Pennsylvania Department of Health
MONTGOMERY SUBACUTE AND RESPIRATORY CENTER
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

MONTGOMERY SUBACUTE AND RESPIRATORY CENTER
Inspection Results For:

There are 90 surveys for this facility. Please select a date to view the survey results.

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MONTGOMERY SUBACUTE AND RESPIRATORY 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, completed on July 26, 2024, it was determined that Montgomery Subacute and Respiratory Center was not in compliance with the following requirements for Long Term Care and the 28 Pa. Code, Commonwealth of Pennsylvania Long Term Care Regulations as they relate to the health portion of the survey.

Plan of Correction:

483.12 REQUIREMENT Free from Misappropriation/Exploitation:

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.

§483.12
The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms.

Plan of Correction - To be completed: 08/20/2024

a. Residents R18, R21, R29, R49, and R165 were assessed for pain on 05/08/2024 with no further variances noted
b. An audit was completed of current residents to review narcotic counts and documentation. Variances were addressed at the time of the audit and placed on the facility audit tool.
c. The DON/Designee will complete re-education with licensed staff regarding the policy and procedure for narcotic distribution, narcotic counts, as well as documentation regarding audits.
d. The DON/Designee will complete five random audits of current residents to ensure that narcotic counts and narcotic documentation are being completed appropriately three times per week for two weeks, weekly for four weeks and monthly for two months. Audit findings will be submitted to the Quality Assurance and Performance Improvement committee for review and recommendations as needed.

483.10(g)(14)(i)-(iv)(15) REQUIREMENT Notify of Changes (Injury/Decline/Room, etc.):

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

§483.10(g)(14) Notification of Changes.
(i) A facility must immediately inform the resident; consult with the resident's physician; and notify, consistent with his or her authority, the resident representative(s) when there is-
(A) An accident involving the resident which results in injury and has the potential for requiring physician intervention;
(B) A significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications);
(C) A need to alter treatment significantly (that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment); or
(D) A decision to transfer or discharge the resident from the facility as specified in §483.15(c)(1)(ii).
(ii) When making notification under paragraph (g)(14)(i) of this section, the facility must ensure that all pertinent information specified in §483.15(c)(2) is available and provided upon request to the physician.
(iii) The facility must also promptly notify the resident and the resident representative, if any, when there is-
(A) A change in room or roommate assignment as specified in §483.10(e)(6); or
(B) A change in resident rights under Federal or State law or regulations as specified in paragraph (e)(10) of this section.
(iv) The facility must record and periodically update the address (mailing and email) and phone number of the resident
representative(s).

§483.10(g)(15)
Admission to a composite distinct part. A facility that is a composite distinct part (as defined in §483.5) must disclose in its admission agreement its physical configuration, including the various locations that comprise the composite distinct part, and must specify the policies that apply to room changes between its different locations under §483.15(c)(9).

Observations:

Based on review of clinical records, review of facility policies and procedures and interviews with staff, it was determined that the facility failed to promptly notify a resident's representative and physician of a skin impairment for one of 15 residents reviewed. (Resident R28).

Findings include:

1. Review of an undated facility policy titled "Change in a Resident's Condition or Status", revealed "

a.The nurse will notify the resident's attending physician or physician on call when there has been a(an)
b. accident or incident involving the resident;
c. discovery of injuries of an unknown source;
d. adverse reaction to medication;
e. significant change in the resident's physical/emotional/mental condition;
f. need to alter the resident's medical treatment significantly;
g. refusal of treatment or medications two (2) or more consecutive times);
h. need to transfer the resident to a hospital/treatment center;
i. discharge without proper medical authority; and/or
j. specific instruction to notify the physician of changes in the resident's condition.

4. Unless otherwise instructed by the resident, the Nurse Supervisor/Charge Nurse will notify the resident's family or representative (sponsor) when:
e. The resident is involved in any accident or incident that results in an injury including injuries of an unknown source;
f. There is a significant change in the resident's physical, mental, or psychosocial status;
g. There is a need to change the resident's room assignment;
h. A decision has been made to discharge the resident from the facility; and/or
i. It is necessary to transfer the resident to a hospital/treatment center."

Interview with Resident R28's wife on July 19, 2024, at 1:10 p.m. stated back in April she saw a bump and a cut with dried blood in the middle of the bump on resident's forehead. She stated resident did not have any brace or hard surface next to the injury when she saw it. She stated she was concerned about the injury and was upset that the facility did not notify her about the injury before she identified.

Review of facility investigation dated April 18, 2024, revealed that Resident R48's wife reported to the Life Enrichment Director and Director of Nursing that her husband had a skin tear noted on his forehead. The Director of Nursing immediately assisted the resident back to his room to assess the skin tear. The skin tear was noted to be 4 centimeters (cm) long and 0.5cm wide with a red base and pink surrounding area. The resident's wife expressed concern and stated she wanted the resident to be sent to the Emergency Department for evaluation and treatment. The resident's physician was called to inform of the new skin condition for the resident and gave the order for the resident to be transferred to the Emergency Department. The wound care nurse and nurse supervisor also assessed the resident and noted the skin tear above the left eyebrow.

Investigation also revealed that facility interviewed and obtained statements from the nurse and the nurse aide the night before the injury was reported.

Review of statements from Employee E8, Licensed Practical Nurse, who worked on 7:00 p.m. to 7:00 a.m. shift of April 17, 2024, revealed that she did not observe any injury to Resident R28.

Review of statements from Employee E9, Nurse Aide, who worked on 7:00 p.m. to 7:00 a.m. shift of April 17, 2024, revealed that she did observe injury to Resident R28 and reported to Employee E10, Licensed Practical Nurse.

Review of statements from Employee E10 Licensed Practical Nurse, who worked on 7:00 p.m. to 7:00 a.m. shift of April 17, 2024, revealed that he was notified by the aide to a wound on Resident R28's forehead. He observed that the resident had a dark brown patch on the right side of the forehead. He was not assigned to the resident so he though the aide would pass the information to resident's nurse.

Review of statements from Employee E11, Nurse Aide, who worked on 7:00 a.m. to 7:00 p.m. shift of April 18, 2024, revealed that soon after she provided care to Resident R28 she noticed he had a red spot on his head. The area was dry. However, the statement did not reveal any evidence that she reported this to the nurse or the supervisor.

Observation of an image of resident's injury with the administrator revealed that the resident had a red colored skin impairment to the forehead with the surrounding area had raised skin, appeared like swelling.

Review of Resident R1's entire clinical record revealed no documented evidence that Resident R28's physician was notified when the Employee E9 observed the skin impairment on April 17, 2024, 7:00 p.m. to 7:00 a.m. shift and when Employee E11 observed the skin impairment on April 18, 2024

Review of Resident R1's clinical record also revealed no documented evidence that Resident R28's responsible party was notified when the Employee E9 observed the skin impairment on April 17, 2024, 7:00 p.m. to 7:00 a.m. shift and Employee E11 observed the skin impairment on April 18, 2024

Interview with Director of Nursing, Employee E2, on July 19, 2024, at 2:00 p.m. confirmed that the facility documentation did not reveal evidence that the Resident R1's responsible party and physician was notified of Resident R28's skin impairment when it first observed by Employee E9 and later when Employee E11 observed the skin impairment.

28 Pa. Code 201.29(a) Resident Rights

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

Plan of Correction - To be completed: 08/20/2024

a. Resident R28's Physician was notified of the skin impairment on 04/18/2024 after the skin incident.
b. An audit was conducted of resident incidents for the past 30 days to ensure that the resident's physician was notified promptly. Variances will be addressed at the time of the audit and placed on the facility audit tool.
c. The DON/Designee will re-educate licensed staff on the policy and procedure for Physician notification regarding resident changes in condition.
d. The DON/Designee will complete 5 random audits of resident alterations in skin integrity to ensure the resident's physician has been notified promptly three times per week for two weeks, weekly for four weeks and monthly for two months. Audit findings will be addressed and submitted to the Quality Assurance Performance Improvement Committee for further review and recommendations.

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.

Observations:

Based on review of facility policy, resident's clinical record, observation, and staff interview, it was determined that the facility failed to ensure that proper infection control procedures was followed during medication administration for two of four residents observed (Resident R8 and Resident R41).

Findings:

Review facility policy on "Administering Medications" reveal that under Section "Policy Statement", medications are administered in a safe and timely manner and as prescribed. Under section Policy and Interpretation and Implementation: #25 revealed that staff follows established facility infection control procedures. Examples: hand washing, antiseptic technique, gloves, isolation precautions etcetera for the administration of medications as applicable.

Review facility policy on "Hand Washing/Hand Hygiene", revealed that under a section "Policy Statement", this facility considers hand hygiene the primary means to prevent the spread of health associated infection. Under section "Policy Interpretation and Implementation", Administrative Practices to Promote Hand Hygiene #1 All personnel are trained and regularly in serviced on the importance of hand hygiene in preventing the transmission of healthcare associated infection. #2 All personnel are expected to adhere to hand hygiene policies and practices to help prevent the spread of infections to other personnel, residents, and visitors. Under Indications for Hand Hygiene #1 hand hygiene is indicated for #a. Immediately before touching a resident. #b. Before performing an aseptic task. #d. After touching a resident. #e. After touching the resident's environment. #f. Before moving from work on a soil body site to a clean body site on the same resident and #g. Immediately after glove removal.

Medication Administration observation conducted on July 17, 2024, at 8:41am with Employee E3 revealed that during medication administration, Employee E3 was observed administering Fluticasone nasal spray to Resident R8.

Further observation revealed that Employee E3 inserted the nasal applicator/nozzle of the Fluticasone nasal spray into resident R8's right nostrils, sprayed the Fluticasone nasal spray into the Resident R8's right nostrils. Further, Employee E3 then proceeded to remove the nasal applicator/nozzle of the Fluticasone nasal spray from Resident R8's right nostrils and proceeded to insert it into Resident R8's left nostrils without disinfecting, sanitizing, or wiping the nasal applicator/nozzle. Employee E3 then proceeded to spray the Fluticasone nasal spray into resident R8's right nostrils, withdraw the nasal applicator/nozzle out and proceeded to replace the Fluticasone nasal spray back into its box.

Further observation revealed that during medication administration for Resident R41, Employee E3 did not wash/sanitize her hands before putting on gloves. Employee E3 then proceeded to go to Resident R41's room and placed the medications on top of the overhead table. Employee E3 then proceeded to check the Resident R41's heat rate by auscultating (listening to using a stethoscope) Resident R41's chest. After auscultating Resident R41's chest, Employee E3 proceeded to check Resident R41's PEG placement by removing resident R41's gown and auscultation Resident R41's abdomen. Employee E3 then proceeded to administer Resident R41's, medication without washing, sanitizing her hands, or changing her gloves. Further, Employee E3 then proceeded to administer Resident R41's artificial tears eye drops with the same gloves. Resident R41 refused the artificial tears eye drop.

28 Pa. Code 201.14(a) Responsibility of licensee

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

Plan of Correction - To be completed: 08/20/2024

a. The Licensed Nurse was immediately educated on the need for handwashing during medication administration when switching routes of administration on 07/16/2024.
b. A random audit was conducted on random medication administration passes to ensure that appropriate handwashing was completed when applicable. Variances were addressed at the time of the audit and placed on the facility audit tool.
c. The DON/Designee re-educated licensed staff on the proper infection control techniques as well as the policy and procedure for proper handwashing.
d. The DON/Designee will complete random audits on alternating shifts of medication administration to ensure appropriate Infection Prevention and Control techniques are completed three times per week for two weeks, weekly for four weeks and monthly for two months. Audit findings will be submitted to the Quality Assurance and Performance Improvement committee for review and recommendations as needed.

483.60(i)(1)(2) REQUIREMENT Food Procurement,Store/Prepare/Serve-Sanitary:

§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 observations, interviews with staff, and a review of facility policies and documentation, it was determined that the facility did not ensure that food was stored, prepared, distributed, and served in accordance with professional standards for food service safety.

Findings include:

The November 2022, policy "Food Receiving and Storage" states, "All food stored in the refrigerator and freezer are covered, dates and labeled. Refrigerated foods are labeled, dated and monitored so they are used by their "use-by" date, frozen, or discarded. Functioning of the refrigeration and food temperatures are monitored daily and at designated intervals throughout the day by the food and nutrition services manager or designee and documented according to state-specific requirements. Refrigerators must have working thermometers and are monitored for temperature according to state-specific guidelines.

An initial tour of the Food Service Department was conducted on July 16, 2024, at 9:24 a.m. with Employee E13, Food Service Director (FSD), which revealed the following:

The facility staff was washing dishes using hot water dish machine. The label on the dish machine read the required temperature for washing cycle as Wash-150 and Rinse 180.

The temperature read at the time of washing the dish at 9:43 a.m. as wash 140 and rinse 130. The temperature did not go up to the required temperature during the process. It was observed that the employee removed dishes from the dish washer and took it back to the kitchen to storage. During the observation surveyor asked if the dishes were washed and clean and the employee said "yes"

Interview with Employee E13 on July 16, 2024, at 9:50 p.m. stated the dishes are not clean and disinfected if the required temperature was not met.

Observation of the refrigerator with Employee E13 revealed that there were expired beats, expired cranberry sauce and bags of bread, bagels and burger bun with no expiration date or open date. Employee E13 stated the above food items should be discarded.

Observation inside the kitchen revealed that there was ice machine inside the kitchen. A cleaning log was displayed above the kitchen with monthly cleaning schedule. Further observation revealed that the last ice machine cleaning was completed in May and the June and cleaning was documented as completed.

Observations of resident room 304 revealed that there was a refrigerator inside resident's room. It was observed that there was left over food and other food items in the refrigerator without any labelling. There was no documentation available at the location for temperature monitoring. It was observed that the resident in the room, Resident R18, had a tracheostomy (a permanent or temporary opening in the neck that's surgically created to provide an alternative airway for breathing) tube and had a BIMS(Brief Interview for Mental Status- a tool to assess cognitive function) score of 11 which indicated that the resident's cognitive ability was moderately impaired.

Interview with the FSD at 12:00 p.m. on July 19, 2024, confirmed the there was no temperature monitoring for the refrigerator in resident room 304 and it was the staff's responsibility to clean, date and monitor the refrigerator.

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

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

Plan of Correction - To be completed: 08/20/2024

a. The refrigerator in the resident's room was immediately assessed for proper labeling, dating and temperature. The dish machine was checked immediately to ensure that the temperature was appropriate. Also, the food items noted were discarded as appropriate on 07/19/2024.
b. An audit was completed of resident rooms to ensure if a refrigerator is present, that the contents were checked for labeling, dating and temperature. No further variances identified. A random audit was conducted of the dish machine water temperatures on subsequent cleanings at various times to ensure the temperature was holding appropriately. No further variances were identified. An audit was conducted in the kitchen storage areas to ensure that supplies were labeled and dated appropriately. Variances were addressed at the time of the audit and placed on the facility audit tool.
c. The NHA/Designee re-educated the Dietary Director on the policy and procedures for food procurement and storage, appropriate dish machine temperatures and resident personal refrigerators.
d. The NHA/Designee will complete random audits of dish machine water temperatures, resident personal refrigerators and kitchen storage to ensure that water temperatures are appropriate, resident personal food items are labeled and dated appropriately, personal refrigerators are at the correct temperatures and that food storage items are labeled and dated appropriately three times per week for two weeks, weekly for four weeks and monthly for two months. Audit findings will be submitted to the Quality Assurance and Performance Improvement committee for review and recommendations as needed.

483.45(g)(h)(1)(2) REQUIREMENT Label/Store Drugs and Biologicals:

§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:

Review of clinical records, review of facility policy, observation and staff interview, it was determined that the facility failed to ensure that all drugs and biologicals are stored and labeled in accordance with professional standards for one of three medication carts observed. (Medication carts: McKracken Nursing Unit Front, McKracken Nursing Unit Back and Senton Nursing Unit)

Findings include:

Review facility policy on administering medications reveal that under Section "Policy Statement", medications are administered in a safe and timely manner and as prescribed. Under section "Policy and Interpretation and Implementation" #2 Director of Nursing Services supervises and directs all personnel who administer medications and or have related functions. #19. During administration of medications, the medication cart is kept closed and locked when out of sight of the medication nurse or aid. It may be kept in the doorway of the residence room with open drawers facing inwards and all other sides closed. No medications are kept on top of the cart. The cart must be clearly visible to the person administering medications, and all outward sides must be inaccessible to residents or others passing by.

Review of facility policy on "Controlled Substances" with most recent revision date of 2022 revealed that under section "Policy Statement" the facility complies with all laws, regulations and other requirements relating to handling, storage, disposal, and documentation of a controlled medication. Section "Policy Interpretation and Implementation" revealed that: Handling Controlled Substances #1. Only authorized licensed nursing and or pharmacy personnel have access to Schedule II controlled substances maintained on premises, #2. The Director of Nursing services identify staff members who are authorized to handle controlled substances.

Review of Resident R8's clinical record revealed that Resident R8 was admitted to the facility on March 14, 20216 with diagnoses of but not limited to Chronic Respiratory Failure, Hemiplegia/Hemiparesis affecting the right dominant side, Insomnia, Generalized Anxiety Disorder.

Review of Resident R8's physician's orders revealed an order for Clonazepam Tablet 0.5 MG *Controlled Drug* Give 0.5 mg by mouth one time a day related to Generalized Anxiety Disorder Hold for sedation with order date of June 22, 2023.

Medication Administration observation conducted on July 17, 2024, at 8:41 am with Employee E3 revealed that during medication administration process, Employee E3 was observed removing Clonazepam Tablet 0.5 MG from the medication cart's narcotic box and logged the Clonazepam Tablet 0.5 MG that was removed into the narcotic book.

Further observation revealed that Employee E3 crushed the Clonazepam Tablet 0.5 MG together with the other pills. Further, Employee E3 placed the crushed pills (including the crushed Clonazepam Tablet 0.5 MG) on top of the medication cart and went into Resident R8's room which was located two doors away from where the cart was located, went into the room, and left the medication cup containing the crushed medication which also contained the crushed Clonazepam Tablet 0.5 MG unattended.

Interview with Employee 8 conducted at the time of the observation reveled that she went int the room to take Resident R3's vital signs. Further Employee E3 also confirmed that she left the crushed Clonazepam Tablet 0.5 MG on the medication cart unattended.

28 Pa. Code 2018(b)(l) management

28 Pa. Code 211.12(d) Nursing services

28 Pa. Code 211.9(i) Pharmacy services

Plan of Correction - To be completed: 08/20/2024

a. Resident R8's controlled medication was administered on 07/17/2024.
b. A random medication administration observation was completed of nurses administering resident medications to ensure medications were not left unattended on the medication carts. Variances were addressed at the time of the audit and placed on the facility audit tool.
c. The DON/Designee re-educated the licensed staff on the policy and procedure for medication administration to include leaving medication unattended while preparing for administration.
d. The DON/Designee will complete random audits of medication administrations to ensure that medications are not left unattended during administration three times per week for two weeks, weekly for four weeks and monthly for two months. Audit findings will be submitted to the Quality Assurance and Performance Improvement committee for review and recommendations as needed.

483.45(c)(3)(e)(1)-(5) REQUIREMENT Free from Unnec Psychotropic Meds/PRN Use:

§483.45(e) Psychotropic Drugs.
§483.45(c)(3) A psychotropic drug is any drug that affects brain activities associated with mental processes and behavior. These drugs include, but are not limited to, drugs in the following categories:
(i) Anti-psychotic;
(ii) Anti-depressant;
(iii) Anti-anxiety; and
(iv) Hypnotic

Based on a comprehensive assessment of a resident, the facility must ensure that---

§483.45(e)(1) Residents who have not used psychotropic drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record;

§483.45(e)(2) Residents who use psychotropic drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs;

§483.45(e)(3) Residents do not receive psychotropic drugs pursuant to a PRN order unless that medication is necessary to treat a diagnosed specific condition that is documented in the clinical record; and

§483.45(e)(4) PRN orders for psychotropic drugs are limited to 14 days. Except as provided in §483.45(e)(5), if the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she should document their rationale in the resident's medical record and indicate the duration for the PRN order.

§483.45(e)(5) PRN orders for anti-psychotic drugs are limited to 14 days and cannot be renewed unless the attending physician or prescribing practitioner evaluates the resident for the appropriateness of that medication.

Observations:

Based on a review of clinical records, facility policy, and staff interview, it was determined that the facility failed to ensure that a physician provided a clinical rationale and the duration for the continued use of a PRN (as needed) psychotropic (affecting the mind) medication beyond 14 days for two of four residents reviewed (Resident R57 and R56).

Findings include:

Facility policy titled "Antipsychotic Medication Use" (revised 2019), indicated that "PRN orders for psychotropic medications are limited to 14 days. If the prescriber or attending physician believes it is appropriate to extend the PRN order beyond 14 days, he or she will document the rationale for extending the use and include the duration for the PRN order".

Clinical record review revealed Resident R57 was admitted to the facility June 28, 2024 with a diagnosis that included but not limited to Acute Respiratory Failure with Hypercapnia (inability of lungs to exchange oxygen and high levels of carbon dioxide properly), Cognitive Communication Deficit (communication difficulty caused by a cognitive impairment), and anxiety disorder.

Review of Resident R57 medication orders revealed a physician order initiated June 28, 2024 to administer Xanax 0.5 mg (anti-anxiety medication) orally (by mouth) every 8 hours as needed for anxiety. The medication order indicated a stop date of "indefinite", which lacked the required stop date within 14 days or a clinical rationale for continuing beyond 14 days.

During an interview on June 19, 2024, at 8:56 am, Employee E4, Regional Nurse, confirmed that Resident R57 lacked the required stop date within 14 days and a rationale for continued use beyond 14 days.

Review of pharmacy's consultant report for June 24, 2024, revealed a pharmacy consultant recommendation for Resident R56 which stated, " Recently admitted on Seroquel (quetiapine) with no clear diagnosis to support current use. Please consider obtaining a psychosocial workup along with performing a medical workup asap to assess for underlying causes of behaviors. Should the workups and nursing behavioral monitoring reveal no significant behaviors ... of a chronic psychiatric condition, please consider implementing a tapering schedule and/or discontinue Seroquel."

Further review of the report revealed that the physician commented and signed to the recommendation and signed on June 28, 2024, with recommendation for psych consult. There was no evidence that the facility implemented the recommendation to complete a psych consult.

Review of physician order for Resident R56 dated June 21, 2024 revealed an order for Seroquel 100 mg at bed time for restlessness and agitation which was not approved diagnosis for Seroquel.

28 Pa. Code 211.2 (d)(3)(9) Medical Director.

28 Pa. Code 211.9 (k) Pharmacy Services.

Plan of Correction - To be completed: 08/20/2024

a. Resident R56 and R57's primary physician was notified of the discrepancy in their psychotropic orders and adjustments were made as ordered on 7/22/2024.
b. An audit was conducted of current residents receiving psychotropic medications to ensure that PRN psychotropic medications have a 14-day stop date unless otherwise specified, appropriate diagnoses are written within the physician's orders, and physician recommendations are completed on pharmacy recommendations. Variances were addressed at the time of the audit and placed on the facility audit tool.
c. The DON/Designee re-educated licensed staff on the policy and procedure for Psychotropic Medications to include PRN medication 14-day stop dates and appropriate diagnoses for specific medications. Also, licensed staff were re-educated on the policy and procedure for Pharmacy Consultant Recommendations.
d. The DON/Designee will complete random audits of residents prescribed PRN psychotropics for stop dates, new psychotropic medications for appropriate diagnoses, and pharmacy consultant recommendations to ensure physician recommendations are completed timey three times per week for two weeks, weekly for four weeks and monthly for two months. Audit findings will be submitted to the Quality Assurance and Performance Improvement committee for review and recommendations as needed

483.45(c)(1)(2)(4)(5) REQUIREMENT Drug Regimen Review, Report Irregular, Act On:

§483.45(c) Drug Regimen Review.
§483.45(c)(1) The drug regimen of each resident must be reviewed at least once a month by a licensed pharmacist.

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

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

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

Observations:

Based on review of clinical records and staff interviews, it was determined that the facility failed to ensure a response to the consultant pharmacist's recommendation related to the potentially unnecessary medications in a timely manner for two of five residents reviewed. (Resident R63 and Resident R8).

Findings include:

Review of pharmacy's consultant report for April 15, 2024, revealed a pharmacy consultant recommendation for Resident R23 which stated, "Currently receiving hydroxyzine (Atarax) scheduled for prevention of depression. Please note per survey guidelines hydroxyzine is "Not appropriate for use as an antidepressant. Consider discontinue now, if appropriate"." Further review of the report revealed that the physician agreed and signed to the recommendation and signed on May 7, 2024, with diagnosis changed to pruritis(an irritating sensation that makes you want to scratch). There was no evidence that the facility implemented the recommendation until July 2, 2024

Review of pharmacy's consultant report for May 19, 2024, revealed a pharmacy consultant recommendation for Resident R23 which stated, "Currently receiving hydroxyzine (Atarax) scheduled for prevention of depression. Please note per survey guidelines hydroxyzine is "Not appropriate for use as an antidepressant"." Further review of the report revealed that the physician commented and signed to the recommendation and signed on June 12, 2024, with diagnosis changed to anxiety. There was no evidence that the facility implemented the recommendation until June 15, 2024

Review of pharmacy's consultant report for June 8, 2024, revealed a pharmacy consultant recommendation for Resident R23 which stated, "Currently receiving hydroxyzine (Atarax) scheduled for prevention of depression. Please note per survey guidelines hydroxyzine is "Not appropriate for use as an antidepressant. Consider discontinue now, if appropriate"." Further review of the report revealed that the physician agreed and signed to the recommendation and signed on July 2, 2024, with diagnosis changed to pruritis (an irritating sensation that makes you want to scratch). There was no evidence that the facility implemented the recommendation until July 2, 2024

Review of pharmacy's consultant report for June 8, 2024, revealed a pharmacy consultant recommendation for Resident R51 which stated, "Resident is receiving the antipsychotic agent Aripiprazole, but lack an allowable diagnosis to support its use. The following DSM-IV are considered appropriate diagnosis/conditions." The options included affective disorder. Further review of the report revealed that the physician agreed to the recommendation and signed on July 2, 2024.

Review of physician order for Resident R51 dated May 23, 2024, revealed an order for Aripiprazole 15 mg once a day for adverse effect of unspecified antipsychotics and neuroleptics. This was not the approved diagnosis per physician recommendations on July 2, 2024 and from the list of approved diagnosis/condition for antipsychotics.

Interview held on July 19, 2024, at 1:11 p.m. with the Director of Nursing, Employee 2 confirmed that the pharmacy consultant recommendations for Resident R51 and Resident R23 was not completed in a timely manner and Resident R51's recommendation of June 8, 2024 was not implemented as approved by the physician.

28 Pa. Code 211.9(k)Pharmacy services

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

Plan of Correction - To be completed: 08/20/2024

a. Resident R23 and R51's pharmacy recommendations were reviewed to ensure that all ordered measures had been taken on 08/13/2024.
b. An audit was completed of the prior 60 days of completed pharmacy regimen reviews were completed within the timeframe laid out in the policy and completed within the resident's medical record. Variances were addressed at the time of the audit and placed on the facility audit tool.
c. The DON/Designee re-educated the Clinical Nurse Leads on the policy and procedure for completion of the Pharmacy Recommendation Reviews.
d. The DON/Designee will complete random audits of pharmacy recommendation reviews to ensure timeliness and thorough completion was conducted appropriately weekly for four weeks and monthly for two months. Audit findings will be submitted to the Quality Assurance and Performance Improvement committee for review and recommendations as needed.

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

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

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

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

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

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

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

Observations:

Based on the review of facility documentation, clinical records, staff and resident interviews, it was determined that the facility failed to provide necessary pharmaceutical services for three of 15 residents reviewed. (Resident R22, R44 and R2)

Findings include:

Review of facility policy "Administering Medications" dated April 2019 revealed that "

Medications are administered in accordance with prescriber orders, including any required time frame. Medication administration times are determined by resident need and benefit, not staff convenience. Factors that are considered include:
a. enhancing optimal therapeutic effect of the medication;
b. preventing potential medication or food interactions; and
c. honoring resident choices and preferences, consistent with his or her care plan.

Medications are administered within one (1) hour of their prescribed time, unless otherwise specified (for example, before and after meal orders)."

Review of physician orders for Resident R22 revealed an order dated July 12, 2024, for Macrobid oral capsule 100 mg two times a day for urinary tract infection. The medication was originally scheduled to start at 8:00 p.m. on July 12, 2024.

Review of Medication Administration Record for Resident R22, revealed that resident did not receive the medication until July 13, 2024, until 1:00 p.m.

Review of clinical record revealed that the medication was not available to be administered.

Interview with Regional Nurse, Employee E4, on July 19, 2024. At 10:33 a.m. stated the medication was not available to be administered as ordered. Employee E4 stated the medication should have been administered on the same day which was ordered to treat urinary tract infection.

Review of physician orders for Resident R44 revealed an order dated July 15, 2024, for Macrobid oral capsule 100 mg two times a day for fever. The medication was originally scheduled to start at 8:00 p.m. on July 15, 2024.

Review of Medication Administration Record for Resident R44, revealed that resident did not receive the medication until July 16, 2024, until 9:00 p.m.

Review of clinical record revealed that the medication was not available to be administered.

Interview with Regional Nurse, Employee E4, on July 19, 2024. At 10:33 a.m. stated the medication was not available to be administered as ordered for Resident R44. Employee E4 stated the medication should have been administered on the same day.

Review of a progress note for Resident R2 dated July 15, 2024, revealed that resident was on antibiotic Zosyn intravenously for sputum infection based on culture and sensitivity lab result. Further review of the progress note revealed that outside provider was contacted to insert the intravenous line.

Review of progress note dated July 17, 2024, at 12:58 p.m. revealed that the outside provider was successful in placing the intravenous line and medication Zosyn was supposed to start on July 17, 2024. Continued review of the progress note revealed that the medication was not available from the pharmacy.

Review of physician orders for Resident R2 revealed an order dated July 15, 2024, for Macrobid oral capsule 100 mg two times a day for fever. The medication was originally scheduled to start at 8:00 p.m. on July 15, 2024.

Review of Medication Administration Record for Resident R2, revealed that resident did not receive the medication until July 17, 2024, until 9:00 p.m.

Review of clinical record revealed that the medication was not available to be administered.

Interview with Regional Nurse, Employee E4, on July 19, 2024. At 10:33 a.m. stated the medication was not available to be administered as ordered for Resident R2. Employee E4 stated the medication should have been administered on the same day.

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

28 Pa. Code: 211.9(a)(1)(f)(2)(4)(g)(h)(k) Pharmacy services.

Plan of Correction - To be completed: 08/20/2024

a. The facility is unable to retroactively correct the delivery of resident R2, R22, and R44 identified medications.
b. An audit was completed of current residents recently ordered a new antibiotic to ensure that the medication was administered within an appropriate timeframe. Variances were addressed at the time of the audit and placed on the facility audit tool.
c. The DON/Designee re-educated the licensed staff on the policy and procedure for ordering medications and utilizing the Med Bank for initial doses if necessary.
d. The DON/Designee will complete 5 random audits of residents ordered new antibiotics to ensure that medication orders and deliveries were placed appropriately and the Med Bank was utilized if necessary three times per week for two weeks, weekly for four weeks and monthly for two months. Audit findings will be submitted to the Quality Assurance and Performance Improvement committee for review and recommendations as needed.

483.25(k) REQUIREMENT Pain Management:

§483.25(k) Pain Management.
The facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences.

Plan of Correction - To be completed: 08/20/2024

a. The resident was immediately assessed for pain and pain management was completed on 07/18/2024.
b. An audit was completed of residents receiving wound care for pressure injuries to ensure that pain evaluations had been completed prior to administering treatment changes. Variances were addressed at the time of the audit and placed on the facility audit tool.
c. The DON/Designee re-educated the licensed staff on the policy and procedure for pain management and pain evaluations prior to treatment changes.
d. The DON/Designee will complete 5 random audits of pain evaluation completion and intervention implementation prior to dressing changes for pressure injuries three times per week for two weeks, weekly for four weeks and monthly for two months. Audit findings will be submitted to the Quality Assurance and Performance Improvement committee for review and recommendations as needed.

483.25(h) REQUIREMENT Parenteral/IV Fluids:

§ 483.25(h) Parenteral Fluids.
Parenteral fluids must be administered consistent with professional standards of practice and in accordance with physician orders, the comprehensive person-centered care plan, and the resident's goals and preferences.

Observations:

Based on observations, reviews of clinical records, facility policies and procedures, and interviews with staff, it was determined that the facility failed to provide adequate treatment and care for intravenous catheter (IV) line in accordance with professional standards of practice for three of three residents reviewed with IV (Resident R6, R51, R28).

Findings include:

Review of facility policy "Peripheral And Midline IV Dressing Changes" dated March 2022 revealed that: The purpose of this procedure is to prevent complications associated with intravenous therapy, including catheter-related infections associated with contaminated, loosened or soiled catheter-site dressings.

Steps in the Procedure
1.Assemble equipment.
2.Perform hand antisepsis.
3.Remove old dressing from distal to proximal (towards the head) while placing pressure on the catheter to prevent dislodgement.
4.Clean insertion site with antiseptic solution per protocol.
5.Visually inspect and/or palpate the insertion site as described above. Use sterile gloves if there is a need to touch the insertion site.
6.Allow area to air dry.
7.Apply alcohol-free skin barrier if indicated. Allow to dry before applying the dressing.
8.Do not apply antibiotic ointment to insertion site as part of routine site care.
9.Place new dressing (TSM or gauze) over insertion site. Label dressing with the date and time of dressing change, and initials.

Observation of Resident R6 on July 16, 2024, at 10:30 a.m., revealed that the resident had a mid-line intravenous catheter to the left arm. There was no documentation of date on the dressing to indicate the date of insertion or dressing change.

Observation of Resident R51 on July 16, 2024, at 10:32 a.m., revealed that the resident had a mid-line intravenous catheter to the left arm. There was no documentation of date on the dressing to indicate the date of insertion or dressing change.

Observation of Resident R28 on July 16, 2024, at 10:48 a.m., revealed that the resident had a intravenous catheter to the right arm. There was no documentation of date on the dressing to indicate the date of insertion or dressing change.

Interview and observation with Employee E12, Licensed Practical Nurse on July 16, 2024, at 10:48 a.m., confirmed that IV lines of Resident R6, R51, and R28 did not have dressing date for insertion or dressing change. Employee E12 stated staff should date when inserting IV catheter or when changing the IV dressing.

28 Pa. Code: 211.10 (c) Resident care policies

Plan of Correction - To be completed: 08/20/2024

a. R6, R28, and R51 had intravenous line dressing changes on 07/19/2024.
b. An audit was completed of residents with intravenous line access to ensure that the dressings are dated appropriately. Variances were addressed at the time of the audit and placed on the facility audit tool.
c. The DON/Designee re-educated the licensed staff on the policy and procedure for changing and dating Intravenous line dressings.
d. The DON/Designee will complete 5 random audits of resident intravenous line dressings to ensure that the proper date was placed with the changes three times per week for two weeks, weekly for four weeks and monthly for two months. Audit findings will be submitted to the Quality Assurance and Performance Improvement committee for review and recommendations as needed.

483.25(c)(1)-(3) REQUIREMENT Increase/Prevent Decrease in ROM/Mobility:

§483.25(c) Mobility.
§483.25(c)(1) The facility must ensure that a resident who enters the facility without limited range of motion does not experience reduction in range of motion unless the resident's clinical condition demonstrates that a reduction in range of motion is unavoidable; and

§483.25(c)(2) A resident with limited range of motion receives appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion.

§483.25(c)(3) A resident with limited mobility receives appropriate services, equipment, and assistance to maintain or improve mobility with the maximum practicable independence unless a reduction in mobility is demonstrably unavoidable.

Observations:

Based on observations, review of clinical records, facility policies, and interview with staff, it was determined that the facility failed to ensure that a resident with limited range of motion, received appropriate services to prevent further decline in range of motion and maintain appropriate positioning for one of 15 residents reviewed. (Resident R16).

Finding Include:

Observation of Resident R16 on July 19, 2024, at 1:04 p.m. revealed that the resident was seated in Geri-chair (a large, padded chair that is designed to help seniors with limited mobility). Resident had contractures to upper and lower extremities and resident did not maintain a normal body alignment. Resident was not wearing a splint or brace.

Review of care plan for Resident R16 dated April 18, 2015, revealed a care plan which indicated that the resident had contracture with interventions to Bedside passive range of motion to bilateral lower extremity and upper extremity. Resident had ADL self-care deficit related to decline in overall function, decreased activity tolerance.

Further review of care plan for Resident R16 dated February 14, 2027, revealed that the resident had contractures of bilateral lower extremity and upper extremity. The care plan interventions included, bedside passive range of motion to Neck, bilateral lower extremity and upper extremity. Left resting hand splint on 4hrs on/off schedule. Bilateral elbow and knee splints for up to 8 hours. Pillow roll to offload right elbow and prevent right elbow from touching right thigh.

Review of active physician orders, treatment administration and nurse aide documentation for Resident R16 on July 19, 2024, revealed no evidence that the facility established a splint schedule for Resident R16, or implemented any interventions or services for Resident R16 for head/neck and extremity positioning or prevent further decline in functional range of motion.

Interview with Employee E2, Director of Nursing, on July 19, 2024, at 1:04 p.m.. confirmed that the resident had contracture to the extremities. Employee E2 also confirmed that there was no intervention or services for head/neck positioning, bilateral lower and upper extremities positioning or prevent further decline in functional range of motion.

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

28 Pa. Code: 201.18 (b)(2) Management

28 Pa. Code: 211.10 (d) Resident care policies

Plan of Correction - To be completed: 08/20/2024

a. Resident R16 was evaluated by therapy to evaluate the resident's splint/brace schedule and prevention of further contractures on ________________________.
b. An audit was completed of current residents with contractures to ensure that appropriate braces and splints are ordered according to therapy recommendations. Variances were addressed at the time of the audit and placed on the facility audit tool.
c. The DON/Designee re-educated licensed staff on the policy and procedure for brace and splint schedules and preventing contractures.
d. The DON/Designee will complete random audits of residents ordered braces and splints to ensure that wearing schedules are being followed as ordered three times per week for two weeks, weekly for four weeks and monthly for two months. Audit findings will be submitted to the Quality Assurance and Performance Improvement committee for review and recommendations as needed.

483.12(c)(2)-(4) REQUIREMENT Investigate/Prevent/Correct Alleged Violation:

§483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must:

§483.12(c)(2) Have evidence that all alleged violations are thoroughly investigated.

§483.12(c)(3) Prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress.

§483.12(c)(4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken.

Observations:

Based on review of clinical records, facility policies and procedures, interviews with staff, it was determined that the facility failed to conduct a complete and thorough investigation of one alleged violation of unknown source of injury for one of 15 residents reviewed. (Resident R28).

Findings include:

Review of the facility policy titled, "Abuse, Neglect, Exploitation or Misappropriation -, Reporting and Investigating" dated, September 2022, revealed, "All reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigations are documented and reported.

Upon receiving any allegations of abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source, the administrator is responsible for determining what actions (if any) are needed for the protection of residents.

The individual conducting the investigation as a minimum:
a. reviews the documentation and evidence;
b. reviews the resident's medical record to determine the resident's physical and cognitive status at the time of the incident and since the incident;
c. observes the alleged victim, including his or her interactions with staff and other residents;
d. interviews the person(s) reporting the incident;
e. interviews any witnesses to the incident;
f. interviews the resident (as medically appropriate) or the resident's representative;
g. interviews the resident's attending physician as needed to determine the resident's condition;
h. interviews staff members (on all shifts) who have had contact with the resident during the period of the alleged incident;
i. interviews the resident's roommate, family members, and visitors;
j. interviews other residents to whom the accused employee provides care or services;
k. reviews all events leading up to the alleged incident; and
l. documents the investigation completely and thoroughly"

Interview with Resident R28's wife on July 19, 2024, at 1:10 p.m. stated back in April she saw a bump and a cut with dried blood in the middle of the bump on resident's forehead. She stated resident did not have any brace or hard surface next to the injury when she saw it. She stated she was concerned about the injury and was upset that the facility did not notify her about the injury before she identified.

Review of facility investigation dated April 18, 2024, revealed that Resident R48's wife reported to the Life Enrichment Director and Director of Nursing that her husband had a skin tear noted on his forehead. The Director of Nursing immediately assisted the resident back to his room to assess the skin tear. The skin tear was noted to be 4cm long and 0.5cm wide with a red base and pink surrounding area. The resident's wife expressed concern and stated she wanted the resident to be sent to the Emergency Department for evaluation and treatment. The resident's Physician was called to inform of the new skin condition for the resident and gave the order for the resident to be transferred to the ED. The wound care nurse and nurse supervisor also assessed the resident and noted the skin tear above the left eyebrow.

Further review of the investigation revealed that an investigation was initiated immediately, and no perpetrator had been identified at that time. Facility interviewed the nurses, nurse aide and respiratory therapist on the hall, Facility also interviewed the staff on the previous day.

Review of facility investigation revealed that the facility was not able to identify the exact cause of the injury however concluded that it may have caused from a brace the resident wearing which might not have positioned properly.

Investigation also revealed that facility interviewed and obtained statements from the nurse and the nurse aide the night before the injury was reported.

Review of statements from Employee E8 Licensed Practical Nurse, who worked on 7:00 p.m. to 7:00 a.m. shift of April 17, 2024, revealed that she did not observe any injury to Resident R28.

Review of statements from Employee E9 Nurse Aide, who worked on 7:00 p.m. to 7:00 a.m. shift of April 17, 2024, revealed that she did observe injury to Resident R28 and reported to Employee E10, Licensed Practical Nurse.

Review of statements from Employee E10 Licensed Practical Nurse, who worked on 7:00 p.m. to 7:00 a.m. shift of April 17, 2024, revealed that he was notified by the aide to a wound on Resident R28's forehead. He observed that the resident had a dark brown patch on the right side of the forehead. He was not assigned to the resident so he though the aide would pass the information to resident's nurse.

Review of statements from Employee E11 Nurse Aide, who worked on 7:00 a.m. to 7:00 p.m. shift of April 18, 2024, revealed that soon after she provided care to resident R28 she noticed he had a red spot on his head. The area was dry. However, the statement did not reveal any evidence that she reported this to the nurse or the supervisor.

Observation of an image of resident's injury with the administrator revealed that the resident had a red colored skin impairment to the forehead with the surrounding area had raised skin, appeared like swelling.

Continued review of the investigation revealed that facility did not obtain statements or conducted interviews with other staff who provided care to the resident prior to the injury or other staff who worked on the unit which included respiratory therapists on both shifts.

Interview with the Administrator on July 19, 2024, at 2:00 p.m. stated confirmed that the facility investigation did not include statements from other staff who provided care to Resident R28 or other staff who worked on the unit which included respiratory therapists on both shifts,

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

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

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

Plan of Correction - To be completed: 08/20/2024

a. The facility is unable to retroactively continue the investigation regarding resident R28's skin issues.
b. An audit was completed for the prior 30 days of resident investigations regarding injuries of unknown origin to ensure that the investigation was comprehensive and all encompassing regarding the event. Variances were addressed at the time of the audit and placed on the facility audit tool.
c. The DON/Designee re-educated the licensed staff regarding the policy and procedure for thorough investigations of injuries of unknown origin.
d. The DON/Designee will conduct random audits of residents with injury of unknown origin to ensure that thorough and complete investigations have been completed three times per week for two weeks, weekly for four weeks and monthly for two months. Audit findings will be submitted to the Quality Assurance and Performance Improvement committee for review and recommendations as needed.

483.10(e)(1), 483.12(a)(2) REQUIREMENT Right to be Free from Physical Restraints:

§483.10(e) Respect and Dignity.
The resident has a right to be treated with respect and dignity, including:

§483.10(e)(1) The right to be free from any physical or chemical restraints imposed for purposes of discipline or convenience, and not required to treat the resident's medical symptoms, consistent with §483.12(a)(2).

§483.12
The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms.

§483.12(a) The facility must-

§483.12(a)(2) Ensure that the resident is free from physical or chemical restraints imposed for purposes of discipline or convenience and that are not required to treat the resident's medical symptoms. When the use of restraints is indicated, the facility must use the least restrictive alternative for the least amount of time and document ongoing re-evaluation of the need for restraints.

Observations:

Based on observation, a review of select facility's policy, clinical records review, and staff interviews, it was determined that the facility failed to ensure the evaluation of resident's need and use of restraints, including evaluation of the least restrictive measure needed to treat the resident's medical symptom and failed to obtain informed consent prior to the use of restraint for two of two sampled residents with residents reviewed. (Residents R22 and R56)

Findings include:

A review of a facility policy titled " Use of Restraints -," revised on April 2017 revealed Use of " Restraints shall only be used for the safety and well-being of the resident(s) and only after other alternatives have been tried unsuccessfully.
Restraints shall only be used to treat the resident's medical symptom(s) and never for discipline or staff' convenience, or for the prevention of falls
" When the use of restraints is indicated, the least restrictive alternative will be used for the least amount of time necessary, and the ongoing re-evaluation for the need for restraints will be documented.
Physical Restraints"' are defined as any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement or restricts normal access to one's body.
Restraints shall only be used upon the written order of a physician and after obtaining consent from the resident and/or representative (sponsor).
Prior to placing a resident in restraints, there shall be a pre-restraining assessment and review to determine the need for restraints. The assessment shall be used to determine possible underlying causes of the problematic medical symptom and to determine if there are less restrictive interventions (programs, devices, referrals, etc.) that may improve the symptoms.

Residents and/or surrogate/sponsor shall be informed about the potential risks and benefits all options under consideration, including the use of restraints, not using restraints, and the alternatives to restraint use."

Review of facility documentation (Informed Consent for the use of Restraint" revealed that the facility had a process of obtaining informed consent prior to the use of restraints including documentation of benefits, potential negative outcome, recommendation and the written acknowledgement of resident representative of the understanding of benefits and negative outcome of restraint use.

Observation Resident R22 on July 16, 2024, at 10:37 a.m. revealed that the resident was using hand mitt (a thumbless mitten device is used to restrain a patient's hands) to the left hand.

Clinical record review revealed that Resident R22 was admitted to the facility on April 2, 2024, with the diagnosis of person injured in motor vehicle accident and diffuse brain injury with loss of consciousness.

A review of the quarterly Minimum Data Set Assessment (MDS) - a federally mandated standardized assessment process conducted periodically to plan resident care) dated June 14, 2024, revealed Resident 22's BIMS interview (Brief Interview for Mental Status- a tool to assess cognitive function) was not completed; which indicated that the resident was unable to provide or did not provide answers to complete this section).

A physician order for Resident R22 dated May 20, 2024, revealed an order for hand mitt to left hand and remove every 2 hours for circulation and skin check for patient safety.

Review of clinical record for Resident R22 revealed no evidence that the resident was evaluated of resident's need and use of restraints, including evaluation of the least restrictive measure needed to treat the resident's medical symptom when the facility started using restraint for Resident R22.

Further review of clinical record for Resident R22 revealed no evidence that the facility obtained informed consent prior to the use of restraint.

Review of progress note for Resident R56 from June 21, 2024 to July 17, 2024 revealed that the facility applied restraint to Resident R56.

A physician order for Resident R56 dated June 22, 2024, revealed an order for bilateral soft hand mitt in place at all times to prevent from dislodging tubes and trach. Remove every 2 hours.
for range of motion and skin checks.

Review of clinical record for Resident R56 revealed no evidence that the resident was evaluated of resident's need and use of restraints, including evaluation of the least restrictive measure needed to treat the resident's medical symptom when the facility started using restraint for Resident R56.

Further review of clinical record for Resident R56 revealed no evidence that the facility obtained informed consent prior to the use of restraint.

Interview with Director of Nursing on July 17, 2024, at 1:30 p.m. confirmed that the facility did not evaluate Resident R56 and R22 of residents' need and use of restraints, including evaluation of the least restrictive measure needed to treat the resident's medical symptom when the facility started using restraint and obtained documented informed consent prior to the use of restraint.

28 Pa. Code 211.8 (c.1)(f) Use of restraints

28 Pa. Code 211.12(d) Nursing services

Plan of Correction - To be completed: 08/20/2024

a. Resident R22 and R56 had informed consent and a restraint evaluation completed for the ordered restraints on 07/22/2024
b. An audit was completed of current residents with restraints ordered for informed consents and restraint evaluations present in their medical record. Variances were addressed at the time of the audit and placed on the facility audit tool.
c. The DON/Designee re-educated licensed staff on the policy and procedure for obtaining Informed Consent for Restraints prior to implementation of the restraint.
d. The DON/Designee will complete random audits of current residents to ensure that Informed Consent and restraint evaluations have been obtained prior to restraint implementation three times per week for two weeks, weekly for four weeks and monthly for two months. Audit findings will be submitted to the Quality Assurance and Performance Improvement committee for review and recommendations as needed.

483.10(j)(1)-(4) REQUIREMENT Grievances:

§483.10(j) Grievances.
§483.10(j)(1) The resident has the right to voice grievances to the facility or other agency or entity that hears grievances without discrimination or reprisal and without fear of discrimination or reprisal. Such grievances include those with respect to care and treatment which has been furnished as well as that which has not been furnished, the behavior of staff and of other residents, and other concerns regarding their LTC facility stay.

§483.10(j)(2) The resident has the right to and the facility must make prompt efforts by the facility to resolve grievances the resident may have, in accordance with this paragraph.

§483.10(j)(3) The facility must make information on how to file a grievance or complaint available to the resident.

§483.10(j)(4) The facility must establish a grievance policy to ensure the prompt resolution of all grievances regarding the residents' rights contained in this paragraph. Upon request, the provider must give a copy of the grievance policy to the resident. The grievance policy must include:
(i) Notifying resident individually or through postings in prominent locations throughout the facility of the right to file grievances orally (meaning spoken) or in writing; the right to file grievances anonymously; the contact information of the grievance official with whom a grievance can be filed, that is, his or her name, business address (mailing and email) and business phone number; a reasonable expected time frame for completing the review of the grievance; the right to obtain a written decision regarding his or her grievance; and the contact information of independent entities with whom grievances may be filed, that is, the pertinent State agency, Quality Improvement Organization, State Survey Agency and State Long-Term Care Ombudsman program or protection and advocacy system;
(ii) Identifying a Grievance Official who is responsible for overseeing the grievance process, receiving and tracking grievances through to their conclusions; leading any necessary investigations by the facility; maintaining the confidentiality of all information associated with grievances, for example, the identity of the resident for those grievances submitted anonymously, issuing written grievance decisions to the resident; and coordinating with state and federal agencies as necessary in light of specific allegations;
(iii) As necessary, taking immediate action to prevent further potential violations of any resident right while the alleged violation is being investigated;
(iv) Consistent with §483.12(c)(1), immediately reporting all alleged violations involving neglect, abuse, including injuries of unknown source, and/or misappropriation of resident property, by anyone furnishing services on behalf of the provider, to the administrator of the provider; and as required by State law;
(v) Ensuring that all written grievance decisions include the date the grievance was received, a summary statement of the resident's grievance, the steps taken to investigate the grievance, a summary of the pertinent findings or conclusions regarding the resident's concerns(s), a statement as to whether the grievance was confirmed or not confirmed, any corrective action taken or to be taken by the facility as a result of the grievance, and the date the written decision was issued;
(vi) Taking appropriate corrective action in accordance with State law if the alleged violation of the residents' rights is confirmed by the facility or if an outside entity having jurisdiction, such as the State Survey Agency, Quality Improvement Organization, or local law enforcement agency confirms a violation for any of these residents' rights within its area of responsibility; and
(vii) Maintaining evidence demonstrating the result of all grievances for a period of no less than 3 years from the issuance of the grievance decision.

Observations:

Based on observation, facility policy review, staff and residents' interview, it was determined that the facility failed to provide residents access to grievance information on two out of three nursing units. (2nd floor and First floor Stenton unit).

Findings include:

A review of an undated facility policy and procedure titled, "Grievances/Complaints. Filing", indicated "Residents and their representatives have the right to file grievances, either orally or in writing, to the facility staff or to the agency designated to hear grievances (e.g., the State Ombudsman).

Grievances and/or complaints may be submitted orally or in writing and may be filed anonymously."

During the resident council group meeting that was held on February 27, 2024, at 10:37 a.m. with 7 alert and oriented residents (R11, R36, R24, R6, R8, R23 and R20) reported that they were not aware of the facility grievance process and how to file grievances. Residents also stated they did know how to access grievance forms and file grievances anonymously.

An interview and observation on July 17, 2024, at 12:15 p.m., with Regional Nurse, Employee, E4, it was revealed that there were no grievance forms or grievance instruction available on both side of the First floor Stenton unit. On the Second-floor nursing unit there were no grievance forms or grievance instruction were available on the unit. First floor Stenton unit and second floor unit did not have any availability for residents to file an anonymous grievance.

28 Pa. Code 201.18(b)(2) Management

28 Pa. Code 201.29(a)(i) Resident rights

Plan of Correction - To be completed: 08/20/2024

a. Grievance postings were placed on all resident units in visible areas notifying the grievance officer and how to file an anonymous grievance on 07/17/2024. Grievance forms were also placed on all resident units on 07/17/2024.
b. An audit was completed of all resident units and common areas to ensure that grievance forms and postings were present. Variances were addressed at the time of the audit and placed on the facility audit tool.
c. The NHA/Designee re-educated the Interdisciplinary Team on the policy and procedure for the availability of grievance forms and postings in all resident areas.
d. The NHA/Designee will complete random audits of grievance forms and postings to ensure that they are present and appropriately placed for resident units weekly for four weeks and monthly for two months. Audit findings will be addressed and submitted to the Quality Assurance Performance Improvement Committee for further review and recommendations.

483.10(g)(17)(18)(i)-(v) REQUIREMENT Medicaid/Medicare Coverage/Liability Notice:

§483.10(g)(17) The facility must--
(i) Inform each Medicaid-eligible resident, in writing, at the time of admission to the nursing facility and when the resident becomes eligible for Medicaid of-
(A) The items and services that are included in nursing facility services under the State plan and for which the resident may not be charged;
(B) Those other items and services that the facility offers and for which the resident may be charged, and the amount of charges for those services; and
(ii) Inform each Medicaid-eligible resident when changes are made to the items and services specified in §483.10(g)(17)(i)(A) and (B) of this section.

§483.10(g)(18) The facility must inform each resident before, or at the time of admission, and periodically during the resident's stay, of services available in the facility and of charges for those services, including any charges for services not covered under Medicare/ Medicaid or by the facility's per diem rate.
(i) Where changes in coverage are made to items and services covered by Medicare and/or by the Medicaid State plan, the facility must provide notice to residents of the change as soon as is reasonably possible.
(ii) Where changes are made to charges for other items and services that the facility offers, the facility must inform the resident in writing at least 60 days prior to implementation of the change.
(iii) If a resident dies or is hospitalized or is transferred and does not return to the facility, the facility must refund to the resident, resident representative, or estate, as applicable, any deposit or charges already paid, less the facility's per diem rate, for the days the resident actually resided or reserved or retained a bed in the facility, regardless of any minimum stay or discharge notice requirements.
(iv) The facility must refund to the resident or resident representative any and all refunds due the resident within 30 days from the resident's date of discharge from the facility.
(v) The terms of an admission contract by or on behalf of an individual seeking admission to the facility must not conflict with the requirements of these regulations.

Observations:

Based on review of clinical records and facility documentation and interview with staff, it was determined that the facility failed to provide the required advance notice through a Notice of Medicare Non-Coverage related to the termination of Medicare services for three of three residents reviewed (Resident R166, Resident R167 and Resident R35).

Findings include:

Review facility policy on "Medicare Advance Beneficiary and Medicare Non-coverage Notices" revealed that under section "Policy Statement", Residents are informed in advance when changes will occur to their bills. Under section Policy Interpretation and Implementation. Skilled Nursing Facility Advance Beneficiary Notice (CMS form 10055) # 1. If the director of admissions or benefits coordinator believes (upon admission or during the resident's stay) that Medicare (Part A of the Fee for Service Medicare Program) will not pay for an otherwise covered skilled service(s), the resident (or representative) is notified in writing why the service(s) may not be covered and of the resident's potential liability for payment of the non-covered service(s). #2. The facility issues the Skilled Nursing Facility Advance Beneficiary Notice (CMS form 10055) for the following triggering events: "Initiation" - In the situation in which the director of admissions or benefits coordinator believes Medicare will not pay for extended care items or services that a physician has ordered, a SNFABN is issued to the beneficiary before those non-covered extended care items or services are furnished to the beneficiary., "Reduction" - In the situation in which the facility proposes to reduce a beneficiary's extended care items or services because it expects that Medicare will not pay for a subset of extended care items or services, or for any items or services at the current level and/or frequency of care that a physician has ordered, the SNFABN is issued to the beneficiary before items or services to the beneficiary are reduced., "Termination" - In the situation in which the facility proposes to stop furnishing all extended care items or services to a beneficiary because it expects that Medicare will not continue to pay for the items or services that a physician has ordered and the beneficiary would like to continue receiving the care, the SNF ABN is issued to the beneficiary before such extended care items or services are terminated.
#3. The resident (or representative) is informed that they may choose to continue receiving the skilled services that may not be paid for by Medicare and assume financial responsibility. Notice of Medicare Non-Coverage (CMS form 10123) #1. If the resident's Medicare covered Part A stay or when all of Part B therapies are ending, a Notice of Medicare Non-Coverage (CMS form 10123) is issued to the resident at least two calendar days before benefits end. #2. The Notice of Medicare Non-Coverage informs the resident of the pending termination of coverage and of his/her right to an expedited review by a Quality Improvement Organization. #3. The Notice of Medicare Non-Coverage is not given if: #a. the beneficiary exhausts the SNF benefits coverage (100 days), thus exhausting their Medicare Part A SNF benefit; #b. the beneficiary initiates the discharge from the SNF; or #c. the beneficiary elects the hospice benefit or decides to revoke the hospice benefit and return to standard Medicare coverage.

Review of the list of residents were discharged from a Medicare covered part A stay with benefit days remaining in the past six months revealed that Resident R166, Resident R167 and Resident R35 were discharged from a Medicare covered part A stay with benefit days remaining.

Interview with Regional Administrator, Employee E7 conducted on July 19, 2024, at 9:12 a.m. confirmed that Resident R166, Resident R167 and Resident R35 were discharged from a Medicare covered part A stay with benefit days remaining during the past six months. Further Employee E7 revealed that the facility did not provide the Resident R166, Resident R167 and Resident R35 or their responsible parties with a notification of termination of services under Medicare covered part A.

Further interview with Employee E7 revealed that the business office person was not aware that a notice of Medicare non-coverage had to be sent to family members or residents who were discharged from a Medicare covered part A stay with benefit days remaining.

28 Pa. Code 201.14(a) Responsibility of licensee

28 Pa. Code 201.29(a) Resident rights

Plan of Correction - To be completed: 08/20/2024

a. Resident R35, R166, and R167t had a NOMNC completed and distributed on 07/22/2024.
b. An audit was conducted of residents recently taken off their Medicare Benefits to ensure that appropriate NOMNCs were given. Variances will be addressed at the time of the audit and placed on the facility audit tool.
c. The NHA/Designee re-educated the Social Services Director on the policy and procedure for presenting residents with the Notice of Medicare Non-Coverage appropriately.
d. The NHA/Designee will complete 5 random audits of residents recently taken off of Medicare Benefits to ensure that the Notice of Medicare Non-Coverage was presented appropriately weekly for four weeks and monthly for two months. Audit findings will be addressed and submitted to the Quality Assurance Performance Improvement Committee for further review and recommendations.

483.10(g)(5)(i)(ii) REQUIREMENT Required Postings:

Least serious deficiency but affects more than a limited number of residents, staff, or occurrences. This deficiency has the potential for causing no more than a minor negative impact on the resident but is not found to be throughout this facility.

§483.10(g)(5) The facility must post, in a form and manner accessible and understandable to residents, resident representatives:
(i) A list of names, addresses (mailing and email), and telephone numbers of all pertinent State agencies and advocacy groups, such as the State Survey Agency, the State licensure office, adult protective services where state law provides for jurisdiction in long-term care facilities, the Office of the State Long-Term Care Ombudsman program, the protection and advocacy network, home and community based service programs, and the Medicaid Fraud Control Unit; and
(ii) A statement that the resident may file a complaint with the State Survey Agency concerning any suspected violation of state or federal nursing facility regulation, including but not limited to resident abuse, neglect, exploitation, misappropriation of resident property in the facility, and non-compliance with the advanced directives requirements (42 CFR part 489 subpart I) and requests for information regarding returning to the community.

Observations:

Based on observations and interview with staff and residents, it was determined that the facility failed to post contact information for the Pennsylvania Department of Health and the State Long-Term Care Ombudsman program as required for one of four nursing units that was accessible to residents. (First floor B)

Findings include:

During resident council meeting held July 16, 2024 at 11:15 a.m. revealed 5 of 7 residents were unaware of where the State Department of Health contact information or the State Long-Term Care Ombudsman program contact information was posted. Residents stated they did not recall signs with the information posted in the facility.

Observations conducted on July 16, 2024 at 12:15 pm on each nursing floor of the facility revealed that the facility did not have the State Department of Health contact information available and accessible to residents on first floor B nursing unit. Floor B failed to post the State Department of Health contact information on the bulletin board. Further observation revealed the State Long-Term Care Ombudsman program contact information was posted in Spanish on the bulletin board for residents. The State Long-Term Care Ombudsman program contact information in English was posted behind the nursing station, which made it inaccessible for residents.

An interview was conducted with Employee E4, Regional Nurse, on July 16, 2024 at 12:30 p.m. and confirmed the required contact information was not available and accessible to residents on Floor B.

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

28 Pa. Code: 201.18(e) Management

Plan of Correction - To be completed: 08/20/2024

a. The Pennsylvania Department of Health and the State Long-Term Care Ombudsman contact information was posted on the resident care units on 07/17/2024.
b. An audit was completed of all units to ensure that The Pennsylvania Department of Health and the State Long-Term Care Ombudsman contact information was posted appropriately. No further variances were identified.
c. The NHA/Designee completed re-education with the Interdisciplinary Team regarding the required posting of The Pennsylvania Department of Health and the State Long-Term Care Ombudsman contact information in visible areas on the resident units.
d. The NHA/Designee will complete random audits of the resident units to ensure that The Pennsylvania Department of Health and the State Long-Term Care Ombudsman contact information is posted and visible to the residents weekly for four weeks and monthly for two months. Audit findings will be addressed and submitted to the Quality Assurance Performance Improvement Committee for further review and recommendations as needed.

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