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

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GARDENS AT CAMP HILL, THE
Inspection Results For:

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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, Civil Rights survey and a complaint survey completed on August 1, 2024, it was determined that The Gardens at Camp Hill was not in compliance with the following requirements of 42 CFR Part 483 Subpart B, Requirements for Long Term Care Facilities and the 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.


 Plan of Correction:


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

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

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

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

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

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

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

Based on review of facility policy, clinical record review, observations, and staff interviews, it was determined that the facility failed to maintain a system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases, and failed to ensure staff follow professional standards of infection control practices during medication administration for two of five residents observed for medication administration (Residents 34 and 78).

Findings include:

Facility policy, titled "Infection Control Prevention, Control and Antibiotic Stewardship", last reviewed July 25, 2024, read, in part, "E. Measures for the Detection, Control and Prevention of HealthCare Acquired Infections. Detection of HealthCare Acquired Infections (HCAI) is accomplished through a facility based ongoing system of surveillance. All infections are identified and reported to the facility Infection Control Preventionist of designee ... A Line Listing of residents with infections is maintained and tracked for trending and outbreak potential. Follow up review of lab data is compared. A monthly IC review is completed to identify trends."

An interview on July 31, 2024 at 11:11 AM, with the Director of Nursing (DON) revealed the facility has been without an Infection Preventionist (IP) since April 2024. The DON stated that infection tracking was not being done since the IP left. The DON provided a binder titled, "Infection Prevention."

Review of the aforementioned binder revealed no infection control surveillance and data analysis had been done for April 2024, May 2024, June 2024, and July 2024.

Review of Resident 34's clinical record revealed diagnoses that included end stage renal disease (severe decrease in the kidneys ability to filter toxins from the blood resulting) and dementia (progressive, irreversible degenerative brain disease that results in decreased contact with reality and decreased ability to perform activities of daily living).

During medication administration observation on July 31, 2024, at approximately 9:00 AM, Employee 1 was observed preparing medications for Resident 34. During the preparation of medication, Employee 1 was observed dispensing multiple docusate sodium 100 milligram (mg - metric unit of measure) tablets into the lid of the medications multidose container. Employee 1 was observed placing an ungloved finger onto an extra tablet to prevent it from being poured into Resident 34's medication cup. After pouring the prescribed number of tablets into a medicine cup, Employee 1 was observed pouring the unused tablet back into the multidose container. Employee 1 then stored the multidose container of docusate sodium 100 mg back in the medication cart.

Review of Resident 78's clinical record revealed diagnoses that included epilepsy (disorder of nerve cell activity within the brain that can cause muscle contractions and/or spasms, amnesia, loss of consciousness, and/or abnormal behavior) and congestive heart failure (CHF-disease of the heart muscle that results in decreased ability of the heart to circulate blood efficiently through the body).

During medication administration observation on July 31, 2024, at approximately 8:45 AM, Employee 1 was observed preparing medications for Resident 78. During the medication preparation, Employee 1 was observed to pick up one tablet of potassium chloride 20 milliequivalent (mEq - metric unit of measure) with Employee 1's bare hand to break the tablet in half. Employee 1 was also observed preparing vitamin C 500 milligrams (mg - metric unit of measure) and aspirin 81 mg by dispensing tablets into the lid of the multidose container for each medicine. Employee 1 was observed placing an ungloved finger onto an extra tablet of both the vitamin C 500 mg and aspirin 81 mg, holding it while pouring the ordered amount into a medicine cup; after which Employee 1 returned the unused tablet back to the multidose container. Employee 1 was observed returning the vitamin C 500 mg multidose container and aspirin 81 mg multidose container to the medication cart for storage. After preparation, Employee 1 was observed administering the medications to Resident 78.

During a staff interview on August 1, 2024, at approximately 10:10 AM, the DON revealed it was the facility's expectation that staff do not touch medications with their bare hands.

28 Pa. Code 211.12 (c)(d)(3)(5) Nursing services
28 Pa. Code 211.10 (d) Resident care policies


 Plan of Correction - To be completed: 09/10/2024

1. No ill effects to Resident 34 or Resident 78 related to observations during medication passing observation. Unable to correct past missing line list as this is a past occurrence.
2. Medication pass observations to be completed for licensed nurses to ensure appropriate IC practices. Review of line listing for July to ensure infections are captured appropriately.
3. Education to licensed nurses on Infection Control practices during medication administration. Education to administrative nurses regarding maintaining monthly line list. In house RN accepted the IP position and completed the CDC training as of August 9, 2024.
4. Medication pass observations to be completed on 3 licensed nurses weekly for one month, then monthly for two months to ensure Infection Control practices by DON or designee. Audit of line list weekly to ensure capturing of infections weekly for one month then monthly by DON or designee. Results to be reviewed in QAPI.

483.10(f)(1)-(3)(8) REQUIREMENT Self-Determination: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(f) Self-determination.
The resident has the right to and the facility must promote and facilitate resident self-determination through support of resident choice, including but not limited to the rights specified in paragraphs (f)(1) through (11) of this section.

§483.10(f)(1) The resident has a right to choose activities, schedules (including sleeping and waking times), health care and providers of health care services consistent with his or her interests, assessments, and plan of care and other applicable provisions of this part.

§483.10(f)(2) The resident has a right to make choices about aspects of his or her life in the facility that are significant to the resident.

§483.10(f)(3) The resident has a right to interact with members of the community and participate in community activities both inside and outside the facility.

§483.10(f)(8) The resident has a right to participate in other activities, including social, religious, and community activities that do not interfere with the rights of other residents in the facility.
Observations:

Based on clinical record review, facility documentation review, and resident and staff interviews, it was determined that the facility failed to ensure one of one residents reviewed were provided the right to self-determination in regard to a room change (Resident 10).

Findings include:

Review of Resident 10's clinical record revealed diagnoses that included anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities) and major depressive disorder (a mental health disorder characterized by persistent low mood, decreased involvement in pleasurable activities, sleep and appetite pattern disruptions).

During an interview with Resident 10 on July 29, 2024, at 2:02 PM, Resident 10 indicated that the Resident had requested a room change that had not been accommodated. Resident 10 indicated that the he had requested the room change because their roommate yells out frequently.

Review of Resident 10's clinical record revealed a social services note dated April 5, 2024, at 11:37 AM, that indicated "Resident requested a room change. He was notified that there are currently no male beds available. He agreed to be added to a list and offered a room when one opened."

Review of Resident 10's clinical record revealed a social services note dated May 30, 2024, at 11:26 AM, that indicated "Resident continues desire to be on a Room Change List. He was offered, but is not interested in moving to a different room."

Further review of Resident 10's clinical record failed to reveal any notes between May 30, 2024, and July 31, 2024, that the Resident was offered a room change as requested.

Review of the facility provided list of residents requesting room changes revealed that Resident 10 was at the top of the list of male residents requesting a room change.

Review of facility provided list of new admissions to the facility from May 30, 2024, to July 30, 2024, revealed that 10 additional male residents had been admitted to the facility during this timeframe.

During an interview with the Nursing Home Administrator and Director of Nursing (DON) on August 1, 2024, at 10:29 AM, the DON confirmed that Resident 10 was still at the top of the list for males requesting a room change. The DON also confirmed that Resident 10 should have been offered a room change between May 30, 2024, and July 30, 2024, since the facility was receiving new male admissions.

28 Pa Code 201.29(a) Resident rights


 Plan of Correction - To be completed: 09/10/2024

1. For Resident 10, the resident was reviewed for room change availability. After previous offers that were not accepted On August 13th Resident 10 was offered another room and agreed that he is pleased with the room and his roommate, and looks forward to changing rooms.
2. Residents on room change list revisited for bed availability and updates provided to residents.
3. Room change request list to be provided to Admissions Coordinator and education provided to SSD working with Admissions to facilitate room changes.
4. Room Change Request List will be audited by DON or designee weekly for one month, then monthly for two months to ensure room changes being offered. Results to be reviewed in QAPI.

483.95(g)(1)-(4) REQUIREMENT Required In-Service Training for Nurse Aides: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.
§483.95(g) Required in-service training for nurse aides.
In-service training must-

§483.95(g)(1) Be sufficient to ensure the continuing competence of nurse aides, but must be no less than 12 hours per year.

§483.95(g)(2) Include dementia management training and resident abuse prevention training.

§483.95(g)(3) Address areas of weakness as determined in nurse aides' performance reviews and facility assessment at § 483.70(e) and may address the special needs of residents as determined by the facility staff.

§483.95(g)(4) For nurse aides providing services to individuals with cognitive impairments, also address the care of the cognitively impaired.
Observations:

Based on review of personnel training records and staff interviews, it was determined that the facility failed to ensure each nurse aide was provided with the required in-service training consisting of no less than 12 hours per year for five of five nurse aide employee records reviewed (Employees 6, 7, 8, 9, and 10), and failed to provide annual training that included resident abuse prevention for one of five nurse aide employee records reviewed (Employee 6).

Findings Include:

Review of personnel information revealed Employee 6's hire date was November 18, 1992; Employee 7's hire date was October 16, 2000; Employee 8's hire date was November 15, 2004; Employee 9's hire date was October 15, 2007; and Employee 10's hire date was December 19, 2022.

Review of facility training records failed to reveal that the aforementioned Employees completed 12 hours of required annual training in the past 12 months.

Further review of facility training records failed to reveal evidence that abuse prevention training was completed by Employee 6 within the past 12 months.

During an interview with the Nursing Home Administrator (NHA), Director of Nursing (DON), and Employee 4 (Regional Director of Clinical Services) on August 1, 2024, at 10:30 AM, Employee 4 confirmed that they could not provide documentation to show that Employees 6, 7, 8, 9, and 10 received the required 12 hours of education for the past year. The NHA and DON both confirmed that they would expect nurse aides to receive the required 12 hours of education on an annual basis.

During a follow-up interview with the NHA, DON, and Employee 4, on August 1, 2024, at 12:10 PM, the DON confirmed she could not provide any documentation that Employee 6 had received abuse prevention training in the past year, and confirmed that all staff should receive this training at least annually.

28 Pa. Code 201.14(a) Responsibility of licensee
28 Pa. Code 201.18(b)(1)(3) Management
28 Pa. Code 201.19(7) Personnel policies and procedures
28 Pa. Code 201.20(a)(d) Staff development


 Plan of Correction - To be completed: 09/10/2024

1. Identified staff provided additional training to meet requirements
2. Audit of CNA files to ensure requirements have been met
3. Education to administrative nursing and HR on required CNA training requirements
4. Audit of 10 CNA files monthly x 3 to ensure training completed as scheduled by DON or designee. Results to be reviewed in QAPI


483.80(b)(1)-(4) REQUIREMENT Infection Preventionist Qualifications/Role:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
§483.80(b) Infection preventionist
The facility must designate one or more individual(s) as the infection preventionist(s) (IP)(s) who are responsible for the facility's IPCP. The IP must:

§483.80(b)(1) Have primary professional training in nursing, medical technology, microbiology, epidemiology, or other related field;

§483.80(b)(2) Be qualified by education, training, experience or certification;

§483.80(b)(3) Work at least part-time at the facility; and

§483.80(b)(4) Have completed specialized training in infection prevention and control.
Observations:

Based on review of regulations, facility policy review, and staff interviews, it was determined that the facility failed to have an Infection Preventionist (IP) that worked at least part time at the facility.

Findings Include:

The Centers for Medicare and Medicaid Services regulation stated, "The facility must designate one or more individual(s) as the infection Preventionist(s) (IP)(s) who are responsible for the facility ' s IPCP. The IP must: Work at least part-time at the facility. ... The IP must physically work onsite in the facility. He/she cannot be an off-site consultant or perform the IP work at a separate location such as a corporate office or affiliated short term acute care facility."

Review of facility policy, titled "Infection Control Prevention, Control and Antibiotic Stewardship", last reviewed July 25, 2024, revealed "The facility designates one or more individual(s) as the infection Preventionist(s)(IPs) who are responsible for the facility IPCP. The IP works at least part-time at the facility."

During an interview with the Director of Nursing, it was revealed that the prior IP left the role in April 2024 and that the facility does not currently have an IP.

28 Pa. Code 201.14(a) Responsibility of licensee
28 Pa. Code 201.18(b)(1) Management


 Plan of Correction - To be completed: 09/10/2024

1. Unable to correct this past occurrence for identified timeframe.
2. Position accepted for the Infection Preventionist working at least part time by RN currently on staff and has completed the CDC training.
3. Education provided to administrative nursing on requirement of qualified IP
4. Monthly audit of trained IP personnel on file by HR. Result to be reviewed in QAPI.

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

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

Based on a review of the facility's infection prevention and control policy and staff interview, it was determined that the facility failed to maintain an antibiotic stewardship program that includes a system to effectively monitor antibiotic usage.

Findings include:

Facility policy, titled "Infection Control Prevention, Control and Antibiotic Stewardship", last reviewed July 25, 2024, read, in part, "A. Mission and Goals. The infection Prevention and Control Plan is a comprehensive process that addresses preventing, identifying, reporting, investigating, and controlling infections and communicable diseases and monitoring judicious use of antibiotic to individuals ...the goals of the program are to: 3. Optimize the use of antibiotics to meet resident and community specific needs ...6. Facilitate compliance with state and federal regulations relating to infection control and antibiotic stewardship. B. Scope 6. Core Elements of Antibiotic Stewardship Action: Formal review procedure for the appropriateness of any antibiotics prescribed by the Infection Preventionist on a regular basis when antibiotic orders are prescribed. Tracking: Monitoring antibiotic prescribing and resistance patterns. Reporting: Regular reporting information on antibiotic use and resistance to doctors, nurses, and relevant staff."

An interview on July 31, 2024 at 11:11 AM, with the Director of Nursing (DON), revealed the facility has been without an Infection Preventionist since April 2024. The DON stated she was unsure of when antibiotic tracking was last completed. The DON provided a binder titled, "Infection Prevention."

Review of the aforementioned binder revealed no antibiotic tracking had been done for April 2024, May 2024, June 2024, and July 2024.

28 Pa. Code 211.12 (d)(1)(2) Nursing services
28 Pa. Code 211.10 (a) Resident Care Policies


 Plan of Correction - To be completed: 09/10/2024

1. Unable to correct missed tracking of antibiotic usage as this was a past occurrence.
2. Review of last 3 months of antibiotics usage conducted and July antibiotics usage reviewed for effectiveness, and conservative usage as well as provider follow up on medically necessary usage.
3. Education to Infection Preventionist and administrative nursing staff on antibiotics stewardship.
4. Audit of antibiotics usage by DON or designee monthly for 3 months to ensure appropriate antibiotic stewardship is maintained and practiced throughout the facility. Results to be reviewed in QAPI.




483.75(g)(1)(i)-(iii)(2)(i); 483.80(c) REQUIREMENT QAA Committee: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(g) Quality assessment and assurance.
§483.75(g) Quality assessment and assurance.
§483.75(g)(1) A facility must maintain a quality assessment and assurance committee consisting at a minimum of:
(i) The director of nursing services;
(ii) The Medical Director or his/her designee;
(iii) At least three other members of the facility's staff, at least one of who must be the administrator, owner, a board member or other individual in a leadership role; and
(iv) The infection preventionist.

§483.75(g)(2) The quality assessment and assurance committee reports to the facility's governing body, or designated person(s) functioning as a governing body regarding its activities, including implementation of the QAPI program required under paragraphs (a) through (e) of this section. The committee must:
(i) Meet at least quarterly and as needed to coordinate and evaluate activities under the QAPI program, such as identifying issues with respect to which quality assessment and assurance activities, including performance improvement projects required under the QAPI program, are necessary.

§483.80(c) Infection preventionist participation on quality assessment and assurance committee.
The individual designated as the IP, or at least one of the individuals if there is more than one IP, must be a member of the facility's quality assessment and assurance committee and report to the committee on the IPCP on a regular basis.
Observations:

Based on review of the sign-in sheets for the facility's Quality Assurance (QA) Committee and staff interview, it was determined that the required members failed to attend a meeting at least quarterly for two of three quarters over the past year.

Findings include:

Review of all available documentation submitted by the facility revealed no evidence that the Nursing Home Administrator (NHA) and the facility Infection Control Preventionist attended a meeting during the quarter of October 2023, November 2023, and December 2023.

Review of all available documentation submitted by the facility revealed no evidence that the facility Infection Control Preventionist attended a meeting during the quarter of April 2024, May 2024, and June 2024.

During an interview with the NHA and the Director of Nursing (DON) on August 1, 2024, at approximately 9:28 AM, the NHA indicated that the facility QA committee meets monthly. He confirmed that the aforementioned members did not attend at least one meeting in the last quarter of 2023 or the second quarter of 2024. He further indicated that he would expect all required members to attend a QA meeting at a minimum of quarterly.

28 Pa. Code 201.14(a) Responsibility of licensee
28 Pa. Code 201.18(b)(1)(3) Management


 Plan of Correction - To be completed: 09/10/2024

1. QAPI meeting for June reviewed with members not present at time of meeting.
2. Last 6 months of QAPI meetings to be reviewed for presence of members on a quarterly basis.
3. Education to Medical Director, Lab Services, and Pharmacy representatives on requirement for participation in QAPI.
4. Audit of QAPI sign in sheets monthly for 3 months to ensure participation by required members by DON or designee. Results to be reviewed in QAPI.

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 facility policy review, observations, and staff interviews, it was determined that the facility failed to store food and utilize equipment in accordance with professional standards for food service safety in the main kitchen.

Findings include:

Review of facility policy, titled "Chapter 3 Food", not dated, read, in part, "Packaged food shall be labeled as specified in law including food labeling, labeling marking devices, and containers. Food shall be protected from cross contamination. During preparation, unpackaged food shall be protected from environmental sources of contamination. A test kit or other device that accurately measures the concentration of sanitizing solutions shall be provided."

Observation of the walk-in freezer on July 29, 2024, at 9:38 AM, revealed a bag of mixed vegetables not dated; one bag of corn not dated; one bag of peas not dated; two angel food cakes not dated; and one frozen beverage cup as well as one frozen shake from an outside source.

During an interview with Employee 5 (Dietary Manager) on July 29, 2024, at 9:39 AM, he revealed the aforementioned outside sourced items belong to dietary staff and should not be in facility food storage areas.

Observation of reach-in refrigerator 1 on July 29, 2024, at 9:41 AM, revealed 20 containers of mixed beverages not dated; two containers of mixed beverage dated prepared on July 23, 2024; and one to-go box container of food.

Interview with Employee 5 on July 29, 2024, at 9:42 AM, revealed the juices should be labeled and discarded once expired, and the to-go box belongs to staff and should not be in the reach-in refrigerator.

Observation of the walk-in refrigerator on July 29, 2024, at 9:44 AM, revealed a container of chicken salad labeled use by July 27; a container of ham labeled use by July 23; an open container of shredded cheese without an open date; and a plastic container of food from an outside source belonging to staff.

Observation of reach in refrigerator 2 on July 29, 2024, at 9:48 AM, revealed one container of hamburger buns not dated and open to air; and four containers of mixed beverage not dated.

Observation of the ice machine in the main kitchen on July 29, 2024, at 9:50 AM, failed to reveal an air gap between the floor drain and the drain of the ice machine.

Observation in the main kitchen on July 29, 2024, at 9:52 AM, revealed a shelf with a container of toasted-O cereal labeled use by July 28; one container of puffed rice cereal labeled use by July 17.

Further observation in the main kitchen on July 29, 2024, at 9:54 AM, revealed an open package of grits not dated with an open date; two containers of dry rub spice not dated; one bin of thickener not dated; and a bin of potatoes with many potatoes appearing to be rotten.

During an observation of the three-compartment sink in the main kitchen on July 29, 2024, at 9:56 AM, the surveyor requested Employee 5 to test the concentration of the sanitizer water. Employee 5 tested the water with test strips that were not in an original container to indicate when they expire.

Surveyor review of the second bottle of test strips on the shelf on July 29, 2024, at 9:57 AM, revealed they were the incorrect test strips based on the sanitizer being used and had an expiration date of March 1, 2024.

Interview with Employee 5 on July 29, 2024, at 9:58 AM, revealed he does not have a recorded log for the three-compartment sink sanitizer concentration. He further revealed he has to decide how he wants staff to record activity, as they utilize the sink for both food preparation and sanitizing kitchen equipment.

Observation of the dry storage area on July 29, 2024, at 10:01 AM, revealed an open bag of penne pasta without an open date; an open bag of thickener without an open date; and a bag of orzo not dated.

Interview with the Nursing Home Administrator on July 31, 2024, at 11:11 AM, he revealed it is the facility's expectation that food items and kitchen equipment are stored and utilized in accordance with professional standards.

28 Pa. Code 211.6(f) Dietary services
28 Pa. Code 201.18(b)(3)(e)(2.1) Management


 Plan of Correction - To be completed: 09/10/2024

1. Identified areas of concern addressed at time of survey, including expired, unlabeled, undated, and personal foods in walk-in freezer, refrigerator, reach-in refrigerator, main kitchen , and dry storage disposed of. Air gap corrected for ice machine. Correct test strips ordered for 3 compartment sink.
2. Audit of kitchen and pantry areas conducted by Food Services Director to ensure foods appropriately labeled and dated. Audit of facility ice machines to ensure air gaps in place.
3. Education provided to dietary staff on food handling, safety, and storage.
4. Audits of walk-in refrigerator and freezer, reach in refrigerator, dry storage and main kitchen weekly for one month, monthly for two months by dietary manager or designee. Audit of ice machine for appropriate air gap monthly x 3 months. Audit of 3 compartment sink to ensure use of correct test strips weekly x 4 weeks then monthly x 2 . Results to be reviewed in QAPI.


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 affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
§483.45(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 act upon the licensed pharmacist's report of a medication irregularity for one of five residents reviewed for unnecessary medications (Resident 29).

Findings include:

Review of facility policy, titled "Medication Regimen Review", last reviewed July 25, 2024, read, in part "The consultant pharmacist performs a comprehensive medication regimen review (MRR) at least monthly. Recommendations are acted upon and documented by the facility staff and or the prescriber. The director of nursing of designated licensed nurse address and document recommendations that do not require a physician intervention, e.g., monitor blood pressure."

Review of Resident 29's clinical record revealed diagnoses that included hypotension (low blood pressure), dysphagia (difficulty swallowing), and atrial fibrillation (abnormal heart rhythm characterized by rapid and irregular beating).

Review of Resident 29's physician orders revealed the following orders:

Midodrine HCl Tablet 5 MG (milligram-unit of measure), Give one tablet by mouth two times a day, hold if systolic blood pressure (SBP) is greater 120 related to hypotension, with a start date of August 4, 2023, and an end date of January 22, 2024.

Midodrine HCl Tablet 5 MG Give one tablet by mouth three times a day, hold if systolic BP >120 related to hypotension, with a start date of February 2, 2024, and an end date of February 11, 2024.

Midodrine HCl Tablet 5 MG Give one tablet by mouth three times a day, hold if systolic BP >120 related to hypotension, with a start date of February 13, 2024, and an end date of February 21, 2024.

Review of Resident 29's MRR from December 4, 2023, revealed a recommendation from the pharmacist, "Please be aware of the hold parameters noted in the Midodrine order. Hold for SBP > 120. Administered outside the order", the report was not signed by facility staff or the provider.

Review of Resident 29's December 2023 MAR (Medication Administration Record- documentation for medication/treatment administered or monitored), revealed the Midodrine medication continued to be administered outside of parameters on December 9, 14, 16, 17, 18, 23, 25, 28, 30, and 31, 2024.

Review of Resident 29's January 2024 MAR, revealed the Midodrine medication continued to be administered outside of parameters on January 3, 6, 7, 10, 13, 14, 16, 17, and 19-21, 2024.

Review of Resident 29's February 2024 MAR, revealed the Midodrine medication continued to be administered outside of parameters on February 4, 8, 9, 14, 16, and 17, 2024.

Interview with the Director of Nursing on August 1, 2024, at 12:04 PM, revealed she was not able to locate documentation to indicate the facility responded to the pharmacy recommendation, or that interventions or staff education were implemented in response to that recommendation.

28 Pa Code 211.9(a)(1) Pharmacy Services
28 Pa Code 211.12(d)(3)(5) Nursing Services


 Plan of Correction - To be completed: 09/10/2024

1. Resident 29 had the medication recommendations and order evaluated, updated and no ill effects noted to resident, medication error completed.
2. Last 30 days of MRR reviewed to ensure recommendations addressed by MD and orders implemented as appropriate.
3. Education to nursing administration on review of MRRs with MD and if not addressed in 14 days resubmission to MD.
4. Audit of MRR for timely completion by MD and implementation of orders monthly for three months by DON or designee. Results to be reviewed at QAPI.

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 facility policy review, clinical record review, and resident representative and staff interviews, it was determined that the facility failed to ensure each resident received treatment in accordance with professional standards of practice for two of 21 residents reviewed (Residents 25 and 85).

Findings Include:

Facility policy, titled "Pacemaker, Care of a Resident", with a last reviewed July 25, 2024, read, in part, "Monitoring. 3. The pacemaker battery will be monitored remotely through the telephone or an internet connection. 4. The resident will have an EKG (electrocardiogram) annually, or as ordered, to monitor for changes in the heart's electrical activity. 5. Make sure the resident has a medical identification card that indicates he or she has a pacemaker. The medical record must contain this information as well. Documentation. 1. For each resident with a pacemaker, document the following in the medical record and on a pacemaker identification card upon admission: a. The name, address, and telephone number of the cardiologist; b.Type of pacemaker; c. Type of leads; d. Manufacturer and model; e. Serial number; f. Date of implant; and g. Paced rate."

Further review of Resident 25's clinical record revealed diagnoses that included schizophrenia (serious mental illness that affects a person's thoughts, feelings, and behaviors) and right bundle branch block (delay or blockage on the right side of the heart that prevents the heart's electrical signals to move at the same speed as the left side of the heart, creating an irregular heartbeat). Further review of Resident 25's clinical records revealed Resident 25 was admitted to the facility May 8, 2024, from the hospital.

Review of Resident 25's comprehensive plan of care revealed a focus area for "resident is at risk for complications related to pacemaker, with interventions that included EKG as ordered.

Review of Resident 25's physician progress notes revealed a note dated May 10, 2024, that read, in part, "H&P (history and physical) past medical history of ... high grade AV (atrioventricular) block status post pacemaker March 2024."

Review of Resident 25's physician orders failed to reveal orders for monitoring Resident 25's pacemaker.

Review of Resident 25's hospital records from admission revealed "past surgical history: leadless pacemaker implant March 7, 2024."

Further review of Resident 25's clinical record failed to reveal an EKG had been completed.

Review of a chest Xray dated May 11, 2024, read, in part, "impression ... loop recorder over the heart."

During an interview on July 31, 2024 at 11:48 AM, with Employee 3, she stated she had spoken with staff and Resident 25 does not have a pacemaker. At that time, the surveyor requested additional information regarding Resident 25's physician's note, hospital records, and chest Xray indicating Resident 25 had a pacemaker.

During an additional staff interview on August 1, 2024 at 10:18 AM, with the Nursing Home Administrator, Director of Nursing (DON), Employee 3, and Employee 4, the DON confirmed Resident 25 did not have an EKG done and stated she would have expected the hospital to include Resident 25's pacemaker orders in the discharge orders. The DON also stated that a call had been placed to the cardiology office listed in Resident 25's hospital paperwork, and that it was the expectation of the facility that residents with pacemakers have orders for pacemaker care and monitoring.

Review of Resident 85's clinical record revealed diagnoses that included cirrhosis of liver (permanent scarring that damages your liver) and hypertension (high blood pressure).

During an interview with Resident 85's Representative on July 30, 2024, at 2:30 PM, revealed Resident 85 missed his oncology appointment that was scheduled for July 24, 2024, due to staff forgetting to schedule transportation. The Representative revealed Resident 85 was to start chemotherapy for a brain tumor that day and now it has been delayed.

Review of Resident 85's July 2024 MAR (Medication Administration Record) revealed an appointment scheduled for July 24, 2024, at 9:00 AM.

Further review of Resident 85's July 2024 MAR revealed that the order for his appointment on July 24, 2024, was marked "16", which is code for "hold/see nurse notes".

Review of Resident 85's clinical record revealed a nursing progress note on July 24, 2024, at 11:30 AM, with the following note text: "This nurse spoke with resident's representative and resident has been rescheduled for August 6, 2024, at 10:00 AM, transportation has been faxed with confirmation."

During an interview with the DON on July 31, 2024, at 10:30 AM, she revealed the nurse forgot to schedule transportation for Resident 85's appointment that was initially scheduled on July 24, 2024, and that it has been rescheduled for August 6, 2024.

28 Pa. Code 201.18(b)(1) Management
28 Pa. Code 211.12(d)(1)(3)(5) Nursing services



 Plan of Correction - To be completed: 09/10/2024

1. Call was placed to Cardiology for Resident 25 at time of survey. Resident 85's missed Oncology appointment on 7/24/24 was made up on Aug. 6, 2024.
2. Audit of residents with pacemakers/ICDs will be conducted for Cardiology routine follow up orders. Audit of residents with oncology appointments to ensure transportation request are properly placed for outside appointments.
3. Education provided to nursing staff on ensuring residents with pacemakers/ICDs have established follow up per Cardiology and submitting transportation requests for outside appts.
4. Audit of residents with new pacemakers/ICDs weekly for one month, then monthly for two months for Cardiology follow up by DON or designee. Audit of residents with new orders for oncology consults to ensure transportation request sent weekly for one month then monthly for two months by DON or designee. Results to be reviewed at QAPI.


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 facility policy review, record review, and resident and staff interviews, it was determined that the facility failed to review and revise the resident plan of care and ensure the residents right to participate in the care planning process for seven of 27 residents reviewed (Resident 3, 34, 56, 58, 71, 73, and 81).

Findings include:

Review of facility policy, titled "Care Planning - Interdisciplinary Team", last revised September 2013, read, in part, "The resident, the resident's family and/or the resident's legal representative/guardian or surrogate are encouraged to participate in the development of and revisions to the resident's care plan. Every effort will be made to schedule care plan meetings at the best time of the day for the resident and family."

Review of Resident 3's clinical record revealed diagnoses that included hypertension (high blood pressure) and dementia (loss of memory, language, problem-solving, and other thinking abilities that are severe enough to interfere with daily life).

During an interview with Resident 3 on July 30, 2024, at approximately 10:30 AM, revealed she does not get invited to her care plan meetings.

Review of Resident 3's clinical record revealed the last comprehensive Minimum Data Set (MDS - standardized assessment tool utilized to identify a resident's physical, mental, and psychosocial needs) was an Annual MDS with an assessment reference date of May 6, 2024.

Review of Resident 3's clinical record revealed no evidence that a care plan meeting was conducted in response to the comprehensive assessment.

During an interview with Employee 2 (Social Services Director) on July 31, 2024, at approximately 12:30 PM, revealed that Resident 3 did not have a care plan meeting after their Annual MDS on May 6, 2024, and could not provide any evidence so show they were invited to their most recent care plan meeting.

Review of Resident 34's clinical record revealed diagnoses that included end stage renal disease (severe decrease in the kidneys ability to filter toxins from the blood resulting) and dementia (progressive, irreversible degenerative brain disease that results in decreased contact with reality and decreased ability to perform activities of daily living).

Review of Resident 34's clinical record revealed the last comprehensive MDS was a Significant Change MDS with an assessment reference date of November 10, 2023. Review of Resident 34's clinical record revealed no evidence that a care plan meeting was conducted in response to the comprehensive assessment.

Review of Resident 56's clinical record revealed diagnoses that included hyperlipidemia (high cholesterol), diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time), and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest in things).

Interview with Resident 56 on July 29, 2024, at 11:27 AM, revealed he does not get invited to his care plan meetings.

Review of Resident 56's clinical record failed to indicate he was invited to his quarterly care plan meetings, or that quarterly care plan meetings had been held.

Review of Resident 58's clinical record revealed diagnoses that included epilepsy (disorder of nerve cell activity within the brain that can cause muscle contractions and/or spasms, amnesia, loss of consciousness, and/or abnormal behavior) and hypertension.

Review of Resident 58's clinical record revealed the most recent comprehensive MDS was an Annual MDS with an assessment reference date of September 23, 2024. Review of Resident 58's clinical record revealed no evidence that a care plan meeting was conducted in response to the comprehensive assessment.

Review of Resident 71's clinical record revealed diagnoses that included chronic obstructive pulmonary disease (COPD - a common lung disease causing restricted airflow and breathing problems) and chronic respiratory failure (when the lungs cannot get enough oxygen into the blood or eliminate enough carbon dioxide from the body).

During an interview with Resident 71 on July 30, 2024, at approximately 10:30 AM, revealed he does not get invited to his care plan meetings.

Review of Resident 71's clinical record revealed the last comprehensive MDS was a Quarterly MDS with an assessment reference date of May 2, 2024. Review of Resident 71's clinical record revealed no evidence that a care plan meeting was conducted in response to the comprehensive assessment.

During an interview with Employee 2 on July 31, 2024, at approximately 12:30 PM, revealed that Resident 71 did not have a care plan meeting after their Quarterly MDS on May 2, 2024, and could not provide any evidence so show the Resident was invited to their most recent care plan meeting.

Review of Resident 73's clinical record revealed diagnoses that included congestive heart failure (CHF - disease of the heart muscle that results in decreased ability of the heart to circulate blood efficiently through the body) and hypertension.

Review of Resident 73's clinical record revealed the most recent comprehensive MDS was an Annual MDS with an assessment reference date of February 1, 2024. Review of Resident 73's clinical record revealed no evidence that a care plan meeting was conducted in response to the comprehensive assessment.

Interview with Employee 2 on July 31, 2024, at 12:39 PM, revealed she has been trying to get care plan meetings back on track since she started working at the facility in March 2024, but she has not gotten to schedule a care plan meeting for Resident 56, and, looking back, she can't find the last time he had one.

Further, review of Resident 73's interdisciplinary progress notes entered by Employee 2 on July 5, 2024, revealed Resident 73 had requested a Nursing Home Transition (NHT) Program (Pennsylvania State initiative that works towards Residents' receiving care in the community setting rather than in a Long Term Care facility).

On July 9, 2024, Employee 2 entered a progress note that stated an NHT referral for Resident 73 had been completed.

Review of Resident 73's comprehensive plan of care revealed it contained a care plan with a focus of "Resident is [Long Term Care] and will remain in [the facility]", with the sole intervention of, "Staff to assist with tasks that resident is unable to complete independently", both with an initiation date of May 6, 2024. Resident 73's care plan did not include Resident 73's discharge planning for returning to the community.

During a staff interview on August 1, 2024, at approximately 12:05 PM, Director of Nursing (DON) revealed it was the facility's expectation that Resident 73's care plan would include the plan for discharge for Resident 73.

Review of Resident 81's clinical record revealed diagnoses that included major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest) and hyperlipidemia (when there are high levels of fat particles in the blood).

Review of Resident 81's clinical record revealed the last comprehensive MDS was a Quarterly MDS with an assessment reference date of May 6, 2024. Review of Resident 81's clinical record revealed no evidence that a care plan meeting was conducted in response to the comprehensive assessment.

During an interview with Employee 2 on July 31, 2024, at approximately 12:30 PM, revealed that Resident 81 was admitted in January 2024 and has never had a care plan meeting.

During an interview with the Nursing Home Administrator on July 31, 2024, at 12:39 PM, he revealed he would expect quarterly care plan meetings to be held and residents and/or their representatives to be invited.

During a staff interview on August 1, 2024, at approximately 12:05 PM, the DON revealed it was the facility's expectation that care plan meetings are conducted at least after a residents' comprehensive assessment.

28 Pa. Code 211.10(d)(a) Resident care policies
28 Pa. Code 211.11(d)(3)(5) Nursing services



 Plan of Correction - To be completed: 09/10/2024

1. Unable to correct past occurrences of care plan meetings and invitations for residents 3, 34, 56, 58, 71, and 81 Residents 73 care plans updated at time of survey.
2. Audit of last 14 days of care plan meetings to ensure held and residents invited. Audit of discharge care plans to ensure accuracy of plan.
3. Education provided to SSD and IDT team on completion of care plan meeting and inviting residents and/or RR. Education provided to SS on care plan revisions related to discharge plan and updating in a timely manner.
4. Audit of care plan meetings weekly for one month, then monthly for two months to ensure they are held and resident and/or RR invited to participate and that discharge care plan is accurate by Director of Social Services or designee. Results to be reviewed at QAPI.


483.21(b)(1)(3) REQUIREMENT Develop/Implement Comprehensive Care Plan: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)(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.
§483.21(b)(3) The services provided or arranged by the facility, as outlined by the comprehensive care plan, must-
(iii) Be culturally-competent and trauma-informed.
Observations:

Based on policy review, clinical record review, and staff interviews, it was determined that the facility failed to ensure the resident's comprehensive plan of care accurately reflected the needs of the resident for three of 21 residents reviewed (Residents 20, 60, and 72).

Findings include:

Review of the facility policy, titled "Care Plans, Comprehensive Person-Centered", with a review date of July 25, 2024, revealed "Policy Statement. A comprehensive, person-centered care plan that includes objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and for each resident ... 8. The comprehensive, person-center care plan will: b. Describe services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being... 13. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change."

Review of Resident 20's clinical record revealed diagnoses that included type two diabetes mellitus (condition where the body doesn't produce enough insulin or doesn't use insulin properly), generalized anxiety disorder (severe ongoing anxiety that interferes with daily activities), and paroxysmal atrial fibrillation (type of irregular heartbeat that occurs in brief episodes).

Review of Resident 20's physician orders revealed orders apixaban 2.5 milligram (mg) twice daily for paroxysmal atrial fibrillation; novolog Pen 100 unit/milliliter (ml) sliding scale coverage at bedtime for type two diabetes mellitus; insulin glargine solostar 100 unit/ml four units at bedtime for type two diabetes mellitus; and seroquel 25 mg at bedtime for generalized anxiety.

Review of Resident 20's comprehensive plan of care failed to reveal Resident 20 had any focus areas or interventions that addressed diabetes mellitus, insulin use, anticoagulant medication use, and psychotropic medication use.

During an interview on July 31, 2024, at 10:24 AM, with the Nursing Home Administrator (NHA), Director of Nursing (DON), Employee 3, and Employee 4, it was confirmed that aforementioned areas were not captured on Resident 20's comprehensive plan of care. The DON stated it was the expectation of the facility that comprehensive care plans be completed accurately.

Review of Resident 60's clinical record revealed diagnoses that included stage three chronic kidney disease (CKD - decrease in the kidney's ability to filter toxins from the blood) and type two diabetes mellitus.

Review of Resident 60's clinical record revealed that on May 25, 2024, Resident 60 had a foley catheter placed (tube inserted into the bladder to drain urine from the body).

Review of Resident 60's comprehensive plan of care revealed that Resident 60 had a care plan with a focus of, "The resident has urinary incontinence [related to] diuretic use, muscle weakness, and decreased mobility", which was initiated and last revised on May 8, 2024. Review of Resident 60's comprehensive plan of care revealed that the use of a foley catheter was not included in Resident 60's comprehensive plan of care.

During a staff interview on August 1, 2024, at approximately 12:05 PM, the DON revealed it was the facility's expectation that Resident 60's care plan would have been updated to include the use of a foley catheter.

Review of Resident 72's clinical record revealed diagnoses that included hypertension and stage three chronic kidney disease (decrease in the kidney's ability to filter toxins from the blood).

Review of Resident 72's clinical record revealed that on June 15, 2024, Resident 72 had a foley catheter placed.

Review of Resident 72's comprehensive plan of care revealed that Resident 72 had a care plan with a focus of, "The resident is incontinent of urine", which was initiated on March 9, 2023; and an intervention of, "Assist to toilet as needed" and "Provide incontinence care as needed", with an initiation and revision date of June 13, 2024. Review of Resident 72's comprehensive plan of care revealed that the use of a foley catheter was not included.

During a staff interview on August 1, 2024, at approximately 10:15 AM, the DON revealed it was the facility's expectation that Resident 72's care plan would have been updated to include the use of a foley catheter.

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


 Plan of Correction - To be completed: 09/10/2024

1. Residents 20, 60, and 72 updated at time of survey.
2. Audit of residents with Foleys, Anticoagulant medications, psychotropic medications, DM, and insulin will be reviewed to ensure care plan is accurate.
3. Education provided to IDT team on development of comprehensive care plans
4. Audit of 10 residents with Foleys, Anticoagulants, psychotropics, DM, or insulin completed weekly for one month, then monthly for two months by DON or designee for completion of comprehensive care plan. Results to be reviewed in QAPI


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 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(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 a review of resident council meeting minutes, policy review, and resident and staff interviews, it was determined that the facility failed to have evidence to support that resident council grievances were acted upon.

Findings include:

Review of the facility's policy, titled "Activities/Recreation Administration", revealed that the Activities/Recreation department shall maintain monthly resident council minutes and communicates appropriate information to facility staff.

Resident Council meeting minutes for April 2024, May 2024, June 2024, and July 2024 revealed that there were no concerns expressed during the meetings.

During an interview on July 30, 2024, at 10:00 AM, with a group of five residents, revealed that the Residents have brought up multiple concerns at the Resident Council meeting and have been given no resolution regarding their concerns. The Residents stated that they go over the same concerns during every Resident Council meeting and do not review "old business" at the meetings. In the past four months, they have reported complaints about cold food, long waits for call bells to be answered, and staff being rude. The Residents stated that they have received no response from the facility's administration regarding the Council's complaints.

During an interview with the Director of Nursing on July 31, 2024, at 10:35 AM, revealed that the Activities Director is responsible for writing down minutes during every Resident Council meeting and that they will work on a better system for documenting resident concerns that are brought up during Resident Council meetings.

28 Pa. Code 211.12(c)(d)(2) Nursing services
28 Pa. Code 201.18(b)(3) Management
28. Pa. Code 201.29(i) Resident rights


 Plan of Correction - To be completed: 09/10/2024

1. Unable to correct past occurrences
2. Additional meeting of resident council to establish any unresolved concerns still to be addressed.
3. Education to be provided to Activities Director on meeting minutes and follow up with residents at next meeting on addressing resident concerns. Our Grievance process will be followed for any care concerns and distributed to appropriate departments in morning meeting.
4. Audit of resident council minutes monthly for 3 months to ensure timely follow up to all concerns discussed at previous meeting by NHA or designee. Results to be reviewed in QAPI.


483.10(j)(1)-(4) REQUIREMENT Grievances: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(j) Grievances.
§483.10(j)(1) The resident has the right to voice grievances to the facility or other agency or entity that hears grievances without discrimination or reprisal and without fear of discrimination or reprisal. Such grievances include those with respect to care and treatment which has been furnished as well as that which has not been furnished, the behavior of staff and of other residents, and other concerns regarding their LTC facility stay.

§483.10(j)(2) The resident has the right to and the facility must make prompt efforts by the facility to resolve grievances the resident may have, in accordance with this paragraph.

§483.10(j)(3) The facility must make information on how to file a grievance or complaint available to the resident.

§483.10(j)(4) The facility must establish a grievance policy to ensure the prompt resolution of all grievances regarding the residents' rights contained in this paragraph. Upon request, the provider must give a copy of the grievance policy to the resident. The grievance policy must include:
(i) Notifying resident individually or through postings in prominent locations throughout the facility of the right to file grievances orally (meaning spoken) or in writing; the right to file grievances anonymously; the contact information of the grievance official with whom a grievance can be filed, that is, his or her name, business address (mailing and email) and business phone number; a reasonable expected time frame for completing the review of the grievance; the right to obtain a written decision regarding his or her grievance; and the contact information of independent entities with whom grievances may be filed, that is, the pertinent State agency, Quality Improvement Organization, State Survey Agency and State Long-Term Care Ombudsman program or protection and advocacy system;
(ii) Identifying a Grievance Official who is responsible for overseeing the grievance process, receiving and tracking grievances through to their conclusions; leading any necessary investigations by the facility; maintaining the confidentiality of all information associated with grievances, for example, the identity of the resident for those grievances submitted anonymously, issuing written grievance decisions to the resident; and coordinating with state and federal agencies as necessary in light of specific allegations;
(iii) As necessary, taking immediate action to prevent further potential violations of any resident right while the alleged violation is being investigated;
(iv) Consistent with §483.12(c)(1), immediately reporting all alleged violations involving neglect, abuse, including injuries of unknown source, and/or misappropriation of resident property, by anyone furnishing services on behalf of the provider, to the administrator of the provider; and as required by State law;
(v) Ensuring that all written grievance decisions include the date the grievance was received, a summary statement of the resident's grievance, the steps taken to investigate the grievance, a summary of the pertinent findings or conclusions regarding the resident's concerns(s), a statement as to whether the grievance was confirmed or not confirmed, any corrective action taken or to be taken by the facility as a result of the grievance, and the date the written decision was issued;
(vi) Taking appropriate corrective action in accordance with State law if the alleged violation of the residents' rights is confirmed by the facility or if an outside entity having jurisdiction, such as the State Survey Agency, Quality Improvement Organization, or local law enforcement agency confirms a violation for any of these residents' rights within its area of responsibility; and
(vii) Maintaining evidence demonstrating the result of all grievances for a period of no less than 3 years from the issuance of the grievance decision.
Observations:

Based on observations, facility policy review, clinical record review, and staff interviews, it was determined that the facility failed to provide residents access to grievance forms in a manner that honors the right to file grievances anonymously for one of two resident areas observed (first floor), as well as five of five residents in attendance at the group interview (Residents 3, 17, 46, 71, and 87); and failed to make prompt efforts to resolve a grievance for one of six residents reviewed (Resident 85).

Findings include:

Review of the facility policy, titled "Grievance Policy", with a review date of July 25, 2024, revealed that "The facility will make information on how to file a grievance or complaint available to the resident by notifying the resident individually or with prominent postings throughout the facility to include: the right to file a grievance anonymously."

Multiple observations from July 29, 2024, to August 1, 2024, in the facility failed to reveal that grievance forms were readily available to residents or resident representatives (first floor).

Review of Resident 3's clinical record revealed Resident 3 had a BIMS (Brief Interview for Mental Status - a cognitive assessment) score of 14 (a score of 13-15 indicates a person is cognitively intact).

Review of Resident 17's clinical record revealed Resident 17 had a BIMS score of 15 (a score of 13-15 indicates a person is cognitively intact).

Review of Resident 46's clinical record revealed Resident 46 had a BIMS score of 15 (a score of 13-15 indicates a person is cognitively intact).

Review of Resident 71's clinical record revealed Resident 71 had a BIMS score of 15 (a score of 13-15 indicates a person is cognitively intact).

Review of Resident 87's clinical record revealed Resident 87 had a BIMS score of 15 (a score of 13-15 indicates a person is cognitively intact).

During Resident Council group interviews on July 30, 2024, at approximately 10:00 AM, Residents 3, 17, 46, 71, and 87 were in attendance. When asked how they would file or submit a grievance or concerns, the Residents said they are located behind the nurses' station on the first floor, and they have to ask staff for them. Resident 71 revealed that when a grievance form is filled out and handed back to the staff at the nurses' station to give to the grievance official, the grievance is read by multiple staff members and not kept confidential.

Surveyor accompanied the Nursing Home Administrator (NHA) on August 1, 2024, at approximately 11:00 AM, to the first-floor nurses' station and the NHA asked for a grievance form. A staff member sitting behind the nurses' station opened a filing cabinet behind the nurses' station and handed the NHA a blank form.

Interview with the NHA on August 1, 2024, at 11:25 AM, revealed there is a locked grievance box located on the first floor in the lobby with a grievance form bin above it, however, the bin was empty. NHA revealed that he just made copies of blank grievance forms and placed them in the bin so that the residents are able to file a grievance anonymously.

Review of Resident 85's clinical record revealed diagnoses that included cirrhosis of liver (permanent scarring that damages your liver) and hypertension (high blood pressure).

Review of a grievance filed by Resident 85's Representative on behalf of Resident 85 on May 16, 2024, revealed multiple concerns including: Resident 85's lunch tray was at the foot of his bed, and he was pointing down at his brief that he was wet. The call bell was rung and no one came. Resident 85's Representative went to the nurses' station with the call bell still on and spoke to the charge nurse who "didn't do anything"; Resident 85's call bell not being within reach; Resident being taken to the dining area and was left in there all day and never changed; and concerns with Resident 85 not receiving showers.

Further review of the grievance form indicated there were no steps taken to investigate the grievance, and no summary of pertinent findings or conclusions regarding the Resident's concerns. The corrective action taken or to be taken by the facility as a result of the grievance filed consisted of the following: Nursing supervisor to check the room two times a shift and make sure resident is fed, checked, and changed per interim Director of Nursing. The grievance form failed to address all of the concerns mentioned. Review of the grievance form had a resolution date of May 18, 2024.

During an interview with the NHA on August 1, 2024, at approximately 11:00 AM, he revealed that he would expect grievances to be available for residents to file anonymously, and for grievances to be responded to and resolved appropriately.

28 Pa Code 201.18(b)(2)(3) Management


 Plan of Correction - To be completed: 09/10/2024

1. Resident 85's Grievance was investigated and addressed. Box to submit anonymous grievances was made accessible. During Resident Council meetings the grievance process is reviewed with residents as well.
2. Last 30 days of grievances reviewed for completion in all areas. Boxes for grievances will be checked by grievance officer routinely.
3. Education provided to grievance officer regarding grievance policy and process for completion.
4. Audit of grievances to be completed weekly by Social Services or designee weekly for one month then monthly for two months to ensure all aspects are addressed. Random interviews of 5 alert and oriented residents to ensure they are aware of how and where to file an anonymous grievance weekly for one month then monthly for two months by SSD or designee. Results to be reviewed in QAPI.


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

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

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

Based on facility policy review, clinical record review, and staff interviews, it was determined that the facility failed to include a resident in the development of their baseline care plan to establish the initial goals of the resident, and failed to provide the resident or their representative a written summary of their baseline care plan for two of two residents reviewed (Residents 6 and 30).

Findings include:

Review of facility policy, titled "Care Plans- Baseline", with a revised date of December 2016, and a last review date of July 25, 2024, revealed "4. The facility must provide the resident and the representative, if applicable, with a written summary of the baseline care plan by completion of the of the comprehensive care plan."

Review of facility policy, titled "Care Planning - Interdisciplinary Team", last revised September 2013, read, in part, "The resident, the resident's family and/or the resident's legal representative/guardian or surrogate are encouraged to participate in the development of and revisions to the resident's care plan. Every effort will be made to schedule care plan meetings at the best time of the day for the resident and family."

Review of facility policy, titled "Resident Rights", with a revised date of June 2023, and a last review date of July 25, 2024, revealed "be informed of and participate in development, planning and implementation of the resident's person centered plan of care and treatment."

Review of Resident 6's clinical record revealed that the Resident was admitted to the facility on March 6, 2024, with diagnoses that included chronic diastolic congestive heart failure (heart failure that occurs when the heart does not relax properly between beats, causing the heart to be unable to pump an adequate amount of blood to the body) and hypertension (high blood pressure).

Review of Resident 6's baseline care plan revealed that it was completed on March 7, 2024, and was signed by six facility interdisciplinary team members in the section titled "Facility Staff", and that there were no signatures located in the section titled "Resident/Family."

Review of Resident 6's clinical record failed to reveal any documentation that Resident 6 or their responsible party participated in the development of their baseline care plan, or that Resident 6 or their responsible party were provided a written summary of their baseline care plan.

Review of Resident 30's clinical record revealed that the Resident was admitted to the facility on March 11, 2024, with diagnoses that included chronic obstructive pulmonary disease (COPD-a type of progressive lung disease characterized by long term respiratory symptoms and airflow limitations) and post-traumatic stress disorder (PTSD-a disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event with triggers that can bring back memories of the trauma accompanied by intense emotional and physical reactions).

Review of Resident 30's baseline care plan revealed that it was completed on March 12, 2024, and was signed by six facility interdisciplinary team members in the section titled "Facility Staff", and that there were no signatures located in the section titled "Resident/Family."

Review of Resident 30's clinical record failed to reveal any documentation that Resident 30 or their responsible party participated in the development of their baseline care plan, or that Resident 30 or their responsible party were provided a written summary of their baseline care plan.

During an interview with the Nursing Home Administrator (NHA), Director of Nursing (DON), and Employee 4 (Regional Director of Clinical Services) on July 31, 2024, at 1:27 PM, the NHA and DON indicated they had no additional information to offer. In addition, they both confirmed that Resident 6 and Resident 30 should have been invited to participate in the development of their baseline care plans and that the Residents should have been provided a summary or copy of their baseline care plan.

28 Pa. Code 201.29(a) Resident rights
28 Pa. Code 211.12(d)(2) Nursing services


 Plan of Correction - To be completed: 09/10/2024

1. Care plans for residents 6 and 30 were reviewed with the residents and/or their representatives and summaries were offered to both residents
2. Audit of admissions for last 30 days were performed to ensure baseline care plans were reviewed with resident and/or resident representatives.
3. Education provided to licensed nursing staff on completion of baseline care plan and review of same with the resident and or resident's representative.
4. Audit of new admissions to be completed weekly for one month, then monthly for two months to ensure baseline care plans developed and reviewed with resident and or resident representative by DON or designee. Results to be reviewed in QAPI.

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

Based on facility policy, observation, clinical record review, and resident and staff interviews, it was determined that the facility failed to provide services necessary to maintain adequate personal grooming of residents' dependent on staff for assistance with these activities of daily living for two of three residents reviewed (Residents 36 and 53).

Findings Include:

Review of facility policy, titled "Activities of Daily Living (ADLs), Supporting", with a review date of July 25, 2024, revealed "Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: hygiene (bathing, dressing, grooming, and oral care)."

Review of Resident 36's clinical record revealed diagnoses that included hypertension (high blood pressure) and chronic obstructive pulmonary disease (COPD-a common lung disease causing restricted airflow and breathing problems).

During an interview with Resident 36 on July 29, 2024, at 10:15 AM, revealed that Resident 36 has not had a shower in a long time, and stated that she needed her hair shampooed. Resident 36 revealed that she prefers to receive a shower over a bed bath.

Review of Resident 36's comprehensive plan of care revealed a care plan focus area of, "The resident has an ADL Self Care Performance Deficit related to weakness", with an initiation date of October 1, 2020, and a revision date of October 9, 2020; as well as an intervention area of, "resident prefers a shower."

Review of Resident 36's clinical record revealed that she received a bed bath on the following days: July 3, 6, 13, and 27, 2024. Review of Resident 36's clinical record revealed she did not receive a shower in the past 30 days reviewed.

During an interview with the Director of Nursing (DON) on August 1, 2024, at 10:20 AM, revealed that Resident 36 should not be getting bed baths regularly.

Review of Resident 53's clinical record revealed diagnoses that included major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest) and fibromyalgia (a long-term condition that involves widespread body pain and tiredness).

Observation on July 29, 2024, at 2:00 PM, revealed Resident 53 lying in bed, with facial hair noted to on her chin and upper lip.

During an interview with Resident 53 on July 29, 2024, at 2:00 PM, Resident 53 revealed her facial hair was getting so long she can put beads in it soon. Resident 53 revealed she prefers her facial hair to be shaved, but staff do not offer to shave her every time she receives a shower.

Observation on July 30, 2024, at 12:42 PM, and July 31, 2024, at 11:45 AM, revealed Resident 53 lying in bed, with facial hair noted to on her chin and upper lip.

Review of Resident 53's comprehensive plan of care revealed a care plan focus area of, "The resident has an ADL Self Care Performance Deficit related to weakness, history of fibromyalgia, depression, malnutrition", with an initiation date of July 18, 2020, and a revision date of December 1, 2021; as well as an intervention area of: "ensure the resident is well groomed and appropriately dressed" and "personal hygiene/oral care: the resident requires 1 or 2 staff participation with personal hygiene and oral care", both with an initiation date of July 27, 2020.

During an interview with the DON on August 1, 2024, at 10:21 AM, revealed that Resident 53 has been offered to have her facial hair removed.

28 Pa Code 211.12(a)(c)(d)(1)(3)(5) Nursing services
28 Pa. Code 201.29(j) Resident rights


 Plan of Correction - To be completed: 09/10/2024

1. Resident 36 was offered a shower, and resident 53 was offered shaving at time of survey.
2. Bathing documentation for last 14 days reviewed to ensure bathing being completed per resident preference. Female residents audited for presence of facial hair.
3. Education provided to nursing staff on ADL care including bathing per preference and ensuring female residents are without facial hair unless otherwise care planned.
4. Audit of bathing for 10 residents to ensure provided per preference and refusals documented weekly for one month then for two months by DON or designee. Audit of 5 female residents to ensure the absence of facial hair per preference weekly for one month and then two months by DON or designee. Results to be reviewed at QAPI


483.60(i)(4) REQUIREMENT Dispose Garbage and Refuse Properly: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(i)(4)- Dispose of garbage and refuse properly.
Observations:

Based on observations and staff interviews, it was determined that the facility failed to ensure that garbage and refuse was disposed of properly, and sanitary conditions were maintained in the garbage storage area for one of one dumpster observed.

Findings include:

Observation of the receiving area dumpster on July 29, 2024, at 9:25 AM, revealed there were two bags of garbage on the ground in front of the dumpster; one was open and garbage was spilled out onto the ground, and there were five bags of garbage piled up on the ground to the left of the dumpster. Employee 5 (Dietary Manager) opened the sliding door to the garbage receptacle and it was empty.

Interview with Employee 5 on July 29, 2024, at 9:29 AM, revealed the trash was left there by housekeeping staff and it should not be on the ground.

Observation on July 30, 2024, at 8:39 AM, 11:40 AM, and 1:52 PM, revealed the sliding door to the dumpster was open while not in use.

Interview with the Nursing Home Administrator on July 31, 2024, at 11:09 AM, revealed it is his expectation that the dumpster sliding door should be kept closed and areas around the dumpster should be clean and free of waste.

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


 Plan of Correction - To be completed: 09/10/2024

1. Garbage removed from the ground and sliding door closed at time of survey
2. Audit of facility grounds for areas with trash bags on ground to ensure disposed of appropriately and that trash receptacle doors are closed.
3. Education provided facility-wide, including Housekeeping and Maintenance Staff regarding proper handling of garbage.
4. Audit of facility grounds 3x/week for one month, then weekly for 8 weeks to ensure proper management of garbage by Housekeeping Supervisor or designee. Results to be reviewed in QAPI.


§ 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 Federal, State and local agencies responsible for the health and welfare of residents. This includes complying with all applicable Federal and State laws, and rules, regulations and orders issued by the Department and other Federal, State or local agencies.

Observations:

Based on staff interviews, state regulations, and review of the facility's Infection Control Meeting attendance records, the facility failed to ensure that four of the required nine multidisciplinary members were present at the Infection Control meetings (Laboratory Personnel, Pharmacy Staff, Physical Plant Personnel, and Infection Control Team members), and failed to report health care-associated infections to the Pennsylvania Patient Safety Authority.

Findings include:

Review of Act 52 (The Act of March 20, 2002, P.L.154, No. 13), known as the Medical Care Availability and Reduction of Error (Mcare) Act, Chapter 4, Section 403(1) Infection Control plan stated, "A health care facility... shall develop and implement an internal infection control plan that shall include...a multidisciplinary committee including representatives from each of the following if applicable to that specific health care facility." A review of the applicable members included Medical Staff, Administration, Nursing Staff, Patient Safety Officer, Physical Plant Personnel, a community member, Laboratory Personnel, Pharmacy Staff, and Infection Control Team members.

Review of Infection Control Meeting signatory pages revealed that no Pharmacy Staff was present for the Infection Control Committee meetings conducted on December 19, 2023; January 17, 2024; February 15, 2024; March 27, 2024; April 18, 2024; May 21, 2024; June 18, 2024; and July 25, 2024. No Infection Control Team members were present for meetings held on December 19, 2023; April 18, 2024; May 21, 2024; June 18, 2024; and July 25, 2024. No Laboratory Personnel was present for meetings held on February 15, 2024, and June 18, 2024. No Physical Plant Personnel was present for meetings held on May 21, 2024, and June 18, 2024.

During a staff interview on August 1, 2024, at approximately 10:30 AM, the Director of Nursing (DON) confirmed that no infection control team members, laboratory personnel, or physical plant personnel attended meetings on the aforementioned dates. The DON revealed that pharmacy staff attend the meetings in-person if they are in the facility but, if they are not, they attend the meeting via phone.

The facility failed to provide documentation that a pharmacy staff member attended the aforementioned meetings via phone.

Review of Act 52, subsection 1303.404 "Health care facility reporting", revealed it stated, "(a) Nursing Home Reporting. - In addition to reporting pursuant to The Health Care Facilities Act, a nursing home shall also electronically report health care-associated infection data to the department and the authority using nationally recognized standards based on CDC definitions, provided that the data is reported on a patient-specific basis in the form ..."

On July 31, 2024, at 11:11AM, the DON revealed the facility was unable to provide evidence of reporting of health care-associated infections to the Pennsylvania Patient Safety Authority.



 Plan of Correction - To be completed: 09/10/2024

1. Unable to correct past missing line list and PaPSRS's reporting as this is a past occurrence.
2. Review of line listing for July to ensure infections are captured appropriately and have reported per Act 52 requirements.
3. Education to administrative nurses regarding maintaining monthly line list and required reporting under Act 52. Online link for virtual meeting or multi person phone conference will be sent to required attendees for QAPI and IC Control Meetings. Those not in attendance will receive minutes via email. IC Team Members will be educated on required attendance.
4. Audit of line list weekly to ensure capturing of infections and appropriate reporting weekly for one month then monthly for 2 months by DON or designee. QAPI/IC Meeting Attendance audited monthly x 3 for required attendance by NHA or designee. The
results to be reviewed in QAPI.



§ 211.12(f.1)(3) LICENSURE Nursing services. :State only Deficiency.
(3) Effective July 1, 2024, a minimum of 1 nurse aide per 10 residents during the day, 1 nurse aide per 11 residents during the evening, and 1 nurse aide per 15 residents overnight.

Observations:


Based on review of facility staffing documents and staff interview, it was determined that the facility failed to ensure a required minimum of one nurse aide per 20 residents on the night shift for one of 14 days reviewed (April 17, 2024); and failed to ensure a required minimum of one nurse aide per 12 residents on the evening shift for one of 14 days reviewed (April 18, 2024) prior to July 1, 2024; and failed to ensure a required minimum of one nurse aide per 15 residents on night shift for three of seven days reviewed (July 26, 27, and 28, 2024).

Findings Include:

Review of the facility provided staffing ratio information for April 14-20, on night shift, revealed a resident census of 88-91 residents; thus, requiring a nurse aide staffing ratio of 4.40-4.55.

Review of facility provided staffing ratio information for April 17, 2024, on night shift, revealed a census of 90 residents. Further review revealed a nurse aide ratio of 3.93; therefore, the facility did not meet the required minimum nurse aide ratio for the facility census on that shift.

Review of the facility provided staffing ratio information for April 14-20, on evening shift, revealed a resident census of 88-91 residents; thus, requiring a nurse aide staffing ratio of 7.33-7.58.

Review of facility provided staffing ratio information for April 18, 2024, on evening shift, revealed a census of 89 residents. Further review revealed a nurse aide ratio of 7.23; therefore, the facility did not meet the required minimum nurse aide ratio for the facility census on that shift.

During an interview with the Nursing Home Administrator (NHA) and the Director of Nursing on August 1, 2024, at 9:38 AM, the NHA he indicated that they had no other information to provide and confirmed that he would expect the facility to be staffed according to state regulations.

Review of the facility provided staffing ratio information for July 24-30, 2024, on night shift, revealed a resident census of 85-90 residents; thus, requiring a nurse aide staffing ratio of 5.67-6.00.

Review of facility provided staffing ratio information for July 26, 2024, on night shift, revealed a census of 90 residents. Further review revealed a nurse aide ratio of 5.37; therefore, the facility did not meet the required minimum nurse aide ratio for the facility census on that shift.

Review of facility provided staffing ratio information for July 27, 2024, on night shift, revealed a census of 87 residents. Further review revealed a nurse aide ratio of 5.42; therefore, the facility did not meet the required minimum nurse aide ratio for the facility census on that shift.

Review of facility provided staffing ratio information for July 28, 2024, on night shift, revealed a census of 87 residents. Further review revealed a nurse aide ratio of 2.36; therefore, the facility did not meet the required minimum nurse aide ratio for the facility census on that shift.

During an interview with the Nursing Home Administrator (NHA) and the Director of Nursing on August 1, 2024, at 9:38 AM, the NHA he indicated that they had no other information to provide and confirmed that he would expect the facility to be staffed according to state regulations.


 Plan of Correction - To be completed: 09/10/2024

1. Facility will have NA ratios to meet requirements.
2. An audit will be completed of staffing levels for last 14 days to determine if NA ratios were met.
3. DON or designee will provide re-education to Nursing Scheduler that NA ratios are to be one nurse aide per 10 residents on 1st shift, one per 11 residents on the 2nd shift, and one nurse aide per 15 residents on the overnight shift. The schedule will be reviewed daily by the NHA and DON to enable sufficient staffing ratios. Daily Staffing meetings are to be held daily and communication is to occur between scheduling, RN supervisors and nursing administration when there is an open shift to find coverage and fill the need accordingly. Incentive bonuses will be offered to staff, credentialed in house ancillary staff will be offered the opportunity to fill vacancies, and we will contact agency client service liaison for assistance filling shifts.
4. DON or designee will complete three random audits of daily NA ratios weekly for 4 weeks and then monthly for 2 months to ensure the NA ratios were met. Audit findings will be reported to the QAPI Committee.

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

Based on review of facility staffing documents and staff interview, it was determined that the facility failed to ensure a required minimum of one licensed practical nurse (LPN) per 40 residents on night shift for 10 of 21 days reviewed (December 31, 2023; January 1, 2024; April 14, 15, 16, and 19, 2024; July 26, 27, 29, and 30, 2024).

Findings Include:

Review of the facility provided staffing ratio information for December 31, 2023, through January 6, 2024, on night shift, revealed a resident census of 85-87 residents; thus, requiring an LPN staffing ratio of 2.13 to 2.18.

Review of facility provided staffing ratio information for December 31, 2023, on night shift, revealed a census of 85 residents. Further review revealed an LPN ratio of 1.03; therefore, the facility did not meet the required minimum LPN ratio for the facility census on that shift.

Review of facility provided staffing ratio information for January 1, 2024, on night shift, revealed a census of 86 residents. Further review revealed an LPN ratio of 1.38; therefore, the facility did not meet the required minimum LPN ratio for the facility census on that shift.

Review of the facility provided staffing ratio information for April 14-20, 2024, on night shift, revealed a resident census of 88-91 residents; thus, requiring an LPN staffing ratio of 2.20 to 2.28.

Review of facility provided staffing ratio information for April 14, 2024, on night shift, revealed a census of 88 residents. Further review revealed an LPN ratio of 2.09; therefore, the facility did not meet the required minimum LPN ratio for the facility census on that shift.

Review of facility provided staffing ratio information for April 15, 2024, on night shift, revealed a census of 90 residents. Further review revealed an LPN ratio of 2.06; therefore, the facility did not meet the required minimum LPN ratio for the facility census on that shift.

Review of facility provided staffing ratio information for April 16, 2024, on night shift, revealed a census of 91 residents. Further review revealed an LPN ratio of 2.06; therefore, the facility did not meet the required minimum LPN ratio for the facility census on that shift.

Review of facility provided staffing ratio information for April 19, 2024, on night shift, revealed a census of 89 residents. Further review revealed an LPN ratio of 1.97; therefore, the facility did not meet the required minimum LPN ratio for the facility census on that shift.

Review of the facility provided staffing ratio information for July 24-30, 2024, on night shift, revealed a resident census of 85-90 residents; thus, requiring an LPN staffing ratio of 2.13 to 2.25.

Review of facility provided staffing ratio information for July 26, 2024, on night shift, revealed a census of 90 residents. Further review revealed an LPN ratio of 2.15; therefore, the facility did not meet the required minimum LPN ratio for the facility census on that shift.

Review of facility provided staffing ratio information for July 27, 2024, on night shift, revealed a census of 87 residents. Further review revealed an LPN ratio of 2.12; therefore, the facility did not meet the required minimum LPN ratio for the facility census on that shift.

Review of facility provided staffing ratio information for July 29, 2024, on night shift, revealed a census of 85 residents. Further review revealed an LPN ratio of 2.00; therefore, the facility did not meet the required minimum LPN ratio for the facility census on that shift.

Review of facility provided staffing ratio information for July 30, 2024, on night shift, revealed a census of 85 residents. Further review revealed an LPN ratio of 2.00; therefore, the facility did not meet the required minimum LPN ratio for the facility census on that shift.

During an interview with the Nursing Home Administrator (NHA) and the Director of Nursing on August 1, 2024, at 9:38 AM, the NHA he indicated that they had no other information to provide, and confirmed that he would expect the facility to be staffed according to state regulations.



 Plan of Correction - To be completed: 09/10/2024

1. Facility will have LPN ratios to meet requirements.
2. An audit will be completed of staffing levels for last 14 days to determine if LPN ratios were met.
3. DON or designee will provide re-education to Nursing Scheduler that LPN ratios are to be one LPN per 25 residents on the 1st shift and one LPN per 30 residents on the evening shift and one LPN per 40 residents on the overnight shift. The schedule will be reviewed daily by the NHA and DON to enable sufficient staffing ratios.
Staffing meetings are to be held daily and communication is to occur between scheduling, RN supervisors and nursing administration when there is an open shift to find coverage and fill the need accordingly. Incentive bonuses will be offered to staff, credentialed in house ancillary staff will be offered the opportunity to fill vacancies, and we will contact agency for filling shifts.
4. DON or designee will complete three random audits of LPN ratios weekly for 4 weeks and then monthly for 2 months to ensure the LPN ratios were met. Audit findings will be reported to the monthly QAA for review and recommendations.




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