Pennsylvania Department of Health
MANOR AT PENN VILLAGE, THE
Patient Care Inspection Results

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MANOR AT PENN VILLAGE, THE
Inspection Results For:

There are  144 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.
MANOR AT PENN VILLAGE, THE - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:
Based on an Abbreviated Survey in response to three Complaint Investigations completed on April 9, 2024, it was determined that The Manor at Penn Village 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 Regulations as they relate to the Health portion of the survey process.


 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.
Observations:

Based on clinical record review and staff interview, it was determined that the facility failed to provide the highest practicable care regarding physician ordered medications and treatments for four of four residents reviewed (Residents 1, 2, 3, and 4).

Findings include:

Clinical record review for Resident 1 revealed active physician orders for staff to administer the following:

Levothyroxine Sodium (medication used to treat an underactive thyroid, hypothyroidism) 125 mcg (micrograms) via G-tube (tube inserted through the abdominal skin into the stomach for the purpose of instilling nutrition, fluids, and/or medications) in the morning
Omeprazole (medication used to treat certain stomach problems such as acid reflux or ulcers) 20 mg (milligrams) via G-tube daily
Famotidine (medication used to treat ulcers of the stomach and intestines) 20 mg via G-tube twice daily
Petroleum jelly (topical ointment for moisturization) external ointment to lips twice a day
Check enteral (involving or passing through the intestine, either naturally via the mouth and esophagus, or through an artificial opening) residual every shift and notify the physician if greater than 60 milliliters
Change Ziploc bag daily for storage of mickey extension tube (G-tube extension piece) every night shift
Apply anti-fungal treatment (an antifungal medication, also known as an antimycotic medication, used to treat and prevent mycosis such as athlete's foot, ringworm, or thrush) to left lower extremity itchy, red patches twice daily
Hydrocortisone (man-made steroid used to decrease the immune system's response to various diseases) cream to abdomen every day and evening shift
Sodium Fluoride (used to prevent tooth decay) 1.1 percent cream twice daily as toothpaste every morning and bedtime
Colostomy (surgically created opening for the colon, or large intestine, through the abdomen) and Stoma (opening created via colostomy surgery) care every shift
Stoma powder to ostomy (surgically created stoma) with every ostomy wafer change
Clean ostomy site with soap and water, apply skin prep (a liquid applied to the skin to form a protective film or barrier) around ostomy site, apply hydrogel (material that can absorb relatively large amounts of fluid; high water content, soft structure, and porosity closely resemble living tissues) to MASD (Moisture Associated Skin Damage, skin breakdown) to the left of the ostomy site and place Optifoam (foam wound dressings that help create an ideal healing environment), wafer (colostomy wafer, a plastic ring that adheres to the skin around the stoma used to connect the pouch system and the skin barrier designed to protect delicate stomal skin from caustic output), and ostomy (collection) bag twice weekly every Monday and Friday

Review of Resident 1's MAR (Medication Administration Record, an electronic method to document the administration of medications) and TAR (Treatment Administration Record, an electronic method to document the administration of treatments) dated March and April 2024 revealed that staff failed to document the completion of the following:

Levothyroxine Sodium 125 mcg on March 22, 2024, at 5:00 AM
Omeprazole 20 mg on April 1, 2024, at 9:00 AM
Famotidine 20 mg on April 1, 2024, at 9:00 AM
Petroleum jelly external ointment to lips on April 1, 2024, at 9:00 AM
Enteral residual check (notify the physician if greater than 60 milliliters) on March 18, 2024, day shift
Change Ziploc bag for storage of mickey extension tube on March 23, 2024
Anti-fungal treatment to left lower extremity patches March 27, 2024, day shift, and April 1, 2024, day shift
Hydrocortisone cream to abdomen on March 27, 2024, day shift
Sodium Fluoride cream as toothpaste on March 27, 2024, day shift
Colostomy and Stoma care on March 27, 2024, day shift
Stoma powder to ostomy with ostomy wafer change on March 27, 2024, day shift
Ostomy cleansing, skin prep, hydrogel to MASD, Optifoam, wafer, and ostomy bag on Monday, April 1, 2024

Clinical record review for Resident 2 revealed physician orders for staff to administer the following:

PICC (A PICC line is a long, flexible tube that is inserted into a vein in your upper arm and threaded to a central vein near the heart to deliver fluids and/or medications for a longer period of time) or Midline (A midline catheter is a small tube inserted into a vein in your arm to give treatments; the end of a midline, inside your body, does not go past the top of your armpit) measure upper arm circumference and external catheter length on admission, with each dressing change, and as needed every dayshift on Friday
Change (PICC or Midline) dressing on admission or 24 hours after insertion and weekly thereafter and as needed every Friday dayshift
Vancomycin (antibiotic) HCL intravenous solution, 1500 mg two times daily
Gabapentin (medication used to treat seizures or nerve pain) 200 mg three times a day
Flush PICC or Midline with 10 milliliters of normal saline every shift
Remove knee high TED (thromboembolism-deterrent, T.E.D, compression stockings are socks worn to provide support to the lymphatic drainage and veins of the lower extremities) stockings in the evening

Review of Resident 2's MAR and TAR dated March and April 2024 revealed that staff failed to document the completion of the following:

PICC or Midline, measure upper arm circumference and external catheter length on admission, with each dressing change and as needed every dayshift on Friday, March 15, 2024, and April 5, 2024
Change (PICC or Midline) dressing on admission or 24 hours after insertion and weekly thereafter every Friday on Friday, March 15, 2024, and April 5, 2024

Vancomycin HCL intravenous solution, 1500 mg on:

March 11, 2024, at 8:00 AM
March 12, 2024, at 8:00 PM
March 17, 2024, at 8:00 PM
March 18, 2024, at 8:00 AM,
March 20, 2024, at 8:00 AM and 8:00 PM
March 21, 2024, at 8:00 PM
March 26, 2024, at 8:00 PM
March 27, 2024, at 8:00 AM
March 28, 2024, at 8:00 AM and 8:00 PM
April 3, 2024, at 8:00 PM
April 7, 2024, at 8:00 PM

Gabapentin 200 mg on March 15, 2024, at 12:00 PM

Flush PICC or Midline with 10 milliliters of normal saline every shift on:

March 11, 2024, day shift
March 12, 2024, evening, and night shifts
March 14, 2024, day shift
March 15, 2024, day shift
March 17, 2024, evening shift
March 18, 2024, day shift
March 19, 2024, night shift
March 20, 2024, day shift, and evening shift
March 21, 2024, evening shift
March 26, 2024, evening shift
March 27, 2024, day shift
March 28, 2024, day shift, evening, and night shifts
March 31, 2024, night shift
April 3, 2024, evening shift
April 5, 2024, night shift
April 6, 2024, night shift
April 7, 2024, evening shift

Remove knee high TED stockings in the evening on March 15, 2024, and March 22, 2024

Clinical record review for Resident 3 revealed physician orders for staff to administer the following:

Change (oxygen) tubing, mask, and/or nasal cannula (thin tubing with prongs on one end used in the nose to administer supplemental oxygen) weekly every Saturday night
Flush foley (tubing inserted through the penis and into the bladder to drain urine) with 60 milliliters of normal sterile saline every day and evening shift
Zinc Oxide (topical treatment used to treat diaper rash, minor burns, severely chapped skin, or other minor skin irritations) cream to groin and abdominal folds every day and evening shift
Zinc Oxide cream to sacrum and buttocks every shift
Betadine (an antiseptic used for skin disinfection) swab to open area on penis every shift and as needed

Review of Resident 3's MAR and TAR dated March and April 2024 revealed that staff failed to document the completion of the following:

Tubing, mask, and/or nasal cannula change Saturday, March 23, 2024, night shift

Foley flush with 60 milliliters of normal sterile saline on:

March 1, 2024, evening shift
March 4, 2024, evening shift
March 6, 2024, evening shift
March 14, 2024, day shift
March 15, 2024, evening shift

Zinc Oxide cream to groin and abdominal folds on:

March 1, 2024, evening shift
March 4, 2024, evening shift
March 6, 2024, evening shift
March 14, 2024, day shift
March 15, 2024, evening shift
March 22, 2024, evening shift
March 28, 2024, day shift
April 1, 2024, evening shift

Zinc Oxide cream to sacrum and buttocks every shift on:

March 1, 2024, evening shift
March 4, 2024, evening shift
March 6, 2024, evening shift
March 14, 2024, day shift
March 15, 2024, evening shift
March 22, 2024, evening shift
March 28, 2024, day shift
April 1, 2024, evening shift

Betadine swab to open area on penis on:

March 1, 2024, evening shift
March 4, 2024, evening shift
March 6, 2024, evening shift
March 14, 2024, day shift
March 15, 2024, evening shift
March 22, 2024, evening shift
March 23, 2024, evening, and night shifts

Clinical record review for Resident 4 revealed physician orders for staff to administer the following:

Circulation checks to RUE (right upper extremity, arm) every shift
Hipsters (padded material worn as pants under clothing to cushion hip joints) every shift
Wanderguard (a wireless system that alerts caregivers when a resident with a wearable pendant approaches a programmed door or area) check function and placement every shift
Biofreeze (a topical analgesic used to relieve minor to moderate joint or muscle discomfort) external gel to left rib/flank four times a day

Review of Resident 4's MAR and TAR dated March 2024 revealed that staff failed to document the completion of the circulation checks to her RUE, hipsters, and Wanderguard function and placement check, on March 15 and 22, 2024, evening shift. Staff failed to document the completion of the application of Biofreeze external gel to Resident 4's left rib/flank on March 15 and 22, 2024, at 4:00 PM and 8:00 PM.

The surveyor reviewed concerns regarding medication and treatment omissions for Residents 1, 2, 3, and 4 during an interview with the Nursing Home Administrator and the Director of Nursing on April 8, 2024, at 8:30 PM.

483.25 Quality of Care
Previously cited deficiency 1/26/24 and 3/6/24

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


 Plan of Correction - To be completed: 05/21/2024

Residents 1,2,3, and 4's attending physicians were notified that the facility failed to ensure that the physician orders were followed.
A one week look back of all residents will be conducted to identify residents at risk for unfollowed physician orders indicated by missing documentation. Indications of unfollowed physicians orders will be reported to the resident's physician.
Licensed nursing staff will be educated on the procedure for following and administering medications and treatments per physician orders.
Audits of 5 residents will be conducted 5x a week x 6 weeks to ensure medications and treatments are administered and documented on per physician's orders.

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

Based on review of select facility policies and procedures, clinical record review, and resident and staff interview, it was determined that the facility failed to implement necessary treatment and services to promote pressure ulcer healing, prevent pressure ulcer worsening, and prevent new ulcers from developing for two of two residents reviewed for pressure ulcer concerns (Residents 1 and 2).

Findings include:

The facility policy entitled, "Skin and Wound," last reviewed without changes on January 4, 2023, indicated that the facility's policy is to provide a system for identifying risk and implementing resident-centered interventions to promote skin health, prevention, and healing of pressure injuries. The process includes that resident's skin is evaluated upon admission/re-admission and documented in the medical record. The nurse is to complete skin evaluations weekly and document in the medical record. Pressure Injury Mitigation Strategies include developing resident-centered interventions based on resident risk factors. Skin Impairment Identification includes: Document presence of skin impairment(s)/new skin impairment(s) when observed and weekly until resolved; nurse to report changes in skin integrity to the physician/physician extender, resident/resident representative, and document in the medical record; develop resident centered interventions; refer to therapy as appropriate; monitor resident's response to treatment and modify as indicated. On-going evaluation includes to evaluate the effectiveness of interventions, and progress towards goals, during the standard of care and the care plan meetings.

Clinical record review for Resident 1 revealed wound consultant documentation dated March 5, 2024, that indicated the presence of a Stage III pressure ulcer (wounds that affect the top two layers of skin as well as fatty tissue) of the left lower buttock that was 3 cm (centimeters) by 2.5 cm by an unmeasurable depth due to the presence of tissue overgrowth.

Wound consultant documentation dated March 12, 2024, indicated that Resident 1 continued with the Stage III pressure ulcer of the left lower buttock; and developed a new Stage III pressure ulcer on her sacrum (tailbone)measuring 1.2 cm by 2 cm by 0.1 cm. The plan of care included an upgrade to an offloading chair cushion (pressure is loaded onto a greater surface area through the built-in contours of a cushion that help align and stabilize the spine, pelvis, and lower extremities) as well as wound treatment with alginate calcium with silver (calcium alginate with silver is a type of wound dressing that contains silver alginate that inhibits the growth of microorganisms, absorbs a lot of bacteria and fluid from the wound, and transforms into a soft, cohesive gel when moistened) every day to both the left lower buttock and sacral wounds.

Nursing documentation dated March 12, 2024, at 3:23 PM indicated that the registered nurse called the facility's durable medical equipment provider regarding Resident 1's wheelchair seat cushion. The provider indicated that there were issues with payment. The writer indicated that the issue was referred to the Director of Nursing (DON) to call the durable medical equipment provider to assist with the issue. The writer stipulated that the "DON later stated that she took care of issue, and a new cushion should be available in 7-10 days."

Nursing documentation dated March 13, 2024, at 12:34 PM by the same registered nurse indicated that the physician's assistant ordered a custom cushion for Resident 1's wheelchair; and that a therapy screen for the cushion was discussed. The documentation indicated that administration staff was involved in getting the cushion from the durable medical equipment provider in seven to 10 days.

A physician's order dated March 13, 2024, indicated the implementation of a custom cushion for Resident 1's wheelchair due to the sacral wound.

Nursing documentation by the Regional Director of Clinical Services dated March 15, 2024, at 4:01 PM indicated that Resident 1's responsible party was made aware of new orders for a new wheelchair cushion.

Resident 1's clinical record did not contain evidence (e.g., nursing, or skilled therapy progress note documentation) that Resident 1 received a new, custom, wheelchair cushion.

Wound consultant documentation dated March 19, 2024, March 26, 2024, and April 2, 2024, continued to indicate that the plan of care included an upgrade to an offloading chair cushion as well as wound treatment with alginate calcium with silver every day to both the left lower buttock and sacral wounds.

Review of Resident 1's TAR (treatment administration record, electronic documentation of the provision of care) dated March and April 2024 revealed that staff failed to document daily wound treatment to Resident 1's sacrum and buttock on the following dates:

March 17, 23, and 27, 2024
April 1, 2024

The wound consultant documentation dated April 2, 2024, indicated that Resident 1's left lower buttock wound progress was not at goal and had increased in surface area from the previous assessment of 7 cm to 7.5 cm.

Interview with the Nursing Home Administrator on April 8, 2024, at 3:00 PM and 8:30 PM; and electronic communication dated April 9, 2024, at 12:45 PM and 1:53 PM, revealed that the facility had no documentation from the facility's durable medical equipment provider that a new cushion was delivered for Resident 1 following the March 12, 2024, wound consultant provider recommendation.

Clinical record review for Resident 2 revealed that the facility admitted him on March 8, 2024, with diagnoses that included extradural and subdural abscess (unspecified infection within the brain or spinal cord), intraspinal (within the spine) abscess and granuloma (tiny lump of immune cells formed when the body tries to fight infection or inflammation), unspecified cord compression, sepsis (blood infection) due to MRSA (methicillin-resistant Staphylococcus aureus, a type of bacteria that is resistant to several antibiotics), abscess of lung without pneumonia, cutaneous (skin) abscess of back (except buttock), acute and subacute infective endocarditis (inflammation of the inner lining of the heart).

Interview with Resident 2 on April 8, 2024, at 11:36 AM revealed that he had been at the facility for approximately one month; and that he had a large wound on his back. Resident 2 used his cellphone to show the surveyor a picture of a pressure ulcer in the area of a coccyx that he claimed was taken of him on April 6, 2024. Resident 2 described it as, "a huge sore," and indicated that he believed that it had gotten larger. Resident 2 stated that the sore on his "bottom" had gotten, "really, really, bad."

Clinical record review of an admission Braden assessment (standardized tool to assess the risk for developing a pressure ulcer) indicated Resident 2 was at a high risk (score of 11) on March 8, 2024.

The Admission/Readmission Data Collection assessment on March 8, 2024, included the identification of a wound on Resident 2's sacrum (number 53 on the diagram), described as, "above sacrum, Stage II (sore has broken through the top and part of the second layer of skin), 3.6 cm by 1.1 cm by 0.2 cm; wound bed with pink epithelial (thin, packed, layer of cells typically deemed healthy) tissue; edges regular and periwound blanches."

Admission physician orders for Resident 2 dated March 9 to 11, 2024, included instructions for staff to apply a Duoderm (hydrocolloid products for light to moderately draining wounds; they form a moist wound healing environment, absorb drainage, and provide wound protection) to the Stage II wound above his sacrum; change every three days and as needed. A physician's order effective March 11 to 19, 2024, instructed staff to continue the Duoderm to Resident 2's Stage II wound located above his sacrum; change every three days and as needed on day shift.

There was no evidence in Resident 2's medical record that staff assessed Resident 2's sacral wound after March 8, 2024, to evaluate Resident 2's response to the Duoderm treatment.

Nursing documentation dated March 19, 2024, at 3:32 PM (11 days after Resident 2's admission) indicated that a wound doctor was in to see Resident 2 and changed the wound care instructions.

Progress note documentation by the facility's consulting wound care provider dated March 19, 2024, noted that Resident 2 presented with wounds on his sacrum and his right buttock. The documentation indicated that the sacral wound was unstageable (due to necrosis, unhealthy tissue), full thickness, 9 cm by 13 cm by a depth that was not measurable due to the presence of nonviable tissue and necrosis; 70 percent black necrotic tissue (eschar). The documentation indicated the presence of a Stage II pressure wound on his right buttock, partial thickness, 1 cm by 1.5 cm by a depth not measurable due to tissue overgrowth. The plan was to apply house barrier cream daily to the Stage II wound; and change the treatment to the sacral wound to fill the wound with betadine (liquid antiseptic used to treat or prevent skin infection) saturated gauze and a thin hydrocolloid sheet dressing and ABD pad (thick, cushioned, dressing) daily.

Resident 2's clinical record contained no evidence that staff assessed his sacral wound between his admission date of March 8, 2024, and the consulting wound care provider documentation of March 19, 2024, to evaluate the effectiveness of the interventions or intervene timely as Resident 2's skin condition worsened. Resident 2's sacral wound worsened in size and appearance; and Resident 2 developed a second pressure ulcer, between March 8, 2024, and March 19, 2024.

The surveyor reviewed the above concerns regarding Resident 2 during an interview with the Nursing Home Administrator and the Director of Nursing on April 8, 2024, at 8:30 PM.

483.25(b)(1)(i)(ii) Treatment/svcs to Prevent/heal Pressure Ulcer
Previously cited deficiency 1/26/24

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


 Plan of Correction - To be completed: 05/21/2024

Facility is unable to retroactively address wounds for residents 1 and 2.
A one week look back of residents with active wounds was completed to ensure that the ordered treatments are available and are being completed per physician orders.
Licensed nursing staff will be educated on the procedure for following and administering wound treatments per physician orders.
Audits of 5 residents with active wounds will be conducted 5x a week x6 weeks to ensure that wounds treatments are being conducted per physician's orders

483.25(g)(1)-(3) REQUIREMENT Nutrition/Hydration Status Maintenance:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.25(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 review of select facility policies and procedures, clinical record review, and staff interview, it was determined that the facility failed to implement interventions to maintain acceptable parameters of nutritional status for two of two residents reviewed for weight loss concerns (Residents 1 and 4).

Findings include:

The facility policy entitled, "Best Practice Weight Change," last reviewed without changes on January 4, 2023, revealed that an identified weight change (gain or loss) is 2.5 percent in one week, five percent in one month, or 10 percent in three months. The document listed interventions that included a referral to the registered dietitian for a nutritional review and to update food preferences.

Clinical record review for Resident 1 revealed diagnoses that included cerebral palsy (group of disorders of the brain that affects movement and posture) and dysphagia (difficulty swallowing food or liquid).

Resident 1's physician orders indicated that Resident 1 was to have nothing by mouth since August 22, 2022.

A physician's order dated January 25, 2024, instructed staff to obtain weekly weight assessments every Monday and Thursday.

Review of Resident 1's weight assessment record revealed that staff failed to obtain a weight assessment on the following dates:

Thursday, February 1, 2024
Monday, February 5, 2024
Thursday, February 15, 2024
Monday, February 19, 2024
Thursday, February 22, 2024
Thursday, March 7, 2024
Monday, March 11, 2024
Monday, March 18, 2024
Thursday, March 21, 2024

A physician's order active from January 2, 2024, to February 19, 2024, instructed staff to give 237 milliliters of Jevity 1.2 (liquid nutrition) bolus feeding via a syringe five times a day due to Resident 1's dysphagia diagnosis.

A physician's order active from February 19 to 27, 2024, instructed staff to give 237 ml of Jevity 1.2 bolus feeding via a syringe four times a day.

The current physician's order starting February 27, 2024, instructed staff to continue to give 237 milliliters of Jevity 1.2 bolus feeding via a syringe four times daily.

Review of Resident 1's treatment administration record (TAR, electronic documentation of the administration of physician ordered treatments) dated February, March, and April 2024 revealed that no staff documented the provision of Resident 1's bolus feeding on the following dates and times:

February 13, 2024, at 8:00 PM
March 9, 2024, 1:00 PM
March 17, 2024, at 9:00 AM and 1:00 PM
April 1, 2024, at 9:00 AM

Review of Resident 1's weight assessment record revealed that her weight assessments fluctuated from 71.5 pounds to 67 pounds from February 3, 2024, through April 1, 2024.

Clinical record review for Resident 4 revealed the following weight assessments:

January 5, 2024, at 12:00 PM, 171.9 pounds
February 5, 2024, at 11:10 AM, 165.8 pounds
February 7, 2024, at 11:45 AM, 154.7 pounds (a 17.2-pound, 10 percent severe weight loss in one month)
February 19, 2024, at 1:42 PM, 152.8 pounds
February 26, 2024, at 1:55 PM, 146.8 pounds (a 7.9-pound, 5.10 percent additional weight loss since February 7, 2024)
February 28, 2024, at 10:13 PM, 130.0 pounds (a 16.8-pound, 11.44 percent weight loss since the weight assessment two days prior; a 24.7-pound, 15.96 percent severe weight loss within one month; a 41.9-pound, 24.37 percent severe weight loss in two months)
March 4, 2024, at 10:58 AM, 130.0 pounds

A Standards of Care Note dated February 15, 2024, at 1:40 PM indicated that the registered nurse Regional Director of Clinical Services noted Resident 4's weight loss as five percent in 30 days and 10 percent in 180 days. The documentation indicated that the writer would suggest Med Pass 2.0 (liquid nutritional supplement) three times a day and weekly weight assessments as well as an update to Resident 4's preferences.

The documentation by the registered nurse Regional Director of Clinical Services did not identify that the weight assessment on February 7, 2024, reflected a 10 percent loss in one month. There was no indication that a registered dietitian or nutritional staff responded to Resident 4's severe weight loss at that time. Resident 4's clinical record did not contain evidence of an assessment of food preferences.

A physician's order dated February 18, 2024 (three days later) instructed staff to supply 60 milliliters of Med Pass (nutritional supplement) two times a day (not three times a day as suggested by the February 15, 2024, documentation).

Resident 4's clinical record did not contain evidence that nutritional, or nursing staff evaluated Resident 4's response to the nutritional interventions between February 18, 2024, and February 26, 2024; or responded to the additional weight loss identified on February 26, 2024.

There was no evidence that staff obtained a re-weight assessment to determine the validity of Resident 4's severe weight loss in the two days from February 26 to 28, 2024. Resident 1's clinical record contained no evidence of a nursing or dietary staff response to the February 26 or 28, 2024, severe weight loss assessments until March 4, 2024.

Dietary documentation dated March 4, 2024, at 8:51 PM indicated that a registered dietitian assessed Resident 4's weight loss of 11.44 percent in one week. The documentation indicated that the plan would be to increase the Med Pass supplement to four times a day and add a house supplement with meals. The documentation indicated an assessment of the calories and protein provided by the Med Pass supplement four times a day.

Resident 4's most recent weight assessment available at the time of the onsite survey, dated April 1, 2024, revealed that Resident 4 was 136 pounds (a six-pound gain in one month) since the implementation of the March 4, 2024, recommendations.

The facility failed to thoroughly assess Resident 4's severe weight loss, implement interventions timely, and assess Resident 4's response to implemented interventions to maintain acceptable parameters of nutrition.

The surveyor reviewed the concerns regarding the omitted weight assessments and gastrostomy feedings for Resident 1 during an interview with the Nursing Home Administrator and the Director of Nursing on April 8, 2024, at 8:30 PM.

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


 Plan of Correction - To be completed: 05/21/2024

Facility cannot retroactively address the significant weight changes for residents 1 and 4.
HCSG regional team to conduct initial audit of all significant weight changes and
documentation in place.
HCSG regional team to educate Registered Dietitian at Penn Village on facility policy for weight
management and nutrition documentation.
HCSG regional team to conduct chart audits of all significant weight changes will be
completed to ensure RD assessments or progress notes are in place for timely
evaluation and intervention of residents with significant/ severe weight loss.
Weekly audits x 4 weeks beginning 4/15
Weekly/monthly audits to continue until compliance results are achieved.

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

483.45(h) Storage of Drugs and Biologicals

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

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

Based on observation and staff interview, it was determined that the facility failed to ensure security of medications and biologicals on one of four nursing units (Unit C, second floor, Resident 6).

Findings include:

Observation of the second-floor nursing unit on April 8, 2024, at 4:55 PM revealed the door to the medication prep room was open. The cabinet doors were visibly open from the doorway and noted to contain numerous over-the-counter medications such as:

Acetaminophen (Tylenol), analgesic
Multivitamin nutritional supplement
Hydrogen peroxide (liquid antiseptic)
Low dose aspirin, 81 milligrams (analgesic used to reduce risk of heart attacks)
Milk of Magnesia (liquid laxative)
FeSO4 (iron nutritional supplement)

The room also contained two unlocked treatment carts that contained numerous creams, lotions, and medicated treatments such as:

Diclofenac Sodium (medication used to treat swelling/inflammation)
Premarin vaginal cream (estrogen hormone medication)
Nystatin topical powder (antifungal medication)
Fluocinolone acetonide topical solution (steroid topical skin treatment used to reduce inflammation and itching)
Boxes of nicotine patches (topical patches containing the addictive substance found in tobacco)
Tube of dermasyn hydrogel wound dressing (hydrogel wound dressing that is enriched with Vitamin E that provides a moist, healthy, wound environment)

While observing the medication prep room on April 8, 2024, at 5:00 PM Resident 6, propelled her wheelchair to the doorway to request ice. Resident 6 stated that the nurse was on the other hallway, which was not visible to the surveyor.

Interview with Employee 1 (licensed practical nurse) on April 8, 2024, at 5:01 PM revealed that the door to the medication prep room was open because maintenance staff were installing a padlock on the refrigerator in that room. Employee 1 stated that maintenance staff were alone in the medication prep room because she needed to complete her medication pass.

483.45(g)(h)(1)(2) Label/store Drugs and Biologicals
Previously cited deficiency 1/26/24

28 Pa. Code 211.9(k) Pharmacy services

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


 Plan of Correction - To be completed: 05/21/2024

Facility cannot retroactively ensure the security of medications and biologicals on the second floor nursing unit.
A house audit was conducted to ensure the medication prep rooms on each unit were secure.
Licensed staff were educated on the need to ensure the security of medications and biologicals.
The DON or designee will conduct audits 5x week x 6 weeks of the facilities medication prep rooms to ensure that each is secure and/or under the observation of authorized facility personnel.

483.60 REQUIREMENT Provided Diet Meets Needs of Each Resident: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.
483.60 Food and nutrition services.
The facility must provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs, taking into consideration the preferences of each resident.
Observations:

Based on review of select facility policies and procedures, staff and resident interview, and observation, it was determined that the facility failed to provide residents with palatable food on two of four nursing units (Unit C, second floor, Residents 2 and 3; Unit F, third floor, Resident 5).

Findings include:

The facility policy entitled, "Food: Quality and Palatability," last reviewed without changes on January 4, 2023, revealed that food will be prepared by methods that conserve nutritive value, flavor, and appearance. Food will be palatable, attractive, and served at a safe and appetizing temperature. The policy did not indicate any temperatures used as a guide to ensure the food delivered to the residents met an expected palatable temperature.

Interview with Resident 2 who resided on the second-floor nursing unit on April 8, 2024, at 11:36 AM revealed that he thought that the food was, "...not that great, most of the time cold."

Interview with Resident 3 who resided on the second-floor nursing unit on April 8, 2024, at 5:41 PM revealed that he requested the nurse aide call the kitchen for peanut butter and jelly sandwiches because the pork chop that was delivered for his evening meal was too tough for him to eat.

Observation of the Unit F, third floor, nursing unit on April 8, 2024, at 6:15 PM revealed the facility's last food cart arrived on the unit.

Observation of Resident 5 in the third-floor nursing unit dining area on April 8, 2024, at 6:23 PM revealed staff delivered his meal tray to him, and he began to eat. Resident 5 stated that the carrots were, "barely warm."

Staff delivered meal trays from the meal cart on April 8, 2024, at 6:15 PM, until the last resident tray was delivered at 6:40 PM.

Observation of a test meal tray on April 8, 2024, at 6:40 PM with Employee 2 (nurse aide) revealed the following findings:

Pork chop, lukewarm, at 122.9 degrees Fahrenheit
White rice, lukewarm, at 115.6 degrees Fahrenheit
Carrots, lukewarm, at 109.8 degrees Fahrenheit

Interview with the Nursing Home Administrator and the Director of Nursing on April 8, 2024, at 8:30 PM confirmed that the facility had no policy or procedure that stipulated an expectation of food temperatures at the point of service (to the resident) to ensure palatable meals for residents.

28 Pa. Code 201.14(a) Responsibility of licensee

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


 Plan of Correction - To be completed: 05/21/2024

Facility cannot retroactively improve the palatability of the food observed on April 8th.
At the facilities next resident council palatability and serving temperature will be discussed to ensure the facility is providing meals that are palatable, attractive, and served at a safe and appetizing temperature.
The facilities Dietary Manager will receive education on facilities policy entitled Food: Quality and Palatability.
Facility will audit provided meals 5x week x 6 weeks to ensure provided meals are palatable, attractive, and served at a safe and appetizing temperature.

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

Observations:

Based on a review of nursing staffing hours and staff interview, it was determined that the facility failed to ensure a minimum of one nurse aide per 12 residents during the day and evening shifts on six of the 17 days reviewed and failed to ensure a minimum of one nurse aide per 20 residents during the overnight shifts on three of the 17 days reviewed.

Findings include:

Review of nursing staff care hours provided by the facility revealed the following staff scheduled for the following resident census:

Day shift (requires one nurse aide per 12 residents):

March 23, 2024, nine nurse aides for a census of 118, requires 9.83 nurse aides
March 25, 2024, eight nurse aides for a census of 118, requires 9.83 nurse aides
March 31, 2024, 9.5 nurse aides for a census of 118, requires 9.83 nurse aides

Evening shift (requires one nurse aide per 12 residents):

March 26, 2024, 4.5 nurse aides for a census of 116, requires 9.66 nurse aides
March 31, 2024, 9.75 nurse aides for a census of 118, requires 9.83 nurse aides
April 1, 2024, 9.5 nurse aides for a census of 119, requires 9.91 nurse aides

Overnight shift (requires one nurse aide per 20 residents):

March 24, 2024, five nurse aides for a census of 118, requires 5.9 nurse aides
March 25, 2024, 5.5 nurse aides for a census of 118, requires 5.9 nurse aides
March 29, 2024, 4.5 nurse aides for a census of 121, requires 6.05 nurse aides

Interview with the Nursing Home Administrator on April 8, 2024, at 1:20 PM confirmed that he was aware that the facility did not meet regulatory nurse aide-to-resident ratios as evidenced above.


 Plan of Correction - To be completed: 05/21/2024

The facility cannot retroactively correct past Nursing aide ratios.
The facility will continue to take measures to adequately provide nurse-aid staff to ensure the needs of the residents are met. Measures will be put in place to adequately provide staff with the required nurse aide to resident ratios. These measures include, continuing our retention committee, increased advertising efforts, utilization of agency staff, and sign on bonuses.
The Director of Nursing/designee will educate minimum staffing ratios to RN Supervisors, HR, and the nursing scheduler who are responsible to maintain adequate staffing ratios. The Director of Nursing/designee will audit the daily schedules to ensure that the minimum number of nurse aide staff to resident ratios have been scheduled. The results of the audits will be reviewed at the facilities QAPI meeting for recommendations.

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

Based on a review of nursing staffing hours and staff interview, it was determined that the facility failed to ensure a minimum of one licensed practical nurse per 25 residents during the day for two of the 17 days reviewed, one licensed practical nurse per 30 residents during the evening shifts on one of the 17 days reviewed, and failed to ensure a minimum of one licensed practical nurse per 40 residents during the overnight shifts on two of the 17 days reviewed.

Findings include:

Review of nursing staff care hours provided by the facility revealed the following staff scheduled for the following resident census:

Day shift (requires one licensed practical nurse per 25 residents):

April 6, 2024, four licensed practical nurses for a census of 114, requires 4.56 licensed practical nurses
April 7, 2024, four licensed practical nurses for a census of 114, requires 4.56 licensed practical nurses

Evening shift (requires one licensed practical nurse per 30 residents):

March 30, 2024, 3.5 licensed practical nurses for a census of 115, requires 3.83 licensed practical nurses

Overnight shift (requires one licensed practical nurse per 40 residents):

March 23, 2024, 2.5 licensed practical nurses for a census of 118, requires 2.95 licensed practical nurses
March 29, 2024, three licensed practical nurses for a census of 121, requires 3.03 licensed practical nurses

Interview with the Nursing Home Administrator on April 8, 2024, at 1:20 PM, confirmed that he was aware that the facility did not meet regulatory licensed practical nurse-to-resident ratios as evidenced above.


 Plan of Correction - To be completed: 05/21/2024

The facility cannot retroactively correct past LPN ratios. The facility will continue to take measures to adequately provide LPN staff to ensure the needs of the residents are met. Measures will be put in place to adequately provide staff with the required LPN to resident ratios. These measures include, continuing our retention committee, increased advertising efforts, utilization of agency staff, and sign on bonuses. The Director of Nursing/designee will educate minimum staffing ratios to RN Supervisors, HR, and the nursing scheduler who are responsible to maintain adequate staffing ratios.
The Director of Nursing/designee will audit the daily schedules to ensure that the minimum number of nurse aide staff to resident ratios have been scheduled. The results of the audits will be reviewed at the facilities QAPI meeting for recommendations.

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

Observations:

Based on review of nursing staffing hours and staff interview, it was determined that the facility failed to ensure the total of nursing care hours provided in each 24-hour period was a minimum of 2.87 hours per patient day (PPD), effective July 1, 2023, on six of the 17 days reviewed.

Findings include:

Review of nursing staff care hours provided by the facility revealed that the facility failed to meet the minimum hours per patient day on:

March 23, 2024, with 2.76 hours per resident per day
March 24, 2024, with 2.81 hours per resident per day
March 25, 2024, with 2.75 hours per resident per day
March 26, 2024, with 2.43 hours per resident per day
March 29, 2024, with 2.84 hours per resident per day
March 31, 2024, with 2.83 hours per resident per day

Interview with the Nursing Home Administrator on April 8, 2024, at 1:20 PM confirmed the above noted findings related to the nursing PPD. The interview confirmed that the Nursing Home Administrator was aware that the facility failed to meet the required nursing staffing PPD.


 Plan of Correction - To be completed: 05/21/2024

The facility cannot retroactively correct past PPD staffing levels. The facility will continue to take measures to adequately provide nursing staff to ensure the needs of the residents are met. Measures will be put in place to adequately provide staff. These measures include, continuing our retention committee, increased advertising efforts, utilization of agency staff, and sign on bonuses. The Director of Nursing/designee will educate ppd staffing levels to RN Supervisors, HR, and the nursing scheduler who are responsible to maintain adequate staffing ratios. The Director of Nursing/designee will audit the daily schedules to ensure that the minimum PPD staffing levels have been scheduled. The results of the audits will be reviewed at the facilities QAPI meeting for recommendations.

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