Nursing Investigation Results -

Pennsylvania Department of Health
BEACON RIDGE, A CHOICE COMMUNITY
Patient Care Inspection Results

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
BEACON RIDGE, A CHOICE COMMUNITY
Inspection Results For:

There are  50 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.
BEACON RIDGE, A CHOICE COMMUNITY - 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 October 10, 2019, it was determined that Beacon Ridge, A Choice Community 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:


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

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

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


Based on review of policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that medications were administered in a safe manner via a gastrostomy tube, and failed to ensure that daily tube site care was performed for one of 38 residents reviewed (Resident 57) who had a gastrostomy tube.

Findings include:

The facility's policy regarding administering medications through a gastrostomy tube (a tube surgically inserted through the abdomen into the stomach), dated August 1, 2019, indicated that staff were to remove the plunger from the syringe being used to administer the medications and administer medications by gravity flow (letting the medication flow into the stomach and not pushing the medication in with the plunger), and as the last of the medication began to drain from the tubing, to flush the medication by adding the prescribed amount of water.

A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 57, dated September 2, 2019, indicated that the resident was alert and oriented, was totally dependent upon staff for daily care tasks, had a history of cerebral palsy (condition of impaired muscle coordination), had limited range of motion (joint movement) in both arms and both legs, and received the majority of his nutritional needs via a gastrostomy tube.

Physician's orders for Resident 57, dated July 30, 2018, included an order for the resident to receive 500 milligrams (mg) of levetiracetam (a seizure medication) to be given four times a day via the gastrostomy tube.

Observations during medication administration on October 9, 2019, at 1:59 p.m. revealed that Licensed Practical Nurse 4 drew up 30 cubic centimeters (cc's) water into a feeding/irrigation syringe, attached the syringe to the gastrostomy tube, and instilled the water by depressing the plunger and pushing the water through the tube. She then closed the clamp on the gastrostomy tube and drew up 500 mg of levetiracetam with the syringe, attached that syringe to the resident's tube, unclamped the tube, and used the plunger to push the medication through the tube. Licensed Practical Nurse 4 then closed the clamp on the tube, removed the syringe, and drew up 60 cc's of water from a cup, reattached the syringe to the gastrostomy tube, unclamped the tube, and instilled the water by depressing the plunger and pushing the water through the tube, she repeated this with another 60 cc's, then another 30 cc's for a total of 150 cc's of water.

Interview with Licensed Practical Nurse 4 on October 9, 2019, at 2:10 p.m. confirmed that she did not let Resident 57's water and medications flow through the tube by gravity and she used the plunger of the syringe to push the water and medication through the tube. Licensed Practical Nurse 4 stated that she did this because Resident 57 would frequently cough when receiving medications and water through the tube, and if he coughed when the plunger was not in the syringe, the contents of the syringe would be expelled out of the syringe and splash all over the resident and the person administering the fluids and/or mediations. She indicated that this was very upsetting to Resident 57 when it happened, so she always used a plunger when administering meds and fluids so as not to upset the resident.

Interview with the Director of Nursing on October 9, 2019, at 4:25 p.m. confirmed that staff were to administer medications and fluids via the gastrostomy by letting them flow through the tube by gravity and not pushing them in with the plunger of the syringe.

The facility's policy regarding gastrostomy tube care, dated August 1, 2019, indicated that staff were to ensure that a physician's order for tube site care was in place, in order to promote cleanliness and protect the gastrostomy site from irritation, breakdown and infection.

Physician's orders for Resident 57, dated July 24, 2019, included orders to check the placement of the gastrostomy tube prior to administering feedings, fluids and medications every shift, and to flush the gastrostomy tube with 30 cubic centimeters (cc) of water before and after medication administration every shift. There were no physician's orders for gastrostomy tube site care.

Observations during medication administration on October 9, 2019, at 1:59 p.m. revealed that as Licensed Practical Nurse 4 removed the sheets from Resident 57's abdomen in preparation to administer medications and fluids via the gastrostomy tube, there was no dressing in place around the resident's gastrostomy tube and it was open to the air. There were three round, brown, scab-like areas on the skin near the insertion site of the tube; the largest one at approximately the ten o'clock position, then two others near the five and seven o'clock positions.

Resident 57's Medication Administration Records (MAR's) and Treatment Administration Records (TAR's) for Resident 57 revealed no documented evidence that any type of gastrostomy tube site care was performed from March 1 through October 9, 2019.

Interview with Licensed Practical Nurse 4 on October 9, 2019, at 2:14 p.m. confirmed that there were no orders for gastrostomy tube site care for Resident 57's and no documented evidence that care of the site was ever completed.

Interview with the Assistant Director of Nursing on October 10, 2019, at 4:14 p.m. confirmed that staff should have obtained physician's orders for gastrostomy tube site care but did not.

28 Pa. Code 211.12(d)(3)(5) Nursing services.
Previously cited 11/30/18.


 Plan of Correction - To be completed: 12/09/2019

The facility is unable to retroactively correct the observations for Resident 57 identified on October 9, 2019 regarding the administration of medications and fluids via the gastrostomy tube. The Licensed Practical Nurse was re educated regarding the policy for gastrostomy gravity flow procedure.

The Director of Nursing and/or designee will complete an audit of current residents with gastrostomy tubes and obtain their preference for administration of medications and fluids. The orders and plan of care will be updated with their preference.

The Director of Nursing and/or designee will educate the Licensed nursing staff on following the physician orders and resident preference per their plan of care regarding administration of medications and fluids via their gastrostomy tubes.

The Director of Nursing and/or designee will complete audits weekly for 4 weeks and monthly for 3 to assure the Licensed nursing staff is following the physician orders and resident preference per their plan of care regarding administration of medications and fluids via their gastrostomy tube. Audit results will be reported to and reviewed by the facility Quality Assurance Performance Improvement Committee for further recommendation to achieve and maintain compliance.


The facility is unable to retroactively correct the observations for Resident 57 identified on October 9, 2019 regarding the physician orders for gastrostomy tube site care. The Licensed Practical Nurse was re educated regarding the need for the order for the gastrostomy tube care.

The Director of Nursing and/or designee will complete an audit of current residents with gastrostomy tubes to assure there are orders for their gastrostomy tube care.

The Director of Nursing and/or designee will educate the Licensed nursing staff on obtaining and following the physician orders for gastrostomy tube care and notifying the Registered Nurse and/or Physician of any issues with enteral tubes becoming difficult to flush or backing up, or leaking out.
New/agency Licensed Nursing staff will received education on obtaining and following the physician orders for gastrostomy tube care and notifying the Registered Nurse and/or Physician of any issues with enteral tubes becoming difficult to flush or backing up, or leaking out.
If the residents preferences are outside of the facility Policy and Standards of Practice the physician will be updated and the resident will be educated on the consequences of such preferences and their plan of care will be updated.

The Director of Nursing and/or designee will complete audits weekly for 4 weeks and monthly for 3 to assure the Licensed nursing staff has obtained and is following the physician orders for gastrostomy tube care. Audit results will be reported to and reviewed by the facility Quality Assurance Performance Improvement Committee for further recommendation to achieve and maintain compliance.
483.75(g)(2)(ii) REQUIREMENT QAPI/QAA Improvement Activities:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
483.75(g) Quality assessment and assurance.

483.75(g)(2) The quality assessment and assurance committee must:
(ii) Develop and implement appropriate plans of action to correct identified quality deficiencies;
Observations:


Based on review of the facility's plans of correction 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 correction for State Survey and Certification (Department of Health) survey ending November 30, 2018, 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 October 10, 2019, identified repeated deficiencies related to failures to provide care according to professional standards, accident hazards, respiratory care, and storage and labeling medications.

The facility's plan of correction for a deficiency regarding failing to follow professional standards of care, cited during the survey ending November 30, 2018, revealed that audits would be completed, and the results would be reported to the QAPI committee for review. The results of the current survey, cited under F658, revealed that the QAPI committee was ineffective in maintaining compliance with the regulation regarding professional standards of care.


The facility's plan of correction for a deficiency regarding accident hazards, cited during the survey ending November 30, 2018, revealed that audits would be completed, and the results would be reported to the QAPI committee for review. The results of the current survey, cited under F689, revealed that the QAPI committee was ineffective in maintaining compliance with the regulation regarding accident hazards.

The facility's plan of correction for a deficiency regarding respiratory care, cited during the survey ending November 30, 2018, revealed that audits would be completed, and the results would be reported to the QAPI committee for review. 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 medication storage and labeling, cited during the survey ending November 30, 2018, revealed that audits would be completed, and the results would be reported to the QAPI committee for review. The results of the current survey, cited under F761, revealed that the QAPI committee was ineffective in maintaining compliance with the regulation regarding medication storage and labeling.

Refer to F658, F689, F695, F761.

42 CFR 483.75(g)(2)(ii) QAPI/QAA Improvement Activities.
Previously cited 11/30/18.

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

28 Pa. Code 201.18(e)(1) Management.
Previously cited 11/30/18.





 Plan of Correction - To be completed: 12/09/2019

The facility is unable to retroactively correct these observations related to Quality Assessment and Assurance (QA&A) programs.

The facility has developed plans of correction for the observations of this survey related to F658, F689, F695 F761, and F867.

The Quality Assurance Performance Improvement (QAPI) committee uses a root cause approach in adressing new deficiencies as well as repeat deficiencies. Plans for auditing have been established to monitor compliance for F0658, F0689, F0695, F0761 and F0867. The audit results will be reviewed by the facility's Quality Assurance Performance Improvement Committee to monitor effectiveness of the plans of correction and additional monitoring will be initiated if indicated.

The Quality Assurance Performance Improvement Committee members will complete random annual audits of all areas cited under the most recent survey to assess ongoing compliance. Facility has annual mock surveys to identify potential variances from state and federal regulations. The Quality Assurance Performance Improvement Committee members shall review these results and develops audits to monitor compliance where necessary.
483.60(i)(1)(2) REQUIREMENT Food Procurement,Store/Prepare/Serve-Sanitary:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
483.60(i) Food safety requirements.
The facility must -

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

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


Based on review of facility policies, observations and staff interviews, it was determined that the facility failed to ensure that food was served under sanitary conditions for one of 38 residents reviewed (Resident 78).

Findings include:

The facility's policies regarding food handling, dated August 1, 2019, revealed that staff were to wear gloves when handling food with their hands to ensure that bacteria were not transferred from the food handlers' hands to the food product being served.

A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 78, dated September 23, 2019, revealed that the resident was usually able to make himself understood, could usually understand others, and required assistance for eating.

Observations during the lunch meal on the Harbor unit on October 7, 2019, at 11:54 a.m. revealed that Nurse Aide 2 picked up Resident 78's roll with her bare hands and put butter on it. Interview with Nurse Aide 2 on October 7, 2019, at 12:26 p.m. confirmed that she used her bare hands to butter Resident 78's roll.

Interview with the Dietary Chef Manager on October 7, 2019, at 12:33 p.m. confirmed that the nurse aide should have worn gloves when handling Resident 78's roll.

28 Pa. Code 211.6(f) Dietary services.






 Plan of Correction - To be completed: 12/09/2019

The facility is unable to retroactively correct the observations for Residents 78 on October 7, 2019 of staff not wearing gloves when buttering the roll during tray pass. The Certified Nurses Aide was verbally re-educated regarding the need for using gloves while buttering a resident's roll.

The Infection Control Coordinator and/or designee will complete random audit's weekly for 4 weeks and monthly for 3 months monitoring the proper handling of food during tray pass.

Licensed Nursing staff and Certified Nurse Aides will receive re education regarding the proper handling of food and not touching food with hands, utilizing gloves during tray pass and the location and availability of gloves in the dining room, corridors and resident rooms.
New/agency Licensed Nursing staff and Certified Nurse Aides will receive education regarding the proper handling of food and not touching food with hands, utilizing gloves during tray pass and the location and availability of gloves in the dining room, corridors and resident rooms.

The Infection Control Coordinator and/or designee will complete random audits of proper handling of food during tray pass. Audit results will be reported to and reviewed by the facility Quality Assurance Performance Improvement Committee for review and recommendations to achieve and maintain compliance.

483.21(b)(2)(i)-(iii) REQUIREMENT Care Plan Timing and Revision:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.21(b) Comprehensive Care Plans
483.21(b)(2) A comprehensive care plan must be-
(i) Developed within 7 days after completion of the comprehensive assessment.
(ii) Prepared by an interdisciplinary team, that includes but is not limited to--
(A) The attending physician.
(B) A registered nurse with responsibility for the resident.
(C) A nurse aide with responsibility for the resident.
(D) A member of food and nutrition services staff.
(E) To the extent practicable, the participation of the resident and the resident's representative(s). An explanation must be included in a resident's medical record if the participation of the resident and their resident representative is determined not practicable for the development of the resident's care plan.
(F) Other appropriate staff or professionals in disciplines as determined by the resident's needs or as requested by the resident.
(iii)Reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments.
Observations:


Based on clinical record reviews, observations, and resident and staff interviews, it was determined that the facility failed to update residents' care plans to reflect their current and individualized care needs for one of 38 residents reviewed (Resident 73).

Findings include:

Physician's orders for Resident 73, dated May 31, 2019, included orders for the resident to receive Tylenol "as needed" for mild pain, and Ultram (a controlled pain medication) "as needed" for moderate pain. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs), dated June 7, 2019, revealed that the resident was alert and oriented, required extensive assistance with many daily care tasks, had occasional pain that she rated as a 5 (on a scale of 1 to 10 where 10 is the worst pain), and received "as needed" pain medication.

Nursing notes and skin/wound notes dated August 13 and 20, 2019, revealed that the resident developed a bruised area to her right upper leg/thigh, that became red and firm, and which caused discomfort with palpation (examine by touch). A nursing note dated August 21, 2019, revealed that the resident had three firm areas below the skin surface, two that were dark brown/black, and a new area that was red. All three areas were painful to palpation and warm to touch. A physician's progress note, dated August 22, 2019, revealed that the resident had right thigh pain, and wound consultation notes dated September 5, 12, 19 and 26, 2019, revealed that the resident exhibited increasing pain related to the right thigh wounds that the resident described as burning pain.

A quarterly MDS assessment, dated September 18, 2019, indicated that the resident now had open lesions (other than ulcers), and had frequent pain that she rated as a 5.

A skin/wound note dated September 20, 2019, revealed that the three wounds on the resident's right thigh measured a total of 5.5 x 6.0 centimeters (cm) and new treatment orders were given, including for staff to apply Lidocaine Ointment 5 percent (define) to the right thigh wounds 30 minutes prior to the dressing change.

Interviews with Resident 73 on October 8, 2019, at 2:21 p.m. and October 9, 2019, at 9:51 a.m. revealed that when the dressing to the wound on her right thing is changed, she screams in pain, and she has so much pain that she tries to pull the nurse's hands away. The dressing change has been painful for over a month, and the resident was not certain that anything was being done to prevent the pain.

On October 8, 2019, at 4:25 p.m., Licensed Practical Nurse 7 completed a dressing change to the wounds on Resident 73's right thigh. Observations of the dressing change, and interviews with Licensed Practical Nurse 7 and Resident 73 at that time revealed that the resident's wounds started as a black bruise that eventually got very lumpy, developed a thick crust over it, and recently opened. Observations revealed that the area on top was large and open with thick eschar (dead tissue, similar to a scab) and fat and muscle were exposed. The lower area was smaller and deep with fat tissue exposed and eschar present. The resident displayed severe pain with slight touch and was biting on her shirt when the nurse touched the smaller area to put a bandage on it. The resident stated that she feels pain from her hip down her leg, it hurts with all movement, and bathing is very difficult. Licensed Practical Nurse 7 indicated that the resident gets very anxious around the time of wound care.

As of October 10, 2019, Resident 73's care plan, last revised on September 6, 2019, included that the resident had pain related to arthritis and gout; however, there was no documented evidence that the care plan was revised to reflect the resident's care needs related to the pain being caused by the resident's thigh wounds and dressing changes to the wounds.

Interview with the Nursing Home Administrator on October 10, 2019, at 11:15 a.m. confirmed that Resident 73's care plan should have been updated/revised to reflect her current care needs related to the pain she experienced due to the wound on her thigh.

28 Pa. Code 211.10(d) Resident care plan.




 Plan of Correction - To be completed: 12/09/2019

Preparation and evaluations of the following plans of correction set forth in this document does not constitute admission or agreement by the provider of the truth of the facts alleged or concluded set forth in the statement of deficiencies. The plans for correction are prepared and/or executed solely because it is required by the provision of Federal and State law.

Care plan for Resident 73 was updated October 10, 2019 to include pain related to her thigh wounds and dressing changes to her thigh.

The Registered Nurse Assessment Coordinator and/or designee will complete an audit of current resident with pain related to their wound or wound care to assure that there is an updated plan of care.

The Registered Nurse Assessment Coordinator and/or designee will be re educated on the need to address all areas of pain with the discomfort or pain plan of care.
New/agency staff will receive education on the need to address all areas of pain with the discomfort or pain plan of care.
The interdisciplinary care planning team reviews care plans regularly to ensure that they are updated with all current needs and with any new orders or changes.

The Registered Nurse Assessment Coordinator and/or designee will complete audits weekly for 4 weeks and monthly for 3 months to assure that plan of care for residents with pain are accurate. Audit results will be reported to and reviewed by the facility Quality Assurance Improvement Performance Committee.

483.21(b)(3)(i) REQUIREMENT Services Provided Meet Professional Standards:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.21(b)(3) Comprehensive Care Plans
The services provided or arranged by the facility, as outlined by the comprehensive care plan, must-
(i) Meet professional standards of quality.
Observations:


Based on review of Pennsylvania's Nursing Practice Act, clinical records and incident reports, as well as staff interviews, it was determined that the facility failed to ensure that a professional (registered) nurse completed an assessment of a skin condition for one of 38 residents reviewed (Resident 57).

Findings include:

The Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, 21.11 (a)(1)(2)(4) indicated that the registered nurse was to collect complete and ongoing data to determine nursing care needs, analyze the health status of individuals and compare the data with the norm when determining nursing care needs, and carry out nursing care actions that promote, maintain and restore the well-being of individuals.

A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 57, dated September 2, 2019, revealed that the resident was alert and oriented, did not ambulate (walk), and required extensive assistance for care. Nursing progress notes dated October 1, 2019 at 7:43 and 8:11 a.m., and written by Licensed Practical Nurse 4, revealed that she was called to the resident's room by the staff performing morning care to look at a red, raised rash with fluid-filled pustules on the right buttock. The note indicated that the registered nurse was in the room and assessed the rash; however, there was no documented evidence that a registered nurse assessed the rash.

Interview with Licensed Practical Nurse 4 on October 9, 2019, at 3:39 p.m. revealed that she asked Registered Nurse 5 to look at the rash, but was not sure if he documented anything or not.

Interview with the Director of Nursing on October 9, 2019, at 4:04 p.m. confirmed that there was no documented evidence of a registered nurse assessment of the rash on Resident 57's right buttock and there should have been.

42 CFR 483.21(b)(3)(i) Services Provided Meet Professional Standards.
Previously cited 11/30/18.

28 Pa. Code 211.12(d)(1)(5) Nursing services.
Previously cited 11/30/18.




 Plan of Correction - To be completed: 12/09/2019

The facility is unable to retroactively correct the observations for Resident 57 on October 9, 2019 regarding a Registered Nurse Assessment. The Registered Nurse was re educated regarding the policy for change of condition in relation to rashes.

The Director of Nursing and/or designee will complete an audit of current residents for the past 30 days to monitor for any change of condition regarding rashes.

The Director of Nursing and/or designee will educate the Registered Nursing Staff on completing and documenting on a residents change in condition related to rashes.
New/agency Registered Nursing staff will be educated on completing and documenting on a residents change in condition related to rashes.

Nursing notes will be reviewed regularly to monitor for any changes in condition to ensure that a Registered Nurse assessment was completed.

The Director of Nursing and/or designee will complete audits weekly for 8 weeks and monthly for 4 to assure that a Registered Nurse completed and documented an assessment regarding rashes. Audit results will be reported to and reviewed by the facility Quality Assurance Performance Improvement Committee for further recommendation to achieve and maintain compliance.
483.25(a)(1)(2) REQUIREMENT Treatment/Devices to Maintain Hearing/Vision: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(a) Vision and hearing
To ensure that residents receive proper treatment and assistive devices to maintain vision and hearing abilities, the facility must, if necessary, assist the resident-

483.25(a)(1) In making appointments, and

483.25(a)(2) By arranging for transportation to and from the office of a practitioner specializing in the treatment of vision or hearing impairment or the office of a professional specializing in the provision of vision or hearing assistive devices.
Observations:


Based on clinical record reviews, and resident, family and staff interviews, it was determined that the facility failed to ensure that residents received assistance to obtain glasses for one of 38 residents reviewed (Resident 51).

Findings include:

An annual Minimum Data Set (MDS) assessment for Resident 51, dated August 26, 2019, revealed that the resident was usually understood and could usually understand, required extensive assistance with many daily care tasks, and had impaired vision with glasses in use, and had diagnoses that included diabetes (disease that interferes with blood sugar control and which can cause issues with vision). The resident's care plan, originally dated April 16, 2018, and most recently revised on September 13, 2019, revealed that the resident had impaired vision related to diabetes and staff were to arrange consultations with an eye care practitioner as required.

A note in Resident 51's clinical record, dated March 8, 2019, indicated that the resident's eye doctor and a local vision center were contacted, and neither would cover glasses for the resident. Resident Family Member 51B was notified and indicated that she would speak with Resident Family Member 51A and would get back to the writer of the note.

There was no documented evidence that the facility completed any follow-up actions related to obtaining new glasses for Resident 51.

Interviews with Resident 51 and Resident Family Member 51A on October 7, 2019, at 1:52 p.m. revealed that both the resident and her family member indicated that the resident's glasses needed to be checked because the resident has not been able to see well with them on.

Interview with the Nursing Home Administrator on October 10, 2019, at 1:434 p.m. confirmed that there was no follow-up related to obtaining new glasses for Resident 51.

28 Pa. Code 211.12(d)(3)(5) Nursing services.
Previously cited 11/30/18.


 Plan of Correction - To be completed: 12/09/2019

The facility is unable to retroactively correct the observations for Resident 51 identified October 7, 2019 regarding her glasses.

The Social Services Director and/or designee will complete an audit of current residents for the past 30 days to monitor for any follow up or request of any vision appointment or services.

The Social Services Director and/or designee will educate the Licensed Nursing Staff, Certified Nurse Aides, and the Unit Clerk on reporting any follow up or request for vision services.
New/agency staff will receive education on reporting any follow up or request for vision services.

Residents will be reviewed on admission and at least bi annually with Minimum Data Set review to assess for any vision service need.

The Social Services Director and/or designee will complete audits weekly for 4 weeks and monthly for 3 to assure that all requests for vision services or follow up were arranged. Audit results will be reported to and reviewed by the facility Quality Assurance Performance Improvement Committee for further recommendation to achieve and maintain compliance.
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 review of clinical records and incident investigation documents, as well as staff interviews, it was determined that the facility failed to ensure that care planned fall prevention interventions were followed for one of 38 residents reviewed (Resident 51).

Findings include:

An annual Minimum Data Set (MDS) assessment for Resident 51, dated January 8, 2019, revealed that the resident could usually understand and be understood and required the extensive assistance of two staff to transfer and use the toilet. The resident's care plan, originally written on April 3, 2018, revealed that the resident had a history of falls, including falls on June 22, July 25, July 27, August 26 and December 26, 2018, and January 19, 2019; was at risk for further falls; and interventions to prevent further falls included that staff were to ensure that the resident was wearing appropriate footwear.

Nursing notes and an incident report for Resident 51, dated February 6, 2019, revealed that the resident was found on her bathroom floor near the sink, lying on her right side. The resident indicated that she was trying to pull up her pants, tripped and fell. The incident report indicated that at the time of the fall the resident had "improper footwear" on and was wearing only diabetic socks.

A statement from Nurse Aide 8, dated February 6, 2019, revealed that the resident was already on the toilet (had taken herself to the bathroom) and the nurse aide provided care and put the resident's pajamas on. The resident said she needed a few minutes and the nurse aide left the room.

There was no documented evidence that while providing care to Resident 51 while she was on the toilet on February 6, 2019, that Nurse Aide 8 ensured that the resident was wearing appropriate footwear, in accordance with her care plan for fall prevention.

Interview with the Nursing Home Administrator on October 10, 2019, at 3:11 p.m. confirmed that Nurse Aide 8 did not make sure that Resident 51 had on proper footwear when she provided care to the resident while on the toilet.

42 CFR 483.25(d)(1)(2) Free of Accident Hazards/Supervision/Devices.
Previously cited 11/30/18.

28 Pa. Code 211.10(d) Resident care plan.

28 Pa. Code 211.12(d)(5) Nursing services.
Previously cited 11/30/18.


 Plan of Correction - To be completed: 12/09/2019

The facility is unable to retroactively correct the observations for Resident 51 regarding footwear in accordance to their care plan for falls.

The Director of Nursing and/or designee will complete an audit of current resident falls for the past 30 days to assure that they were wearing proper footwear in accordance with their care plan for fall prevention.

The Director of Nursing and/or designee will re educate the Licensed nursing staff and Certified Nurse Aides on providing and ensuring proper footwear is applied in accordance with the residents care plan for fall prevention,where the information on the interventions is found and the consequences of not following the residents plan of care.

New/agency Licensed nursing staff and Certified Nurse Aides will be educated on providing and ensuring proper footwear is applied in accordance with the residents care plan for fall prevention, where the information on the interventions is found and the consequences of not following the residents plan of care.

Care plan information is available for staff in Point ClickCare under the Care Plan tab and under the Task tab within the Task List and Kardex.

The Director of Nursing and/or designee will complete audits weekly for 8 weeks and monthly for 4 months to ensuring proper footwear is applied in accordance with the residents care plan for fall prevention. Audit results will be reported to and reviewed by the facility Quality Assurance Performance Improvement Committee for further recommendation to achieve and maintain compliance.
483.25(i) REQUIREMENT Respiratory/Tracheostomy Care and Suctioning:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.25(i) Respiratory care, including tracheostomy care and tracheal suctioning.
The facility must ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals and preferences, and 483.65 of this subpart.
Observations:


Based on review of manufacturer's instructions, and clinical records, as well as observations and staff interviews, it was determined that the facility failed to provide tracheostomy care in accordance with manufacturer's instructions for one of 38 residents reviewed (Resident 57).

Findings include:

Undated manufacturer's instructions, which were also printed on the storage container, for the Passy Muir/speaking valve (a one way valve attachment that allows individuals with a tracheostomy [an opening surgically created through the neck into the windpipe] to speak), indicated that the valve was to be cleaned by swishing it in warm (not hot) soapy water for about 10 seconds, then rinsing the valve thoroughly in lukewarm (not hot) running water, then allowing the valve to air dry. The instructions also indicated that the valve was not to be placed in the storage container until it was completely dry, and peroxide, bleach, vinegar, alcohol, brushes or cotton swabs were NOT to be used to clean the valve.

A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 57, dated September 2, 2019, indicated that the resident was alert and oriented, and had a tracheostomy due to respiratory failure. Physician's orders, dated September 20, 2018, included an order for tracheostomy care every shift and as needed.

Observations of tracheostomy care and suctioning for Resident 57 on October 9, 2019, at 2:40 p.m. revealed that Registered Nurse 9 removed the resident's Passy Muir speaking valve from the hub of his tracheostomy tube and handed it to Licensed Practical Nurse 4 to clean. Licensed Practical Nurse 4 placed the valve into a one-and-a-half inch round, pink storage container with a lid that was filled with a clear liquid, and that also had another clear valve soaking in the liquid. Licensed Practical Nurse 4 then used a cotton applicator to swab the inside and outside surfaces of the valve, and as she did so, a scant amount of white foam appeared on the surfaces of the valve.

Interview with Registered Nurse 9 on October 9, 2019, at 2:42 p.m. revealed that the pink storage container contained hydrogen peroxide (an antiseptic) and a second Passy Muir valve, and upon reading the directions printed on the storage container, Registered Nurse 9 confirmed that the directions indicated that hydrogen peroxide was NOT to be used to clean the Passy Muir valves.

42 CFR 483.25(i) Respiratory/Tracheostomy Care and Suctioning.
Previously cited 11/30/18.

28 Pa. Code 211.12(d)(5) Nursing services.
Previously cited 11/30/18.






 Plan of Correction - To be completed: 12/09/2019

The facility is unable to retroactively correct the observations for Residents 57 on October 9, 2019 and the cleaning of the Passy Muir valve. The Licensed Practical Nurse was verbally re-educated regarding the manufacture guidelines for cleaning of the Passy Muir.

The Infection Control Coordinator and/or designee will complete random audits of the proper cleaning of the Passy Muir valve.

Licensed nursing staff will receive re education regarding the manufactures instructions of the cleaning of the Passy Muir valve.
New/agency Licensed Nursing staff will receive education regarding the manufactures instructions of the cleaning of the Passy Muir valve.

Competencies regarding the cleaning of the Passy Muir valve per the manufacture instructions will be completed on existing Licensed Nursing staff and any new/agency Licensed Nursing staff.

The Infection Control Coordinator and/or designee will complete audits of residents requiring tracheostomy care to assure that manufactures guideline are followed for the cleaning of the Passy Muir valve weekly for 8 weeks and monthly for 4 months. Audit results will be reported to and reviewed by the facility Quality Assurance Performance Improvement committee for further recommendation and follow up to achieve and maintain compliance.
483.25(k) REQUIREMENT Pain Management: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(k) Pain Management.
The facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences.
Observations:


Based on clinical record reviews, observations, and resident and staff interviews, it was determined that the facility failed to determine if pain monitoring and management were being provided consistent with the resident's goals and preferences for one of 38 residents reviewed (Resident 73).

Findings include:

Physician's orders for Resident 73, dated May 31, 2019, included orders for the resident to receive Tylenol "as needed" for mild pain, and Ultram (a controlled pain medication) "as needed" for moderate pain. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs), dated June 7, 2019, revealed that the resident was alert and oriented, required extensive assistance with many daily care tasks, had occasional pain that she rated as a 5 (on a scale of 1 to 10 where 10 is the worst pain), and received "as needed" pain medication.

Nursing notes and skin/wound notes dated August 13 and 20, 2019, revealed that the resident developed a bruised area to her right upper leg/thigh that became red and firm, and which caused discomfort with palpation (examine by touch). A nursing note dated August 21, 2019, revealed that the resident had three firm areas below the skin surface, two that were dark brown/black, and a new area that was red. All three areas were painful to palpation and warm to touch. A physician's progress note, dated August 22, 2019, revealed that the resident had right thigh pain, and wound consultation notes dated September 5, 12, 19 and 26, 2019, revealed that the resident exhibited increasing pain related to the right thigh wounds that the resident described as burning pain.

A quarterly MDS assessment, dated September 18, 2019, indicated that the resident now had open lesions (other than ulcers), and had frequent pain that she rated as a 5.

A skin/wound note dated September 20, 2019, revealed that the three wounds on the resident's right thigh measured a total of 5.5 x 6.0 centimeters (cm) and new treatment orders were given, including for staff to apply Lidocaine Ointment 5 percent (define) to the right thigh wounds 30 minutes prior to the dressing change.

Interviews with Resident 73 on October 8, 2019, at 2:21 p.m. and October 9, 2019, at 9:51 a.m. revealed that when the dressing to the wound on her right thing is changed, she screams in pain, and she has so much pain that she tries to pull the nurse's hands away. The dressing change has been painful for over a month, and the resident was not certain that anything was being done to prevent the pain.

On October 8, 2019, at 4:25 p.m., Licensed Practical Nurse 7 completed a dressing change to the wounds on Resident 73's right thigh. Observations of the dressing change and interviews with Licensed Practical Nurse 7 and Resident 73 at that time revealed that the resident's wounds started as a black bruise that eventually got very lumpy, developed a thick crust over it, and recently opened. Observations revealed that the area on top was large and open with thick eschar (dead tissue, similar to a scab) and fat and muscle were exposed. The lower area was smaller and deep with fat tissue exposed and eschar present. The resident displayed severe pain with slight touch and was biting on her shirt when the nurse touched the smaller area to put a bandage on it. The resident stated that she feels pain from her hip down her leg, it hurts with all movement, and bathing is very difficult. The resident thought that her physician was aware of the pain she was experiencing, but had not made any changes to her care. Licensed Practical Nurse 7 indicated that the resident gets very anxious around the time of wound care.

As of October 10, 2019, Resident 73's care plan, last revised on September 6, 2019, included that the resident had pain related to arthritis and gout; however, there was no documented evidence that the care plan was revised to reflect the resident's care needs and preferences related to the pain that was being caused by the resident's thigh wounds and dressing changes to the wounds. There was also no documented evidence that evaluations of the effectiveness of the Lidocaine were completed, no documented evidence that ongoing assessments of the resident's wound pain were completed, and no documented evidence that the resident's goals and preferences for pain control were determined.

Interview with the Nursing Home Administrator on October 10, 2019, at 11:15 a.m. confirmed that Resident 73's care plan should have been updated/revised to reflect her current care needs related to the pain she experienced due to the wound on her thigh. She could provide no documented evidence that the resident's wound pain was assessed on an ongoing basis and that the resident's pain management goals and preferences were determined.

28 Pa. Code 211.12(d)(5) Nursing services.
Previously cited 11/30/18.


 Plan of Correction - To be completed: 12/09/2019

The facility is unable to retroactively correct the observations for Resident 73 identified on October 10, 2019 monitoring the effectiveness of Lidoaine medication. The Licensed Practical Nurse was re educated regarding evaluating the effectiveness of the Lidocaine medication administration.

The Director of Nursing and/or designee will complete an audit of current residents ordered Lidocaine and will add the monitoring of effectiveness of Lidoaine's pain management in regards to wound and wound dressing changes.

The Licensed Nursing staff will be re educated on the need to monitor and policy regarding the documentation of the effectiveness of Lidocaine in the Medication Administration Record in regards to wound and wound dressing changes and notifying the physician if ineffective.
New/agency Licensed Nursing staff will be educated on the need to monitor and on the need to monitor and policy regarding the documentation of the effectiveness of Lidocaine in the Medication Administration Record in regards to wound and wound dressing changes and notifying the physician if ineffective.

The Director of Nursing and/or designee will complete audits weekly for 4 weeks and monthly for 3 months to assure that the effectiveness of Lidocaine is being monitored for wound pain and wound care. Audit results will be reported to and reviewed by the facility Quality Assurance Improvement Performance Committee.
483.25(l) REQUIREMENT Dialysis: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(l) Dialysis.
The facility must ensure that residents who require dialysis receive such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences.
Observations:


Based on clinical record reviews and staff interviews, it was determined that the facility failed to complete the dialysis communication forms for one of three dialysis residents reviewed (Resident 68).

Findings include:

The facility's dialysis communication policy, dated August 1, 2019, indicated that communication with the dialysis provider would ensure the continuity of care during transfer to dialysis and subsequent return to the facility. Staff were to complete the designated areas of the "Dialysis/Observation Communication" form when sending residents to, and upon receiving residents from, dialysis.

Diagnosis information for Resident 68, dated February 12, 2019, revealed that the resident had diagnoses that included end-stage renal (kidney) disease. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 68, dated September 12, 2019, revealed that the resident was understood, could understand others, and received dialysis treatments. The resident's care plan, dated June 11, 2019, indicated that staff were to monitor the resident's dialysis access site every shift.

Review of Resident 68's dialysis communication documents revealed that "Dialysis/Observation Communication" forms were not completed by the facility's staff on August 1, 3, 6, 8, 10, 17, 22, 26, 27, 29 and 31; September 3, 5, 10, 12, 14, 17, 19, 21, 24 and 28; and October 1, 3 and 5, 2019.

Interview with the Director of Nursing on October 8, 2019, at 3:34 p.m. confirmed that dialysis communication forms should have been completed for each of Resident 68's transfers to the dialysis provider.

28 Pa. Code 211.12(d)(3)(5) Nursing services.
Previously cited 11/30/18.









 Plan of Correction - To be completed: 12/09/2019

The facility is unable to retroactively correct the dialysis communication form for Resident 68. The Licensed Practical Nurse was verbally re-educated regarding the completion of the dialysis communication form.

The Director of Nursing and/or designee will complete an audit on dialysis communication forms from the past 30 days. Nurses will receive individual verbal re-education for any communication forms that were not completed.

Licensed Nursing staff will receive re education regarding the proper completion of the dialysis communication form.
New/agency Licensed Nursing staff will receive education regarding the proper completion of the dialysis communication form.

The Licensed Nursing staff will be responsible to send the dialysis communication form on departure for dialysis and to review the communication form upon return to ensure any new issues are addressed. The dialysis communication form will be maintained as part of the clinical record.

The Director of Nursing and/or designee will complete random audits of the completion of the dialysis communication form. Audit results will be reported to and will be reviewed by the facility Quality Assurance Performance Improvement Committee.
483.45(c)(1)(2)(4)(5) REQUIREMENT Drug Regimen Review, Report Irregular, Act On:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.45(c) Drug Regimen Review.
483.45(c)(1) The drug regimen of each resident must be reviewed at least once a month by a licensed pharmacist.

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

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

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


Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that physician's orders given in response to monthly pharmacy reviews were followed for one of 38 residents reviewed (Resident 14).

Findings include:

The facility's policy regarding monthly pharmacy medication regimen reviews, dated August 1, 2019, indicated that the consultant pharmacist was to document medication regimen review findings for the prescriber and/or nursing to review, which were to be communicated in a timely fashion, and acted upon and documented by the facility staff and/or the prescriber.

A consulting pharmacy medication regimen review for Resident 14, dated August 22, 2019, indicated that the pharmacist recommended that the resident's daily 10 milligram (mg) dose of cetirizine (an allergy medication) be decreased to 5 mg daily due to declining kidney function, and the physician checked that he agreed with the recommendation and signed and dated the form on September 20, 2019. However, review of the resident's Medication Administration Records (MAR's) for September and October 2019 revealed that the resident continued to receive 10 mg of cetirizine up to and including October 8, 2019.

Interview with the Director of Nursing on October 8, 2019, at 11:42 a.m. confirmed that the dose of cetirizine should have been decreased as recommended by the pharmacist on August 22, 2019, and as directed by the physician on September 20, 2019, but it was not.

28 Pa. Code 211.12(d)(3)(5) Nursing services.
Previously cited 11/30/18.


 Plan of Correction - To be completed: 12/09/2019

The facility is unable to retroactively correct the observations for Resident 14 identified on October 8, 2019 in regards to his Cetirizine.

The Director of Nursing and/or designee will complete an audit of pharmacy recommendations in the past 30 days to assure that physician orders were followed.

The Licensed Nursing staff will be re educated on the need to implement and proceed with the physician orders in reference to the pharmacy recommendation.
New/agency Licensed Nursing staff will be educated on the need to implement and proceed with the physician orders in reference to the pharmacy recommendation.

The Director of Nursing and/or designee will review the pharmacy recommendations and ensure that the attending physician was notified and if the attending physician concurs that the recommendations were implemented.

The Director of Nursing and/or designee will complete audits monthly for 3 months to assure that the pharmacy recommendation and physician orders are followed.

Audit results will be reported to and reviewed by the facility Quality Assurance Improvement Performance Committee.
483.45(g)(h)(1)(2) REQUIREMENT Label/Store Drugs and Biologicals:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.45(g) Labeling of Drugs and Biologicals
Drugs and biologicals used in the facility must be labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable.

483.45(h) Storage of Drugs and Biologicals

483.45(h)(1) In accordance with State and Federal laws, the facility must store all drugs and biologicals in locked compartments under proper temperature controls, and permit only authorized personnel to have access to the keys.

483.45(h)(2) The facility must provide separately locked, permanently affixed compartments for storage of controlled drugs listed in Schedule II of the Comprehensive Drug Abuse Prevention and Control Act of 1976 and other drugs subject to abuse, except when the facility uses single unit package drug distribution systems in which the quantity stored is minimal and a missing dose can be readily detected.
Observations:


Based on review of policies and temperature logs, as well as observations and staff interviews, it was determined that the facility failed to ensure that medications were properly labeled and stored in two of four medication carts reviewed (Harbor Medication Carts 1 and 2), and failed to ensure that the temperature was monitored for one of two medication storage refrigerators reviewed (Bayside).

Findings include:

The facility's policies regarding medications, dated August 1, 2019, indicated that when a multi-dose vial was opened, the date was to be recorded on the vial's label or an accessory label.

Observations of Harbor Medication Cart 1 on October 8, 2019, at 3:04 p.m. revealed that an opened multi-dose vial of Lantus insulin for Resident 68 was not labeled with the date it was opened. Interview with Licensed Practical Nurse 3 at that time confirmed that the vial was opened and not dated.

Observations of Harbor Medication Cart 1 on October 8, 2019, at 3:10 p.m. revealed that there were three whole pills (yellow/oval, white/round and gray/round) and two half pills (pink/round and one white/round) that were loose in the drawers. Interview with Licensed Practical Nurse 3 at that time confirmed that the pills were loose in the cart and should not have been.

Observations of Harbor Medication Cart 2 on October 8, 2019, at 3:20 p.m. revealed that there was one loose pill (yellow/round) that was loose in the second drawer down. Interview with Licensed Practical Nurse 3 at that time confirmed that the pill was loose in the cart and should not have been

Interview with the Director of Nursing on October 8, 2019, at 3:35 p.m. confirmed that medications should not be loose in the medication carts and the vial of insulin should have been dated when it was opened.


The facility's policy regarding medication storage, dated August 1, 2019, indicated that medications and biologicals were to be stored at appropriate temperatures and humidity, and medications requiring refrigeration were to be kept at temperatures between 36 to 46 degrees Fahrenheit (F), in a refrigerator with a thermometer. The policy included that the facility was to maintain a temperature log for the medication refrigerators, and staff were to record the temperatures at least once a day.

Observations of the medication refrigerator on the Bayside nursing unit on October 10, 2019, at 10:13 a.m. revealed that the refrigerator contained vials of injectable medications, suppositories and liquid oral medications. Review of the medication refrigerator temperature log revealed that the temperature was not recorded on June 28, 29, and 30, 2019; July 2, 3 ,5,18, 23, 26, 28 and 31, 2019; August 1, 4, 10, 11, 14, 23, 24, 25 and 28, 2019; September 6, 7, 8, 12, 16, 17, 20, 21, 22 and 25, 2019; and October 4, 5 and 6, 2019.

Interview with the Director of Nursing on October 10, 2019, at 10:40 a.m. confirmed that the medication refrigerator temperatures were to be checked and recorded daily, and this was not done on the above dates for the Bayside unit and should have been.

42 CFR 483.45(g)(h)(1)(2) Label/Store Drugs and Biologicals.
Previously cited 11/30/18.

28 Pa. Code 211.9(h) Pharmacy services.
Previously cited 11/30/18.

28 Pa. Code 211.12(d)(5) Nursing services.
Previously cited 11/30/18.




 Plan of Correction - To be completed: 12/09/2019

The facility is unable to retroactively correct the observation for Residents 68. The Licensed Practical Nurse was verbally re-educated regarding the labeling of the insulin vials.

The unlabeled multi-dose vial of Lantus insulin for Residents 68 was discarded immediately following the observations on October 8, 2019 and was replaced. Upon receipt of replacement insulin vial for Residents 68, the vial was labeled with the date opened.

The Director of Nursing and/or designee will complete an audit of current residents with physician orders for insulin to assure that the insulin vials are labeled with the date opened and that the opened insulin vials are within manufacturer recommended storage dates.

Licensed nursing staff will receive re education regarding labeling insulin vials with the date opened and related timeframes for discarding opened insulin vials based on manufacturer recommended discard dates for individual insulin type.
New/agency Licensed Nursing staff will receive education regarding labeling insulin vials with the date opened and related timeframes for discarding opened insulin vials based on manufacturer recommended discard dates for individual insulin type.

The Director of Nursing and/or designee will complete random audits of current residents with physician orders for insulin weekly for 8 weeks and monthly for 4 months to assure that (1) the insulin vials are labeled with the date opened and that (2) the opened insulin vials are within manufacturer recommended storage dates. Audit results will be reported to and reviewed by the facility Quality Assurance Performance Improvement Committee for additional recommendations to achieve and maintain compliance.



The facility is unable to retroactively correct the loose medication in Harbor Medication Cart 1 and 2 on October 8, 2019. The Licensed Practical Nurse was verbally re-educated regarding monitoring and disposing of any loose medications.

The pills were discarded from Harbor Medication Cart 1 and 2.

The Director of Nursing and/or designee will complete an audit weekly for 4 weeks and monthly for 3 months of current medication carts to monitor that there is no loose medication in the carts.

Licensed nursing staff will receive education regarding monitoring for any loose medication in the medication carts and to appropriately discard.
New/agency Licensed Nursing staff will receive education regarding monitoring for any loose medication in the medication carts and to appropriately discard.

The Director of Nursing and/or designee will complete random audits of medication carts monitoring for any loose medication. Audit results will be reported to and reviewed by the facility Quality Assurance Improvement Performance Committee.



The facility is unable to retroactively correct the temperatures that were not recorded on the log for the Bayside unit. The Licensed Practical Nurse was verbally re-educated regarding the proper monitoring and completion of the temperature log.

The Director of Nursing and/or designee will complete an audit weekly for 4 weeks and monthly for 3 months of current temperature logs to monitor that there are no missing temperatures.

Licensed nursing staff will receive re education regarding the recording the proper temperature for storage and recording the temperatures on the log.
New/agency Licensed nursing staff will receive education regarding the proper temperature for storage and recording of the temperatures on the log.

The Director of Nursing and/or designee will complete random audits of the temperatures logs monitoring for recording of the temperatures. Audit results will be reported to and reviewed by the facility Quality Assurance Performance Improvement Committee for review and recommendations to achieve and maintain compliance.

A check sheet for the Licensed Practical Nurses will be devised for monitoring for undated vials of medications, loose pills in medication carts, and medication refrigerator temperatures including the proper temperatures for storage for completion at the end of each shift.

The Director of Nursing and/or designee will complete random audits of the check sheets monitoring the undated vials of medications, loose pills in the medication cart medication refrigerator temperatures. Audit results will be reported to and reviewed by the facility Quality Assurance Performance Improvement Committee for review and recommendations to achieve and maintain compliance.

483.55(b)(1)-(5) REQUIREMENT Routine/Emergency Dental Srvcs in NFs:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.55 Dental Services
The facility must assist residents in obtaining routine and 24-hour emergency dental care.

483.55(b) Nursing Facilities.
The facility-

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

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

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

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

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


Based on clinical record reviews, and resident, family and staff interviews, it was determined that the facility failed to provide routine dental services for two of 38 residents reviewed (Residents 51, 73).

Findings include:

An annual Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 51, dated August 26, 2019, indicated that the resident was admitted to the facility in April 2018, was usually understood, and could usually understand. As of October 9, 2019, the resident's clinical record revealed no documented evidence that the resident was offered or received routine dental services, including an evaluation for obtaining a bottom denture.

Interview with Resident 51 and Resident Family Member 51A on October 7, 2019, at 12:54 p.m. revealed that the resident had a top denture but did not have teeth or a denture on the bottom, and she was interested in obtaining a bottom denture but had never been offered dental services while at the facility.

Interview with the Nursing Home Administrator on October 9, 2019, at 1:28 p.m. confirmed that there was no documented evidence that the resident was offered dental services or had seen a dentist since her admission to the facility.


A quarterly MDS assessment for Resident 73, dated September 18, 2019, indicated that the resident was admitted to the facility in December 2018 and was alert and oriented. As of October 9, 2019, the resident's clinical record revealed no documented evidence that the resident was offered or received routine dental services.

Interview with Resident 73 on October 7, 2019, at 10:27 a.m. revealed that the resident had her own teeth, they were discolored, and she had not seen a dentist since her admission to the facility but would like to.

Interview with the Director of Nursing on October 9, 2019, at 10:00 a.m. revealed that the facility does not ask residents if they want dental services, they wait for residents to ask.

Interview with the Nursing Home Administrator on October 9, 2019, at 1:28 p.m. confirmed that there was no documented evidence that the resident was offered dental services or had seen a dentist since her admission to the facility.

28 Pa. Code 211.15(a) Dental services.




 Plan of Correction - To be completed: 12/09/2019

The facility is unable to retroactively correct the observations for Resident 51 identified October 7, 2019 regarding her bottom dentures and Resident 73 identified October 7, 2019 regarding her desire to see a dentist.

The Social Services Director and/or designee will complete an audit of current residents for the past 30 days to monitor for any request or desire regarding a dental appointment or services.

The Social Services Director and/or designee will educate the Licensed Nursing Staff, Certified Nurse Aides, and the Unit Clerk on reporting any follow up or request for dental services.
New/agency Licensed Nursing staff, Certified Nurse Aides, and any new Unit Clerk will be educated on reporting any follow up or request for dental services.

Licensed Nursing staff and/or designee will assess the resident on admission and at least bi annually with Minimum Data Set review to assess for any dental service needs and reporting any follow up or request for dental services.

The Social Services Director and/or designee will complete audits weekly for 4 weeks and monthly for 3 months to assure that all requests for dental services are arranged and received. Audit results will be reported to and reviewed by the facility Quality Assurance Performance Improvement Committee for further recommendation to achieve and maintain compliance.
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 policies and clinical records, as well as staff interviews, it was determined that the facility failed to maintain clinical records that were complete and accurately documented for one of 38 residents reviewed (Resident 57).

Findings include,

The facility's policy regarding documentation of medication administration, dated August 1, 2019, indicated that a nurse was to document all medications administered to each resident on the resident's Medication Administration Record (MAR).

Physician's orders for Resident 57, dated July 30, 2018, included an order for the resident to receive 500 milligrams (mg) of levetiracetam (seizure medication) to be administered four times a day. There was no documented evidence in the resident's clinical record, including on the MAR, that staff administered levetiracetam to the resident at 6:30 p.m. on September 8, 9 and 28, 2019, and at 1:00 p.m. on September 28, 2019.

Physician's orders for Resident 57, dated July 31, 2018, included an order for the resident to receive 150 mg of ranitidine HCL (a medication to prevent excess stomach acid) to be administered twice a day. There was no documented evidence in the resident's clinical record, including on the MAR, the ranitidine was administered as ordered at 5:00 pm. on September 8, and 28, 2019.

Physician's orders for Resident 57, dated March 14, 2019, included an order for the resident to receive 0.125 mg of hyoscyamine sulfate (medication to reduce oral secretions) to be administered every eight hours. There was no documented evidence in the resident's clinical record, including on the MAR, that hyoscyamine sulfate was administered as ordered at 6:00 a.m. on September 21 and 26, 2019, and at 2:00 p.m. on September 28, 2019.

Physician's orders for Resident 57, dated June 6, 2019, included an order for the resident to receive 150 milliliters (ml) of water to be instilled via the resident's gastrostomy tube (a tube surgically inserted through the abdomen into the stomach) every four hours at 1:00 a.m., 5:00 a.m., 9:00 a.m, 1:00 p.m., 5:00 p.m., and 9:00 p.m. daily. There was no documented evidence that 150 ml of water was administered as ordered at 5:00 p.m. on September 8, 2019; at 1:00 a.m. and 5:00 a.m. on September 21, 2019; at 5:00 a.m. on September 26, 2019; and at 1:00 p.m. and 5:00 p.m. on September 28, 2019.

Interview with the Director of Nursing on October 9, 2019, at 4:15 p.m. confirmed that there was no documented evidence that the above medications and fluids were administered, which should have been documented on the resident's MAR.

28 Pa. Code 211.5(f) Clinical records.
Previously cited 11/30/18.



 Plan of Correction - To be completed: 12/09/2019

The facility is unable to retroactively correct the observations for Resident 57 identified on October 9, 2019 in regards to no documented evidence on the Medication Administration Record that the medication was administered.

The Director of Nursing and/or designee will complete an audit of Medication Administration Records in the past 30 days to identify any missing documentation.

The Licensed Nursing staff will be re educated on the need to accurately document that the medication was administered on the Medication Administration Record, to monitor compliance thru Point Click Care Clinical Dashboard and consequences for failure to document.
New/agency Licensed Nursing staff will be re educated on the need to accurately document that the medication was administered on the Medication Administration Record, to monitor compliance thru Point Click Care Clinical Dashboard and consequences for failure to document.

The Director of Nursing and/or designee will complete audits weekly for 4 weeks and monthly for 3 months to assure that the Licensed nursing staff accurately documented that the medication was administered on the Medication Administration Record. Audit results will be reported to and reviewed by the facility Quality Assurance Improvement Performance Committee.
483.90(g)(2) REQUIREMENT Resident Call System: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.
483.90(g) Resident Call System
The facility must be adequately equipped to allow residents to call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area.

483.90(g)(2) Toilet and bathing facilities.
Observations:


Based on review of policies and manufacturer's instructions, as well as observations and staff interviews, it was determined that the facility failed to ensure that residents' call lights were functional and allowed the resident to call for assistance from staff for one of 38 residents reviewed (Resident 41).

Findings include:

The facility's policy regarding the nurse call system, the Ciscor-Devi 9000, dated August 1, 2019, revealed that the system's computer was to automatically identify and notify the facility if a call pendant was not functioning or if it had a low battery that would be exhausted within two weeks. The residents could wear call pendants so they could access the system for assistance from any location inside or outside the facility.

The manufacturer's manual for the Ciscor-Devi 9000 call bell system indicated that the supervisory failure alarm was generated when the wireless device failed to transmit a check-in signal.

Interview with Resident 41 on October 8, 2019, at 10:00 a.m. revealed that her call bell pendant did not work when she pressed the button. Observations on October 8, 2019, at 1:06 p.m. revealed that Resident 41 was in her room and pushed her call pendant. Interview with Nurse Aide 1 at 1:12 p.m. confirmed that the resident's call pendant did not work, as it did not ring into her pager device.

Interview on October 8, 2019, at 1:50 p.m. with the Staffing Coordinator, who was the responsible party for the facility's call bell system, confirmed that Resident 41's call pendant was not working, even after replacing the battery.

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




 Plan of Correction - To be completed: 12/09/2019

The facility is unable to retroactively correct the observation related to Resident 41 call pendent on October 8, 2019. Resident 41 was given a new functioning pendent when concern was reported on October 8, 2019.

Licensed nursing staff and Certified Nurse Aides will receive education regarding the automatic identification and report of a non functioning pendent and the procedure to follow.
New/agency Licensed nursing staff and Certified Nurse Aides will receive education regarding the automatic identification and report of a non functioning pendent and the procedure to follow.

A check sheet for the Licensed Practical Nurses will be devised for monitoring event history for an unrestored alarm, a pendent that fails to transmit a check in signal and work properly. The Licensed Practical Nurses will identify the location and description at the end of each shift with notation of how the concern was addressed and/or resolved.

The Administrator and/or designee will complete a random audit weekly for 4 weeks and monthly for 3 months to monitor the transmit of the pager device.

The Administrator and/or designee will complete random audits of monitoring functioning of the pendent's and replacing them. Audit results will be reported to and reviewed by the facility Quality Assurance Performance Improvement Committee for review and recommendations to achieve and maintain compliance.

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