Nursing Investigation Results -

Pennsylvania Department of Health
QUALITY LIFE SERVICES - CHICORA
Patient Care Inspection Results

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QUALITY LIFE SERVICES - CHICORA
Inspection Results For:

There are  81 surveys for this facility. Please select a date to view the survey results.

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QUALITY LIFE SERVICES - CHICORA - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:
Based on a Medicare/Medicaid Recertification, State Licensure, and Civil Rights Compliance survey completed on January 17, 2020, it was determined that Quality Life Service - Chicora Medical Center 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:


483.60(i)(1)(2) REQUIREMENT Food Procurement,Store/Prepare/Serve-Sanitary:This is a less serious (but not lowest level) deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents.  This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
§483.60(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 review of facility policies, observations and staff interviews it was determine that the facility failed to properly restrain facial hair, perform proper hand washing, in the Main Kitchen (Main Kitchen) and maintain refrigeration in a sanitary condition in three of four nursing unit pantries (Memory Lane, Fairgrounds, and Chicora Cove Nursing Units).

Findings include:

A review of facility "Employee Sanitary Practices" policy dated 1/2/19, indicated that employee will wear hair restrains and wash hands before handling food products.

A review of facility "Food Safety and Sanitation" policy dated 1/2/19, indicated that beard nets are required when the beard is untrimmed.

A review of facility "Bare Hand Contact with Food and Use of Vinyl Gloves" policy dated 1/2/19, indicated that Gloves are like hands. they get soiled. Anytime a contaminated surface is touched the gloves must be changed such as touching packages.

A review of facility "Hand Washing" policy dated 1/2/19, indicated that hand washing is to be performed after touching soiled equipment or utensils and after engaging in other activities that contaminate the hands.

During a tray line operation observation in the Main Kitchen on 1/14/20, at 12:04 p.m. Dietary Aide Employee E11 was observed preparing food products without properly restraining his facial hair. Dietary Aide Employee E12 was observed with gloved hands touching the outside of a package of hot dog buns, with the same gloved hands reach inside the package and retrieve a hot bun. She then proceeded to open the bun and place it onto a plate without performing hand washing and changing gloves.

During an interview on 1/14/20, at 12:56 p.m. the Food Service Director Employee E10 confirmed that Dietary Aide Employee E11 failed to properly restrain his facial hair and Dietary Aide Employee E12 failed to perform proper hand washing and changing gloves which both created the potential for cross contamination.

During an observation of the nursing unit pantries on 1/15/20, at 2:00 p.m. the following as observed:
- the freezer door gasket on Memory Lane contained a build up of a black substance
- the freezer door gasket on Fairgrounds contained a build up of food debris
- freezer and refrigerator door gaskets on Chicora Cove contained a build up of food debris.

During an interview of 1/15/20, at 2:10 p.m. Food Service Director Employee E10 confirmed that the facility failed to maintain the refrigeration/freezers on Memory Lane, Fairgrounds, and Chicora Cove in a sanitary condition which created the potential for cross contamination.

28 PA Code: 211.6(c)(d)(f) Dietary services.



 Plan of Correction - To be completed: 03/09/2020

Plan of Correction:

Intervention:

-Dietary staff will be provided with proper hair restraints to cover facial hair.
-Dietary staff will be provided with education by Dietary Manager or designee regarding proper hair restraints for facial hair.
-Dietary staff will be educated by the Dietary Manager on the "Bare Hands Contact with Food and Use of Vinyl Gloves" Policy.
-The house keeping staff will be provided with education on proper cleaning of freezer and refrigerator door gaskets by Dietary Manager or designee.
-The freezer and refrigerator door gaskets were cleaned to remove food debris and black substances by the housekeeping staff immediately.
Evaluation:

-Audits of proper facial hair coverage will be completed by the Dietary Manager or designee for each shift daily for 1 week and then 3 times a week for 3 weeks.
-Audits of proper food handling while wearing gloves will be conducted by the Dietary Manager or designee 3 times weekly for 4 weeks.
-Audits of freezer and refrigerator gasket cleanliness will be completed weekly for 4 weeks by the Dietary Manager or designee.
-Results of audits will be reviewed at the next scheduled quality assessment and assurance meetings.

Responsible party: Dietary Manager or designee


483.20(g) REQUIREMENT Accuracy of Assessments: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.
§483.20(g) Accuracy of Assessments.
The assessment must accurately reflect the resident's status.
Observations:
Based on review of the Resident Assessment Instrument (RAI) instructions, facility clinical records and staff interviews it was determined that the facility failed to accurately complete a Minimum Data Set (MDS - periodic assessment of care needs) assessment for three of 29 residents reviewed (Resident R48, R60 and CR103).

Findings include:

The Minimum Data Set (MDS - periodic assessment of care needs) dated 12/3/19, indicated that Resident R60 was readmitted to the facility on 12/1/19, with the current diagnosis that include irregular heart beat, anxiety, falls, heart disease and diabetes.

A review of Resident R60's progress notes dated 11/16/19, revealed that Resident R60 had been transferred out of the facility due to a fall with major injury.

A review of Resident R60's MDS, Section A Identification Information, Most Recent Admission/Entry or Reentry into this facility A1600 Entry Date was coded 12-01-2019, A 1700 Type of Entry was coded a 2 (Reentry).

A review of the RAI instructions for the coding of Section J 1700 Fall History on Admission/Entry or Reentry indicates that the section is completed if Section A0310A is coded 1 or Section A0310E is coded 1.

A review of Resident R60's Quarterly MDS dated 12/3/19, Section A Identification Information A0310 Type of Assessment Section E, Is this assessment the first assessment since the most recent admission/entry or reentry? was coded a zero (0) indicating No. Review of Section J 1700 Fall History was not coded and blank.

During an interview on 1/14/2020, at 11:10 a.m. Registered Nurse Assessment Coordinator (RNAC) Employee E2 confirmed that Resident R60's Quarterly MDS dated 12/3/19, was Resident R60's first assessment since reentry into the facility on 12/1/19, and was inaccurately coded a zero (0) in Section A0310E and should have been coded a one (1). This error incorrectly triggered Section J 1700 Fall History Sections A, B and C not to be completed which failed to capture Resident R60's fall with major injury on 11/16/19.

The MDS dated 11/21/19, indicated that Resident R48 was admitted to the facility on 2/20/16, with the current diagnosis that include muscle weakness, low blood pressure, anxiety, pain, difficulty walking, and cancer.

During a review of Resident R48's progress notes date 1/13/2020, 1/8/2020, 1/7/2020, 1/6/2020, and 1/2/2020, revealed that Resident R48 was provided care by a hospice aide.

A review of Resident R48's Significant Change MDS Section O Special Treatment, Procedures, and Programs Section K Hospice Care dated 8/26/19, was coded with an X indicating that Resident R48 was receiving hospice care while a resident of the facility.

A review of Resident R48's Quarterly MDS Section O Special Treatment, Procedures, and Programs Section K Hospice Care dated 11/21/19, was not coded and left blank indicating the resident was not receiving hospice care while in the facility.

During an interview on 1/14/2020, at 11:10 a.m. RNAC Employee E2 confirmed that Resident R48's Quarterly MDS Dated 11/21/19, Section O Special Treatments, Procedures, and Programs Section K Hospice Care was inaccurately coded and failed to capture that Resident R48 was receiving hospice care while in the facility.

A review of the RAI instructions for the coding of Section A2100 Discharge Status indicated that a resident that is discharged to the community (private home/apt, board/care. assisted living, group home) the section is coded 01.

A review of Resident CR103's clinical record indicated that resident was admitted to the facility on 10/2919, with the diagnosis that included muscle weakness, diabetes, breathing difficulties, urinary tract infection, heart disease and difficulty walking.

A review of the Admission Record for Resident CR103 revealed that Resident CR103 was admitted to the facility on 10/29/19, with the diagnoses of fusion of the spine, unsteadiness on feet, and muscle weakness.

A review of the Clinician (Physician) Discharge Summary date 11/15/19, at 3:44 p.m. indicated Resident CR103 was to be discharged from the facility to home with physical therapy (PT), occupational therapy (OT), social worker (SW), and a home health nurse (HHN).

A review of the progress notes dated 11/16/19, revealed that Resident CR103 was discharged from the facility to home via private vehicle.

A review of Resident CR103's MDS dated 11/16/19, revealed that Section A2100 Discharge Status was coded 03 indicating that Resident CR103 was discharged to an Acute Hospital.

During an interview on 1/16/2020, at 1:11 p.m. Clinical Support Specialist (CSS) Employee E3 confirmed that Resident CR103's MDS dated 11/16/19, was inaccurate and that Section A2100 should have been coded 01 indicating that the resident discharged to home.

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


 Plan of Correction - To be completed: 03/09/2020

Quality Life Services Chicora has adopted internal processes as part of our on-going commitment to provide quality care to the residents we serve. The attached information contains Quality Life Services –Chicora's Plan of Correction which we are submitting in response to specific deficiencies identified by the Pennsylvania Department of Health and is required for purposes of our facility's licensures and certification. The information and responses contained in our Plan of Correction are consistent with our own quality improvement efforts and should not be construed as an admission of or agreement with the deficiencies cited in the departments findings. This Plan of Correction is not an admission of wrong doing on the part of Quality Life Services-Chicora.

Intervention:

-Resident R60's re-entry MDS dated 11/16/19 was corrected to include falls with major injury.
-Resident R48's quarterly MDS dated 11/21/19 was corrected to reflect hospice care.

-Resident CR103's MDS dated 11/16/19 section A2100 was corrected to indicate resident was discharged home.
-MDS audits of all current hospice residents for the last year were completed.
-RNAC will be educated on proper documentation and MDS types by Clinical Reimbursement Specialist.
-Random MDS audits of residents discharged within the last 3 months will be completed by the RNAC or designee for accuracy of discharge status.
-MDS audits of all re-entry residents will be completed for accuracy of coding.

Evaluation:

-Audits on all new hospice resident's MDS to be completed for 4 weeks.
-Audits on all re-entry MDS to be completed for 4 weeks.
-Audits on all discharge MDS to be completed for 4 weeks.
-Results of audits will be reviewed at the next scheduled quality assessment and assurance meetings.

Responsible party: RNAC or designee
483.80(d)(1)(2) REQUIREMENT Influenza and Pneumococcal Immunizations: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(d) Influenza and pneumococcal immunizations
§483.80(d)(1) Influenza. The facility must develop policies and procedures to ensure that-
(i) Before offering the influenza immunization, each resident or the resident's representative receives education regarding the benefits and potential side effects of the immunization;
(ii) Each resident is offered an influenza immunization October 1 through March 31 annually, unless the immunization is medically contraindicated or the resident has already been immunized during this time period;
(iii) The resident or the resident's representative has the opportunity to refuse immunization; and
(iv)The resident's medical record includes documentation that indicates, at a minimum, the following:
(A) That the resident or resident's representative was provided education regarding the benefits and potential side effects of influenza immunization; and
(B) That the resident either received the influenza immunization or did not receive the influenza immunization due to medical contraindications or refusal.

§483.80(d)(2) Pneumococcal disease. The facility must develop policies and procedures to ensure that-
(i) Before offering the pneumococcal immunization, each resident or the resident's representative receives education regarding the benefits and potential side effects of the immunization;
(ii) Each resident is offered a pneumococcal immunization, unless the immunization is medically contraindicated or the resident has already been immunized;
(iii) The resident or the resident's representative has the opportunity to refuse immunization; and
(iv)The resident's medical record includes documentation that indicates, at a minimum, the following:
(A) That the resident or resident's representative was provided education regarding the benefits and potential side effects of pneumococcal immunization; and
(B) That the resident either received the pneumococcal immunization or did not receive the pneumococcal immunization due to medical contraindication or refusal.
Observations:
Based on review of facility policy, clinical record review and interview with staff, it was determined that the facility failed to ensure that a pneumococcal immunization was offered to three of five residents reviewed (Residents R34, R72, and R91).

Findings include:

A review of the facility policy, "Standing Orders for Administering Pneumococcal Vaccine to Adults " dated 1/2/19, indicated all residents will be identified for the need and receive the pneumococcal vaccine.

A review of the clinical record revealed Resident R34 was admitted to the facility on 12/28/18. There was no documentation to indicate that the resident had been offered or assessed to receive the pneumococcal vaccine.

A review of the clinical record revealed Resident R72 was admitted to the facility on 8/10/17. There was no documentation to indicate that the resident had been offered or assessed to receive the pneumococcal vaccine.

A review of the clinical record revealed Resident R91 was admitted to the facility on 10/23/16. There was no documentation to indicate that the resident had been offered or assessed to receive the pneumococcal vaccine.

During an interview on 1/17/20, at 11:50 a.m., the Director of Nursing (DON) stated that if the vaccination data was not recorded in the clinical record then it was not offered or administered to the resident and the facility failed to ensure that a pneumococcal immunization was offered to Residents R34, R72, and R91.

28 Pa. Code 211.5(f) Clinical records



 Plan of Correction - To be completed: 03/09/2020

Intervention:

-Residents R72, R91, R34 offered Pneumococcal vaccine.
-Education to be provided to RNs and LPNs on Pneumococcal vaccine policy by Director of Nursing or designee.
-Audit of all current residents Pneumococcal vaccine status to assess if vaccine was offered or administered.
-All resident not up to date on vaccine to be educated and offered the Pneumococcal vaccine.
-Infection Control Nurse will review charts for all new admissions weekly to ensure that every resident has been educated on and offered the Pneumococcal vaccine.

Evaluation:

-Audits to be completed by Director of Nursing or designee on all new admissions vaccine status weekly times 4 weeks.
- Results of audits will be reviewed at the next scheduled quality assessment and assurance meetings.

Responsible party: Director of Nursing or designee

483.80(a)(1)(2)(4)(e)(f) REQUIREMENT Infection Prevention & Control: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 Infection Control
The facility must establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections.

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

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

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

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

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

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

Based on review of facility policy, observation and interview with staff it was determined that the facility failed to prevent the potential for cross contamination and infections during blood glucose monitoring (test for sugar in the blood by pricking the finger and getting a blood sample) for three of three residents reviewed (Resident R62, R93, and R152).

A review of the facility policy "Blood Glucose Meter" dated 1/2/19, indicated to clean glucose meters (instrument used to detect blood sugar levels) with a bleach product following manufacturers guidelines.

The manufacturer directions for the blood sugar monitoring device utilized by the facility indicated that cleaning and disinfecting can be completed using a commercially available registered disinfectant detergent or germicide wipe. The facility had available individual packets of bleach wipes for the nursing staff to use for disinfecting the glucometers.

During observation of a medication administration on 1/14/20, at 11:15 a.m. Licensed Practical Nurse (LPN) Employee E13 performed a blood glucose monitoring on resident R93. LPN Employee E13 wiped the glucose meter with an alcohol wipe. LPN Employee E13 then did a glucose monitoring on resident R62, and cleansed the glucose meter with an alcohol wipe. LPN Employee E13 then did a glucose monitoring on resident R152 and cleansed the glucose meter with an alcohol wipe.

During an interview on 1/14/20, at 12:00 p.m. LPN Employee E13 confirmed she did not clean the glucometer with bleach wipes.

During an interview on 1/14/20, at 12:30 p.m., the Regional Director Employee E3 confirmed the above findings and that bleach wipes were to be used to clean the glucometers and the facility failed to prevent the potential for cross contamination and infections during blood glucose monitoring for residents R62, R93, and R152.

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

28 Pa. Code: 211.12(d)(1)(2)(3)(5) Nursing services.










 Plan of Correction - To be completed: 03/09/2020

Intervention:

-All licensed nurses to be educated on facility policy on cleaning/disinfecting glucometers with bleach wipes by the Director of Nursing or designee.
-Education provided to E13 on proper cleaning of glucometers immediately.
-All licensed nurses to be educated on the bleach wipes from new supply distributor.
-No negative outcomes or signs/symptoms of infection noted to resident E13, R62, or R152 from possible cross contamination.

Evaluation:

-Random audits for proper glucometer disinfection will be completed 3 times a week for 4 weeks.
-Results of audits will be reviewed at the next scheduled quality assessment and assurance meetings.

Responsible party: Director of Nursing or designee

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

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

§483.60(d)(2) Food and drink that is palatable, attractive, and at a safe and appetizing temperature.
Observations:
Based on a review of facility policy and documents, observations, and resident and staff interviews, it was determined that the facility failed to provide the residents with a palatable meal for one of one lunch meal observed. (Lunch Meal on 1/14/2020).

Findings include :

A review of facility "Food Temperatures" policy dated 1/2/19, indicated that hot foods are held at or above 135F (Fahrenheit) and cold foods are held at or below 41F (Fahrenheit).

A review of facility "Test Meal/Tray Audit" form dated 1/2/19, revealed that the facility has not established acceptable point of service food temperatures based on the satisfaction of their residents.

During a group interview on 1/14/20, at 11:15 a.m. Resident R500 indicated that he is food is often cold and bland.

During an interview on 1/13/20, at 11:07 a.m. Resident R90 indicated that he is food is bland, not appetizing and of poor quality.

During an test tray observation on 1/14/20, at 12:42 p.m. the following food temperatures were observed:
Roast Turkey 130.3F (Fahrenheit),
Green Beans 119F (Fahrenheit),
Stuffing 126.9F (Fahrenheit),
Orange Juice 55F (Fahrenheit),
2% milk 55F (Fahrenheit).
The recorded temperatures were out of compliance of the holding temperatures of
- hot foods held at or above 135F (Fahrenheit)
- cold foods held at or below 41F (Fahrenheit).

During an interview on 1/14/20, at 12:56 p.m. the Food Service Director Employee E10 confirmed the temperatures of the test tray.

During the test tray observation on 1/14/20, at 12:42 p.m. the state agency tasted the food products for palatability and determined the following:
- the green beans were bland and lacked flavor,
- the overall taste of the food had a metallic flavor or aftertaste it the food products.

During an interview on 1/15/20, at 1:49 p.m. the Food Service Director Employee E10 confirmed that the facility failed to establish point of service food temperatures that met the satisfaction of the residents and that the food served the residents lack flavor, and seasoning which created the potential for resident to receive a palatable meal.

28 PA Code: 211.6(b)(c)(d) Dietary services.


 Plan of Correction - To be completed: 03/09/2020

Plan of Correction:

Interventions:

-Cold beverages will be served on ice separate from hot items for each individual nursing unit.
-Education to be provided to staff on prompt delivery of all meal trays to residents by the Dietary Manager.
-Individual packets of seasoning will be placed on each resident's tray during tray line.
-Dietary staff to be educated by the Dietary Manager regarding recipe compliance and proper seasoning of food.

Evaluation:

-Test trays will be completed to evaluate palatable temperatures and flavor 3 times a week for two weeks, then weekly for 2 weeks.
-Ten residents will be interviewed each week for 4 weeks for food satisfaction. The questionnaire will include palatability for flavor and temperature.
-Results of audits and surveys will be reviewed at the next scheduled quality assessment and assurance meeting.

Responsible party: Dietary Manager or designee


483.35(d)(7) REQUIREMENT Nurse Aide Peform Review-12 hr/yr In-Service: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.
§483.35(d)(7) Regular in-service education.
The facility must complete a performance review of every nurse aide at least once every 12 months, and must provide regular in-service education based on the outcome of these reviews. In-service training must comply with the requirements of §483.95(g).
Observations:
Based on a review of facility personnel files and staff interviews it was determined that the facility failed to annually evaluate the skills and competency levels of five of five employees as required. (Nursing Assistant (NA) Employee E4, E5, E6, E7, and E8).

Findings include:

A review of the facility's personnel files revealed the following:
- NA Employee E4 was hired on 11/14/08,
- NA Employee E5 was hired on 1/26/05,
- NA Employee E6 was hired on 8/20/15,
- NA Employee E7 was hired on 4/23/18,
- NA Employee E8 was hired on 3/23/07.

A review of the facility Employee Performance Review records revealed the following:
- NA Employee E4's last performance review was conducted in 2011,
- NA Employee E5's last performance review was conducted in 2015,
- NA Employee E6 did not have a performance review
- NA Employee E7 did not have a performance review
- NA Employee E8's last performance review was in 2011.

During an interview on 1/16/2020, at 1:00 p.m. Human Resources Director Employee E9 confirmed that the facility failed to conduct annual performance reviews for 2019, for NA Employee E4, E5, E6, E7, and E8 which created the potential for the employee not to receive training for the development and improvement of skills and competencies.

28 PA Code: 201.20(a)(c)(d) Staff development.


 Plan of Correction - To be completed: 03/09/2020

Plan of Correction:

Intervention:

-Current nursing assistant employee files will be reviewed for performance evaluations.
-Any nursing assistant employed for 1 year who does not have a performance evaluation within the past year will have the evaluation completed by 3/6/2020.
-Performance evaluations will be completed on E4, E5, E6, E7, and E8 by 2/14/2020.
-Human Resources Director will be educated on providing names to the Director of Nursing each week and ensuring evaluations are done timely.

Evaluation:

-Files of nursing assistants with recent anniversaries beginning 2/1/2020 will be audited for performance evaluations weekly for 4 weeks.
- Results of audits will be reviewed at the next scheduled quality assessment and assurance meetings.

Responsible party-Director of Nursing or designee.


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

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

Based on facility policy and record review, observation, and staff interview it was determined that the facility failed to make certain that the environment is free of hazards to prevent a potential accident (burn) for one of 19 cognitively impaired residents reviewed (Resident R153).

Findings include:

Review of the facility policy "Accidents and Incidents," dated 1/2/19, indicated a safe environment will be promoted for all residents.

Review of the clinical record revealed Resident R153 was admitted to the facility on 1/2/20, with diagnoses that included vascular dementia (a chronic disorder of the mental processes caused by brain disease, and marked by memory disorders, personality changes, and impaired reasoning), and altered mental status. Resident R153 ambulates using a wheelchair throughout the facility.

Review of Resident R153's current plan of care revealed: Resident R153 requires monitoring of safety due to wandering, confusion, requires supervision and assistance with decision making, and needs to be provided a safe environment.

During an observation on 1/14/20, at 11:45 a.m. Resident R153 was observed with both feet propped up on the baseboard heating radiator. Temperature of the heating radiator at the time of observation was 135 degrees Farenheit and hot to the touch.

During an interview on 1/14/20, at 12:00 p.m. Director of Environmental Services Employee E1 confirmed the above findings and the radiator was hot to the touch.

During an interview on 1/14/20, at 3:00 p.m. the Director of Nursing confirmed the above findings and that the facility failed to make certain that the environment is free of hazards to prevent a potential accident (burn) for Resident R153.

28 Pa. Code 201.14(a) Responsibility of licensee
28 Pa. Code 201.18(b)(1) Management
28 Pa. Code 211.10(c) Resident care policies




 Plan of Correction - To be completed: 03/09/2020

Intervention:

-The thermostats on all heaters in question were turned down immediately.
-All electric heaters were monitored for temperature every 30 minutes for 48 hours beginning on 1/14/2020 at 3:00 pm.
-Estimates to replace the heaters in question will be obtained by 2/28/2020.


-All staff will be educated by the Maintenance director or designee regarding proper heater temperatures, proper procedure to report if out of range, and resident safety around the heaters.
-No negative outcomes or signs/symptoms of burns were noted to resident R153 from contact with heater.

-Evaluation:

-Audits will be completed daily by the Maintenance Director or designee for 1 week and then 3 times a week for 3 weeks to ensure temperature remains <125 degrees Fahrenheit.
-Results of audits will be reviewed at the next scheduled quality assessment and assurance meetings.

Responsible party: Maintenance Director or designee
483.60(d)(4)(5) REQUIREMENT Resident Allergies, Preferences, Substitutes: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(d) Food and drink
Each resident receives and the facility provides-

§483.60(d)(4) Food that accommodates resident allergies, intolerances, and preferences;

§483.60(d)(5) Appealing options of similar nutritive value to residents who choose not to eat food that is initially served or who request a different meal choice;
Observations:
Based on review of facility policies and menus, observations, and resident and staff interviews, it was determined that the facility failed to follow the resident food preference, offer resident alternative selections to the main menu and offer a variety of food types for meal service for four of nine residents. (Resident R500, R501, R502, R503).

Findings include:

A review of facility "Displaying the Menu" Policy dated 1/2/19, indicated that planned menus will be posted each week within the dining areas.

A review of facility "Alternatives/Always Offered Menu for Food Dislikes" dated 1/2/19, indicated that appropriate alternate foods are prepared and substituted for food dislikes. Menu alternates are planned in advance.

A review of facility "Obtaining Food Preferences" dated 1/2/19, indicated that food preferences are obtained at the time of admission.

A review of facility "Menu Planning" policy dated 1/2/19, indicated that menus are posted in areas and at heights where all residents can easily view them.

During an observation of the two dining room area menu boards on 1/13/20, at 12:15 p.m. it was revealed that the facility failed to post an alternate menu selection for the lunch and dinner menus as displayed.

During a group interview on 1/14/20, at 11:15 a.m. the following was revealed:
- Resident R501 stated she does not receive her food preferences and that there are no food choices if you don't like something, there are no alternative foods, eggs are served everyday for breakfast.
- Resident R502 stated she often receives food products she is not to receive,
- Resident R503 stated that he did not like white meat and that is all he is offered. He stated that he is not aware of any alternate menu selections.
- Resident R500 stated there are no alternative menu selections

A review of the facility five week cycle menu for the lunch and dinner meals dated 10/8/19, revealed that the facility failed to plan in advance alternative menu selections.

A review of the facility breakfast menu dated 10/8/19, revealed a seven day cycle menu (meals repeated every seven days).

During an interview on 1/14/20, at 12:56 p.m. Food Service Director Employee E10 confirmed that the facility failed to offer a variety of menu selections for the breakfast meal and that the facility did not offer an alternate menu selection to the main entree for the lunch and dinner meals.

28 PA Code: 211.6(a) Dietary services.


 Plan of Correction - To be completed: 03/09/2020

Plan of Correction:

Intervention:

-Table menus will be placed at each table in the dining rooms and in resident's rooms for those that prefer to eat there.
-Alternatives/always offered menu for food dislikes has been added with bigger font to the bottom of the weekly menu and on all table menus.
-All residents will be given a copy of the alternative/always available menu.
-Alternate menu options will be placed on menu boards in both dining rooms.
-Resident will be asked each day for their food preferences by nursing staff via select menu 24 hours before each day.
-CDM reviewed menus and breakfast will be on a 5 week rotating menu.
-R500, R501, R502, R503 were interviewed for preferences and suggestions.
-The Dietary manager or designee will meet with a group of resident representatives to discuss the menu selections and to gather ideas for always offered menu.

Evaluation:

-Weekly audits completed by Dietary Manager or designee to ensure that table menus remain on tables and in resident rooms.
-10 meal satisfaction surveys will be completed each week for 4 weeks by the Dietary Manager or designee to ensure the resident is receiving choices and preferences.
-The Dietary Manager or designee will audit the kitchen weekly for 4 weeks to ensure proper menu compliance of the 5 week cycle.
-Results of audits will be reviewed at the next scheduled quality assessment and assurance meeting.

Responsible party: Dietary manager or designee


483.20(f)(5), 483.70(i)(1)-(5) REQUIREMENT Resident Records - Identifiable Information:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
§483.20(f)(5) Resident-identifiable information.
(i) A facility may not release information that is resident-identifiable to the public.
(ii) The facility may release information that is resident-identifiable to an agent only in accordance with a contract under which the agent agrees not to use or disclose the information except to the extent the facility itself is permitted to do so.

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

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

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

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

§483.70(i)(5) The medical record must contain-
(i) Sufficient information to identify the resident;
(ii) A record of the resident's assessments;
(iii) The comprehensive plan of care and services provided;
(iv) The results of any preadmission screening and resident review evaluations and determinations conducted by the State;
(v) Physician's, nurse's, and other licensed professional's progress notes; and
(vi) Laboratory, radiology and other diagnostic services reports as required under §483.50.
Observations:
Based on review of facility policy, clinical records, observations and staff interview it was determined that the facility failed to maintain accurate documentation regarding an elopement for one of one resident reviewed (Resident R79).

Findings include:

The facility "Resident medical records" policy last reviewed 1/2/19, indicated the medical record contains medical data, progress notes, physician orders, that reflect the day to day services provided to the resident.

A review of the clinical record revealed resident R79 was admitted to the facility on 5/8/18, with diagnoses that included traumatic brain injury and dementia.

A review of the quarterly minimum data set (MDS - periodic assessment of care needs) dated 8/2/19, indicated these diagnoses remained current and Resident R79 had severely impaired cognition.

A review of a facility incident report dated 10/7/19, indicated Resident R79 had crawled out the window to take a walk and was given a ride back to the facility from the end of the driveway.

There was no documentation in the clinical record that this incident had occurred.

During an interview on 1/15/20, at 1:15 p.m., the Director of Nursing confirmed the above findings and that the facility failed to maintain accurate documentation in the clinical record regarding an elopement for Resident R79.

28 Pa Code: 211.5(f)(g)(h) Clinical records.



 Plan of Correction - To be completed: 03/09/2020

Plan of Correction:

Intervention:

-Late entry note added to resident R79's medical record from information noted in risk management from 10/7/2019.
-Risk management reports from the last 3 months (November 2019, December 2019, and January 2020) will be randomly audited to ensure accurate documentation.
-Any information found missing from risk management reports will be added immediately.
-Nursing staff will be educated on proper documentation of incidents in the progress notes and risk management reports by the Director of Nursing or designee.

Evaluation:

-Audits will be completed on all new risk management reports weekly for 4 weeks to ensure accurate documentation by the Director of Nursing or designee.- - Results of audits will be reviewed at the next scheduled quality assessment and assurance meetings.

Responsible party: Director of Nursing or designee


483.75(g)(1)(i)-(iii)(2)(i) REQUIREMENT QAA Committee: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.
§483.75(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;

§483.75(g)(2) The quality assessment and assurance committee must:
(i) Meet at least quarterly and as needed to identifying issues with respect to which quality assessment and assurance activities are necessary.
Observations:
Based on review of facility documents and staff interviews it was determined that the facility failed to make certain that all the required members of the Quality Assurance (QA) Committee were in attendance for two of four quarters as required. (Third and Fourth Quarters).

Findings include:

A review of the facility QA attendance rosters dated 7/19, 8/19, 9/19, and 11/19, revealed that the Medical Director was not in attendance.

During an interview on 1/17/2020, at 11:05 a.m. the Nursing Home Administrator confirmed that the facility failed to make certain that the Medical Director was in attendance at the quarterly QA committee meeting s as required.

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


 Plan of Correction - To be completed: 03/09/2020

Intervention:

-Education will be provided to the Medical Director regarding need to attend quality assessment and assurance at least every quarter by the Administrator or designee.
-Medical Director will be given a schedule of quality assessment and assurance meeting dates/times.

Evaluation:

-Minutes for quality assessment and assurance will be monitored quarterly for Medical Director's attendance at least quarterly by the Director of Nursing or designee
-Results of audits will be reviewed at the next scheduled quality assessment and assurance meetings.

Responsible party: Nursing Home Administrator

§ 205.10(c) LICENSURE Doors.:State only Deficiency.
(c) A door to a toilet room which swings into the toilet area shall be equipped with special hardware which permits the door to be opened from the outside, and swing out, in case of emergency.
Observations:
Based on observation and staff interview, it was determined that the facility failed to make certain that resident restroom doors could be opened from the outside and swing outward in the event of an emergency on one of four nursing units (Fairground Nursing Unit).

Findings include:

Observation on 1/17/20, at 12:45 p.m. of the Fairground Nursing Unit revealed two resident restrooms (male and female), located in the hallway area. The restroom doors did not have the ability to swing outward in the event of an emergency.

During an interview and observation on 1/17/20, at 1:05 p.m. the Nursing Home Administrator and Director of Nursing confirmed the restroom doors do not have the ability to swing outward in the event of an emergency. During this interview a male resident was observed in the restroom with wheelchair having difficulty opening door.


 Plan of Correction - To be completed: 03/09/2020

Interventions:

-Doors to both female and male restrooms on Fairgrounds have been locked by the Maintenance Director and made available to staff and visitors only effective immediately until the door frame can be equipped with specific hardware to allow door to swing out.
-Residents were notified of need to look restrooms immediately.

§ 205.39(b) LICENSURE Toilet room equipment.:State only Deficiency.
(b) Toilets used by residents shall be provided with handrails or assist bars on each side capable of sustaining a weight of 250 pounds and an emergency call bell within reaching distance.
Observations:
Based on observations and staff interview it was determined that the facility failed to provide handrails or assist bars on each side of toilets capable of sustaining a weight of 250 pounds on one of four nursing units (Fairground Nursing Unit).

Findings include:

During an observation on 1/17/20, at 12:45 a.m. of the Fairground Nursing Unit revealed two resident restrooms (male and female), located in the hallway area that had no handrails or assist bar located on both sides of the toilets

During an interview on 1/17/20, at 1:05 p.m. the Nursing Home Administrator and Director of Nursing confirmed the restroom toilets do not have handrails or assist bars on each side of toilets.


 Plan of Correction - To be completed: 03/09/2020

Interventions:

-Doors to both female and male restrooms on Fairgrounds have been locked by the Maintenance Director. Going forward restrooms are now only available for staff and visitors, with the key available at the nurse's station.
- Residents were notified of need to look restrooms immediately.

§ 205.61(b) LICENSURE Heating requirements.:State only Deficiency.
(b) Exposed heating pipes, hot water pipes or radiators in rooms and areas used by residents or within reach of residents, shall be covered or protected to prevent injury or burns to residents. This includes hot water steam piping above 125 degrees Fahrenheit.
Observations:
Based on observation and staff interview it was determined that the facility failed to provide covered or protected radiators to prevent potential injury on two of four nursing units. (Miller's Crossing and Chicora Cove).

Findings include:

During an observation on 1/14/20, at 11:45 a.m., it was revealed that the base board heater on the entrance to Miller's crossing nurse unit had a temperature of 135degrees and was not covered. The base board heaters located at the entrance of Chicora Cove nursing unit had a temperature of 130.2degrees and was not covered and outside room 410 had a temperature of 169degrees and was not covered.

During an interview on 1/14/20, at 12:00 p.m., the Director of Maintenance Employee E1 confirmed that Miller's Crossing and Chicora Cove nursing units had uncovered base board radiators with temperatures above 125degrees.



 Plan of Correction - To be completed: 03/09/2020

Intervention:

-The thermostats on all heaters in question were turned down immediately.
-All electric heaters were monitored for temperature every 30 minutes for 48 hours beginning on 1/14/2020 at 3:00 pm.
-Estimates to replace the heaters in question will be obtained by 2/28/2020
-All staff will be educated regarding proper heater temperatures, proper procedure to report if out of range, and resident safety around the heaters
-No negative outcomes or signs/symptoms of burns were noted to resident R153 from contact with heater.

Evaluation:

-Audits will be completed daily for 1 week and then 3 times a week for 3 weeks to ensure temperature remains <125 degrees Fahrenheit.
-Results of audits will be reviewed at the next scheduled quality assessment and assurance meetings.

Responsible party: Maintenance Director or designee

§ 209.8(b) LICENSURE Fire Drills.:State only Deficiency.
(b) A written report shall be maintained of each fire drill which includes date, time required for evacuation or relocation, number of residents evacuated or moved to another location and number of personnel participating in a fire drill.
Observations:
Based on a review of the facility fire drill records and staff interviews it was determined that the facility failed to evacuate residents it a safe location for eight of 12 fire drills as required (3/13/19, 4/9/19, 6/13/19, 7/16/19, 8/21/19, 9/18/19, 11/26/19, and 12/11/19).

Findings include:

A review of the facility fire drill records dated 3/13/19, 4/9/19, 6/13/19, 7/16/19, 8/21/19, 9/18/19, 11/26/19, and 12/11/19, revealed that the facility failed to evacuate residents to a safe location as required during the fire drills.

During an interview on 1/17/20, at 11:05 a.m. the Nursing Home Administrator confirmed that during fire drills the facility failed to properly evacuate residents to a safe location as required.



 Plan of Correction - To be completed: 03/09/2020

Intervention:

-Education to be provided to all staff by the Maintenance Director or designee regarding fire evacuation policy and staff roles during a fire drill and evacuation.

Evaluation:

-Fire drill records will be evaluated to include evacuation of residents to a safe location 8 of 12 fire drills.
- Results of fire drill records will be reviewed at the next scheduled quality assessment and assurance meetings.

Responsible party: Maintenance Director or designee


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