Pennsylvania Department of Health
GARDENS AT MILLVILLE, THE
Patient Care Inspection Results

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GARDENS AT MILLVILLE, THE
Inspection Results For:

There are  131 surveys for this facility. Please select a date to view the survey results.

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GARDENS AT MILLVILLE, THE - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on a Medicare/Medicaid Recertification, State Licensure, Revisit, Civil Rights Compliance and Abbreviated Complaint Survey completed on April 12, 2024, it was determined that The Gardens at Millville failed to correct the federal deficiencies cited during the survey of February 15, 2024, and continued to be out of 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:


483.25(d)(1)(2) REQUIREMENT Free of Accident Hazards/Supervision/Devices:This is the most serious deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one which places the resident in immediate jeopardy as it has caused (or is likely to cause) serious injury, harm, impairment, or death to a resident receiving care in the facility. Immediate corrective action is necessary when this deficiency is identified. This deficiency was not found to be throughout this facility.
483.25(d) Accidents.
The facility must ensure that -
483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and

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


Based on a review of clinical records and water temperature logs, observations, and resident and staff interviews it was determined that the facility failed to maintain an environment free of potential accident hazards by failing to maintain hot water temperatures within a safe range for residents, including Resident 12, 13, and 69, residing on the West Hall A and B unit, placing these 27 residents out of 97 residents residing in the facility in immediate jeopardy due to the potential for serious burns.

Findings include:

According to the U.S. Consumer Product Safety Commission, "most adults will suffer third-degree burns if exposed to 150 degree water for two seconds. Burns will also occur with a six-second exposure to 140 F degree water or with a thirty second exposure to 130 degree water. Even if the temperature is 120 F degrees, a five-minute exposure could result in third-degree burns.

Observation on the A unit, April 10, 2024, at 9:04 AM revealed that the temperature of the hot water in the bathroom sink of resident room 216 was 115.6 Farenheit.

Observation on the A unit, April 10, 2024, at 9:13 AM revealed that the hot water temperature in the facility's West Wing shower room measured 121.5 Farenheit.

Observation on the A unit, April 10, 2024, at 9:24 AM revealed that the hot water temperature at the sink in the bathroom in resident room 210 was 119.9 Farenheit.

During an interview on April 10, 2024, at 9:29 AM, Employee 3, a nurse aide, stated that she took the morning water temperatures earlier this morning, prior to showering residents. She explained that the facility never trained her on the procedure for checking water temperatures prior to showering residents, but she figured out the method on her own. She explained that there is a blue thermometer in the shower stall to measure the water temperature. When asked to demonstrate how she measures and records the water temperature obtained prior to showering residents, Employee 3, nurse aide, was observed looking at the blue thermometer but not placing the thermometer under the flowing water. She stated that the thermometer read 80 degrees Farenheit. She explained that she always makes sure the water is safe by testing it with her hand and asking residents if the water is comfortable. She stated, at the time of this interview, she had just completed Resident 13's shower.

During an interview on April 10, 2024, at 9:33 AM, Employee 4, nurse aide, stated that he was trained to utilize a blue thermometer that was hanging in the shower. He stated that the water shower temperature is then recorded on the temperature log sheet. He stated that he was not aware of a temperature that was too high for the residents to be showered. He explained that he always asks the residents about their comfort with the water temperature and feels the water temperature prior to letting residents shower. During an observation on April 10, 2024, at the same time as the interview, the facility's West Wing shower room water temperature measured 128 Fahrenheit. The measurement was taken by Employee 4, nurse aide.

During a resident group interview on April 10, 2024, at 10:00 AM, Resident 69 stated that when he independently takes showers, the water temperatures fluctuate from hot to cold. He explained that when the water becomes too hot, he points the shower handle away from his body. Resident 69 stated that he may have to wait up to two minutes before the water temperature is comfortable enough to resume showering with the water.

Water temperatures were obtained in the bathrooms of the resident rooms the B unit (locked dementia unit) and common bathing/shower room on April 10, 2024, at approximately 10:30 AM:

Resident rooms 216 & 217 -122.2 degrees Fahrenheit
Resident room 218 (a four bedded room) 122.7 degrees Fahrenheit
Resident room 219/221- 133.8 degrees Fahrenheit
Resident room 223/225--128.8 degrees Fahrenheit
Resident room 224/226--129.7 degrees Fahrenheit
Resident room 220 & 222--119.9 degrees Fahrenheit
Resident room 209 & 211-- 134.6 degrees Fahrenheit
Resident room 227 (a single room) - 127 degrees F, the cold water in the sink did not work at the time of the observation.

Observation in Resident room 227 at this time, revealed Resident 12, who was alert and oriented was attempting to use the sink in her room to wash her hands. The resident confirmed that the cold water did not work but she was "ok" to use just the hot water. The surveyor redirected the resident another area to wash her hands with a safe water temperature at that time or perform hand hygiene.

The B unit resident shower hot water temperature was 124.4 degrees Fahrenheit.

There were 27 residents residing on the B unit locked dementia unit, all who utilized the shower on the unit for bathing and some utilized the sinks in their respective resident rooms.

An observation April 10. 2024 at 9 AM in the resident common shower area on the west hall B unit revealed a clipboard with water shower temperature listings dated March 23, 2024 through April 5 , 2024. The documentation noted that all that all the water shower temperatures were noted to be exactly 100 degrees Fahrenheit.

During an interview on April 10, 2024 at 9 AM Employee 1, a nurse aide, stated that she was routinely scheduled to work in the B unit (locked dementia unit). She stated that the hot water temperature at the sinks in the resident rooms on the unit has been "really hot" for "a while." She stated that the unit shower water was also "really hot". Employee 1 stated that the Director of Nursing (DON) told her to document 100 degrees Fahrenheit for every shower given despite the actual temperature obtained.

During an interview on April 10, 2024 at 9:05 AM, Employee 2, a nurse aide, stated that hot water in the resident room sinks and the common resident shower is "very hot." She stated that the DON instructed her, after taking a shower water temperature, to document (on the designated shower temperature log, located in the shower room) 100 degrees Fahrenheit no matter what the actual temperature reads on the thermometer.

An interview with the Nursing Home Administrator at 1:30 PM on April 10, 2024, revealed that the NHA confirmed that the elevated hot water temperatures obtained and noted above were correct. He also verified that Resident 12 was at risk for burns due to the temperature of the hot water at the sink in the resident's room and the lack of running cold water at the sink at the time of the observation. He further stated that an unknown employee turned the cold water off underneath the sink in Resident 12's room, failed to tell maintenance of any issues, and did not turn the cold water back on for resident use. The NHA was unable to state how long the hot water temperatures were at an unsafe level.


Immediate Jeopardy was called on April 10, 2024, due to the facility's failure to ensure that the environment for the residents on the West unit, the A and B (locked dementia unit) resident hallways was free of potential accident hazards in the form of elevated hot water temperatures.

The facility was notified of the Immediate Jeopardy on April 10, 2024, at 11:15 AM and the IJ template provided to the facility.

An immediate plan of correction was requested and received on April 10, 2024.

The plan included:

-The plumber was called at 11:30 AM, April 10, 2024 and arrived shortly there after to diagnosis the problem.

-The hot water to the west side of the facility was temporarily turned off at 11:15 AM. Hot water will be rerouted from a second hot water heater (servicing the East side of the facility) by April 10, 2024 at 3:30 PM.

-The cold water tap in resident room 227 will be repaired by April 10, 2024 at 3 PM.

-All staff will be reeducated on the proper method of assessing water water temperatures prior to washing bathing and showering residents to assure accuracy of the temperature to timely assure accuracy of hot water temperatures. Education will be complete April 10, 2024.

-Random water temperatures throughout the facility will be checked every shift on each hall to avoid future occurrences starting April 10, 2024.

- During the time period the hot water is off, hand sanitizer and hot water from unaffected areas in the building will be used to meet resident needs.

The Immediate Jeopardy was lifted on April 10, 2024, at 5 PM when the removal plan was verified as completed.



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

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

28 Pa. Code 205.37 (c) Equipment for bathrooms









 Plan of Correction - To be completed: 05/14/2024

F 0689
The facility cannot retroactively correct the deficiency cited by the surveyors. Once aware of the excessive hot water temperatures the hot water to the affected area was shut off and a plumber called. During the period the hot water was off hand sanitizer and hot water from the unaffected areas were used to meet the resident's needs. The problem was corrected is appox. 4 hours by re-routing the hot water supply from a second hot water heater.
The cold water in the sink of room 227 was immediately repaired by replacing a faulty valve stem.
Nursing staff will be re-educated by the facility's Maintenance Director or designee on the proper method of assessing water temperatures prior to washing, bathing and showering a resident to assure accuracy of the temperature to timely identify unsafe hot water temperatures. Random water temperatures through-out the facility will be checked Q-Shift on each hall for 4 weeks and then daily thereafter to assure compliance. Any water temperatures over 110 degrees or any temperature noted to be too cool should be immediately reported to the Nursing Supervisor the Maintenance Director, the Director of Nursing and the Administrator and an immediate decision would be made if showers / bathing should be put on hold or hot water needs to be shut off till temperature is controlled. If water is shut off to an affected area, hand sanitized and hot water from the unaffected area of the facility would be utilized until the water temperature is corrected.
The random water temperature checks will be forwarded to the monthly Quality Assurance meeting to review for recommendations.

483.60(i)(1)(2) REQUIREMENT Food Procurement,Store/Prepare/Serve-Sanitary:This is a less serious (but not lowest level) deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents.  This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.60(i) Food safety requirements.
The facility must -

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

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

Based on observation and staff interview, it was determined that the facility failed to maintain acceptable practices for the storage and service of food to prevent the potential for contamination and microbial growth in food, which increased the risk of food-borne illness in the dietary department, and Alzheimer's dementia care unit kitchenette/pantry area, and East and West medication rooms.

Findings include:

Food safety and inspection standards for safe food handling indicate that everything that comes in contact with food must be kept clean and food that is mishandled can lead to foodborne illness. Safe steps in food handling, cooking, and storage are essential in preventing foodborne illness. You cannot always see, smell, or taste harmful bacteria that may cause illness according to the USDA (The United States Department of Agriculture, also known as the Agriculture Department, is the U.S. federal executive department responsible for developing and executing federal laws related to food).

A review of a facility policies entitled "Storage Areas" and Handling Clean Equipment and Utensils" last reviewed by the facility on June 21, 2023, indicated that food storage facilities should keep food safe, wholesome, and appetizing and stored in an area that is clean, dry, and free from contaminants. All containers must me legibly and accurately labeled and dated. Food is stored at a minimum of six-inches above the floor and eighteen-inches from the ceiling and on clean racks or other clean surfaces that are protected from splash, overhead pipes, or other contamination (i.e., sprinklers, sewer/waste disposal pipes, and vents). All foods will be stored off the floor. Clean equipment and utensils will be stored in a clean, dry location in a way that protects them from contamination by splashes and dust. Other stored utensils should be covered or inverted whenever possible.

The initial tour of the kitchen was conducted with the facility's Certified Dietary Manager (CDM) on April 9, 2024, at 9:15 a.m., revealed the following unsanitary practices with the potential to introduce contaminants into food and increase the potential for food-borne illness, was identified:

Upon entering the walk-in produce/milk 19 cases of food was observed stored directly on the floor.

Four cases of thawed four-ounce high calorie shake supplements, were not dated with a thaw date/discard date. The manufacturer's label noted that nutritional shakes and drinks were to be used within 14 days of thawing.
Interview with the CDM at that time confirmed that the cases of four-ounce shakes were thawed and lacked dates and the CDM was not sure when the shakes were thawed for use.

Observation inside of the dry storage area that there were two plastic bins that contained bulk flour and sugar that were not dated when filled. There were two ceiling tiles, near the wall air conditioning unit, that had brown colored stains.

Observation of the dry storage areas revealed serving food serving utensils and food preparation utensils, uncovered, and hanging on the wall, next to utility pipes and under water stained ceiling tiles.

During a tour of the dementia care unit's kitchenette on April 9, 2024, at 11:18 a.m., revealed that inside of the resident freezer there was a gallon of vanilla ice cream dated December 2023 that was melted and refrozen and had ice crystals covering the surface of the food. Also, there were six frozen cheese pizzas that were not dated.

A sticky brown substance was observed splattered on the cabinets and wall above the stove hood and on the ceiling.

An accumulation of dirt and debris with sticky splatter was observed on the floor in the dementia care unit kitchenette A dirty broom and dust pan were left on the side next to the wall ovens.

An observation of the East Wing medication room and in the presence of Employee 6, RN Supervisor, on April 10, 2024, at 8:55 a.m., revealed a 32-ounce fortified nutritional shake opened and not dated when opened. The manufacturer's label indicated that the shakes should be consumed/used within four days after opening. Employee 6 confirmed the that the shake was not dated and the open date was unknown.

Observation of the West Wing medication room on April 10, 2024, at 9:10 a.m., revealed that there was one 4-ounce high calorie shakes dated March 26, 2024, beyond the manufacturer's recommended 14-day discard date. One 4-ounce high calorie shake also lacked a thaw date or discard date.

During an interview with the Nursing Home Administrator (NHA) on April 10, 2024, at 1:30 p.m., confirmed that the facility failed to ensure that the dietary department and resident pantry/kitchenette food storage were maintained in a sanitary manner and failed to ensure proper labeling



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

28 Pa. Code 211.6 (f) Dietary Services




 Plan of Correction - To be completed: 05/14/2024

F 0812
The produce, milk and cases of food were removed from the floor of the walk-in cooler and properly stored. The four cases of thawed high calorie shakes, sugar and flour which were not dated were disposed of. Two stained ceiling tiles in the dry storage room were replaced and the food serving utensils hanging in the storage room have been relocated for proper storage. The ice cream and frozen pizza was disposed of from the Diet Kitchenette on the dementia unit and the cabinets, walls and floor were cleaned and the broom and dustpan properly stored. The undated / expired shakes in the East and West Side Med room have been disposed of.
The facility recognizes that all residents have the potential to be affected by the noted practice. See section 3 and 4 for system changes and monitoring.
The facility's Dietary Staff, Activities Staff and Licensed Nursing Staff will be re-educated by the Dietary Manager or designee on sanitary practices, proper food storage, labeling/dating and disposal of supplements/shakes
The Dietary Manager or designee will randomly audit sanitation, food storage and labeling including the Diet Kitchenette and any areas supplements/shakes are stored weekly for 4 weeks and then monthly for 2 months to verify compliance.
All audits will be reviewed at the monthly QA meeting and any concerns will be immediately addressed by the Dietary Manger.

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

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

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

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

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

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

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



Based on review of clinical records, the facility's infection control data, and infection control program and policies and staff interview, it was determined that the facility failed to maintain a comprehensive program to monitor and prevent infections in the facility.

Findings include:

A review of the facility's current infection control policy provided during the survey ending April 12, 2024, revealed that it is the purpose of the facility Infection Prevention and Control Program is to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of communicable diseases and infections and to improve antibiotic use. The facility adheres to the mission and goals set forth in the infection control plan.

A review of the facility's compiled infection data since the last standard survey ending May 12, 2023, revealed that during the months from August 2023 through March 2024 multiple resident infections were identified each month. However, there was no documented evidence that the infection preventionist/designee had evaluated potential causative factors and tracked the infections for any potential patterns or trends and evidence of the the corresponding applicable interventions initiated to prevent occurrence of similar infections.

The monthly infection tracking logs dated August 2023 through March 2024 included no descriptive information on the infections listed to include symptoms, culture or testing, organisms identified, completed treatment information or resolution dates.

There was no indication that the limited infection data that the facility had compiled was then evaluated to determine what could be done to prevent the spread or recurrence of infection.
The facility failed to demonstrate that its infection control program included, at a minimum, a system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, and visitors following accepted standards and guidelines.

Interview on April 11, 2024, at 10 AM with the facility Infection Control Nurse confirmed that the facility's current infection control program did not meet the intent of the requirements contained in the long term care regulations.


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

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

































 Plan of Correction - To be completed: 05/14/2024

F0880
The facility cannot retroactively correct the deficiency cited by the surveyors. Facility infections have been reviewed, identified and documented with potential causative factors and tracked for potential patterns or trends with documented interventions for the intention to prevent occurrence of similar infections.
The facility recognizes that all residents have the potential to be affected by the noted practice. See section 3 and 4 for system changes and monitoring.
The Regional Director of Clinical Services will re-educate the Director of Nursing and the Infection Preventionist on identifying and documenting with potential causative factors and tracking for potential patterns or trends with documented interventions with for intention to prevent occurrence of similar infections. New infections will be audited at the scheduled morning Interdisciplinary Meeting to verify proper identification, documentation, interventions along with trending and tracking to avoid further occurrences.
Audits will be submitted to the Monthly Quality Assurance meeting for review and further recommendations.

483.10(i)(1)-(7) REQUIREMENT Safe/Clean/Comfortable/Homelike Environment:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
483.10(i) Safe Environment.
The resident has a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

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

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

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

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

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

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

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

Based on observations and staff interviews, it was determined that the facility failed to provide housekeeping services to maintain a clean and orderly environment on four of the four nursing units (Nursing West A, West B, East C, and East D Hall).

Findings include:

An observation on April 9, 2024, at 10:24 AM revealed the window blinds in resident room 211 were broken or missing slats. Pieces of the slats were observed on the floor of the resident's room. A film of dust, black debris, and white paint chips were observed on the window sill. A build-up of dust and debris was observed on the radiator cover extending along the floor on the window-side wall.

An observation on April 9, 2024, at 11:15 AM in the West A Hall exit, near resident rooms 201 and 20,2 revealed a black substance debris on the floor to the left of the exit doors. The bottom corner of the exit door was observed to have a dirt buildup of approximately 0.25 inches thick.

An observation on April 9, 2024, at 12:02 PM in the West Resident Dayroom revealed a green chair with white stains.

An observation on April 9, 2024, at 12:24 PM revealed that the window blinds in resident room 213 were broken and missing slats.

An observation on April 9, 2024, at 1:20 PM revealed the window in resident room 213 had one detached hinge. The window was observed hanging approximately a foot lower on the right side.

An observation on April 10, 2024, at 9:16 AM in the East C Hall Resident Shower Room revealed a white shower chair with brown fecal like substance observed on the seat and on the bars below the chair seat.

An observation on April 10, 2024, at 10:00 AM in the West B Hall shower room revealed a plastic ceiling light fixture containing dead insects. The corners of the shower room floor were observed to have a buildup of dirt, dust, and a sticky film.

An observation on April 10, 2024, at 10:05 AM in the bathroom of resident room 215 revealed that the floor was dirty and sticky. The floor near the baseboard was dirty and sticky. There was dirt and debris on the floor, and accumulated in the bathroom floor corners. A thick yellow urine like substance, hair and debris were observed on the base of the toilet, along with a sticky brown film surrounding the base of the toilet. There was a brown film surrounding the water controls in the sink.

An observation on April 10, 2024, at 10:05 AM in resident room 215 revealed an overbed table with sticky film on top. The table legs and wheels had a buildup of sticky brown film. The base boards running the perimeter of the floor were dirty and observed to have a sticky brown film. A thick yellow urine like substance, hair and debris were observed on the base of the toilet and a sticky brown film was also observed surrounding the base of the toilet.

During an interview on April 11, 2024, at approximately 12:30 PM, the Nursing Home Administrator (NHA) confirmed that the facility is be maintained in a clean and sanitary manner.


28 Pa. Code 201.18 (e)(1)(2.1) Management

28 Pa. Code 201.29 (a) Resident Rights






 Plan of Correction - To be completed: 05/14/2024

Preparation and/or execution of this plan of correction does not institute an admission or agreement by the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The plan of correction is prepared solely because it is by the provisions of federal and state law. The plan of correction represents the facility's credible allegation of compliance as of May 14, 2024.
F 0584
To address the deficiencies noted: The damaged window blind in room 211 will be replaced and the windowsill, radiator cover and wall along the window wall will be cleaned. The exit door and floor near exit door on A-Hall near rooms 201 and 202 will be cleaned. The green chair with white stains was removed for the West Side Day Room. The hinge on the window in room 213 will be repaired and the damaged window blind replaced. The white shower chair in C-Hall shower room was cleaned. B-Hall shower room light fixtures and floor will be cleaned. Room 215 and bathroom floor, baseboard, over-bed table, toilet and sink will be cleaned.
The facility recognizes that other residents have the potential to be affected. Please see sections 3 and 4 for system changes and monitoring.
The Environmental Services Director, and their staff will be re-educated on the need to provide and maintain a clean, sanitary and orderly environment. The Environmental Service Director will conduct rounds of the facility daily and weekly with the Nursing Home Administrator or designee for 4 weeks and then monthly for 2 months to verify a clean and orderly environment.
The results of the rounds will be reviewed at the monthly Quality Assurance meeting and any concern will be forwarded to the appropriate department manager to address immediately.

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

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

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

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

Based on staff interviews and a review of documentation provided by the facility, it was determined that the facility failed to conduct a facility wide assessment that accurately reflected the personnel and specific resources presently available and to identify those that are necessary to care for its current resident population.

Findings include:

At the time of the survey ending April 12, 2024, the facility had reviewed its facility assessment on June 3, 2023, to determine the specific and unique needs of its resident population and the available and accessible resources to meet these needs on a daily basis and during emergent situations.

The facility provided a facility assessment tool to the survey team on April 11, 2024. There was no documentation on the form that identified and addressed the needs of the locked B unit, Dementia/Memory care unit. The form did not include any focus on the care and needs of the 48 residents with documented diagnosis of Dementia/Alzheimers disease, including the 27 residents residing on the locked dementia unit.

There was no addressed dementia care and dementia care needs of their current resident population in the facility assessment, and identified the available resources for making staffing and operating budget decisions while managing the resident census to ensure that the facility had the necessary staff resources to care for its resident population in a manner that met minimum licensure and certification standards.

The facility assessment presented to the survey team during the survey ending April 12, 2024, did not include updated comprehensive data with respect to its current resident population and updated resources necessary to competently and safely care for the residents in the facility.

Refer F 744

28 Pa. Code 201.14(a) Responsibility of licensee

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













 Plan of Correction - To be completed: 05/14/2024

F 0838
The facility cannot retroactively correct the deficiency cited by the surveyors. The facility assessment will be updated to better identify the needs of the dementia care unit and the residents with a documented diagnosis of dementia.
The facility recognizes that all residents have the potential to be affected by the noted practice. See section 3 and 4 for system changes and monitoring.
The Nursing Home Administrator will continue to review and update the facility assessment quarterly as required and update as needed including any change in need as it relates to the facility's Dementia Care Unit or residents with the diagnosis of Dementia.
The assessment will be reviewed at the quarterly Quality Assurance with the Interdisciplinary team for any recommendations.

483.70 REQUIREMENT Administration: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.
483.70 Administration.
A facility must be administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident.
Observations:


Based on observations, resident and staff interviews and a review of clinical records and water temperature logs it was determined that the facility was not administered in a manner to effectively use its resources to promote safety and physical well-being of residents by failing to ensure safe hot water temperatures on the West Hall A and B unit.

Findings included:


A review of clinical records and water temperature logs, observations, and resident and staff interviews it was determined that the facility failed to maintain an environment free of potential accident hazards by failing to maintain hot water temperatures within a safe range for residents, including Resident 12, 13, and 69, residing on the West Hall A and B unit, placing these 27 residents out of 97 residents residing in the facility in immediate jeopardy due to the potential for serious burns.

According to the U.S. Consumer Product Safety Commission, "most adults will suffer third-degree burns if exposed to 150 degree water for two seconds. Burns will also occur with a six-second exposure to 140 F degree water or with a thirty second exposure to 130 degree water. Even if the temperature is 120 F degrees, a five-minute exposure could result in third-degree burns.

Observation on the A unit, April 10, 2024, at 9:04 AM revealed that the temperature of the hot water in the bathroom sink of resident room 216 was 115.6 Farenheit.

Observation on the A unit, April 10, 2024, at 9:13 AM revealed that the hot water temperature in the facility's West Wing shower room measured 121.5 Farenheit.

Observation on the A unit, April 10, 2024, at 9:24 AM revealed that the hot water temperature at the sink in the bathroom in resident room 210 was 119.9 Farenheit.

During an interview on April 10, 2024, at 9:29 AM, Employee 3, a nurse aide, stated that she took the morning water temperatures earlier this morning, prior to showering residents. She explained that the facility never trained her on the procedure for checking water temperatures prior to showering residents, but she figured out the method on her own. She explained that there is a blue thermometer in the shower stall to measure the water temperature. When asked to demonstrate how she measures and records the water temperature obtained prior to showering residents, Employee 3, nurse aide, was observed looking at the blue thermometer but not placing the thermometer under the flowing water. She stated that the thermometer read 80 degrees Farenheit. She explained that she always makes sure the water is safe by testing it with her hand and asking residents if the water is comfortable. She stated, at the time of this interview, she had just completed Resident 13's shower.

During an interview on April 10, 2024, at 9:33 AM, Employee 4, nurse aide, stated that he was trained to utilize a blue thermometer that was hanging in the shower. He stated that the water shower temperature is then recorded on the temperature log sheet. He stated that he was not aware of a temperature that was too high for the residents to be showered. He explained that he always asks the residents about their comfort with the water temperature and feels the water temperature prior to letting residents shower. During an observation on April 10, 2024, at the same time as the interview, the facility's West Wing shower room water temperature measured 128 Fahrenheit. The measurement was taken by Employee 4, nurse aide.

During a resident group interview on April 10, 2024, at 10:00 AM, Resident 69 stated that when he independently takes showers, the water temperatures fluctuate from hot to cold. He explained that when the water becomes too hot, he points the shower handle away from his body. Resident 69 stated that he may have to wait up to two minutes before the water temperature is comfortable enough to resume showering with the water.

Water temperatures were obtained in the bathrooms of the resident rooms the B unit (locked dementia unit) and common bathing/shower room on April 10, 2024, at approximately 10:30 AM:

Resident rooms 216 & 217 -122.2 degrees Fahrenheit
Resident room 218 (a four bedded room) 122.7 degrees Fahrenheit
Resident room 219/221- 133.8 degrees Fahrenheit
Resident room 223/225--128.8 degrees Fahrenheit
Resident room 224/226--129.7 degrees Fahrenheit
Resident room 220 & 222--119.9 degrees Fahrenheit
Resident room 209 & 211-- 134.6 degrees Fahrenheit
Resident room 227 (a single room) - 127 degrees F, the cold water in the sink did not work at the time of the observation.

Observation in Resident room 227 at this time, revealed Resident 12, who was alert and oriented was attempting to use the sink in her room to wash her hands. The resident confirmed that the cold water did not work but she was "ok" to use just the hot water. The surveyor redirected the resident another area to wash her hands with a safe water temperature at that time or perform hand hygiene.

The B unit resident shower hot water temperature was 124.4 degrees Fahrenheit.

There were 27 residents residing on the B unit locked dementia unit, all who utilized the shower on the unit for bathing and some utilized the sinks in their respective resident rooms.

An observation April 10. 2024 at 9 AM in the resident common shower area on the west hall B unit revealed a clipboard with water shower temperature listings dated March 23, 2024 through April 5 , 2024. The documentation noted that all that all the water shower temperatures were noted to be exactly 100 degrees Fahrenheit.

During an interview on April 10, 2024 at 9 AM Employee 1, a nurse aide, stated that she was routinely scheduled to work in the B unit (locked dementia unit). She stated that the hot water temperature at the sinks in the resident rooms on the unit has been "really hot" for "a while." She stated that the unit shower water was also "really hot". Employee 1 stated that the Director of Nursing (DON) told her to document 100 degrees Fahrenheit for every shower given despite the actual temperature obtained.

During an interview on April 10, 2024 at 9:05 AM, Employee 2, a nurse aide, stated that hot water in the resident room sinks and the common resident shower is "very hot." She stated that the DON instructed her, after taking a shower water temperature, to document (on the designated shower temperature log, located in the shower room) 100 degrees Fahrenheit no matter what the actual temperature reads on the thermometer.

An interview with the Nursing Home Administrator at 1:30 PM on April 10, 2024, revealed that the NHA confirmed that the elevated hot water temperatures obtained and noted above were correct. He also verified that Resident 12 was at risk for burns due to the temperature of the hot water at the sink in the resident's room and the lack of running cold water at the sink at the time of the observation. He further stated that an unknown employee turned the cold water off underneath the sink in Resident 12's room, failed to tell maintenance of any issues, and did not turn the cold water back on for resident use. The NHA was unable to state how long the hot water temperatures were at an unsafe level.

Immediate Jeopardy was called on April 10, 2024, due to the facility's failure to ensure that the environment for the residents on the West unit, the A and B (locked dementia unit) resident hallways was free of potential accident hazards in the form of elevated hot water temperatures.

The job description of the Nursing Home Administrator dated, July 27, 2016, revealed, the primary purpose of the job position is to manage the facility in accordance with the current applicable federal, state and local standards, guidelines and regulations that govern long term care facilities. To follow all facility policies and apply them uniformly to all employees. To ensure the highest degree of quality care is provided to out residents at all times.

The Job Description for Direction of Nursing Services dated, February 23, 2023, revealed the purpose of the director of nursing is to plan, organize, develop and direct the overall operation of the Nursing Service Department in accordance with current federal, state and local standards, guidelines and regulations that govern the facility, and as may be directed by the administrator and the Medical Director, to ensure the highest degree of quality care is maintained at all times.

The deficiency cited under the Code of Federal Regulatory Groups for Long Term Care, Quality of Care (F689) 483.12(a)(1) , revealed that the NHA and DON failed to fulfill the essential job duties for ensuring the safety of the residents and adherence to regulatory guidelines.

Refer F689



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

28 Pa. Code 211.12 (c) Nursing services






 Plan of Correction - To be completed: 05/14/2024

F 0835
The facility cannot retroactively correct the deficiency cited by the surveyors. Once aware of the excessive hot water temperatures the hot water to the affected area was shut off and a plumber called. During the period the hot water was off hand sanitizer and hot water from the unaffected areas were used to meet the resident's needs. The problem was corrected is appox. 4 hours by re-routing the hot water supply from a second water.
The cold water in the sink of room 227 was immediately repaired by replacing a faulty valve stem.
Nursing staff will be re-educated by the facility's Maintenance Director or designee on the proper method of assessing water temperatures prior to washing, bathing and showering a resident to assure accuracy of the temperature to timely identify unsafe hot water temperatures. Random water temperatures throughout the facility will be checked Q-Shift on each hall for 4 weeks and then daily thereafter to assure compliance. Any water temperatures over 110 degrees or any temperature noted to be too cool should be immediately reported to the Nursing Supervisor the Maintenance Director, the Director of Nursing and the Administrator and an immediate decision would be made if shower / bathing should be put on hold or hot water needs to be shut off till temperature is controlled. If water is shut off to an affected area, hand sanitized and hot water from the unaffected area of the facility would be utilized until the water temperature is corrected. The Maintenance Director or designee will report hot water temperatures at the morning daily scheduled IDT meeting to the Administrator and / or the Director of Nursing with any concerns to be immediately addressed. Additionally, the Administrator and/or Director of Nursing will review the water temperature logs weekly for 4 weeks and then monthly for 2 months to verify compliance.
The random water temperature check will be forwarded to the monthly Quality Assurance meeting to review for recommendations.

483.60(d)(4)(5) REQUIREMENT Resident Allergies, Preferences, Substitutes:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
483.60(d) Food and drink
Each resident receives and the facility provides-

483.60(d)(4) Food that accommodates resident allergies, intolerances, and preferences;

483.60(d)(5) Appealing options of similar nutritive value to residents who choose not to eat food that is initially served or who request a different meal choice;
Observations:

Based on observation, a review of facility's planned menus and resident and staff interview it was determined that the facility failed to serve menus that accommodated, to the extent possible, the food preferences of the resident population, to promote acceptance and satisfaction with meals, including three residents of 20 residents reviewed (Resident 69, 80, and 91).

Findings included:

During an interview with Resident 69 on April 9, 2024, at 1:00 p.m., the resident stated that that the food served lacks flavor and the facility menu lacks variety. He reported that he regularly attends food committee meetings and voices his concerns regarding the lack of a varied menu, such as repetitive menu options. Resident 69 stated that the Certified Dietary Manager (CDM) was very understanding and did a good job, but he feels that her "hands are tied" due to budgetary restraints from the facility's corporate staff. Resident 69 stated that the facility's CDM and Registered Dietitian (RD) weren't involved in the development of the menu and that the corporate dietitian develops the menu for multiple long-term care facilities owned by the facility's corporation without considering the resident population in each facility's location, including local and cultural preferences of the residents in each building.

During a group meeting with residents conducted on April 10, 2024, at 10:00 a.m., residents in attendance reported that the facility's menu was very repetitive and that they receive the same types of meals multiple times per week, and even for consecutive meals in a row.

Resident 80 stated that he "was frustrated that the facility does not listen to residents' suggestions about food." Resident 80 stated that the new Spring/Summer menu includes several of the same meals as the Fall/Winter menu. Resident 80 reported that the menu had offered grilled cheese, but the facility doesn't have a grill to properly cook the sandwich and questioned "why would they \ put it on the menu if they don't have the equipment to make the food" here?

Resident 91 stated that the menu included "too much beef and chicken" served.

A review of the facility's regular 4-week menu cycle "Spring/Summer Menu: Week 1 Regular Diet", revealed the following meal patterns:

Sunday lunch the planned meal was meatloaf (ground beef) and at dinner a hot turkey (poultry) sandwich and then on Monday at lunch chicken tenders (poultry) and Monday dinner hamburger on a bun (ground beef).

At the Wednesday dinner, the planned meal was grilled cheese, however the facility had to substitute this meal due to not having the equipment in the kitchen to prepare for the census.

Wednesday dinner was spaghetti and meatballs and lunch on Thursday was Salisbury steak (beef two meals in a row).

A review of "Spring/Summer Menu: Week 2 Regular Diet", revealed the following meal patterns:

Monday dinner was chicken Monterey and Tuesday dinner was herbed turkey; on Wednesday lunch entree was chicken parmesan and a turkey sandwich was served Thursday dinner.

Week 2 Saturday lunch was meatloaf and then on for Sunday week 3 dinner a meatball hoagie (ground beef).

A review of "Spring/Summer Menu: Week 3 Regular Diet", revealed the following meal patterns:

Sunday week 3 lunch orange glazed turkey, and Monday week 3 lunch was BBQ chicken, and for Tuesday dinner a chicken salad sandwich (repeat chicken entree).

Tuesday lunch was hamburger on a bun and then on Wednesday dinner was lasagna and meat sauce (repeat ground beef)

Thursday week 3 dinner was baked macaroni and cheese with stewed tomatoes; Lunch on Friday was cheese pizza (repeat cheese and tomato combination)

A review of "Spring/Summer Menu: Week 4 Regular Diet", revealed the following meal patterns:

Monday week 4 lunch was chicken and biscuits, and Tuesday dinner was a turkey sandwich. Monday Week 4 dinner was beef chili and Tuesday lunch was spaghetti and meatballs (repeat ground beef).

Thursday week 4 lunch was ranch chicken and Saturday lunch was chicken parmesan with penne.

Friday week 4 lunch was baked macaroni and cheese with stewed tomatoes and for Friday dinner a cheese pizza (same menu as the prior Friday).

During an observation of the lunch meal on April 9, 2024, at 12:00 p.m., revealed that the planned dessert for lunch was watermelon. However, mixed fruit cocktail was substituted for watermelon.

During an interview with the CDM on April 9, 2024, at 1:00 p.m., the CDM stated that mixed fruit was substituted due to the cost of watermelon. She stated that the cost of watermelon was $15.00 per melon due to the fruit not being in season and exceeding the facility's food budget.

During an interview with the facility's CDM on April 11, 2024, at 12:45 p.m., the CDM confirmed that the facility's kitchen does not have a grill cooktop to accommodate making a large quantity of grilled cheese sandwiches. The CDM confirmed that the corporate RD creating the menu did not consider the equipment available at the facility or the local culture and preferences of the facility's residents when planning menus.

Interview with the Nursing Home Administrator (NHA) on April 12, 2024, at 10:00 AM, confirmed that the facility failed to develop menus that reflect variety and accommodated resident preferences



28 Pa. Code 211.6 (a) Dietary services

28 Pa. Code 201.18 (a) Resident rights



 Plan of Correction - To be completed: 05/14/2024

F 0806
The facility cannot retroactively correct the deficiency noted by the surveyor.
The facility recognizes that all residents have the potential to be affected by the noted practice. See section 3 and 4 for system changes and monitoring.
The menu/diet will be reviewed by the Corp. Dietitian for possible increase in variety and meeting the resident preferences to the extent possible. A portable stove top griddle will be purchased to accommodate the making of a larger quantity of griddled sandwiches.
The facility's Certified Dietary Manager will review menu changes with residents at the monthly food committee meeting, discuss preferences and document in minutes.
The Nursing Home Administrator with review the food committee meeting minutes and forward them to the monthly QA Committee for review and any concerns will be addressed immediately with the Corp. Dietitian.

483.45(a)(b)(1)-(3) REQUIREMENT Pharmacy Srvcs/Procedures/Pharmacist/Records:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
483.45 Pharmacy Services
The facility must provide routine and emergency drugs and biologicals to its residents, or obtain them under an agreement described in 483.70(g). The facility may permit unlicensed personnel to administer drugs if State law permits, but only under the general supervision of a licensed nurse.

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

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

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

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

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

Based on review of controlled drug records and staff interview, it was determined that the facility failed to implement pharmacy procedures for reconciling controlled drugs and records accounting for their administration for one of 20 residents sampled (Resident 36) .

Finding include:

A review of the clinical record revealed that Resident 36 had a physician order dated January 18, 2024, for Oxycodone (a narcotic opioid pain medication) 10 mg Tablet, one tablet every 6 hours as needed for severe pain 7-10 (a pain scale, 1-10, 1 least pain, 10 most pain).

A review of the controlled substance record accounting for the above narcotic medication revealed that on April 1, 2024, at 12:00 AM, April 1, 2024 at 11:45 AM, April 2, 2024, at 8:30 PM, April 4, 2024 at 11:40 PM, April 5, 2024 at 5:30 PM, April 6, 2024, at 5:30 AM, April 7, 2024, at 5:37 AM, April 8, 2024, at 11:30 AM, and April 8, 2024, at 12:30 PM, nursing staff signed out a dose of the resident's supply of Oxycodone 10 mg . However, the administration of the controlled drug to the resident was not recorded on the resident's Medication Administration Record (MAR) on those dates and times.

A review of Resident 36's MAR for December 2023, revealed nursing signed out 106 doses of the resident's supply of Oxycodone 10 mg. January 2024, MAR revealed 97 doses of Oxycodone 10 mg was signed out. February 2024, MAR revealed 88 doses of Oxycodone 10 mg was signed out. March 2024 from March 1-March 28, 2024, revealed 96 doses of Oxycodone was signed out.

There was no controlled drug narcotic sign out records available at the time of the survey ending April 12, 2024, for the months of December 2023, January 2024, February 2024, and March 1-28, 2024, to reconcile the accounting of the resident's supply of the controlled drug.

During an interview, April 11, 2024, at 1:25 PM the Director of Nursing confirmed the inconsistencies in the accounting and administration of the opioid pain medications for the above resident and confirmed the narcotic drug records were missing for the above months and not available to reconcile with the quantity dispensed for the resident and to verify administration to the resident on those date and times.


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

28 Pa Code 211.9(a)(1)(2)(k) Pharmacy services.

















 Plan of Correction - To be completed: 05/14/2024

F 0755
The facility cannot retroactively correct the deficiency cited by the surveyor related to resident 36.
The facility recognizes other residents prescribed controlled medications have the potential to be affected. Please see sections 3 and 4 for system changes and monitoring.
Licensed Nursing Staff will be re-educated by the Director of Nursing or designee on proper procedure for documenting the administration of a controlled medication both in the electronic Medication Administration Record and Controlled Substance Accountability Count Sheet. The Director of Nursing or designee will conduct randomly daily audits for 4 weeks and then weekly for 2 months to verify compliance.
Audits will be submitted to the Monthly Quality Assurance meeting for review and further recommendations.

483.25(c)(1)-(3) REQUIREMENT Increase/Prevent Decrease in ROM/Mobility:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
483.25(c) Mobility.
483.25(c)(1) The facility must ensure that a resident who enters the facility without limited range of motion does not experience reduction in range of motion unless the resident's clinical condition demonstrates that a reduction in range of motion is unavoidable; and

483.25(c)(2) A resident with limited range of motion receives appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion.

483.25(c)(3) A resident with limited mobility receives appropriate services, equipment, and assistance to maintain or improve mobility with the maximum practicable independence unless a reduction in mobility is demonstrably unavoidable.
Observations:


Based on clinical record review and resident and staff interviews, it was determined that the facility failed to provide restorative nursing services planned to maintain the mobility and functional abilities of one of the 20 residents sampled (Resident 16).

Findings included:

A clinical record review revealed that Resident 16 was admitted to the facility on September 5, 2022, with diagnoses that included end-stage renal disease (final stage of kidney decline where the kidneys are no longer able to function to meet the body's needs).

A review of a quarterly Minimum Data Set assessment (MDS - a federally mandated standardized assessment process conducted periodically to plan resident care) dated February 28, 2024, revealed that Resident 16 is cognitively intact with a BIMS score of 15 (Brief Interview for Mental Status- a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 13-15 indicates cognition is intact).

Resident 16's care plan, initiated July 29, 2019, revealed that the resident had the potential for a decline in ambulatory function and the need for a restorative program. Planned interventions were for the resident for the resident to receive 50 feet of restorative walking with a two-wheeled walker and the assistance of one staff member.

A Physical Therapy Discharge Summary dated March 19, 2024, revealed that Resident 16 reached her maximum potential with skilled therapy services. The discharge recommendation was for the facility to establish a restorative ambulation program to include the resident ambulating 50 feet daily with a two wheeled walker (mobility device) and with the assistance of one staff member. The summary noted that Resident 16 had a good prognosis to maintain her current level of functioning with consistent staff follow-through.

Facility tracking of staff completion of the task of providing the resident's restorative walking dated from March 19, 2024, through April 10, 2024, revealed that Resident 16 refused to be assisted with walking 16 times, participated in the walking five times, and the task was not applicable once.

During an interview on April 9, 2024, at 10:26 AM, Resident 16 stated that staff are not providing her a restorative ambulation program. She stated that the facility staff did not offer or provide her the restorative walking assistance for her walk 50 feet with a two-wheeled walker. The resident stated that she would "like to get stronger and walk more often."

Further review of the facility's tracking of the task of restorative walking task, revealed that on April 9, 2024, at 12:36 PM, Resident 16 declined to attend the restorative nursing program for walking, on April 10, 2024, at 11:44 AM nursing noted that Resident 16 was not available for the program, Resident 16 had a dialysis appointment on April 10, 2024, however, the Resident 16 returned to the facility on 12:38 PM on April 10, 2024.

During an interview on April 11, 2024, at 9:45 AM, Resident 16 stated nursing staff did not offer or provide her restorative nursing program for walking intervention 50 feet with a two-wheeled walker on April 9th or April 10th, 2024, nor did the resident refuse to ambulate on those dates as noted in the task documentation.

During an interview on April 11, 2024, at approximately 13:30 PM, the Nursing Home Administrator (NHA) confirmed that Resident 16 is alert and oriented and aware of her care and should be provided the restorative nursing services planned. The NHA was unable to state why staff were not consistently providing the program and documenting the resident's refusals, when the resident stated that the program was not offered on those dates.





28 Pa. Code: 211.5(f) Medical records

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






 Plan of Correction - To be completed: 05/14/2024

F 0688
The facility cannot retroactively correct the deficiency cited by the surveyor related to resident 16.
The facility recognizes other residents have the potential to be affected and will complete an audit of residents with orders for a restorative program to verify it is being offered and its acceptance or refusal is properly documented.
The Director of Nursing or designee will re-educate nursing staff on the importance of offering and properly documenting the acceptance or refusal. The Director of Nursing or designee will conduct random audits of resident with orders for a restorative program to verify it has been offered to the resident and its acceptance or refusal properly documented weekly for 4 weeks and then monthly for 2 months.
All audits will be reviewed at the monthly QA meeting and any concern will be forwarded to the Director of Nursing.

483.12(c)(2)-(4) REQUIREMENT Investigate/Prevent/Correct Alleged Violation:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must:

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

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

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


Based on review of clinical records and select facility policies and staff interviews, it was determined that the facility failed to thoroughly investigate injuries of unknown origin, bruising, to rule out abuse, neglect or mistreatment as the potential cause for one out of 20 sampled residents (Resident 90).

Findings included:

A review of the facility's policy "Abuse Policy" that was last reviewed by the facility on June 21, 2023, indicated that a timely and thorough investigations of all reports and allegations of abuse to include injuries of unknown origin. An alleged violation of abuse, neglect, exploitation or mistreatment (including injuries of unknown sources, misappropriation of resident property) and reasonable suspicion of a crime resulting in bodily injury will be reported immediately, but not later than two (2) hours if the alleged violation involves abuse OR has resulted in serious bodily injury; or twenty-four (24) if the alleged does not involve abuse AND has not resulted in serious bodily injury.

The facility policy entitled "Accidents and Incidents - Investigating and Reporting" that was last reviewed by the facility on June 21, 2023, indicated that the Nurse Supervisor/Charge Nurse and/or the department director or supervisor shall promptly initiate and document investigation of the accident or incident. The following data shall be included on the Report of Incident/Accident form: the nature of the injury/illness (e.g., bruise); circumstances surrounding the incident; where the accident took place; the name(s) of the witnesses and their accounts of the accident or incident; the time the injured person's Attending Physician was notified, as well as the time the physician responded and his/her instructions; the date and time the injured person's family was notified; the condition of the injured person, including his/her vital signs; any corrective action taken; follow-up information; other pertinent data as necessary or required. The Nurse Supervisor/Charge Nurse and/or the department director or supervisor shall complete a Report of Incident/Accident form and submit the original to the Director of Nursing within 24-hours of the incident or accident.

A review of Resident 90's clinical record revealed that the resident was admitted to the facility on August 31, 2023, with diagnoses that included dysphagia (difficulty swallowing), history of falls, and generalized muscle weakness.

Progress notes completed by Employee 7, a licensed practical nurse (LPN), dated January 22, 2024, at 5:43 p.m., indicated that this nurse \ found bruises on the resident as follows: one on the left hip measuring 17.0 centimeters (cm) by 5.5 cm deep and purple in color, one on the left inner thigh 7.0 cm by 4.0 cm deep purple in color, and one on inner left wrist measuring 1.0 cm by 0.5 cm and was purple in color, and one on left wrist distal from first one 0.9 cm by 2.5 cm. Resident had no recollection on how the bruises formed. The bruises were measured, and RN was made aware. Alarms were placed on resident bed. MD made aware and resident representative (RP) called

At the time of the survey ending April 12, 2024, there was no documented evidence that the facility had investigated the potential origin of Resident 90's bruises to rule out abuse, neglect or mistreatment as the potential cause of the injuries.

During an interview with the Director of Nursing (DON) on April 11, 2024, at 11:25 a.m., revealed that she was unaware of Resident 90's bruises that were identified by Employee 7. The DON confirmed that the facility failed to implement the facility's abuse prevention policy related to investigating the bruising of unknown origin that were found on Resident 90 by Employee 7.





28 Pa. Code 201.29(a)(c)(d) Resident rights

28 Pa. Code 201.14(a) Responsibility of Licensee

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


 Plan of Correction - To be completed: 05/14/2024

F 0610
The facility can't retroactivity correct the deficient practice related to resident #90 as identified by the surveyor.
The facility recognizes that other residents have the potential to be affected. New bruises and skin tears will be assessed initially and as part of the facility's weekly skin assessment which will include color and size of bruise.
Staff will be re-educated by the Director of Nursing or designee on the investigation policy and procedure for injuries or unknown origin. Injuries of unknown origin will be audited at the daily scheduled morning inter-disciplinary meeting to verify the injury was thoroughly investigated to rule out abuse, neglect or mistreatment.
Audits will be reviewed at the monthly facility Quality Assurance Meeting and any concerns will be addressed by the Director of Nursing or designee.

483.21(a)(1)-(3) REQUIREMENT Baseline Care Plan:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.21 Comprehensive Person-Centered Care Planning
483.21(a) Baseline Care Plans
483.21(a)(1) The facility must develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. The baseline care plan must-
(i) Be developed within 48 hours of a resident's admission.
(ii) Include the minimum healthcare information necessary to properly care for a resident including, but not limited to-
(A) Initial goals based on admission orders.
(B) Physician orders.
(C) Dietary orders.
(D) Therapy services.
(E) Social services.
(F) PASARR recommendation, if applicable.

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

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

Based on clinical record review and staff interview it was determined the facility failed to include, in the resident's baseline plan of care, minimum standards of care to fully address the resident's immediate needs upon admission for one resident out 20 sampled (Resident 299).

Findings include:

Review of Resident 299's clinical record revealed that the resident was admitted to the facility on April 2, 2024, with diagnoses to include ischemic cardiomyopathy (the hearts decreased ability to pump blood properly due to heart damage), paroxysmal atrial fibrillation (an irregular, often rapid heart rate that causes poor blood flow), and the presence of an automatic implantable cardiac defibrillator (AICD- is a microcomputer that is implanted under the skin of the upper chest area. It monitors heart rate and delivers therapy in the form of small electrical pulses. An AICD is a permanent device inserted into the right ventricle and typically placed near the collarbone under the skin of the chest).

There was no documented evidence at the time of the survey ending April 12, 2024, that the facility timely identified and addressed the resident's care needs related to the AICD device as an area of focus with interventions to provide AICD checks as ordered or to monitor for signs and symptoms of AICD complications. The facility failed to address the emergency care of the AICD device and actions to be taken if the AICD was activated (i.e., consulting the physician, obtaining vital signs [clinical measurements, specifically pulse rate, temperature, respiration rate, and blood pressure, that indicate the state of a patient's essential body functions] and keeping the resident and staff safe from the electrical shock. The resident should notify staff if a shock is felt, and staff should be aware not to touch resident is being shocked since the shock can be felt)

Interview with the Nursing Home Administrator and Director of Nursing on April 12, 2024, at 9:00 AM confirmed that the facility failed to sufficiently address the care and management of Resident 299's AICD on the resident's baseline plan of care.



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





 Plan of Correction - To be completed: 05/14/2024

F 0655
The facility cannot retroactively correct the deficiency cited by the surveyor related to resident 299. This resident care-plan has been updated.
The facility recognizes other residents have the potential to be affected and will complete an audit of residents admitted within the last 30 days to verify an appropriate baseline plan of care was in place.
The RAI Specialist of designee will re-educate the licensed nursing staff, social service director and clinical care coordinators on developing an appropriate baseline care plan for residents within 48 hours of admission. New admissions will be audited daily at the morning Interdisciplinary Meeting for 4 weeks and then monthly for 2 months to verify an appropriate baseline plan of care is in place.
All audits will be reviewed at the monthly QA meeting for any recommendations.

483.40(b)(3) REQUIREMENT Treatment/Service for Dementia:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.40(b)(3) A resident who displays or is diagnosed with dementia, receives the appropriate treatment and services to attain or maintain his or her highest practicable physical, mental, and psychosocial well-being.
Observations:

Based on a review of clinical records and select facility policy and staff interviews, it was determined that the facility failed to develop and implement individualized plans to manage residents' dementia-related behavioral symptoms to promote resident safety and the residents' highest practicable physical and mental well-being for one resident out of 20 sampled (Resident 14).

Findings include:

A review of facility policy titled "Alzheimer/Dementia Disease," last reviewed by the facility on June 21, 2023, indicated that "Dementia care requires constant adjustments. New challenges arise, meaning that a caregiver must be constantly observant to behavioral changes."

A clinical record review revealed Resident 14 was admitted to the facility on February 23, 2009, with diagnoses to include Alzheimer's disease (a brain disorder that slowly destroys memory and thinking skills and, eventually, the ability to carry out the simplest tasks) and unspecified psychosis (a disturbance in thought and perception disrupting a person's ability to discern reality).

An annual comprehensive Minimum Data Set assessment (MDS - a federally mandated standardized assessment process conducted periodically to plan resident care) dated March 26, 2024 revealed that Resident 14 is moderately cognitively impaired with a BIMS score of 09 (Brief Interview for Mental Status- a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 8-12 moderate cognitive impairment).

Resident 14's care plan, initiated April 11, 2014, indicated that the resident uses psychotropic medications for psychosis with behaviors like yelling at others and false beliefs or repetitive verbalizations of not wanting to go to the hospital. Planned interventions included asking the resident to show her stuffed animal collection, asking the resident what she needs, offering the resident soda, a nap, coloring, and reorientation. The most recent intervention added, June 5, 2023, was that if the resident is exhibiting aggression, attempt a second caregiver; if this continues to be ineffective, staff is to ensure the resident is in a safe position, and re-approach at a later time. The resident's care plan, initiated August 6, 2012, also indicated that the resident has a chronic and progressive decline in intellectual functioning characterized by a deficit in memory, judgment, decision-making, and thought processes related to Alzheimer's disease with interventions of allowing adequate time for resident response, attempting a second caregiver when the resident is upset, and attempting to de-escalate the resident.

A review of the resident's care plan, and progress notes in the clinical record dated during the months of September 2023, November 2023, and April 2024, that the resident displayed physical and aggressive behaviors towards others.

The resident's care plan for physical aggression, however, had not been revised since June 5, 2023, despite the resident's ongoing display of these behaviors, there was no review of the existing currently planned interventions in reducing or managing these behaviors.

A progress note dated November 2, 2023, at 10:36 AM revealed that Resident 14 became aggressive towards a nurse aide when attempting to assist the resident with a transfer and that redirection was effective.

A progress note dated November 9, 2023, at 2:30 PM revealed that Resident 14 kicked and attempted to punch and pinch nurse aides; staff explained to the resident why this behavior was unacceptable.

A progress note dated November 17, 2023, at 2:30 PM revealed that Resident 14 yelled and hit the housekeeper who was cleaning the floor in the resident's room, and redirection and offering coffee were ineffective.

The resident's treatment report record dated February 2024 revealed Resident 14 presented with agitation, paranoia, physical aggression, and/or verbal aggression on February 18, 19, 20, 21, and 22 of 2024. Interventions attempted on February 18, 2024, but were ineffective and the interventions were "not applicable" on February 19, 20, 21, and 22.

There was no additional documentation describing the resident's behavior or the interventions attempted.

A progress note dated March 6, 2024, at 1:54 AM indicated that social services met with Resident 46 to provide education regarding her recent incident of yelling at another resident.

The resident's treatment report dated March 2024 revealed that the resident presented with agitation, paranoia, physical aggression, and/or verbal aggression on March 12, 2024, and no interventions were implemented, and the result was effective. A clinical record review failed to reveal further information describing the resident's behavior.

A progress note dated April 3, 2024, at 6:04 PM indicated that Resident 14 became physically aggressive with staff and punched a nurse and staff provided education to the resident.

Interview on April 11, 2024, at approximately 2:30 PM, with the NHA, failed to provide evidence that facility evaluated the interventions planned, and implemented, through an interdisciplinary team approach, to meet the resident's dementia care needs and in response to the resident's dementia related behavioral symptoms for their continued appropriateness and effectiveness in managing, modifying or limiting the resident's dementia related behavioral symptoms.




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

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







 Plan of Correction - To be completed: 05/14/2024

F 0744
Resident 14's care plan has been updated to identify the specific dementia related behaviors the resident exhibits and individualized interventions to address these behavior.
Residents identified with a diagnosis of dementia with behaviors within the last 30 days will be reviewed to verify that an appropriate care plan has been developed and updated with intervention to address their individual behaviors. Review of Behavior tracking documentation to ensure consistent and accurate monitoring and the effectiveness of the interventions.
Clinical RAI Specialist will re-educate the Clinical Care Coordinator, Social Service Director and Licensed nursing staff on the identification of behaviors and the development and updating of a resident centered care plan with accurate monitoring and tracking of the behavior to ensure the current interventions are effective. Review of instructions for completing the Behavior tracking documentation monitoring tool.
Clinical Care Coordinator or designee will perform random audits weekly for 4 weeks and then monthly for 2 months on care plans to ensure resident centered care (individualized) for behaviors are completed. The Interdisciplinary Team at the daily scheduled morning meeting will verify that a care plan has been developed / updated to manage any ongoing / new behavior and that the corresponding Behavior Monitoring Tool reflects the current behavior and intervention effectiveness documentation.
Audits will be submitted to the Monthly Quality Assurance meeting for review and further recommendations.

483.45(d)(1)-(6) REQUIREMENT Drug Regimen is Free from Unnecessary Drugs:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.45(d) Unnecessary Drugs-General.
Each resident's drug regimen must be free from unnecessary drugs. An unnecessary drug is any drug when used-

483.45(d)(1) In excessive dose (including duplicate drug therapy); or

483.45(d)(2) For excessive duration; or

483.45(d)(3) Without adequate monitoring; or

483.45(d)(4) Without adequate indications for its use; or

483.45(d)(5) In the presence of adverse consequences which indicate the dose should be reduced or discontinued; or

483.45(d)(6) Any combinations of the reasons stated in paragraphs (d)(1) through (5) of this section.
Observations:



Based on a review of clinical records and staff interviews it was determined that the facility failed to ensure that the resident's drug regimen was free of unnecessary antibiotic drugs for one out of 20 residents sampled (Resident 15).

Findings included:

Clinical record review revealed that Resident 15 was admitted to the facility on September 25, 2019, with diagnoses to include dementia, chronic kidney disease stage 3 and was severely, cognitively impaired.

A review of an RN Practitioner assessment of the resident dated March 15, 2024, revealed that a "Chart review indicates \ with multiple UTIs in the past, asked nursing to collect urine and dip is suspicious for UTI sent for U/A C&S (urinalysis and culture and sensitivity), initial urine appears suspicious for infection, collect U/A C&S via straight cath."

The noted plan included "Elevated white blood cell count, no clinical signs of infection, vital signs stable, collect U/A C&S (urinalysis and culture and sensitivity).

The RN practitioner ordered a urinalysis and culture and sensitivity (report to indicate what antibiotic will treat the infection) to rule out a urinary tract infection at that time and ordered Augmentin (an oral antibiotic medication) 500/125 mg, one by mouth twice a day for 5 days for UTI (urinary tract infection) on March 15, 2024.

Nursing documentation dated from March 1, 2024, through March 15, revealed no documentation that the resident was displaying signs or symptoms of a UTI.

A review a nurses note dated March 19, 2024, at 1:31 PM revealed that a new order was noted from the CRNP to discontinue Augmentin, and start Ceftin 250 mg BID x 5 days.

An RN Practitioner assessment dated March 19, 2024, revealed "Examined bedside follow-up, reviewed U/A C&S, mother suspicious of UTI will start Ceftin 250 mg twice daily and encourage fluids."

The CRNP order dated March 19, 2024, was noted for Ceftin 250 (an oral antibiotic) mg twice daily, for 5 days for UTI.

A review of the resident's March 2024 medication administration record (MAR) revealed that Resident 15 received Augmentin 500/125 mg by mouth on March 17th, two doses, March 18th two doses and one dose on March 19th. According to the March 2024 MAR, Augmentin was discontinued on March 19, 2024, and Ceftin 250 mg, by mouth, twice daily was given as prescribed until March 24, 2024 (10 doses).

A review of a culture and sensitivity results dated March 21, 2024, revealed that Resident 15's urine contained greater than 100, 000 colonies/ml Klebsiella pneumonae bacteria. The corresponding sensitivity report did not include the initial antibiotic prescribed for the resident, ( Augmentin ). There was no corresponding prescriber documentation to indicate the rationale for initiating Augmentin, prior to receipt of the results of the C & S, and then discontinuing Augmentin after five doses, then starting Ceftin, prior to receiving the results of the C & S.

Interview with the Director of Nursing on April 12, 2024, at 12:45 PM, confirmed that the administration of Augmentin was not clinically justified for treatment of Resident 15's UTI



28 Pa. Code 211.2 (3) Medical Director

28 Pa. Code 211.9 (k) Pharmacy Services

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

28 Pa. Code 211.5 (f) Medical records










 Plan of Correction - To be completed: 05/14/2024

F 0757
The facility cannot retroactively correct the deficiency cited by the surveyors related to resident 15.
The facility recognizes that all residents have the potential to be affected by the noted practice. See section 3 and 4 for system changes and monitoring.
The facility will re-educated attending physicians and Nurse Practitioners on the facility's Antibiotic Stewardship policy. Any new order for an antibiotic will be audited at the scheduled morning Interdisciplinary Meeting to verify the order is following the facility's Antibiotic Stewardship policy.
Audits will be submitted to the Monthly Quality Assurance meeting for review and further recommendations.

483.45(g)(h)(1)(2) REQUIREMENT Label/Store Drugs and Biologicals:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.45(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 observation, a review of select facility policy and staff interview, it was determined that the facility failed to implement procedures to ensure acceptable storage and use by dates for multi-dose medications on one of two medication storage rooms (Med Room West).

Findings include:

A review of the facility policy titled "Vials and Ampules of Injectable Medications", last reviewed by the facility June 21, 2023, indicate that the purpose is to ensure medications are used in accordance with the manufacturer's recommendations or the provider pharmacy directions for storage, use, and disposal. The beyond use date and initials of the first person to use the vial are recorded on the multidose vials. Medication in multidose vials may be used for twenty-eight days if inspection reveals no problems during that time.

An observation of the medication room on the West Wing on April 10, 2024, at 9:05 AM, in the presence of Employee 6 (RN Supervisor), of medication stored in the medication refrigerator revealed a multi-dose bottle of Aplisol (solution used for screening for tuberculosis) that had been opened and dated November 19, 2023. Review of the manufacturer dosage and administration for Aplisol revealed that vials in use for more than 30 days should be discarded. The current vial was 5 months beyond the manufacturer's recommended discard date.

Further observation of the refrigerator revealed a multi-dose vial of Spikevax (COVID 19 vaccine) opened and dated with a discard date of March 20, 2024, 21 days beyond the discard date.

The above observations were confirmed by Employee 6.

Interview with the Nursing Home Administrator and Director of Nursing on April 12, 2024, at approximately 9:05 AM confirmed that medication expiration/use by dates were to be checked prior to administration and removed from the medication refrigerator upon expiration.


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

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






 Plan of Correction - To be completed: 05/14/2024

F 0761
The Multi-dose bottle of Aplisol and a multi-dose vial Spikevax both opened, dated and beyond their discard date found in the West Wing Medication Room refrigerator have been destroyed.
The facility recognizes that all residents have the potential to be affected by the noted practice. Multi-Dose medications have been checked to assure the medication expiration/use by dates are validate.
Licensed staff will be re-educated by the Director of Nursing or designee on the procedure to ensure acceptable storage and use by dates of multi-dose medications. The Director of Nursing or designee will randomly audit the storage and use by dates of multi-dose medication weekly for 4 weeks and then monthly for 2 months to verify compliance.
Audits will be submitted to the Monthly Quality Assurance meeting for review and further recommendations.

483.75(c)(d)(e)(g)(2)(i)(ii) REQUIREMENT QAPI/QAA Improvement Activities:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.75(c) Program feedback, data systems and monitoring.
A facility must establish and implement written policies and procedures for feedback, data collections systems, and monitoring, including adverse event monitoring. The policies and procedures must include, at a minimum, the following:

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

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

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

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

483.75(d) Program systematic analysis and systemic action.

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

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

483.75(e) Program activities.

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

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

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

483.75(g) Quality assessment and assurance.

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

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

Based on a review of the statement of deficiencies from the survey ending February 15, 2024, it was determined that the facility's Quality Assurance Performance Improvement (QAPI) committee failed to develop and implement corrective action plans to prevent continued quality deficiencies related to ensuring that the facility environment was maintained in a safe, clean, comfortable, and homelike environment.

Findings included:

During an abbreviated complaint survey completed on February 15, 2024, deficient facility practice was identified under the requirement of safe, clean, comfortable, and homelike environment whereas the facility failed to provide housekeeping services to maintain a clean and orderly environment on four of four nursing units (Nursing Hall A, B, C and D).

In response to the deficiency cited during the survey of February 15, 2024, the facility developed a plan of correction to include a quality assurance monitoring component to ensure that solutions were sustained. This plan was to be completed by March 19, 2024, and indicated that the following would be performed:

The areas noted in the resident TV rooms on the East Side and West Sides, A and B Hallways, Rooms 210, 214, and 221 and their bathrooms, C-Hall shower room, A-Hall shower room, Small hole in C-Hall wall, C-Hall green floor molding and stained peeling paint on/ by exit door/frame, stained/discolored chair seat cushion of chairs in C-Hall exit corridor, Room 105, 118, and 119, D-Hall laundry cart cover will be cleaned, painted, repaired or replaced as needed to address the deficiencies noted.

The Environmental Services Director, Maintenance Director and their staff would be re-educated on the need to provide and maintain a clean and orderly environment. Both the Environmental Service Director and Maintenance Director with conduct rounds of the facility with the Nursing Home Administrator or designee weekly for 4 weeks and then monthly for 2 months to verify compliance.

The results of the rounds would be reviewed at the month Quality Assurance meeting and any concern will be forwarded to the appropriate department manager to address immediately.

This corrective active plan was to be in place by March 19, 2024. However, at the time of the revisit survey ending April 12, 2024, revealed that the facility failed to prevent a continuing quality deficiency under this same requirement whereas the facility failed to provide housekeeping services to to maintain a clean and orderly environment on four of the four nursing units (Nursing West A, West B, East C, and East D Hall).

The facility's quality assurance monitoring plan failed to identify ongoing deficient practice with the facility's housekeeping and maintenance of a clean, sanitary and orderly environment.

Refer F584


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



 Plan of Correction - To be completed: 05/14/2024

F 0867
The facility cannot retroactively correct the deficiency cited by the surveyors. The facility will take the necessary steps to correct the areas of concern noted by the surveyors and maintain a clean, sanitary and orderly environment.
The facility recognizes that all residents have the potential to be affected. Please see sections 3 and 4 for system changes and monitoring.
The Environmental Services Director, and their staff will be re-educated on the need to provide and maintain a clean and orderly environment. The Environmental Service Director with conduct rounds of the facility daily and weekly with the Nursing Home Administrator or designee for 4 weeks and then monthly for 2 months to verify a clean and orderly environment.
The results of the rounds will be reviewed at the monthly Quality Assurance meeting and any concern will be forwarded to the appropriate department manager to address immediately.

483.80(a)(3) REQUIREMENT Antibiotic Stewardship Program:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.80(a) Infection prevention and control program.
The facility must establish an infection prevention and control program (IPCP) that must include, at a minimum, the following elements:

483.80(a)(3) An antibiotic stewardship program that includes antibiotic use protocols and a system to monitor antibiotic use.
Observations:


Based on a review of clinical records and the facility's infection control policies and staff interview it was determined that the facility failed to maintain an antibiotic stewardship program that includes a system to effectively monitor antibiotic usage as evidenced by one of 20 sampled residents (Resident 15).

Findings include:

A review of the facility policy for Antibiotic Stewardship, dated as reviewed June 21, 2023, revealed that the plan was designed to facilitate compliance with state and federal regulations relating to infection control and antibiotic stewardship. It is the purpose of the facility Infection Prevention and Control Program is to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of communicable diseases and infections and to improve antibiotic use. The facility adheres to the mission and goals set forth in the infection control plan.

Clinical record review revealed that Resident 15 was admitted to the facility on September 25, 2019, with diagnoses to include dementia, chronic kidney disease stage 3 and was severely, cognitively impaired.

A review of an RN Practitioner assessment of the resident dated March 15, 2024, revealed that a "Chart review indicates \ with multiple UTIs in the past, asked nursing to collect urine and dip is suspicious for UTI sent for U/A C&S (urinalysis and culture and sensitivity), initial urine appears suspicious for infection, collect U/A C&S via straight cath."

The noted plan included "Elevated white blood cell count, no clinical signs of infection, vital signs stable, collect U/A C&S (urinalysis and culture and sensitivity).

The RN practitioner ordered a urinalysis and culture and sensitivity (report to indicate what antibiotic will treat the infection) to rule out a urinary tract infection at that time and ordered Augmentin (an oral antibiotic medication) 500/125 mg, one by mouth twice a day for 5 days for UTI (urinary tract infection) on March 15, 2024.

Nursing documentation dated from March 1, 2024, through March 15, revealed no documentation that the resident was displaying signs or symptoms of a UTI.

A review a nurses note dated March 19, 2024, at 1:31 PM revealed that a new order was noted from the CRNP to discontinue Augmentin, and start Ceftin 250 mg BID x 5 days.

An RN Practitioner assessment dated March 19, 2024, revealed "Examined bedside follow-up, reviewed U/A C&S, mother suspicious of UTI will start Ceftin 250 mg twice daily and encourage fluids."

The CRNP order dated March 19, 2024, was noted for Ceftin 250 (an oral antibiotic) mg twice daily, for 5 days for UTI.

A review of the resident's March 2024 medication administration record (MAR) revealed that Resident 15 received Augmentin 500/125 mg by mouth on March 17th, two doses, March 18th two doses and one dose on March 19th. According to the March 2024 MAR, Augmentin was discontinued on March 19, 2024, and Ceftin 250 mg, by mouth, twice daily was given as prescribed until March 24, 2024 (10 doses).

A review of a culture and sensitivity results dated March 21, 2024, revealed that Resident 15's urine contained greater than 100, 000 colonies/ml Klebsiella pneumonae bacteria. The corresponding sensitivity report did not include the initial antibiotic prescribed for the resident, ( Augmentin ). There was no corresponding prescriber documentation to indicate the rationale for initiating Augmentin, prior to receipt of the results of the C & S, and then discontinuing Augmentin after five doses, then starting Ceftin, prior to receiving the results of the C & S.

There was no evidence at the time of the survey of a functioning antibiotic stewardship program that included antibiotic use protocols and a system to monitor antibiotic use to prevent unnecessary antibiotic use.

During an interview April 11, 2024, at 1 P.M., the Director of Nursing confirmed that the resident received unnecessary doses of antibiotics that was not consistent with antibiotic stewardship.

Refer F757

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

28 Pa. Code 211.2 (d)(8) Medical Director

28 Pa. Code 211.10 (a)(d) Resident Care Policies






















 Plan of Correction - To be completed: 05/14/2024

F 0881
The facility cannot retroactively correct the deficiency cited by the surveyors related to resident 15.
The facility recognizes that all residents have the potential to be affected by the noted practice. See section 3 and 4 for system changes and monitoring.
The facility will re-educate attending physicians and Nurse Practitioners on the facility's Antibiotic Stewardship policy. Any new order for an antibiotic will be audited at the scheduled morning Interdisciplinary Meeting to verify the order is following the facility's Antibiotic Stewardship policy.
Audits will be submitted to the Monthly Quality Assurance meeting for review and further recommendations.

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

Observations:

Based on review of nursing time schedules and staff interviews, it was determined that the facility failed to provide a minimum of one nurse aide per 12 residents during the evening shifts, and one nurse aide per 20 residents during the night shift on 6 of 21 days (February 24, 2024, February 25, 2024, and March 19, 2024, March 21, 2024, April 5, 2024 and April 6, 2024.

Findings include:

Review of facility census data indicated that on February 24, 2024, the facility census was 95, which required 7.92 nurse aides during the day shift.

Review of the nursing time punch detail documentation revealed only 7.13 nurse aides provided care on the day shift on February 24, 2024. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on February 25, 2024, the facility census was 97, which required 8.08 nurse aides during the day shift.

Review of the nursing time schedules and time punch documentation revealed that only 7.78 nurse aides worked on the day shift on February 25 2024. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on March 19, 2024, the facility census was 95, which required 7.92 nurse aides during the evening shift.

Review of the nursing time schedules and time punch documentation revealed 7.63 nurse aides worked on the evening shift on March 19, 2024. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on March 21, 2024, the facility census was 96, which required 8 nurse aides during the evening shift.

Review of the nursing time schedules and time punch documentation revealed 7.94 nurse aides worked on the evening shift on March 21, 2024. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on April 5, 2024, the facility census was 97, which required 8.08 nurse aides during the evening shift.

Review of the nursing time schedules and time punch documentation revealed 6.84 nurse aide worked on the evening shift on April 5, 2024. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on April 6, 2024, the facility census was 97, which required 4.85 nurse aides during the night shift.

Review of the nursing time schedules and time punch documentation revealed 4.09 nurse aide worked on the night shift on April 6, 2024. No additional excess higher-level staff were available to compensate this deficiency.

An interview April 11, 2024, at 1 PM., the Nursing Home Administrator confirmed that the facility did not meet state minimum staffing ratios for nurse aides.






 Plan of Correction - To be completed: 05/14/2024


P 5510
The facility cannot retroactively correct the deficiency cited by the surveyor related to maintaining the required staffing ratio for nurse aides on 6 of 21 days reviewed.
The facility recognizes all residents have the potential to be affected. Please see sections 3 and 4 for system changes and monitoring.
The nursing staff scheduler will be re-educated by the Nursing Home Administrator on the required nurse staffing ratio for nurse aides. Recruitment of nursing staff will continue via facility websites, Indeed, social media websites, local newspaper, job fairs and off site recruiters. Agency will be utilized for open shifts as needed.
Calculation of daily shift ratios will be completed and reviewed daily for accuracy by the scheduler, DON, and NHA. All efforts will be made to meet the staffing ratio. If call offs occur, all efforts will be made to attempt to fill that position.
Daily ratios will be audited weekly for 4 weeks and then monthly for 2 months.
Results will be forwarded to the QA committee monthly for review and recommendations.

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

Based on review of nursing time schedules and staff interviews, it was determined that the facility failed to provide a minimum of one licensed practical nurse (LPN) per 25 residents during the day shift, 1 LPN per 30 residents on the evening shifts, and one LPN per 40 residents during the night shift on two of 21 days (February 26, 2024 and March 15, 2024).

Findings include:

Review of facility census data indicated that on February 26,2024, the facility census was 96, which required 3.84 LPNs during the day shift.

Review of the nursing time schedules and time punch card documentation revealed 3.50 LPNs provided care on February 26, 2024, provided care on the day shift.

No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on March 15, 2024, the facility census was 97, which required 3.88 LPNs on the day shift.

Review of the nursing time schedules and time punch documentation revealed 3.84 LPN worked the day shift on March 15, 2024.

No additional excess higher-level staff were available to compensate this deficiency.

An interview April 11, 2024 at 1 P.M., the Nursing Home Administrator confirmed that the facility did not meet the state minimum nursing ratios for LPNs

















 Plan of Correction - To be completed: 05/14/2024

P 5530

The facility cannot retroactively correct the deficiency cited by the surveyor related to maintaining the required staffing ratio for licensed practical nurses (LPN) on 2 out 21 days reviewed.
The facility recognizes all residents have the potential to be affected. Please see sections 3 and 4 for system changes and monitoring.
The nursing staff scheduler will be re-educated by the Nursing Home Administrator on the required nurse staffing ratio for LPNs. Recruitment of nursing staff will continue via facility websites, Indeed, social media websites, local newspaper, job fairs and off site recruiters. Agency will be utilized for open shifts as needed.
Calculation of daily shift ratios will be completed and reviewed daily for accuracy by the scheduler, DON, and NHA. All efforts will be made to meet the staffing ratio. If call offs occur, all efforts will be made to attempt to fill that position.
Daily ratios will be audited weekly for 4 weeks and then monthly for 2 months.
Results will be forwarded to the QA committee monthly for review and recommendations.

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

Observations:

Based on a review of nurse staffing and resident census and staff interview, it was determined that the facility failed to consistently provide minimum of 2.87 general nursing care hours to each resident daily.

Findings include:

A review of the facility's weekly staffing levels revealed that on the following dates the facility failed to provide minimum nurse staffing of 2.87 hours of general nursing care to each resident:

February 25, 2024 - 2.85 direct care nursing hours per resident
April 5, 2024 - 2.85 direct care nursing hours per resident
April 6, 2024 - 2.82 direct care nursing hours per resident

During an interview on April 11, 2024, at 2:00 p.m. the Nursing Home Administrator confirmed that the facility's nurse staffing was below minimum required hours on the dates noted above.





 Plan of Correction - To be completed: 05/14/2024

P 5630

The facility cannot retroactively correct the deficiency cited by the surveyor related to not maintaining the required PPD on 3 days of days reviewed.
The facility recognizes all residents have the potential to be affected. Please see sections 3 and 4 for system changes and monitoring.
The nursing staff scheduler will be re-educated by the Nursing Home Administrator on the required minimum daily PPD. Recruitment of nursing staff will continue via facility website, Indeed, social media websites, local newspaper, job fairs and off site recruiters. Agency will be utilized for open shifts as needed.
Calculation of daily PPD will be completed and reviewed daily for accuracy by the scheduler, DON, and NHA. All efforts will be made to meet the PPD daily. If call offs occur, all efforts will be made to attempt to fill that position.
Daily PPD will be audited weekly for 4 weeks and then monthly for 2 months.
Results will be forwarded to the QA committee monthly for review and recommendations.


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