Pennsylvania Department of Health
LANCASTER NURSING AND REHABILITATION CENTER
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

LANCASTER NURSING AND REHABILITATION CENTER
Inspection Results For:

There are 208 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.


LANCASTER NURSING AND REHABILITATION CENTER - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:
Based on a Medicare/Medicaid Recertification Survey, State Licensure Survey, Civil Rights Compliance Survey, and a Complaint Investigation completed on May 23, 2024, it was determined that Lancaster Nursing and Rehabilitation Center was not in compliance with the following requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care and the 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulation as they relate to the Health portion of the survey process.
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Plan of Correction:

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.

Plan of Correction - To be completed: 07/11/2024

Preparation and/or execution of this plan of correction does not constitute an admission or agreement by the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of Federal and State Law. The plan of correction represents the facility's credible allegation of compliance.
Tag 0684 Quality of Care: Failed to follow physician orders
1. Resident #67 Fluid restriction: exceeded the amount fluids allotted was addressed with physician. Resident #222 Bowel protocol MOM not given was addressed with the physician. Resident #269 Fluid Restriction: no documentation on how much fluid received was addressed with the physician.
2. Current residents on bowel protocol will be audited that bowel regiment is being followed.
Current residents with fluid restrictions will be reviewed to ensure residents receive the correct amount of fluids per physician order.
3. Director of Nursing/designee will educate licensed staff on bowel regimen protocol and on medication administration documentation.
4. DON or designee will audit random medication administration records for those residents on bowel regimen protocol and for resident on fluid restrictions to ensure that residents are receiving medications per physician orders weekly x 4 weeks then Monthly x 2. Audits will be reported to QAPI monthly for review and further recommendations
5. Date of Compliance: 7/11/2024

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

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

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

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

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

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

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

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

483.25(g)(4)(5) REQUIREMENT Tube Feeding Mgmt/Restore Eating Skills:

§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 clinical record review and staff interviews, it was determined that the facility failed to provide enteral nutrition (delivery of nutrition by a feeding tube) in accordance with physician's order for four of 11 residents receiving enteral feeding (Residents 72, 244, 259, and 364).

Findings include:

A review of the facility's policy titled "Enteral Nutrition", revised in November 2018, revealed facility will provide adequate nutritional support through enteral nutrition to the residents as ordered.

Review of Resident 72's physician's order of October 18. 2023 included an order for enteral feeding Jevity 1.5 via peg tube continuous at a rate of 55 milliliter(mL)/hour for a total volume of 1210 mL/24 hours.

Review of Resident 72's April 2024 Medication Administration Record (MAR) revealed that the resident exceeded 1210 mL/24 hours for six of 30 days. Documentation on four of 90 shifts revealed staff were documenting the rate of 55 mL/hour instead of the volume received.

Review of the May 2024 MAR revealed that the resident exceeded 1210 mL/24 hours for three of 20 days and two of 60 shifts documented the rate of 55 mL/hour.

This information was presented to the NHA on May 21, 2024, at 1:45 p.m.

Clinical records review revealed Resident 244 had a diagnosis of Anoxic brain damage (Which occurs when the brain is deprived of oxygen). The resident had a Tracheostomy (An opening surgically created through the neck into the trachea to allow air to fill the lungs), and a Gastrotomy Tube (GT- A medical device used to provide nutrition to people who cannot obtain nutrition by mouth).

A review of Resident 244's Physician's order dated January 9, 2024, revealed Enteral Feed Order: Osmolyte 1.5 Cal @ 55 ml/hr. Total volume per hour 1210 ml.

A review of the May 2024, Medication Administration Record dated May 1, 2024, until May 22, 2024, revealed that Resident 244 was not provided with a total volume of 1210 ml of Osmolyte on the following days: May 3, 4, 5, 10, 11, 12, 16, 17, 18, and 19 2024. The total GT feeding provided on those days ranged only from 550 ml to 1035 ml which was less than the total feeding volume ordered by the physician.

Clinical records review revealed Resident 259 had a diagnosis of Amyotrophic Lateral Sclerosis (ALS- A nervous system disease that weakens muscles and impacts physical function). The resident had a Tracheostomy and a GT.

A review of Resident 259's Physician's order dated April 19, 2024, revealed an Enteral Feed order every shift: Nutren 1.5 via peg tube continuous at rate 45 ml for 22/24 hours, documenting total shift intake.

A review of the May 2024 MAR failed to reveal a documented feeding tube total shift intake from May 1, 2024, until May 15, 2024. A review of the same MAR revealed a total intake of 450 ml on May 17, 2024, 765 ml on May 18, 2024, and 765 ml on May 19, 2024, which was less than the 990 ml /22/24 hours total feeding intake ordered by the physician.

Clinical records review revealed Resident 364 had a diagnosis of Cerebral Infarction (stroke). The resident had a Tracheostomy and GT.

A review of Resident 364's Physician's order dated May 6, 2024, revealed an Enteral Feed order every shift: Jevity 1.5 continuous at 60 ml/hr for 22/24 hours administration (Total 1320 ml).

A review of the May 2024 MAR from May 6, 2024, until May 22, 2024, revealed that Resident 365 was not provided with a total volume of 1320 ml of Jevity 1.5 on the following days: May 11, 12, 16, 17, and 20, 2024. The total GT feeding provided on hose days ranges only from 600 ml - 960 ml which was less than the total feeding volume (1320 ml) ordered by the physician.

The above was conveyed to the Nursing Home Administrator on May 22, 2024, at 11:00 a.m.

The facility failed to ensure residents on tube feeding were provided with adequate and ordered tube feeding.

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

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

Plan of Correction - To be completed: 07/11/2024

Preparation and/or execution of this plan of correction does not constitute an admission or agreement by the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of Federal and State Law. The plan of correction represents the facility's credible allegation of compliance.
Tag 0693 Tube feeding management/restore eating skills
1) Resident #72, 244, 259 and 364 Documentation of feeding infused
2) Current residents with tube feeding orders will be reviewed to ensure residents receive the correct amount of feeding per physician order.
3) Director of Nursing/Designee will educate nursing staff on PCC order entry of tube feeding order and documentation.
4. DON or designee will audit random new tube feeding orders to ensure that the order was documented in EMR as ordered x4 weeks. The audits will be reviewed by the QAPI committee and the QAPI committee will determine the need for further audits.
6. 5. Date of Compliance: 7/11/2024

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 interview, it was determined that the facility failed to ensure that assessments accurately reflected the resident's status for three of 35 residents reviewed (Residents 165, 250, and 396).

Findings include:

Review of Resident 165's progress note of November 1, 2023, revealed resident was found on the floor and reported severe pain to the lower back and right hip area. The physician was notified and ordered the resident be sent to the hospital. Review of additional progress note of November 1, 2023, revealed that a CT scan (computed tomography scan - type of x-ray that creates cross-sectional images) showed a comminuted impacted right acetabular (hip) fracture with right iliac (hip) muscle hematoma (bruise) and right inferior pubic ramus (part of the pelvis) fracture.

Review of Resident 165's significant change MDS (Minimum Data Set - periodic assessment of resident needs) of November 10, 2023, section J1700A indicated that the resident did not have a fall any time in the last month prior to admission/entry or reentry and section J1700C indicated that the resident did not have a fracture related to a fall in the 6 months prior to admission/entry or reentry.

Interview with the RNAC (registered nurse assessment coordinator) Employee E6 on May 22, 2024, at 9:10 a.m. confirmed that Resident 165's significant change MDS was coded incorrectly.

Review of Resident 250's quarterly Minimum Data Set (MDS-periodic assessment of resident needs) dated April 18, 2024 revealed the resident had a fall with a major injury.

Review of Resident 250's clinical record revealed the resident had not had a fall with a major injury in the past year.

Interview with Licensed Nursing Employee E6 on May 22, 2024 at 9:45 a.m. confirmed Resident 25 was incorrectly coded for a fall with major injury on the quarterly MDS dated April 18, 2024.

Review of Resident 396's discharge MDS dated February 20, 2024 revealed the resident was coded as being discharged to an acute care hospital.

Review of Resident 396's progress notes revealed a nursing entry dated February 20, 2024 stating, "Patient discharged to home".

Interview with Licensed Nursing Employee E6 on May 22, 2024 at 9:45 a.m. confirmed Resident 396 was incorrectly coded for a discharge to an acute care hospital on the discharge MDS on February 20, 2024.

F641 Accuracy of Assessments
Previously cited 7/27/2023

28 Pa. Code 211.5(f) Clinical records
Previously cited 7/27/23

28 Pa. Code 211.12(c) Nursing services

28 Pa. Code 211.12(d)(1)(5) Nursing services
Previously cited 7/27/23

Plan of Correction - To be completed: 07/11/2024

Preparation and/or execution of this plan of correction does not constitute an admission or agreement by the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of Federal and State Law. The plan of correction represents the facility's credible allegation of compliance.

F0641 Accuracy of Assessments
1. For residents #165, #250 and #396, the MDS has been corrected.
2. MDS's that were completed in the last 90 days were reviewed to ensure that they are coded correctly.
3. NHA or designee will educate the RNAC/LPNAC on proper documentation of MDSs.
4. NHA or designee will conduct 3 random audits to ensure MDSs are coded correctly. These audits will be completed 1 time monthly for one month and 2 times monthly for 2 months until substantial compliance has been achieved. The audits will be reviewed by the QAPI committee and the QAPI committee will determine the need for further audits.
5. Date of Compliance: 7/11/2024

483.21(b)(1)(3) REQUIREMENT Develop/Implement Comprehensive Care Plan:

§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 review of clinical records and staff interview, it was determined that the facility failed to develop a comprehensive care plan for one of 35 residents reviewed (Resident 73).

Findings include:

Review of Resident 73's physician's orders included an order dated September 22, 2023, for Eliquis (anticoagulation - medication used to prevent blood clots) 2.5 milligrams one tablet twice a day for paroxysmal atrial fibrillation (type of irregular heartbeat). Review of quarterly MDS (Minimum Data Set - periodic assessment of resident needs) of March 20, 2024, revealed that resident was receiving an anticoagulant.

Review of Resident 73's current care plan revealed no care plan or interventions for anticoagulant medication.

Interview with the Nursing Home Administrator on May 21, 2024, at 1:30 confirmed that Resident 73 did not have a care plan to address the anticoagulant.

483.21 Comprehensive Resident Centered Care Plan
Previously cited 7/27/23

28 Pa. Code 211.5(f) Clinical records
Previously cited 7/27/23

28 Pa. Code 211.12(d)(1)(5) Nursing services
Previously cited 7/27/23

Plan of Correction - To be completed: 07/11/2024

Preparation and/or execution of this plan of correction does not constitute an admission or agreement by the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of Federal and State Law. The plan of correction represents the facility's credible allegation of compliance.
F656 Develop/Implement Comprehensive Care Plan
1. R73's care plan has been updated to include the physician ordered anticoagulant
2. Audit will be completed of the current residents with anticoagulants to ensure and care plans updated to include anticoagulant medication.
3. Staff Development or designee will in-service licensed staff on completion on develop/implement comprehensive care plans.
4. DON or designee will audit random new anticoagulant orders to ensure that the care plan is complete weekly x4 weeks. The audits will be reviewed by the QAPI committee and the QAPI committee will determine the need for further audits.
5. Date of Compliance: 7/11/2024

483.25(g)(1)-(3) REQUIREMENT Nutrition/Hydration Status Maintenance:

§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, and staff interview, it was determined that the facility failed to obtain and monitor weights for two of 35 residents reviewed for nutrition (Residents 259 and 348).

Findings include:

Review of facility policy "Weight Assessment and Intervention" revised September 2008 indicated that "any weight change of 5% or more since the last weight assessment will be retaken the next day for confirmation. If the weight is verified, nursing will immediately notify the dietitian in writing. The dietitian will notify nursing witin 48-72 hours after weight is reviewed for needed re-weights".

Review of Resident 259's clinical records revealed Resident 259 had a diagnosis of Amyotrophic Lateral Sclerosis (ALS- nervous system disease that weakens muscles and impacts physical function). The resident had a Tracheostomy (An opening surgically created through the neck into the trachea to allow air to fill the lungs) and a Gastrostomy Tube (GT- medical device used to provide nutrition to people who cannot obtain nutrition by mouth).

Review of the weight and vitals revealed a weight of 192.5 pounds on April 19, 2024, and a weight of 181.4 pounds on May 13, 2024, an 11.1 pounds (5.77 %) weight loss in less than a month. A review of the same report revealed resident ' s weight was not rechecked until May 21, 2024. (181.3 pounds) eight days after significant weight change was identified.

Interview with the Dietitian was conducted on May 22, 2024, who reported that she/he was not notified of the significant weight loss identified on May 13, 2024. The employee learned about the weight loss on May 21, 2024, when the reweight was done. The dietitian confirmed that the resident should have been re-weighed within 24-48 hours when a significant weight change is identified.

Review of Resident 348's clinical record revealed a weight of 118.4 pounds on April 4, 2024. Weight was recorded on May 7, 2024 at 105.8 pounds (loss of 12.6 pounds or 10.6%) with no reweight obtained.

Further review of Resident 348's clinical record revealed a weight of 93.2 pounds on May 12, 2024 (loss of 12.6 pounds or 11.9% over five days) with no reweigh obtained.

Further review of Resident 348's clinical record revealed no evidence that the Registered Dietitian reviewed the record due to the significant weight loss.

Interview with the Registered Dietitian, Employee E9, on May 22, 2024, at 9:15 a.m. revealed that reweights should be done within 24-48 hours for a significant weight loss of 5% or more. Employee E9 also confirmed that reweights should have been completed for Resident 348.

28 Pa. Code 211.5(f) Clinical Records
Previously cited 7/27/23

28 Pa. Code 211.10(c) Resident Care Policies
Previously cited 7/27/23

28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services
Previously cited 7/27/23

Plan of Correction - To be completed: 07/11/2024

Preparation and/or execution of this plan of correction does not constitute an admission or agreement by the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of Federal and State Law. The plan of correction represents the facility's credible allegation of compliance.
Tag 0692 Nutrition/Hydration Status Maintenance.
1. Resident #259, 348 re-weights will be obtained, and dietician will complete review of weights.
2. A house wide audit will be completed on all residents with a significant weight change in the last 30 days to ensure any re-weights were completed.
3. Director of Nursing/designee will educate nursing staff on weight assessment and intervention policy.
4. Audits will be conducted to ensure that any weight change of 5% or more since the last assessment of their weight was taken the next day for confirmation. These audits will be conducted daily for 4 weeks then weekly x 4 weeks or until substantial compliance has been achieved. Audits will be reported to QAPI monthly for review and further recommendations.
5. Date of Compliance: 7/11/2024

483.45(d)(1)-(6) REQUIREMENT Drug Regimen is Free from Unnecessary Drugs:

§483.45(d) Unnecessary Drugs-General.
Each resident's drug regimen must be free from unnecessary drugs. An unnecessary drug is any drug when used-

§483.45(d)(1) In excessive dose (including duplicate drug therapy); or

§483.45(d)(2) For excessive duration; or

§483.45(d)(3) Without adequate monitoring; or

§483.45(d)(4) Without adequate indications for its use; or

§483.45(d)(5) In the presence of adverse consequences which indicate the dose should be reduced or discontinued; or

§483.45(d)(6) Any combinations of the reasons stated in paragraphs (d)(1) through (5) of this section.

Observations:

Based on clinical record review, it was determined the facility failed to administer as needed pain medications for appropriate pain levels for one of ten residents reviewed for unnecessary medications (Resident 97).

Findings include:

Review of Resident 97's physician's orders revealed an order dated January 30, 2024, for Oxycodone (narcotic pain reliever) 5 milligrams (mg) every 8 hours as needed for moderate to severe pain.

Review of Resident 97's May 2024 Medication Administration Report (MAR) revealed the resident received Oxycodone on May 8, 2024, and May 10, 2024, for pain rated "1" on a scale of 1-10.

Review of resident 97's April 2024 MAR revealed the resident received Oxycodone 5mg on April 3, 2024, and April 4, 2024, for pain rated "0", April 19, 2024, for pain rated "1", and April 21, 2024, for pain rate "3" on a scale of 1-10.

Review of resident 97's March 2024 MAR revealed the resident received Oxycodone 5mg on March 1, 2024, March 2, 2024, and March 3, 2024, for pain rated "1" on a scale of 1-10.

Interview with Director of Nursing (DON) on May 22, 2024, at 12:43 pm., confirmed that Resident 97 should not have received as needed pain medication for a pain rating of "0-3". Interview with DON confirmed moderate to severe pain should be rated "4-6".

28 Pa Code 211.5 (f) Clinical records

28 Pa code 211.10 (c) Resident care policies

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

Plan of Correction - To be completed: 07/11/2024

Preparation and/or execution of this plan of correction does not constitute an admission or agreement by the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of Federal and State Law. The plan of correction represents the facility's credible allegation of compliance.
F757 Drug Regimen is free from unnecessary drugs.
1. R97 is receiving pain medication per physician order.
2. Residents on PRN pain medications will be reviewed to ensure pain medications are administered per physician orders.
3. Staff development or designee will in-service licensed nurses on administering pain medications per physician orders.
4. DON or designee will audit random pain medication administration to ensure pain medications are administered per physician order weekly x4 weeks. The audits will be reviewed by the QAPI committee and the QAPI committee will determine the need for further audits.
5. Date of Compliance: 7/11/2024

483.45(f)(2) REQUIREMENT Residents are Free of Significant Med Errors:

The facility must ensure that its-
§483.45(f)(2) Residents are free of any significant medication errors.

Observations:

Based on resident interview and clinical record review, it was determined that the facility failed to ensure one of three residents reviewed for dialysis was free of significant medication errors (Resident 220).

Findings include:

Interview with Resident 220 on May 20, 2024, at approximately 1:10 p.m. revealed the resident received insulin (medication given to lower blood sugar) but was not receiving it "correctly." Further interview with Resident 220 at this time revealed the resident did not receive certain medications on the days the resident attended dialysis.

Review of Resident 220's physician's orders revealed an order dated May 2, 2024, for insulin lispro (fast acting insulin), inject per sliding scale:

If blood sugar is 0-199 - give 0 units of insulin
If blood sugar is 200-250 - give 4 units of insulin
If blood sugar is 251-300 - give 6 units of insulin
If blood sugar is 301-350 - give 8 units of insulin
If blood sugar is 351-400 - give 10 units of insulin; and if blood sugar is greater than 400, give 10 units of insulin and call the physician.

The order further read to hold the morning insulin dose on Monday, Wednesdays, and Fridays (the resident ' s dialysis days.)

Review of Resident 220's May 2024 Medication Administration Record revealed the resident received insulin on Monday, Wednesday, and Friday mornings on the following dates:

Friday, May 3, 2024, at 6:00 a.m. the resident was given 10 units of insulin for a blood sugar of 377
Monday, May 6, 2024, at 6:00 a.m. the resident was given 4 units of insulin for a blood sugar of 208
Wednesday, May 8, 2024, at 6:00 a.m. the resident was given 10 units of insulin for a blood sugar of 385
Monday, May 13, 2024, at 6:00 a.m. the resident was given 8 units of insulin for a blood sugar of 339
Friday, May 17, 2024, at 6:00 a.m. the resident was given 4 units of insulin for a blood sugar of 221
Monday, May 20, 2024, at 6:00 a.m. the resident was given 8 units of insulin for a blood sugar of 305

Further review of Resident 220's physician's orders revealed an order dated May 15, 2024, that the facility "May adjust medication times on dialysis days as needed."

Further review of Resident 220's physician's orders revealed orders dated May 1, 2024 for Bisacodyl (laxative) 5 milligrams (mg) one time a day at 8:00 a.m., Bumetanide (diuretic) 2mg one time daily at 8:00 a.m., Docusate Sodium (stool softener) 100mg once daily at 8:00 a.m., probiotic one capsule one time daily at 8:00 a.m., umeclidinium-vilanterol (inhaler used to treat wheezing and shortness of breath) one puff daily at 8:00 a.m., calcium acetate 667mg two capsules three times daily, lactulose (used to treat cirrhosis) oral solution 20 grams/30 milliliters give 30 mls three times daily, Sevelamer Carbonate (a medication used to treat an increased level of phosphate in the blood) 800 mg two tablets three times daily, and albuterol sulfate (inhaler that relaxes muscles in the airways and increases air flow to the lungs) two puffs every four hours.

Review of Resident 220's May 2024 MAR revealed the resident did not receive the abovementioned medications 8:00 a.m. doses on Mondays, Wednesdays, and Fridays, due to the resident being out of the facility at dialysis. There was no documentation to show the medications were offered when the resident returned from dialysis.

Interview with the Nursing Home Administrator on May 22, 2024, at approximately 1:30 p.m. confirmed the above findings.

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

Plan of Correction - To be completed: 07/11/2024

Preparation and/or execution of this plan of correction does not constitute an admission or agreement by the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of Federal and State Law. The plan of correction represents the facility's credible allegation of compliance.
F760 Nursing services: free from significant med errors.
1. Resident R 220 is receiving medications per physician orders.
2. An audit of residents on insulin sliding scale will be reviewed to ensure insulins are being administered per physician orders. An audit of residents with special instructions on medication orders are being administered per physician order.
3. Staff Development or designee will in-service licensed staff on administering medication as ordered.
4. DON or designee will complete random audits weekly x 4 to ensure that residents medications are administered as ordered. The audits will be reviewed by the QAPI committee and the QAPI committee will determine the need for further audits.
5. Date of Compliance: 7/11/2024

483.60(g) REQUIREMENT Assistive Devices - Eating Equipment/Utensils:

§483.60(g) Assistive devices
The facility must provide special eating equipment and utensils for residents who need them and appropriate assistance to ensure that the resident can use the assistive devices when consuming meals and snacks.

Observations:

Based on observation, resident, and staff interviews, it was determined that the facility failed to ensure assistive devices for eating were made available for one of the 18 residents reviewed (Resident 189).

Findings include:

Review of resident 189's diagnosis list includes Diabetes with Mononeuropathy (nerve damage caused by high blood sugar levels), legal blindness, and Brachial plexus disorder (An injury in the network of nerve fibers that innervates the skin and musculature of the upper extremity. It causes a burning sensation, numbness or weakness of the arm, severe pain, and inability to move or feel the affected arm).

Review of Resident 189's Quarterly Minimum Data Set (MDS- standardized assessment tool that measures health status in long-term care residents) dated May 3, 2024, revealed Resident 189 was cognitively intact. The same MDS revealed resident had one side impairment of the upper extremity.

Interview was conducted with Resident 189 on May 21, 2024, at 12:10 p.m. The resident reported that due to limitations on his/her hands/fingers, he was provided with a "special" kind of spoon and fork, and plate to use during meals but has not been provided to him/her during meals for more than a month now.

Observation in the presence of licensed nurse Employee E3 was conducted on May 22, 2024, at 8:40 a.m., and revealed resident's meal was served on a regular plate and was provided with a regular spoon and fork.

Review of the resident breakfast meal ticket dated May 22, 2024, revealed adaptive equipment: scoop plate; large, handled fork; left-handed spoon.

Interview with Licensed nurse, Employee E3 was conducted on May 22, 2024, at 8:45 a.m., and confirmed Resident 189 uses an adaptive utensil and a scoop plate during mealtime. Employee E3 does not know the reason why Resident was not provided with his/her adaptive spoon and plate.

Interview with non licensed, Employee E4 was conducted on May 22, 2024, at 8:48 a.m. Employee E4 reported being the regular nurse aide of Resident 189. Non licensed, Employee E4 reported that she/he was informed that the resident's adaptive utensils and plate comes from the kitchen. Employee E4 reported that the kitchen had not sent the resident's adaptive equipment for eating for almost a month now.

Review of the Occupational Therapy notes dated October 24, 2023, revealed Resident will use built-up utensils and scoop plates with supervision during mealtime to increase participation and independence with successful mealtimes for self-feeding.

Interview with the Rehabilitation Director, Employee E5 was conducted on May 22, 2024, at 11:00 a.m., who confirmed that OT recommended that the resident use an adaptive equipment device for eating on October 24, 2023.

The facility failed to ensure Resident 189 was provided with the recommended adaptive equipment device during mealtime.

28 Pa. Code: 211.5(f) Clinical records

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

§ 201.22(a) LICENSURE Prevention, control and surveillance of tuber:

(a) The facility shall have a written TB infection control plan with established protocols which address risk assessment and management, screening and surveillance methods, identification, evaluation, and treatment of residents and employees who have a possible TB infection or active TB.

Observations:
Based on staff record review and staff interview it was determined the facility failed to screen for tuberculosis prior to hire for 2 of 5 records reviewed. (Employees E7 and E8)

Findings Include:

Review of Employee E7 employee file revealed a hire date of March 18, 2024. Review of Employee E7 entire employee file revealed there was no evidence Employee E7 was tested for tuberculosis prior to hire.

Review of Employee E8 employee file revealed a hire date of March 11, 2024. Review of Employee E8 entire employee file revealed there was no evidence Employee E8 was tested for tuberculosis prior to hire.

Interview with the Nursing Home Director on May 22, 2024 at 2:15 p.m. confirmed Employees E7 and E8 were not tested for tuberculosis prior to hire.

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