at the next scheduled meeting.

483.45(c)(3)(e)(1)-(5) REQUIREMENT Free from Unnec Psychotropic Meds/PRN Use:

§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.

Plan of Correction - To be completed: 07/16/2024

NHA, or designee, will in-service the Medical Director on the facility "Medication Regimen Review" policy and procedure to ensure that all residents are free from potentially unnecessary medications and are addressed in accordance with this policy.

DON, or designee, will audit all current residents MRR's to ensure that they have been addressed properly and in accordance with the facility policy and procedure for the Medication Regimen Review.

DON, or designee, will monitor all new MRR's to ensure they are completed timely and accurately in line with the "Medication Regimen Review" policy weekly x 3 and monthly thereafter. (MRR's are issued monthly from pharmacy).

All in-services, audits and monitoring will be reported to the QAPI team at the next scheduled meeting

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

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

§483.45(h) Storage of Drugs and Biologicals

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

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

Observations:

Based on review of facility policy, observation, and staff interviews, it was determined that the facility failed to date opened medications and properly store medications in one of two medication carts (West Assignment).

Findings include:

Review of facility policy "Storage of Medications" dated 3/4/24, indicated medications are stored safely, securely, and properly, following manufacture's recommendations or those of the supplier.

Review of Title 42 Code of Federal Regulations (CFR) Labeling of Drugs and Biologicals indicated if a multi-dose vial has been opened of accessed (e.g., needle-punctured), the vial should be dated and discarded within 28 days unless the manufacturer specifies a different (shorter or longer) date for that opened vial.

During an observation on 5/15/24, at 9:16 a.m. of the West Assignment medication cart indicated the following medications stored in one compartment without individual packaging or separation from other residents medications:
- Resident R10's Lantus (prefilled pen to inject long acting insulin under the skin) pen not in a box or individual bag
- Two of Resident R10's Lantus pens not in a box or individual bag
- R46's Lantus pen not in a box or individual bag
- R213's Lantus pen not in a box or individual bag

Continued observation indicated the following medications not dated upon opening:
- Resident R10's Lantus pen, no date opened.
- Two of Resident R30's Lantus pens, no date opened.
- Resident R46's Lantus pen, no date opened.
- Resident R46's atropine (a medication used to treat swelling in the eyes) drops, no date opened.
- Resident R213's Lantus pen, no date opened.
- Two of Resident R213's Admelog (a rapid-acting insulin) vials, no date opened.

During an interview on 5/15/24, at 9:23 a.m. Licensed Practical Nurse Employee E1 confirmed the findings noted above.

During an interview on 5/15/24, at 1:48 p.m. the Director of Nursing confirmed that the facility failed to date opened medications and properly store medications in one of two medication carts (West Assignment).

28 Pa. Code: 201.14 (a) Responsibility of licensee.
28 Pa. Code: 201.18 (b)(1)(e)(1) Management.
28 Pa. Code: 211.9 (a)(1) Pharmacy services.
28 Pa. Code: 211.12 (d)(1)(3)(5) Nursing services.

Plan of Correction - To be completed: 07/16/2024

DON, or designee, will in-service all RN's/LPN's on the facility "Medication Storage" policy and procedure to ensure all Nurses are aware of the storage policies for properly dating and storing diabetic medication.

DON, or designee, will audit all medication storage areas to ensure all medications is stored per facility policy and regulatory requirements.

DON, or designee, will monitor all medication storage units to ensure compliance with the facility medication storage policy and regulatory compliance bi-weekly x 2, weekly x 2 and monthly thereafter.

All in-services, audits and monitoring will be reported to the QAPI team at the next scheduled meeting.

483.55(a)(1)-(5) REQUIREMENT Routine/Emergency Dental Srvcs in SNFs:

§483.55 Dental services.
The facility must assist residents in obtaining routine and 24-hour emergency dental care.

§483.55(a) Skilled Nursing Facilities
A facility-

§483.55(a)(1) Must provide or obtain from an outside resource, in accordance with with §483.70(g) of this part, routine and emergency dental services to meet the needs of each resident;

§483.55(a)(2) May charge a Medicare resident an additional amount for routine and emergency dental services;

§483.55(a)(3) Must have a policy identifying those circumstances when the loss or damage of dentures is the facility's responsibility and may not charge a resident for the loss or damage of dentures determined in accordance with facility policy to be the facility's responsibility;

§483.55(a)(4) Must if necessary or if requested, assist the resident;
(i) In making appointments; and
(ii) By arranging for transportation to and from the dental services location; and

§483.55(a)(5) Must promptly, within 3 days, refer residents with lost or damaged dentures for dental services. If a referral does not occur within 3 days, the facility must provide documentation of what they did to ensure the resident could still eat and drink adequately while awaiting dental services and the extenuating circumstances that led to the delay.

Observations:

Based on a review of facility policy, clinical records, and resident and staff interviews it was determined that the facility failed to ensure that emergency dental care was provided for one of two residents (Resident R19).

Findings include:

Review of facility policy "Dental Services", dated 3/4/24, indicated that routine and emergency dental services are available to meet the resident's oral health services in accordance with the resident's assessment and plan of care. Social Services representatives will assist residents with appointments, transportation arrangements, and reimbursement of dental services under the state plan, if eligible.

Review of the clinical record revealed that Resident R19 was admitted to the facility on 5/1/23.

Review of Resident 19's MDS (Minimum Data Set, periodic assessment of resident care needs) dated 4/8/24, indicated diagnoses of high blood pressure, dementia (neuro-cognitive disorder impacting reasoning, judgment, and memory), and mild intellectual disabilities.

Review of Resident R19's clinical record revealed a physician's order dated 5/1/23 for dental consult as needed.

During an interview on 5/14/24, at 9:52 a.m. Resident R19 stated, "My tooth hurts. It needs fixed".

Review of Resident R19's clinical record revealed documentation on 5/3/24, that Resident R19 was seen by the Nurse Practitioner for a toothache. The note stated "Seen today per staff request, patient complains of toothache. He reports left lower molar pain. Tooth is grey in color without redness or swelling noted to gum line. Staff reports on list to get appointment for outpatient dentist. Dental consult for possible extraction". Ibuprofen (a medication used to treat pain) 400 mg (milligrams) twice a day for five days was ordered, as well as Orajel (an ointment that is applied to the mouth to help relieve pain) as needed.

Review of Resident R19's clinical record revealed documentation on 5/6/24, that Resident R19 was seen again by Nurse Practitioner for toothache and facial swelling. The note stated "Tooth is grey in color without redness now with facial swelling. Staff reports on list to get appointment for outpatient dentist. He states he is able to eat/chew on other side. Dental consult for possible extraction". Amoxicillin (an antibiotic medication used to treat infection) 500 mg twice a day for seven days, Orajel, and a soft diet were ordered.

Review of Resident R19's clinical record revealed documentation on 5/10/24, that Resident R19 was seen again by Nurse Practitioner for monthly review of acute and chronic conditions. The note stated "Patient acutely seen for toothache, waiting for dentist appointment. Eating and drinking without difficulty. Dental consult for possible extraction".

During an interview on 5/15/24, at 12:40 p.m. Social Worker Employee E2 stated that she did not make a dentist appointment for Resident R19, but that Central Supply Employee E7 schedules those particular types of appointments.

During an interview on 5/15/24, at 12:45 p.m. Central Supply Employee E7 stated "I don't believe I did". In regards to making Resident R19 a dentist appointment. Central Supply Employee E7 then looked at her calendar and confirmed that she had not received notification to make Resident R19 a dentist appointment. Central Supply Employee E7 stated that typically staff would place a paper in her mailbox that an appointment needed to be made, but stated that she had not received any such notification.

During an interview on 5/15/24, at 1:02 p.m. Resident R19 stated that his tooth only hurts when he chews on that side, but can chew on the other side without difficult. Resident R19 confirmed that he has not yet been notified about any upcoming dentists appointments.

During an interview on 5/15/24, at 1:40 p.m. Director of Nursing confirmed that the facility failed to provide emergency dental care and stated that Central Supply Employee E7 is "calling around now. It's hard to find a dentist that accepts MA (medical assistance) ".

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

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

28 Pa. Code 211.15(a) Dental services

Plan of Correction - To be completed: 07/16/2024

Resident identified during survey was completing antibiotic for infection, went to Katsur dental on 5/23, dentist started him on another antibiotic and was referred to an oral surgeon for tooth extraction and 6/24 resident has 2 teeth extracted with no adverse reactions.

DON, or designee, will inservice the IDT Team, RN's and LPN's on the facility "Dental Services" policy and procedure to ensure all residents are seen in compliance with the facility policy.

All in-services, audits and monitoring will be reported to the QAPI team at the next scheduled meeting.

DON, or designee, will audit all current residents to ensure compliance with the facility "Dental Services" policy and procedure.

DON, or designee, will monitor all residents weekly x 4 and monthly thereafter to ensure all dental needs are met be the facility and in compliance with the Dental Services policy and procedure.

All in-services, audits and monitoring will be reported to the QAPI team at the next scheduled meeting.

483.95(a) REQUIREMENT Communication Training:

§483.95(a) Communication.
A facility must include effective communications as mandatory training for direct care staff.

Observations:

Based on review of facility documents, employee education records, and staff interview, it was determined that the facility failed to provide training on effective communication for one of five direct care staff members (Nurse Aide Employee E10).

Findings include:

Review of the "Nurse Aide Job Description", indicated that nurse aide employees shall participate in required trainings and complete all related clinical competencies.

Review of Nurse Aide (NA) Employee E10's facility provided staff list indicated she was hired on 3/9/81. Review of NA Employee E10's training record for 3/9/23, through 3/9/24, did not include training on effective communication.

During an interview on 5/16/24, at 2:42 p.m. Assistant Director of Nursing (ADON)Employee E11 confirmed that the facility failed to provide training on effective communication for one of five staff members.

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

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

28 Pa Code: 201.20 (a)(c) Staff development.

Plan of Correction - To be completed: 07/16/2024

CNA identified during survey out of compliance for the required training was instructed on which trainings needed to be completed and they were completed before survey ended.

DON, or designee, will in-service the Staff Educator on the facility "Staff Development" and "In-service Training- All Staff" policy and procedure to ensure compliance with all regulatory training requirements for facility staff.

ADON completed a whole house CNA audit at the completion of survey to identify which CNA's had outstanding education to complete and they were then completed.

DON, or designee, will monitor staff education weekly x 4 weeks then monthly thereafter to ensure compliance with all regulatory training requirements for existing and new employees.

All in-services, audits and monitoring will be reported to the QAPI team at the next scheduled meeting.

483.95(d) REQUIREMENT QAPI Training:

§483.95(d) Quality assurance and performance improvement.
A facility must include as part of its QAPI program mandatory training that outlines and informs staff of the elements and goals of the facility's QAPI program as set forth at § 483.75.

Observations:

Based on review of facility documents, employee education records, and staff interview, it was determined that the facility failed to provide training on QAPI (Quality Assurance and Performance Improvement) for five of five staff members (Employees E10, E12, E13, E14. E15).

Findings include:

Review of the "Nursing Home Administrator (NHA) Job Description" dated 9/1/23, indicated that the NHA will ensure all compliance with required trainings and in-services.

Review of Nurse Aide (NA) Employee E10's facility provided staff list indicated she was hired on 3/9/81. Review of NA Employee E10's training record for 3/9/23, through 3/9/24, did not include training on QAPI.

Review of Licensed Practical Nurse (LPN) Employee E12's facility provided staff list indicated she was hired on 2/4/02. Review of LPN Employee E12's training record for 2/4/23, through 2/4/24, did not include training on QAPI.

Review of NA Employee E13's facility provided staff list indicated she was hired on 5/3/17. Review of NA Employee E13's training record for 5/3/23, through 5/3/24, did not include training on QAPI.

Review of NA Employee E14's facility provided staff list indicated she was hired on 5/6/14. Review of NA Employee E14's training record for 5/6/23, through 5/6/24, did not include training on QAPI.

Review of the NA Employee E15's facility provided staff list indicated she was hired on 6/23/94. Review of NA Employee E15's training record for 6/23/22, through 6/23/23, did not include training on QAPI.

During an interview on 5/16/24, at 2:42 p.m. Assistant Director of Nursing Employee E11 confirmed that the facility failed to provide training on QAPI for five of five staff members.

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

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

28 Pa Code: 201.20 (a)(c) Staff development.

Plan of Correction - To be completed: 07/16/2024

Staff Educator will in-service all staff on the facility QAPI plan to ensure compliance with all regulatory requirements.

Upon identification during survey, it was determined that no staff members had the QAPI trainings required to meet regulatory compliance.

Staff Educator, or designee, will monitor all new hires weekly x 4 and monthly thereafter to ensure that QAPI training is covered during orientation to ensure regulatory compliance.

ADON completed a whole house CNA audit at the completion of survey to identify which CNA's had outstanding education to complete and they were then completed.

All in-services, audits and monitoring will be reported to the QAPI team at the next scheduled meeting.

483.95(i) REQUIREMENT Behavioral Health Training:

§483.95(i) Behavioral health.
A facility must provide behavioral health training consistent with the requirements at §483.40 and as determined by the facility assessment at §483.70(e).

Observations:

Based on review of facility documents, employee education records, and staff interview, it was determined that the facility failed to provide training on behavioral health for one of five staff members (Nurse Aide Employee E10).

Findings include:

Review of the "Facility Assessment" dated 3/4/24, indicated staff training/education and competencies will be completed during general orientation upon hire, and annually. Education listed included, but not limited to:
-Alzheimer's disease and related disorders
-Dementia Care

Review of Nurse Aide (NA) Employee E10's facility provided staff list indicated she was hired on 3/9/81. Review of NA Employee E10's training record for 3/9/23, through 3/9/24, did not include training on behavioral health.

During an interview on 5/16/24, at 2:42 p.m. Assistant Director of Nursing Employee E11 confirmed that the facility failed to provide training on behavioral health for one of five staff members.

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

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

28 Pa Code: 201.20 (a)(c) Staff development.

Plan of Correction - To be completed: 07/16/2024

Staff Educator will in-service all CNA's on the Behavior Management training required for regulatory compliance in order to meet compliance.

ADON completed a whole house CNA audit at the completion of survey to identify which CNA's had outstanding education to complete and they were then completed.

Staff Educator, or designee, will monitor all new hires weekly x 4 and monthly thereafter to ensure to ensure that Behavior Management in-services training is covered during the orientation period.

All in-services, audits and monitoring will be reported to the QAPI team at the next scheduled meeting.

§ 201.20(a)(2) LICENSURE Staff development.:

(2) Restorative nursing techniques.

Observations:
Based on a review of facility documents, employee education records and staff interviews, it was determined that the facility failed to ensure that employees completed the required annual restorative nursing techniques education for one of five employees reviewed (Nurse Aide Employee E10).

Findings include:

Review of the "Nurse Aide Job Description", indicated that nurse aide employees shall participate in required trainings and complete all related clinical competencies.

Review of Nurse Aide (NA) Employee E10's facility provided staff list indicated she was hired on 3/9/81. Review of NA Employee E10's training record for 3/9/23, through 3/9/24, did not include documentation on restorative nursing techniques.

During an interview on 5/16/24, at 2:42 a.m. Assistant Director of Nursing Employee E 11 confirmed that the facility failed to provide training on restorative nursing techniques for one of five staff members.

Plan of Correction - To be completed: 07/16/2024

Staff Educator will in-service all CNA's on the Relias Module "restorative Nursing Foundations" to ensure compliance with all regulatory requirements.

ADON completed a whole house CNA audit at the completion of survey to identify which CNA's had outstanding education to complete and they were then completed.

Staff Educator, or designee, will monitor all new hires weekly x 4 and monthly thereafter to ensure that Restorative Nursing Foundations in-services training is covered during the orientation period.

All in-services, audits and monitoring will be reported to the QAPI team at the next scheduled meeting.

§ 201.20(a)(3) LICENSURE Staff development.:

(3) Emergency preparedness in accordance with 42 CFR 483.73(d) (relating to emergency preparedness).

Observations:
Based on a review of facility documents, employee education records and staff interviews, it was determined that the facility failed to ensure that employees completed the required annual emergency preparedness education for one of five employees reviewed (Nurse Aide Employee E10).

Findings include:

Review of the "Nurse Aide Job Description", indicated that nurse aide employees shall participate in required trainings and complete all related clinical competencies.

Review of Nurse Aide (NA) Employee E10's facility provided staff list indicated she was hired on 3/9/81. Review of NA Employee E10's training record for 3/9/23, through 3/9/24, did not include documentation on emergency preparedness education.

During an interview on 5/16/24, at 2:42 a.m. Assistant Director of Nursing Employee E 11 confirmed that the facility failed to provide training on emergency preparedness education for one of five staff members.

Plan of Correction - To be completed: 07/16/2024

Staff Educator will in-service all CNA's on the Relias Module "Emergency Preparedness for Healthcare" to ensure compliance with all regulatory requirements.

ADON completed a whole house CNA audit at the completion of survey to identify which CNA's had outstanding education to complete and they were then completed.

Staff Educator, or designee, will monitor all new hires weekly x 4 and monthly thereafter to ensure that Emergency Preparedness for Healthcare training is covered during the orientation period.

All in-services, audits and monitoring will be reported to the Emergency Preparedness for Healthcare will be reported to the QAPI team at the next scheduled meeting.

§ 201.20(a)(4) LICENSURE Staff development.:

(4) Fire prevention and safety in accordance with 42 CFR 483.90 (relating to physical environment).

Observations:
Based on a review of facility documents, employee education records, and staff interviews, it was determined that the facility failed to ensure that employees completed the required annual fire prevention and safety education for one of five employees reviewed (Nurse Aide Employee E10 ).

Findings include:

Review of the "Nurse Aide Job Description", indicated that nurse aide employees shall participate in required trainings and complete all related clinical competencies.

Review of Nurse Aide (NA) Employee E10's facility provided staff list indicated she was hired on 3/9/81. Review of NA Employee E10's training record for 3/9/23, through 3/9/24, did not include documentation on fire prevention and safety education.

During an interview on 5/16/24, at 2:42 a.m. Assistant Director of Nursing Employee E 11 confirmed that the facility failed to provide training on fire prevention and safety education for one of five staff members.

Plan of Correction - To be completed: 07/16/2024

Staff Educator will in-service all CNA's on the Relias Module "Fire Safety: The Basics" to ensure compliance with all regulatory requirements.

ADON completed a whole house CNA audit at the completion of survey to identify which CNA's had outstanding education to complete and they were then completed.

Staff Educator, or designee, will monitor all new hires weekly x 4 and monthly thereafter to ensure that Fire Safety: The Basics training is covered during orientation period.

All in-services, audits and monitoring will be reported to the QAPI team at the next scheduled meeting.

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