Pennsylvania Department of Health
 YORKVIEW NURSING AND REHABILITATION
Patient Care Inspection Results

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YORKVIEW NURSING AND REHABILITATION
Inspection Results For:

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YORKVIEW NURSING AND REHABILITATION - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:
Based on a Medicare/Medicaid Recertification, State Licensure, Civil Rights, and an Abbreviated Complaint survey completed on June 6, 2024, it was determined that Yorkview Nursing and Rehabilitation 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:


483.21(b)(1)(3) REQUIREMENT Develop/Implement Comprehensive Care Plan:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
§483.21(b) Comprehensive Care Plans
§483.21(b)(1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at §483.10(c)(2) and §483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following -
(i) The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under §483.24, §483.25 or §483.40; and
(ii) Any services that would otherwise be required under §483.24, §483.25 or §483.40 but are not provided due to the resident's exercise of rights under §483.10, including the right to refuse treatment under §483.10(c)(6).
(iii) Any specialized services or specialized rehabilitative services the nursing facility will provide as a result of PASARR recommendations. If a facility disagrees with the findings of the PASARR, it must indicate its rationale in the resident's medical record.
(iv)In consultation with the resident and the resident's representative(s)-
(A) The resident's goals for admission and desired outcomes.
(B) The resident's preference and potential for future discharge. Facilities must document whether the resident's desire to return to the community was assessed and any referrals to local contact agencies and/or other appropriate entities, for this purpose.
(C) Discharge plans in the comprehensive care plan, as appropriate, in accordance with the requirements set forth in paragraph (c) of this section.
§483.21(b)(3) The services provided or arranged by the facility, as outlined by the comprehensive care plan, must-
(iii) Be culturally-competent and trauma-informed.
Observations:

Based on staff interviews, facility policy review, and clinical record review, it was determined that the facility failed to ensure that a comprehensive, person-centered care plan was developed for three of 34 residents reviewed (Residents 12, 142, and 163) .

Findings include:

Review of facility policy, titled "Care Plans, Comprehensive Person-Centered", with a last revised date of September 2022, revealed the following: "1) The interdisciplinary team, in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person centered care plan for each resident; 8) h. incorporate identified problem areas; and 10) identifying problem areas and their causes, and developing interventions that are targeted and meaningful to the resident, are the endpoint of an interdisciplinary process."

Review of Resident 12's clinical record revealed diagnoses that included vascular dementia (a decline in thinking skills caused by conditions that block or reduce blood flow to various regions of the brain) and paroxysmal atrial fibrillation (a fast irregular heartbeat that last a few hours or days).

Review of Resident 12's physician orders revealed an order for apixaban (an anticoagulant [blood thinning] medication) oral tablet five milligrams by mouth two time a day.

Review of Resident 12's comprehensive plan of care failed to reveal focus areas for Resident 12's diagnosis of dementia and use of anticoagulant medication.

During an interview on June 6, 2024 at 9:49 AM, with the Nursing Home Administrator (NHA) and Director of nursing (DON), the DON revealed Resident 12's comprehensive plan of care had been updated to include focus areas for dementia and use of anticoagulant medication. The DON stated that it was the facility's expectation that comprehensive care plans be developed accurately and timely.

A review of the clinical record for Resident 142 on June 4, 2024, at 9:00 AM, revealed diagnoses that included
type 2 diabetes mellitus (a form of diabetes that is characterized by high blood sugar, insulin resistance, and relative lack of insulin) and hypertension (elevated blood pressure).

Review of Resident 142's current physician orders revealed that the Resident was receiving two types of insulin (Novolog and Insulin glargine) since April 2024.

A review of Resident 142's current care plan failed to reveal a care plan for type 2 diabetes mellitus.

During an interview with the DON on June 6, 2024, at 1:00 PM, the DON agreed that Resident 142 should be care planned for type 2 diabetes mellitus.

A review of the clinical record for Resident 163 on June 4, 2024, at 9:00 AM, revealed diagnoses that included atrial fibrillation (irregular and rapid heartbeat) and and type 2 diabetes mellitus.

Review of Resident 163's current physician orders revealed that the Resident was receiving coumadin (a blood thinner to treat and prevent clots).

During an interview with the DON on June 6, 2024, at 1:00 PM, the DON agreed that Resident 163 should be care planned for atrial fibrillation and receiving a blood thinner.

Further review of Resident 163's record revealed the Resident had a fall on May 21, 2024, and sustained a large hematoma to her right forehead and scalp area. The Resident was transferred to the hospital where a wound bandage was applied to the open area of the hematoma (a collection of blood outside of a blood vessel that can occur due to trauma or injury). On May 23, 2024, the physician documented to continue to monitor the hematoma.

A review of Resident 163's care plan on June 4, 2024, failed to include the fall, monitoring of the hematoma, or any wound care.

During an interview with the DON on June 6, 2024, at 1:00 PM, the DON agreed that Resident 163 should be care planned for monitoring and care of the hematoma.

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



 Plan of Correction - To be completed: 07/01/2024

Development and/or execution of this plan of correction does not constitute admission or agreement by this provider of the truth in the statement of deficiency. This plan of correction is prepared and/or executed by provision of Federal or State Law.

1. R12's care plan was updated to reflect the diagnosis of Dementia and the use of anticoagulant medication. R142's care plan was updated to reflect type 2 Diabetes Mellitus. R163's care plan was updated to reflect Atrial Fibrillation, receiving a blood thinner, and monitoring of the hematoma with any wound care.
2. ADON/Designee will audit all residents for appropriate care plans for Dementia, Type 2 Diabetes Mellitus, Atrial Fibrillation, Coumadin, Apixaban, Hematomas, and Hematoma wound care. Any identified inaccuracies will be corrected by ADONS/Designee.
3. ADON/Designee will educate licensed staff that a comprehensive, person-centered care plan is developed for all residents.
4. ADON/Designee will conduct 3 random resident care plan audits x2 weekly for 1 month, and then 4 random resident care plan audits monthly x2, to ensure that residents have a comprehensive, person-centered developed care plan. ADONS/Designee will report audit results monthly x3 at the QAPI Committee meeting for further recommendations.
5. Date of compliance July 1, 2024.



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 policy, observations, and interviews, it was determined that the facility failed to store and serve food/beverages in accordance with professional standards for food safety in the kitchen and two of two nourishment pantries observed (B/C unit and Wedge Wood 1).

Findings include:

Review of facility policy Food Storage Areas, revised July 2023, read, in part, storage of dry items must be accurately labeled and dated. Leftover food is clearly labeled, dated, a used within three days or discarded. All refrigerators are kept clean. All food should be covered labeled and date. Frozen food should be defrosted in a refrigerator and date marked with a pull and use by date.

Review of facility policy Food from Outside Sources, revised July 2023, read, in part, perishable foods will be marked with a "use by" date which is three days from the date that it was brought into the facility. Visitors/family members will label food and beverages with the resident's name, room number, and date.

Observation in the walk-in refrigerator on June 3, 2024, at 9:42 AM, revealed one pound American cheese wrapped in plastic wrap, not date marked, and five 1-pound packages of thawed sliced turkey, not date marked with a pull date.

During an interview with Employee 5 (Food Service Director) on June 3, 2024, at 9:44 AM, it was revealed that the American Cheese should be date marked once opened, and the sliced turkey should be date marked when pulled from the freezer.

Observation in the reach in refrigerator on June 3, 2024, at 9:50 AM, revealed one tray with 16 dished servings of fruit that were not date marked.

During an interview with Employee 5 on June 3, 2024, at 9:51 AM, it was revealed that the fruit or the tray should've been date marked.

Observation in the chemical room near the dry storeroom on June 3, 2024, at 9:47 AM, revealed inside of the dustpan contained food particles.

During an interview with Employee 5 on June 3, 2024, at 9:48 AM, it was revealed that the dustpan needed to be cleaned.

Observation in the dry storeroom on June 3, 2024, at 9:48 AM, revealed 12 Styrofoam bowls of dry oat cereal weren't date marked.

During an interview with Employee 5 on June 3, 2024, at 9:48 AM, it was revealed that the staff was still cleaning up from breakfast, and that the cereal would be date marked.

Additional observation on June 3, 2024, at 2:19 PM, revealed the cart with the bowls of cereal contained crumbs of raisin bran cereal and the bowls of oat cereal weren't date marked.

Observation in the B/C- unit nourishment pantry on June 3, 2024, at 9:53 AM, in the freezer revealed: one open plastic cup with freezer burned orange slices; one Styrofoam cup with freezer burned orange slices; and one ham and egg croissant sandwich, not marked with a resident identifier or date. On the table next to the refrigerator, there was one 32-ounce container of butter pecan nutritional supplement that was open with contents partially removed, noted to be at room temperature to the touch, and was not date marked with an open or use by date. In the refrigerator: one plastic bag with foil wrapped chicken and corn without a resident identifier or date; one plastic container of sweet tea opened with a use by date of January 29, 2024; one plastic container of cooked broccoli not marked with a resident identifier or date; one 32-ounce container of butter pecan nutritional supplement, open with contents partially removed, and not marked with an open or use by date; one 8-ounce plastic cup of orange juice not marked with resident identifier or date; and the bottom shelf contained dried brown and red liquid.

During an interview with Employee 5 on June 3, 2024, at 9:59 AM, it was revealed that resident items should be marked with a resident identifier and date, items should be date marked when opened, open nutritional supplements should be stored in the refrigerator, and the refrigerator should be cleaned.

Observation in the Wedge Wood 1 nourishment pantry on June 3, 2024, a 10:05 AM, revealed one plastic container of Chinese takeout chicken/rice didn't contain a resident identifier or date, and one plastic container beef tacos dated June 3rd and didn't contain a resident identifier. In the freezer there was one plastic cup with a frozen milk shake that was not covered and didn't contain a resident identifier or date.

During an interview with Employee 5 on June 3, 2024, it was revealed items should be securely covered and contain a resident identifier and date.

During an interview with the Nursing Home administrator on June 5, 2024, at 12:17 PM, it was revealed that the items in the kitchen should be marked with a date, and the resident items should be marked with a resident identifier and date.

28 Pa. Code 211.6 Dietary Services



 Plan of Correction - To be completed: 07/01/2024

Development and/or execution of this plan of correction does not constitute admission or agreement by this provider of the truth in the statement of deficiency. This plan of correction is prepared and/or executed by provision of Federal or State Law.

1. Food items noted with no date marked on June 3, 2024, in the walk-in refrigerator, reach-in refrigerator, and dry storage area in the kitchen were discarded. Dust pans in the chemical storage area were cleaned. Resident food items noted with no resident identifier or date in the B/C and Wedge Wood 1 nourishment refrigerators were discarded. The refrigerator in the B/C nourishment room was cleaned by housekeeping.
2. FSD/Designee will conduct a sweep of the walk-in refrigerator, reach-in refrigerator, dry storage area, chemical storage area, and nourishment pantry refrigerators for proper storage, labeling, and sanitation is in place.
3. Current Dietary, Housekeeping, and Nursing staff were re-educated on the proper storage, labeling, and sanitation of food for their respective areas by ADON/Designee.
4. An audit of the walk-in refrigerator, reach-in refrigerator, dry storage area, chemical storage area, and nourishment pantry refrigerators will be completed 2x weekly, then 2x monthly x1, by the NHA/Designee to ensure proper storage, labeling and sanitation. Results of the audits will be reviewed at the QAPI committee meeting monthly x2 by the NHA/Designee to identify any patterns, trends, or necessary changes.
5. Date of compliance July 1, 2024.


483.60(c)(1)-(7) REQUIREMENT Menus Meet Resident Nds/Prep in Adv/Followed: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(c) Menus and nutritional adequacy.
Menus must-

§483.60(c)(1) Meet the nutritional needs of residents in accordance with established national guidelines.;

§483.60(c)(2) Be prepared in advance;

§483.60(c)(3) Be followed;

§483.60(c)(4) Reflect, based on a facility's reasonable efforts, the religious, cultural and ethnic needs of the resident population, as well as input received from residents and resident groups;

§483.60(c)(5) Be updated periodically;

§483.60(c)(6) Be reviewed by the facility's dietitian or other clinically qualified nutrition professional for nutritional adequacy; and

§483.60(c)(7) Nothing in this paragraph should be construed to limit the resident's right to make personal dietary choices.
Observations:

Based on clinical record review, document review, observations, and resident and staff interviews, it was determined that the facility failed to provide a nutritionally adequate menu substitution for one of two meals observed (June 3rd and 4th, 2024, lunch meal) and failed to follow the menu for lunch meals observed on June 3, 2024, for one of seven resident areas observed (Rosemont Hall).

Findings include:

A review of the facility's planned lunch menu for June 3, 2024, included chicken tenders, dipping sauce, French fries, coleslaw, cinnamon applesauce, and assorted beverages.

A review of the menu extension sheet (documentation of menu substitutions for therapeutic and altered textured diets) documented that all diets except for the finger food diet were to receive applesauce.

During an interview with Employee 9 (Dietary Aide) June 3, 2024, at 2:22 PM, it was revealed that they ran out of applesauce during the F- west unit food cart and that the remaining residents were served ice cream.

A review of the tray delivery schedule documented that there were two food carts delivered to A unit following the F-west food cart.

During an interview with Employee 5 (Food Service Director) on June 3, 2024, at 2:23 PM, it was revealed that he wasn't told that they ran out of applesauce and that he would expect there would be a substitution provided to the residents.

A review of the menu substitution log on June 3, 2024, at 2:20 PM, failed to document a substitution for applesauce.

A review of the facility's planned lunch menu for June 4, 2024, included kielbasa, buttered noodles, sauteed cabbage, dinner roll, watermelon, and assorted beverages.

A review of the menu extension sheet documented that puree diets (food blended to a smooth consistency) should've been served applesauce in place of the watermelon.

A review of Resident 24's clinical record revealed diagnoses that included hypertension (elevated blood pressure) and dementia (a group of conditions characterized by impairment of at least two brain functions, such as memory loss and judgment).

An observation of Resident 24's lunch tray on June 3, 2024, at 12:05 PM, revealed no cinnamon applesauce, 2% milk, coffee, or hot tea, as documented to be served according to the meal ticket.

A review of Resident 115's clinical record revealed diagnoses that included dementia and vitamin D deficiency (a condition where there is not enough of this vitamin in your body. You need vitamin D to grow and maintain your bones).

An observation of Resident 115's lunch tray on June 3, 2024, at 12:10 PM, revealed no cinnamon applesauce, 2% milk, coffee, or hot tea, as documented to be served according to the meal ticket.

An immediate interview with Resident 115 revealed he was not offered any drinks and would prefer to have milk to drink with his meals.

A review of Resident 58's clinical record documented diagnoses that included high blood pressure.

A review of Resident 58's physician orders included a fortified foods diet, puree texture, thin consistency, with a start date of April 16, 2024, House Supplement two times a day 4 oz @ 1000, 2000 9/14/23.

A review of Resident 58's tray ticket for the lunch meal on June 4, 2024, documented the Resident was to receive puree kielbasa, pureed noodles, pureed cabbage, fortified food (which was mashed potato), puree dinner roll, applesauce, milk, and coffee.

Meal observation on June 4, 2024, at 1:00 PM, of Resident 58's meal tray, and confirmed by Employee 8 (Nursing Assistant) who assisted the Resident with his meal, revealed the Resident was served puree kielbasa, puree noodles, mashed potato, pureed cabbage, diced peaches, milk, and coffee; he didn't receive a puree dinner roll or applesauce. Employee 8 confirmed that she didn't serve the diced peaches to the Resident.

During an interview with the Nursing Home Administrator on June 4, 2024, at 2:11 PM, it was revealed that the residents should've received food items per the extension sheet or provided an applicable substitution, as well as items that are to be served per the resident's meal tickets.

28 Pa. Code 211.6 Dietary Services


 Plan of Correction - To be completed: 07/01/2024

Development and/or execution of this plan of correction does not constitute admission or agreement by this provider of the truth in the statement of deficiency. This plan of correction is prepared and/or executed by provision of Federal or State Law.

1. Facility is unable to correct lunch meals served on June 3 and June 4, 2024.
2. FSD/Designee will observe a lunch meal for nutritionally adequate menu substitutions and following the menu for the lunch meal.
3. FSD/Designee will educate the dietary staff on following the menu extension sheets for menu substitutions, completing the menu substitution log, and following the planned lunch menu.
4. FSD/Designee will audit 2 lunch meals 2x weekly, then 2x monthly x1, for following the menu extension sheets for menu substitutions, completing the menu substitution log, and following the planned lunch menu. FSD/Designee will report findings at the QAPI Committee meeting x2 months for further review and recommendations.
5. Date of compliance July 1, 2024.


483.45(g)(h)(1)(2) REQUIREMENT Label/Store Drugs and Biologicals:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
§483.45(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 observations, facility policy review, manufacturer label review, and staff interviews, it was determined that the facility failed to store medications in a manner consistent with professional standards for two of five medication carts observed (300 medication cart and F Wing 2 medication cart).

Findings include:

Review of facility policy, titled "Storage of Medications", last revised April 2007, revealed the policy statement read, "The facility shall store all drugs and biologicals in a safe, secure, and orderly manner." Subsection 1 stated, "Drugs and biologicals shall be stored in the packaging, containers or other dispensing systems in which they are received. Only the issuing pharmacy is authorized to transfer medication between containers." Further, subsection 2 stated, "The nursing staff shall be responsible for maintaining medication storage AND preparation areas in a clean, safe, and sanitary manner."

Observation of the 300 medication cart on June 6, 2024, at approximately 11:15 AM, revealed two Lantus insulin pen (insulin delivery system), that were partially used, with no opened date.

Review of the manufacturer's storage requirements revealed that Lantus insulin pens should be discarded after 28 days when in-use and non-refrigerated.

Observation of the F Wing 2 medication cart on June 6, 2024, at approximately 11:40 AM, revealed a medicine cup filled approximately half-way with small, round, green tablets. During a staff interview at the time of the observation, Employee 18 (Licensed Practical Nurse) stated the pills appeared to be iron supplements, but was unsure as Employee 18 was not the one that placed them in the medicine cart. F Wing 2 cart was also found to have multiple loose pills contained in two drawers.

During a staff interview on June 6, 2024, at approximately 12:00 PM, Director of Nursing (DON) revealed it was the facility's expectation that insulin pens are dated by staff when opened. Further, the DON revealed that medication carts are expected to be cleaned frequently, at least once-a-month by the nightshift nursing staff. Finally, DON revealed it was the facility's expectation that medications are contained in the manufacturer's supplied container.

28 Pa code 211.9(j.1)(5) Pharmacy services
28 Pa code 211.12(d)(1)(5) Nursing services


 Plan of Correction - To be completed: 07/01/2024

Development and/or execution of this plan of correction does not constitute admission or agreement by this provider of the truth in the statement of deficiency. This plan of correction is prepared and/or executed by provision of Federal or State Law.

1. The two Lantus insulin pens found partially used with no open date in the 300 medication cart was discarded. The medicine cup found filled halfway with small green tablets in the F Wing 2 medication cart were discarded. The multiple loose pills found in 2 drawers in the F Wing 2 medication cart were discarded.
2. RN Supervisor/Designee will conduct a sweep of the facility medication carts for any Lantus insulin pens opened with no open date and any loose pills or tablets; any found items will be discarded.
3. ADON/Designee will re-educate licensed staff on dating insulin pens when opened, that medications are to be contained in the manufacturer's supplied container, and medication carts are to be cleaned monthly by night shift nursing staff.
4. DON/Designee will audit 2 medication carts 2x weekly, then 2x monthly x1, for open insulin pens not dated and medications not contained in the manufacturer's supplied container. DON/Designee will report findings at the QAPI Committee meeting x2 months for further review and recommendations.
5. Date of compliance July 1, 2024.

483.25(l) REQUIREMENT Dialysis: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(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 document review, clinical record review, and staff interviews, it was determined that the facility failed to ensure that residents who require dialysis receive such services consistent with professional standards of practice for one of one resident reviewed for dialysis (Resident 46).

Findings include:

Review of the facility's "Nursing Home Dialysis Transfer Agreement", read, in part, "#3. Designated resident information. Facility shall ensure that all appropriate medical, social, administrative, and other information accompany all Designated Residents at the time of transfer to Center. This information shall include but is not limited to where appropriate the following: (d) Appropriate medical records, including history of the Designated Resident's illness, including laboratory and x-ray findings. (e) Treatment presently being provided to the Designated Resident, including medications and any changes in a patient's condition (physical or mental), change of medication, diet, or fluid intake. (h) Any other information that will facilitate the adequate coordination of care, as reasonably determined by Center."

Review of Resident 46's clinical record revealed diagnoses that included chronic kidney disease (CKD) stage five (when the kidneys are severely damaged and can no longer filter waste from the blood) and dependence on renal dialysis (need for treatment that removes extra fluid and waste products from the blood when the kidneys are not able to).

Review of Resident 46's physician orders revealed that Resident 46 was ordered to receive dialysis every Monday, Wednesday, and Friday.

Review of Resident 46's dialysis communication forms reveled there were no forms for the following dates: April 1, 3, 5, 8, 10, 12, 15, 17, 19, 22, 24, 26, and 29, 2024; May 1, 3, 6, 8, 10, 13, 15, 17, 20, 22, 24, 27, 29, and 31, 2024; and June 3, 2024.

During a staff interview with Employee 23 on June 5, 2024 at 11:15 AM, it was revealed that, when Resident 46 returns from dialysis, the communication form is placed in the physician's communication folder to be reviewed and signed.

Review of the physician's communication folder revealed no communication forms for Resident 46.

Review of documentation provided by the facility revealed that Resident 46 had received dialysis on the aforementioned dates.

During an interview on June 5, 2024 at 11:34 AM, with the Nursing Home Administrator (NHA), it was revealed the facility does not have a policy for dialysis care.

During an interview on June 6, 2024 at 12:13 PM, with the Director of Nursing (DON), in the presence of the NHA, revealed the facility had called the dialysis center and obtained the missing dialysis communication forms for Resident 46 from the aforementioned dates. The DON stated that it was the facility's expectation that dialysis communication forms be obtained immediately upon the residents return to the facility.

28 Pa Code 201.18 (d) Management
28 Pa Code 211.5 (f) Clinical records
28 Pa Code 211.12 (d)(1)(3)(5) Nursing services


 Plan of Correction - To be completed: 07/01/2024

Development and/or execution of this plan of correction does not constitute admission or agreement by this provider of the truth in the statement of deficiency. This plan of correction is prepared and/or executed by provision of Federal or State Law.

1. Facility obtained the noted missing dialysis communication forms for R46 for the MD to review and sign.
2. Current residents receiving dialysis will be reviewed for dialysis communication forms and physician signatures by DON/Designee.
3. Licensed nursing staff will be re-educated on obtaining dialysis communication forms upon resident return to the facility for physician review and signatures by ADON/Designee.
4. DON/Designee will review resident dialysis communication forms 2x weekly x1 month, then 2x monthly x1, for physician review and signatures. DON/Designee will report findings monthly x2 to be reviewed at the QAPI Committee meeting for further review or recommendations.
5. Date of compliance July 1, 2024.

483.25(g)(1)-(3) REQUIREMENT Nutrition/Hydration Status Maintenance: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) Assisted nutrition and hydration.
(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)(1) Maintains acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that this is not possible or resident preferences indicate otherwise;

§483.25(g)(2) Is offered sufficient fluid intake to maintain proper hydration and health;

§483.25(g)(3) Is offered a therapeutic diet when there is a nutritional problem and the health care provider orders a therapeutic diet.
Observations:

Based on facility policy, clinical record review, observations, and resident and staff interviews, it was determined that the facility failed to provide a therapeutic diet, per physician's order, for two of 34 residents reviewed (Resident 74 and 137).

Findings include:

Review of facility Snack policy, revised July 2023, read, in part, afternoon snacks will be provided to those residents as "labelled" snacks per Registered Dietitian or resident request. Nourishing snack is defined as an offering of items, single or in combination, from the basic food groups.

Review of facility policy Encouraging and Restricting Fluids, revised October 2010, read, in part, when a resident had been placed on restricted fluids, remove the water pitcher and cup from residents' room.

Clinical record review for Resident 74 revealed diagnosis that included diabetes mellitus (the body's ability to produce or respond to the hormone insulin is impaired, resulting in abnormal metabolism of carbohydrates and elevated levels of glucose in the blood and urine).

During an interview with Resident 74 on June 3, 2024, at 10:58 AM, it was revealed that she had experienced a weight loss.

Review of Resident 74's weigh history documented a significant weight loss of 27 pounds in the past six months.

Review of Resident 74's physician orders included consistent carbohydrate diet, mechanical soft texture, thin consistency, with a start date of December 19, 2023; and significant snack or choice in afternoon related to diabetes mellitus, with a start date of December 24, 2023.

During interview with Employee 7 (Licensed Practical Nurse) on June 4, 2024, at 12:54 PM, revealed dietary staff are to put a peanut butter and jelly sandwich on Resident 74's lunch tray for an afternoon snack, but the Resident doesn't always get it.

Meal observation on June 4, 2024, at 12:55 PM, Resident 74's tray ticket read, in part, consistent carbohydrate mechanical soft diet, puree vegetables, puree white bread, and yogurt. Resident 74 received ground kielbasa, puree cabbage, noodles, regular dinner roll, and yogurt on her meal tray.

During an interview with Resident 74 on June 4, 2024, at 12:55 PM, it was confirmed she didn't receive a peanut butter and jelly sandwich on her meal tray. Surveyor observed that the peanut butter and jelly sandwich was not documented on ticket.

During an interview with Employee 6 (Licensed Practical Nurse) on June 4, 2024, at 1:05 PM, it was revealed that Resident 74 received a grilled cheese sandwich that day on her lunch tray, and the Resident ate that in place of her meal.

Review of progress note dated June 4, 2024, at 1:17 PM, read, in part, the kitchen was called to order a peanut butter and jelly sandwich for the Resident's afternoon significant snack of choice.

Review of Resident 74's March 2024, April 2024, and June 2024 MAR (Medication Administration Record- documentation of medications, nutritional supplements, or physician ordered snacks) failed to document the significant afternoon snack was administered at 2:00 PM on March 12th, 2024; April 4th, 2024; and June 2nd, 2024.

Further clinical record review revealed no progress notes for the aforementioned dates documenting rational for not administering the significant snack.

During an interview with Nursing Home Administrator (NHA) on June 5, 2024, at 12:20 PM, revealed the peanut butter and jelly sandwich was added to Resident 74's tray ticket, and staff should remove it from the lunch tray and save it for the afternoon snack.

During an interview with the Director of Nursing (DON) on June 5, 2024, at 2:28 PM, it was revealed that Resident 74 should've been provided a significant afternoon snack per physician order.

Review of Resident 137's clinical record documented diagnoses that included hypokalemia (low potassium in the blood) and heart failure (the heart doesn't pump blood the way it should).

Review of Resident 137's June 2024 physician orders on June 3, 2024, at 1:22 PM, documented fluid restriction 2000 milliliters (ml - unit of measure) total per 24 hours, with a start date of November 31, 2023.

Observation on June 4, 2024, at 10:25 AM, revealed there was a Styrofoam cup with water on Resident 137's over the bed table, with the date of June 4th.

During an interview with Resident 137 on June 4, 2024, at 10:25 AM, it was revealed that he is provided a Styrofoam cup of water daily.

Review of Resident 137's May and June 2024 MAR documented the fluids nursing provided with medications per shift; there weren't fluid administration guidelines for meals or medications documented. The average daily fluid intake documented by nursing of fluids provided with medications on the June MAR was between 180 ml to 720 ml per day, and on the May MAR was between 540 ml and 1440 ml per day.

Review of Resident 137's meal ticket documented 2 milligram sodium diet (low sodium diet) and 1500 ml fluid restriction.

Review of physician orders on June 5, 2024, at 2:26 PM, read, in part, 2000 ml fluid restriction: breakfast 540 ml, lunch 420 ml, dinner 300 ml; medication pass 240 ml each shift; each shift 2000 ml fluid restriction with meals AND every shift for 2000 ml fluid restriction with medication administration; start date June 5, 2024, at 7:00AM.

During an interview with the NHA on June 5, 2023, at 2:30 PM, revealed that, prior to June 5, 2024, the volume of fluids provided by dietary and nursing should've been planned and communicated, and that the tray ticket should match the physician order. It was also revealed that fluid intake at meals was not recorded by nursing staff, only the fluids provided during medication pass.

28 Pa. Code 211.10 Resident care policies
28 Pa. Code 211.12 Nursing Services



 Plan of Correction - To be completed: 07/01/2024

Development and/or execution of this plan of correction does not constitute admission or agreement by this provider of the truth in the statement of deficiency. This plan of correction is prepared and/or executed by provision of Federal or State Law.

1. A peanut butter and jelly sandwich was added to R74's lunch ticket. Unable to retroactively correct documentation regarding significant afternoon snack on R74's MAR for March 12, 2024; April 4, 2024; and June 2, 2024. Fluid restriction order was discontinued for R137.
2. A review of residents with orders for a significant afternoon snack and fluid restrictions will be completed by Dietitian/Designee. Any identifiable concerns will be immediately addressed.
3. Nursing and Dietary staff will be re-educated on the facility policies for Snack and Encouraging/Restricting Fluids by ADON/Designee.
4. RN Supervisor/Designee will observe and monitor 3 random residents weekly x4, and 2x monthly x1, to ensure that physician ordered therapeutic diets are followed for significant snacks and fluid restrictions, as well as completing documentation on the MAR if applicable. RN Supervisor/Designee will report findings monthly x2 to be reviewed at the QAPI Committee meeting for further review or recommendations.
5. Date of compliance July 1, 2024.

483.25 REQUIREMENT Quality of Care:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
§ 483.25 Quality of care
Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices.
Observations:

Based on review of the clinical record, observations, and staff and resident interviews, it was determined that the facility failed to ensure care and services are provided in accordance with professional standards of practice that will meet each resident's physical, mental, and psychosocial needs for two of 34 residents reviewed (Residents 140 and 163).

Findings include:

Review of Resident 140's clinical record revealed diagnoses that included malignant neoplasm of the colon (colorectal cancer, is a cancerous tumor that develops in the colon or rectum) and diabetes (a chronic disease that occurs when the pancreas does not produce enough insulin).

Observation of Resident 140 on June 2, 2024, at 10:45 AM, revealed the Resident lying in bed. During an immediate interview with Resident 140, the Resident revealed he was on hospice.

Review of Resident 140's current physician orders on June 3, 2024, failed to reveal a current physician order for Hospice care and services.

Review of Resident 140's Care Plan on June 4, 2024, revealed a care plan of, "Resident is receiving hospice care related to end stage illness", with a date initiated and revised of March 8, 2024.

Review of facility provided hospice contracts revealed a hospice contract between the facility and Resident 140's hospice provider dated March 7, 2024.

Interview with the Nursing Home Administrator (NHA) on June 5, 2024, at 9:00 AM, revealed that Resident 140 was receiving hospice services when he came to the facility on March 8, 2024, and currently does not have any physician's orders for hospice services.

Review of Resident 163's clinical record revealed diagnoses that included atrial fibrillation (irregular, rapid heart rate) and diabetes.

Observation of Resident 163 on June 2, 2024, at 10:45 AM, revealed the Resident lying in bed. When asked about the bandage on her right forehead and the large area of bruising and swelling to the right side of her face, the Resident replied, "I fell two weeks ago and had to go to the hospital for a CT scan (computed tomography-a medical imaging technique that uses x-rays and computers create detailed pictures of the inside of the body) and x-rays to my left shoulder." The Resident also revealed she had a fracture (broken bone) of the left shoulder. Resident also had a large hematoma (collection of blood outside of a blood vessel that can occur due to trauma and injury) of the right forehead and scalp area.

On June 3, 2024, Resident 163's fall investigation report was reviewed, which verified the Resident sustained a fall out of her wheelchair when bending foreward to pick something off of the floor. The fall report revealed the Resident sustained the hematoma measuring 6 cm (centimeters) by 4 cm. Neurological checks were initiated prior to the Resident being sent to the hospital, and convened on return to the facility until completed, per policy. All neurological checks were within normal limits.

Further interview with Resident 163 revealed that the mesh wound dressing covering the open area of the hematoma was applied during the hospital visit on May 21, 2024.

On June 6, 2024, at 7:00 AM, the facility obtained orders from the physician to remove the current dressing, cleanse the area with normal saline solution, and to apply a dry dressing every dayshift the open area of the hematoma until healed.

During an interview with the NHA on June 6, 2024, the NHA stated that she would expect the staff to follow-up with the physician regarding care and treatment to the open area of the hematoma when no instructions were provided by the hospital on the discharge summary.

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



 Plan of Correction - To be completed: 07/01/2024

Development and/or execution of this plan of correction does not constitute admission or agreement by this provider of the truth in the statement of deficiency. This plan of correction is prepared and/or executed by provision of Federal or State Law.

1. R140's physician orders for hospice services were obtained. R163's physician orders for monitoring hematoma and wound care were obtained.
2. Current residents' physician orders have been reviewed for hospice services, hematoma monitoring, and treatment to hematoma open areas. Any identified discrepancies will be followed up with the physician for appropriate orders.
3. Licensed nursing staff will be educated by ADON/Designee for follow-up with physicians regarding care when no instructions are provided on the discharge summary provided by hospitals and obtaining physician orders for residents on hospice services, hematoma monitoring, and treatment to any hematoma open areas.
4. DON/Designee will audit 3 random residents' physician orders weekly x 4, and 2x monthly x 1, for hospice services and residents returning from the hospital.
Results of the audits will be reviewed at the QAPI meeting by the DON/Designee monthly x2 for any further recommendations.
5. Date of compliance July 1, 2024.

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

Based on clinical record review and staff interviews, it was determined that the facility failed to ensure that the resident assessment accurately reflected the resident's status for one of 34 residents reviewed (Resident 5).

Findings include:

Review of Resident 5's clinical record documented diagnoses that included sleep apnea (a sleep disorder in which breathing repeatedly stops and starts), heart failure (the heart doesn't pump blood as it should), and respiratory failure (a condition in which your blood doesn't have enough oxygen or has too much carbon dioxide).

Review of Resident 5's physician orders included BiPAP (a bilevel positive airway pressure machine - a type of ventilator that helps people breathe by delivering pressurized air int their lungs through a mask) minimum 5, maximum 20, PS 4-8 (unit of measure) with 2 Liters oxygen bleed, in at bedtime, with a start date of June 2, 2022.

Review of Resident 5's annual MDS (Minimum Data Set - an assessment tool to review all care areas specific to the resident such as a resident's physical, mental, or psychosocial needs) assesment dated May 2, 2024, and quarterly MDS assessments dates March 18, 2024; February 16, 2024; and November 6, 2023, failed to document use of a noninvasive ventilator.

During an interview with Employee 20 (Registered Nurse Assessment Coordinator) on June 6, 2024, at 10:55 AM, it was revealed that Resident 5's aforementioned assessments should've been coded for use of a noninvasive ventilator.

During an interview with Nursing Home Administrator on June 6, 2024, at 11:02 AM, it was revealed that the aforementioned assessments should've been coded correctly.

28 Pa. Code 211.5 Medical records


 Plan of Correction - To be completed: 07/01/2024

Development and/or execution of this plan of correction does not constitute admission or agreement by this provider of the truth in the statement of deficiency. This plan of correction is prepared and/or executed by provision of Federal or State Law.

1. R5's assessment dates November 6, 2023, February 16, 2024, March 18, 2024, and May 2, 2024, have been corrected to accurately reflect use of a noninvasive ventilator.
2. RNAC/Designee will audit all current residents' use of a noninvasive ventilator to ensure accurate coding of MDS assessments. Any identified inaccuracies will be modified per CMS procedure.
3. Facility RNAC staff will be educated by Regional RAI Specialist/Designee on completing accurate coding for use of a noninvasive ventilator per CMS procedure.
4. RNAC/Designee will conduct 2 random resident MDS Assessment audits weekly for 1 month, and then 2 random resident MDS Assessment audits monthly x2, to ensure that use of a noninvasive ventilator was coded accurately. DON/Designee will report audit results monthly x3 at the QAPI Committee meeting for further recommendations.
5. Date of compliance July 1, 2024.


483.24(a)(1)(b)(1)-(5)(i)-(iii) REQUIREMENT Activities Daily Living (ADLs)/Mntn Abilities:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
§483.24(a) Based on the comprehensive assessment of a resident and consistent with the resident's needs and choices, the facility must provide the necessary care and services to ensure that a resident's abilities in activities of daily living do not diminish unless circumstances of the individual's clinical condition demonstrate that such diminution was unavoidable. This includes the facility ensuring that:

§483.24(a)(1) A resident is given the appropriate treatment and services to maintain or improve his or her ability to carry out the activities of daily living, including those specified in paragraph (b) of this section ...

§483.24(b) Activities of daily living.
The facility must provide care and services in accordance with paragraph (a) for the following activities of daily living:

§483.24(b)(1) Hygiene -bathing, dressing, grooming, and oral care,

§483.24(b)(2) Mobility-transfer and ambulation, including walking,

§483.24(b)(3) Elimination-toileting,

§483.24(b)(4) Dining-eating, including meals and snacks,

§483.24(b)(5) Communication, including
(i) Speech,
(ii) Language,
(iii) Other functional communication systems.
Observations:

Based on observations, review of clinical records, and resident and staff interviews, it was revealed that the facility failed to provide necessary individualized services to maintain Activities of Daily Living (ADL- wash face, brush teeth, eating, brush hair) regarding fingernail care for one of 34 residents reviewed (Resident 110).

Findings include:

Review of Resident 110's clinical record revealed diagnoses that included diabetes mellitus (the body's ability to produce or respond to the hormone insulin is impaired, resulting in abnormal metabolism of carbohydrates and elevated levels of glucose in the blood and urine), macular degeneration in both eyes (an eye disease that causes vision loss), anxiety (a feeling of worry, nervousness, or unease), and dementia (a condition characterized by progressive loss of intellectual functioning, impairment of memory and abstract thinking).

Observation on June 3, 2024, at 10:43 AM, revealed Resident 110's fingernails on both hands were long and jagged.

During an interview with Resident 110 on June 3, 2024, at 10:43 AM, it was revealed that he is offered a shower once a week; however, he prefers to wash up at his sink in his room, and that he does receive assistance from the staff. It was also revealed that he would like his fingernails trimmed, or an Emery board (flat long object with emery paper used for fingernail and toenail care) so he can do it himself.

During an interview with Employee 6 (Licensed Practical Nurse) it was revealed that Resident 110 will refuse showers an times, he is very private, and hygiene is difficult.

Review of Resident 110's bathing tasks on June 6, 2024, at 9:16 AM, revealed the Resident was scheduled for showers on Thursday evening shift. No showers or baths were documented as provided over the past 30 days, however, there were documented Resident refusals on May 16th and 30th, 2024.

Observation and interview regarding Resident 110's fingernail with Employee 6 on June 3, 2024, at 11:09 AM, the Resident agreed to have them trimmed after lunch.

Review of Resident 110's care plan failed to document rejection of care.

Review of Resident 110's quarterly MDS (Minimum Data Set - an assessment tool to review all care areas specific to the resident such as a resident's physical, mental or psychosocial needs) dated April 5, 2024, failed to document rejection of care, and documented the Resident as independent with bathing.

Review of progress notes April 6th through June 6th, 2024, failed to document rejection of care.

During an interview with the Nursing Home Administrator on June 4, 2024, at 2:03 PM, it was revealed that Nursing Assistants should trim fingernails during scheduled showers. It was also revealed that Resident 110 tends to refuse care, and that refusal of care should be documented.

28 Pa. Code 211.12 Nursing Services


 Plan of Correction - To be completed: 07/01/2024

Development and/or execution of this plan of correction does not constitute admission or agreement by this provider of the truth in the statement of deficiency. This plan of correction is prepared and/or executed by provision of Federal or State Law.

1. R110's nails were trimmed by licensed nursing staff and the care plan was updated to reflect rejection of care.
2. Current residents were observed for needed nail care and care was completed as needed by licensed nursing staff or CNAs. Current residents noted to refuse care were reviewed by Social Services/Designee and care plans updated as needed.
3. Nursing staff were re-educated by ADON/Designee on providing nail care and documenting refusal of care.
4. ADONs/Designee will conduct 3 random resident observations for residents needing nail care and documentation for refusal of care weekly x 4, and 2x monthly x1.
Results of the audits will be reviewed at the QAPI meeting by the DON/Designee monthly x2 for any further recommendations.
5. Date of compliance July 1, 2024.

483.25(b)(1)(i)(ii) REQUIREMENT Treatment/Svcs to Prevent/Heal Pressure Ulcer: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(b) Skin Integrity
§483.25(b)(1) Pressure ulcers.
Based on the comprehensive assessment of a resident, the facility must ensure that-
(i) A resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable; and
(ii) A resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing.
Observations:

Based on review of facility policy, observation, and staff interview, it was determined that the facility failed to ensure the resident received care, consistent with professional standards, to prevent pressure ulcers for one of 37 residents reviewed (Resident 140).

Findings Include:

Review of facility policy, titled "Wound Care", revised October 2010, revealed "Steps in the Procedure, 1. Use disposable cloth (paper towel is adequate) to establish clean field on resident's overbed table. Place all items to be used during the procedure on the clean field." Also, "4. Put on exam glove. Loosen tape and remove dressing. 5. Pull glove over dressing and discard into appropriate receptacle. Wash and dry your hands thoroughly. 6. Put on gloves."

Review of Resident 140's clinical record revealed diagnoses that included pressure ulcer of left heel (skin ulcer caused by excess pressure) and diabetes (a chronic disease that occurs when the pancreas does not produce enough insulin).

Observation of a dressing change to Resident 140's left heel on June 5, 2024, at 10:47 AM, revealed Employee 17 gathered dressing supplies, took them to Resident 140's room, and placed the supplies onto Resident 140's overbed table without placing a drape or washing/disinfecting the table to create a clean field. Further observation of Employee 17 revealed that, after the dressing on Resident 140's left heel was removed, Employee 17 cleansed the pressure ulcer, applied medicated ointment, and applied a clean bandage prior to washing her hands and applying new clean gloves. Further observation of Employee 17 revealed that, when the dressing change was complete, Employee 17 gathered the supplies off of Resident 140's overbed table and left the room without cleaning the overbed table.

Interview with the Director of Nursing (DON) on June 6, 2024, at 11:45 AM, revealed that Employee 17 should have created a clean field to work from prior to completing the dressing change.

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



 Plan of Correction - To be completed: 07/01/2024

Development and/or execution of this plan of correction does not constitute admission or agreement by this provider of the truth in the statement of deficiency. This plan of correction is prepared and/or executed by provision of Federal or State Law.

1. Unable to correct dressing change treatment for R140. RN was educated by Wound Nurse/Designee to follow facility policy for Wound Care. MD and Resident Representative were notified.
2. Wound Nurse/Designee will conduct skin assessments for residents with pressure ulcers to ensure skin integrity. Any areas of concern will be immediately addressed.
3. Wound Nurse/Designee will re-educate licensed nursing staff to follow the facility policy on Wound Care.
4. Wound Nurse/Designee will perform a weekly observation of dressing changes for 2 residents weekly x4, then 2x monthly x1, to ensure the facility policy on Wound Care is followed. Wound Nurse/Designee will report audit results monthly x2 at the QAPI Committee meeting for further review or recommendations.
5. Date of compliance July 1, 2024.

483.35(d)(7) REQUIREMENT Nurse Aide Peform Review-12 hr/yr In-Service:This is a less serious (but not lowest level) deficiency and 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.
§483.35(d)(7) Regular in-service education.
The facility must complete a performance review of every nurse aide at least once every 12 months, and must provide regular in-service education based on the outcome of these reviews. In-service training must comply with the requirements of §483.95(g).
Observations:

Based on document review and staff interview, it was determined that the facility failed to complete a performance review of every nurse aide at least once every 12 months for two of five nurse aide documents reviewed (Employees 12 and 13).

Findings Include:

A review of Employee 12's personnel information revealed a hire date of May 13, 1991.

A review of Employee 12's most recent Competency Evaluation revealed a review and completion date of May 6, 2023.

A review of Employee 13's personnel information revealed a hire date of April 9, 2013.

A review of Employee 13's most recent Competency Evaluation revealed a review and completion date of April 5, 2023.

An interview with the Director of Nursing on June 6, 2024, at 12:15 PM, revealed the evaluations provided are the most recent and additional information will be sought. After the survey, no additional information was provided to verify the completion of annual performance reviews for Employees 12 and 13 thus far in the year 2024.

28 Pa. Code 201.19 (2) Personnel policies and procedures


 Plan of Correction - To be completed: 07/01/2024

Development and/or execution of this plan of correction does not constitute admission or agreement by this provider of the truth in the statement of deficiency. This plan of correction is prepared and/or executed by provision of Federal or State Law.

1. Employees 12 and 13 have received their performance reviews.
2. HR/Designee will review current nurse aide staff for completed annual performance reviews. Any performance reviews found not to be completed will be addressed.
3. HR/Designee will educate licensed nursing staff on completing annual performance reviews for nurse aides.
4. HR/Director will review nurse aide annual performance reviews due weekly x4, then 1x monthly for completion. HR/Director will report findings monthly x2 to be reviewed at the QAPI Committee meeting for further review or recommendations.
5. Date of compliance July 1, 2024.


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

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

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

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

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

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

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

Based on staff interview and document review, it was determined the facility failed to develop a water management program based on a risk analysis of the facility for the prevention, detection, and control of water-borne contaminants, such as Legionella, a bacteria that may cause Legionnaires' Disease (a serious type of pneumonia).

Findings include:


On June 4, 2024, the facility provided a policy, titled "Legionella Surveillance and Detection", last revised September 2022. The policy focused on the signs and symptoms of Legionnaires' Disease when a resident develops pneumonia.

On June 4, 2024, the facility was requested to provide their water management program that includes a water flow schematic, a documented risk analysis for areas at risk of contamination with Legionella (gram negative bacteria), and any routine preventative measures being performed that includes water temperature logs, flushing of stagnant water flow systems. The facility in response provided the Center for Disease Control (CDC) toolkit, titled "Developing a Legionella Water Management Program."

During an interview with the Nursing Home Administrator (NHA) on June 6, 2024, at 11:00 AM, the NHA was unable to provide a detailed water management program specific to the facility. The NHA also stated that maintenance staff was preparing a water flow schematic that was provided on June 6, 2024, at approximately 1:00 PM. The water flow schematic failed to show water flow for the facility.

28 Pa. Code 201.18(b)(1)(3) Management



 Plan of Correction - To be completed: 07/01/2024

Development and/or execution of this plan of correction does not constitute admission or agreement by this provider of the truth in the statement of deficiency. This plan of correction is prepared and/or executed by provision of Federal or State Law.

1. A detailed water management program was developed with a schematic of water flow for the facility.
2. The Legionella annual test was completed on 6/14/24. Water temperature logs are completed 2x weekly. Flushing of stagnant water is completed 1x weekly. Facility hot water heater that has a monitoring system that regulates water flow.
3. The facility's Water management program will be reviewed annually by NHA, DON, IFC Nurse, and Maintenance Director.
4. Maintenance Director/Designee will audit water temp logs and flushing of stagnant water weekly x4 and then 2x monthly x1. Results of the audits will be reviewed at the QAPI committee meeting monthly x2 by the Maintenance Director/Designee for any further recommendations.
5. Date of compliance July 1, 2024.

483.90(g)(1)(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 from-

§483.90(g)(1) Each resident's bedside; and
§483.90(g)(2) Toilet and bathing facilities.
Observations:

Based on observation and resident and staff interviews, it was determined that the facility failed to ensure each resident's bedside is equipped to allow for residents to call for staff assistance through a communication system for one of seven resident areas reviewed (Rosemont Hall).

Findings Include:

Observations on the Rosemont Hall in one room occupied by Residents 16 and 135 on June 4, 2024, at 9:24 AM, revealed no call bell cords leaving the Resident wall above the beds.

Interviews with Residents 16 and 135 revealed they have no call bells available to call for staff assistance.

An interview with the Nurse Aide (Employee 19) on June 4, 2024, at 9:28 AM, confirmed the lack of call bells available to Residents 16 and 135 in their room.

An interview with the Nursing Home Administrator on June 5, 2024, at 11:58 AM, confirmed the room lacked call bells for Residents 16 and 135, and that the call bells were added and are now available for the Residents to contact staff for assistance as needed.

28 Pa. Code 205.67 (j) Electric requirements for existing construction


 Plan of Correction - To be completed: 07/01/2024

Development and/or execution of this plan of correction does not constitute admission or agreement by this provider of the truth in the statement of deficiency. This plan of correction is prepared and/or executed by provision of Federal or State Law.

1. R16 and R135 call bell cords were replaced on June 5, 2024.
2. SSW/Designee will audit Rosemont Unit for call bell cords. Any identified missing call bell cords will be immediately replaced.
3. ADON/Designee will educate staff that residents must have call bells available to call for staff assistance and that maintenance department should be notified if any call bell cords are missing.
4. SSW/Designee will audit call bell cords on Rosemont Unit weekly x4 and then 2x monthly x1. Results of the audits will be reviewed at the QAPI committee meeting monthly x2 by the SSW/Designee for any further recommendations.
5. Date of compliance July 1, 2024.

§ 211.12(f.1)(2) LICENSURE Nursing services. :State only Deficiency.
(2) Effective July 1, 2023, a minimum of 1 nurse aide per 12 residents during the day, 1 nurse aide per 12 residents during the evening, and 1 nurse aide per 20 residents overnight.

Observations:

Based on document review and staff interview, it was determined that the facility failed to ensure a required minimum of one nurse aide per 12 residents on both day and evening shifts for three of seven days reviewed (June 2, 3, and 5, 2024).

Findings Include:

A review of facility-provided staffing ratio information for June 2, 2024, on the day shift, revealed a census of 172 residents. Further review revealed a nurse aide ratio of 13.09 worked that shift; therefore, the facility did not meet the required minimum nurse-aide ratio for the facility census on that shift.

A review of the facility-provided staffing ratio information for June 3, 2024, on the evening shift, revealed a census of 174 residents. Further review revealed a nurse aide ratio of 14.48 worked that shift; therefore, the facility did not meet the required minimum nurse-aide ratio for the facility census on that shift.

A review of the facility-provided staffing ratio information for June 5, 2024, on the evening shift, revealed a census of 176 residents. Further review revealed a nurse aide ratio of 12.01 worked that shift; therefore, the facility did not meet the required minimum nurse-aide ratio for the facility census on that shift.

An interview with the Nursing Home Administrator, on June 6, 2024, at 11:40 AM, revealed the facility had not met the required nurse aide staffing ratio on those dates.


 Plan of Correction - To be completed: 07/01/2024

Development and/or execution of this plan of correction does not constitute admission or agreement by this provider of the truth in the statement of deficiency. This plan of correction is prepared and/or executed by provision of Federal or State Law.

1. Residents continued to receive care during the days the required nurse aide ratio on day and evening shifts were not met.
2. The facility has identified that all the residents have the potential to be affected by not meeting the required nurse aide ratio on day and evening shifts.
3. DON/Designee will review the Staffing Grid Calculation Tool daily to ensure the required ratios for CNA's are met for day and evening shifts. If the facility is expecting to not meet the ratio for a shift, the scheduler and RN Supervisor will approach current staff and staff off duty to fulfill the ratio need.
4. HR Director/Designee will conduct 2 random audits weekly for 1 month, and then 2 random audits monthly x1, for required nurse aid ratios on day and evening shifts. HR/Designee will report audit results monthly x2 for QAPI Committee to address any trends or patterns, need for further review, and or recommendations.
5. Date of compliance 7/1/24.

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

Based on document review and staff interview, it was determined that the facility failed to ensure a required minimum of one Licensed Practical Nurse per 30 residents on the evening shift for one of seven days reviewed (June 2, 2024).

Findings Include:

A review of facility-provided staffing ratio information for June 2, 2024, on the evening shift, revealed a census of 172 residents. Further review revealed a Licensed Practical Nurse (LPN) ratio of 6.26 worked that shift; therefore, the facility did not meet the required minimum LPN ratio for the facility census on that shift.

An interview with the Nursing Home Administrator, on June 6, 2024, at 11:40 AM, revealed the facility had not met the required LPN ratio on that date.


 Plan of Correction - To be completed: 07/01/2024

Development and/or execution of this plan of correction does not constitute admission or agreement by this provider of the truth in the statement of deficiency. This plan of correction is prepared and/or executed by provision of Federal or State Law.

1. Residents continued to receive care during the evening shift when the required Licensed Practical Nurse ratio was not met.
2. The facility has identified that all the residents have the potential to be affected by not meeting the required Licensed Practical Nurse on the evening shift.
3. DON/Designee will review the Staffing Grid Calculation Tool daily to ensure the required ratios for LPN's are met for evening shifts. If the facility is expecting to not meet the ratio for a shift, the scheduler and RN Supervisor will approach current staff and staff off duty to fulfill the ratio need.
4. HR Director/Designee will conduct 2 random audits weekly for 1 month, and then 2 random audits monthly x1, for required Licensed Practical Nurse on the evening shifts. HR/Designee will report audit results monthly x2 for QAPI Committee to address any trends or patterns, need for further review, and or recommendations.
5. Date of compliance 7/1/24.


§ 211.12(i)(1) LICENSURE Nursing services.:State only Deficiency.
(1) Effective July 1, 2023, the total number of hours of general nursing care provided in each 24-hour period shall, when totaled for the entire facility, be a minimum of 2.87 hours of direct resident care for each resident.

Observations:

Based on a review of staffing information furnished by the facility and staff interview, it was determined that the facility failed to ensure the total number of nursing care hours provided in each 24 hours be a required minimum of 2.87 hours of direct care for each resident for one of seven days reviewed (June 2, 2024).

Findings Include:

A review of staffing information provided by the facility dated May 30, 2024, through June 5, 2024, revealed the facility provided 2.78 direct care hours for each resident on June 2, 2024; therefore, not meeting the state minimum of 2.87 direct care hours per resident per day.

An interview with the Nursing Home Administrator, on June 6, 2024, at 11:40 AM, revealed the facility had not met the required direct care hours for its residents on that date.


 Plan of Correction - To be completed: 07/01/2024

Development and/or execution of this plan of correction does not constitute admission or agreement by this provider of the truth in the statement of deficiency. This plan of correction is prepared and/or executed by provision of Federal or State Law.

1. Residents continued to receive required care during the day the staffing fell below 2.87 direct care hours per resident per day.
2. The facility has identified that all the residents have the potential to be affected by the average nursing care hours falling below 2.87 in a 24-hour period of direct care hours per resident per day.
3. The Nurse Supervisors and Scheduler will be re-educated by DON/Designee on the state required minimum of 2.87 hours of direct care for each resident per day. If the facility is expecting to not meet the ratio for a shift, the scheduler and RN Supervisor will approach current staff and staff off duty to fulfill the ratio need.
4. HR Director/Designee will conduct 2 random audits weekly for 1 month, and then 2 random audits monthly, for the minimum of 2.87 hours of direct care for each resident per day. HR/Designee will report audit results monthly x2 for QAPI Committee to address any trends or patterns, need for further review, and or recommendations.
5. Date of compliance 7/1/24.


35 P. S. § 448.809b LICENSURE Photo Id Reg:State only Deficiency.
Law amended July 11, 2022 Act 79 2022 HB 2604

(1) The photo identification tag shall include a recent
photograph of the employee, the employee's first name, the
employee's title and the name of [the health care facility or
employment agency.] any of the following:
(i) The health care facility.
(ii) The health system.
(iii) The employment agency.
(iv) The fictitious name of an entity under
subparagraph (i), (ii) or (iii) which is registered with
the Department of State under 54 Pa.C.S. Ch. 3 (relating
to fictitious names) or a successor statute.

(2) The title of the employee shall be as large as possible
in block type and shall occupy a one-half inch tall strip as
close as practicable to the bottom edge of the badge.


(3) Titles shall be as follows:
(i) A Medical Doctor shall have the title "Physician."
(ii) A Doctor of Osteopathy shall have the title
"Physician."
(iii) A Registered Nurse shall have the title
"Registered Nurse."
(iv) A Licensed Practical Nurse shall have the title
"Licensed Practical Nurse."
(v) All other titles shall be determined by the
department. Abbreviated titles may be used when the title
indicates licensure or certification by a Commonwealth
agency.

(4)A notation, marker or indicator included on an identification badge that differentiates employees with the same first name is considered acceptable in lieu of displaying an employee's last name.


Observations:

Based on observations, staff interviews, and document review, it was determined that the facility failed to ensure the employee photo identification tag includes a recent photograph, the employee's first name, the employee's title, and the name of the facility for three employees observed on one of seven resident areas observed (Employees 2, 21, and 22 on the Rosemont Hall).

Findings Include:

A review of the facility-provided handbook document, titled "Name Badges," effective November 1, 2021, read "All employees must wear a name badge at all times so that residents can identify you. " "All name badges are to be supplied by [facility]."

An observation of Employee 22's (Therapeutic Recreation Assistant) uniform on June 4, 2024, at 9:04 AM, revealed no identification badge. An immediate interview with Employee 22 revealed she had not worn the badge on that date.

An observation of Employee 2 (Licensed Practical Nurse) on June 4, 2024, at 10:40 AM, revealed no identification badge on his uniform. An immediate interview with Employee 2 revealed he "forgot" his identification badge.

An observation of Employee 21 (Nurse Aide) on June 4, 2024, at 12:46 PM, revealed no identification badge on her uniform. An immediate interview with Employee 21 revealed her identification badge was "broken."

An interview with the Nursing Home Administrator on June 4, 2024, at 1:40 PM, revealed the facility can provide identification badges on site and all employees should be wearing them.

28 Pa. Code 201.14 (a) Responsibility of licensee


 Plan of Correction - To be completed: 07/01/2024

Development and/or execution of this plan of correction does not constitute admission or agreement by this provider of the truth in the statement of deficiency. This plan of correction is prepared and/or executed by provision of Federal or State Law.

1. Employees 2, 21, and 22 have been educated by HR Director/Designee on always wearing their name badges so that residents can identify them.
2. HR Director/Designee will do an observation audit of the facility staff for wearing their name badges. Any missing name badges will be provided.
3. HR Director/Designee will educate staff of the facility provided handbook that states all employees must wear a name badge at all times so that residents can identify them.
4. HR Director/Designee will audit 5 employees 2x weekly x4, then 2x monthly x1, for staff adherence for wearing name badges. Results of the audits will be reviewed at the QAPI committee meeting monthly x2 by the HR Director/Designee for any further recommendations.
5. Date of compliance July 1, 2024.


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