Pennsylvania Department of Health
WINDBER WOODS SENIOR LIVING & REHABILITATION CENTER
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

WINDBER WOODS SENIOR LIVING & REHABILITATION CENTER
Inspection Results For:

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WINDBER WOODS SENIOR LIVING & REHABILITATION CENTER - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:

Based on a Medicare/Medicaid Recertification survey, State Licensure survey, Civil Rights Compliance survey, and Complaint survey completed on April 18, 2024, it was determined that Windber Woods Senior Living and Rehabilitation 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 policies, observations, and staff interviews, it was determined that the facility failed to ensure that food stored in the kitchen was labeled, dated and secured.

Findings include:

The facility policy regarding food storage, dated December 14, 2023, revealed that any food that has been opened must be labeled, dated and secured in such a way that the food item is air tight.

Observations in the walk-in freezer on April 15, 2024, at 8:35 a.m. revealed that there was one bag containing six chicken tenders that was not labeled, dated or secured and one bag containing five chicken patties that was dated but unsecured.

Observations in the cook's cooler on April 15, 2024, at 8:40 a.m. revealed that there was approximately eighteen sausage patties in a box that was dated but the bag holding the sausage patties was open and unsecured.

Interview with the Dietary Manager on April 15, 2024, at 8:45 a.m. confirmed that all food items in the kitchen should be labeled, dated and secured.

Interview with the Nursing Home Administrator on April 15, 2024, at 10:26 a.m. confirmed that all food items in the kitchen should be labeled, dated and secured.

28 Pa. Code 211.6(f) Dietary Services.

Plan of Correction - To be completed: 06/17/2024

1. Corrective Action
- Dietary Director immediately discarded all unsecured, unlabeled, and undated foods.

2. Identifying other residents
- All residents have the potential to be affected by the practice.

3. Systemic Changes
- Education will be provided to the dietary department by the Nursing Home Administrator and/or Dietary manager to ensure that food is secured, dated and labeled appropriately.

4. Monitoring
- The Dietary manager or designee will complete audits to ensure that food items are secured, dated and labeled appropriately and in compliance with professional standards for food safety.
- Audits will be completed daily x 1 week, weekly x 4 weeks, monthly x 3 or until compliance is achieved and maintained
- Audit results will be submitted to Quality Assurance Performance Improvement (QAPI) for analysis and will be addressed as needed

483.10(i)(1)-(7) REQUIREMENT Safe/Clean/Comfortable/Homelike Environment:

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

§483.10(i) Safe Environment.
The resident has a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

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

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

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

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

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

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

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

Observations:

Based on review of policies, as well as observations and staff interviews, it was determined that the facility failed to maintain a clean and homelike environment for one of 32 residents reviewed (Resident 7).

Findings include:

The facility's policy regarding cleaning and disinfecting, dated December 14, 2023, indicated that housekeeping was to remove visible debris from surfaces and that proper cleaning was necessary to provide a healthy environment.

A quarterly Minimum data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 7, dated March 12, 2024, revealed that the resident was cognitively impaired, required extensive assistance from staff for daily care needs, had diagnoses that included pulmonary embolism (a blood clot that stops blood flow to the lung) and anemia (not enough red blood cells to carry oxygen to the tissues). A care plan, dated March 14, 2024, indicated that Resident 7 had a potential for altered respiratory status related to her pulmonary embolism and was to receive oxygen as needed at 2 to 4 liters per minute via nasal cannula (tube that delivers oxygen into the nostrils).

Observations on April 15, 2024, at 11:54 a.m. revealed that the resident was lying in her bed with a fan sitting on her over-bed table. The fan was blowing directly on her. The fan was noted to have a moderate amount of visible dirt and debris accumulated on the blade cover.

Observations on April 16, 2024, at 9:07 a.m. revealed that the resident was sitting in her chair with a fan sitting on her dresser. The fan was blowing directly on the resident. The fan was noted to have a moderate amount of visible dirt and debris accumulated on the blade cover.

Interviews with Housekeeper 1 and Licensed Practical Nurse 2 on April 16, 2024, at 11:04 a.m. confirmed that the fan was blowing directly on the resident, it had a moderate amount of dirt and debris accumulated on the blade cover, and that it should have been clean and it was not.

Interview with the Nursing Home Administrator on April 16, 2024, at 1:55 p.m. confirmed that Resident 7's fan cover should be clean, and it was not.

28 Pa. Code 207.2(a) Administrator's Responsibility.

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

Plan of Correction - To be completed: 06/17/2024

1. Corrective Action
- Resident #7 currently resides in the Facility.
- Resident #7's fan was immediately cleaned by housekeeping.

2. Identifying other residents
- Current residents have the potential to be affected by the deficient practice.
- Director of Housekeeping/designee shall conduct an audit for all resident's utilizing portable fans in their room for cleanliness.

3.Systemic Changes
- Housekeeping director/designee shall in-service housekeeping services (no agency/contracted staff are in this department) on providing a clean, homelike environment by maintaining portable fans that are free from debris and dust

4. Monitoring
- Director of Housekeeping/designee shall audit residents utilizing portable fans to ensure appropriate fan cleanliness daily x 1 week, weekly x 4 weeks then monthly x 3 months or until compliance is achieved and maintained.
- Audit results shall be submitted to Quality Assurance Performance Improvement for analysis. Any audits found to be non-compliant to be addressed as appropriate.

483.21(b)(2)(i)-(iii) REQUIREMENT Care Plan Timing and Revision:

§483.21(b) Comprehensive Care Plans
§483.21(b)(2) A comprehensive care plan must be-
(i) Developed within 7 days after completion of the comprehensive assessment.
(ii) Prepared by an interdisciplinary team, that includes but is not limited to--
(A) The attending physician.
(B) A registered nurse with responsibility for the resident.
(C) A nurse aide with responsibility for the resident.
(D) A member of food and nutrition services staff.
(E) To the extent practicable, the participation of the resident and the resident's representative(s). An explanation must be included in a resident's medical record if the participation of the resident and their resident representative is determined not practicable for the development of the resident's care plan.
(F) Other appropriate staff or professionals in disciplines as determined by the resident's needs or as requested by the resident.
(iii)Reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments.

Observations:

Based on review of clinical records and observations, as well as resident and staff interviews, it was determined that the facility failed to ensure that care plans were updated to reflect changes in care needs for one of 32 residents reviewed (Resident 51).

Findings include:

An annual Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 51, dated February 2, 2024, revealed that the resident was cognitively intact, required assistance with daily care needs, and had diagnoses that included obstructive and reflux uropathy (a disorder of the urinary tract that occurs due to obstructed urinary flow).

A care plan for Resident 51, revised on February 16, 2024, indicated that the resident had an indwelling foley catheter (tube that is inserted into the bladder allowing urine to drain in to a collection bag) size 16 French, 10 cc balloon. Physician's orders, dated February 2, 2024, included an order to change the size of the indwelling foley catheter to an 18 French, 10 cc balloon.

There was no documented evidence in Resident 51's clinical record to indicate that her care plan was revised when the size of the indwelling foley catheter was changed.

Interview with the Nursing Home Administrator on April 17, 2024, at 3:10 p.m. confirmed that Resident 51's care plan should have been revised when the size of the indwelling foley catheter was changed.

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

Plan of Correction - To be completed: 06/17/2024

1. Corrective Action
- Resident # 51 currently resides in the facility.
- Care plan for resident #51 was updated to reflect changes in foley catheter and balloon size.

2. Identifying other residents
a. Residents with indwelling foley catheters have the potential to be affected.
b. The Director of Nursing or Designee will conduct an audit on residents with indwelling foley catheters for foley catheter size and compare to care plan for accuracy.

3. Systemic Changes
a. Director of Nursing/designee shall in-service Registered Nurse Assessment Coordinator's to ensure timely updates of care plans involving Foley Catheters
b. Registered Nurse Assessment Coordinators will run Order reports every business day to capture any Foley catheter insertions/exchanges and change in catheter size so care plans can be updated accurately and timely.

4. Monitoring
a. Director of Nursing/ designee shall audit residents with foley catheters for exchanges and verify balloon and foley size to care plan weekly x 4 weeks, then monthly x 3 or until compliance is achieved and maintained.
b. Audit results shall be submitted to Quality Assurance Performance Improvement for analysis and audit found to be non-compliant will be addressed as appropriate.

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

§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 clinical record reviews, observations, and staff interviews, it was determined that the facility failed to ensure that the residents' environment remained as free of accident hazards as possible by transporting a resident without leg rests for one of 32 residents reviewed (Resident 70), and failed to conduct thorough investigations for one of 32 residents reviewed (Resident 84) by using photocopied witness statements for fall investigations.

Findings include:

An annual Minimum Data Set (MDS) assessment (a federally-mandated assessment of a resident's abilities and care needs) for Resident 70, dated February 21, 2024, revealed that the resident was cognitively intact, required extensive assistance for all of her care, and used a wheelchair.

Observations on April 16, 2024, at 12:47 p.m. revealed that Licensed Practical Nurse 3 pushed Resident 70 in a wheelchair without leg rests around other residents who were waiting at the elevator, through the hallway, and into the common area while the resident elevated her feet. The leg rests were in a bag hanging off the back of the wheelchair.

An interview with Licensed Practical Nurse 3 on April 16, 2024, at 12:51 p.m. revealed that she was aware that leg rests were to be used when transporting Resident 70 in her wheelchair.

An interview with the Director of Nursing on April 16, 2024, at 1:27 p.m. confirmed that staff should be using leg/footrests on wheelchairs when residents are being transported in their wheelchairs.

An accident/incident policy, dated December 14, 2023, revealed that every witness to an incident is to complete a paper witness statement form.

A quarterly MDS assessment for Resident 84, dated February 15, 2024, revealed that the resident was cognitively impaired, required extensive assistance for daily care needs, and had a history of falls.

Nursing notes for Resident 84 revealed that the resident had unwitnessed falls on August 12, 2023; September 9, 2023; and October 11, 2023.

Witness statements for the incident with Resident 84 on August 23, 2023, all stated, "Bed alarm sounded when staff responded, resident was observed lying on right side of bottom of bed on the floor, resident continent at this time, slipper socks on, call bell within reach, not on. Resident stated she hit her head, no injury noted by registered nurse." The witness statement was photocopied and each witness signed an exact copy. There was no evidence to indicate that a thorough investigation was conducted.

Witness statements for the incident with Resident 84 on September 9, 2023, all stated, "Resident noted to be in a 'praying position' in her room. Her upper body was on the bed, and she was kneeling on the floor. Alarm did not sound due to her upper body still being on it. She stated she didn't know what happened." The witness statement was photocopied, and all witnesses signed an exact copy. There was no evidence to indicate that a thorough investigation was conducted.

Witness statements for incident with Resident 84 on October 11, 2023, all stated, "Bed alarm sounding, noted resident sitting upright on floor beside her bed. Resident denies pain and denies hitting head, she stated she was 'getting outta here.' Registered nurse in to assess, resident's roommate stated, 'She slid right onto her butt.'" The witness statement was photocopied, and all witnesses signed an exact copy. There was no evidence to indicate that a thorough investigation was conducted.

There was no documented evidence that witnesses completed individual witness statements for the above incidents with Resident 84, and no evidence to indicate that a thorough investigation was conducted for each.

Interview with the Nursing Home Administrator on April 16, 2024, at 3:14 p.m. confirmed that there was no individualized witness statements for the above incidents, and that the witnesses needed to write statements in their own words, not just sign a photocopy of someone else's statement.

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

Plan of Correction - To be completed: 06/17/2024

1. Corrective Action
- Resident #70 currently resides in the facility and did not have any adverse outcome related to being pushed in her wheelchair without leg/footrests.
- Resident #84 currently resides in the facility and did not have any adverse outcome related to photocopied witness statements from a previous event.
- Licensed Practical Nurse #3 was re-educated on using leg/footrests when transporting residents in their wheelchairs.

2. Identifying other residents
- Residents currently using wheelchairs have the potential to be affected.
- All residents have the potential to be affected by witness statements that are not individualized and do not have a thorough investigation completed.

3. Systemic Changes
- Director of Nursing (DON)/designee shall in-service staff including agency staff regarding proper transport of residents using leg/footrests on wheelchairs.
- DON/designee shall review incident report witness statements to ensure a thorough fall investigation occurred.

4. Monitoring
- DON/designee shall audit residents being pushed in wheelchair for leg/footrest use and audit all incident report witness statements daily x 1 week, then weekly x 4 weeks then monthly x 3 months or until compliance is achieved and maintained.
- Audit results shall be submitted to Quality Assurance Performance Improvement for analysis and to be addressed as appropriate.

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 review of policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that a no smoking/oxygen-in-use sign was in place for one of 32 residents reviewed (Resident 7).

Findings include:

The facility's policy regarding oxygen therapy, dated December 14, 2023, indicated that a sign would be in place indicating that oxygen was in use.

A quarterly Minimum data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 7, dated March 12, 2024, revealed that the resident was cognitively impaired, required extensive assistance from staff for daily care needs, had diagnoses that included pulmonary embolism (a blood clot that stops blood flow to the lung ) and anemia (not enough red blood cells to carry oxygen to the tissues). Physician's orders, dated September 27, 2023, included orders for the resident to receive oxygen as needed at a flow rate of 2 to 4 liters per minute by nasal cannula (tubes that deliver oxygen into the nostrils). The resident's care plan, revised March 14, 2024, revealed that she has a potential for altered respiratory status related to a pulmonary embolism.

Observations of Resident 7 on April 15, 2024, at 11:54 a.m. and April 16, 2024, at 9:07 a.m. revealed that the resident was in her room with oxygen in place via nasal cannula at 2 liters per minute. There was no signage on Resident 7's door frame indicating that oxygen was in use.

An interview with Licensed Practical Nurse 4 on April 16, 2024, at 10:28 a.m. confirmed that Resident 7 was receiving oxygen at 2 liters per minute, and there was no signage in place on her door indicating that oxygen was in use, and there should have been.

An interview with the Nursing Home Administrator on April 16, 2024, at 1:55 a.m. confirmed that Resident 7 was receiving oxygen at 2 to 4 liters per minute, and there was no signage in place on her door frame indicating that oxygen was in use, and there should have been.

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

Plan of Correction - To be completed: 06/17/2024

1. Corrective Action
- Resident #7 currently resides in the Facility. The resident did not sustain any adverse outcome due to missing signage on the door frame indicating oxygen in use.
- Oxygen signage obtained and posted on door frame to room indicating oxygen in use.
- Oxygen signage was made available on all nursing units by the Director of Nursing, the extra signage was placed in all nursing stations

2. Identifying other residents
- Residents currently receiving oxygen therapy have the potential to be affected.
- Director of Nursing/designee shall conduct an audit for residents utilizing oxygen to ensure appropriate signage is posted indicating oxygen in use.

3. Systemic Changes
- Director of Nursing/designee shall in-service nurses including agency staff to ensure residents utilizing oxygen have appropriate signage on the doorframe indicating oxygen is in use.
- Oxygen signage will be made available on all

4. Monitoring
- Director of Nursing/designee shall audit for residents utilizing oxygen to ensure appropriate signage for oxygen therapy is posted on the resident's door frame indicating oxygen in use. daily x 1 week, then weekly x 4 weeks then monthly x 3 months or until compliance is achieved and maintained.
- Audit results shall be submitted to Quality Assurance Performance Improvement for analysis and to be addressed as appropriate.

483.45(a)(b)(1)-(3) REQUIREMENT Pharmacy Srvcs/Procedures/Pharmacist/Records:

§483.45 Pharmacy Services
The facility must provide routine and emergency drugs and biologicals to its residents, or obtain them under an agreement described in §483.70(g). The facility may permit unlicensed personnel to administer drugs if State law permits, but only under the general supervision of a licensed nurse.

§483.45(a) Procedures. A facility must provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident.

§483.45(b) Service Consultation. The facility must employ or obtain the services of a licensed pharmacist who-

§483.45(b)(1) Provides consultation on all aspects of the provision of pharmacy services in the facility.

§483.45(b)(2) Establishes a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation; and

§483.45(b)(3) Determines that drug records are in order and that an account of all controlled drugs is maintained and periodically reconciled.

Observations:

Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to maintain accountability for controlled medications (drugs with the potential to be abused) for one of 33 residents reviewed (Resident 64).

Findings include:

The facility's policy regarding narcotic patches, dated December 14, 2023, indicated that all narcotic patches should be placed immediately in a sharps container when discarding and require a double signature.

An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 64, dated January 2, 2024, revealed that the resident was cognitively intact, received routine pain medication, received an opioid (a controlled pain medication), and had diagnoses that included a fracture.

Physician's orders for Resident 64, dated January 4, 2024, included an order for the resident to receive a 12 micrograms (mcg) Fentanyl (a narcotic pain patch) patch to be applied every three days for pain.

The Medication Administration Record (MAR) and a controlled drug count record (tracks each dose of a controlled medication) for Resident 64 dated January, February and March 2024 revealed that a new Fentanyl patch was applied to the resident on the following dates: January 9, 2024; January 12, 2024; January 15, 2024; January 18, 2024; January 21, 2024; January 24, 2024; February 20, 2024; February 29, 2024; March 3, 2024; March 6, 2024; March 9, 2024; March 11, 2024; March 14, 2024; March 17, 2024; and March 20, 2024. There was no documented evidence of two signatures when the old Fentanyl patch was removed and discarded on the above dates.

Interview with the Nursing Home Administrator on April 17, 2024, at 10:13 a.m. confirmed that there were not two witness signatures for the destruction of Fentanyl patches for the above dates in January 2024, February 2024, and March 2024, and there should have been.

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

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

Plan of Correction - To be completed: 06/17/2024

1. Corrective Action
- Resident #64 currently resides in the facility and did not have any adverse outcome related to missing of secondary signature on patch discard.

2. Identifying other residents
- Residents currently receiving controlled medication patches have the potential to be affected.
- Director of Nursing/designee shall conduct an audit of current controlled drug records to identify any other residents with missing secondary signatures verifying discard on narcotic patches.

3. Systemic Changes
- Director of Nursing/designee shall in-service nurses including agency staff regarding proper documentation of controlled medication patch discard.
- Nursing Home Administrator contacted Forest Hills Pharmacy and the controlled drug record was revised for narcotic patches adding a second signature line for verification of discard.

4. Monitoring
- Director of Nursing/designee shall audit controlled drug records to ensure administered controlled medication patches are properly documented with a secondary signature on discard of patch. weekly x 4 weeks then monthly x 3 months or until compliance is achieved and maintained.
- Audit results shall be submitted to Quality Assurance Performance Improvement for analysis and to be addressed as appropriate.

483.75(c)(d)(e)(g)(2)(i)(ii) REQUIREMENT QAPI/QAA Improvement Activities:

§483.75(c) Program feedback, data systems and monitoring.
A facility must establish and implement written policies and procedures for feedback, data collections systems, and monitoring, including adverse event monitoring. The policies and procedures must include, at a minimum, the following:

§483.75(c)(1) Facility maintenance of effective systems to obtain and use of feedback and input from direct care staff, other staff, residents, and resident representatives, including how such information will be used to identify problems that are high risk, high volume, or problem-prone, and opportunities for improvement.

§483.75(c)(2) Facility maintenance of effective systems to identify, collect, and use data and information from all departments, including but not limited to the facility assessment required at §483.70(e) and including how such information will be used to develop and monitor performance indicators.

§483.75(c)(3) Facility development, monitoring, and evaluation of performance indicators, including the methodology and frequency for such development, monitoring, and evaluation.

§483.75(c)(4) Facility adverse event monitoring, including the methods by which the facility will systematically identify, report, track, investigate, analyze and use data and information relating to adverse events in the facility, including how the facility will use the data to develop activities to prevent adverse events.

§483.75(d) Program systematic analysis and systemic action.

§483.75(d)(1) The facility must take actions aimed at performance improvement and, after implementing those actions, measure its success, and track performance to ensure that improvements are realized and sustained.

§483.75(d)(2) The facility will develop and implement policies addressing:
(i) How they will use a systematic approach to determine underlying causes of problems impacting larger systems;
(ii) How they will develop corrective actions that will be designed to effect change at the systems level to prevent quality of care, quality of life, or safety problems; and
(iii) How the facility will monitor the effectiveness of its performance improvement activities to ensure that improvements are sustained.

§483.75(e) Program activities.

§483.75(e)(1) The facility must set priorities for its performance improvement activities that focus on high-risk, high-volume, or problem-prone areas; consider the incidence, prevalence, and severity of problems in those areas; and affect health outcomes, resident safety, resident autonomy, resident choice, and quality of care.

§483.75(e)(2) Performance improvement activities must track medical errors and adverse resident events, analyze their causes, and implement preventive actions and mechanisms that include feedback and learning throughout the facility.

§483.75(e)(3) As part of their performance improvement activities, the facility must conduct distinct performance improvement projects. The number and frequency of improvement projects conducted by the facility must reflect the scope and complexity of the facility's services and available resources, as reflected in the facility assessment required at §483.70(e). Improvement projects must include at least annually a project that focuses on high risk or problem-prone areas identified through the data collection and analysis described in paragraphs (c) and (d) of this section.

§483.75(g) Quality assessment and assurance.

§483.75(g)(2) The quality assessment and assurance committee reports to the facility's governing body, or designated person(s) functioning as a governing body regarding its activities, including implementation of the QAPI program required under paragraphs (a) through (e) of this section. The committee must:

(ii) Develop and implement appropriate plans of action to correct identified quality deficiencies;
(iii) Regularly review and analyze data, including data collected under the QAPI program and data resulting from drug regimen reviews, and act on available data to make improvements.

Observations:

Based on review of the facility's plans of correction for previous surveys, and the results of the current survey, it was determined that the facility's Quality Assurance Performance Improvement (QAPI) committee failed to correct quality deficiencies and ensure that plans to improve the delivery of care and services effectively addressed recurring deficiencies.

Findings include:

The facility's deficiencies and plans of corrections for State Survey and Certification (Department of Health) survey ending March 16, 2023, and March 12, 2024, revealed that the facility developed plans of correction that included quality assurance systems to ensure that the facility maintained compliance with cited nursing home regulations. The results of the current survey, ending April 18, 2024, identified repeated deficiencies related to free of accident hazards/supervision/devices, respiratory care, pharmacy services/procedures/records, and food procurement storage/prepare/serve-sanitary.

The facility's plan of correction for a deficiency regarding free of accident hazards/supervision/devices, cited during the survey ending March 12, 2024, revealed that free of accident hazards/supervision/devices would be monitored by QAPI. The results of the current survey, cited under F689, revealed that the QAPI committee was ineffective in maintaining compliance with the regulation regarding free of accident hazards supervision devices.

The facility's plan of correction for a deficiency regarding respiratory care, cited during the survey ending March 16, 2023, revealed that respiratory care would be monitored by QAPI. The results of the current survey, cited under F695, revealed that the QAPI committee was ineffective in maintaining compliance with the regulation regarding respiratory care.

The facility's plan of correction for a deficiency regarding pharmacy services/procedures/records, cited during the survey ending March 16, 2023, revealed that pharmacy services/procedures/records would be monitored by QAPI. The results of the current survey, cited under F755, revealed that the QAPI committee was ineffective in maintaining compliance with regulation regarding pharmacy services/procedures/records.

The facility's plan of correction for a deficiency regarding food procurement, storage/prepare/serve-sanitary, cited during the survey ending March 16, 2023, revealed that food procurement, storage/prepare/serve-sanitary would be monitored by QAPI. The results of the current survey, cited under F812, revealed that the QAPI committee was ineffective in maintaining compliance with food procurement, storage/prepare/serve-sanitary.

Refer to F689, F695, F755, F812

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

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

Plan of Correction - To be completed: 06/17/2024

1. Corrective Action
- Quality Assurance Performance Improvement (QAPI) committee initiated for repeated deficiencies related to development/implementation of accident hazards/supervision/devices, respiratory care, pharmacy services/procedures/records, and food procurement storage/prepare/serve-sanitary.

2. Identifying other residents
- Current residents have the potential to be affected by the deficient practice.

3. Systemic Changes
- Director of Nursing(DON)/designee shall in-service all staff including agency staff regarding QAPI policy and procedures.

4. Monitoring
- DON/designee shall facilitate QAPI meetings to address repeated deficiencies related to development/implementation of accident hazards/supervision/devices, respiratory care, pharmacy services/procedures/records, and food procurement storage/prepare/serve-sanitary. weekly x 2 weeks then monthly x 3 months or until compliance is achieved and maintained.
- Audit results shall be submitted to QAPI for analysis and to be addressed as appropriate.

483.90(i)(4) REQUIREMENT Maintains Effective Pest Control Program:

§483.90(i)(4) Maintain an effective pest control program so that the facility is free of pests and rodents.

Observations:

Based on observations, a review of clinical records, as well as staff interviews, it was determined that the facility failed to maintain an effective pest control program.

Findings include:

The facility's policy on pest control, dated December 14, 2023, indicated that the facility will maintain a pest control program and that treatment will be rendered as required to control insects.

Observations of the handwashing sink in the kitchen on April 15, 2024, at 8:36 a.m. revealed a large number of ants on the sink around the faucet area, as well as on the wall directly behind the sink. There were also several gnats in the area as well as a gnat trap on the sink by the faucet.

Interview with Dietary Manager on April 15, 2024, at 8:38 a.m. revealed that he did not realize that the ants were there. However, he was aware of some gnats in the sink area, as there was a small red container on the sink to catch gnats. He stated that the ants and gnats should not be around the handwashing sink in the kitchen.

Interview with Maintenance Director on April 17, 2024, at 9:39 a.m. revealed that the pest control company was last there on February 27, 2024, and that they were due to come again on April 24, 2024. They are scheduled to come four times a year and anytime the facility calls them. He stated they have a good working relationship with them. He went on to say that because of all the recent rain that the ants and spiders are getting pushed out of their burrows and coming more to the surface. He stated it can be a constant battle, especially in the spring. He indicated that he has placed ant traps and frequently sprays the perimeter of the facility. He stated that the ants and gnats should not be around the handwashing sink in the kitchen.

Interview with the Nursing Home Administrator on April 18, 2024, at 9:26 a.m. confirmed that ants and gnats should not be in the kitchen.

28 Pa. Code 207.2(a) Administrator's Responsibility.

28 Pa. Code 201.18(e)(2)(3) Management.

Plan of Correction - To be completed: 06/17/2024

1. Corrective Action
- No residents were affected by the deficient practice.
- The causative drain in the kitchen was cleaned along with the sink and wall behind the sink. The maintenance director sprayed for pest accordingly immediately after the area was sanitized.

2. Identifying other residents
- Current residents have the potential to be affected by the deficient practice.
- Director of Maintenace, Director of Dietary/designee shall conduct an audit inspecting for pests with appropriate implementation to get rid of identified pests appropriately.

3. Systemic Changes
- Director of Maintenace, Director of Dietary/designee shall in-service all maintenance staff and dietary staff on providing a living environment free of pests with treatment rendered as required to control insects.
- Plunkett's Pest Control is scheduled to come in May 2024 since the Maintenance Director immediately sprayed the area and the issue was resolved.

23. Monitoring
- Director of Maintenace, Director of Dietary/designee shall audit for pests' weekly x 4 weeks then monthly x 3 months or until compliance is achieved and maintained.
- Audit results shall be submitted to Quality Assurance Performance Improvement committee for analysis and to be addressed as appropriate.

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