Pennsylvania Department of Health
COLE PLACE
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

There are 52 surveys for this facility. Please select a date to view the survey results.

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


COLE PLACE - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:

Based on a Medicare/Medicaid Recertification Survey, State Licensure Survey, and Civil Rights Compliance Survey completed on May 10, 2024, it was determined that Cole Place was not in compliance with the following requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care and the 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations as they relate to the Health portion of the survey process.

Plan of Correction:

483.25(d)(1)(2) REQUIREMENT Free of Accident Hazards/Supervision/Devices:

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(d) Accidents.
The facility must ensure that -
§483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and

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

Observations:

Based on observation and staff interview, it was determined that the facility failed to prevent potential accident hazards in the facility's laundry area.

Findings include:

Observation of the facility's laundry area and concurrent interview with Employee 1, manager of environmental services, and Employee 2, supervisor of environmental services, on May 9, 2024, at 1:44 PM revealed that the dryer vent and piping had build-up of lint inside the vent/pipe area with significant white lint noted on the ground below the vent. This has the potential of causing a fire.

This surveyor reviewed this information during an interview with the Nursing Home Administrator and Director of Nursing Home on May 9, 2024, at 2:11 PM

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

28 Pa. Code 211.10(d) Resident care policies

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

483.80(a)(1)(2)(4)(e)(f) REQUIREMENT Infection Prevention & Control:

§483.80 Infection Control
The facility must establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections.

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

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

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

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

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

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

Observations:

Based on observation, clinical record review, and resident and staff interview, it was determined that the facility failed to implement appropriate enhanced barrier transmission-based precautions for three of eight residents reviewed (Residents 3, 14, and 120) and failed to ensure an environment free from the potential spread of infection in the facility's laundry area.

Findings include:

Review of the memo entitled "Enhanced Barrier Precautions (EBP, gown and glove use) in Nursing Homes to Prevent the Spread of Multi-drug Resistant Organisms" released by the Center for Medicaid and Medicare Services (CMS) on March 20, 2024, with an implementation date of April 1, 2024, revealed that nursing care facilities are to use EBP for residents with chronic wounds or indwelling medical devices (i.e., indwelling urinary catheters) during high-contact resident care activities regardless of their multidrug-resistant organism status. High-contact activity would include things like dressing, transferring, changing linens, providing hygiene, changing briefs, wound care, or device care.

A review of the current physician orders for Resident 14 revealed the resident was on isolation precautions and specified enhanced barrier precautions due to methicillin resistant staphylococcus aureus (MRSA, a bacteria that is resistant to certain antibiotics) dated February 7, 2024. The resident also had current orders for daily wound care for a coccyx wound one time daily and as needed for soiling.

A review of the current care plan for Resident 14 revealed the resident was on enhanced barrier precautions. An intervention included using proper personal protective equipment (i.e., gowns, gloves, etc.) when performing personal care.

Admission documentation for Resident 14 dated October 26, 2022, revealed the resident was admitted with the wound on his coccyx.

Observation outside of Resident 14's room on May 9, 2024, at 10:16 AM revealed two signs on the wall adjacent to the resident's door that indicated the resident in the room was on Enhanced Barrier Precautions and a gown and gloves must be worn for "high-contact resident activities." Another sign indicated to "Stop, Precautions Required. Report to Nurse Before Entering." There was a plastic container with several plastic drawers outside of the doorway to the room that contained personal protective equipment such as gowns and gloves to use for care.

Observation of wound care for Resident 14 on May 9, 2024, at 10:23 AM revealed Employee 3, licensed practical nurse, entered the resident's room with no gown. Employee 3 proceeded to change the resident's dressing on his coccyx, clean the wound, apply the ordered treatment, and redress the wound. Employee 3 did not utilize a gown and only wore gloves during the high-contact resident activity.

An interview with Employee 3 outside of Resident 14's room regarding the signs and personal protective equipment revealed that the employee was unsure if she should have worn a gown and would have to "check with the charge nurse."

Employee 3 confirmed with Employee 7, registered nurse, that Resident 14 was on enhanced barrier precautions.

An interview with the Nursing Home Administrator (NHA) and Director of Nursing on May 9, 2024, at 10:50 AM revealed the wound on Resident 14's coccyx was chronic and the history of MRSA was from a wound on the resident's lower extremity that has since resolved. However, the resident was currently on Enhanced Barrier Precautions due to the current chronic wound since admission.

Employee 3 failed to wear the appropriate personal protective equipment during wound care of Resident 14.

Clinical record review for Resident 120 revealed that she had a physician ordered Foley (urinary) catheter for a diagnosis of obstructive uropathy (blockage of the urinary system).

Observation on May 8, 2024, at 11:30 AM of the hallway outside Resident 120's room revealed that there was no enhanced barrier precaution signage to indicate the need to utilize PPE (personal protective equipment, to prevent infectious disease transmission) and/or no PPE items outside Resident 120's room. Immediate observation thereafter of Resident 120 in her room revealed that she had an indwelling Foley (urinary) catheter device as ordered by her physician.

Clinical record review for Resident 3 revealed an active physician order dated April 29, 2024, for staff to maintain an indwelling urinary catheter (flexible tube inserted into the bladder for the purpose of draining urine).

A physician's order dated April 30, 2024, instructed staff to administer the antibiotic, Levaquin, 750 mg (milligrams) every day for 10 days for treatment of a urinary tract infection and blood stream infection.

Nursing documentation dated May 2, 2024, at 12:24 PM revealed that Resident 3 had to have his indwelling catheter collection bag changed after a small hole was discovered in it. Staff also noted Resident 3 had a small to moderate amount of bloody drainage oozing around the catheter.

Observation of Resident 3 on May 8, 2024, at 10:45 AM revealed he was in his room with an indwelling catheter collection bag hanging from his walker.

Interview with Employee 8 (nurse aide) on May 8, 2024, at 12:05 PM confirmed that there was no signage in or around Resident 3's room regarding enhanced barrier precautions and no plastic bin with PPE outside his room door.

Interview with the Director of Nursing and the Nursing Home Administrator on May 8, 2024, at 2:00 PM confirmed that staff informed them that Resident 3 did not have EBP in place on the date and time of the surveyor's observation.

Observation of the facility's laundry area and concurrent interview with Employee 1, manager of environmental services, and Employee 2, supervisor of environmental services, on May 9, 2024, at 1:44 PM revealed that there were no gowns available for staff to utilize when processing soiled items prior to washing and prevent the potential spread of infection in the facility. Further observation revealed that there was no handwashing sink and/or hand sanitizer available in the laundry area for staff to wash and/or clean their hands after handling soiled laundry and prior to touching other surfaces, therefore preventing the potential spread of infection in the facility.

This surveyor reviewed the above information during an interview on May 9, 2024, at 2:11 PM with the Nursing Home Administrator and the Director of Nursing.

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

28 Pa. Code 211.10(d) Resident care policies

Plan of Correction - To be completed: 06/25/2024

1. All signage was corrected, and all PPE was put in place for rooms that required enhanced barrier precautions on Resident rooms # 3, #14 and #120. Employee #3 was educated on enhanced barrier precautions. Gowns, gloves and hand sanitizer have been made available in laundry room.

2. All residents reviewed to ensure that there were proper enhanced barrier precautions in place. All staff will be made aware of enhanced barrier precaution application by DON or designee.

3. Upon admission all new residents will be screened to ensure that they do or do not meet the criteria for enhanced barrier precautions. Education will be completed for all staff that provide hands-on care in enhanced barrier precautions by DON or designee. Education completed with housekeeping in utilization of PPE when doing laundry by Housekeeping Supervisor or designee.

4. Audits will be completed on enhanced barrier precaution signage and PPE outside of rooms weekly x4 and monthly x3. Audits of the use of proper PPE in enhanced barrier rooms will be conducted weekly x4 and monthly x3. Audits will be completed in the laundry washer room weekly x4 and monthly x3 on PPE and proper hand hygiene.

483.25(n)(1)-(4) REQUIREMENT Bedrails:

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

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

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

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

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

Observations:

Based on observation, review of select facility policies, clinical record review, and staff and resident interview, it was determined that the facility failed to assess for the risk of side rail entrapment, for five of five residents reviewed for accident hazards (Residents 3, 4, 6, 7, and 11).

Findings include:

The facility policy entitled "Enabler Bar Policy," last reviewed without changes on March 11, 2024, revealed that the facility will identify and reduce safety risk and hazards commonly associated with the use of enabler bars while also enhancing resident's mobility. The facility identified seven potential zones of bed entrapment. A resident evaluation and screening tool will be used before determining what type of mattress, rail frame, etc. the resident will use to ensure safety prior to the resident getting into bed. If enabler bars are appropriate, staff will incorporate close attention to the design of the bars and relationship between the bars and other parts of the bed and implement interventions to reduce the risk of entrapment.

A Bed System Measurement Device Test Results Worksheet (form the facility used to document the assessment of entrapment risk zones) revealed that the facility only assessed zones two (between the bottom of the rail and top of compressed mattress), three (between the edge of the mattress and inside of the rail), and four (between the top of the compressed mattress and the bottom of the rail at the end of the rail. The assessment did not address zone one (within the rail), zone six (between the end of the rail and the side edge of the head or foot board), or zone seven (between head or foot board and end of mattress) as defined by the facility policy.

Observation of Resident 6 on May 7, 2024, at 2:55 PM revealed that the resident was in bed with bilateral enabler bars observed on the bed.

Clinical record review for Resident 6 revealed a Bed System Measurement Test Results Worksheet dated May 2, 2024, revealed that the facility measured, assessed, and passed enabler bars for zones two, three, and four.

Observation of Resident 7 on May 7, 2024, at 2:42 PM revealed that the resident was in bed with bilateral enabler bars observed on the bed.

Clinical record review for Resident 7 revealed a Bed System Measurement Test Results Worksheet dated April 11, 2024, revealed that the facility measured, assessed, and passed the enabler bars for zones two, three, and four.

There was no documentation indicating that the facility assessed Resident 6 and 7's enabler bars for entrapment zones one, six, or seven.

The surveyor reviewed the above information during an interview with the Nursing Home Director and the Director of Nursing on May 9, 2024, at 10:30 AM.

Observation of Resident 4 on May 8, 2024, at 10:39 AM revealed the resident was in bed. There were bilateral enabler bars on the bed. A concurrent interview with Resident 4 revealed the resident used the enabler bars to assist with mobility.

A review of current physician orders for Resident 4 revealed an order for a "bed enabler" dated May 10, 2022.

A review of the facility documentation for Resident 4 revealed a document titled, "Bed System Measurement Device Test Results Worksheet." This document included the measurement of various zones for the enabler bars to determine if these zones would pass/fail. The document noted that the facility measured zones two, three, and four. The assessment did not address zone one, six, or seven

A form for Resident 4 titled, "Enabler Bar Request Form," dated May 8, 2022, which was a document completed by different disciplines (such as nursing or skilled therapy) to ensure all five steps of the evaluation are completed before the implementation of enabler bars. Step One revealed the following: "Resident initial evaluation for enabler bars complete by nursing (utilize tool and document findings in medical record as well as alternatives attempted and why failed)." The form noted to determine if the resident was low risk, high risk, or not clear, and the form for Resident 4 indicated that the resident was marked as both a low risk and high risk. The selection of high risk prompted the assessor to "STOP; enabler bars will not be added due to risk of injury or not appropriate to enhance independent mobility." Further review of the form revealed no signature to determine what staff member completed the assessment.

The facility proceeded to allow enabler bar use for Resident 4 despite that the document indicated a high-risk assessment and inappropriate use of enabler bars.

Observation of Resident 11 on May 7, 2024, at 1:15 AM revealed the resident was in bed. There were bilateral enabler bars on the bed. A concurrent interview with Resident 11 revealed the resident used the enabler bars to assist with mobility and "to hang stuff on."

A review of current physician orders for Resident 11 revealed an order for a "bed enabler" dated September 21, 2022.

A review of the facility documentation for Resident 11 revealed a document titled, "Bed System Measurement Device Test Results Worksheet." This document included the measurement of various zones for the enabler bars to determine if these zones would pass/fail. The document noted that the facility measured zones two, three, and four. The assessment did not address zone one, six, or seven.

The above information for Resident 4 and Resident 11 was reviewed in a meeting with the Nursing Home Administrator on May 9, 2024, at 10:55 AM.

Clinical record review for Resident 3 revealed a physician's order dated May 26, 2023, for the use of a bed enabler.

Observation of Resident 3's room on May 8, 2024, at 10:44 AM revealed bilateral assist bars at the head of his bed. His bed was equipped with a headboard and a footboard.

An Enabler Bar Request Form dated May 24, 2023, indicated that the first step, "Resident initial evaluation for enabler bars complete by nursing," assessed that Resident 3 was both a low risk and a high risk. The selection of high risk prompted the assessor to "STOP; enabler bars will not be added due to risk of injury or not appropriate to enhance independent mobility."

The facility proceeded to allow enabler bar use for Resident 3 despite that the document indicated a high-risk assessment and inappropriate use of enabler bars.

Review of a Bed Rail Evaluation dated January 25, 2024, revealed the licensed practical nurse completed the Bed Rail Evaluation, and the assessment indicated that four zones of entrapment risk were assessed and passed.

A Bed System Measurement Device Test Results Worksheet revealed that only zones two, three, and four passed. The assessment did not address four zones. The assessment did not capture zone one, zone six, or zone seven.

Interview with the Nursing Home Administrator on May 9, 2024, at 10:29 AM confirmed that the available documentation for Resident 3 did not capture an assessment of zone one, six, or seven, and that the initial checklist assessed Resident 3 at high risk. The interview indicated that the facility could not determine who completed the initial checklist assessment as it did not include a signature.

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

Plan of Correction - To be completed: 06/25/2024

1. Initial measurements of all relevant zone areas were obtained on May 13, 2024. Resident 3 & 4 enabler bar request form was re-evaluated and clarified as low risk.

2. Official measurements of all required zones will be obtained on all residents and documented by LPNAC or designee. All enabler bar request forms will be checked for accuracy by LPNAC or the designee before the implementation of enabler bars.

3. NHA or designee will educate Administrative and licensed staff on zone measurement requirements. RN's will be educated on the proper completion of the enabler bar request forms by NHA or designee.

4. Random audit of 3 charts for measurements of enabler bar zones to be done weekly x4 then monthly x3. Audits of enabler bar request forms will be completed weekly x4 and monthly x3. Results of the audit will be reviewed at the quarterly QAPI Meeting.

483.12(b)(1)-(5)(ii)(iii) REQUIREMENT Develop/Implement Abuse/Neglect Policies:

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

§483.12(b) The facility must develop and implement written policies and procedures that:

§483.12(b)(1) Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property,

§483.12(b)(2) Establish policies and procedures to investigate any such allegations, and

§483.12(b)(3) Include training as required at paragraph §483.95,

§483.12(b)(4) Establish coordination with the QAPI program required under §483.75.

§483.12(b)(5) Ensure reporting of crimes occurring in federally-funded long-term care facilities in accordance with section 1150B of the Act. The policies and procedures must include but are not limited to the following elements.

§483.12(b)(5)(ii) Posting a conspicuous notice of employee rights, as defined at section 1150B(d)(3) of the Act.

§483.12(b)(5)(iii) Prohibiting and preventing retaliation, as defined at section 1150B(d)(1) and (2) of the Act.

Observations:

Based on review of select facility policies and procedures, employee personnel records, and staff interview, it was determined that the facility failed to implement an abuse prohibition policy that required a thorough investigation of prospective employee's employment history for two of five newly hired employees reviewed (Employees 4 and 5).

Findings include:

The facility policy entitled, "Abuse, Neglect, Exploitation General Policy," last reviewed without changes on March 11, 2024, revealed a section of the policy titled, "Screening." The policy indicated that prior to an employee's first day of employment the facility will make reasonable efforts to obtain personal and/or professional reference information. The documentation will note the conducted attempts and the feedback from the reference will be noted in the employee file as indicated.

Review of Employee 4's (Activities Assistant) personnel record revealed a hire date of April 22, 2024. Employee 4's personnel record contained no evidence that the facility attempted to obtain personal and/or professional reference information (whether favorable or unfavorable). This was confirmed with the Nursing Home Administrator (NHA) and Employee 6 (Human Resources) on May 9, 2024, at 12:27 PM.

Review of Employee 5's (Service Assistant) personnel record revealed a hire date of March 16, 2024. Employee 5's personnel record contained no evidence that the facility attempted to obtain personal and/or professional reference information (whether favorable or unfavorable). This was confirmed with the NHA and Employee 6 on May 9, 2024, at 12:30 PM.

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

28 Pa. Code 201.19 Personnel policies and procedures

483.20(g) REQUIREMENT Accuracy of Assessments:

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

Observations:

Based on clinical record review and staff interview, it was determined that the facility failed to ensure the accuracy of MDS assessments for one of eight residents reviewed (Resident 2).

Findings include:

Clinical record review for Resident 2 revealed a diagnoses list that included:
Cerebral Palsy (brain disorder that affects the muscles' ability to move and person's ability to maintain balance and posture)
Major Depressive Disorder (mood disorder causing persistent sadness and loss of interest)
Generalized Anxiety (excessive worry interfering with daily life)
Dementia in other diseases ("umbrella category" describing mental decline that is severe enough to interfere with daily living)
Unspecified Psychosis not due to a substance or known physiological condition (mental state characterized by a loss of touch with reality and may involve hallucinations, delusions, disordered thinking, and behavioral changes)

A PASRR (Preadmission Screening Resident Review, assessment tool to make certain that a nursing facility is the most appropriate setting/placement for a resident with mental, intellectual, or other conditions) dated March 18, 2003, and signed by a state utilization management review representative on April 4, 2003, indicated that Resident 2 met the criteria for the target group; and that a PASRR II (assessment tool to identify the need for possible mental, intellectual, or other specialized services required in the nursing facility's plan of care) evaluation was required.

Documentation from the Office of Long-Term Living dated April 15, 2003, assessed Resident 2 as needing specialized services; and that she was eligible for the program available to nursing facility residents. Resident 2 was considered by the state level II PASRR process to meet the criteria for services.

An annual MDS (Minimum Data Set, an assessment tool completed at specific intervals to determined resident care needs) assessment dated March 10, 2024, assessed Resident 2 as not considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition.

Interview with the Nursing Home Administrator on May 9, 2024, at 10:30 AM confirmed that the coding on the annual MDS was an error; Resident 2 was considered by the level II PASRR process to have a qualifying condition for specialized services.

28 Pa. Code 211.5(f)(ix) Medical records

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

483.25(e)(1)-(3) REQUIREMENT Bowel/Bladder Incontinence, Catheter, UTI:

§483.25(e) Incontinence.
§483.25(e)(1) The facility must ensure that resident who is continent of bladder and bowel on admission receives services and assistance to maintain continence unless his or her clinical condition is or becomes such that continence is not possible to maintain.

§483.25(e)(2)For a resident with urinary incontinence, based on the resident's comprehensive assessment, the facility must ensure that-
(i) A resident who enters the facility without an indwelling catheter is not catheterized unless the resident's clinical condition demonstrates that catheterization was necessary;
(ii) A resident who enters the facility with an indwelling catheter or subsequently receives one is assessed for removal of the catheter as soon as possible unless the resident's clinical condition demonstrates that catheterization is necessary; and
(iii) A resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible.

§483.25(e)(3) For a resident with fecal incontinence, based on the resident's comprehensive assessment, the facility must ensure that a resident who is incontinent of bowel receives appropriate treatment and services to restore as much normal bowel function as possible.

Observations:

Based on a review of select facility policies and procedures, clinical record review, and staff interview, it was determined that the facility failed to provide treatment and services to prevent or treat urinary tract infections for one of two residents with indwelling catheters (Resident 3) and for one of three residents reviewed for urinary tract infection concerns (Resident 5).

Findings include:

The facility policy entitled, "Urinary Catheters," last reviewed without changes on March 11, 2024, revealed that the facility cited no professional standard (e.g., CDC, Centers for Disease Control) used to develop the policy. Recommendations for prevention of Urinary Tract Infections (UTIs) listed the following:
Do not change catheters routinely
Maintain closed sterile drainage system
Use intermittent method for irrigation
Use narrowest, softest tube possible to drain urine

The facility policy included to maintain a closed system; however, also included to use an intermittent method for irrigation (which would break the closed, sterile, system).

The current CDC Guideline for Prevention of Catheter-Associated Urinary Tract Infections (https://www.cdc.gov/infectioncontrol/guidelines/cauti/) notes that Proper Techniques for Urinary Catheter Maintenance include:
If breaks in aseptic technique, disconnection, or leakage occur, replace the catheter and collecting system using aseptic technique and sterile equipment.
Changing indwelling catheters or drainage bags at routine, fixed intervals is not recommended. Rather, it is suggested to change catheters and drainage bags based on clinical indications such as infection, obstruction, or when the closed system is compromised.
Unless obstruction is anticipated (e.g., as might occur with bleeding after prostatic or bladder surgery) bladder irrigation is not recommended.
If obstruction occurs and it is likely that the catheter material is contributing to obstruction, change the catheter.

Clinical record review for Resident 3 revealed the following active physician orders:
April 29, 2024, indwelling urinary catheter (Foley, a flexible tube inserted into the bladder to drain urine), size 18 French, 10 ml (milliliter) balloon
October 27, 2023, change the catheter as needed with a catheter size of 16 French, 10 ml balloon
May 31, 2023, change the catheter collection bag as needed

Active physician orders for Resident 3 provided instructions to use two different size indwelling catheters. The active physician orders also instructed staff to change the collection bag as needed (breaking the closed system instead of replacing the catheter and collecting system).

A plan of care developed by the facility to address Resident 3's risk for infection related to an indwelling catheter included interventions (dated May 24, 2023) to change the drainage bag using aseptic technique PRN (as needed). The plan of care did not include the size catheter used for Resident 3 or the plan regarding for what symptom/need staff should change the indwelling catheter.

Nursing documentation dated May 2, 2024, at 12:24 PM revealed that Resident 3 had to have his foley bag changed after a small hole was discovered in it. Staff also noted Resident 3 had a small-to-moderate amount of bloody drainage oozing around the catheter.

Facility staff disrupted the closed, sterile, system to change the collection bag but did not change the catheter.

Review of Resident 3's MAR/TAR (Medication Administration Record/Treatment Administration Record, electronic documentation of the administration of medications and/or the completion of treatments) dated May 2024 revealed that staff failed to document that staff changed Resident 3's urine collection bag on May 2, 2024.

Review of Resident 3's MAR/TAR dated December 2023, January 2024, February 2024, March 2024, and April 2024, revealed the following:

Staff changed the urine collection bag (not the indwelling catheter) on December 6, 2023, December 20, 2023, January 20, 2024, February 20, 2024, and April 7, 2024.

The facility discontinued the order to routinely change the urine collection bag monthly on March 19, 2024.

A physician's order dated April 30, 2024, instructed staff to administer the antibiotic, Levaquin, 750 mg (milligrams) every day for 10 days for treatment of a UTI (urinary tract infection) and blood stream infection.

The surveyor reviewed the above concerns regarding Resident 3's indwelling catheter care during an interview with the Nursing Home Administrator and the Director of Nursing on May 8, 2024, at 2:00 PM.

A May 8, 2024, revision (following the surveyor's questioning) to Resident 3's physician orders related to indwelling catheter size eliminated the physician orders for a 16 French, 10 ml, catheter. Physician orders instructed staff to utilize an 18 French catheter with a 10 ml balloon.

Interview with the Director of Nursing on May 9, 2024, at 11:53 AM reviewed the facility's indwelling catheter policy contradictions, opposition to current CDC guidelines, and lack of professional standards used to develop the facility policy.

Interview with the Director of Nursing on May 9, 2024, at 12:53 PM indicated Resident 3 had an indwelling catheter change on March 3, 2024; however, confirmed that there was no clarification in the as needed catheter change order instructing staff when it was appropriate to change the catheter.

A physician's order dated May 9, 2024, at 1:34 PM (following the surveyor's questioning) revised Resident 3's physician order to change the catheter PRN for obstruction, leaking, or damaged line.

Interview with the Director of Nursing on May 10, 2024, at 11:17 AM confirmed that the facility had no evidence of consults with a urologist for Resident 3 in the past year.

Clinical record review for Resident 5 revealed documentation by activities staff dated April 26, 2024, at 11:33 AM that Resident 5 was yelling in her room, crying. Resident 5 stated that, "it burns when (she) is trying to pee." The documentation indicated that the activities staff alerted the wing nurse.

Review of the Suspected UTI SBAR (Situation, Background, Assessment, and Recommendation, form that nursing uses to communicate a change in the resident's condition to the physician) form provided by the facility indicated that staff use the form to implement best practices and facility protocols where a minimum of one of three criteria are necessary to indicate an active UTI infection. Nurses are directed to check the box to indicate whether criteria are met. If criteria are met, the resident may require a urinalysis with culture and sensitivity testing (laboratory testing of urine to identify an infection and what antibiotics are effective against that infection) or an antibiotic. If criteria are not met, the resident does not need an immediate prescription for an antibiotic but may need additional observation. The first of the three situations on the form was acute dysuria (painful urination) alone.

A Suspected UTI SBAR dated April 26, 2024, assessed that Resident 5 had acute dysuria. The registered nurse that completed the form errantly indicated and reported to the physician that the nursing home protocol was not met. Resident 5 did not receive physician orders for a urinalysis or an antibiotic.

Interview with the Nursing Home Administration on May 9, 2024, at 1:50 PM confirmed that the SBAR was completed incorrectly by the registered nurse who indicated and reported to the physician that the nursing home protocol was not met. The interview confirmed that the facility had no evidence of any new intervention implemented in response to Resident 5's complaint on April 26, 2024.

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

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

Plan of Correction - To be completed: 06/25/2024

The Facility submits this Plan of Correction under procedures established by the Department of Health in order to comply with the Department's directive to change conditions which the Department alleges is deficient under State and/or Federal Long Term Care Regulations. This Plan of Correction should not be construed as either a waiver of the facility's right to appeal or challenge the accuracy or severity of the alleged deficiencies or an admission of past of ongoing violation of State or Federal regulatory requirements.

1. Orders for prn catheter bag changes have been discontinued for Resident 3. Resident 3's order was changed to indicate appropriate catheter and balloon size. Resident 3 has an appointment to see a urologist. Resident 5 received a verbal order to encourage and monitor fluids.

2. All orders have been discontinued for prn catheter bag changes for all residents. All residents with catheters orders have been checked to ensure correct catheter and balloon size. Ensure any resident entering the facility with an indwelling catheter has proper clinical documentation for the need of the foley catheter. A urologist consult will be obtained for residents with a catheter. All SBARS have been reviewed for accuracy for the prior months.

3. DON or designee will complete education to LPN's and/or RN's regarding CDC (Centers for Disease Control) guidelines for maintaining foley catheters as well as documentation guidelines for care of catheters. DON or designee will complete education with RN's regarding obtaining urology consult for resident with foley catheters. DON or designee will complete education regarding ensuring proper documentation of the need for a foley catheter. DON or designee will complete education of accurate completion of SBAR's. Upon completion of SBAR's they will be given DON to review for accuracy.

4. Audits on all catheter orders including catheter size, balloon size, catheter maintenance and catheter bag changes prn orders are d/c will be completed weekly x4 and monthly x3. Any resident with a current indwelling catheter within the facility will be audited to ensure the proper clinical condition demonstrates that catherization is necessary and that urology consult was obtained. Audits will be completed on proper clinical conditions for indwelling catheter weekly x4 and monthly x3. SBAR will be audited weekly x4 and monthly x3. Results of the audit will be reviewed at the quarterly QAPI Meeting.

483.25(i) REQUIREMENT Respiratory/Tracheostomy Care and Suctioning:

§ 483.25(i) Respiratory care, including tracheostomy care and tracheal suctioning.
The facility must ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals and preferences, and 483.65 of this subpart.

Observations:

Based on clinical record review, observation, and staff and resident interview, it was determined that the facility failed to store CPAP equipment per professional standards of practice for one of three residents reviewed for respiratory concerns (Residents 1) and ensure appropriate respiratory care regarding a flutter valve for one of three residents reviewed (Resident 11).

Findings include:

Clinical record review for Resident 1 revealed a medical history that included obstructive sleep apnea (OSA, apnea syndromes due primarily to collapse of the upper airway during sleep).

A current physician's order for Resident 1 indicated to apply continuous positive airway pressure (CPAP, a non-invasive ventilation machine that involves the administration of air usually through the nose by an external device at a predetermined level of pressure).

The current care plan for Resident 1 revealed the resident has apnea during hours of sleep and an intervention included to maintain cleanliness of the CPAP as recommended by the manufacturer.

Observation of Resident 1's CPAP mask on May 7, 2024, at 1:04 PM; May 8, 2024, at 10:30 AM; and May 8, 2024, at 2:40 PM revealed the mask was sitting on top of the CPAP machine on a dresser next to the resident's bed and unprotected from dirt and contaminants from the ambient environment.

An interview with the Nursing Home Administrator on May 8, 2024, at 2:00 PM revealed that the facility policy is followed regarding cleaning the CPAP masks and the masks should be bagged to protect them from contamination from the ambient environment.

An interview with Employee 3, licensed practical nurse, on May 8, 2024, at 2:51 PM revealed that the masks are not placed in an approved protective bag that the employee is aware of, and it was unclear how they are protected from contamination such as dust or debris from the ambient environment.

A review of the policy entitled, "BiPAP / CPAP Cleaning and Disinfection," last reviewed on March 11, 2024, revealed instructions for cleaning and disinfection of the CPAP equipment; however, it did not address the storage of the mask (i.e., store it in a dedicated cabinet or an approved protective bag) when not in use or after cleaning to prevent contamination from dust or debris from the environment.

Interview with Resident 11 on May 7, 2024, at 1:19 PM revealed the resident had a dry, non-productive cough that the resident stated the facility staff and physician were aware of.

A current physician order for Resident 11 dated May 1, 2024, at 1:52 PM revealed an order for a flutter valve (a handheld device used to clear the airway from excessive mucus). The order did not contain a frequency on how often the resident should use the device.

A follow-up interview with Resident 11 on May 8, 2024, at 1:52 PM revealed the resident had a flutter valve and proceeded to show the surveyor the device. However, the resident was unsure how often to use the flutter valve. The resident further noted that staff did instruct her how to use it once, but the resident has forgotten those instructions.

Clinical documentation review for Resident 11 revealed no evidence that the staff were ensuring or documenting the resident was utilizing the device. There was also no documentation regarding follow-up with the resident to ensure the device was being used properly or to clarify the frequency for how often the flutter valve should be used.

The above information for Resident 1 and Resident 11 were reviewed in a meeting with the Nursing Home Administrator and Director of Nursing on May 8, 2024, at 2:00 PM.

28 Pa. Code 211.10(a) Resident care policies

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

Plan of Correction - To be completed: 06/25/2024

1. A bag was obtained to store Resident 1's CPAP with date and name on it. Resident 11 was educated regarding usage of flutter valve and given illustrations on flutter valve use. Resident 11 demonstrated understanding of flutter valve use by demonstrating of using it. Order clarification for flutter valve frequency was verified with PA and Resident 11 was updated of use frequency. The order was changed to meet specifications.
2. House audit will be obtained on all CPAP Machines to ensure baggage. Continued documentation regarding compliance of baggage and education of flutter valve usage. A house audit will be conducted for CPAP machine baggage and flutter valve orders will be clarified regarding frequency of use.
3. Education will be provided to LPN's regarding proper storage of CPAP devices by DON or designee. RN's will be educated on demonstrating to residents the proper use of flutter valves as well as on documentation of f/u and order completion by DON and designee.
4. Audits on CPAP bag usage will be completed weekly x4 and monthly x3. Audits on orders for flutter valves will be completed weekly x4 and monthly x3. Results of the audit will be reviewed at the quarterly QAPI Meeting.

483.45(f)(1) REQUIREMENT Free of Medication Error Rts 5 Prcnt or More:

§483.45(f) Medication Errors.
The facility must ensure that its-

§483.45(f)(1) Medication error rates are not 5 percent or greater;

Observations:

Based on observation and staff interview, it was determined that the facility failed to ensure a medication error rate below five percent (Residents 10 and 120).

Findings include:

The facility's medication error rate was 7.14 percent based on 28 medication opportunities with two medication errors.

Observation of a medication administration pass on May 8, 2024, at 7:57 AM revealed Employee 3 (licensed practical nurse) prepared medications for administration to Resident 10. Labels on the following medications indicated the scheduled medications prepared would equal nine and one-half tablets as follows:

Acetaminophen (over-the-counter analgesic) 325 mg (milligrams) two tablets
Calcium citrate (calcium dietary supplement) 200 mg two tablets
Cerovite senior (multivitamin) one tablet
Glipizide (medication used to lower blood sugar) one-half of a 5 mg tab (2.5 mg)
Metformin (medication used to lower blood sugar) 1000 mg one tablet
Vitamin B12 (vitamin dietary supplement) 1000 mcg (micrograms) one tablet
Vitamin B6 (vitamin dietary supplement) 25 mg one tablet
Sertraline (antidepressant medication) 100 mg one tablet

Interview with Employee 3 on May 8, 2024, at 8:08 AM confirmed that she had only eight and one-half tablets in the cup prepared for administration to Resident 10. Employee 3 recounted the tablets in the cup, and the number of tablets ordered via the medications' labeling and confirmed that she should have nine and one-half tablets; however, she poured only eight and one-half tablets. Employee 3 determined that she omitted one of the two calcium citrate tablets until after the surveyor's questioning.

Continued observation of the medication administration pass on May 8, 2024, at 8:42 AM revealed Employee 3 prepared medications for Resident 120 that included the following:

Carvedilol (medication to lower blood pressure) 12.5 mg tablet. The label on the medication instructed the user to take the medication with food.
Gemfibrozil (medication to lower "bad" cholesterol (LDL and triglycerides) and raise "good" (HDL) cholesterol) one-half of 600 mg tab. The label on the medication instructed the user to take the medication one-half hour before a meal.
Magnesium oxide (vitamin dietary supplement) 400 mg tablet. The label on the medication instructed the user to take the medication with a meal.

Teaching instructions included in the EMAR (electronic medication administration record, electronic system used by the facility to document the administration of medications) for the Gemfibrozil medication noted, "How to Use," which stipulated that the medication is usually taken twice a day (30 minutes before the morning and evening meals).

Interview with Employee 3 on May 8, 2024, at 8:55 AM verified the Gemfibrozil label instructions noted to take the medication before a meal; but Resident 120 had already finished her breakfast. Employee 3 confirmed that the schedule for the above three medications for Resident 120 result in the administration of medications to be given with food along with the administration of a medication to be given one-half hour before a meal.

Review of Resident 120's clinical record revealed that the facility discontinued the active physician order for Gemfibrozil 600 mg medication on May 8, 2024, at 11:05 AM (following the above observation and staff interview).

The surveyor reviewed the above concerns regarding the medication administration pass during an interview with the Nursing Home Administrator and the Director of Nursing on May 8, 2024, at 2:00 PM.

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

Plan of Correction - To be completed: 06/25/2024

1. Employee #3 was educated on the proper procedures for administering medication at the proper dose and proper time. No ill effects to resident occurred.
2. Med pass audits on dosages and administration times will be completed 3x a week by DON or designee.
3. Education to the licensed nursing staff on medication doses and proper administration times will be completed by DON or designee.
4. DON or designee will conduct audits for medication passes to ensure proper doses and administration times. These will be completed weekly x4 and monthly x3 with results presented to QAPI.

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

(2) Effective July 1, 2023, a minimum of 1 nurse aide per 12 residents during the day, 1 nurse aide per 12 residents during the evening, and 1 nurse aide per 20 residents overnight.

Plan of Correction - To be completed: 06/25/2024

1. Facility ensures that sufficient personnel are provided on a 24-hour basis to provide nursing care to meet the needs of all residents.

2. Facility designee will continue to recruit and retain nurse aide staff through utilizing recruitment fairs, engagement events and visiting community career centers.

3. Education given to staff responsible for regulation P5510. Ongoing/reoccurring meetings with facility recruiting will take place.

4. Facility designee will conduct random audits to review nurse aide schedule for regulation P5510 x3 months.

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

(4) Effective July 1, 2023, a minimum of 1 LPN per 25 residents during the day, 1 LPN per 30 residents during the evening, and 1 LPN per 40 residents overnight.

Plan of Correction - To be completed: 06/25/2024

1. Facility ensures that sufficient personnel are provided on a 24-hour basis to provide nursing care to meet the needs of all residents.

2. Facility designee will continue to recruit and retain licensed practical nurse (LPN) staff through utilizing recruitment fairs, engagement events and visiting community career centers.

3. Education given to staff responsible for regulation P5530. Ongoing/reoccurring meetings with facility recruiting will take place.

4. Facility designee will conduct random audits to review licensed practical nurse (LPN) schedule for regulation P5530 x3 months.

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