Pennsylvania Department of Health
BRYN MAWR VILLAGE
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

BRYN MAWR VILLAGE
Inspection Results For:

There are 109 surveys for this facility. Please select a date to view the survey results.

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


BRYN MAWR VILLAGE - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:

Based on a Medicare/Medicaid Recertification Survey, Civil Rights Compliance Survey, State Licensure Survey and an Abbreviated survey in response to a complaint, completed on May 10, 2024, it was determined that Bryn Mawr Village, was not in compliance with the requirements of 42 CFR part 483, Subpart B, Requirements for Long Term Care Facilities and the 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations related to the health portion of the survey process.

Plan of Correction:

483.25(g)(1)-(3) REQUIREMENT Nutrition/Hydration Status Maintenance:

This is the most serious deficiency although it is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one which places the resident in immediate jeopardy as it has caused (or is likely to cause) serious injury, harm, impairment, or death to a resident receiving care in the facility. Immediate corrective action is necessary when this deficiency is identified.

§483.25(g) Assisted nutrition and hydration.
(Includes naso-gastric and gastrostomy tubes, both percutaneous endoscopic gastrostomy and percutaneous endoscopic jejunostomy, and enteral fluids). Based on a resident's comprehensive assessment, the facility must ensure that a resident-

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

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

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

Plan of Correction - To be completed: 07/01/2024

(1) What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice?

The Resident was immediately reweighed, and the dietician and physician were notified to implement interventions as needed on 5/8/2024.
The resident was reassessed by the physician on 5/9/2024.
The resident was re-interviewed by the dietary manager 5/9/2024 to update preferences related to preferred vegetarian diet.

(2) How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken:

Current facility residents were re-weighed on 5/8/2024 and 5/9/2024. The physician and dietician were notified of any significant changes with interventions implemented if applicable.
Currently facility residents were interviewed by the Certified Dietary Manager on 5/9/2024 to ensure their diet preferences were up-to-date and to ensure their preferences were being honored. An additional audit of the meal tracker system was completed by the Certified Dietary Manager to ensure that orders accurately reflected residents' current preference.
Dietary recommendations for the last 30 days were reviewed on 5/9/2024 to ensure that any recommendations made were implemented.

(3) What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur:

Facility Licensed Nurses received education on starting on 5/8/2024 and was completed on 5/9/2024 from the Director of Nursing regarding the procedures for obtaining resident weights and notifying the physician and dietician of any significant changes, along with implementing dietary recommendations in a timely manner.
Facility clinical staff received education starting on 5/9/2024 and will be completed on 5/9/2024 from Director of Nursing on ensuring that resident meal intake is appropriately monitored and documented.
Facility Dietary Staff received education from the CDM starting on 5/9/2024 and was completed on 5/9/2024 on ensuring that residents are receiving the appropriate diet based on their preferences.
An Ad Hoc QAPI Meeting was held on 5/9/2024 to discuss the events surrounding the resident's weight loss, to identify the root cause, and to initiate improvements to the facility's processes and procedures regarding obtaining weights, communication with the IDT team when significant changes occur, implementing physician/dietician recommendations in a timely manner and ensuring that resident meal preferences are honored.

(4) How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place:

Audits will be conducted as follows: bi-monthly resident interviews by the CDM to ensure that resident food and diet preferences remain up to date; random audits of 5 residents weekly to ensure that food intake is being appropriately monitored and documented.

The Quality Improvement Performance Committee will continue to hold weekly meetings to review and discuss the results of the ongoing quality monitoring. The findings of these quality reviews to be reported to the Quality Assurance/Performance Improvement Committee weekly. Quality Review schedule modified based on findings.

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 observations, interviews with staff, and a review of facility procedures, it was determined that the facility did not ensure that food was stored in accordance with professional standards for food service safety.

Findings include:

Review of facility undated dating and labeling procedure guide revealed that "all items in the refrigerator must be dated and labeled" with a date, use by date, initials, and item name.

An initial tour of the main kitchen was conducted on May 3, 2034, at 8:56 a.m. with the facility Administrator, Employee E1, and Kitchen Supervisor, Employee E3.

Observations revealed that the main cook was not wearing a hair net while cooking in the main kitchen area.

Observations in the main refrigerator revealed all items were dated with one date, March 28, 2024, including defrosted pork loins, cheddar cheese, mozzarella cheese, and yogurt. Interview with the kitchen supervisor, Employee E3 revealed that the day, March 28, 2024, indicated the "open" date.

Further observations revealed that pulled ham was dated May 25, 2024, and the cheese was dated April 1, 2024. Interview with the assistant supervisor revealed that the dated ham and cheese must be "used by" the indicated date.

Interview with the kitchen supervisor, Employee E3, and Administrator at approximately 10:15 a.m. confirmed that the food items stored in the refrigerator were not labeled in accordance with professional standards for food service safety and facility foodservice procedures.

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

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

Plan of Correction - To be completed: 07/01/2024

(1) What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice?

Food not appropriately dated and labeled was immediately disposed of. Staff not wearing the appropriated hair coverings were immediately educated with hair covering initiated as required.

(2) How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken:

An audit of facility food storage areas was conducted by the CDM to ensure that food stored was appropriately labeled and dated with any items being disposed of immediately that did not meet the requirements.

(3) What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur:

Culinary staff educated on the components of this regulation with an emphasis on ensuring that food stored in the facility are appropriately labeled and dated and ensuring that they are wearing the appropriate hair nets and sanitary items while preparing and serving food.

(4) How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place:

CDM/NHA/Designee to conduct random visual audits of facility food storage areas and culinary staff to ensure that food stored in the facility are appropriately labeled and dated and ensuring that they are wearing the appropriate hair nets and sanitary items while preparing and serving food.

Audits to occur 2x a week x4 weeks, 1x a week x4 weeks, 2x a month x2 months, then monthly x2 months.

The findings of these quality monitoring's to be reported to the Quality Assurance/Performance Improvement Committee until monthly and/or until substantial compliance is met. Quality Monitoring schedule modified based on findings.

483.35(d)(7) REQUIREMENT Nurse Aide Peform Review-12 hr/yr In-Service:

This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.

§483.35(d)(7) Regular in-service education.
The facility must complete a performance review of every nurse aide at least once every 12 months, and must provide regular in-service education based on the outcome of these reviews. In-service training must comply with the requirements of §483.95(g).

Observations:

Based on the review of facility documentation, review of personnel files and interview with staff, it was determined that the facility did not ensure that a nurse aide had a minimum of 12-hour annual training to ensure continuing competence as required for five of five employees reviewed. (Employee E15, E16, E17, E18 and E19)

Finding include:

A request was made to the facility Nursing Home Administrator and Director of Nursing for annual training records for five nursing assistants, Employees E15, E16, E17, E18 and E19 on May 8, 2024, at 10:15 a.m.

Facility did not submit training records for Employees E15, E16, E17, E18 and E19.

Interview with the facility Administrator on May 8, 2024, at 1:30 p.m. confirmed that the facility did not track, and complete annual in-service as required by the training requirements for nursing assistants.

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

28 Pa. 211.12(c) Nursing services

Plan of Correction - To be completed: 07/01/2024

(1) What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice?

No residents have been found to be affected by the facilities allegedly deficient practice related to employee education.

(2) How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken.

An audit of current CNAs employed by the facility was conducted by the HR Director to ensure that annual evaluations were completed as directed with any deficiencies identified corrected immediately.

(3) What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur:

The NHA educated the DON/HR director on the components of this regulation with an emphasis on ensuring that CNA evaluations are being completed annually as required.

(4) How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place:

The NHA/Designee to conducted employee file audits of CNAs to ensure that they have received an annual performance evaluation as required.

Audits to occur 2x a month x6 months.

The findings of these quality monitoring's to be reported to the Quality Assurance/Performance Improvement Committee until monthly and/or until substantial compliance is met. Quality Monitoring schedule modified based on findings.

483.10(h)(1)-(3)(i)(ii) REQUIREMENT Personal Privacy/Confidentiality of Records:

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

§483.10(h) Privacy and Confidentiality.
The resident has a right to personal privacy and confidentiality of his or her personal and medical records.

§483.10(h)(l) Personal privacy includes accommodations, medical treatment, written and telephone communications, personal care, visits, and meetings of family and resident groups, but this does not require the facility to provide a private room for each resident.

§483.10(h)(2) The facility must respect the residents right to personal privacy, including the right to privacy in his or her oral (that is, spoken), written, and electronic communications, including the right to send and promptly receive unopened mail and other letters, packages and other materials delivered to the facility for the resident, including those delivered through a means other than a postal service.

§483.10(h)(3) The resident has a right to secure and confidential personal and medical records.
(i) The resident has the right to refuse the release of personal and medical records except as provided at §483.70(i)(2) or other applicable federal or state laws.
(ii) The facility must allow representatives of the Office of the State Long-Term Care Ombudsman to examine a resident's medical, social, and administrative records in accordance with State law.

Observations:

Based on observation, interview with staff, and review of facility policy, it was determined that the facility failed to maintain confidentiality of residents' medical records and provide privacy to a resident during incontinence care for two of 12 residents reviewed (Resident R30 and R41).

Findings include:

Review of facility policy titled, "HIPPA Training Program" revised 2007, revealed that the facility staff must ensure the confidentiality if residents protected information.

Interview with Resident R22's Power of Attorney (POA), on May 6, 2024, at 1:39 p.m. revealed that she had requested her mother's Resident R22's, medical records on March 27, 2024. On March 28, 2024, she had received her mothers' medical records which contained Resident R30's medical information. Resident R22's POA provided pictures of Resident R30's protected health information to the surveyor, in the conference room.

Review of facility documentation titled, "Disclosure/release of prohibited health information" and interview with the Medical Records Staff, Employee E4, confirmed that Resident R22's medical records were received by Resident R22's POA on March 28, 2024. Further interview revealed that Resident R30's medical records must have "accidentally passed on to Resident R22's POA" because she did not review the packet to ensure only
[Resident R22's] medical information was being released.

Observations on the CE nursing unit, conducted on April 3, 2024, at 1:32 p.m. revealed Employee E5 was providing incontinence care to Resident R41 and had the room door fully open, exposing the resident. The Director of Nursing, Employee E2, confirmed this finding immediately.

28 Pa. code: 211.5(b) Clinical records.

28 Pa. Code: 201.29(i) Resident Rights

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

Plan of Correction - To be completed: 07/01/2024

(1) What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice?

The affected resident was interviewed by the Social Services Director to ensure there were no undesired outcomes related to the alleged violation of their dignity by facility staff.

The facility is unable to retroactively correct the alleged deficiency related the medical chart.

(2) How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken:

The Social Services Director/Designee will interview current residents and/or their representative to ensure there has been no violation of their dignity while in the facility.

Medical Records Clerk/Designee will audit the last 30 days of Medical Records requests to ensure that records provided follow HIPPA regulations.

(3) What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur:

Facility staff will be educated by the DON/Designee on the components of this regulation with an emphasis on ensuring that residents' dignity is maintained while providing care.

Medical records will be educated by the NHA/Designee on ensuring the medical records provided to other entities are within the guidelines of HIPPA regulations.

(4) How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place:

The NHA/DON/Designee will conduct random visual audits of 5 staff members while providing care to ensure that the residents' dignity is being maintained.

The Social Services Director/Designee will conduct 3 random resident and/or representative interviews to ensure that their dignity has been maintained while in the facility.

The NHA/Designee will review medical record requests to ensure that they meet HIPPA regulations before being delivered to the requesting party.

Audits to occur 2x a week x4 weeks, 1x a week x4 weeks, 2x a month x2 months, then monthly x2 months.

The findings of these quality monitoring's to be reported to the Quality Assurance/Performance Improvement Committee until monthly and/or until substantial compliance is met. Quality Monitoring schedule modified based on findings.

483.25 REQUIREMENT Quality of Care:

§ 483.25 Quality of care
Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices.

Observations:

Based on review of facility policies, clinical record review and interviews with staff, it was determined that the facility failed to follow the physician orders related to weekly weights for one of 13 residents reviewed (Residents R37).

Findings include:

Review of facility policy titled, Weight Assessment and Intervention, revised September 2008, revealed that "the multidisciplinary team will strive to prevent, monitor, and intervene for undesirable weight loss" for residents. Nursing will measure resident weights weekly for two weeks on admission.

Review of physician orders for Resident R37 revealed an order dated, April 27, 2024, for "weekly weights x 4 weeks; in the morning every Friday."

Review of Resident R37's clinical records revealed the last registered weight of 170.5 pounds on April 26, 2024.

Interview with the Registered Dietitian, Employee E6, on May 7, 2024, at 2:07 p.m. confirmed that there were no further documented weights for Resident R37. Further interview revealed that after immediately reweighing Resident R37 on May 7, 2024, his weight registered 157 pounds. Employee E6 confirmed that the resident experienced a significant weight loss of 8% in eleven days (13.5 pounds).

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

Plan of Correction - To be completed: 07/01/2024

(1) What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice?

Resident was immediately weighed per physicians' orders and information was reported to the physician for follow up orders. Resident was assessed by the dietician with new interventions implemented.

(2) How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken:

An audit was performed of current residents to ensure that prescribed weights are being completed and that follow up assessments were completed if indicated.

(3) What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur:

Licensed Nurses educated on the components of this regulation with an emphasis on ensuring that weights are obtained as ordered and that follow as occurred as indicated.

(4) How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place:

DON/Designee to conduct audits of 5 residents' medical records to ensure that resident weights are being obtained as ordered and that appropriate follow up has occurred as indicated.

Audits to occur 2x a week x4 weeks, 1x a week x4 weeks, 2x a month x2 months, then monthly x2 months.

The findings of these quality monitoring's to be reported to the Quality Assurance/Performance Improvement Committee until monthly and/or until substantial compliance is met. Quality Monitoring schedule modified based on findings.

483.25(b)(2)(i)(ii) REQUIREMENT Foot Care:

§483.25(b)(2) Foot care.
To ensure that residents receive proper treatment and care to maintain mobility and good foot health, the facility must:
(i) Provide foot care and treatment, in accordance with professional standards of practice, including to prevent complications from the resident's medical condition(s) and
(ii) If necessary, assist the resident in making appointments with a qualified person, and arranging for transportation to and from such appointments.

Observations:

Based on review of facility policies, review of clinical records, observations and resident, resident representative and staff interviews, it was determined that the facility failed to ensure that foot care needs were provided timely for one of 13 residents reviewed (Resident R38).

Findings include:

Review of care plan for Resident R38 dated April 3, 2024, revealed that the resident required assistance for Activities of Daily Living functions.

Observation of Resident R38 on May 3, 2024 at 10:33 a.m., revealed that the resident had long and thick toenails on both feet. Resident R38's representative statedat the time of the observation that he asked staff to consult a podiatrist at least five times but no response was received.

Interview with Director of Nursing (DON) on May 7, 2024 at 12:00 p.m. confirmed that resident's toe nails were long and a podiatrist should have consulted. He also confirmed that there was no appointment made for Resident R38. DON also stated facility had a podiatry service physician that comes into the building as needed and for emergency.

Review of progress note for Resident R38 dated May 7 2024, revealed that "Resident observed with grossly long toe nails. Request sent to podiatrist for podiatry services. No injury or skin break down observed."

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

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

Plan of Correction - To be completed: 07/01/2024

(1) What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice?

A Podiatry consult was set up for the residents identified in the 2567 to address foot care concerns.

(2) How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken.

Current facility residents were assessed by the DON/Designee to ensure that foot care was provided to include toenail care and ensure that follow ups were made to podiatry if needed.

(3) What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur:

Current clinical staff will be educated by the DON/Designee on the components of this regulation with an emphasis on ensuring that foot care is being provided including follow ups with podiatry as needed.

(4) How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place:

The DON/Designee will conduct random visual audits of 5 residents to ensure that foot care has been provided as required and to ensure that consults have been made to podiatry as needed with follow up provided.

Audits to occur 2x a week x4 weeks, 1x a week x4 weeks, 2x a month x2 months, then monthly x2 months.

The findings of these quality monitoring's to be reported to the Quality Assurance/Performance Improvement Committee until monthly and/or until substantial compliance is met. Quality Monitoring schedule modified based on findings.

483.30(a)(1)(2) REQUIREMENT Resident's Care Supervised by a Physician:

§483.30 Physician Services
A physician must personally approve in writing a recommendation that an individual be admitted to a facility. Each resident must remain under the care of a physician. A physician, physician assistant, nurse practitioner, or clinical nurse specialist must provide orders for the resident's immediate care and needs.

§483.30(a) Physician Supervision.
The facility must ensure that-

§483.30(a)(1) The medical care of each resident is supervised by a physician;

§483.30(a)(2) Another physician supervises the medical care of residents when their attending physician is unavailable.

Observations:

Based on clinical record review, facility policy and interviews with staff, it was determined that the facility did not ensure that a physician assessment was completed related to unplanned weight loss for one of 3 residents with weight loss reviewed (Resident R21).

Findings include:

Review of facility policy "Weight Assessment and Intervention" dated September 2008, revealed that "Weight Assessment The nursing staff will measure resident weights on admission, the next day, and weekly for two weeks thereafter.

The threshold for significant unplanned and undesired weight loss will be based on the following criteria [where percentage of body weight loss = (usual weight- actual weight) (usual weight) x 100):
1 month -5% weight loss is significant; greater than 5% is severe a.
3 months =7.5% weight loss is significant; greater than 7.5% is severe.
6 months - 10% weight loss is significant; greater than 10% is severe.

The Physician and the multidisciplinary team will identify conditions and medications that may be causing anorexia, weight loss or increasing the risk of weight loss."

Review of weight assessment for Resident R20 dated November 1, 2023, revealed that the resident weighed 132 .6 pounds.

Review of weight assessment for Resident R20 dated November 28, 2023, revealed that the resident weighed 119.0 pounds which was 10.25 % weight loss in a month (severe weight loss)

Review of a reweight assessment for Resident R20 dated December 1, 2023, revealed that the resident weighed 115.0 pounds which was 13.27 % weight loss in a month (severe weight loss)

Review of weight assessment for Resident R20 dated January 2, 2024, revealed that the resident weighed 107.0 pounds which was 6.95 % weight loss in a month and 18.9 % in three months (severe weight loss)

There were no monthly weighs available for the month of February 2024.

Review of weight assessment for Resident R20 dated March 29, 2024, revealed that the resident weighed 91 pounds which was 13.33 % weight loss from the last weight of January 5, 2024. and 31.5 % in six months (severe weight loss)

Review of weight assessment for Resident R20 dated April 24, 2024, revealed that the resident weighed 88.8 pounds which was 2.41 % weight loss from the last weight of March 29, 2024. and 33.03 % in six months (severe weight loss).

Review of dietician weight change note dated January53, 2024, in response to a weight on January 5, 2024, revealed that the weight loss was confirmed. Resident on cardiac diet, vegetarian. Dietician recommended to liberalize the diet and discontinue cardiac diet. Recommended to start house shake (protein supplement) once daily, magic cup (protein supplement) once daily and weekly weights for monitoring. It was also revealed that it was recommended to notify the physician of the weight loss.

Review of clinical record for the month of January 2023 revealed that the physician was not notified and an assessment was not completed.

Review of dietician weight change note dated April 28, 2024, in response to a weight on April 24, 2024, revealed that resident lost significant weight and weighed 88.8 pounds. Weight loss continued, recommended to add boost breeze, requested to add percentage consumed for the supplements for monitoring. It was also revealed that it was recommended to notify the physician of the weight loss.

Review of clinical record for May 2024 revealed that the physician was not notified as recommended by the dietician as of May 3, 2024.

Interview with Physician for Resident R20, on May 7, 2024, at 2:00 p.m. stated she was not aware of Resident R20's weight loss. She also confirmed that there was no assessment was completed for Resident R21 in response to weight losses.

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

28 Pa. Code:211.2(a) Physician services.

28 Pa. Code 211.5(f) Clinical records

Plan of Correction - To be completed: 07/01/2024

(1) What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice?

The resident identified in the statement of deficiencies was immediately assessed by the physician in relation to unplanned weight loss.

(2) How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken.

An audit was conducted of current facility residents by the DON/Designee to identify if there were concerns related to weight loss that needed to be assessed by the physician.

(3) What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur:

The facility's Medical Director and rounding practitioners were educated by the DON on the components of this regulation with an emphasis on ensuring that residents with weight loss concerns are seen by the physician and that the weight loss has been addressed.

(4) How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place:

The Director of Nursing/Designee to conduct audits of residents with identified loss to ensure that they have been seen by the physician and that their weight loss has been assessed with appropriate follow up as required.

Audits to occur 2x a week x4 weeks, 1x a week x4 weeks, 2x a month x2 months, then monthly x2 months.

The findings of these quality monitoring's to be reported to the Quality Assurance/Performance Improvement Committee until monthly and/or until substantial compliance is met. Quality Monitoring schedule modified based on findings.

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

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

§483.45(h) Storage of Drugs and Biologicals

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

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

Observations:

Based on observation, staff interviews, and review of facility policy, it was determined that the facility failed to ensure that all drugs and biologicals used in the facility were stored in accordance with professional standards for one of one medication storage rooms observed (first floor cart A and second floor medication storage room).

Findings include:

Observation of the facility east medication storage room on May 6, 2024, at 10:14 a.m., revealed that the storage room was open. The door had a lock, but it was left unlocked.

Observation inside the medication storage room revealed that there was a medication refrigerator with medications. The refrigerator had metal hooks for locks, but the lock was missing.

Interview with Employee E11, Licensed Practical Nurse, on May 6, 2024, at 10:14 a.m. confirmed that the medication storage room and the refrigerator was unlocked.

28 Pa. Code 201.14(a) Responsibility of licensee

28 Pa. Code. 211.12(c) Nursing services

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

Plan of Correction - To be completed: 07/01/2024

(1) What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice?

The med room was immediately locked, and a lock was installed on the med room refrigerator.

(2) How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken.

An audit of facility refrigerators and cabinets that store drugs and biologicals was conducted by the DON to ensure that they were locked per regulation.

(3) What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur:

Licensed staff was educated by the DON/Designee on the components of this regulation with an emphasis on ensuring that areas designated for drug and biological storage are locked as required per regulation.

(4) How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place:

The DON/Designee to conduct random visual audits of facility drug storage areas to ensure that they are locked per regulation at all times.

Audits to occur 2x a week x4 weeks, 1x a week x4 weeks, 2x a month x2 months, then monthly x2 months.

The findings of these quality monitoring's to be reported to the Quality Assurance/Performance Improvement Committee until monthly and/or until substantial compliance is met. Quality Monitoring schedule modified based on findings.

483.60(c)(1)-(7) REQUIREMENT Menus Meet Resident Nds/Prep in Adv/Followed:

§483.60(c) Menus and nutritional adequacy.
Menus must-

§483.60(c)(1) Meet the nutritional needs of residents in accordance with established national guidelines.;

§483.60(c)(2) Be prepared in advance;

§483.60(c)(3) Be followed;

§483.60(c)(4) Reflect, based on a facility's reasonable efforts, the religious, cultural and ethnic needs of the resident population, as well as input received from residents and resident groups;

§483.60(c)(5) Be updated periodically;

§483.60(c)(6) Be reviewed by the facility's dietitian or other clinically qualified nutrition professional for nutritional adequacy; and

§483.60(c)(7) Nothing in this paragraph should be construed to limit the resident's right to make personal dietary choices.

Observations:

Based on observations, review of the facility's planned written menus, menu extensions, and facility policy, and staff interviews, it was determined that the facility failed to follow approved vegetarian diet to ensure nutritional adequacy for one of 13 residents reviewed. (Resident R21)

Findings included:

Review of an undated facility policy "Vegetarian Diet" revealed that, "The vegetarian Diet accommodates the food preference of the individuals avoiding certain animal food in their diet.

Upon admission, the nursing will submit a Tray Card Slip to the dietary department denoting the physician's order for vegetarian diet. The patient will be placed on a vegetarian diet."

Review of facility documentation revealed that the facility had a vegetarian extension of the cycle menu.

Review of an admission nutritional assessment dated October 13, 2024, revealed that the resident was on a vegetarian and on a cardiac diet. Resident weighed 132 pounds with a BMI of 20.7, with an estimated calorie need of 2000-2200 kcal 63-83 g of protein.

Interview with Food Service Director, Employee E13, on May 7, 2024, at 3:11 p.m. stated he was aware that the resident was on a vegetarian diet. He stated kitchen made vegetarian dishes like salads, vegetable burgers as available in the kitchen. He stated she was not aware of a vegetarian menu extension which has been approved by a dietician based on appropriate nutritional needs. Employee E13 stated he was not sure how much calorie intake the resident had or had no documentation of what kind of food the resident received for the past 4 months. Employee E13 confirmed that the facility did not follow the approved vegetarian menu.

Interview with Regional Food Service Staff, Employee E14, on May 8, 2024, at 12:00 p.m. stated facility had approved vegetarian menu extension. The Food Service Director, Employee E13 indicated during interview that she did not know how to assess the vegetarian extension electronically and as a result the vegetarian menu extension was not followed.

28 Pa. Code 211.6 (a) Dietary services.

28 Pa. Code 201.18 (e)(2)(3) Management

Plan of Correction - To be completed: 07/01/2024

(1) What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice?

A vegetarian menu was obtained and provided to dietary staff.

(2) How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken:

An audit of current residents will be conducted by the CDM/Designee to ensure that diets are being provided based on their preference and that menus are available for residents to view.

(3) What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur:

Dietary staff were educated by the RCDM on referencing the vegetarian menu to ensure that meals provided to residents with vegetarian restrictions are accurate.

(4) How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place:

CDM and Administrator will audit the vegetarian menu to ensure it is posted in a conspicuous area in the kitchen and that staff are referencing the menu during the tray line to ensure accuracy.

Audits to occur 2x a week x4 weeks, 1x a week x4 weeks, 2x a month x2 months, then monthly x2 months.

The findings of these quality monitoring's to be reported to the Quality Assurance/Performance Improvement Committee until monthly and/or until substantial compliance is met. Quality Monitoring schedule modified based on findings.

483.60(d)(4)(5) REQUIREMENT Resident Allergies, Preferences, Substitutes:

§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 review of facility documentation, observations, and staff interviews, it was determined that the facility failed to provide food that accommodates resident allergies, intolerances, and preferences for one of 13 residents reviewed. (Resident R37)

Findings Include:

Review of Resident R37's admission nutrition assessment dated April 7, 2024, revealed that the resident had a lactose allergy and intolerance to lactose.

Review of physician orders dated April 18, 2024, revealed an order for "lactose intolerance, no milk."

Further review of resident's nutrition assessment dated May 2, 2024, revealed that Resident R37 had a lactose allergy and intolerance.

Further review revealed an order dated May 2, 2024, for "fortified foods one time a day for nutritional supplement Super Cereal."

Interview with Resident R37 and his wife, on May 3, 2024, at 2:07 p.m. revealed that "Resident R37 cannot tolerate a single dairy product." Further interview revealed that the resident had requested a nutritional supplement, Boost Breeze (fruit flavored clear nutritional supplement) to avoid dairy.

Interview with the Registered Dietitian, Employee E6, conducted on May 7, 2024, at 2:07 p.m. revealed the fortified cereal contains oatmeal, dry milk, whole milk, butter, brown sugar, water, and salt.

Interview with Resident R37 on May 7, 2024, at 2:30 p.m. confirmed that the resident has been receiving and consuming the fortified cereal each morning.

28 Pa. Code: 211.6(a)(c) Dietary service

28 Pa. Code 201.29(j) Resident rights

Plan of Correction - To be completed: 07/01/2024

(1) What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice?

CDM interviewed resident and spouse and they clarified that he cannot tolerate drinking milk but can tolerate it as an ingredient in a prepared food.

(2) How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken:

A review of current residents' preferences was conducted by the CDM to ensure that meal tickets accurately reflect their preferences.

(3) What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur:

The CDM was educated on the components of this regulation with an emphasis on ensuring that resident preferences are identified and that their meal ticket accurately reflect their preferences.

(4) How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place:

Nursing Home Administrator/CDM will conduct audits random resident interviews and visual audits of meal tickets to ensure that resident preferences are accurate.

Audits to occur 2x a week x4 weeks, 1x a week x4 weeks, 2x a month x2 months, then monthly x2 months.

The findings of these quality monitoring's to be reported to the Quality Assurance/Performance Improvement Committee until monthly and/or until substantial compliance is met. Quality Monitoring schedule modified based on findings.

483.60(e)(1)(2) REQUIREMENT Therapeutic Diet Prescribed by Physician:

§483.60(e) Therapeutic Diets
§483.60(e)(1) Therapeutic diets must be prescribed by the attending physician.

§483.60(e)(2) The attending physician may delegate to a registered or licensed dietitian the task of prescribing a resident's diet, including a therapeutic diet, to the extent allowed by State law.

Observations:

Based on review of facility policy, review of clinical record, observations, and staff and resident interviews, it was determined that the facility failed provide food items consistent with the prescribed diet order for two of 10 residents observed during dining (Resident R25, R14).

Findings Include:

Review of facility policy, Therapeutic Diets, undated, revealed that 'therapeutic diets are prepared and served as ordered by the attending physician."

Review of physician orders for Resident R25 confirmed an order dated, October 14, 2022, for "health shake three times a day" and "double portions" dated August 24, 2024.

Observations during dining, on May 6, 2024, at 12:57 p.m. revealed Resident R25's meal ticket indicated that the resident was ordered to receive "double portions" and a "mighty shake" supplement. Observations revealed resident was not served a double portion lunch meal which consisted of ham, and a mighty shake supplement.

Review of physician orders for Resident 14 confirmed an order dated October 14, 2022, for a "Health Shake."

Observation of dining, on May 6, 2024, at 12:57 p.m. revealed that Resident R14's meal ticket indicated, "magic cup" which was not provided on her meal tray.

Interview with Licensed Practical Nurse, Employee E11, on May 6, 2024, at 1:15 p.m. confirmed the above-mentioned findings.

Follow-up dining observations on May 7, 2024, at approximately 12:30 p.m. revealed that Resident R25 and Resident R14 did not receive a mighty shake according to their meal ticket and physician diet order. Interview with Licensed practical Nurse, Employee E11, and Unit Manager, Employee E12, at 12:45 p.m. confirmed this finding.

28 Pa. Code 211.6 (a) Dietary Services

Plan of Correction - To be completed: 07/01/2024

(1) What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice?

CDM amended the meal ticket and removed the mighty shake from ticket as it is not delivered together with the meal. Test tray audit was conducted to ensure that residents were receiving double portions and mighty shakes at the prescribed time.

(2) How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken:

A review of current residents' preferences was conducted by the CDM to ensure that meal tickets are accurate and reflect the current physician prescribed diet order.

(3) What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur:

CDM was educated on the components of this regulation with an emphasis on ensuring that residents are receiving the appropriate physician ordered diet and that their meal ticket is accurate.

(4) How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place:

CDM/Designee to conduct random audits to ensure that residents are receiving the appropriate physician ordered diet and that their meal ticket is accurate based on their preferences.

Audits to occur 2x a week x4 weeks, 1x a week x4 weeks, 2x a month x2 months, then monthly x2 months.

The findings of these quality monitoring's to be reported to the Quality Assurance/Performance Improvement Committee until monthly and/or until substantial compliance is met. Quality Monitoring schedule modified based on findings.

483.70 REQUIREMENT Administration:

§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.

Plan of Correction - To be completed: 07/01/2024

(1) What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice?

Resident #20 was weighed, assessed by the physician and dietician and vegetarian diet was implemented as requested by the resident.

(2) How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken.

An audit was conducted of current residents to by the DON/Designee to ensure that weights are current and that they have been assessed by the physician and dietician with interventions initiated and to ensure that the residents are receiving the appropriate diet based on their preferences.

(3) What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur:

The NHA/DON were educated on the components of this regulation with an emphasis on effectively managing the facility and ensuring that residents are provided with nutritional interventions, timely nutritional assessments, notification to the resident's physician of the resident's weight loss, and that residents are provided an appropriate diet based on their preferences.

(4) How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place:

The RDO/RDCO/Designee to conduct random audits of facility management and resident records to ensure that the DON/NHA/Facility staff are appropriately managing the facility related to residents weights, timely nutritional assessments and interventions, physician notification and residents diet preferences.

Audits to occur 1x a week x6 months.

The findings of these quality monitoring's to be reported to the Quality Assurance/Performance Improvement Committee until monthly and/or until substantial compliance is met. Quality Monitoring schedule modified based on findings.

§ 211.12(f.1)(2) LICENSURE Nursing services. :

(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 a review of nursing schedules, staffing information provided by the facility, and staff interviews, it was determined that the facility failed to ensure a minimum of one nurse aide (NA) per 12 residents on the day shift and one nurse aide per 20 residents on night for three of 21 days. (May 1, 2024; December 24, 2023; December 26, 2023)

Findings Include:

Review of facility census data indicated that on December 24, 2023, the facility census was 33, which required 2.75 (33 residents divided by 12 nurse aids) NA's during the day shift. Review of the nursing time schedules revealed 2.00 NA's provided care on the day shift on December 24, 2024. No additional excess higher-level staff were available to compensate for this deficiency.

Review of facility census data indicated that on December 26, 2023, the facility census was 31, which required 2.58 (31 residents divided by 12 nurse aids) NA's during the day shift. Review of the nursing time schedules revealed 2.00 NA's provided care on the day shift on December 26, 2024. No additional excess higher-level staff were available to compensate for this deficiency.

Review of facility census data indicated that on May 1, 2024, the facility census was 41, which required 3.05 (41 residents divided by 20) NA's during the night shift. Review of the nursing time schedules revealed 2.00 NA's provided care on the night shift on May 1, 2024. No additional excess higher-level staff were available to compensate for this deficiency.

This information was confirmed by the facility Administrator on May 13, 2024, at 9:52 a.m.

Plan of Correction - To be completed: 07/01/2024

On 6/14/2024, the Director of Nursing will conduct an audit of current residents to ensure that there were no negative outcomes related to the facility's alleged deficiency of insufficient staffing.
On 6/7/2024 the Staffing Coordinator and Director of Nursing were educated by the Nursing Home Administrator on the components of this regulation with an emphasis on ensuring that the facility is appropriately staffed according to state minimum requirements, including staffing to ratio for CNAs and Licensed Nurses.
The Nursing Home Administrator/Designee will audit Daily Schedules and Staffing Ratios 3x a week x 3 months to ensure that ratios have been met. If any deficiencies are noted, the facility will utilize the appropriate resources available to ensure appropriate staffing.
The findings of these quality monitoring's to be reported to the Quality Assurance/Performance Improvement Committee monthly.

§ 211.12(f.1)(4) LICENSURE Nursing services. :

(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 staff schedules, punch reports and interviews with staff, it was determined that the facility failed to maintain required staffing ratios, including one LPN (Licensed Practical Nurse) per 25 residents during the day shift, and one LPN (Licensed Practical Nurse) per 30 residents during the evening shift, on three of twenty-one days reviewed (December 25, 2023, through December 27, 2023).

Findings include:

Review of facility census data revealed that o December 27, 2023, the facility census was 31, which required 9.92 hours of LPN's during the day shift. Review of the nursing time schedules, and punch reports revealed 8.00 hours of LPN care was provided during the shift. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data revealed that on December 25, 2023, the facility census was 26, which required 9.60 hours of LPNs during the evening shift. Review of nursing time schedules and punch reports revealed 8.00 hours of LPN care was provided during the shift. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data revealed that on December 26, 2023, the facility census was 31, which required 8.27 hours of LPNs during the evening shift. Review of nursing time schedules and punch reports revealed 0.00 hours of LPN care was provided during the shift. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data revealed that on December 27, 2023, the facility census was 31, which required 8.27 hours of LPNs during the evening shift. Review of nursing time schedules and punch reports revealed 1.00 hours of LPN care was provided during the shift. No additional excess higher-level staff were available to compensate this deficiency.

This information was confirmed by the Administrator on May 13, 2024, at 9:52 a.m.

28 Pa Code 211.12(f)(e) Nursing services

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