Pennsylvania Department of Health
 CATHEDRAL VILLAGE
Patient Care Inspection Results

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
CATHEDRAL VILLAGE
Inspection Results For:

There are  96 surveys for this facility. Please select a date to view the survey results.

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CATHEDRAL 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, completed on May 2, 2024, it was determined that Cathedral Village, was not in compliance with the requirements of 42 GFR part 483, Subpart B, Requirements for Long Term Care Facilities and the 28 PA Code, Commnwealth of Pennsylvania of Long Term Care Licensure regulations related to the health portion of the survey process.



 Plan of Correction:


483.35(a)(3)(4)(c) REQUIREMENT Competent Nursing Staff:This is the most serious deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one which places the resident in immediate jeopardy as it has caused (or is likely to cause) serious injury, harm, impairment, or death to a resident receiving care in the facility. Immediate corrective action is necessary when this deficiency is identified. This deficiency was not found to be throughout this facility.
§483.35 Nursing Services
The facility must have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment required at §483.70(e).

§483.35(a)(3) The facility must ensure that licensed nurses have the specific competencies and skill sets necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care.

§483.35(a)(4) Providing care includes but is not limited to assessing, evaluating, planning and implementing resident care plans and responding to resident's needs.

§483.35(c) Proficiency of nurse aides.
The facility must ensure that nurse aides are able to demonstrate competency in skills and techniques necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care.
Observations:

Based on the review of facility documentation, review of personnel records and interviews with staff, it was determined that the facility failed to ensure six of six employees possessed the appropriate skills and competencies to provide nursing and related care and services to assure resident safety and to attain or maintain the highest practicable physical, mental, and psychosocial wellbeing of each resident. Further, review of Employee E21's personnel file revealed that the Employee E21 was an unlicensed staff, who provided care and services as a Registered Nurse, without verifiable educational background and registration as a nurse. This failure placed 63 residents who received care and services from Employee E21 at the facility, at risk of injury and/ or harm and resulted in an Immediate Jeopardy situation. (Employees E16, 17, 18, 19, 20 and 21).

Findings Include:

Review of the "Professional Nursing Law" "The Act of May 22" P.L 317, No 69, revealed that "Section 3. Registered Nurse, Clinical Nurse Specialist, Certified Registered Nurse Anesthetist, Use of Title and Abbreviation "R.N.," "C.N.S." or "C.R.N.A."; Credentials; Fraud.--(a) Any person who holds a license to practice professional nursing in this Commonwealth, or who is maintained on inactive status in accordance with section 11 of this act, shall have the right to use the titles "nurse" and "registered nurse" and the abbreviation "R.N." No other person shall engage in the practice of professional nursing or use the titles "nurse" or "registered nurse" or the abbreviation "R.N." to indicate that the person using the same is a registered nurse, except that the title "nurse" also may be used by a person licensed under the provisions of the act of March 2, 1956 (1955 P.L.1211, No.376), known as the "Practical Nurse Law." No person shall sell or fraudulently obtain or fraudulently furnish any nursing diploma, license, record, or registration or aid or abet therein. (b) An individual who holds a license to practice professional nursing in this Commonwealth who meets the requirements under sections 6.2 and 8.5 of this act to be a clinical nurse specialist shall have the right to use the title "clinical nurse specialist" and the abbreviation "C.N.S." No other person shall have that right."

Review of job description for Registered Nurse (RN) revised on June 6, 2022, revealed that "Education and Experience Requirements: Current state professional nursing license, one to two years' experience, geriatric/long term care experience preferred, maintain or able to obtain current CPR certification. Job accountabilities. 1. Plan, directs and provides resident care according to physician orders and the interdisciplinary plan of care. 2. Communicates changes in resident's condition in a timely fashion to include but not limited to physicians, other disciplines, the following shift, and family members. 3. Administer medications, treatments in compliance with federal, state and local laws and with the community policies and procedures. 6. Performs venipuncture to obtain blood.

Further review of job description for Registered Nurse revealed that skills and competencies are required for the job accountabilities including; Administering medications and treatments, performs venipuncture to obtain blood specimens according to community practice, use of standard precautions to prevent spread of communicable disease, enforces and trains proper infection control practices to team members, exhibits knowledge of and effectively executes disaster plans and communicates changes in residents' condition in a timely fashion to include but not limited to the RN, physician other disciplines the following shift and family members.

Review of a blank facility competency evaluation form indicated that the facility developed a competency evaluation program with performance indicators to ensure that the nurses including RNs and LPNs have the competency to perform necessary job accountabilities which indicated if a job function are met or not met.

Review of facility documentation dated February 2, 2024, revealed that "A concern was brought to this NHA (Administrator) on February 2, 2024, at approximately 10:13 am regarding a licensure investigation for an employee of Cathedral Village. Currently this employee is not working in the building. Cathedral Village has reached out to this employee for more details and clarification. Employee informed us that she will provide required documents".

Further review of the documentation revealed that upon hire Employee E21, Registered Nurse, presented a registered nursing license with the name (First name Last name). This license was active on the hire date, and the licensure status was also verified and found to be in good standing. The individual (RN) remained on administrative leave while facility conducted investigation and did not submit any further documentation.

Continued review of the documentation revealed that background checks including criminal history were verified under Employee E21's real name (which included a name with three parts, last name included two parts). License was verified under a similar name (but only had two parts to the name, last name with only one part) as this was the name provided on the nursing license she presented. Both Social security card and driver's license were presented with a name that has three parts. Employee 21's name on the identification document provided was different from the RN license. There was no documentation available to indicate if the facility human resource or other facility staff clarified the discrepancy in the name.

A request for competency evaluation for Employee E21 was requested from the Nursing Home Administrator on April 12, 2024 at 2:17 p.m. Facility did not provide evidence of competency evaluation for Employee E21.

Review of Employee E21's personnel file revealed that the employee was offered the job as an RN with a hire date of November 22, 2023. Further review of the personal file revealed that the employee worked in the facility as an RN until February 1, 2024. Employee worked 30 shifts as an RN, which 23 of the 30 shift she worked independently providing all responsibilities as an RN.

Continued review of Employee E21's personnel file did not include any verifiable nursing or any related education. Personnel files did not include any competency evaluation form.

Review of facility documentation from November 23, 2023, to February 24, 2024, revealed that Employee E21 administered medications to residents including anxiolytics, antihypertensive, antipsychotics, Parkinson's medications, antidepressants, anticonvulsants, anticoagulant, antibiotics, diuretics, beta blockers (slows heart rate, treat chest pain), anti-diabetic medication, steroids, antiviral medications, which require monitoring of side effects.

Review of clinical record also revealed that Employee E21 administered resident complex resident assessment which needed specialized skills and competencies including wound care, neurological assessments, administered insulin, admission assessments, skin assessments change of condition assessments and PICC line assessments.

There was no documentation available to review to determine that facility ensured Employee E21 was competent in performing these services.

Review of facility documentation from November 23, 2023, to February 24, 2024, revealed that Employee E21 provided care and services in the capacity of a registered nurse to 63 residents over 30 shifts. Employee E21 provided care to approximately 20 residents per shift.

A review of the facility record revealed that the facility had one resident with PICC line/Midline catheter who received treatment and care from the staff such as dressing change, medication and fluid administration, site assessment and monitoring.

Interview with the Director of Nursing (DON) on April 15, 2024, at 11:00 a.m. stated nursing staff provided care for residents with PICC lines and midline.

A review of the facility record revealed that the facility had residents with pressure ulcers (injuries to the skin and underlying tissue, primarily caused by prolonged pressure on the skin.) and other wounds who received care and services from staff such as dressing change and wound assessment.

A request for the evidence of PICC line/midline/ IV care and wound care staff competencies or annual evaluations of additional 5 selected licensed and registered nurses, Employee E16, 17, 18, 19, 20 were made to the Nursing Home Administrator and Director of nursing on April

Facility was not able to provide evidence of PICC line/midline/ IV care and wound care staff competencies or annual evaluations of 5 selected licensed and registered nurses.

During an interview on April 15, 2024, at 11:30 a.m. the Nursing Home Administrator confirmed that the nursing staff competencies or annual evaluations related to PICC line/midline/ IV care and wound care was not completed for the nursing staff in the past year. The Nursing Home Administrator also confirmed that the facility did not have a process of competency evaluation. The Nursing Home Administrator stated facility has a competency evaluation program developed to evaluate the competencies of the nurse but the facility did not implement the program for the nurses.

An Immediate Jeopardy situation was identified to the Nursing Home Administrator on April 30, 2024, at 4:00 p.m. for the facility's failure to ensure that Employee E21, (unlicensed staff who provided care and services as a Registered Nurse without verifiable educational background as a nurse) possessed appropriate skill sets and competencies to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial wellbeing of each resident This failure placed 63 residents who received care and services from Employee E21 at the facility at risk of injury and or harm and resulted in an immediate jeopardy situation.

The facility submitted a written plan of action on April 29, 2024, at 9:00 p.m. and implemented the plan of action which included:

Employee A was immediately removed from the schedule and placed on administrative leave. Incident reported to local police department and Department of Health in accordance to local and state laws. Legal counsel notified of multi state and identity theft investigations and agencies informed. Department of State who issues licenses will be informed on 5/1/2024. Legal counsel notified that state's Attorney General is involved. An electronic health record audit was completed on 4/30/24 by the Nursing Home Administrator or designee to review residents who may have received care or treatment from Employee E21. Current residents identified from this audit will be interviewed by a Licensed Nurse and Social Worker. This inquiry will include a statement from the individual related to medication administration, evaluations and assessments, wound care, and general care and nursing services provided was completed 5/1/24. A physical head to toe skin evaluation of the residents in the assignments of Employee E21 was completed on 2/2/24- 2/5/2024.

An audit was conducted by the Human Resource Department to ensure that licensed staff have a skills competency completed and present in their employee file within the last year on 4/30/24. Any licensed staff identified not to have had skills competency completed will have the competency completed prior to their next scheduled shift; all staff completed by 5/3/24.

An audit was completed by human resource department on current licensed nurses employed by PSL (Presbyterian Senior Living) at the community to ensure compliance with licensure verification on 2/4/2024, no variances identified. The human resource department team members at the community were re-educated on new hire/pre- employment processes for licensed staff by the Vice President of Employee Relations or designee on 2/12/2024.

The Human Resource department team members at the community were re-educated by the Vice President of Employee Relations or designee on- the requirement to ensure that all licensed staff have a current skill competency checklist completed at new hire during the orientation period and then annually in their employee file to ensure that all licensed staff possess competencies, education, and license as applicable to provide nursing care, all staff completed by. 5/3/24.

On May 2, 2024, at 11:40 a.m. the action plan was reviewed, personell records were reviewed, interviews were conducted with staff to confirm that the in-service education was completed. Facility audits were reviewed.

The Immediate Jeopardy was lifted on May 2, 2024, at 11:40 a.m.

Refer to F839

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

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

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

















 Plan of Correction - To be completed: 06/18/2024

A. Employee # 21 was immediately removed from the schedule and placed on administrative leave. Incident reported to local police department and Department of Health in accordance to local and state laws. Legal counsel notified of multi state and identity theft investigations and agencies informed. Department of State who issues licenses was informed on 5/1/2024. Legal counsel notified that state's Attorney General is involved.

B. An electronic health record audit was completed on 4/30/24 by the Nursing Home Administrator or designee to review residents who may have received care or treatment from Employee E21. Current residents identified from this audit were interviewed by a Licensed Nurse and Social Worker. This inquiry included a statement from the individual related to medication administration, evaluations and assessments, wound care, and general care and nursing services provided was completed 5/1/24. A physical head to toe skin evaluation of the residents in the assignments of Employee E21 was completed on 2/2/24- 2/5/2024. An audit was conducted by the Human Resource Department to ensure that licensed staff have a skills competency completed and present in their employee file within the last year on 4/30/24. Any licensed staff identified not to have had skills competency completed had the competency completed prior to their next scheduled shift. An audit was completed by human resource department on current licensed nurses employed by PSL (Presbyterian Senior Living) at the community to ensure compliance with licensure verification on 2/4/2024, no variances identified. The human resource department team members at the community were re-educated on new hire/pre-employment processes for licensed staff by the Vice President of Employee Relations or designee on 2/12/2024.

C. The Human Resource department team members at the community were re-educated by the Vice President of Employee Relations or designee on- the requirement to ensure that all licensed staff have a current skill competency checklist completed at new hire during the orientation period and then annually in their employee file to ensure that all licensed staff possess competencies, education, and license as applicable to provide nursing care, all staff completed by 5/3/24.

D. The Human Resources department will conduct an audit on up to 3 newly hired licensed nurses weekly x 4 weeks and then monthly x 2 months to ensure licensed staff members have current competency checklist on record. Audit findings will be forwarded to the Quality Assurance Performance Improvement team for review and recommendations, to include ensuring successful evaluation.

483.70(f)(1)(2) REQUIREMENT Staff Qualifications:This is the most serious deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one which places the resident in immediate jeopardy as it has caused (or is likely to cause) serious injury, harm, impairment, or death to a resident receiving care in the facility. Immediate corrective action is necessary when this deficiency is identified. This deficiency was not found to be throughout this facility.
§483.70(f) Staff qualifications.
§483.70(f)(1) The facility must employ on a full-time, part-time or consultant basis those professionals necessary to carry out the provisions of these requirements.

§483.70(f)(2) Professional staff must be licensed, certified, or registered in accordance with applicable State laws.
Observations:


Based on the review of facility documentation, review of personal records and interviews with staff, it was determined that the facility failed to ensure that a professional staff possessed required nursing license in accordance with applicable state law. Review of one of six personnel files revealed that Employee E21, who was an unlicensed staff, and provided care as a Registered Nurse, to 63 residents. Employee E21 did not have a verifiable educational background and registration, as a Registered Nurse. This failure resulted in an Immediate Jeopardy situation to 63 residents who received care and services from Employee E21. (Employee E21).

Findings Include:

Review of the "Professional Nursing Law" "The Act of May 22" P.L 317, No 69, revealed that "Section 3. Registered Nurse, Clinical Nurse Specialist, Certified Registered Nurse Anesthetist, Use of Title and Abbreviation "R.N.," "C.N.S." or "C.R.N.A."; Credentials; Fraud.--(a) Any person who holds a license to practice professional nursing in this Commonwealth, or who is maintained on inactive status in accordance with section 11 of this act, shall have the right to use the titles "nurse" and "registered nurse" and the abbreviation "R.N." No other person shall engage in the practice of professional nursing or use the titles "nurse" or "registered nurse" or the abbreviation "R.N." to indicate that the person using the same is a registered nurse, except that the title "nurse" also may be used by a person licensed under the provisions of the act of March 2, 1956 (1955 P.L.1211, No.376), known as the "Practical Nurse Law." No person shall sell or fraudulently obtain or fraudulently furnish any nursing diploma, license, record, or registration or aid or abet therein. (b) An individual who holds a license to practice professional nursing in this Commonwealth who meets the requirements under sections 6.2 and 8.5 of this act to be a clinical nurse specialist shall have the right to use the title "clinical nurse specialist" and the abbreviation "C.N.S." No other person shall have that right."

Review of job description for Registered Nurse revised on June 6, 2022, revealed that "Education and Experience Requirements: Current state professional nursing license, one to two years' experience, geriatric/long term care experience preferred, maintain or able to obtain current CPR certification. Job accountabilities. 1. Plan, directs and provides resident care according to physician orders and the interdisciplinary plan of care. 2. Communicates changes in resident's condition in a timely fashion to include but not limited to physicians, other disciplines, the following shift, and family members. 3. Administer medications, treatments in compliance with federal, state and local laws and with the community policies and procedures. 6. Performs venipuncture to obtain blood

Review of facility information dated February 2, 2024, revealed that "A concern was brought to this NHA(Nursing Home Administrator) on February 2, 2024, at approximately 10:13 a.m. regarding a licensure investigation...Currently this employee is not working in the building. Cathedral Village has reached out to this employee for more details and clarification. Employee informed us that she will provide required documents".

Further review of the documentation revealed that upon hire on September 22, 2023, Employee E21, presented a Registered Nurse's license with the name (First name and Last name). This license was active on the hire date, and the licensure status was also verified and found to be in good standing.

Continued review of the documentation revealed that background checks including criminal history were verified under Employee E21's real name (which included first name and last name which had two parts). The Registered nurse license was verified under a similar name (but only the last name with only one part) as this was the name provided on the nursing license she presented. Both Social security card and driver's license were presented with a last name that had two parts. Employee 21's last name on the identification document provided was different from the RN license. There was no documentation available to indicate if the facility human resource or other facility staff clarified the discrepancy with Employee E21's last name.

Interview with previous facility Nursing Home Administrator (Administrator at the time of the alleged incident), on April 12, 2024, at 2:00 p.m. stated Employee E21 provided a fraudulent RN license by obtaining identity of another person with similar name. Facility did not follow up on the discrepancy between the name provided and the name on the license. Facility also did not ask the employee to provide the copy of the license issues by the state to the individual who possessed the license. Facility only verified and kept copy of the license which was available online to the public. She confirmed that the Employee E21 obtained identity of another individual who possessed a RN license with similar name and worked in the facility for 4 months and provided care to the residents including medication administration and licensed/registered nurse's assignments.

Review of Employee E21's personal file revealed that the employee was offered the job as an RN with a hire date of November 22, 2023. Further review of the personal filed file revealed that the employee worked in the facility as an RN till February 1, 2024. Employee worked 30 shifts as an RN, which 23 of the 30 shift she worked independently providing all responsibilities as an RN.

Continued review of Employee E21's personal file did not include any verifiable nursing or any related education.

Review of facility documentation from November 23, 2023, to February 24, 2024, revealed that Employee E21 administered medications to residents including anxiolytics, antihypertensive, antipsychotics, Parkinson's medications, antidepressants, anticonvulsants, anticoagulant, antibiotics, diuretics, beta blockers (slows heart rate, treat chest pain), anti-diabetic medication, steroids, antiviral medications, which require monitoring of side effects.

Review of clinical record also revealed that Employee E21 administered resident complex resident assessment which needed specialized skills and competencies including wound care, neurological assessments, administered insulin, admission assessments, skin assessments change of condition assessments and PICC line assessments.

There was no documentation available to review to determine that facility ensured Employee E 21 was competent in performing these services.

Review of facility documentation from November 23, 2023, to February 24, 2024, revealed that Employee E21 provided care and services in the capacity of a registered nurse to 63 residents over 30 shifts. Employee E21 provided care to approximately 20 residents per shift.

An Immediate Jeopardy situation was identified to the Nursing Home Administrator on April 30, 2024, at 4:00 p.m. for the facility's failure to ensure that professional staff possessed requited licenses or registration in accordance with applicable state law. This failure resulted in Employee E21, unlicensed staff, who provided care and services as a Registered Nurse, without verifiable educational background and registration, as a nurse and placed 63 residents at the facility at risk of injury and or harm and resulted in an Immediate jeopardy situation.

The facility submitted a written plan of action on April 29, 2024, at 9:00 p.m. and implemented the plan of action which included:

Employee 21 was immediately removed from the schedule and placed on administrative leave. Incident reported to local police department and Department of Health in accordance to local and state laws. Legal counsel notified of multi state and identity theft investigations and agencies informed. Department of State who issues licenses who be informed 5/1/2024. Legal counsel notified that state's Attorney General is involved. An audit was completed by human resource department on current licensed nurses employed by PSL at the community to ensure compliance with licensure verification as applicable according to the job description and state laws on 2/4/2024. All licensed staff after the initial audit have also been audited by the Human Resource department prior to employment.

The policy for employee onboarding process was updated and revised on 2/10/24 to ensure licensed staff are appropriately licensed and educated as applicable according to the job description and state laws. The Human Resource department team members at the community were re-educated by the Vice President of Employee Relations or designee on the updated policy on 2/12/2024.

All licensed staff after the initial audit which was completed on 2/4/24 have also been audited by the Human Resource department prior to employment. Audits started 2/27/24 no concerns identified and will continue to be completed biweekly according to new employee orientation schedule. Audits will continue to be going forward.

On May 2, 2024, at 11:40 a.m. the action plan was reviewed, personal records were reviewed, interviews were conducted with staff to confirm that the in-service education was completed. Facility audits were reviewed.

The Immediate Jeopardy was lifted on May 2, 2024, at 11:40 a.m.


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

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

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











 Plan of Correction - To be completed: 06/18/2024

A. Employee #21 was immediately removed from the schedule and placed on administrative leave on 2/02/2024. Employee #21 was terminated on 02/22/2024 per community investigation

B. Human Resources or designee completed an audit on current licensed staff to ensure state nursing licenses matched employees current legal name in accordance with internal policy and state, federal and local regulations completed on 2/02/2024.

C. The Vice President of Employee Relations or designee provided reeducation to Human Resources, and recruiting on the on-boarding license verification process 2/12/2024. 2The Executive Director reeducated the Nursing Home Administrator and Director of Nursing on their applicable job descriptions on 5/23/2024.

D. Human Resources or designee will conduct an audit on up to 3 newly hired licensed nurses weekly x 4 weeks and then monthly x 2 months to ensure state nursing licenses match employees current legal name in accordance with internal policy state, federal, and local regulations. Audit findings will be forwarded to the Quality Assurance Performance Improvement team for review and recommendations, to include ensuring successful evaluation.

483.60(d)(1)(2) REQUIREMENT Nutritive Value/Appear, Palatable/Prefer Temp: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(d) Food and drink
Each resident receives and the facility provides-

§483.60(d)(1) Food prepared by methods that conserve nutritive value, flavor, and appearance;

§483.60(d)(2) Food and drink that is palatable, attractive, and at a safe and appetizing temperature.
Observations:

Based on review of facility documentation, observations, and staff and resident interviews, it was determined that the facility failed to provide food that was served at palatable temperatures for two of two nursing units observed (second and third floor nursing units).

Findings Include:

Interview during the initial tour of the kitchen on April 10, 2024, at 10:15 a.m. with the Food Service Director, Employee E5, revealed each dining room on the 2nd and 3rd floor nursing units have small kitchens that are equipped with steam tables for serving the dining rooms and residents who eat in their rooms.

Review of dining committee notes for the 3rd floor nursing unit, dated March 20, 2024, revealed resident concerns included cold food.

Interviews during the group meeting on April 11, 2024, at 11:00 a.m. with alert and oriented Residents R2, R59, R8, R32, R60, and R1 revealed food is often cold both when eating in the dining room and when served in rooms.

Interview on April 11, 2024, at 12:20 p.m. with the Food Service Director, Employee E5, revealed dietary staff are responsible for checking temperatures the of food items held on the steam tables in the 2nd and 3rd floor dining rooms before beginning meal service.

Review of facility documentation "Daily Temperature Checklist" revealed temperature standards for the entris 155-165 degrees Fahrenheit and vegetable is 145-155 degrees Fahrenheit.

A test tray was made on April 11, 2024, at 12:23 p.m. with food plated directly from the steam table in the 3rd floor dining room with the Food Service Director, Employee E5. Temperatures taken by the Food Service Director, Employee E5, revealed the breaded veal was 127 degrees Fahrenheit and the broccoli was 104 degrees Fahrenheit. Further, the surveyor tasted the food items which confirmed temperatures were not palatable for temperature.

On April 11, 2024, at 12:35 p.m. in the 2nd floor dining room the Food Service Director, Employee E5, temped the food items directly on the steam table which revealed the veal was 123 degrees Fahrenheit and the broccoli was 103 degrees Fahrenheit.

Observations on April 12, 2024, at 9:04 a.m. revealed a stainless-steel tray delivery cart on the 2nd floor nursing unit in front of the nurse's station with about 14 breakfast trays waiting to be passed to residents, including Resident R17.

Follow-up observations on April 12, 2024, at 9:28 a.m. revealed Resident R17 was just served her breakfast tray.

Interview on April 12, 2024, at 9:31 a.m. with Resident R17 revealed the cream of wheat (hot breakfast cereal) was "lukewarm" and that the resident has been "eating cold food for a long time".

28 Pa. Code 201.14(a) Responsibility of licensee

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






 Plan of Correction - To be completed: 06/18/2024

A. Resident #1, 2, 8, 10, 32, And 60 had no ill effects from the meals identified.

B. The Dining Director or designee will conduct an audit in the dining room for three days for breakfast, lunch and dinner to ensure meals are being served at the proper temperatures by 6/2/2024.

C. The Dining Director or designee staff will provide reeducation to the dining staff on the appropriate temperature ranges food should be served and the process to correct if the temperatures are not in the appropriate range by 6/18/2024.

D. The Dining Director or designee will conduct 4 random test tray audits during random mealtimes weekly X4 weeks and then monthly X 2 months to ensure meals are being served at the proper temperatures. Audit findings will be forwarded to the Quality Assurance Performance Improvement team for review and recommendations, to include ensuring successful evaluation.

483.10(a)(1)(2)(b)(1)(2) REQUIREMENT Resident Rights/Exercise of Rights:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
§483.10(a) Resident Rights.
The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility, including those specified in this section.

§483.10(a)(1) A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the resident.

§483.10(a)(2) The facility must provide equal access to quality care regardless of diagnosis, severity of condition, or payment source. A facility must establish and maintain identical policies and practices regarding transfer, discharge, and the provision of services under the State plan for all residents regardless of payment source.

§483.10(b) Exercise of Rights.
The resident has the right to exercise his or her rights as a resident of the facility and as a citizen or resident of the United States.

§483.10(b)(1) The facility must ensure that the resident can exercise his or her rights without interference, coercion, discrimination, or reprisal from the facility.

§483.10(b)(2) The resident has the right to be free of interference, coercion, discrimination, and reprisal from the facility in exercising his or her rights and to be supported by the facility in the exercise of his or her rights as required under this subpart.
Observations:

Based on the review of clinical records, interviews with staff, review of employees' personnel files and review of facility policy, it was determined that the facility failed to promote resident rights related to the communication to residents of an alleged violation reported to the facility which affected the safety and wellbeing of 63 residents at the facility for one of six personnel files reviewed. (Employee E21)

Findings Include:

Review of facility policy "Abuse Neglect or Exploitation" revealed that "It is the policy of "Facility Name" facilities that each resident is provided with a safe environment where they are not subject to mental, physical, verbal, and sexual abuse. Residents shall also be protected from mistreatment, neglect, exploitation, and misappropriation of property.

Exploitation: An act or course of conduct, including misrepresentation or failure to obtain informed consent which results in monetary, personal or other gain of profit for the perpetrator or monetary or personal loss to the resident.
Misappropriation of Resident's Property: Includes but is not limited to the deliberate misplacement, exploitation, or wrongful (temporary or permanent) use of a resident's belongings or funds without the resident's consent. Also includes denying the resident of property for personal gain or satisfaction.

Residents or residents' representatives shall be informed of all reports filed on the residents' behalf regarding abuse, neglect and/or misappropriation unless informing the resident would put the resident at risk of serious harm, or the resident, representative for either a competent or incompetent resident. "

Substantiated incidents require the Administrator or designee to: 1. Report to the licensing/certifying authorities, any actions by a court of law, which would indicate an employee is unfit for service. 2. Analyze the occurrences to determine what changes in policy, procedure or practice that may be needed to prevent further occurrences.

Review of facility documentation dated February 2, 2024, revealed that "A concern was brought to this NHA(Administrator) on February 2, 2024, at approximately 10:13 a.m. regarding a licensure investigation... Currently this employee is not working in the building. Cathedral Village has reached out to this employee for more details and clarification. Employee informed us that she will provide required documents".

Further review of Employee E21's personnel file revealed that upon hire Employee E21, Registered Nurse, presented a registered nursing license with the name (First name and last name). This license was active on the hire date, and the licensure status was also verified and found to be in good standing. The individual (RN) remained on administrative leave while facility conducted investigation and did not submit any further documentation.

Continued review of the documentation revealed that background checks including criminal history were verified under Employee E21's real name (which included a name with three parts, last name included two parts). License was verified under a similar name (but only had two parts to the name, last name with only one part) as this was the name provided on the nursing license she presented. Both Social security card and driver's license were presented with a name that has three parts. Employee 21 name on the identification document provided was different from the RN license.

Interview with previous Facility Administrator (Administrator at the time of the alleged incident), on April 12, 2024, at 2:00 p.m. stated Employee E21 provided a fraudulent RN license by obtaining identity of another person with similar name. She stated this employee was being investigated by multiple law enforcement agencies for identity theft and fraud.

Review of facility documentation from November 23, 2023, to February 24, 2024, revealed that Employee E21 provided care and services in the capacity of a registered nurse to 63 residents over 30 shifts. Employee E21 provided care to approximately 20 residents per shift.

Interview with the Administrator on May 2, 2024, at 11:00 a.m. stated facility did not inform resident or resident representative of the investigation related to Employee E21 who provided medications and treatments to the resident while employed by the facility.

28 Pa. Code 201.14(a) Responsibility of licensee

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

28 Pa. Code: 201.29(b)(c) Resident rights







 Plan of Correction - To be completed: 06/18/2024

A. Residents and/or resident representatives of those in the community during the impacted time frame will be notified of the event by 6/18/2024.

B. Reportable events submitted to the Department of Health via the electronic reporting system from 5/2/2024 through 6/2/2024 will be audited ensure that communication was made notifying the resident and/or resident representative of the event.

C. The Nursing Home Administrator and Director of Nursing will be reeducated on the Abuse and Neglect policy and that a reportable event is required to have communication notifying the resident and/or resident representative of the event by the Vice President of Clinical Excellence by 5/29/2024.

D. The Nursing Home Administrator or designee will conduct a weekly audit on reportable events submitted to the Department of Health via the electronic reporting system weekly X4 weeks and then monthly X2 months to ensure the impacted resident and/or resident representative have been notified of the reported event. Audit findings will be forwarded to the Quality Assurance Performance Improvement team for review and recommendations, to include ensuring successful evaluation.

483.80(a)(3) REQUIREMENT Antibiotic Stewardship Program: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.
§483.80(a) Infection prevention and control program.
The facility must establish an infection prevention and control program (IPCP) that must include, at a minimum, the following elements:

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

Based on a review of facility documentation, facility policies and staff interviews, it was determined that the facility failed to maintain an effective antibiotic stewardship program that includes a system to effectively monitor antibiotic usage for three of four months of antibiotic stewardship program data reviewed. (January 2024, February 2024, and March 2024).

Findings Include:

Review of facility policy "Antibiotic Stewardship" dated May 31, 2023, revealed the "The antibiotic stewardship policy is a set of commitments and actions designed to optimize the treatment of infections while reducing the adverse events associated with antibiotic use such as the threat of antibiotic resistance. 4. Monitoring measures for antibiotics use and outcomes will be implemented and reported through the community QUAPI process. 9. Data will be monitored monthly to review the number of new antibiotics ordered to determine if criteria were met.

Review of facility documentation for the month of January 2024 revealed that the facility used 13 antibiotics for 19 residents. Further review of facility documentation revealed that a review of antibiotic usage for appropriateness or if the usage criteria were met was not completed for the antibiotics prescribed according to facility antibiotic stewardship program.

Review of facility documentation for the month of February 2024 revealed that the facility used 9 antibiotics for 10 residents. Further review of facility documentation revealed that a review of antibiotic usage for appropriateness or if the usage criteria were met was not completed for the antibiotics prescribed according to facility antibiotic stewardship program.

Review of facility documentation for the month of March 2024 revealed that the facility used 17 antibiotics for 24 residents. Further review of facility documentation revealed that a review of antibiotic usage for appropriateness or if the usage criteria were met was not completed for the antibiotics prescribed according to facility antibiotic stewardship program.

Interview with the Director of Nursing (DON) on April 15, 2024, at 11:00 a.m. confirmed that a review of antibiotic usage for appropriateness or if the usage criteria were met was not completed for the antibiotics prescribed according to facility antibiotic stewardship program.

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

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






 Plan of Correction - To be completed: 06/18/2024

A. There was no ill effect of residents by antibiotic usage not being monitored.

B. The Director of Nursing or designee will conduct on audit of current residents receiving antibiotics to ensure a symptom review and documentation in the Infection Tracker section of the resident's electronic health record to determining if McGeer's criteria was met for infections is completed by 6/2/2024

C. The Director of Nursing or designee will provide reeducation to the Licensed nursing staff and Infection Preventionist on the Infection Control Policy and Antibiotic Stewardship Policy by 6/18/2024.

D. The Infection Preventionist or designee will conduct an audit of up to 3 residents who are on antibiotics weekly X4 weeks and then monthly X2 months to ensure proper antibiotic usage review and infection tracking to determine if McGeer's criteria was met. Audit findings will be forwarded to the Quality Assurance Performance Improvement team for review and recommendations, to include ensuring successful evaluation.

483.60(f)(1)-(3) REQUIREMENT Frequency of Meals/Snacks at Bedtime:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
§483.60(f) Frequency of Meals
§483.60(f)(1) Each resident must receive and the facility must provide at least three meals daily, at regular times comparable to normal mealtimes in the community or in accordance with resident needs, preferences, requests, and plan of care.

§483.60(f)(2)There must be no more than 14 hours between a substantial evening meal and breakfast the following day, except when a nourishing snack is served at bedtime, up to 16 hours may elapse between a substantial evening meal and breakfast the following day if a resident group agrees to this meal span.

§483.60(f)(3) Suitable, nourishing alternative meals and snacks must be provided to residents who want to eat at non-traditional times or outside of scheduled meal service times, consistent with the resident plan of care.
Observations:

Based on facility documentation, observations, and resident interviews, it was determined that the facility failed to provide meals in accordance with resident preferences for two of two nursing units observed (Second and Third Floor Nursing Units).

Findings Include:

Review of facility documentation "Meal Service Times" revealed breakfast is served between 8:00 a.m. and 9:00 a.m., and lunch is served between 12:00 p.m. and 1:00 p.m.

Interview during the initial tour of the kitchen on April 10, 2024, at 10:15 a.m. with the Food Service Director, Employee E5, revealed each dining room on the 2nd and 3rd floor nursing units have small kitchens that are equipped with steam tables for serving the dining rooms and residents who eat in their rooms.

Interviews during the group meeting on April 11, 2024, at 11:00 a.m. with alert and oriented residents R2, R59, R8, R32, R60, and R1 revealed residents need to wait long periods of time in the dining room to be served a meal. Residents reported going to the dining room when lunch is supposed to start at 12:00 p.m. but can wait up to 45 minutes to be served.

Observations on April 11, 2024, at 12:17 p.m. in the 3rd floor dining room revealed approximately nine residents were waiting to be served lunch (Resident R11, R8, R24, R55, R9, R63, R26, R69, and R53).

Observations on April 11, 2024, at 12:35 p.m. in the 2nd floor dining room revealed approximately 10-15 residents who were sitting in the dining room were still not served. Observations revealed the dietary employee who was responsible for plating the meals from the steam table was still taking orders from the residents at 12:35 p.m. and had not yet began plating resident lunches for the dining room.

Interview on April 11, 2024, at 12:35 p.m. with the Food Service Director, Employee E5, confirmed Dietary Employee who was responsible for plating resident meals was also taking resident orders.

Follow-up observations on April 11, 2024, at 12:40 p.m. in the 3rd floor dining room revealed Residents R11 was just served at 12:40 p.m. and the other residents (Resident R8, R24, R55, R9, R63, R26, R69, and R53) were still not served. Resident R24 kept asking staff where her sandwich was.

Observations on April 12, 2024, revealed the following residents were served breakfast after 9:00 a.m. Resident R51 and R48 were served at 9:25 a.m., Resident R17 was served breakfast at 9:31 a.m., Resident R47 was served breakfast at 9:34 a.m.


28 Pa. Code 201.14(a) Responsibility of licensee

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




 Plan of Correction - To be completed: 06/18/2024

A. No residents experienced any ill effects from being served meals at different times than their preference.

B. The Director of Dining or Designee will conduct an audit to ensure residents are served meals at their preferred time by 6/2/2024.

C. The Dining Director or designee will provide reeducation on the importance of ensuring resident preference is honored for mealtime preference by 6/18/2024.

D. The Dining Director or designee will conduct audits on 5 random meals weekly x 4 weeks and then monthly x 2 months to ensure resident preference with mealtime is being honored. Audit findings will be forwarded to the Quality Assurance Performance Improvement team for review and recommendations, to include ensuring successful evaluation.

483.24(a)(2) REQUIREMENT ADL Care Provided for Dependent Residents: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.
§483.24(a)(2) A resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene;
Observations:

Based on observations, review of clinical records, and resident and family interviews, it was determined that the facility failed to ensure dependent resident received assistance with personal hygiene for six of 31 residents reviewed (Resident R2, R8, R32, R60, R1, and R10).

Findings Include:

Review of Resident R10's Comprehensive Minimum Data Set (MDS - federally mandated resident assessment and care screening) dated April 1, 2024, revealed the resident was dependent (helper does all of the effort) for shower/bathing and personal hygiene. Further review of the MDS revealed the resident was cognitively impaired.

Review of Resident R2's quarterly MDS dated March 21, 2024, revealed the resident required partial/moderate assistance (helper lifts, holds, or supports trunk or limbs) with shower/bathing.

Review of Resident R8's quarterly MDS dated January 11, 2024, revealed the resident required supervision or touching assistance (helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity) with shower/bathing.

Review of Resident R32's quarterly MDS dated April 4, 2024, revealed the resident required substantial/maximal assistance (helper lifts or holds trunk or limbs) with shower/bathing.

Review of Resident R60's quarterly MDS dated February 13, 2024, revealed the resident required partial/moderate assistance with shower/bathing.

Review of Resident R1's quarterly MDS dated March 4, 2024, revealed the resident required substantial/maximal assistance with shower/bathing.

Interview on April 10, 2024, at 12:20 p.m. with Resident R10's family member revealed concerns that the resident is not getting routine showers. Further interview with the family member revealed Resident R10 was supposed to have a shower on Tuesday night, April 9, 2024, but was unsure because the resident's hair looked dirty.

Observations on April 10, 2024, at 1:05 p.m. revealed Resident R10 was in the dining room having lunch. Observations confirmed Resident R10's hair looked unkept and dirty.

Interview on April 10, 2024, at 2:45 p.m. with another family member of Resident R10 revealed if Resident R10 misses a shower on the scheduled shower day, the resident needs to wait until the next scheduled shower day to be bathed.

Interviews with alert and oriented Resident's R2, R8, R32, R60, R1 during the group meeting on April 11, 2024, at 11:00 a.m. revealed sufficient staff is not available, and resident's will subsequently not be provided showers due to lack of staff.

Via email communication on April 15, 2024, at 12:10 p.m. with the Nursing Home Administrator regarding shower/bathing documentation revealed "the X's on the shower sheet represent the days that the shower are not scheduled, when you see a number ... that is the date that the aides documented".

Review of Resident R10's shower sheet revealed the resident was scheduled for bathing on Tuesday and Friday nights. Further review of Resident R10's March and April 2024 shower sheets revealed the last time nursing staff documented giving a shower was March 1, 2024.

Review of Resident R2's shower sheet revealed the resident was scheduled for bathing on Wednesday and Saturday mornings. Further review of Resident R2's March and April 2024 shower sheets revealed only one documented shower on March 23, 2024. No documented showers given for April 2024.

Review of Resident R8's shower sheet revealed the resident was scheduled for bathing on Wednesday and Saturday evenings. Further review of Resident R8's March and April 2024 shower sheets revealed the only documented showers given were March 20, March 23, and April 3, 2024.

Review of Resident R32's shower sheet revealed the resident was scheduled for bathing on Tuesday and Friday mornings. Further review of Resident R32's March and April 2024 shower sheets revealed only one documented shower on March 1, 2024. No documented showers given for April 2024.

Review of Resident R60's shower sheet revealed the resident was scheduled for bathing on Monday and Thursday nights. Further review of Resident R60's March and April 2024 shower sheets revealed no documented showers given for March and April 2024.

Review of Resident R1's shower sheet revealed the resident was scheduled for bathing on Wednesday and Saturday mornings. Further review of Resident R1's March and April 2024 shower sheets revealed no documented showers given for March and April 2024.


28 Pa. Code 201.14 (a) Responsibility of Licensee

28 Pa. Code 211.10 (d) Resident Care Policies





 Plan of Correction - To be completed: 06/18/2024

A. Residents #1, #2, #8, #10, #32, #60 received showers. No ill effects were noted to the mentioned residents.

B. The Registered Nurse Reimbursement Coordinator or designee will conduct an audit of current residents who require assistance for showering/bathing to ensure residents preferences for showers/bathing are present in the individualized plan care and linked to the Electronic Health Record documentation system for nursing team members by 6/2/2024.

C. The Director Nursing or designee will provide reeducation to Nursing staff on the process for Electronic Health Record documentation and completion of showering/bathing for residents who require assistance and the procedure for refusals by 6/18/2024. The Director of Nursing or designee will provide reeducation to Licensed staff to review compliance of showering/bathing and documentation on a per shift basis by 6/18/2024.

D. The Director of Nursing or designee will conduct a random audit of 5 residents who require assistance with showering/bathing weekly X 4 weeks and then monthly X 2 months to ensure appropriate documentation and completion of showers per resident preference. Audit findings will be forwarded to the Quality Assurance Performance Improvement team for review and recommendations, to include ensuring successful evaluation.

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

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

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

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

Based on the review of clinical records, interviews with staff, review of facility policy, it was determined that the facility failed to conduct a thorough and complete investigation of an alleged violation of identy theft involving 63 residents of the facility for one of six personnel files reviewed. (Employee E21)

Findings Include:

Review of facility policy "Abuse Neglect or Exploitation" revealed that "It is the policy of "Facility Name" facilities that each resident is provided with a safe environment where they are not subject to mental, physical, verbal, and sexual abuse. Residents shall also be protected from mistreatment, neglect, exploitation, and misappropriation of property.

Exploitation: An act or course of conduct, including misrepresentation or failure to obtain informed consent which results in monetary, personal or other gain of profit for the perpetrator or monetary or personal loss to the resident.

Misappropriation of Resident's Property: includes but is not limited to the deliberate misplacement, exploitation, or wrongful (temporary or permanent) use of a resident's belongings or funds without the resident's consent. Also includes denying the resident of property for personal gain or satisfaction.

Allegations of abuse, neglect, mistreatment of residents or misappropriation of property shall be reported immediately to the supervising nurse or, in PC/AL the administrator designee and documented on an Incident Report.

Investigative skills shall be used to identify injuries, provide treatment of identified injuries, to determine circumstances that might contribute to incident."

Review of facility documentation dated February 2, 2024, revealed that "A concern was brought to this NHA(Administrator) on February 2, 2024, at approximately 10:13 am regarding a licensure investigation... Currently this employee is not working in the building. Cathedral Village has reached out to this employee for more details and clarification. Employee informed us that she will provide required documents".

Further review of the documentation revealed that upon hire Employee E21, Registered Nurse, presented a registered nursing license with the name (First name and last name). This license was active on the hire date, and the licensure status was also verified and found to be in good standing. The individual (RN) remained on administrative leave while facility conducted investigation and did not submit any further documentation.

Continued review of Employee E21's personnel file revealed background checks including criminal history were verified under Employee E21's real name (which included a name with three parts, last name included two parts). License was verified under a similar name (but only had two parts to the name, last name with only one part) as this was the name provided on the nursing license she presented. Both social security card and driver's license were presented with a name that has three parts. Employee 21 name on the identification document provided was different from the RN license.

Interview with previous Facility Administrator (Administrator at the time of the alleged incident7), on April 12, 2024, at 2:00 p.m. stated Employee E21 provided a fraudulent RN license by obtaining identity of another person with similar name. She stated this employee was being investigated by multiple law enforcement agencies for identity theft and fraud.

Review of facility documentation from November 23, 2023, to February 24, 2024, revealed that Employee E21 provided care and services in the capacity of a registered nurse to 63 residents over 30 shifts. Employee E21 provided care to approximately 20 residents per shift.

Continued review of the facility documentation revealed no evidence that the facility obtained statements or interviewed residents who received care and services from Employee E21.

Facility investigation revealed no evidence that there were statements from staff responsible for hiring Employee E21, verifying license or completing competency evaluation for Employee E21.

Interview with the Administrator on May 2, 2024, at 11:00 a.m. confirmed that the facility investigation did not include statements or interviews from residents and staff responsible for hiring Employee E21, verifying license or completing competency evaluation for Employee E21.

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

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







 Plan of Correction - To be completed: 06/18/2024

A. Statements obtained from Human Resource team and added to investigative file.

B. Reportable events submitted to the Department of Health via the electronic reporting system from 5/2/2024 through 6/2/2024 will be audited to ensure that necessary resident or staff statements/interviews were obtained and added to the investigative file.

C. The Nursing Home Administrator and Director of Nursing will be reeducated on the Abuse and Neglect policy and that a reportable event is required to include the necessary resident or staff statements/interviews and added to the investigative file by the Vice President of Clinical Excellence by 5/29/2024.

D. The Nursing Home Administrator or designee will conduct a weekly audit on reportable events submitted to the Department of Health via the electronic reporting system weekly X4 weeks and then monthly X2 months to ensure that necessary statements are obtained and added to the investigative file. Audit findings will be forwarded monthly to the Quality Assurance Performance Improvement team for review and recommendations, to include ensuring successful evaluation.

483.21(b)(2)(i)-(iii) REQUIREMENT Care Plan Timing and Revision:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
§483.21(b) Comprehensive Care Plans
§483.21(b)(2) A comprehensive care plan must be-
(i) Developed within 7 days after completion of the comprehensive assessment.
(ii) Prepared by an interdisciplinary team, that includes but is not limited to--
(A) The attending physician.
(B) A registered nurse with responsibility for the resident.
(C) A nurse aide with responsibility for the resident.
(D) A member of food and nutrition services staff.
(E) To the extent practicable, the participation of the resident and the resident's representative(s). An explanation must be included in a resident's medical record if the participation of the resident and their resident representative is determined not practicable for the development of the resident's care plan.
(F) Other appropriate staff or professionals in disciplines as determined by the resident's needs or as requested by the resident.
(iii)Reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments.
Observations:


Based on review of clinical records and interviews with staff, it was determined that the facility failed to revise/update a care plan with a new intervention for one of eight clinical records reviewed. Resident R53

Findings include:

Review of Resident R53's clinical record revealed that Resident R53 was admitted to the facility January 25, 2024 with diagnoses of sepsis (the body's extreme reaction to an infection), Pneumonia (inflammation and fluids in the lungs caused by bacteria, fungal, or viral infection), COPD,(Chronic Obstructive Pulmonary Disease, an inflammatory lung disease that causes airflow blockage), resp failure (a condition in which the blood does not have enough oxygen or too much carbon dioxide), Alzheimer Disease (a neurodegenerative disease that destroys memory and thinking skills)Type 2 Diabetes (a chronic condition when the body does not use insulin properly and results in has high blood sugar levels), and Hypomagnesemia low level of the electrolyte magnesium.

Review of Resident R53's nursing notes revealed documentation that Resident R53 was expressing belligerent, agitated, uncooperative behaviors beginning February 27, 2024, and continuing through the month of March 2024. The clinical records indicate that the physician was notified and had ordered a medication Ativan (Lorazepam, a sedative used to relieve symptoms of anxiety) to be given as needed. Further review of the nursing notes revealed that resident's behaviors were being monitored daily.

Review of Resident R53's care plan dated January 25, 2023, revealed that there was no care plan developed related to Resident R53's belligerent and uncooperative behaviors.

Interview with Licensed nurse, Employee E2 April 15, 2024, at 1:10 p.m, confirmed that Resident R53 has displayed newly recognized unfavorable behaviors addressed by the nursing staff and physicians. Employee E2 revealed that Resident R53's care plan had not been updated to address the behaviors.

28 Pa. Code 211.10( c) Care plan policies

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







 Plan of Correction - To be completed: 06/18/2024

A. Resident #53 had her care plan updated to include behaviors on 4/26/2024. Resident #53 did not experience any ill effects from care plan not addressing behavior.

B. An audit will be completed by the Social Service worker or designee on current residents who have displayed newly recognized unfavorable behaviors in the past 14 days to ensure their care plan matches the identified behaviors noted by 6/2/2024.

C. The Director of Nursing or designee will provide reeducation to Licensed staff and Social worker that newly recognized unfavorable behaviors are to be reflected in each resident's care plan upon identification to provide plans to address behavior by 6/18/2024.

D. Social Service Worker or designee will conduct a random audit of up to 5 residents weekly x 4 weeks and then monthly X 2 months to ensure residents who have displayed newly recognized unfavorable behaviors are reflected and addressed in their care plan. Audit findings will be forwarded to the Quality Assurance Performance Improvement team for review and recommendations, to include ensuring successful evaluation.

483.25 REQUIREMENT Quality of Care:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
§ 483.25 Quality of care
Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices.
Observations:

Based on review of facility policy, review of clinical records, and family interview, it was determined that the facility failed to ensure one resident received medication in accordance with physician orders for one of 19 residents reviewed (Resident R10).

Findings Include:

Review of facility policy "Medication Administration" dated December 22, 2023, revealed resident shall receive all medications per the orders of the physician including the correct time.

Interview on April 10, 2024, at 2:45 p.m. with Resident R10's family member revealed concerns that the resident does not always receive his Parkinson's (a chronic and progressive disorder that affects the nervous system and causes movement problems) medication timely.

Review of Resident R10's physician orders revealed an order dated July 5, 2023, for Carbidopa-Levodopa (medication used to treat symptoms of Parkinson's disease) daily at 6AM, 10AM, 2PM, and 6PM with specific instructions "DO NOT ADMINSITER ON FLEX-TIME", for Parkinson's disease.

Review of Resident R10's medication administration confirmed the resident did not receive his Carbidopa-Levodopa medication timely/per physician orders on the following days/times:

-February 5, 2024, given at 4:06 p.m. instead of 6:00 p.m.
-February 10, 2024, given at 12:23 p.m. instead of 10:00 a.m.
-February 12, 2024, given at 4:21 p.m. instead of 6:00 p.m.
-February 15, 2024, given at 8:45 p.m. instead of 6:00 p.m.
-February 17, 2024, given at 12:01 p.m. instead of 10:00 a.m.
-February 20, 2024, given at 8:57 p.m. instead of 6:00 p.m.
-February 22, 2024, given at 8:45 p.m. instead of 6:00 p.m.
-February 23, 2024, given at 4:33 a.m., 12:08 p.m., and 8:19 p.m. Missed 2:00 p.m. dose and other doses not given timely.

-March 1, 2024, given at 9:03 p.m. instead of 6:00 p.m.
-March 10, 2024, given at 4:23 p.m. instead of 6:00 p.m.
-March 11, 2024, nurse staff did not administer 6:00 a.m. and 2:00 p.m. dose.
-March 13, 2024, given at 4:00 p.m. instead of 6:00 p.m.
-March 24, 2024, given at 1:17 p.m. instead of 10:00 a.m. and immediately given again at 1:19 p.m. instead of 2:00 p.m. Also given at 4:03 p.m. instead of 6:00 p.m.


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

28 Pa. Code 211.9 (d) Pharmacy Services




 Plan of Correction - To be completed: 06/18/2024

A. Resident # 10 did not sustain any harm from not receiving Carbidopa- Levodopa per physicians ordered administration times.

B. The Director of Nursing or designee will complete an audit of current residents receiving Carbidopa-Levodopa to ensure Licensed staff are following medication administration times ordered by the physician by 6/2/2024.

C. The Director of Nursing or designee will provide reeducation to Licensed staff on the Flexible Medication Policy and Medication Administration Policy by 6/18/2024.

D. The Director of Nursing or Designee will conduct a random audit of up to 4 residents receiving Carbidopa-Levodopa weekly X 4 weeks and then monthly X2 months to ensure licensed staff are following medication administration times ordered by the physician. Audit findings will be forwarded to the Quality Assurance Performance Improvement team for review and recommendations, to include ensuring successful evaluation.

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

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

§483.25(c)(3) A resident with limited mobility receives appropriate services, equipment, and assistance to maintain or improve mobility with the maximum practicable independence unless a reduction in mobility is demonstrably unavoidable.
Observations:
Based on the review of clinical records, review of facility policy, observations, and interview with the staff, it was determined that the facility did not ensure that a resident with limited range of motion received appropriate services according to the professional standards of practice for one of two residents reviewed. (Resident R14)

Findings Include:

Review of a facility policy "Restorative care program" dated February 4, 2022, revealed that "Presbyterian Senior Living facilities will provide restorative services which prevent decline and/or maintain the highest practicable level of functioning in accordance with state and federal regulation."

Review of physician orders for Resident R14 dated February 14, 2024, revealed an order to keep splint on left upper extremity at all times, may remove for showers.

Observation of Resident R14 on April 11, 2024, at 12:00 p.m. revealed that the resident was not wearing a splint as ordered by the physician to the left upper extremity.

Observation of Resident R14 on April 12, 2024, at 2:45 p.m. revealed that the revealed that the resident not wearing a splint as ordered by the physician to the left upper extremity. This observation was confirmed by Employee E15, Registered Nurse.

Observation of Resident R14 on April 15, 2024, at 12:04 p.m. revealed that the resident was not wearing a splint as ordered by the physician to the left upper extremity. This observation was confirmed by Employee E14, Licensed Practical Nurse.

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

28 Pa. Code: 201.18 (b)(2) Management

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



 Plan of Correction - To be completed: 06/18/2024

A. Resident #14 did not experience any ill effects and no longer resides at the community.

B. The Director of Therapy or designee will complete an audit of current residents wearing splints to ensure splints were being worn as per physician order/care plan interventions by 6/2/2024.

C. The Director of Nursing or designee will provide reeducation to Nursing staff and to ensure physician orders/care plan interventions are being followed when splints are being worn by 6/18/2024.

D. The Director of Nursing or designee will conduct a random audit up to 3 residents weekly X4 weeks and then monthly X 2 months to ensure residents who have a physician order/care plan intervention for splints are being worn as prescribed. Audit findings will be forwarded to the Quality Assurance Performance Improvement team for review and recommendations, to include ensuring successful evaluation.

483.25(d)(1)(2) REQUIREMENT Free of Accident Hazards/Supervision/Devices:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
§483.25(d) Accidents.
The facility must ensure that -
§483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and

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

Based on review of facility documentation, review of clinical record, and staff interview, it was determined that the facility failed to provide assistance devices necessary to prevent an avoidable accident from occurring for one of two residents reviewed for falls (Resident R57).

Findings Include:

Review of Resident R57's Quarterly Minimum Data Set (MDS - federally mandated resident assessment and care screening) dated January 7, 2024, revealed the resident had diagnoses of dementia (loss of cognitive functioning that interferes with daily life and activities), Parkinson's Disease (a chronic and progressive disorder that affects the nervous system and causes movement problems), history of falling, and abnormalities of gait and mobility.

Further review of the MDS revealed Resident R57 had impairment on both sides of lower extremities and used a wheelchair for mobility device. Continued review of the MDS revealed the resident was dependent (helper does all the effort) on staff for sit to stand (the ability to come to a standing position from sitting in a wheelchair).

Review of information submitted to the State Survey Agency on March 7, 2024, revealed on March 6, 2024, Resident R57 was being seated in the dining room by a nurse aide when Resident R57 grabbed onto a table attempting to stand from wheelchair and fell forward onto the floor.

Review of facility documentation, incident report dated March 6, 2024, revealed nurse aide, Employee E11, was assisting Resident R57 in her wheelchair to her seat position in the dining room at approximately 4:50 p.m. Resident R57 grasped the dining room table while wheelchair was moving and attempted to stand at the same time, causing Resident R57 to go forward landing on the floor. Continued review of the incident report revealed the wheelchair leg rests were not checked off as being used at the time of the incident.

Interview on April 12, 2024, at 1:34 p.m. with the Director of Nursing, Employee E2, revealed Resident R57 had significant cognitive impairments and history of behaviors of spontaneously grabbing anything within reach and planting feet on floor while being pushed in the wheelchair. Further interview with the Director of Nursing, Employee E2, confirmed Resident R57 should always have footrests on the wheelchair while in use due to behavior of planting feet on floor.

Further interview on April 12, 2024, at 1:34 p.m. with the Director of Nursing, Employee E2, confirmed footrests were not in use at the time of Resident R57's fall on March 6, 2024.


28 Pa. Code 201.14 (a) Responsibility of Licensee

28 Pa. Code 211.10 (d) Resident Care Policies






 Plan of Correction - To be completed: 06/18/2024

A. Resident #57 care plan was reviewed for continued use and appropriateness of footrests while wheelchair is in use.

B. The Director of Nursing or designee will complete and an audit of current residents who have fallen in last 14 days to ensure fall interventions are care planned and being followed by 6/2/2024.

C. The Director of Nursing or designee will provide reeducation to Nursing staff on the Fall Management policy and following care plan interventions by 6/18/2024.

D. The Director of Nursing or designee will conduct an audit of up to 4 random residents who have experienced a fall weekly X4 weeks and then monthly X 2 months to ensure residents who have fall interventions are care planned and interventions are being followed as appropriate. Audit findings will be forwarded to the Quality Assurance Performance Improvement team for review and recommendations, to include ensuring successful evaluation.

483.25(k) REQUIREMENT Pain Management:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
§483.25(k) Pain Management.
The facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences.
Observations:

Based on the review of clinical records, facility policy and interviews with staff, it was determined that the facility failed to ensure that pain management was provided consistent with physician orders and standards of practice for one of one resident reviewed for pain management. (Resident R14)

Findings include:

Review of Resident R14's clinical record reveled that Resident R14 was admitted to the facility with diagnosis including age related osteoporosis (a bone disease that develops when bone mineral density and bone mass decreases, or when the structure and strength of bone changes) with current pathological fracture left femur, vascular dementia and anxiety.

Review of MDS (Minimum Data Set) assessment dated February 6, 2024, revealed that the resident was on a scheduled pain medication regimen and received as needed pain medication. There was no non-medication intervention for pain. It was also revealed that the resident experienced pain almost constantly and it frequently affected sleep and occasionally affected day-to day activities.

Review of physician order for Resident R14 dated April 1, 2024, revealed an order for Acetaminophen (analgesic pain medication) 325 milligrams (mg) take two tablets every six hours for pain.

Review of progress note for Resident R14 dated April 10, 2024, revealed that the resident complained of pain, she stated she felt the pain like she was going to have a baby. It was documented as the pain medication given.

Review of Medication Administration Record for the month of April 2024 revealed no evidence that the pain medication was administered on April 10, 2024.

Review of physician progress note dated April 5, 2024, revealed a medication order for Oxycodone 5 mg as needed.

Review of active physician orders for Resident R14 for the month of April 2024 revealed that the Oxycodone was not included in the active medication list.

Review of clinical record for Resident R14 revealed no documented reason for not following the physician recommendation of Oxycodone.

Interview with the Director of Nursing (DON) on April 15, 2024, at 11:00 a.m. confirmed that there was that no evidence that the pain medication was administered on April 10, 2024, when resident complained of pain. DON confirmed that there was no pain assessment completed when resident complained of pain. DON also confirmed that there was no documented reason for not following the physician recommendation of Oxycodone.

28 Pa. Code 211.10(c) Patient care policies

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



 Plan of Correction - To be completed: 06/18/2024

A. Resident #14 did not experience any ill effects and no longer resides at the community.

B. The Registered Nurse Assessment Coordinator or designee will conduct an audit on current resident's most recent MDS to determine if indicated residents' pain is being evaluated and care plan present by 6/2/2024. The Director of Nursing or designee will conduct an audit of physician progress notes in the past 14 days to ensure physician progress notes is consistent with the resident active medication list by 6/2/2024.

C. The Director of Nursing or designee will provide reeducation to the Licensed Nursing staff on the Pain Management policy and importance of documenting pain assessments, updating plans of care, and as needed pain medications by 6/18/2024. The Director of Nursing will provide reeducation to the Physicians/physician extenders that medications listed in the physician's progress notes are included in the resident's active medication orders list by 6/18/2024.

D. An audit will be conducted on 3 random residents weekly X 4 weeks and then monthly X2 months to determine that pain is being managed and pain medications are documented correctly. Audit findings will be forwarded to the Quality Assurance Performance Improvement team for review and recommendations, to include ensuring successful evaluation.

483.45(g)(h)(1)(2) REQUIREMENT Label/Store Drugs and Biologicals:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
§483.45(g) Labeling of Drugs and Biologicals
Drugs and biologicals used in the facility must be labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable.

§483.45(h) Storage of Drugs and Biologicals

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

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

Based on observation, 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 three medication carts observed. (Second-floor medication cart)

Findings include:

Review of facility policy titled "Medication Storage in the facility" dated May 2018, revealed that only licensed nurses, pharmacy personnel, and those lawfully authorized to administer medications permitted to access medications. Medication rooms, carts, and medication supplies are locked when not attended by persons with authorized access.

Observation of the Second-floor medication cart on April 10, 2024 at 11:12 a.m. revealed the cart positioned outside the second-floor nursing office (an enclosed office surrounded by windows), was left unattended, unlocked with the sixth drawer left open to view all contents contained in the drawer. The cart directly faced two elevators on the floor.

Observation on April 10, 2024, at 11:17 a.m. revealed Licensed staff, Employee E 88 exiting the nurses office approaching the unlocked medication cart. Employee E8 closed the drawers of the cart then locked the cart.

Interview with Licensed staff, Employee E8 at time of observation revealed that she was inside the office assisting another resident. Employee E8 stated that she only walked away from the unlocked cart for one minute. She was coming right back to the cart.

28 Pa. Code 211. 12(d)(1) Nursing services

28 Pa. code 211.9(a)(1) Pharmacy services





 Plan of Correction - To be completed: 06/18/2024

A. Employee # 8 was immediately reeducated on 4/26/2024 that meds carts are to be locked when unattended.

B. The Director of Nursing or Designee will conduct a whole house audit to ensure med carts are locked when a licensed staff member is not in attendance by 6/2/2024.

C. The Director of Nursing or designee will provide reeducation to Licensed staff on the policy for Storage of Drugs and Biologicals with a focus that all drugs and biologicals must be locked in the medication cart when a licensed staff member is not in attendance by 6/18/2024.

D. The Director of Nursing or Designee will conduct random weekly audits X4 weeks and then monthly audits X2 months to ensure med carts are locked when a licensed staff member is not in attendance. Audit findings will be forwarded to the Quality Assurance Performance Improvement team for review and recommendations, to include ensuring successful evaluation.

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

Based on the review of clinical records, job descriptions, facility documentation and interviews with staff, it was determined that the Nursing Home Administrator (NHA) and the Director of Nursing (DON) did not effectively manage the facility by failing to ensure that a Registered Nurse (RN license was accurately verified under the correct name at the time of employment and that nursing staff possessed appropriate skills and competencies to provide nursing and related care and services. This failure resulted in Employee E21, unlicensed staff, who provided care and services as a Registered Nurse, without verifiable educational background, registration and appropriate skills and competencies, as a nurse.

Findings Include:

Review of the job description for the Nursing Home Administrator (NHA) revealed that "Responsible for health center operation in accordance with the established policies and procedures of "Facility Name" as well as in compliance with federal, state and local regulations. Responsible for ensuring quality of care, resident rights, effective team members and fiscal stability of campus. Responsible for or makes recommendations regarding the recruitment, interviewing, hiring, training, supervision and implementation corrective action health center team members."

Review of the job description for the Director of Nursing (DON) revealed that "Responsible for the organization, supervision, administration and overall management of the nursing service program. Develops and maintains nursing policies, procedures, objectives and standards of practice. Responsible for or makes recommendations regarding the recruitment, interviewing, hiring, training, supervision and implementation corrective action for nursing department personnel."

Review of facility documentation dated February 2, 2024, revealed that "A concern was brought to this NHA(Administrator) on February 2, 2024, at approximately 10:13 a.m. regarding a licensure investigation... Currently this employee is not working in the building. Cathedral Village has reached out to this employee for more details and clarification. Employee informed us that she will provide required documents".

Further review of the documentation revealed that upon hire Employee E21, Registered Nurse (RN), presented a registered nursing license with the name (First name and Last name). This license was active on the hire date, and the licensure status was also verified and found to be in good standing. The individual (RN) remained on administrative leave while facility conducted investigation and did not submit any further documentation.

Continued review of the documentation revealed that background checks including criminal history were verified under Employee E21's real name (which included a name with three parts, last name included two parts). License was verified under a similar name (but only had two parts to the name, last name with only one part) as this was the name provided on the nursing license she presented. Both Social Security card and driver's license were presented with a name that has three parts. Employee 21 name on the identification document provided was different from the RN license. There was no documentation available to indicate if the facility human resource or other facility staff clarified the discrepancy in the name.

Review of Employee E21's personnel file revealed that the employee was offered the job as an RN with a hire date of November 22, 2023. Further review of Employee E21's personnel file revealed that the employee worked in the facility as an RN untill February 1, 2024. Employee worked 30 shifts as an RN, which 23 of the 30 shift she worked independently providing all responsibilities as an RN.

Based on the deficiencies identified in this report, the Nursing Home Administrator and Director of Nursing failed to fulfill essential duties and responsibilities of their position to ensure that the Federal and State guidelines and Regulations were followed, contributing to the Immediate Jeopardy situation.

Refer to F726 and F839

28 Pa Code 201.14(a) Responsibility of licensee

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

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









 Plan of Correction - To be completed: 06/18/2024

A. Employee #21 was immediately removed from the schedule and placed on administrative leave on 2/02/2024. Employee #21 was terminated on 02/22/2024 per community investigation.

B. Human Resources or designee completed an audit on current licensed staff to ensure state nursing licenses matched employees current legal name in accordance with internal policy and state, federal and local regulations completed on2/02/2024.

C. The Vice President of Employee Relations or designee provided reeducation to Human Resources, and recruiting on the on-boarding license verification process 2/12/2024. 2The Executive Director reeducated the Nursing Home Administrator and Director of Nursing on their applicable job descriptions on 5/23/2024.

D. Human Resources or designee will conduct an audit on up to 3 newly hired licensed nurses weekly x 4 weeks and then monthly x 2 months to ensure state nursing licenses match employees current legal name in accordance with internal policy state, federal, and local regulations. Audit findings will be forwarded to the Quality Assurance Performance Improvement team for review and recommendations, to include ensuring successful evaluation.

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

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

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

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

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

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

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


Based on review of facility policy, observation, and staff interviews, it was determined that the facility failed to follow acceptable infection control practices during dining for one of 12 resident observed. (Employee E7)

Findings include:

Review of the facility policy titled "Infection control policy" revised January 13, 2022, states the primary purpose of infection control in the facility is to maintain a sanitary environment for all personal residents, visitors, and the general public.

Review of facility policy titled "Nutrition and Hydration for Residents Unable to Feed Themselves", revealed that if a residents needing assistance for dining, it is then the NA (nursing assistant) job to feed them. Further review of this policy revealed that the temperature of the food should be tested by placing the employees' hand over the food to sense the heat. The policy further states that Do not touch the food to test the temperature.

Observation of Resident R65 being assisted with dining on April 12, 2024, 8:35 a.m., revealed the resident was served a bowel of cream of wheat (a hot cereal). Resident R65 was observed with nurse aide, Employee E7 seated to the resident right at the table to assist resident R65 with the consumption of her meal. Nurse aide, Employee E7 was observed inserting her index finger into the resident's bowl of cream of wheat to check for the temperature, then wiped hand in napkin. Nurse aide, Employee E7 was then observed pouring ice cubes into the cereal.

Interview with Nurse aide, Employee E7 at time of observation stated that she placed her hand over the bowel to indicate the temperature of it. Employee E was instructed by dietary staff to wash her hands, apply gloves and resident was given a new bowel of cereal.

28 Pa. Code 211.6 (f) Dietary services




 Plan of Correction - To be completed: 06/18/2024

A. Resident #65 experienced no ill effects. Resident was immediately provided with a new meal. Employee #7 was instructed to apply gloves and not to use finger to assess temperature of meals. Employee # 7 no longer works at Cathedral Village.

B. The Director of Dining or designee will conduct a random audit of meal observations to determine that meals are being temped appropriately by 6/2/2024

C. The Director of Dining or designee will provide reeducation to dining and nursing team members on the Infection control policy related to temping foods by 6/18/2024

D. The Director of Dining or designee will conduct an audit weekly X4 weeks and then monthly X2 months during 3 random meals to ensure infection control practices are being followed as appropriate when temping food. Audit findings will be forwarded to the Quality Assurance Performance Improvement team for review and recommendations, to include ensuring successful evaluation.

§ 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 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 12 residents on evening shift and nurse aide per 20 residents on night for one of 21 days. (February 1, 2024, April 1, 2024, and April 2, 2024)

Findings Include:

Review of facility census data indicated that on February 1, 2024, the facility census was 77, which required 3.88 (77 residents divided by 20) NA's during the night shift. Review of the nursing time schedules revealed 3.07 NA's provided care on the night shift on February 1, 2024. No additional excess higher-level staff were available to compensate for this deficiency.

Review of facility census data indicated that on April 1, 2024, the facility census was 80, which required 4 (80 residents divided by 20) NA's during the night shift. Review of the nursing time schedules revealed 3.07 NA's provided care on the night shift on April 1, 2024. No additional excess higher-level staff were available to compensate for this deficiency.

Review of facility census data indicated that on April 2, 2024, the facility census was 79, which required 3.95 (79 residents divided by 20) NA's during the night shift. Review of the nursing time schedules revealed 3.07 NA's provided care on the night shift on April 1, 2024. No additional excess higher-level staff were available to compensate for this deficiency.

This information was provided during an interview with the Administrator on April 26, 2024, at 1:30 p.m.



 Plan of Correction - To be completed: 06/18/2024

A. Facility to ensure that nurse's aide ratios are met with adequate staffing

B. Staffing Coordinator or designee will conduct an audit of staffing schedules from 5/2/24-6/2/24 to ensure nurses aide ratios are met.

C. Nursing Home Administrator will reeducate Staffing Coordinator on the Department of Health's Guidance for Calculating Staff to Resident Ratios and Direct Nursing Care Hours by 6/18/24.

D. Staffing Coordinator or designee will conduct up to 2 random weekly audits of staffing schedules to ensure that nurses aide ratios are met.

§ 211.12(f.1)(5) LICENSURE Nursing services. :State only Deficiency.
(5) Effective July 1, 2023, a minimum of 1 RN per 250 residents during all shifts.
Observations:

Based on a review of nursing time schedules, it was determined that the facility failed to meet the minimum Registered Nurse (RN) to resident ratio for one of 21 days reviewed. (April 3, 2024)

Findings include:

A review of nursing schedules and facility documentation for April 3, 2024 revealed the following:

The facility failed to meet the minimum RN to resident ratio of one RN for 250 residents on the night (11:00 p.m. to 7:00 a.m.) shift on April 3, 2024. Facility census of 78 and required 8 hours of RN hours. Only 7 hours of RN care provided.



 Plan of Correction - To be completed: 06/18/2024

A. Facility ensured adequate RN staffing on 4/3/2024. 11p-7a Nursing Supervisor worked a total of 8 hours, deployment sheet is reflective of Nursing Supervisors meal break. ADON relieved Nursing Supervisor prior to shift ending, providing full RN coverage.

B. Staffing Coordinator or designee will conduct an audit of staffing schedules from 5/2/24-6/2/24 to ensure RN ratios are met.

C. Nursing Home Administrator will reeducate Staffing Coordinator on the Department of Health's Guidance for Calculating Staff to Resident Ratios and Direct Nursing Care Hours by 6/18/24.

D. Staffing Coordinator or designee will conduct up to 2 random weekly audits of staffing schedules to ensure that RN ratios are met.


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