Pennsylvania Department of Health
MID-VALLEY HEALTH CARE CENTER
Patient Care Inspection Results

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
MID-VALLEY HEALTH CARE CENTER
Inspection Results For:

There are  65 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.
MID-VALLEY HEALTH CARE CENTER - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on a revisit survey and abbreviated complaint survey completed on January 17, 2024, it was determined that Mid Valley Health Care Center, faile to correct the deficiencies cited during the survey of November 9, 2023, and continued to be out of compliance with the following requirements of 42 CFR Part 483 Subpart B Requirements for Long Term Care Facilities, and the 28 PA Code Commonwealth of Pennsylvania Long Term Care Licensure Regulations.





 Plan of Correction:


483.25(b)(1)(i)(ii) REQUIREMENT Treatment/Svcs to Prevent/Heal Pressure Ulcer:This is a more serious deficiency but is isolated to the fewest number of residents, staff, or occurrences. This deficiency results in a negative outcome that has negatively affected the resident's ability to achieve his/her highest functional status.
§483.25(b) Skin Integrity
§483.25(b)(1) Pressure ulcers.
Based on the comprehensive assessment of a resident, the facility must ensure that-
(i) A resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable; and
(ii) A resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing.
Observations:

Based on review of clinical records and select reports and staff interviews it was determined that the facility failed to consistently monitor a resident's skin integrity during use of a therapeutic device to prevent the development of multiple unstageable pressure sores and a Stage II pressure sore, for one resident (Resident 1) and failed to provide timely and necessary care to prevent the development of bilateral heel pressure sores, deep tissue injuries, for one resident (Resident 2) at risk for pressure sores out of three residents sampled.

Findings include:

According to the US Department of Health and Human Services, Agency for Healthcare Research & Quality, the pressure ulcer best practice bundle incorporates three critical components in preventing pressure ulcers: Comprehensive skin assessment, Standardized pressure ulcer risk assessment and care planning and implementation to address the areas of risk.

The American College of Physicians (ACP) is a national organization of internists, who specialize in the diagnosis, treatment, and care of adults. The largest medical-specialty organization and second-largest physician group in the United States) Clinical Practice Guidelines indicate that the treatment of pressure ulcers should involve multiple tactics aimed at alleviating the conditions contributing to ulcer development (i.e. support surfaces, repositioning and nutritional support); protecting the wound from contamination and creating and maintaining a clean wound environment; promoting tissue healing via local wound applications, debridement and wound cleansing; using adjunctive therapies; and considering possible surgical repair.

A review of the clinical record revealed that Resident 1 was most recently admitted to the facility on October 26, 2023, with diagnoses that included dementia, diabetes and after care for a fractured left tibia.

Admission physician orders dated October 26, 2023, included an immobilizer brace to the resident's left lower extremity at all times, which staff may remove for hygeine and skin checks every shift.

An MDS Assessment (Minimum Data Set assessment - a federally mandated standardized assessment process conducted at specific intervals to plan resident care) dated October 30, 2023, revealed that the resident was severely cognitively impaired, dependent on staff assistance for bed mobility, transfers, dressing, personal hygiene, and toilet use and was at risk for pressure sore development.

Resident 1's care plan initiated October 27, 2023, revealed that the resident was at risk for skin breakdown related to decreased mobility, weakness, diagnosis of diabetes and an immobilizer in place to the resident's left lower extremity. The planned interventions were for nursing staff to assess the resident for increased edema when giving care, provide diet as ordered, incontinence products per routine and as needed, a pressure reducing surface to the resident's bed and chair, provide/assist/encourage resident to turn in bed frequently and prn (as needed), and to float heels intermittently as the resident allows.

A nursing note dated October 27, 2023 at 9:31 PM revealed that the resident sustained an abrasion to the right inner ankle caused by bumping the immobilizer on left lower extremity. The RN assessed the abrasion on the resident's right inner ankle and treatment as provided. The immobilizer was padded to prevent further incident. The physician was updated and a referral made to Physical Therapy for evaluation of the immobilizer brace.

When reviewed at the time of the survey ending January 17, 2024, there was no documented evidence that physical therapy had evaluated the resident's use of the immobilizer brace as noted following the abrasion to the resident's right ankle on October 27, 2023.

Nursing noted on November 14, 2023, at 10:40 P.M. that three new pressure injuries were found on the resident's left lower leg under the immobilizer. Nursing noted that the resident was anxious with frequent moaning and calling out. Evidence of pain was noted to the resident's right foot, left lower legion, with verbal signs of pain noted. The resident's daughter was present when the new pressure injuries to left lower leg were found under the immobilizer. Wound care was provided and the physician was notified and a treatment was ordered. There was no nursing assessment of the three new pressure sores documented at the time of identification to include size and appearance.

A review a "skin and wound" note dated November 15, 2023, at 11:50 AM revealed three pressure areas were found under Resident 1's left leg immobilizer/brace:

-area #1, an unstageable pressure area on the left medial leg measuring 3 cm x 1.5 cm x 0.1 cm, covered in 100% slough ( dead skin, yellow/white in color) with scant amount of serous (Serous drainage is a clear to yellow fluid that leaks out of a wound with tissue damage) and a faint odor;
-area #2, an unstageable pressure area on the left posterior lower leg, measuring 3.5 cm x 2 cm , covered in 100% eschar (Eschar, dead tissue that sheds or falls off from the skin. It ' s commonly seen with pressure ulcer wounds. Eschar is typically tan, brown, or black, and may be crusty); and
-area #3, a stage 2 pressure area on the left posterior ankle measuring 2.5 cm x 2.5 cm x 0.1 cm with scant serous drainage.

A review of a treatment administration record for October 2023 and November 2023 revealed nursing staff documented, once a shift, that the resident wore the Immobilizer Brace to Left Lower Extremity for the closed fracture of the left tibia at all times and that it may be removed for hygiene and skin checks, every shift, since October 26, 2023.

However, there was no documented evidence at the time of the survey ending January 17, 2024, that prior to the development of the multiple pressure areas that nursing staff had consistently removed the left lower leg brace to inspect the resident's skin to timely identify skin impairments and prevent the development of the unstageable and stage 2 pressure sores under the brace.

A review of facility provided information indicated that the root cause for the development of the pressure area was "an ill fitting" immobilizer had been provided to the resident prior to admission to the facility for her fractured left leg.

There was no evidence at the time of the survey that the facility's therapy staff had assessed the resident's use of the immobilizer after the initial right ankle abrasion on October 27, 2023. .

During an interview on January 17, 2024 at approximately 2 PM the Nursing Home Administrator confirmed that the facility did not have evidence that nursing staff had removed Resident 1's immobilizer to conduct skin checks prior to the discovery of the three pressure areas on November 15, 2023. The NHA also confirmed that therapy had not conducted the evaluation of the resident's use of the brace as noted on October 27, 2023.

Clinical record review revealed that Resident 2 was admitted to the facility on January 2, 2024, with diagnoses of dementia and hypertension.

A physician order was noted upon admission, dated January 2, 2024, to elevate the resident's heels off the bed, as tolerated, every shift for preventative measures to prevent skin breakdown.

The resident's care plan noted that the resident was at risk for skin breakdown related to decreased mobility and weakness dated January 3, 2024, with interventions to keep the resident's skin clean and dry, monitor for skin breakdown and pressure reducing surface to bed and chair. The care plan did not specifically identify the physician order to elevate the resident's heels off the bed as tolerated, dated January 2, 2024.

An MDS assessment dated January 8, 2024, revealed that Resident 2 was cognitively impaired, required staff assistance for activities of daily living including transfers and bed mobility and was at risk for the development of pressure areas.

A review of the resident's January 2024 TAR (treatment administration record) revealed that nursing staff documented completion of the task of elevating the resident's feet daily during each shift of nursing duty.

A change in condition note dated January 10, 2024 at 02:59 AM revealed that "The Change In Condition/s reported on this CIC Evaluation are/were: Change in skin color or condition,
Noted drainage of right heel, blister of bottom of heel opened,with clear drainage noted. Area cleansed and a dressing applied."

There was no documented evidence at the time of the survey ending January 17, 2024, of any additional nursing assessment, including the size of the pressure area documented in the resident's clinical record at the time of change in condition on January 10, 2024.

A wound and skin note dated January 12, 2024, at 04:15 AM revealed that the resident had developed an additional pressure sore on the left heel. "Pressure, a blister located on the left planter area of the foot (incorrect area noted in this entry, the pressure sore was actually located on the resident's left heel) measuring 0.3 cm x 0.4 cm, in house acquired. Wound bed appearance is pink, area is noted as a blood blister. The physician was contacted and a treatment as well as apply heel bows while in bed ordered. Skin impairment was not present on admission."

During an interview January 17, 2024 at 11 AM the Director of Nursing confirmed that the wound and skin note was incorrect, as it noted that the Wound Location was the left plantar area of left foot and verified at the time of the interview that the pressure sore was a left heel blood blister.

A review of a wound note dated January 12, 2024, at 07:51 AM revealed that on assessment, DTIs (deep tissue injuries) were noted to the resident's bilateral heels.

Location:
-LEFT HEEL Pressure, DTI, 2.5 cm x 2 cm x 0 cm. Calculated area is 5 sq cm.
Wound Base: Localized area of maroon intact skin
Wound Edges: Attached
Periwound: Intact
- RIGHT LATERAL HEEL
Pressure Stage/Severity: DTI
Wound Status: New
Size: 3 cm x 4 cm x 0.1 cm.
Wound Base: 1-24% epithelial , Localized area maroon skin - small opening with epithelial tissue exposed
Wound Edges: Attached
Periwound: Intact
Exudate: Scant amount of Serous

A review of a facility investigation report dated January 12, 2024, at 9:40 A.M. revealed that on January 10, 2024, a change in condition was completed for the identified blood blister to the resident's right heel that had opened and was draining serous fluid. The immediate action taken by the facility was that the nurse completed the change in condition form on January 10, 2024, notified the physician of the identified area and received an order for a treatment.

An interdisciplinary meeting note dated January 12, 2024, revealed that the entry was status post identification of the area to resident's right heel on January 10, 2024, and the left heel on January 12, 2024. On January 10, 2024 a change in condition was completed for a blood blister to the right heel that opened and was draining serous fluid. On January 12, 2024, a report was completed for a blister on the left heel. Nursing noted an intact blister to the left "plantar" area measuring 0.3 cm x 0.4 cm. The wound care nurse practioner was in the facility and assessed both heels and documented that both were deep tissue injuries.

The facility failed to demonstrate the timely and consistent implementation of specific measures designed to prevent pressure sores on the resident's heels.

Interview with the Director of Nursing on January 17, 2024, at approximately 2:10 PM, confirmed that preventative interventions were not timely and consistently implemented to prevent the development of the bilateral heel pressure areas for a resident at risk for skin breakdown.



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

28 Pa. Code 211.5 (f) Medical records












 Plan of Correction - To be completed: 02/06/2024

1. Unable to correct for resident #1
Resident # 2 wound assessments were updated to reflect the most recent assessment of wound and care plan is updated with current interventions
2. To identify other residents that have the potential to be affected, the DON/designee completed a 2 week look back of all new identified skin issues to ensure measurements are completed timely, accurate and if intervention was a therapy screen that is was completed
To identify other residents that have the potential to be affected, the DON/designee reviewed all residents' physician orders to ensure any skin prevention orders area care planned
To identify other residents that have the potential to be affected, the DON/designee completed an audit of all resident ordered a therapeutic device to ensure skin integrity is monitored consistently
3. To prevent this from reoccurring, the DON/designee educated licensed nursing staff on when a new wound is identified, a wound assessment needs to be completed timely and accurately and any interventions that were placed need to be followed up on and completed
To prevent this from reoccurring, the DON/designee educated licensed nursing on ensuring any skin preventions orders from the MD are placed on care plan
To prevent this from reoccurring, the DON/designee educated nursing staff on ensuring they are consistently monitoring skin integrity on residents with therapeutic devices
4. To monitor and maintaining ongoing compliance, the DON/designee will audit nursing progress notes and Incident reports weekly x 4 then monthly x2 to ensure any identified new wounds have accurate and timely assessments, interventions recommended are completed
To monitor and maintain ongoing compliance, the DON/designee will audit MD orders weekly x 4 then monthly x 2 to ensure any new skin preventative orders are care planned
To monitor and maintain ongoing compliance, the DON/designee will audit residents with therapeutic devices to ensure there is documentation of consistent skin integrity monitoring weekly x4 then monthly x 2
5. The results of the audits will be forwarded to the facility QAPI meeting for further review and recommendations

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 select facility policy 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 two of five residents sampled (Resident 3 and 4) .

Finding include:

A review of the clinical record revealed that Resident 3 had a physician order dated January 13, 2023, for Oxycodone (a narcotic opioid pain medication) 5 mg Tablet, 2 tablets every 4 hours, as needed for severe pain, pain scale 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 December 20, 2023, at 8:30 P.M, December 21, 2023, at 4 P.M, December 21, 2023, at 8 P.M., December 22, 2023, at 5 P.M., December 23, 2023, at 5 P.M., nursing staff signed out a dose of the resident's supply of Oxycodone 5 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 a November 2023 MAR revealed that nursing signed out a dose of Resident 3's supply of Oxycodone 5 mg according to the MAR on the following dates:

-November 18, 2023 at 11:50 A.M., November 19, 2023 at 07:56 A.M., November 25, 2023 at 08:03 A.M. and November 26, 2023 at 08:31 A.M.
--October 1, 2023 at 8 A.M., October 1, 2023 at 12:20 P.M., October 3, 2023 at 8:08 A.M., October 3, 2023 at 1:30 P.M., October 4, 2023 at 5:50 P.M., October 5, 2023 at 4 P.M., October 5, 2023 at 9:30 P.M., October 10, 2023 at 8 A.M and October 10, 2023 at 1 P.M.
--September 16, 2023 at 8 A.M., September 16, 2023 at 12:15 P.M., September 17, 2023 at 07:59 A.M., September 17, 2023 at 12:27 P.M., September 19, 2023 at 8:30 A.M., September 19, 2023 at 1:30 P.M., September 25, 2023 at 8:17 A.M.
--August 5, 2023 at 08:01 A.M., August 5, 2023 at 12:25 P.M., August 6, 2023 at 07:39 A.M., August 6, 2023 at 1:05 P.M., August 8, 2023 at 07:36 A.M., August 8, 2023 at 1:01 P.M., August 10, 2023 at 4:43 P.M., August 15, 2023 at 08:31 A.M., August 16, 2023 at 08:08 A.M., August 16, 2023 at 1:31 P.M., August 17, 2023 at 5 P.M., August 17, 2023 at 9:01 P.M., August 22, 2023 at 1 P.M., August 24, 2023 at 08:11 A.M., August 24, 2023 at 1 P.M., August 29, 2023 at 07:51 A.M., August 29, 2023 at 1:04 P.M., August 30, 2023 at 3:20 P.M.

There were no narcotic sign out records available at the time of the survey ending January 29, 2024, for the months of August 2023, September 2023, October 2023 and November 2023 to reconcile the accounting of the resident's supply of the controlled drug.

According to the Medication Administration Records, Employee 1, LPN administered all the doses of Resident 3's prn Oxycodone 5 mg during August 2023, September 2023, October 2023 and November 2023 MARS

During an interview, January 17, 2024, at approximately 2 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.

A review of a facility investigation report dated January 9, 2024, at 3 P.M. revealed that on this date and time during shift to shift narcotic count, the day shift RN and the evening shift RN had noticed that one pill from Resident 4's supply of the medication Lacosamide ( a controlled substance, for seizure treatment) 200 mg pills was missing from the from the card and the nursing staff made the Director of Nursing (DON) aware.

The DON visualized the controlled substance utilization record as well as the physical card of Lacosamide 200 mg. On the bubble pack in slot 25 there was no pill visible. Bubble packets 26, 27 and 28 were visibly removed and accounted for on the controlled substance utilization record. The remaining pockets were visualized and all pills accounted for. The DON contacted the pharmacy and spoke to the pharmacist to notify them of the incident. The missing pill was identified as a Pharmacy fill error.

A review of a pharmacy order invoice revealed that Lacosamide 200 mg by mouth, give one tablet twice daily for seizures. The form indicated that 27 pills were dispensed and delivered to the facility.

During an interview January 17, 2024, at 2:15 P.M., the DON confirmed the Pharmacy error and that the licensed nursing staff receiving the controlled medications did not
ensure the correct count of the controlled meds upon receipt of the meds at the facility. He also confirmed that licensed nurses completing the shift to shift count of the meds did not ensure all the medications were in the card.


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: 02/06/2024

1. Unable to documentation for PRN narcotic documentation on MAR. Unable to locate narcotic utilization records for identified months for resident #3
Unable to correct narcotic utilization record for resident #4
2. To identify other residents that have the potential to be affected, the DON/designee reviewed 72 hours of MAR to narcotic utilization record to identify any omissions on the MAR
To prevent this from reoccurring, the DON/designee will audit current residents who received a narcotic from pharmacy in last month to ensure utilization record if completed, the record is available to review
To identify other residents that have the potential to be affected, the DON/designee reviewed last week of narcotic medications received from pharmacy to ensure they received the same amount as pharmacy invoice dispensed and all pills are accounted for
3. To prevent this from reoccurring, the DON/designee educated licensed nurses to ensure all narcotic medications signed on utilization record are signed off in MAR
To prevent this from reoccurring, the DON/designee educated licensed nursing staff on ensuring the completed narcotic utilization record is given to the DON and is then uploaded to the documents portion of the medical record
To prevent this from reoccurring, the DON/designee educated licensed nursing staff on ensuring when they receive narcotics from the pharmacy, they are removed from the bag immediately, compare the amount of pills in the package to the invoice sheet, then document amount of the narcotic utilization record, sign and date
4. To monitor and maintain ongoing compliance, the DON/designee will audit 5 random residents weekly x 4 then monthly x 2 to ensure any narcotic medications signed off on utilization record are documented in MAR
To monitor and maintain ongoing compliance, the DON/designee will review completed narcotic utilization records weekly x 4 then monthly x 2 to make sure any completed records are uploaded to the medical record
To monitor and maintain ongoing compliance, the DON/designee reviewed narcotic delivery invoices weekly x 4 then monthly x 2 to ensure narcotic utilization record matches invoice and amount of pills in blister pack
5. The results of the audits will be forwarded to the facility QAPI committee for further review and recommendations

483.12 REQUIREMENT Free from Misappropriation/Exploitation: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
The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms.
Observations:

Based on a review of the facility's abuse prohibition policy, select investigative reports, clinical records, and staff interview, it was determined that the facility failed to ensure that one resident was free from misappropriation of resident property, medications, out of five residents sampled (Resident 3).

Findings included:

A review of the facility's abuse prohibition policy last reviewed by the facility August 30, 2023, revealed that the facility will not tolerate abuse, neglect, mistreatment, exploitation of residents, and misappropriation of resident property by anyone. Misappropriation is the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a residents' belongings or money without the resident's consent.

A review of the clinical record review revealed that Resident 3 was admitted to the facility on January 13, 2023, with diagnoses which include hypertension and peripheral vascular disease. The resident was cognitively intact with a BIMS score of 14.

The resident had a physician order initially dated January 13, 2023, for Oxycodone (a narcotic opioid pain medication) 5 mg, two tablets by mouth every 4 hours, as needed, for severe pain.


On December 27, 2023, at approximately 7 PM the Director of Nursing was notified that a medication card containing 30 oxycodone 10 mg tablets belonging to Resident 3 was missing, along with the narcotic count sheet for that controlled drug dispensed for Resident 3.

The pharmacy, physician, and the resident were made aware. The DEA, local police and the Area Agency on Aging were notified. The facility reimbursed the resident for the missing medication, noting that the facility would pay for the new drugs being delivered to the facility. The facility was obtaining staff statements and conducting drug testing of individuals that may have had access to the medication carts.

At the current time the facility discovered the missing medication, the facility implemented the following to prevent recurrence of a similar episode of misappropriation of property:

To identify like residents that have the potential to be affected the RN supervisor/designee counted all the narcotics in the medication carts and completed a cycle count of narcotics in the Omnicell (emergency medication supply), manifestation sheets going back 7 days to ensure all narcotics delivered to the facility were accounted for, interviewed capable residents to ensure they are receiving their pain medication and have no pain, incapable residents who receive pain medication were observed for signs and symptoms of pain. Education is being completed on the following: current staff on the abuse policy, with focus on misappropriation, on the chain of custody of receiving narcotics, and on the shift to shift count form.

To monitor for ongoing compliance the following will occur:
-interview 5 random capable residents weekly x 4 then monthly x 2 to ensure they are receiving their pain medication, observe 5 random incapable residents weekly x 4 then monthly x 2 to
ensure residents who receive pain medication have no s/s of pain, audit the chain of custody documentation weekly x 4 then monthly x 2 to ensure the process is in place and being followed, and Audit the shift to shift count sheet weekly x 4 then monthly x 2 to ensure the form is filled out correctly to prevent drug diversions. Department of State will be updated. PB 22 investigation to follow.

A local detective was in facility on January 2, 2024 to conduct investigation and interview staff. The Detective left facility to conduct interview with Employye 1 (LPN) at police headquarters where Employee 1 (LPN) confessed to stealing the resident's medications. A police report was pending completion. This LPN did have drug testing on file upon hire and was not noted to be or reported by staff to have shown signs or symptoms of intoxication during working hours. Employee 1 (LPN) was terminated by facility. A report with Department of State was submitted to reflect the updated information including LPN's confession. DEA representative to be in the facility on January 3, 2024.

A review of Employee 1's emailed to the facility statement dated December 28, 2023, at 11:26 AM revealed that the nurse stated "I worked short hall on December 25, 2023, from 7 AM to 3 PM. I do not recall seeing 10 mg card oxycodone for 9 w (Resident 3). There were 19 cards at the beginning of my shift. The sheet said 20 (cards of narcotics) due to a paper (narcotic record sign out sheet) that was zero' d out (all the pills adminstered from the card) on another shift by the ADON (assistant Director of Nursing) that was left in the (narcotic) book. When I counted the cards, I never changed the 20 (cards of narcotics) to 19 (cards of narcotics) before my shift ended. Five cards were taken out for a hospitalized resident and I zero' d out one card on my shift. There were 13 cards at the end of my shift."

Employee 1 (LPN) subsequently confessed to taking the oxycodone 10 mg care and the narcotic utilization record during an interview with the local police on January 2, 2024.

Upon conclusion of the facility's investigation, Employee 1 was terminated for misappropriation of Resident 3's narcotic medication oxycodone.

An interview with the NHA on January 19, 2023, at approximately 11:30 AM confirmed the facility failed to ensure all residents were free from misappropriation of resident property, dispensed medications.

This deficiency is cited as past non-compliance.

The facility's corrective action plan included the following:

To identify like residents that have the potential to be affected,

-"The DON/designee reviewed manifestation sheets going back 7 days to ensure all narcotic delivered to the facility were accounted for
- The DON/designee interviewed capable residents who receive narcotic medication to ensure they are receiving their pain medication and have no pain.
-to identify like residents that have the potential to be affected incapable residents who receive pain medication were observed for signs/symptoms of pain
-the facility will develop and implement appropriate plans of action to correct deficiencies and regularly review and analyze data, including data collected under the QAPI program and data specifically related to controlled substance reconciliation.
-The DON/designee educated current staff on the abuse policy, with focus on misappropriation, the chain of custody of receiving narcotics, educate licensed nurses on shift to shift count form
-facility corporation staff will educate the Nursing Home Administrator and interdisciplinary team and Quality Assurance Performance Improvement (QAPI) Committee to ensure the facility's Quality Assurance Improvement Program, and its participants, implement effective systems to correct deficiencies.
-the DON/designee will interview 5 random capable residents weekly x 4 then monthly x 2 to ensure residents are receiving their pin medications
-DON/designee will observe 5 random incapable residents weekly x 4 then monthly x 2 to ensure residents who receive pain medication have no signs/symptoms of pain
-the DON/designee will audit the chain of custody documentation, the shift to shift count sheet, weekly x 4 then monthly x 2 to ensure the process is in place and being followed.
-the DON/designee will interview 5 employees on the abuse policy weekly x 4 then monthly x 2 with focus on misappropriation
-the NHA/designee will audit ad hoc QAPI plans weekly x 4 then monthly x 2 related to pharmacy services (accountability of controlled substances), the results of the auditing and ongoing monitoring reviewed at the Quality Assurance Performance Improvement meetings will be reviewed by the corporate regional vice president of operation to ensure adequate implementation of QAPI plans to maintain ongoing compliance.

This plan was completed by January 11, 2024.


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

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

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





 Plan of Correction - To be completed: 02/05/2024

Past noncompliance: no plan of correction required.
§ 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 7 of 7 days (January 10, 2024, January 11, 2024, Janaury 12, 2024, Janaury 13, 2024, January 14, 2024, January 15, 2024 and January 16, 2024).

Findings include:

Review of facility census data indicated that on January 10, 2024, the facility census was 37, which required 3.08 nurse aides during the day and evening shift.

Review of the nursing time punch detail documentation revealed three nurse aides provided care on the day shift on January 10, 2024. No additional excess higher-level staff were available to compensate this deficiency.

Review of the nursing time schedules and time punch documentation revealed 2.5 nurse aides provided care on the evening shift on January 10, 2024. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on January 11, 2024, the facility census was 37, which required 3.08 nurse aides during the evening shift.

Review of the nursing time schedules and time punch documentation revealed that 2.5 nurse aides worked on the evening shift on January 11 2024. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on January 12, 2024, the facility census was 38, which required 3.16 nurse aides during the evening shift.

Review of the nursing time schedules and time punch documentation revealed 3 nurse aides worked on the evening shift on January 12, 2024. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on January 13, 2024, the facility census was 38, which required 3.16 nurse aides during the day and evening shift.

Review of the nursing time schedules and time punch documentation revealed 3 nurse aides worked on the day shift on January 13, 2024. No additional excess higher-level staff were available to compensate this deficiency.

Review of the nursing time schedules and time punch documentation revealed 2.5 nurse aide worked on the evening shift on January 13, 2024. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on January 14, 2024, the facility census was 38, which required 3.16 nurse aides during the day and evening shift.

Review of the nursing time schedules and time punch documentation revealed 3 nurse aides worked on the day shift and .94 nurse aides worked on the evening shift on January 14, 2024. No additional excess higher-level staff were available to compensate this deficiency.

Review of the nursing time schedules and time punch documentation revealed 2.5 nurse aides worked on the night shift on January 14, 2024. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on January 15, 2024, the facility census was 38, which required 3.16 nurse aides during the day and evening shift.

Review of the nursing time schedules and time punch documentation revealed 3 nurse aides worked on the day shift and 3 nurse aides worked on the evening shift on January 15, 2024. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on January 16, 2024, the facility census was 38, which required 3.16 nurse aides during the day shift.

Review of the nursing time schedules and time punch documentation revealed 3 nurse aides worked on the day shift on January 16, 2024. No additional excess higher-level staff were available to compensate this deficiency.

An interview January 17, 2024 at 2 P.M., the Nursing Home Administrator confirmed that the facility did not meet state minimum staffing for nurse aides.







 Plan of Correction - To be completed: 02/06/2024

1. The Facility cannot retroactively correct the staffing hours on the cited dates. A review of the Residents on those dates demonstrated there were no negative outcomes experience by the Residents related to staffing.
2. The facility cannot retroactively correct past nurse staffing issues. Moving forward the Facility will continue to schedule staff in accordance with the mandated requirements and make a good faith effort to utilize internal and external resources in the event of unforeseen staffing requirement deficits
3. To prevent reoccurrence, the CQS/designee will educate the DON and NHA on the importance of staffing the facility according to regulations and policy.
4. To monitor and maintain on-going compliance, The NHA/designee will audit the direct care staffing ratios weekly times 4 weeks, then monthly times 2 months to ensure regulatory compliance, results of the audits will be forwarded to the QAPI committee.

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

Based on review of nursing time schedules and staff interviews, it was determined that the facility 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 on two of 7 days (January 13, 2024, January 14, 2024 ).

Findings include:

Review of facility census data indicated that on January 13, 2024, the facility census was 38, which required 3.20 LPNs during the day shift.

Review of the nursing time schedules and time punch card documentation revealed 1.06 LPNs provided care on the day shift on January 13, 2024.

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

Review of facility census data indicated that on January 14, 2024, the facility census was 38, which required 3.16 LPNs during the day, 2.63 LPNs on the evening shift.

Review of the nursing time schedules and time punch documentation revealed 1.06 LPNs worked on the day shift and 1.06 LPN worked the evening shift on January 14,2024.

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

An interview January 17, 2024, at 2 PM the Nursing Home Administrator confirmed that the facility did not meet the state minimum nursing ratios for LPNs













 Plan of Correction - To be completed: 02/06/2024

1. The Facility cannot retroactively correct the staffing hours on the cited dates. A review of the Residents on those dates demonstrated there were no negative outcomes experience by the Residents related to staffing.
2. The facility cannot retroactively correct past nurse staffing issues. Moving forward the Facility will continue to schedule staff in accordance with the mandated requirements and make a good faith effort to utilize internal and external resources in the event of unforeseen staffing requirement deficits
3. To prevent reoccurrence, the CQS/designee will educate the DON and NHA on the importance of staffing the facility according to regulations and policy.
4. To monitor and maintain on-going compliance, The NHA/designee will audit the direct care staffing ratios weekly times 4 weeks, then monthly times 2 months to ensure regulatory compliance, results of the audits will be forwarded to the QAPI committee.


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