Nursing Investigation Results -

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

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
GARDENS AT CAMP HILL, THE
Inspection Results For:

There are  137 surveys for this facility. Please select a date to view the survey results.

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


Based on a Medicare/Medicaid recertification, State Licensure and Civil Rights survey and an abbreviated survey in response to three complaints completed on February 6, 2020, it was determined that Gardens of Camp Hill was not in compliance with the requirements of 42 CFR Part 483, Subpart B Requirements for Long Term Care Facilities and the 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations as they relate to the Health portion of the survey process.



 Plan of Correction:


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

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

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

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

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

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

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

Based on observation, facility policy review, clinical record review, and staff interview, it was determined that the facility failed to 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 in two of two nursing units (Floors 1, and 2).

Findings include:

Review of facility document titled, "Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings (2007)" with a review date of February 15, 2017 revealed, "Healthcare personnel caring for patients on Contact Precautions wear a gown and gloves for all interactions that may involve contact with the patient or potentially contaminated areas in the patient's environment. Donning Personal Protective Equipment (PPE) upon room entry and discarding before exiting the patient room is done to contain pathogens, especially those that have been implicated in transmission through environmental contamination (e.g., VRE, C. difficile, noroviruses, and other intestinal pathogens; RSV)"

Observation on February 3, 2020, at 8:56 AM revealed Nurse Aide (NA) 1 entering Resident 41's room, who is on contact precautions for RSV (Respiratory Syncytial Virus -a respiratory virus that usually causes mild, cold-like symptoms). NA 1 entered the room, wearing only a mask (which NA 1 was observed wearing at all times), and gave Resident 41 his breakfast tray. NA 1 then exited the room, did not perform hand hygiene or change her mask and then proceeded to take Resident 80's breakfast tray into his room.

Observation on February 3, 2020, at 9:00 AM revealed NA 1 and NA 2 enter Resident 13's room, who is on contact precautions for RSV. Neither NA 1 or NA 2 donned any PPE, except a mask that NA 1 was wearing continuously. NA 1 and NA 2 were observed, with no PPE, pulling Resident 13 up in the bed. Upon leaving the room, NA 1 did not change her mask.

Observation during medication administration on February 4, 2020, at 8:52 AM revealed Registered Nurse (RN) 1 enter Resident 67's room, who is on contact precautions for RSV. RN 1 donned PPE prior to entering the room and then proceeded to check Resident 67's blood glucose level using a glucometer. RN 1 then exited the room, still wearing the PPE, and was observed putting the glucometer on top of the clean isolation bin outside of the room and removing her PPE and placing it in the trash can in the room across the hall from Resident 67's room. RN 1 stated that since both Residents were on contact precautions for RSV, they were sharing the bins to discard the used PPE.

On February 5, 2020, at 3:08 PM the Nursing Home Administrator (NHA) and the Director of Nursing (DON) were both made aware of the aforementioned observations.

During an interview with RN 3 on February 6, 2020, at 9:16 AM she stated that each room should have two garbage cans in them, one with a red biohazard bag, and that nursing is responsible to put them in the rooms when a resident gets placed on precautions.

Observation during medication administration on February 4, 2020, at 8:33 AM revealed RN 1 checking Resident 54's blood glucose. RN 1 did not clean or disinfect the glucometer after using it on Resdient 54. RN 1 then used the same glucometer to check Resident 67's blood glucose.

Observation during medication administration on February 5, 2020, at 8:31 AM revealed RN 2 checking Resident 46's blood glucose. RN 2 did not clean or disinfect the glucometer after using it to check Resident 46's blood glucose.

Review of the manufacturer's guidelines for the glucometer revealed "The meter should be cleaned and disinfected after use on each patient."

On February 5, 2020, at 3:08 PM the NHA and DON were made aware of the aforementioned observations. No additional information was provided to the surveyor.

Review of facility policy Urinary Catheter, revised September 2014; revealed "be sure the catheter tubing and drainage bag are kept off the floor."

Review of Resident 36's clinical record revealed diagnoses that included; multiple sclerosis (a chronic progressive disease involving damage to the sheaths of nerve cells in the brain and spinal cord, symptoms include numbness, impaired speech, muscle coordination, blurred vision, and severe fatigue),chronic kidney disease (gradual loss of kidney function), and depression (feelings of severe despondency and dejection).

Review of Resident 36's February 2020 physician orders revealed orders that included: Foley catheter (a thin sterile tube inserted into the bladder to drain urine) care every shift related to multiple sclerosis, with start date of November, 25, 2019.

Review of Resident 36's care plan revealed a focus area for alteration in elimination of bowel and bladder related to chronic kidney disease, indwelling urinary catheter (a thin sterile tube inserted into the bladder to drain urine) due to neurogenic bladder (lack of bladder control due to a brain, spinal cord or nerve problem), multiple sclerosis, with an initiated date of August 5, 2011, and a revision date of September 10, 2019. Interventions for the aforementioned focus area included: check placement and function of colostomy bag every shift and as needed, with an initiated date of December 18, 2016, and a revision date of February 15, 2017; deep drainage bag of catheter below the level of the bladder at all times and off the floor, with a n initiated date of August 5, 2011, and a revision date of August 2, 2018.

Observation on February 4, 2020, at approximately 2:42 PM revealed Resident 36 in her room, in her chair with the catheter bag on the floor at the right side of her chair, visible from the hallway.

During an interview with the Nursing Home Administrator on February 6, 2020, at approximately 10:47 AM it was revealed the expectation the catheter bag should not be on the floor, it was also revealed that at times the catheter bag will become un hooked from a bed or chair.

Review of Resident 43's clinical record revealed diagnoses including acute lower respiratory infection (infection of the lung alveoli) and respiratory syncytial virus (a syncytial virus that causes respiratory tract infections).

Review of Resident 43's current physician orders dated February 5, 2020 revealed an order for Contact Precautions ordered January 24, 2020 and started January 24, 2020.

Observation of Nurse Aide 4 (NA 4) on February 3, 2020 at 12: 55 PM revealed NA 4 was in Resident 43's room wearing only vinyl gloves as PPE preparing Resident 43's meal and assisting her with setting up her meal on her over-bed table. NA 4 also adjusted Resident 43's bed so she was in position to eat. NA 4 then stopped assisting Resident 43 with meal preparation went to the exit of the room and retrieved a gown from the PPE bin located outside of Resident 43's room, donned a gown and continued assisting the resident with meal preparation.

Review of Resident 73's February 2020 physician orders revealed diagnoses including hypertension ( elevated blood pressure) and a history of falling.

Observations in Resident 73's room, on February 4, 2020, at 8:43 AM and 1:09 PM revealed one glove on the floor next to her bedside table.

An interview with the Nursing Home Administrator, on February 6, 2020, at approximately 1:30 PM revealed an expectation staff would have picked up and disposed of the glove on Resident 73's floor.

Review of Resident 76's clinical record revealed diagnoses of respiratory syncytial virus (a syncytial virus that causes respiratory tract infections). and altered mental status (a disruption in how your brain works that causes a change in behavior).

Review of Resident 76's current physician orders revealed an order for Droplet precautions ordered January 27, 2020 and started January 27, 2020.

Observation of a PPE bin outside of room 209 (Resident 76's room) on February 3, 2020 at 10:00 revealed a used lancet sitting on top of the PPE bin. When asked about the whether or not the lancet was used, RN3 agreed that it was used and should have been placed into the sharps container hanging in the hallway. RN3 then pointed to the sharps container and the container was full with 4 used disposable razors hanging out of the top of the box. RN3 then directed another staff member to dispose of the container and replace it with a new one. At that time I also made the observation that the PPE disposal bins that are supposed to be located in the room 209 were located in the hallway outside of the room. RN3 agreed and with the observation and moved the PPE disposal bins inside of the room and out of the hallway.

28 Pa code 211.10(d) Resident care policies
28 Pa code 211.12(d)(5) Nursing services












 Plan of Correction - To be completed: 03/25/2020

1. Nurse Aide 1 has been educated on entering R41's room while on contact precautions for RSV for proper Donning/Doffing and hand sanitation prior to exiting this pts room. Nurse Aide 1 and 2 have been educated on donning of PPE including mask changing for R13. Nurse Aide 4 was educated on donning and doffing PPE equipment for resident R43. RN 1 has been educated on the Doffing of PPE equipment before exiting R 67's room, cleaning the glucometer immediately upon exiting R67's and R54's room. RN 2 has been educated on the cleaning of glucometer after checking blood sugar for R 46. The glucometers have since been properly disinfected per manufacturer's guidelines. R36's Foley catheter bag has been appropriately placed and no longer on the floor. The glove observed on the floor in R73's room has been removed and discarded. The lancet observe on the top of the PPE bin for R76 has been removed. The sharps container outside of R76's room has been discarded and a new sharps container has been placed inside the resident's room.
2. Residents requiring Contact precautions and use of glucometers are at risk for this alleged deficient practice. Staff were immediately provided on the spot education regarding appropriate hand hygiene, PPE usage, glucometer cleaning between resident use.
3. The facility will provide staff education regarding the appropriate use, maintaining an infection prevention and control program to ensure a safe sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections.
4. The DNS or designee will perform 5 random audits observing infection control practices weekly x 4 weeks, then monthly x 2 or until substantial compliance has been achieved. All results will be presented at QAPI committee for further review and recommendations as appropriate.
5. The facility will be in substantial compliance by 3/25/2020.

483.10(g)(6)-(9) REQUIREMENT Right to Forms of Communication w/ Privacy: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(g)(6) The resident has the right to have reasonable access to the use of a telephone, including TTY and TDD services, and a place in the facility where calls can be made without being overheard. This includes the right to retain and use a cellular phone at the resident's own expense.

483.10(g)(7) The facility must protect and facilitate that resident's right to communicate with individuals and entities within and external to the facility, including reasonable access to:
(i) A telephone, including TTY and TDD services;
(ii) The internet, to the extent available to the facility; and
(iii) Stationery, postage, writing implements and the ability to send mail.

483.10(g)(8) The resident has the right to send and receive mail, and to receive letters, packages and other materials delivered to the facility for the resident through a means other than a postal service, including the right to:
(i) Privacy of such communications consistent with this section; and
(ii) Access to stationery, postage, and writing implements at the resident's own expense.

483.10(g)(9) The resident has the right to have reasonable access to and privacy in their use of electronic communications such as email and video communications and for internet research.
(i) If the access is available to the facility
(ii) At the resident's expense, if any additional expense is incurred by the facility to provide such access to the resident.
(iii) Such use must comply with State and Federal law.
Observations:
Based on review of facility documentation and staff interviews it was determined that the facility failed to maintain residents' ability to communicate with individuals and entities outside the facility by failing to consistently maintain accessible telephone services.

Findings include:

Review of Resident 23's clinical record revealed diagnoses that included a Right Above Knee Amputation, Left Below Knee Amputation and Chronic Obstructive Pulmonary Disease (a lung disease characterized by chronic obstruction of lung airflow that interferes with normal breathing and is not fully reversible) with the use of continuous oxygen.

Review of Resident 23's clinical progress notes revealed documentation of two phone calls from Resident 23's family on October 10/22/2019 and November 11, 2019.

Review of documentation of the October 10, 2019, call revealed " Incident Note : granddaughter called at 1900 (7:00 PM) and wanted to speak with her grandmother on the phone. The charge nurse informed the granddaughter that (Resident 23) was in bed and unable to come to the phone as she has not been feeling well today. The granddaughter became upset yelling at the charge nurse. This RN heard the charge nurse state "there are no cordless or cell phones available for the resident's use". After a pause, the LPN stated "I will not be spoken to in that manner, I will get my supervisor for you". When I took the phone, the granddaughter stated that her family pays a monthly fee for the landline in her grandmother's room and she wanted to be connected to it immediately. This nurse explained there are no phones in the resident room unless the resident's have personal cell phones. The granddaughter then asked for my name and title and the LPNs name which were provided. She asked how long I was employed and this writer responded less than a year. The granddaughter then stated "then you don't know F***ing anything, I will call management tomorrow" and hung up the phone.

Review of documentation of the November 11, 2019, call revealed " Nursing Note:... Contacted RP, (daughter) and informed her of .."(new physician orders)" ( Daughter asked if the phone had arrived that was to be ordered so the resident could speak to her family. RP was informed there are currently no cordless phones in the facility. The RP stated she will call and speak to the administrator tomorrow regarding a cordless phone for resident use."


During an interview with Director of Nursing (DON) on February 5, 2020, at 10:43 AM, DON revealed that they have had cordless phone in facility since about six weeks...so if the referenced phone calls occurred prior to December 2019, they did not have a phone that could be given to residents. The above phone calls made by Resident 23's family requesting to speak to her thereby occurred during the time frame of the facility not having a cordless phone. No additional information was provided as to when the previous phones had become unavailable. No additional information provided by facility to reveal whether any alternate attempts to facilitate Resident 23's family to speak to her were provided or that facility had contacted family as a result of the family phone calls.

Review of facility "Telephone" policy revealed " The resident has the right to have reasonable access to the use of telephone where calls can be made without being overheard. It is the policy of this facility to provide every resident with an opportunity to have access to a telephone for private conversations with loved ones and friends." Guidelines include "




During interview with director of Nursing (DON) and Nursing Home Administrator o (NHA) on February 5, 2020, at approximately 2:45 PM, the DON revealed the expectation that phones should have been available.




28 Pa. Code 201.14(a) Responsibility of licensee


28 Pa. Code 201.29(j) Resident rights












 Plan of Correction - To be completed: 03/25/2020

1. Resident 23 was offered a cordless phone in order to speak in privacy when requested.
2. Residents who wish to have the ability to communicate with individuals and entities outside the facility are at risk for this alleged deficiency. SSD will ensure that residents have the ability to communicate with individuals and entities outside the facility by informing the resident's through resident council and room visits.
3. The Nursing staff and Department Head Team, will be educated on availability and use of cordless telephones.
4. The NHA or designee will conduct 5 random audits weekly x 4 and monthly x 2 or until substantial compliance is achieved, through resident interviews conducted to verify ability to access cordless phone for privacy use. Results of these observations will be brought to the QAPI committee for further review and recommendations as appropriate.
5. The facility will be in substantial compliance by 3/25/2020.

483.75(a)(2)(h)(i) REQUIREMENT QAPI Prgm/Plan, Disclosure/Good Faith Attmpt: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.
483.75(a) Quality assurance and performance improvement (QAPI) program.

483.75(a)(2) Present its QAPI plan to the State Survey Agency no later than 1 year after the promulgation of this regulation;

483.75(h) Disclosure of information.
A State or the Secretary may not require disclosure of the records of such committee except in so far as such disclosure is related to the compliance of such committee with the requirements of this section.

483.75(i) Sanctions.
Good faith attempts by the committee to identify and correct quality deficiencies will not be used as a basis for sanctions.
Observations:

Based on staff interviews, review of facility documention and facility survey history it was determined that the facility failed to implement and maintain an effective Quality Assurance program to identify and correct ongoing care issues for the the residents.

Findings include:

The QAPI (Quality Assurance and Performance Improvement) Plan was requested at the entrance meeting on February 3, 2020 at approximately 8:45 AM. On February 6, 2020 at 9:03 AM the QAPI plan was requested again. Again on February 6, 2020 at 11:49 AM the QAPI plan was requested.
The facility did not provide a QAPI plan.

During the QAPI interview on February 6, 2020 at 9:03 the Nursing Home Administrator stated that the committee identifies concerns by reviewing grievances, looking for trends, internal audits with medication errors, ect, observations made by staff and quality measure results.

Deficient practice was identified in reviewing and revising care plans, unnecessary medications and complete and accurate documentation on the full health survey in 2016, 2017, 2018 and 2019. Those same deficient practices were identified throught the week.

When interviewed about repeating deficiencies the Nursing Home Administrator stated that they have been working on making sure that the care plans were correct and match the physician orders since August doing approximately four to six residents a week. The survey team identified deficient practice with reviewing and revising the care plan for six residents during the survey.

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

28 Pa. Code: 201.18(b)(1)(2)(e)(1)(3)(4) Management















 Plan of Correction - To be completed: 03/25/2020

1. The facility QAPI plan has been updated to implement and maintain an effective Quality Assurance program to identify and correct ongoing care issues for the residents.
2. Residents requiring care plans, medications, complete and accurate documentation are at risk for this alleged deficient practice. The QAPI committee will meet monthly to discuss current QM/ PIPs and any identified deficient practices.
3. The QAPI team will be in-serviced on the function of the committee to ensure the implementation and the maintenance of an effective Quality Assurance Program to identify and correct ongoing care issues for the residents.
4. The Administrator will audit monthly QAPI meeting minutes for 3 months or until substantial compliance is achieved.
5. The facility will be in substantial compliance by 3/25/2020.

483.60(i)(1)(2) REQUIREMENT Food Procurement,Store/Prepare/Serve-Sanitary: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(i) Food safety requirements.
The facility must -

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

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

Based on observation, review of facility policy, and interviews it was determined that the facility failed to store and serve food/beverages in accordance with professional standards for food safety for two of two panty refrigerators/freezers (pantries on the first and second floors), and maintain a sanitary environment for clean and ready to use dinnerware in the dish room.

Findings include:

Review of facility policy Food Storage, without an initial or revision date, revealed that un-served leftovers shall be labeled, dated and stored for a period not to exceed three days.

Review of facility policy Food From Outside Sources, without an initial or revision date, revealed that "visitors/family member will label food and beverages with the resident's name, room number and date.

Observation in the first floor pantry refrigerator on February 3, 2020, at approximately 08:58 AM, revealed: one container of nectar thickened apple juice that was opened with contents partially removed, wasn't labeled with an open date; one container of honey thickened orange juice that was opened with contents partially removed, wasn't labeled with an opened date; and one container of nectar thickened lemon flavored water that was opened with contents partially removed, wasn't labeled with an open date.

During an interview with Registered Dietitian 1 (RD 1) on February 3, 2020, at approximately 09:00 AM it was revealed that food and beverage items should be dated once they are opened.

During an interview on February 5, 2020, at approximately 3:27 PM with the Director of Nursing it was revealed that food and beverages should be dated once opened.

Observation in the 2nd floor pantry freezer on February 3, 2020, at approximately 09:05 AM revealed one box of frozen pad Thai dinner that did not contain a resident name.

During an interview with Registered Dietitian 1 on February 3, 2020, at approximately 09:05 AM it was revealed that the aforementioned item should be labeled with a resident's name.

During an interview on February 5, 2020, at approximately 3:27 PM with the Director of Nursing an expectation was not revealed, however it was revealed that the pantries are locked and staff would be responsible to store resident food in the refrigerator/freezer.

Observation in the dish room on February 3, 2020, at approximately 2:05 PM on the "clean side" of the dish machine there was a partially eaten grilled cheese sandwich on a napkin, alongside four racks of clean dishes.

During an interview with Registered Dietitian 1 (RD 1) on February 3, 2020, at approximately 2:05 PM it was revealed that no one should eat in the kitchen area, and the sandwich didn't belong on the "clean side" of the dish machine.

During an interview on February 5, 2020, at approximately 3:27 PM with the Nursing Home Administrator it was revealed that there isn't a policy regarding use of the dish machine. However it was revealed that partially eaten food should not be on the clean side of the dish room.

28 Pa code 211.6(b)(d) - Dietary Services











 Plan of Correction - To be completed: 03/25/2020

1. The undated food items have been removed from the first and second floor pantry. The partially eaten grilled cheese sandwich has been removed and discarded from the "clean side" of the dish machine.
2. A facility audit has been completed to ensure that first and second floor pantries contain no open undated or unlabeled food items and no food is placed on the clean side of the dish machine.
3. The nursing and dietary staff will be re-educated on proper storage and serve food/beverages in accordance with professional standards for food safety.
4. The FSD or designee will audit the 1st and 2nd floor pantries weekly x 4, then monthly x 2; audit the clean side of the dishwasher to ensure that no food is being left there weekly x 4, then monthly x 2 or until substantial compliance has been achieved. The results will be presented at QAPI committee for further review and recommendations as appropriate.
5. The facility will be in substantial compliance by 3/25/2020.

483.25 REQUIREMENT Quality of Care:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
483.25 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 observation, clinical record review, and resident and staff interview, it was determined that the facility failed to ensure care and services are provided in accordance with professional standards of practice that will meet each resident's physical, mental, and psychosocial needs for four of 29 residents reviewed (Residents 17, 24, 42 and 52).

Findings include:

Review of the physician orders for Resident 17 revealed diagnoses that included respiratory failure and hypoxia (condition in which the body or a region of the body is deprived of adequate oxygen supply).

On December 3, 2019 Occupational Therapy made a recommendation for Resident 17 to have towel rolls to bilateral hands instead of the hand splints that were ordered because they made Resident 17's hands sweat. Review of physician orders also revealed an order dated August 21, 2019 for heel raising boots to bilateral feet at all times.

Observations on February 3, 2020 at 9:16 AM the resident did not have heel raising boots and her heels were on the bed and not elevated. She also did not have washcloths in her hands. Further observation on February 4th and February 5th revealed that Resident 17 was not wearing heel raising boots and her heels were not elevated.

The facility was made aware of the observations, no further information was provided.

Review of Resident 24's clinical record revealed diagnoses that included Multiple Sclerosis (MS- a disease in which the immune system eats away at the protective covering of nerves) and Parkinson's Disease (a disorder of the central nervous system that affects movement, often including tremors).

During an interview with Resident 24's Responsible Party (RP), on February 3, 2020, at 12:55 PM he stated that Resident 24 was supposed to have a neurology appointment on this day (February 3) but the facility rescheduled it. He stated that the facility called him earlier to tell him they had no transportation to take Resident 24 to her appointment and it had to be rescheduled. As of February 5, 2020, Resident 24's neurology appointment was rescheduled for June 3, 2020, four months later.

Review of nursing progress note dated February 3, 2020, at 11:46 AM revealed that Resident 24's neurology appointment was cancelled due to late notice to transport and they were unable to accommodate Resident 24. Per the nursing note, transportation will reschedule appointment.

Review of Resident 24's clinical record revealed that on June 5, 2019, Resident 24 had an appointment with neurology. Review of the consultation report located in Resident 24's clinical record, revealed that she was to follow up with neurology in six months.

On February 5, 2020, the facility provided the surveyor with a correspondence from the transportation coordinator stating that Resident 24's RP made the appointment and didn't inform them until February 2, 2020. During an interview with Resident 24's RP on February 5, 2020, at 12:09 PM he stated that he got a reminder call about the appointment on Friday, January 31 and he told the facility on that day.

During an interview with the Nursing Home Administrator on February 6, 2020, at 11:02 AM she stated that someone from the facility should have followed up on the six month appointment, per the neurology consult on June 5, 2019.

Review of the physician orders for Resident 42 revealed diagnoses that included visual loss in both eyes and lupus (an autoimmune disease in which the body's immune system becomes hyperactive and attacks normal, healthy tissue).

Review of clinical record revealed that on January 22, 2020, Resident 42 was to have an operative procedure for cataract extraction with implant. Pre-surgery instructions directed staff to not take certain medications the morning of surgery. These medications included: Vitamin C, Hydrochlorothiazide (used to treat high blood pressure and fluid retention) and Benicar (used to treat high blood pressure).

Review of the Medication Administration record for January 2020 revealed that Resident 42 received all of the scheduled medications the day of surgery.

During an interview on February 6, 2020 at 12:35 PM, the Nursing Home Administrator confirmed that the medications were given despite pre-surgery instructions.

Review of Resident 52's clinical record revealed diagnoses that included Diabetes Mellitus (a disease in which the body ' s ability to produce or respond to the hormone insulin is impaired, resulting in abnormal metabolism of carbohydrates and elevated levels of glucose in the blood and urine) and Partial Traumatic Amputation of one Right Lesser Toe.

During interview with Resident 52 on February 3, 2020, at 11:50 AM, resident revealed that since his admission on December 12, 2019, there was a day when his dressings weren't changed, resident was unable to give further detail.
Review of facility Grievance Tracking Log revealed that Resident 52 placed a grievance on January 8, 2020, alleging that his dressing changes were not completed on Janaury 6, 2020. Review of a facility Grievance/Concern Form revealed investigation conclusion that two Licensed Practical Nurses (LPN) 5 and 6, had signed off on Resident 52's Treatment Administration Log on January 6, 2020, to indicate that the treatment "right foot dressing:Remove ACE Wraps-remove wound dressing(may need to soak it off)-cleanse with 1/4 strength Daikins Solution (solution used to prevent and treat skin and tissue infections that could result from cuts, scrapes and pressure sores) -pat dry. Apply betadine to open area. Cover with ABD (used for large wounds or for wounds requiring high absorbency) pad and kling wrap dressing (self-adherent elastic wrap). Apply Light ACE compression from toes to just below knee. off load pressure to area. every day and evening shift" with a start date of December 31, 2019, and a discontinue date of Janaury 15, 2020, had been completed for both the day and evening nursing shifts and that "statements from nurses concluded that because the wound nurse had assessed that morning they thought the treatment had been completed." Further review of the grievance form revealed that education was provided to LPN 1 and 2 as they had not completed the dressing changes they had signed off and that the education provided on January 9, 2020, included "It is the expectation that that staff complete dressing changes as ordered by the physician."

During an interview with Director of Nursing (DON) on February 6, 2020, at 12:01 PM, the DON confirmed that Resident 52's dressing change treatments should have been done.



28 Pa. Code 211.5(f) Clinical records

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









 Plan of Correction - To be completed: 03/25/2020

1. Resident 17 had heel raising boots discontinued, R17 also had towel rolls placed in bilateral hands. Resident 24 had physicians order for neurology follow up discontinued per hospice recommendations. Resident 42's physician was notified and had no negative outcome from receiving medication prior to eye surgery. Resident 52 had his wound dressing changed according to physician orders and nurses were educated on dressing changes and treatment.
2. Residents who require towel rolls, neurology consults, medications prior to surgery and dressing changes are at risk for this alleged deficient practice. The facility completed a house wide audit for resident Kardex reviews to ensure accuracy on heel raising boots, towel rolls, neurological f/u, following physician order medication prior to surgery.
3. Education has been provided to nursing staff to ensure care and services are provided in accordance with professional standards of practice that will meet each resident's physical, mental and psychosocial needs.
4. The DNS or designee will audit 5 random resident Kardex's, 5 resident consult reports, and 5 resident's TAR documentation weekly x 4, then monthly x 2 or until substantial compliance has been achieved.
5. The facility will be in substantial compliance by 3/25/2020.

483.24(c)(1) REQUIREMENT Activities Meet Interest/Needs Each Resident: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(c) Activities.
483.24(c)(1) The facility must provide, based on the comprehensive assessment and care plan and the preferences of each resident, an ongoing program to support residents in their choice of activities, both facility-sponsored group and individual activities and independent activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community.
Observations:

Based on observation, clinical record review and interviews with residents and staff, it was determined that the facility failed to provide an activity program that met the needs and interests of all residents and in accordance with care planned interventions for four of 29 sampled residents (Residents 5, 17, 42 and 51) and failed to employ an activities director for resident activities since August 2019.

Findings include:

During an interview with the Nursing Home Administrator (NHA) on February 6, 2020 at 11:10 AM she confirmed that there was no documentation of activity participation for residents from June 2019 until January 2020.

The NHA confirmed that the activity director went on medical leave and then resigned in December and the Activities Director from another building has been filling in. She was made aware of the lack of activity participation for residents and activity staff to carry out an activity program for residents.

During an interview with the activity aid on February 6, 2020 at 11:24 AM she stated that the activity director left on medical leave in August, returned for four days in November and then came back in in December and resigned. She stated that the Activity director from another building has been coming once a week to help her since December.

Review of Resident 5's February 2020 physician orders revealed diagnoses including difficulty walking and a history of alcohol dependence.

Review of Resident 5's Annual Minimum Data Set (MDS- all tool used to assess all care areas specific to the resident), dated November 2, 2019, revealed under Section F- Preferences for Customary Routine and Activities, Resident 5's responses to questions regarding his likes and desires for passing time.

According to Resident 5, his daily preferences and activity preferences include making personal choices, using the telephone in private, having snacks between meals, listening to music, being around pets, keeping up with the news and having books, newspapers and magazines to read.

Review of Resident 5's interdisciplinary plan of care revealed interventions developed to address his participation in recreational programming such as "introduce me to others with similar interests," "invite me to my favorite activities...music groups, trivia, socials, games, outdoors," and " please help me get music related to my favorite artists and styles."

Review of Resident 5's Individual Daily Activities forms revealed no staff documenation of participlation in his desired recreational activities per his individualized plan of care and MDS assessment.

Review of the physician orders for Resident 17 revealed diagnoses that included respiratory failure and hypoxia (condition in which the body or a region of the body is deprived of adequate oxygen supply). The resident is non-verbal and her cognitive skills are severely impaired.
Daily observations of Resient 17 on February 3rd, 4th, and 5th, she was laying in bed, the room was dark and her roommate had the curtains pulled all around her.
Review of the current care plan revealed a focus area for "Alteration in recreation characterized by
little or no involvement, reduced activity participation related to: Chronic health conditions, cognitive deficits, impaired communication, impaired decision making, impaired mobility, impaired social
interaction. Interventions included to Offer activity program directed toward specific interests/ needs of resident, arrange for activity aide to visit and encourage resident to observe or designate activity.

The facility was unable to provide an activity assessment that for Resident 17 to determine an appropriate activity program.

Review of the physician orders for Resident 42 revealed diagnoses that included visual loss in both eyes and lupus (an autoimmune disease in which the body's immune system becomes hyperactive and attacks normal, healthy tissue).

During an interview with Resident 42 on February 3, 2020 at 8:59 AM she stated that activity participation is a challenge for her because she is blind.

Review of the current care plan for Resident 42 revealed a focus for the need for socialization
secondary to impaired mobility and physical disability. Interventions include to converse of current events, specifically personal interests of resident such as: politics, current events, advise resident of activity programs such as bingo, movies, special events, Converse with resident about topics of interest such as: traveling, hot air balloons, crafting, games and to transport the resident to activity of choice.

Review of the MDS dated November 22, 2019 revealed that it was very important to her to do her favorite activities and go outside. It was also somewhat important for her to do things with groups of people and listen to music.

Review of activity participation for June 2019 revealed that she had two 1:1 visits, one outing, and four "ice cream cart" for the month.

There was no activity documentation until January 2020 which included four coffee/ice cream and one exercise for the month.

Review of Resident 51's February 2020 physician orders revealed diagnoses including aphasia ( loss of ability to understand or express speech, caused by brain damage) and disorders of the brain.

Review of Resident 51's interdisciplinary plan of care revealed the staff's assessment of his desire to participate in recreational activities such as "Music, trivia, socials." Also, "Invite me to outings."

Review of Resident 51's Individual Daily Activities forms revealed no documenation of participation in the assessed recreational activities developed on the individualized plan of care.







28 Pa. Code 201.29(j) Resident rights

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


 Plan of Correction - To be completed: 03/25/2020

1. Resident 5, 17, 42, and 51 have had their activity preferences assessed and care planned accordingly.
2. The facility has hired a permanent Activities Director, who started in the facility on 2/10/2020. Residents with activity preferences are at risk for this alleged deficient practice. A facility review of resident activity preferences will be completed to ensure the needs and interest of all residents in accordance with care planned interventions have been met.
3. Education has been provided to the Activities Director on documenting resident participation in activities and completing activity assessments.
4. The Activities Director will complete 5 random observations for activity documentation and activity preferences weekly x 4, then monthly x 2 or until substantial compliance has been achieved. The findings will be presented at QAPI for review and recommendations.
5. The facility will be in substantial compliance by 3/25/2020.

483.21(b)(2)(i)-(iii) REQUIREMENT Care Plan Timing and Revision: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.
483.21(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 clinical record review, as well staff and resident interview, it was determined that the facility failed to ensure the care plan was reviewed and revised for six of twenty-nine residents reviewed (Residents 17, 24, 43, 61, 72, and 81).

Findings include:


Review of the physician orders for Resident 17 revealed diagnoses that included respiratory failure and hypoxia (condition in which the body or a region of the body is deprived of adequate oxygen supply).

Review of the current care plan on February 4, 2020 revealed a care plan indicating Resident 17 had a foley catheter (a tube placed into the bladder to drain urine).

Observation on February 4, 2020 at 1:05 PM with Registered Nurse (RN) 1 revealed that Resident 17 did not have a foley catheter.

During an interview with Director of Nursing on February 5, 2020 at 10:05 AM she confirmed that the care plan should have been revised when the foley catheter was discontinued.

Review of Resident 24's clinical record revealed diagnoses that included Multiple Sclerosis (MS- a disease in which the immune system eats away at the protective covering of nerves) and Parkinson's Disease (a disorder of the central nervous system that affects movement, often including tremors). During an interview with Resident 24's Responsible Party (RP), on February 3, 2020, at 12:44 PM he stated that Resident 24's upper partial went missing several months ago. He stated she does not have dentures, just an upper partial.

Review of Resident 24's admission nursing evaluation, dated February 5, 2019, revealed that Resident 24 "does not have/wear dentures." Review of Resident 24's current Kardex as of February 5, 2020, revealed Resident 24 is to have denture care every morning and night.

During a staff interview on February 6, 2020, at 11:04 AM the Nursing Home Administrator and Director of Nursing were asked about the contradictory information on the admission assessment and Kardex.

As of February 6, 2020, at 12:21 PM the facility provided no additional information to the surveyor.

Review of Resident 43's clinical record revealed diagnoses including acute lower respiratory infection (infection of the lung alveoli) and respiratory syncytial virus (a syncytial virus that causes respiratory tract infections).

Further review of Resident 43's current interdisciplinary care plan on February 4 revealed a care plan for "Martha is on an antibiotic for lower respiratory infection" with an intervention of "Oxygen as ordered, Date initiated 1/24/2020"

Review of Resident 43's current physician orders dated February 5, 2020 revealed no current physician order for supplemental oxygen.

Review of Resident 43's discontinued/stopped physician orders dated February 5, 2020 revealed that there were no previous orders for supplemental oxygen.

Interview with Nursing Home Administrator on February 6, 2020 at 10:00 AM revealed that she could not find any evidence that Resident 43 ever had an order for supplemental oxygen and that the intervention would be removed from the care plan.

Review of Resident 61's clinical record revealed diagnoses that included dementia (irreversible, progressive degenerative disease of the brain, resulting in loss of reality contact and functioning ability) and quadriplegia (paralysis of all four limbs).

Review of Resident 61's current physician orders revealed an order for DNR/DNI (do not resuscitate/do not intubate) and an order for contact isolation for C-diff (inflammation of the colon caused by the bacteria Clostridium difficile). Review of Resident 61's form titled "Pennsylvania Orders for Life-Sustaining Treatment," dated September 13, 2019, also revealed Resident 61 is a DNR.

Review of Resident 61's current care plan revealed a care plan for a Full Code, with an intervention to perform CPR as needed. Further review of Resident 61's current care plan failed to reveal a care plan for C-diff or contact precautions.

During a staff interview on February 5, 2020, at 10:07 AM the Director of Nursing stated that Resident 61's full code care plan was incorrect. Resident 61's care plan was revised on February 4, 2020, stating Resident 61 is a DNR.

During a staff interview with Registered Nurse 4, on February 5, 2020, at 1:14 PM RN 4 stated that Resident 61 never had a C-diff care plan.

Review of Resident 72's February 2020 physician orders revealed diagnoses including hypertension (elevated blood pressure) and dementia (a chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning).

Further review of Resident 72's physician orders revealed a code status of DNR (do not resuscitate).

A DNR is a request to not be resucitated in the event a person has no pulse and is not breathing.

Review of Resident 72's clinical record revealed a form titled "Pennsylvania Orders for Life-Sustaining Treatment," dated June 3, 2019 that also confirms the code status of DNR.

Review of Resident 72's interdisciplinary plan of care revealed "The resident has an advanced directive of Full Code." Also, "CPR (cardio pulmonary resuscitation) will be performed as needed."

An interview with the Director of Nursing (DON), on February 5, 2020, at 10:05 AM revealed an acknowledgment of the code status discrepancy and an agreement the care plan was "wrong" and changed to DNR status per Resident 72's wishes.

Review of Resident 81's clinical record revealed diagnoses that included History of Alcohol Abuse, Dementia (a chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning) and Chronic Kidney disease Stage VI (moderate kidney damage).

During an interview with Resident 81 on February 3, 2020, at approximately 12:30 PM, the resident brought up the subject of facility Social Worker not working with him to facilitate his getting out of the facility. Resident 81 showed papers which revealed that he had been contacting apartment places and the landlords had been getting back to him that places were available until certain dates and that some of the availability dates had passed recently.

Review of Resident 81's current Care Plan revealed a care focus area of "The resident wishes to transition to the community upon appropriate housing and services" with an initiation date of April 27, 2017, and a revision date of May 18, 2019. Review of this care plan's Goal revealed an initiation date of April 27, 2017, and a Revision date of September 12, 2019. Review of the associated Interventions to this care Focus area revealed nine interventions, all with a creation and revision date of April 27, 2017. The interventions included elements such as establishing living arrangements, community resources, pre-discharge plan, home services and living arrangements.

Review of Social Services notes revealed one note between September 10, 2018, and February 4, 2020. This one note was written on Janaury 9, 2019 (almost one year ago). Related to his discharge planning was written "His plan to transition to the community with the help of the NHT program; he is currently working with Center for independent Living of Central PA." The note written on February 4, 2020, by newly employed Social Worker (SW) 1, revealed that SW 1 had contacted Resident 81's POA (Power of Attorney) who revealed upon speaking with her "I have told him many times it is not safe for him to live alone, he wouldn't take medications, he wouldn't eat, he would die, he needs to stay here." During an interview with SW 1 on February 5, 2020, at 12:10 PM, SW 1 revealed that she didn't feel Resident 81 was appropriate for discharge. SW 1 revealed that she felt the care plan should have included information regarding the status of achieving things necessary for him to leave the facility.

Director of Nursing and Nursing Home Administrator were apprised of concern regarding Resident 81's transition to the community care Focus area not having been followed through with since 2017 on February 4, 2020, at approximately 3:20 PM. No additional information was provided.


42 CFR 483.21(b) Comprehensive Care Plans

28 Pa. Code 211.11(d)(e) Resident care plan

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



 Plan of Correction - To be completed: 03/25/2020

1. Resident's 17, 24, 43, 61, 72, and 81 have had their care plans reviewed and revised.
2. Residents requiring use of care plans are at risk for this deficient practice. A facility review or residents with care plan changes have been reviewed/revised completed in last 7 days to ensure accuracy.
3. Education has been provided to licensed nursing staff on updating and revising care plans.
4. The administrator or designee will complete 5 random audits of resident care plans weekly x 4, then monthly x 2 or until substantial compliance has been achieved. Results of these audits will be brought to the QAPI committee for further review and recommendations as appropriate.
5. The facility will be in substantial compliance by 3/25/2020.

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 is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.10(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 facility policy review, observations and staff interviews, it was determined that the facility failed to ensure that care and services were provided in a manner that enhanced resident dignity for three of 91 residents observed (Residents 17, 62, 87).

Findings Include:

Review of the physician orders for Resident 17 revealed diagnoses that included respiratory failure and hypoxia (condition in which the body or a region of the body is deprived of adequate oxygen supply). The clinical record for Resident 17 revealed that she has a tracheostomy (a tube placed into a person windpipe that allows air to enter the lungs).

Observations on February 3, 2020 at 9:16 AM revealed Resident 17 laying in bed with secretions on the side of her face. On February 4, 2020 at 12:03 PM and 1:05 PM Resident 17 had secretions on the side of her face.

The facility was made aware of the observations on February 5, 2020 at 2:20 PM and no further information was provided.

Review of the facility's policy titled "Quality of Life-Dignity," most recently revised August 2009, reads, in part, "Staff will knock and request permission before entering residents' rooms."

Surveyor observation on February 3, 2020, at 9:57 AM revealed Nurse Aide (NA) 3 entering Resident 87's room to answer his call bell without knocking or asking permission to enter.

During staff interview on February 6, 2020, at 10:55 AM the Director of Nursing stated that staff should be following the facility policy and knocking prior to entering a resident's room.

Review of Resident 62's clinical record revealed diagnosis of Gastro-esophageal reflux disease (a digestive disease in which stomach acid or bile irritates the food pipe lining) and essential hypertension (high blood pressure without a known cause).

On January 3, 2020 at 12:15 PM, Resident 62 was observed to be sitting in the dining room waiting to eat lunch. He was served his meal on a Styrofoam plate and ate his meal with plastic utensils. The other 3 residents at the table with him were served and ate from non-disposable dinnerware.

Review of Resident 62's current physician orders revealed no orders for Resident 62 to eat from Styrofoam plate with plastic utensils.

Review of Resident 62's current care plan revealed no care plan for Resident 62 to eat from Styrofoam plate with plastic utensils.

During an interview with the Nursing Home Administrator on February 5, 2020 at 10:20 AM revealed that Resident 62 was not care planned to eat on a Styrofoam plate with plastic utensils nor did Resident 62 have a physician's order to eat on a Styrofoam plate with plastic utensils. She revealed that she did not know why Resident 62 was served on a Styrofoam plate with plastic utensils that day but he should have been served on non-disposable dinnerware.

28 Pa. Code 201.29(j) Resident rights

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










 Plan of Correction - To be completed: 03/25/2020

1. Resident 17 immediately had the secretions wiped from her face.
Resident 87 is having their door knocked on before entering the room.
Resident 62 has had their plan of care updated to include the usage of disposable plates and utensils.
2. Residents with tracheostomies having secretions on their face, residents that ring their call bell, and residents that have disposable plates and utensils due to behaviors have the potential to be affected by this alleged deficient practice. These residents will have care and services provided in a manner to enhance dignity.
A house wide audit was conducted on residents with tracheostomies to ensure secretions were managed with dignity.
A house wide audit was conducted to ensure staff are knocking on doors before entering rooms.
A house wide audit was conducted on ensuring any residents utilizing disposable plates and utensils is appropriate and dignified per the plan of care.
3. All facility staff will be re- educated on the facility's Dignity Policy specifically ensuring residents with tracheostomies have secretions appropriately cared for, knocking on doors before entering rooms, and proper disposable plate and utensil usage.
4. The DNS or designee will conduct 5 random weekly observations to ensure residents with tracheostomies having secretions on their face, residents that ring their call bell, and residents that have disposable plates and utensils due to behaviors have this care and services provided in a dignified manner. These observations will be conducted weekly x4, then monthly x2 or until substantial compliance has been achieved. Results of these observations will be brought to the QAPI committee for further review and recommendations as appropriate.
5. The facility will be in substantial compliance by 3/25/2020.

483.20(f)(5), 483.70(i)(1)-(5) REQUIREMENT Resident Records - Identifiable Information: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.
483.20(f)(5) Resident-identifiable information.
(i) A facility may not release information that is resident-identifiable to the public.
(ii) The facility may release information that is resident-identifiable to an agent only in accordance with a contract under which the agent agrees not to use or disclose the information except to the extent the facility itself is permitted to do so.

483.70(i) Medical records.
483.70(i)(1) In accordance with accepted professional standards and practices, the facility must maintain medical records on each resident that are-
(i) Complete;
(ii) Accurately documented;
(iii) Readily accessible; and
(iv) Systematically organized

483.70(i)(2) The facility must keep confidential all information contained in the resident's records,
regardless of the form or storage method of the records, except when release is-
(i) To the individual, or their resident representative where permitted by applicable law;
(ii) Required by Law;
(iii) For treatment, payment, or health care operations, as permitted by and in compliance with 45 CFR 164.506;
(iv) For public health activities, reporting of abuse, neglect, or domestic violence, health oversight activities, judicial and administrative proceedings, law enforcement purposes, organ donation purposes, research purposes, or to coroners, medical examiners, funeral directors, and to avert a serious threat to health or safety as permitted by and in compliance with 45 CFR 164.512.

483.70(i)(3) The facility must safeguard medical record information against loss, destruction, or unauthorized use.

483.70(i)(4) Medical records must be retained for-
(i) The period of time required by State law; or
(ii) Five years from the date of discharge when there is no requirement in State law; or
(iii) For a minor, 3 years after a resident reaches legal age under State law.

483.70(i)(5) The medical record must contain-
(i) Sufficient information to identify the resident;
(ii) A record of the resident's assessments;
(iii) The comprehensive plan of care and services provided;
(iv) The results of any preadmission screening and resident review evaluations and determinations conducted by the State;
(v) Physician's, nurse's, and other licensed professional's progress notes; and
(vi) Laboratory, radiology and other diagnostic services reports as required under 483.50.
Observations:



Based on clinical record review and staff interview it was determined that the facility failed to ensure that resident records are complete and accurately documented for two of twenty-nine residents reviewed (Residents 17 and 79).

Findings Include:

Review of the physician orders for Resident 17 revealed diagnoses that included respiratory failure and hypoxia (condition in which the body or a region of the body is deprived of adequate oxygen supply).

Review of the bladder continence documentation from October 30, 2019-November 5, 2019 revealed an entry on November 3, 2019 at 1:32 AM that Resident 17 was continent of urine.

During an interview with the Director of Nursing on February 5, 2020 at 1:21 PM, she confirmed that the documentation was not accurate and that the resident is always incontinent.

Review of Resident 79's February 2020 physician orders revealed diagnoses including hypertension (elevated blood presure) and muscle weakness.

Continued review of Resident 79's physician orders revealed a prescription reading "Trazodone HCL Tablet Give 25 mg by mouth at bedtime related to dementia and other diseases classified elsewhere without behavioral disturbance."
Review of Resident 79's clinical record revealed a form titled "Doctor's Order Sheet" with the following physician's order, dated January 14, 2020: " Start pt [patient] on Trazodone 25 mg PO [by mouth] one tab at bedtime for insomnia."

An interview with the Nursing Home Administrator on February 6, 2020, at approximately 1:39 PM revealed the Trazodone was to be ordered for insomnia and the Certified Registered Nurse Practioner (CRNP) will be addressing the discrepancy in diagnosis in Resident 79's clinical record."

28 Pa. Code 211.15 (f) Clinical records
28 Pa. Code 211.12 (5) (d) Nursing services




 Plan of Correction - To be completed: 03/25/2020

1. Resident 17's documentation was corrected to reflect that she is incontinent of urine. Resident 79's medication order was immediately updated to reflect the correct diagnosis.
2. Incontinent residents and residents receiving Trazodone for insomnia are at risk for this alleged deficient practice. A facility audit will be completed to ensure that resident's currently receiving Trazodone have the correct diagnosis and that resident's who are incontinent of urine are documented as such to ensure that resident records are complete and accurately documented.
3. Licensed nursing staff will be re- educated to ensure that resident records are complete and accurately documented.
4. The DNS or designee will complete 5 random audits of residents who are prescribed Trazodone for appropriate diagnosis weekly x 4 weeks, then monthly x 2; 5 random audits of residents that are incontinent for accurate documentation or until substantial compliance has been achieved. The results will be presented at QAPI committee for further review and recommendations as appropriate.
5. The facility will be in substantial compliance by 3/25/2020.

483.60(c)(1)-(7) REQUIREMENT Menus Meet Resident Nds/Prep in Adv/Followed: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.
483.60(c) Menus and nutritional adequacy.
Menus must-

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

483.60(c)(2) Be prepared in advance;

483.60(c)(3) Be followed;

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

483.60(c)(5) Be updated periodically;

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

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

Based on resident and staff interviews and review of facility documenation, it was determined that the facility failed to accomodate resident's preferences related to menu options for one of 19 residents reviewed (Resident 52).

Findings include:


During an interview with Resident 52 on February 3, 2020, at 11:50 AM, Resident 52 revealed that he did not eat pork or pork products and that there was one night when both the main menu entree and the Alternate were pork items. He also stated that he had then asked for salad and they did not have that either. Resident was unable to recall what he did receive.

Review of Resident 52's clinical record revealed diagnoses that included Diabetes Mellitus (a disease in which the body ' s ability to produce or respond to the hormone insulin is impaired, resulting in abnormal metabolism of carbohydrates and elevated levels of glucose in the blood and urine, Acute Kidney Failure ( an abrupt decline in renal function, clinically manifesting as a reversible acute increase in nitrogen waste products) and Partial Traumatic Amputation of Right toe.

Review of facility Grievance logs revealed an entry from Resident 52 on Janauary 31, 2020, regarding this above noted concern. It was in regards to evening meal on January 30, 2020, and stated there were no other meat options. Investigation report revealed that facility Registered Dietitian (RD) 1 investigated this concern which resulted in education to kitchen staff.

Review of Resident's completed Nutrition Assessment dated for December 13, 2019, revealed written note that the resident's food preferences were obtained. Review of Resident 52's current menu slip reveals "Dislikes: Pork and Pork Products; sausage. Review of Resident 52's current active care plan reveals a care focus area regarding "Resident is at nutritional risk related to Anemia, Diabetes, Renal disease, obesity and surgical incision..." and that Interventions associated with this care focus area include "NO pork products-does not eat pork" with an initiation date of December 16, 2019.

During an interview with RD 1 on February 5, 2020, at approximately 1:30 PM, RD 1 confirmed that both of the meat items available on January 30, 2020, for the evening meal were pork items.

During an interview with Director of Nursing (DON) and Nursing Home Administrator on February 5, 2020, at approximately 2:50 PM, the DON revealed the expectation that acceptable foods would have been available.



The facility failed to accomodate residents preferences related to menu options.


28 Pa Code 201.29(j) Resident rights
















 Plan of Correction - To be completed: 03/25/2020

1. Resident 52 meal preferences have been updated and will be reflected on meal ticket.
2. Residents with food preferences are at risk for this alleged deficient practice. A review of meal tickets has been completed to ensure resident preferences related to menu options.
3. Education will be provided to nursing and dietary staff on following resident preferences related to menu options.
4. The Dietician, FSD or designee will complete 5 random audits of residents with food preferences related to menu options weekly x 4, then monthly x 2 or until substantial compliance has been obtained. The results of audits will be presented at QAPI committee for further review and recommendations as appropriate.
5. The facility will be in substantial compliance by 3/25/2020.

483.55(b)(1)-(5) REQUIREMENT Routine/Emergency Dental Srvcs in NFs: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.
483.55 Dental Services
The facility must assist residents in obtaining routine and 24-hour emergency dental care.

483.55(b) Nursing Facilities.
The facility-

483.55(b)(1) Must provide or obtain from an outside resource, in accordance with 483.70(g) of this part, the following dental services to meet the needs of each resident:
(i) Routine dental services (to the extent covered under the State plan); and
(ii) Emergency dental services;

483.55(b)(2) Must, if necessary or if requested, assist the resident-
(i) In making appointments; and
(ii) By arranging for transportation to and from the dental services locations;

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

483.55(b)(4) Must have a policy identifying those circumstances when the loss or damage of dentures is the facility's responsibility and may not charge a resident for the loss or damage of dentures determined in accordance with facility policy to be the facility's responsibility; and

483.55(b)(5) Must assist residents who are eligible and wish to participate to apply for reimbursement of dental services as an incurred medical expense under the State plan.
Observations:



Based on clinical record review and staff interview it was determined that the facility failed to ensure each resident is assisted with obtaining routine and 24 hour-emergency dental care for one of twenty-nine residents reviewed (Residents 5).

Findings Include:


Review of Resident 5's February 2020 physician orders revealed diagnoses including difficulty walking and a history of alcohol dependence.

An interview with Resident 5 on Feburary 3, 2020, at 1:06 PM revealed his dentures were "stolen" prior to his admission to the facility. Resident 5 presented with no teeth and stated he does not recall any dental visits since his admission to the facility in 2018.

Review of Resident 5's clinical record revealed no dental consults or documenation of staff follow up regarding Resident 5's missing dentures.

An interview with the Nursing Home Administrator (NHA), on February 6, 2020, at 10:43 AM revealed Resident 5's health care agent has been contacted in regards to setting up routine dental services with the facility's contracted provider. The NHA also stated dental services should have been part of Resident 5's admission process.

28 Pa. Code 211.15 (a) Dental services














 Plan of Correction - To be completed: 03/25/2020

1. Resident 5 was immediately offered dental services to evaluate for dentures and resident declined. There was no adverse outcome from this alleged deficient practice.
2. Residents requiring dental services are at risk for this deficient practice. The facility completed an audit of residents required/ requested dental consultation from the last 30 days.
3. The facility will educate licensed nursing staff, residents and RP at time of admission and during quarterly care plan meetings to ensure each resident is assisted with obtaining routine and 24hr emergency dental care.
4. The SSD will randomly audit 5 charts for dental services weekly x4 weeks then monthly x 3 months or until substantial compliance is achieved. The results will be presented at QAPI committee for further review and recommendations as appropriate.
5. The facility will be in substantial compliance by 3/25/2020.

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 surveyor observation, manufacturer information, facility documentation, and staff interview, it was determined that the record the open date of medications on one of 2 medication carts (First floor South hall medication cart) and one of one medication room (first floor medication room) observed.

Findings Include:

Observation of the First-floor South hall medication cart on February 4, 2020 at 11:14 AM revealed one Basaglar (insulin- medication to lower blood sugar) Kwikpen in use with no open date and one Lantus (insulin- medication to lower blood sugar) Solostar pen in use with no open date.

Observation of First floor Medication Storage room on February 4, 2020 at 11:20 AM revealed one vial of Tubersol Purified Protein Derivative (a solution used to aid in the diagnosis of tuberculosis infection) open but with no open date.

Review of product package insert for Tubersol Purified Protein Derivative indicates when a vial has been entered and in use for 30 days should be discarded.

Review of manufacturer information for Basaglar Kwikpen indicates the user should "throw away the pen you are using after 28 days, even if it still has insulin left in it."

Review of manufacturer information for Lantus Solostar pen indicates, "Once you take your SoloSTAR out of cool storage, for use or as a spare, you can use it for up to 28 days. During this time, it should be kept at room temperature (15 30and must not be stored in the refrigerator. If there is any remaining insulin after 28 days, discard it."

Interview with the Nursing Home Administrator on February 5, 2020 at 10:10 AM, revealed that she would have expected the in-use medications to be labeled with their open date.


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

28 Pa. Code 211.9(a)(1)(i) Pharmacy services.

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




 Plan of Correction - To be completed: 03/25/2020

1. The undated/ unlabeled opened medications were discarded from first floor medication storage room and medication cart. New medication was obtained, opened and dated on the first floor south hall medication cart and medication room.
2. Residents who receive medication from the medication room or medication carts are at risk for this alleged deficient practice. A review of med carts and med rooms was completed to ensure that there were no open undated medications.
3. The facility will provide re- education to licensed nursing staff regarding checking for open dated medication in the med rooms and med carts.
4. The DNS or designee will complete 3 random audits of the med carts and med rooms weekly x 4 weeks, then monthly x 2 or until substantial compliance has been achieved. The results of the audits will be presented at QAPI committee for further review and recommendations as appropriate.
5. The facility will be in substantial compliance by 3/25/2020.

483.45(c)(3)(e)(1)-(5) REQUIREMENT Free from Unnec Psychotropic Meds/PRN Use: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(e) Psychotropic Drugs.
483.45(c)(3) A psychotropic drug is any drug that affects brain activities associated with mental processes and behavior. These drugs include, but are not limited to, drugs in the following categories:
(i) Anti-psychotic;
(ii) Anti-depressant;
(iii) Anti-anxiety; and
(iv) Hypnotic

Based on a comprehensive assessment of a resident, the facility must ensure that---

483.45(e)(1) Residents who have not used psychotropic drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record;

483.45(e)(2) Residents who use psychotropic drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs;

483.45(e)(3) Residents do not receive psychotropic drugs pursuant to a PRN order unless that medication is necessary to treat a diagnosed specific condition that is documented in the clinical record; and

483.45(e)(4) PRN orders for psychotropic drugs are limited to 14 days. Except as provided in 483.45(e)(5), if the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she should document their rationale in the resident's medical record and indicate the duration for the PRN order.

483.45(e)(5) PRN orders for anti-psychotic drugs are limited to 14 days and cannot be renewed unless the attending physician or prescribing practitioner evaluates the resident for the appropriateness of that medication.
Observations:




Based on clinical record and staff interview it was determined that the facility failed to ensure each resident's drug regimen is free from unnecessary medications and anti psychotic medications are not given unless necesssary to treat a specific condition for two of twenty-nine residents reviewed (Residents 76 and 79).

Findings Include:

Review of Resident 76's clinical record revealed diagnoses of unspecified dementia without behavioral disturbance (mental disorder in which a person loses the ability to think, remember, learn, make decisions, and solve problems) and altered mental status (a disruption in how your brain works that causes a change in behavior).

Review of Resident 76's clinical record revealed a physician order written on January 10, 2020 for Seroquel (anti-psychotic medication) 25mg 1 tablet by mouth at bedtime related to unspecified dementia without behavioral disturbance.

Interview with the Director of Nursing on February 5, 2020 at 9:15 AM revealed that Resident 76 was taking Seroquel when he was admitted to facility and that he started taking it in the hospital to help with sleep. She agreed that unspecified dementia without behavioral disturbance was not an appropriate diagnosis for continued use of the medication.

Review of Resident 79's February 2020 physician orders revealed diagnoses including dementia ( a chronic or persistent disorder of the mental processes caused by brain disease or injury) without behavior disturbance and hypertension (elevated blood pressure).

Review of Resident 79's clinical record revealed an order for the anti psychotic drug Seroquel "give one tablet by mouth at bedtime related to Dementia in other disease classified elsewhere without behavior disturbance."

Additional review of Resident 79's clinical record revealed an order for Trazodone "give 25 mg by mouth at bedtime related to Dementia in other diseases classified elsewhere without behavioral disturbance."

Further review of Resident 79's physican orders revealed the initial order for Trazodone, written by the Certified Registered Nurse Practioner (CRNP) that reads "Start pt [patient] on Trazodone...at bedtime for insomnia."

An interview with the Nursing Home Administrator, on February 6, 2020, at 1:33 PM revealed the CRNP will change the diagnosis for those medications and stated staff "missed it" when asked if the diagnosis was appropriate for those medications.

28 Pa. Code 211.5 (f) Clinical records
28 Pa. Code 211.12 (d) (5) Nursing services












 Plan of Correction - To be completed: 03/25/2020

1. Resident 76 and 79 have appropriate diagnosis for use of Seroquel. Resident 79 also has an appropriate diagnosis for the use of Trazadone.
2. Residents currently receiving Seroquel and Trazadone are at risk for this alleged deficient practice. A review of residents currently receiving Seroquel and Trazodone has been completed for appropriate diagnosis use.
3. The facility will educate licensed nursing staff regarding use and the need to have appropriate diagnosis for use of Seroquel and Trazodone.
4. The DNS or designee will complete 5 random weekly audits of residents prescribed Seroquel and Trazodone for appropriate diagnosis x 4, then monthly x 2 or until substantial compliance has been achieved. The results will be presented at QAPI committee for further review and recommendations as appropriate.
5. The facility will be in substantial compliance by 3/25/2020.

483.45(c)(1)(2)(4)(5) REQUIREMENT Drug Regimen Review, Report Irregular, Act On: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(c) Drug Regimen Review.
483.45(c)(1) The drug regimen of each resident must be reviewed at least once a month by a licensed pharmacist.

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

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

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

Based on facility policy review, clinical record review, and staff interview it was determined that the facility failed to ensure that the physician provided a rationale for declining a medication regimen review recommendation for one of five residents reviewed for unnecessary medications (Resident 61).

Findings Include:

Review of facility policy titled "Consultant Pharmacist Reports" undated, revealed "Physician accepts and acts upon suggestion or rejects and provides an explanation for disagreeing."

Review of Resident 61's clinical record revealed diagnoses that included dementia (irreversible, progressive degenerative disease of the brain, resulting in loss of reality contact and functioning ability) and quadriplegia (paralysis of all four limbs).

Review of Resident 61's medication regimen review revealed the pharmacist made a recommendation on January 2, 2020. The recommendation made was for a gradual dose reduction to be considered for Resident 61's Ativan (anti-anxiety medication). The recommendation stated "If no dose reduction is indicated, please include a brief rationale below." The provider checked the box marked "continued use is in accordance with relevant current standards of practice AND further reduction would likely impair the resident's function and/or increase distressed behavior by". The provider did not provide a rationale for declining the recommendation and signed the form on January 6, 2020.

During a staff interview on February 5, 2020, at 1:20 PM the Director of Nursing provided the surveyor with the medication regimen review from January 2, 2020, with a rationale that was added on February 5, 2020. At that time, she stated that she educated the provider that a rationale needs to be documented at the time the recommendation is responded to.


28 Pa. Code 211.2(a) Physician services.

28 Pa. Code 211.5(f) Clinical records.









 Plan of Correction - To be completed: 03/25/2020

1. Resident 61's physician has provided rationale for declining pharmacy recommendation.
2. Residents requiring a Drug Regimen Review are at risk for this alleged deficient practice. A facility audit has been completed for the month of January to ensure physicians provide a rationale for declining a medication regime review recommendation.
3. Education will be provided to physicians regarding need for rationale of physician declining a mediation regime review recommendation.
4. The DNS or designee will complete audits of 10 pharmacy recommendations monthly x 3 months or until substantial compliance has been achieved. The results will be presented at QAPI committee for further review and recommendations as appropriate.
5. The facility will be in substantial compliance by 3/25/2020.

483.25(n)(1)-(4) REQUIREMENT Bedrails: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(n) Bed Rails.
The facility must attempt to use appropriate alternatives prior to installing a side or bed rail. If a bed or side rail is used, the facility must ensure correct installation, use, and maintenance of bed rails, including but not limited to the following elements.

483.25(n)(1) Assess the resident for risk of entrapment from bed rails prior to installation.

483.25(n)(2) Review the risks and benefits of bed rails with the resident or resident representative and obtain informed consent prior to installation.

483.25(n)(3) Ensure that the bed's dimensions are appropriate for the resident's size and weight.

483.25(n)(4) Follow the manufacturers' recommendations and specifications for installing and maintaining bed rails.
Observations:



Based on observation, clinical record review and staff interview, it was determined that the facility failed to ensure appropriate alternatives are attempted prior to installation of side rails and provide ongoing assessment to assure the side rails meet the resident's needs for one of twenty-nine residents reviewed (Resident 79).


Findings Include:


Review of Resident 79's February 2020 physician orders revealed diagnoses including hypertension (elevated blood presure) and muscle weakness.

An observation, in Resident 79's room, on February 3, 2020, at 9:02 AM revealed bilateral side rails attached to her bed.

Review of Resident 79's interdisciplinary plan of care revealed a care plan developed to address her mobility impairment with interventions including "bilateral 1/4 enablers to assist with bed mobility and transfers", dated January 2018.

Review of Resident 79's clinical record revealed the facility's Side Rail Evaluation form dated November 8, 2019.

Further review of the clinical record revealed no additional assessments/evaluations for Resident 79's use of the side rail/enabler bars.

An interview with the Nursing Home Administator (NHA) , on February 5, 2020, at 10:08 AM revealed the facility could not locate any additional assessments excluding the assessment completed on November 8, 2019. The NHA confirmed an expectation that side rail/enabler bar assessments are performed quarterly to ensure appropriateness and safety.

The NHA confirmed the assessments would be completed quarterly going forward.

28 Pa. Code 211.5 (f) Clinical records
28 Pa. Code 211.12 (d) (5) Nursing services
























 Plan of Correction - To be completed: 03/25/2020

1. Resident 79 has had bed rail assessment completed.
2. Residents currently utilizing bed enablers in facility are at risk for this alleged deficient practice. These residents have been assessed for the use of bed enablers. Appropriate alternatives will be attempted and ongoing assessments will be completed to ensure side rails meet the needs of the resident.
3. Education will be provided to nursing and therapy staff regarding appropriate use of alternatives be attempted prior to installation of side rails and the need to provide ongoing assessments to assure the side rails meet the resident's needs.
4. The DOR or designee will complete audits of 3 residents currently utilizing bed enablers for appropriate alternatives weekly x 4, then monthly x 2 months or until substantial compliance has been achieved. Audits will be reported to QAPI committee for further review and recommendations as appropriate.
5. The facility will be in substantial compliance by 3/25/2020.

483.25(i) REQUIREMENT Respiratory/Tracheostomy Care and Suctioning: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(i) Respiratory care, including tracheostomy care and tracheal suctioning.
The facility must ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals and preferences, and 483.65 of this subpart.
Observations:
Based on review of clinical records, observations, and staff interviews, it was determined that the facility failed to provide respiratory services consistent with professional standards for two of twenty-nine residents reviewed (Resident 17 and 76).

Findings include:

Review of the physician orders for Resident 17 revealed diagnoses that included respiratory failure and hypoxia (condition in which the body or a region of the body is deprived of adequate oxygen supply).

Resident 17 has a tracheostomy in place (a tube placed into a person windpipe that allows air to enter the lungs).

During an observation on February 3, 2020 at 9:20 AM it was noted that Resident 17 had tubing that covered the tracheostomy to administer humidification.

Review of the current physician orders revealed an order to change the trach (tracheostomy) ties (bands that go around the neck and hold the trach tube in place) every Tuesday and Friday and as needed for soiling.
Further review of the orders revealed no order for the humidification or to change the tubing.

Observation on February 3, 2020 at 9:20 AM revealed tracheostomy ties and humidification tubing with no dates to indicate it was being changed per physician order. The collection bag connected to the humidification tubing was in the trash can. Additional observation at 2:53 PM revealed the same findings.

During an interview with the Director of Nursing on February 5, 2020 at 1:23 PM she stated that she would expect the tubing and and tracheostomy to be labeled to indicate it was changed.



Review of Resident 76's clinical record revealed diagnoses of respiratory syncytial virus (a syncytial virus that causes respiratory tract infections). and altered mental status (a disruption in how your brain works that causes a change in behavior).

Review of Resident 76's current physician orders revealed an order for Ipratropium-Albuterol (a medication consisting of 2 bronchodilators) Solution 0.5-2.5 (3) MG/3ML, 3 ml orally via nebulizer every 6 hours, Order date January 25, 2020 and start date January 25, 2020.

Review of facility policy titled, "Equipment Management", revealed that nebulizer machines should have their tubing and masks changed weekly and PRN.

During an interview with RN3 on February 3, 2020, at 10:00 AM she stated that she could not find an "in use" date on Resident 76's tubing or mask and she does not know when the they were entered into use. She also stated that they should be changed weekly and dated at that time per facility policy. She then provided Resident 76 new tubing and mask and dated them at that time.

During an interview with the Director of Nursing on February 5, 2020 at 10:00 AM she stated she would expect that Resident 76's mask and tubing would be changed weekly and dated per facility policy.


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

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





 Plan of Correction - To be completed: 03/25/2020

1. Resident 17 had humidification tubing and trach ties changed and dated. Resident 76 had nebulizer mask and tubing changed and dated.
2. Resident's requiring respiratory services are at risk for this alleged deficient practice. A house wide audit will be completed on residents with humidification tubing and trach ties to ensure respiratory services are consistent with professional standards. A house wide audit will be completed on residents with nebulizer masks and tubing to ensure respiratory services are consistent with professional standards.
3. The facility will provide education on the importance of dating humidification tubing and trach ties, as well as, nebulizer masks and tubing to licensed nurses.
4. The DNS or designee will complete 5 random audits of residents who require use of oxygen for dated humidification tubing, dated trach ties, and dated nebulizer masks and tubing weekly x 4, monthly x 2 or until substantial compliance has been achieved. Results of audits will be presented at QAPI committee for further review and recommendations as appropriate
5. The facility will be in substantial compliance by 3/25/2020.

483.25(g)(4)(5) REQUIREMENT Tube Feeding Mgmt/Restore Eating Skills: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(g)(4)-(5) Enteral Nutrition
(Includes naso-gastric and gastrostomy tubes, both percutaneous endoscopic gastrostomy and percutaneous endoscopic jejunostomy, and enteral fluids). Based on a resident's comprehensive assessment, the facility must ensure that a resident-

483.25(g)(4) A resident who has been able to eat enough alone or with assistance is not fed by enteral methods unless the resident's clinical condition demonstrates that enteral feeding was clinically indicated and consented to by the resident; and

483.25(g)(5) A resident who is fed by enteral means receives the appropriate treatment and services to restore, if possible, oral eating skills and to prevent complications of enteral feeding including but not limited to aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, and nasal-pharyngeal ulcers.
Observations:

Based on observation, clinical record review and staff interview, it was determined that the facility failed to administer enteral feeding at the correct rate for one of two resident reviewed with tube feedings (Resident 17).

Findings include:


Review of the physician orders for Resident 17 revealed diagnoses that included respiratory failure and hypoxia (condition in which the body or a region of the body is deprived of adequate oxygen supply).

Review of the current physician orders revealed an enteral feed order Jevity 1.5 at 50 ml/hr.

Observation on February 3, 2020 at 9:18 AM revealed the tube feeding infusing at a rate of 55 ml/hr. On February 4, 2020 at 3:15 PM the tube feed was infusing at a rate of 55 ml/hr. On February 5, 2020 at 8:53 AM the tube feed was again infusing at 55 ml/hr.

The facility was made aware of the observations on February 5, 2020 at 2:30 PM.

During an interview with the Nursing Home Administrator on February 6, 2020 at 11:10 AM she stated that when she observed the feeding tube it was infusing at the correct rate.

No further information was provided.


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





 Plan of Correction - To be completed: 03/25/2020

1. Resident 17 received the correct rate of enteral feeding. No adverse effects occurred as a result of this alleged deficient practice.
2. Resident's requiring tube feedings are at risk for this alleged deficient practice. These residents will have physician orders validated to ensure correct rates.
3. The facility will re-educate licensed nursing staff on appropriate procedure for administering enteral feedings at the correct rate per physician's orders.
4. The Administrator will audit 2 resident's enteral feeding rates weekly x 4, then monthly x 2 or until substantial compliance has been achieved. Results of audits will be presented at QAPI committee for further review and recommendations as appropriate.
5. The facility will be in substantial compliance by 3/25/2020.

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 observations, clinical record review, and interviews it was determined that the facility failed to ensure resident with limited mobility received appropriate services, equipment, and assistance to maintain or improve mobility for three of 29 residents reviewed (Residents 17, 29, and 36).

Findings include:

Review of the physician orders for Resident 17 revealed diagnoses that included respiratory failure and hypoxia (a condition in which the body or a region of the body is deprived of adequate oxygen supply).

Review of the physical therapy discharge program recommended for Resident 17 to have bilateral lower extremity range of motion.

Review of the current physician orders and the current Kardex (part of the care plan that the nurse aids reference) revealed that Resident 17 was to receive nursing restorative: PROM (passive range of motion) to bilateral lower extremities (toes, ankles, knees, hips) 10 repetitions x 2 sets with AM/PM care.

Review of facility documentation revealed no evidence that range of motion was being performed on the resident.
The faciity was unable to provide any additional information that PROM was being performed for Resident 17.

Therapy re-evaluated Resident 17 on February 5, 2020. The therapy screen revealed that PROM was not appropriate for the resident at this time but to continue with the wash clothes to bilateral palms
.
During an interview with the Director of Rehab she confirmed the findings of the therapy screen and said that she was unaware that the PROM was not being performed by staff.

Review of Resident 29's clinical record revealed diagnoses that included spinal stenosis (narrowing of the spinal column that causes pressure on the spinal cord, causing numbness or pain in the back and/or weakness of part of a leg or arm), legally blind, spastic hemiplegia (is a neuromuscular condition that results in the muscles on one side of the body being in a constant state of contraction), abnormal posture, contracture left hand (a condition of shortening and hardening of muscles, tendons, or other tissue, leading to deformity and rigidity of joints).

Review of Resident 29's plan of care revealed a focus area for activities of daily living for selfcare with an intervention for nursing rehabilitation: bilateral palm guards at all times, remove for care and hygiene with an initiated date of December 24, 2018.

Observations on February 3, 2020, at approximately 11:04 AM in Resident 29's room it was revealed that Resident 29's bilateral hands were contracted, no palm guards in place, and an orange cloth carrot was observed on Resident 29's dresser. During an interview with Resident 29 on February 3, 2020, at approximately 11:05 AM it was revealed that Resident 29 is on a range of motion program, and he is to use a carrot or splint on his hands because his finger nails dig into his palms and have caused open areas. It was also revealed that the staff doesn't always assist him with the range of motion program or his palm guards/carrot.

During an interview with Registered Nurse 3 on February 3, 2020, at approximately 11:24 AM it was revealed that RN 3 was not sure if Resident 29 should be using the palm carrot, but she would follow up with therapy. During an interview with Physical Therapist 1 on February 3, 2020, at approximately 11:28 AM it was revealed that Resident 29's palm guards were being cleaned, and the cloth carrot is in his room for use in his left hand.

Observation on February 4, 2020, at approximately 2:45 PM revealed Resident 29 resting in bed without a palm guard or cloth carrot in his hand.
Observation on February 5, 2020, at approximately 2:00 PM revealed Resident 29 resting in bed without a palm guard or cloth carrot in his hand.

During an interview with the Nursing Home Administrator on February 4, 2020, at approximately 3:15 PM it was revealed that the Nursing Home Administrator would look into Resident 29's palm guards.

Review of an Occupational Therapy screen provided February 5, 2020, at approximately 8:30 AM revealed the screen was signed by Certified Occupational Therapy Assistant 1 (COTA 1) on February 5, 2020, and revealed "patient screened for appropriateness of palm guards post hospital stay, secondary recent skin issues it was determined palm guards not appropriate at this time."

During an interview on February 6, 2020, at approximately 9:59 AM with the Director of Rehabilitation 1 it was revealed that, the COTA 1 did a screen on Resident 29 for the use of palm guards on February 5, 2020, because the palm guards were not found to be in Resident 29's room. Per Director of Rehabilitation 1 the screen completed by COTA 1 revealed that the palm guards were not appropriate because they were not available. It was also revealed that after the occupation al therapy screen the nursing staff were concerned that the palm guards were discontinued and felt that resident 29 would still benefit from the use of the palm guards. The Director of Rehabilitation 1 revealed that she had Physical Therapist 1 (PT 1) completed an evaluation on Resident 29, which was completed February 5, 2020 at approximately 12:41 PM to evaluate for the appropriateness of the use of palm guards. PT 1 evaluation revealed "patient has been deconditioning, for a long time, today we were looking at his hands, requires palm guard to address hygiene needs, they are appropriate after the hospital stay. Further discussion with the Director of Rehabilitation 1 revealed that therapy communicates with nursing via a paper form titled, Rehab Discharge Program Physical Therapy. At that time it was revealed that the aforementioned form, may not have been completed as of yet to communicate the use of the palm guards for Resident 29.

Review of the aforementioned form, dated February 6, 2020, revealed a recommendation for a restorative program for "bilateral palm guards to be worn daily."

During an interview with the Director of Nursing on February 6, 2020, at approximately 10:47 AM it was revealed the expectation that staff should be monitoring for use of splints and or palm guards throughout their shift to ensure the ordered items are applied.




Review of Resident 36's clinical record revealed diagnoses that included; multiple sclerosis (a chronic progressive disease involving damage to the sheaths of nerve cells in the brain and spinal cord, symptoms include numbness, impaired speech, muscle coordination, blurred vision, and severe fatigue), diabetes mellites (the body's ability to produce or respond to the hormone insulin is impaired, resulting in abnormal metabolism of carbohydrates and elevated levels of glucose in the blood and urine), and depression (feelings of severe despondency and dejection).

Review of Resident 36's February 2020 physician orders revealed an order for a splinting program: resident to wear bilateral palm guards at all times; may remove for care/hygiene; monitor skin integrity every shift and report any issues to RN (Registered Nurse) supervisor immediately; with a start date of January 28, 2019.

Review of Resident 36's plan of care revealed a focus area for Activity of Daily Living/Physical functioning deficit related to: Selfcare impairment-total assist with care due to contracted (a condition of shortening and hardening of muscles, tendons, or other tissue, leading to deformity and rigidity of joints) hands, mobility impairment, range of motion limitations, multiple sclerosis; with an initiation date of August 5, 2011; and a revision date of August 2, 202018. Interventions listed for the aforementioned focus area included "splinting program: resident to wear bilateral palm guards at all times; may remove for care/hygiene; notify RN (Registered Nurse) supervisor immediately of any skin integrity issues Date Initiated: January 28, 2019; Revision on: February 8, 2019."

During an interview with Resident 36 on February 3, 2020, at approximately 1:13 PM it was revealed that Resident 36 is not on therapy services or a nursing range of motion program. Observation of Resident 36 at the aforementioned time revealed both hands were contracted (a condition of shortening and hardening of muscles, tendons, or other tissue, leading to deformity and rigidity of joints), with both elbows bent up towards her chest. It was also observed that Resident 36 utilizes a blow bell to ring for assistance, and was not wearing palm guards at that time.

Observation on February 4, 2020, at approximately 2:42 PM revealed Resident 36 in her room, in her chair without palm guards on. Observations on February 5, 2020, at 10:35 AM and 2:05 PM revealed resident in her room without palm guards on.

During an interview with Licensed Practical Nurse 2 (LPN 2) on February 5, 2020, at approximately 2:15 PM it was revealed that she was unsure if Resident 36 was to be wearing palm guards. LPN 2 verified Resident 36's physician orders and confirmed that Resident 36 should have palm guards on, and that they were probably removed when the Nursing Assistant provided care and they were not put back on.

During an interview with Nursing Assistant 4 (NA 4) it was revealed that Resident 36's palm guards were in a basket on Resident 36's dresser. It was also revealed that the staff will put them on her throughout the day for several hours at a time and then remove them.

During an interview with the Director of Nursing on February 6, 2020, at approximately 10:47 AM it was revealed the expectation that staff should be monitoring for use of splints and or palm guards throughout their shift to ensure the ordered items are applied.


28 Pa. Code 211.11 (a) Resident care plan
28 Pa. Code 211.12(a)(d)(1)(3)(5) Nursing services.




 Plan of Correction - To be completed: 03/25/2020

1. Residents 17's PROM program has been discontinued; towel rolls have been placed in bilateral palms. Resident 29 has been assessed by therapy and has been provided with a palm guard for use to bilateral hands. Resident 36 has been reassessed by therapy and bilateral palm guards have been provided. There was no adverse effect from not using palm guards with Residents 17, 29 or 36.
2. Residents with limited mobility are at risk for this alleged deficient practice. A facility audit has been completed on Residents with limited mobility to ensure receipt of appropriate services, equipment and assistance to maintain or improve mobility.
3. Education has been provided to license nursing staff on compliance with residents with limited mobility to ensure receipt of appropriate services, equipment and assistance to maintain or improve mobility.
4. DON or designee will complete 5 random audits of residents with splint application prders weekly x 4 weeks, then monthly x 2 or until substantial compliance has been achieved. Findings will be reported monthly to QAPI committee for further review and recommendations as appropriate.
5. The facility will be in substantial compliance by 3/25/2020.

483.25(b)(1)(i)(ii) REQUIREMENT Treatment/Svcs to Prevent/Heal Pressure Ulcer: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(b) Skin Integrity
483.25(b)(1) Pressure ulcers.
Based on the comprehensive assessment of a resident, the facility must ensure that-
(i) A resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable; and
(ii) A resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing.
Observations:

Based on review of facility policy, clinical records, and staff interview it was determined that the facility failed ensure the resident received care, consistent with professional standards, to prevent pressure ulcers for one of twenty-nine residents reviewed (Resident 43).

Review of Resident 43's clinical record revealed diagnoses including pressure ulcer of sacral region, stage 4 (open wound on the skin, stage 4 refers to a wound that extends all the way to the muscle, bone, or tendons) and pressure ulcer of the right heel, unstageable ( open wound of the skin, unstageable refers to a pressure ulcer in which the base of the wound is covered by slough or eschar).

Review of facility policy, "Skin and Wound Management System" revised April 2017, revealed "On going weekly evaluations of resident's skin will be completed and documented in PCC (electronic medical record) on the "Weekly Skin Evaluation" form."

Review of Resident 43's current physician orders revealed an order for weekly skin review, ordered December 27, 2019 and started January 3, 2020.

Review of Resident 43's clinical record revealed a "wound evaluation flow sheet" with wound evaluations on November 27, 2019; December 7, 2019; December 13, 2019; December 18, 2019; December 26, 2019; December 30, 2019; January ,18, 2020; January 24, 2020; and January 31, 2020.

Further review of Resident 43's clinical record revealed a "weekly skin review" with skin reviews done completed on December 27, 2019; January 3, 2020; January 17, 2020; January 24, 2020; and January 31, 2020.

Interview with the Director of Nursing on February 5, 2020 at 10:00, revealed that she would expect that the evaluations would be conducted weekly in accordance with facility policy and that she could not locate any evaluations for Resident 43 from January 3, 2020 until January 17, 2020.

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



 Plan of Correction - To be completed: 03/25/2020

1. Resident 43 no longer resides in the facility.
2. Residents with pressure ulcers are at risk for this alleged deficient practice. A house wide audit has been conducted on residents with pressure ulcers requiring wound evaluations have been completed.
3. Education has been provided to license nursing staff on ensuring that all residents who require a weekly wound evaluation must be completed.
4. The DNS or designee will observe 5 random weekly wound evaluations x 4 weeks, then monthly x 2 months or until substantial compliance has been achieved. The results of audits will be shared at QAPI committee for further review and recommendations as appropriate.
5. The facility will be in substantial compliance by 3/25/2020.

483.21(c)(1)(i)-(ix) REQUIREMENT Discharge Planning Process: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(c)(1) Discharge Planning Process
The facility must develop and implement an effective discharge planning process that focuses on the resident's discharge goals, the preparation of residents to be active partners and effectively transition them to post-discharge care, and the reduction of factors leading to preventable readmissions. The facility's discharge planning process must be consistent with the discharge rights set forth at 483.15(b) as applicable and-
(i) Ensure that the discharge needs of each resident are identified and result in the development of a discharge plan for each resident.
(ii) Include regular re-evaluation of residents to identify changes that require modification of the discharge plan. The discharge plan must be updated, as needed, to reflect these changes.
(iii) Involve the interdisciplinary team, as defined by 483.21(b)(2)(ii), in the ongoing process of developing the discharge plan.
(iv) Consider caregiver/support person availability and the resident's or caregiver's/support person(s) capacity and capability to perform required care, as part of the identification of discharge needs.
(v) Involve the resident and resident representative in the development of the discharge plan and inform the resident and resident representative of the final plan.
(vi) Address the resident's goals of care and treatment preferences.
(vii) Document that a resident has been asked about their interest in receiving information regarding returning to the community.
(A) If the resident indicates an interest in returning to the community, the facility must document any referrals to local contact agencies or other appropriate entities made for this purpose.
(B) Facilities must update a resident's comprehensive care plan and discharge plan, as appropriate, in response to information received from referrals to local contact agencies or other appropriate entities.
(C) If discharge to the community is determined to not be feasible, the facility must document who made the determination and why.
(viii) For residents who are transferred to another SNF or who are discharged to a HHA, IRF, or LTCH, assist residents and their resident representatives in selecting a post-acute care provider by using data that includes, but is not limited to SNF, HHA, IRF, or LTCH standardized patient assessment data, data on quality measures, and data on resource use to the extent the data is available. The facility must ensure that the post-acute care standardized patient assessment data, data on quality measures, and data on resource use is relevant and applicable to the resident's goals of care and treatment preferences.
(ix) Document, complete on a timely basis based on the resident's needs, and include in the clinical record, the evaluation of the resident's discharge needs and discharge plan. The results of the evaluation must be discussed with the resident or resident's representative. All relevant resident information must be incorporated into the discharge plan to facilitate its implementation and to avoid unnecessary delays in the resident's discharge or transfer.
Observations:



Based on clinical record review and staff interview it was determined the facility failed to identify each resident's discharge needs and ensure the development of a discharge plan for one of twenty-nine residents reviewed (Resident 5).

Findings Include:

Review of Resident 5's February 2020 physician orders revealed diagnoses including difficulty walking and a history of alcohol dependence.

An interview with Resident 5, on February 3, 2020, at 1:05 PM reveals a desire to be at his home in the community as he takes one medication and describes himself as "independent."

Review of Resident 5's clinical record revealed an interdisciplinary progress note dated October 4, 2019, reading "Res [Resident] alert and oriented. Periods of delusional thinking and anger r/t [related to] discharge planning."

Further review of the interdisciplinary progress notes revealed staff documenting Resident 5's desire to return to the community, with discussions primarily initiated by Resident 5 on November 6, 2019, November 8, 2019 and November 11, 2019.

Review of Resident 5's interdisciplinary plan of care revealed none developed to address Resident 5's discharge goals and interventions to assist staff with addressing Resident 5's needs and behaviors associated with his desire to return to the community.

An interview with the Nursing Home Administrator (NHA), on February 6, 2020, at 10:46 AM revealed Resident 5's interdisciplinary plan of care was updated on February 5, 2020 to reflect his discharge planning goals.

28 Pa. Code 211.5 (f) Clinical records
28 Pa. Code 211.11 (d) (e) Resident care plan













 Plan of Correction - To be completed: 03/25/2020

1. Resident 5 was assessed by SSD for expectations regarding discharge planning and the care plan was updated accordingly.
2. Residents who express an interest in being discharged to the community are at risk for this deficient practice. Residents who express an interest in community discharge, will have their discharge needs reviewed in order to ensure the development of a discharge plan.
2. Education has been provided to licensed nursing staff and SSD on updating and revising care plans to include discharge planning.
3. Administrator or designee will complete 5 random audits of resident's individual discharge plan weekly x 4, then monthly x 2 or until substantial compliance has been achieved. Results of these audits will be brought to the QAPI committee for further review and recommendations as appropriate.
4. The facility will be in substantial compliance by 3/25/2020.

483.21(b)(1) REQUIREMENT Develop/Implement Comprehensive Care Plan:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.21(b) Comprehensive Care Plans
483.21(b)(1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at 483.10(c)(2) and 483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following -
(i) The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under 483.24, 483.25 or 483.40; and
(ii) Any services that would otherwise be required under 483.24, 483.25 or 483.40 but are not provided due to the resident's exercise of rights under 483.10, including the right to refuse treatment under 483.10(c)(6).
(iii) Any specialized services or specialized rehabilitative services the nursing facility will provide as a result of PASARR recommendations. If a facility disagrees with the findings of the PASARR, it must indicate its rationale in the resident's medical record.
(iv)In consultation with the resident and the resident's representative(s)-
(A) The resident's goals for admission and desired outcomes.
(B) The resident's preference and potential for future discharge. Facilities must document whether the resident's desire to return to the community was assessed and any referrals to local contact agencies and/or other appropriate entities, for this purpose.
(C) Discharge plans in the comprehensive care plan, as appropriate, in accordance with the requirements set forth in paragraph (c) of this section.
Observations:

Based on observation, clinical record review as well as resident and staff interviews, it was determined that the facility failed to ensure that a comprehensive, person-centered care plan was developed for one of twenty-nine residents reviewed (Resident 76).

Review of Resident 76's clinical record revealed diagnoses of unspecified dementia without behavioral disturbance (mental disorder in which a person loses the ability to think, remember, learn, make decisions, and solve problems) and altered mental status (a disruption in how your brain works that causes a change in behavior).

Review of Resident 76's current interdisciplinary plan of care, dated February 3, 2020 revealed no evidence of a plan of care, involving her use of psychotropic medications, had been developed.

Review of Resident 76's current physician's orders dated February 4, 2020 revealed an order for Seroquel (anti-psychotic medication) 25mg 1 tablet by mouth related to unspecified dementia without behavioral disturbance ordered on January 10, 2020 and started on January 10, 2020.

Review of Resident 76's Admission MDS (is part of a federally mandated process for clinical assessment of all residents in Medicare or Medicaid certified nursing homes) dated January 16, 2020 revealed, in section N0410a, that Resident 76 had taken an antipsychotic medication six of the previous seven days.

During a staff interview with the Nursing Home Administrator on February 5, 2020 at 10:00 AM, she revealed that she would expect that an interdisciplinary plan of care would have been developed involving Resident 76's use of psychotropic medications.

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

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


 Plan of Correction - To be completed: 03/25/2020

1. Resident 76 had his care plan updated to include the use of psychotropic medications.
2. Residents currently prescribed psychotropic medications are at risk for this alleged deficient practice. Resident's prescribed psychotropic medications have had their care plans reviewed/ updated.
3. Education has been provided to license nursing staff on updating care plans for resident's who are prescribed psychotropic medications.
4. The administrator or designee will complete 5 audits of resident care plans currently receiving psychotropic medications weekly x 4, then monthly x 3 or until substantial compliance has been achieved. Results of these observations will be brought to the QAPI committee for further review and recommendations as appropriate.
5. The facility will be in substantial compliance by 3/25/2020.

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

Based on clinical record review and staff interview, it was determined that the facility failed to ensure that the resident assessment accurately reflected the resident's status for two of 28 residents reviewed (Residents 61 and 80).

Findings Include:

Review of Resident 61's clinical record revealed diagnoses that included dementia (irreversible, progressive degenerative disease of the brain, resulting in loss of reality contact and functioning ability) and quadriplegia (paralysis of all four limbs). Further review of Resident 61's clinical record revealed that she has a Foley catheter (a thin, sterile tube inserted into the bladder to drain urine) and a Colostomy (an operation that creates an opening for the colon through the abdomen which stool drains from).

Review of Resident 61's quarterly MDS (Minimum Data Set - an assessment tool to review all care areas specific to the resident such as a resident's physical, mental or psychosocial needs), dated December 31, 2019, revealed that in Section H, bladder and bowel, Resident 61 is coded as having an indwelling catheter (Foley) and an ostomy (colostomy) and is also coded as being always incontinent of bowel and bladder.

During a staff interview on February 5, 2020, at 10:08 AM the Nursing Home Administrator (NHA) stated that the MDS was coded incorrectly and a modification of the MDS is being completed. The MDS should not have been coded that Resident 61 is always incontinent of bowel and bladder.

Review of Resident 80's clinical record revealed diagnoses that included Bipolar Disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs) and Gastroesophageal Reflux Disease (GERD- acid reflux).

Review of Resident 80's modification of quarterly MDS, dated January 17, 2020, revealed that in Section P, Physical Restraints, Resident 80 is coded as using a bed rail daily.

Surveyor observation of Resident 80's room on February 3, 2020, at 10:51 AM failed to reveal bed rails on Resident 80's bed. Review of Resident 80's clinical record failed to reveal any evidence that Resident 80 has a restraint.

During an interview on February 4, 2020, at 3:01 PM the NHA and Director of Nursing stated that Resident 80 does not have a restraint. During an additional interview on February 5, 2020, at 10:15 AM the NHA stated that the restraint was marked in error on the MDS


28 Pa. Code 211.5(f) Clinical records.

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











 Plan of Correction - To be completed: 03/25/2020

1. Modifications of MDS section H bladder and bowel assessments for Resident 61 has been corrected. Modifications of MDS section P physical restraints for resident 80 has been corrected.
2. Current residents requiring MDS assessments for section H bladder and bowel and P physical restraints are at risk for this alleged deficiency. Residents requiring completion of section H and section P within the past 14 days will be reviewed for accuracy.
3. Education has been provided on accurate coding of section H and Section P to the Clinical Care Coordinators.
4. The Administrator or designee will complete 5 random weekly audits of residents having sections H and P completed x 4 weeks, then monthly x 2 months or until substantial compliance has been achieved. Results of these observations will be brought to the QAPI committee for further review and recommendations as appropriate.
5. The facility will be in substantial compliance by 3/25/2020.

483.20(b)(2)(ii) REQUIREMENT Comprehensive Assessment After Signifcant Chg: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.
483.20(b)(2)(ii) Within 14 days after the facility determines, or should have determined, that there has been a significant change in the resident's physical or mental condition. (For purpose of this section, a "significant change" means a major decline or improvement in the resident's status that will not normally resolve itself without further intervention by staff or by implementing standard disease-related clinical interventions, that has an impact on more than one area of the resident's health status, and requires interdisciplinary review or revision of the care plan, or both.)
Observations:

Based on clinical record review and staff interview, it was determined the facility failed to complete a comprehensive assessment after a significant change in condition for one of 25 residents reviewed (Resident 9).

Findings include:

Review of Resident 9's clinical record revealed diagnoses that included dementia (irreversible, progressive degenerative disease of the brain, resulting in loss of reality contact and functioning ability) and anxiety disorder (intense, excessive, and persistent worry and fear about everyday situations).

Further review of Resident 9's clinical record revealed that she was admitted to hospice services on November 21, 2019.

Review of the Minimum Data Set (MDS) (an assessment tool) revealed that there was not a significant change MDS completed when Resident 9 was admitted to hospice.

During a staff interview on February 5, 2020, at 10:13 AM the Nursing Home Administrator and Director of Nursing both confirmed that a significant change MDS was missed and not completed after Resident 9 was admitted to hospice.

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







 Plan of Correction - To be completed: 03/25/2020

1. Resident 9 had a comprehensive assessment completed on 2/2/2020 which captured hospice services.
2. Residents that have a significant change in condition as a result of hospice services are at risk for this deficient practice. A review of residents with significant changes in condition as a result of hospice services over the last 14 days will be completed to ensure that significant changes are completed timely.
3. The Clinical Care Coordinator will be educated on completing significant change assessments on pts receiving hospice services timely.
4. The Administrator or designee will complete 5 audits of residents who are exhibiting a change in condition to determine if a significant change assessment is required weekly x 4 weeks, then monthly x 2 weeks. Results of these audits will be brought to the QAPI committee for further review and recommendations as appropriate.
5. The facility will be in substantial compliance by 3/25/2020.

483.15(c)(3)-(6)(8) REQUIREMENT Notice Requirements Before Transfer/Discharge: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.
483.15(c)(3) Notice before transfer.
Before a facility transfers or discharges a resident, the facility must-
(i) Notify the resident and the resident's representative(s) of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand. The facility must send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman.
(ii) Record the reasons for the transfer or discharge in the resident's medical record in accordance with paragraph (c)(2) of this section; and
(iii) Include in the notice the items described in paragraph (c)(5) of this section.

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

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

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

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

Based on clinical record review and staff interview it was determined that the facility failed to notify the Office of State Long-Term Care Ombudsman for facility-initiated discharges for two of twenty-nine resident records reviewed (resident 51 and 62).

Findings include:


Review of Resident 51's February 2020 physician orders revealed diagnoses including dementia ( a chronic or persistent disorder of the mental processes caused by brain disease or injury) and muscle weakness.

Review of Resident 51's clinical record revealed transfers to the hospital on August 29, 2019, September 18, 2019 and December 3, 2019.

Further review of Resident 51's clinical record revealed no notification to the Long Term Care Ombudsman of Resident 51's transfers to the hospital on August 29, 2019 and December 3, 2019.

An interview with the Nursing Home Administrator, on February 5, 2020, at 10:05 AM revealed the former Director of Nursing was responsible for sending out the notifications and that she has begun sending out the notifications at this time.

Review of Resident 62's clinical record revealed diagnosis of Gastro-esophageal reflux disease (a digestive disease in which stomach acid or bile irritates the food pipe lining) and essential hypertension (high blood pressure without a known cause).

Review of nursing progress note dated August 12, 2019 revealed Resident 62 was experiencing low blood pressure and syncope and was transported to the hospital emergency room and subsequently admitted.

Review of Resident 62's clinical record revealed no letter was later sent to the office of the ombudsman notifying the ombudsman that resident 62 was transferred to the hospital.

During an interview with Nursing Home Administrator on February 5, 2020, at 10:00 AM, the Nursing Home Administrator revealed that the former Director of Nursing had been responsible for sending out the transfer notices to the Office of State Long-Term Care Ombudsman and that when the former Director of Nursing left she took on that responsibility but the August 12, 2019 transfer was before she started sending them so she could not locate anything from that transfer.

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










 Plan of Correction - To be completed: 03/25/2020

1. Resident's 51 and 62 returned to the facility. Ombudsman was notified of their transfers to the hospital
2. Residents requiring facility initiated discharges are at risk for this alleged deficient practice. These residents will have timely notification to Office of Long- Term Care Ombudsman. Facility review of last 14 days of transfers was completed and reviewed for accuracy.
3. The NHA will be provided education on proper monthly notification of the Ombudsman office.
4. The NHA or designee will complete a monthly review of the facility discharges and hospital transfers prior to submission x 3 months or until substantial compliance has been achieved, to ensure timely notification to the Long- Term Care Ombudsman office. All results will be presented at QAPI committee for further review and recommendations as appropriate.
5. The facility will be in substantial compliance by 3/25/2020.

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

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

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

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

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

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

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

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

Based on observations and staff interview it was determined that the facility failed to maintain a safe, clean and home-like environment for four of 30 resident rooms (Residents 20, 42, 50, and 65).

Findings include:

Review of Resident 50's February 2020 physician orders revealed diagnoses including dementia (a chronic or persistent disorder of the mental processes caused by brain disease or injury) and hypertension (elevated blood pressure).

Observations in Resident 50's room, on February 3, 2020 at 8:52 AM, 1:12 PM, and February 4, 2020, at 1:45PM revealed a bag of clothing on the floor, under his bedside table. An interview with Resident 50 on February 3, 2020, at 8:52 AM revealed his clothing "needs to be washed."

An interview with the Nursing Home Administrator, on February 6, 2020, at 11:01 AM revealed Resdient 50's soiled bag of clothing should have been picked up by staff and placed in the bin to be laundered.

Observations in Resident 65's room on February 3, 2020, at approximately 10:54 AM there was a dried red liquid and dried brown liquid smeared on floor to the left of Resident 65's bed under the bed side table. During an interview with Resident 65 it was revealed that the aforementioned items have been there several days.

During an interview with the Nursing Home Administrator on February 7, 2020, at approximately 11:30 AM it was revealed that housekeeping starts their day at the north end of the building and works down the hallway, however staff could/should pick up items on the floor if they are aware of it.

An observation on February 3, 2020 at 8:43 AM revealed 4 dirty tissues laying on the floor next to Resident 20's bed. There was also crumbs laying under the bedside table.

An observation on February 3, 2020 at 9:15 AM revealed a wet washcloth laying on the floor at the bottom of Resident 42's bed. There was also several pieces of trash located around the trash can beside the bed.

28 Pa. Code 207.2(a) Administration responsibility










 Plan of Correction - To be completed: 03/25/2020

1. Resident 50's laundry bag was immediately removed from resident room and laundered. Residents 20, 42, and 65 had the liquid stains, tissues and crumbs removed and the floors were mopped.
2. Current residents are at risk for this alleged deficiency. A house sweep has been completed to ensure a safe, clean and home-like environment through the removal of tissues, stains and laundry bags needing to be laundered.
3. Staff in the nursing, housekeeping, laundry, and therapy departments will be educated on maintaining a Safe, Clean, Comfortable, Homelike environment.
4. Administrator or designee will perform 10 random observations of floors in resident's room, to ensure they are free from debris and stains, weekly x 4, then monthly x 2. Results of these observations will be brought to the QAPI committee for further review and recommendations as appropriate
5. The facility will be in substantial compliance by 3/25/2020.

483.10(f)(5)(i)-(iv)(6)(7) REQUIREMENT Resident/Family Group and Response:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.10(f)(5) The resident has a right to organize and participate in resident groups in the facility.
(i) The facility must provide a resident or family group, if one exists, with private space; and take reasonable steps, with the approval of the group, to make residents and family members aware of upcoming meetings in a timely manner.
(ii) Staff, visitors, or other guests may attend resident group or family group meetings only at the respective group's invitation.
(iii) The facility must provide a designated staff person who is approved by the resident or family group and the facility and who is responsible for providing assistance and responding to written requests that result from group meetings.
(iv) The facility must consider the views of a resident or family group and act promptly upon the grievances and recommendations of such groups concerning issues of resident care and life in the facility.
(A) The facility must be able to demonstrate their response and rationale for such response.
(B) This should not be construed to mean that the facility must implement as recommended every request of the resident or family group.

483.10(f)(6) The resident has a right to participate in family groups.

483.10(f)(7) The resident has a right to have family member(s) or other resident representative(s) meet in the facility with the families or resident representative(s) of other residents in the facility.
Observations:



Based on document review and staff interview it was determined that the facility failed to ensure each resident's right to participate in the resident council group meeting for two of three months of meeting minutes reviewed (November 2019 and January 2020).

Findings Include:

Review of the requested three months of resident council meeting minutes revealed minutes provided for the month of December 2019.

An interview with residents during the resident council group meeting, on February 5, 2020, at 10:19 AM, revealed the residents desire to meet on a monthly basis and an expectation the resident council group meetings are to be held monthly with facility assistance and coordination.

An interview with the Nursing Home Administator (NHA), on February 6, 2020, at 10:58 AM revealed she could not locate the resident council meeting minutes for the month of November 2019. The NHA stated the Therapeutic Recreation Director is designated to assist with setting up the resident group meeting and that position is currently vacant.

The interview with the NHA also revealed the resident group meeting for the month of January 2020, had been rescheduled to February 3, 2020, however staff did not hold the meeting due to the Department of Health survey team's presence in the building.

28 Pa. Code 201.29 (j) Resident rights
28 Pa. Code 201.18 (b) (2) Management
















 Plan of Correction - To be completed: 03/25/2020

1. Resident council meetings are now being held monthly.
2. Residents that would like to participate in the resident council group meeting have the potential to be affected. These residents will have monthly meetings held upholding their resident's rights.
An additional resident council meeting was held on 2/21/2020.
3. The Activities Director will be educated on ensuring Resident council group meeting is being held monthly allowing residents to participate.
4. The Administrator/designee will conduct monthly observations to ensure resident council group meeting is being held monthly allowing residents to participate. These observations will be conducted monthly x3 or until substantial compliance has been achieved. Results of these observations will be brought to the QAPI committee for further review and recommendations as appropriate.
5. The facility will be in substantial compliance by 3/25/2020.

51.6 (a)(1) LICENSURE IDENTIFICATION OF PERSONNEL:State only Deficiency.
51.6. Identification of personnel

(a) When working in a health care
facility and when clinically feasible,
the following individuals shall wear
an identification tag which displays
that person's name and professional
designation:
(1) Health care practitioners
licensed or certified by Commonwealth
agencies.
Observations:


Based on surveyor observation, facility policy review, and staff interview it was determined that the facility failed to ensure all staff providing direct care to residents wore identification badges.

Findings Include:

Review of the facility's dress code policy, with an effective date of July 1, 2017, reads, in part, "All employees must wear a name badge at all times so that residents can identify you."

Surveyor observation on February 3, 2020, at 9:37 AM revealed Nurse Aide (NA) 3 with a handwritten name tag taped to her shirt.

Surveyor observation on February 4, 2020, at 3:35 PM revealed Licensed Practical Nurse (LPN) 1 with a handwritten name tag taped to his shirt.

Surveyor observation on February 3, 2020, at approximately 12:26 PM Nursing Assistant 6 (NA 6) wasn't wearing an identification badge with a picture. NA 6 wore a piece of tape with her name on it, on her shirt.

Surveyor observation on February 3, 2020, at approximately 10:13 Nursing Assistant 5 (NA 5) wasn't wearing an identification badge with a picture. NA 6 wore a piece of tape with her name on it, on her shirt under her sweater.

Surveyor observation on February 3, 2020, at approximately 12:28 PM Nursing Assistant 4 (NA 4) wasn't wearing an identification badge with a picture. NA 6 wore a piece of tape with her name on it, on her shirt.

Surveyor observation on February 5, 2020, at 9:13 AM revealed Nursing Assistant 7 (NA 7) without an identification badge with a picture.

Surveyor observation on February 5, 2020, at approximately 2:31 PM Nursing Assistant 4 (NA 4) wasn't wearing an identification badge with a picture. NA 6 wore a piece of tape with her name on it, on her shirt.

An interview with the Nursing Home Administrator, on February 5, 2020, at 2:40 PM revealed she expects staff identification badges to be worn per dress code policy.



Chapter 51.6 Identification of Personnel









 Plan of Correction - To be completed: 03/25/2020

1. Facility staff were provided photo IDs to wear while in the building.
2. Current residents are at risk for this alleged deficient practice. House wide audit has been completed to ensure facility staff will wear photo ID while working.
3. The Administrator or designee will provide education to facility staff to ensure all staff providing direct care to resident's wear identification badges while working.
4 The Administrator or designee will perform 5 random audits of facility staff weekly x 4 then monthly x 2 months to ensure compliance with wearing ID badges or until substantial compliance is reached. All results will be presented at QAPI committee for further review and recommendations as appropriate.
5 The facility will be in substantial compliance by 3/25/2020.

201.14(a) LICENSURE Responsibility of licensee.:State only Deficiency.
(a) The licensee is responsible for meeting the minimum standards for the operation of a facility as set forth by the Department and by other State and local agencies responsible for the health and welfare of residents.
Observations:
Based on staff interview, it was determined that the facility failed to provide written notification of health care associated infections to the resident or the resident's responsible party, per Act 52.

During staff interview on February 6, 2020, at approximately 9:20 AM. The infection control nurse (RN 3), in the presence of the Director of Nursing (DON), revealed that the facility was not notifying the residents or the responsible party in writing if there was an occurances of a health care- associated infection.

On February 6, 2020 at 12:35 PM she acknowledged that Act 52 should have been followed.





 Plan of Correction - To be completed: 03/25/2020

1. The facility has provided notification of residents with current infections.
2. Residents with infections are at risk for this alleged deficient practice. The facility will audit resident's currently receiving antibiotics and provide written notification of health care associated infections to the resident or the resident's responsible party.
3. The Infection Control Preventionist or designee will provide education to licensed nursing staff regarding the need to provide written notification to families and RPs according to the Act 52 requirement.
4. The infection Control Preventionist or designee will perform audits of current infections and ensure notifications are completed as appropriate weekly x 1 month, then, monthly x 2 or until substantial compliance has been achieved. All results will be presented at QAPI committee for further review and recommendations as appropriate.
5. The facility will be in substantial compliance by 3/25/2020.


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