Pennsylvania Department of Health
CEDARWOOD REHABILITATION & HEALTHCARE CENTER
Patient Care Inspection Results

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CEDARWOOD REHABILITATION & HEALTHCARE CENTER
Inspection Results For:

There are  123 surveys for this facility. Please select a date to view the survey results.

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CEDARWOOD REHABILITATION & HEALTHCARE CENTER - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:


Based on a Medicare/Medicaid Recertification survey, State Licensure survey, Civil Rights Compliance survey, and a complaint survey completed on February 8, 2024, it was determined that Cedarwood Rehabilitation and Healthcare Center was not in compliance with the following requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care Facilities and the 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.




 Plan of Correction:


483.10(c)(6)(8)(g)(12)(i)-(v) REQUIREMENT Request/Refuse/Dscntnue Trmnt;Formlte Adv Dir: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.
§483.10(c)(6) The right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.

§483.10(c)(8) Nothing in this paragraph should be construed as the right of the resident to receive the provision of medical treatment or medical services deemed medically unnecessary or inappropriate.

§483.10(g)(12) The facility must comply with the requirements specified in 42 CFR part 489, subpart I (Advance Directives).
(i) These requirements include provisions to inform and provide written information to all adult residents concerning the right to accept or refuse medical or surgical treatment and, at the resident's option, formulate an advance directive.
(ii) This includes a written description of the facility's policies to implement advance directives and applicable State law.
(iii) Facilities are permitted to contract with other entities to furnish this information but are still legally responsible for ensuring that the requirements of this section are met.
(iv) If an adult individual is incapacitated at the time of admission and is unable to receive information or articulate whether or not he or she has executed an advance directive, the facility may give advance directive information to the individual's resident representative in accordance with State law.
(v) The facility is not relieved of its obligation to provide this information to the individual once he or she is able to receive such information. Follow-up procedures must be in place to provide the information to the individual directly at the appropriate time.
Observations:


Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that advance directives decisions were documented in the clinical record for 10 of 37 residents reviewed (Residents 23, 28, 37, 47, 55, 62, 64, 73, 78, 82).

Findings include:

The facility's policy regarding advance directives (instructions regarding the provision of health care when the resident is incapacitated), dated January 25, 2024, indicated that the resident has the right to formulate an advanced directive, including the right to accept or refuse medical or surgical treatments. Prior to or on admission of a resident, the social services director or designee inquires of the resident, his or her family members, and/or his or her legal representative about the existence of any written advance directives. The resident or representative is provided with written information concerning the right to refuse or accept medical or surgical treatment and to formulate an advance directive if he or she desires to do so. Copies of these documents are obtained and maintained in the resident's clinical record.

Resident 23's admission orders, dated October 21, 2022, revealed that she was admitted to the facility that day, and a quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs), dated November 13, 2023, revealed that she was cognitively impaired and had a diagnosis of dementia (loss of cognitive functioning). There was no documented evidence that the resident had advance directives or that the resident's power of attorney was offered the opportunity to create advance directives.

Resident 28's admission orders, dated March 29, 2023, revealed that she was admitted to the facility that day, and a quarterly MDS assessment, dated December 17, 2023, revealed that she was cognitively intact. There was no documented evidence that the resident had advance directives or that the resident was offered the opportunity to create advance directives.

Resident 37's admission orders, dated November 13, 2018, revealed that he was admitted to the facility that day, and an annual MDS assessment, dated November 14, 2023, revealed that he was cognitively impaired and had a diagnosis of Alzheimer's dementia (loss of cognitive functioning). There was no documented evidence that the resident had advance directives or that the resident or his representative was offered the opportunity to create advance directives.

Resident 47's admission orders, dated November 5, 2019, revealed that she was admitted to the facility that day, and a quarterly MDS assessment, dated December 21, 2023, revealed that she was severely cognitively impaired and had a diagnosis of Alzheimer's disease. There was no documented evidence that the resident had advance directives or that the resident's power of attorney was offered the opportunity to create advance directives.

Resident 55's admission orders, dated July 2, 2021, revealed that she was admitted to the facility that day, and a quarterly MDS assessment, dated November 23, 2023, revealed that she was cognitively impaired and had a diagnosis of Alzheimer's dementia. There was no documented evidence that the resident had advance directives or that the resident's guardian was offered the opportunity to create advance directives.

Resident 62's admission orders, dated July 25, 2021, revealed that she was admitted to the facility that day, and a quarterly Minimum Data Set MDS assessment, dated November 7, 2023, revealed that she was cognitively impaired. There was no documented evidence that the resident had advance directives or that the resident's power of attorney was offered the opportunity to create advance directives.

Resident 64's admission orders, dated August 7, 2021, revealed that he was admitted to the facility that day, and a quarterly MDS assessment, dated December 21, 2023, revealed that she was alert and oriented and able to make her needs known. There was no documented evidence that the resident had advance directives or that the resident was offered the opportunity to create advance directives.

Resident 73's admission orders, dated February 24, 2023, revealed that she was admitted to the facility that day, and a quarterly MDS assessment, dated March 3, 2023, revealed that she was cognitively intact. There was no documented evidence that the resident had advance directives or that the resident was offered the opportunity to create advance directives.

Resident 78's admission orders, dated September 16, 2023, revealed that he was admitted to the facility that day, and a quarterly MDS assessment, dated November 17, 2023, revealed that he was alert and oriented and able to make his needs known. There was no documented evidence that the resident had advance directives or that the resident was offered the opportunity to create advance directives.

Resident 82's admission orders, dated November 7, 2023, revealed that she was admitted to the facility that day, and an admission MDS assessment, dated November 14, 2023, revealed that she was cognitively intact. There was no documented evidence that the resident had advance directives or that the resident was offered the opportunity to create advance directives.

An interview with the Director of Nursing on February 7, 2024, at 9:00 a.m. confirmed that the above residents did not have advance directive information on their clinical records, including evidence that an opportunity to create advance directives was offered to the residents and/or their legal representatives.

28 Pa. Code 201.29(a)(d) Resident Rights.





 Plan of Correction - To be completed: 03/27/2024

Preparation and submission of this Plan of Correction does not constitute an admission of agreement by the provider of the truth of the facts alleged or the correctness of the conclusions set forth in the
statement of deficiencies. The Plan of Correction is prepared and submitted solely because of requirements under state and federal laws.

1. Residents/Responsible Parties of 23,28,37,47, 55, 62, 64, 73, 78, 82 have been offered information for completing an Advanced Directive.
2. Current residents have been reviewed and those who have not received information regarding completing an Advanced Directive have been given the opportunity to do so.
3. Admission/Social Service staff have been re-educated regarding offering information for completion of an Advanced Directive to resident/RP. Any newly hired admission or social service staff will be trained on F578 during orientation.
4. The Administrator/designee will audit five residents per week for two weeks and ten residents per month for two months to ensure information regarding completion of an advanced directive has been offered. Audits will be reviewed at the monthly Quality Assurance and Performance Improvement meeting.

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


Based on review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to develop and implement comprehensive care plans that included specific and individualized interventions to address specific care needs for two of 37 residents reviewed (Residents 45, 73).

Findings include:

The facility's policy regarding care plans, dated January 25, 2024, indicated that individualized, comprehensive, person-centered care plans would be developed and implemented based on the resident's assessments.

An annual Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 45, dated November 21, 2023, revealed that the resident was cognitively intact, had limited range of motion of one upper extremity, required moderate assistance from staff for dressing, toileting, and bathing, and had diagnoses that included cerebral palsy (disorder that affects movement and balance). A care plan, dated December 6, 2023, for Resident 45 indicated that the resident had a contracture of her hand.

Nursing task documentation from November 2023 thru February 2024 indicated that Resident 45 had restorative nursing assistance with splint or brace. Staff were to apply a right thumb spica splint (splint to add support comfort) for four hours, remove for two hours on a rotation during daylight hours, and monitor skin integrity. There was no documented evidence that a care plan was developed to address the Resident 45's restorative nursing needs for a splint or brace.

Interview with the Director of Nursing on February 8, 2024, at 12:39 p.m. confirmed that a care plan was not developed for Resident 45's restorative nursing needs for use of a hand spica splint.


A quarterly MDS assessment for Resident 73, dated December 1, 2023, revealed that the resident was cognitively intact, was understood, and could understand others.

A nursing note for Resident 73, dated January 22, 2024, revealed that the resident had a chemotherapy port (device used to draw blood and give treatments, including fluids, blood transfusions, or drugs) in left chest area. There was no documented evidence in Resident 73's clinical record that a comprehensive care plan was developed to address the chemotherapy port.

Interview with the Interim Director of Nursing on February 8, 2024, at 9:19 a.m. confirmed that a care plan to address Resident 73's specialized care needs related to having a chemotherapy port was not created and that it should have been.

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



 Plan of Correction - To be completed: 03/27/2024

1. Resident 42 comprehensive care plan has been updated to include the hand splint. Resident 73 comprehensive care plan has been updated to include the cancer port.
2. Current residents with individual specialized needs such as splints or cancer ports have been reviewed and comprehensive plan of care has been reviewed to ensure plan of care includes the appropriate intervention.
3. The Inter Disciplinary Team will be re-educated to complete the comprehensive plan of care to include specialized needs such as splints and cancer ports. Any newly hired Inter Disciplinary Team staff will be trained on completing comprehensive care plans during orientation.
4. The Director of Nursing/designee will audit five residents per week for four weeks and five residents monthly for 2 months with specialized needs such as splints or cancer ports to ensure comprehensive care plan is accurate. Audits will be reviewed at the monthly Quality Assurance and Performance Improvement meeting.

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 clinical records, as well as staff interviews, it was determined that the facility failed to notify the physician that a medication was ineffective for one of 37 residents reviewed (Resident 62).

Findings include:

A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs), for Resident 62, dated November 7, 2023, revealed that she was cognitively impaired and had diagnoses that included seizure disorder (sudden, uncontrolled body movements and changes in behavior that occur because of abnormal electrical activity in the brain), anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), and psychotic disorder (a mental disorder characterized by a disconnection from reality).

Physician's orders for Resident 62, dated December 17, 2023, included orders for the resident to receive 0.5 mg of Xanax (a medication used to treat anxiety) every six hours as needed. The resident's Medication Administration Record (MAR) for December 2023 and January 2024 revealed that the Xanax was ineffective on December 26, 2023, at 5:28 p.m. and on January 7, 2024, at 4:11 p.m.; however, there was no documented evidence that the physician was notified that the Xanax was ineffective.

Interview with the Assistant Director of Nursing on February 8, 2024, at 1:08 p.m. confirmed that the physician should have been notified when Xanax was ineffective for Resident 62.

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






 Plan of Correction - To be completed: 03/27/2024

1. Resident identified cannot be retrospectively affected.
2. Current residents have been reviewed and those who received PRN medication administration since February 21, 2024, where medication was not effective, physician was notified.
3. Licensed staff have been re-educated to notify physician when PRN medication administration is not effective. Any newly hired regular or agency licensed staff will be trained on F580 during orientation.
4. The Director of Nursing/designee will audit ten residents per week for four weeks and 10 residents a month for 2 months to ensure physician was notified if prn medication was ineffective. Audits will be reviewed at the monthly Quality Assurance and Performance Improvement meeting.

483.10(h)(1)-(3)(i)(ii) REQUIREMENT Personal Privacy/Confidentiality of Records: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(h) Privacy and Confidentiality.
The resident has a right to personal privacy and confidentiality of his or her personal and medical records.

§483.10(h)(l) Personal privacy includes accommodations, medical treatment, written and telephone communications, personal care, visits, and meetings of family and resident groups, but this does not require the facility to provide a private room for each resident.

§483.10(h)(2) The facility must respect the residents right to personal privacy, including the right to privacy in his or her oral (that is, spoken), written, and electronic communications, including the right to send and promptly receive unopened mail and other letters, packages and other materials delivered to the facility for the resident, including those delivered through a means other than a postal service.

§483.10(h)(3) The resident has a right to secure and confidential personal and medical records.
(i) The resident has the right to refuse the release of personal and medical records except as provided at §483.70(i)(2) or other applicable federal or state laws.
(ii) The facility must allow representatives of the Office of the State Long-Term Care Ombudsman to examine a resident's medical, social, and administrative records in accordance with State law.
Observations:


Based on review of policies, as well as observations and staff interviews, it was determined that the facility failed to provide confidentiality of residents' personal health information during medication administration for one of 37 residents reviewed (Resident 242).

Findings include:

The facility policy regarding privacy of health information, dated January 25, 2024, indicated that the facility was to protect the confidentiality of a resident's health information.

Observations during medication administration on February 7, 2024, at 8:21 a.m. revealed that Licensed Practical Nurse 1 walked away from her medication cart to retrieve a blood pressure cuff without securing her computer screen. Resident 242's personal health information was visible on the computer screen, which was facing the hallway.

Observations on February 7, 2024, at 8:29 a.m. revealed that Licensed Practical Nurse 1 entered Resident 242's room to administer medication and again left her computer unsecured on her medication cart with Resident 242's personal health information visible on the screen and facing the hallway.

Interview with Licensed Practical Nurse 1 on February 7, 2024, at 8:39 a.m. confirmed that she should have covered the residents' personal information when leaving the medication cart by securing the computer screen.

Interview with the Director of Nursing on February 7, 2024, at 10:13 a.m. confirmed that the computer screen with residents' personal health information should have been covered when the nurse was not attending the medication cart.

28 Pa. Code 211.5(b) Clinical Records.





 Plan of Correction - To be completed: 03/27/2024

1. Residents identified were not affected by health information being in view.
2. Medication passes have been observed and laptop screens did not have resident health information viewable when nurse was not present.
3. Licensed nursing staff have been re-educated to close laptop screen to secure protected health information when not present at medication cart. Any newly hired regular or agency licensed staff will be trained on securing protected health information during orientation.
4. The Director of Nursing/designee will observe five medication passes per week for four weeks and five medication passes monthly for 2 months to ensure PHI is not viewable when staff not present. Audits will be reviewed at the monthly Quality Assurance and Performance Improvement meeting.

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


Based on review of clinical records and observations, as well as resident and staff interviews, it was determined that the facility failed to ensure that care plans were updated to reflect changes in care needs for three of 37 residents reviewed (Residents 23, 62, 78).

Findings include:

A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 23, dated November 13, 2023, revealed that the resident was cognitively impaired, required substantial assistance with care needs, was incontinent of bowel and bladder, was receiving an antibiotic for a urinary tract infection, and had diagnoses that included dementia (loss of cognitive functioning), atrial fibrillation (irregular heart beat), ventricular tachycardia (fast heart rate), congestive heart failure (heart does not pump blood effectively).

Review of Resident 23's cardiac care plan, dated December 8, 2022, indicated that the resident was to have pacemaker checks as ordered; however, the resident did not have a pacemaker.

Interview with the Director of Nursing on February 8, 2024, at 9:15 a.m. revealed that Resident 23 had a defibrillator, not a pacemaker, and did not require pacemaker checks to be done. At this time, the Director of Nursing confirmed that the care plan should have been revised to reflect that the resident had a defibrillator.

Physician's orders for Resident 23, dated February 2, 2024, included an order for contact precautions related to an extended spectrum beta-lactamase (ESBL) infection of the urine (a resistant bacterial infection that can be spread through contact) and was receiving antibiotics. Observations on February 5, 2024, at 12:30 p.m. revealed that the resident had contact precautions in place.

Review of Resident 23's care plan for antibiotic and urinary tract infection, dated February 2, 2024, did not reflect the resident's need for contact precautions related to her ESBL infection.

Interview with the Director of Nursing on February 8, 2024, at 9:15 a.m. confirmed that Resident 23's care plan did not reflect the need for contact precautions, and it should have.

A quarterly MDS assessment for Resident 62, dated November 7, 2023, revealed that she was cognitively impaired and had diagnoses that included seizure disorder (sudden, uncontrolled body movements and changes in behavior that occur because of abnormal electrical activity in the brain), anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), and psychotic disorder (a mental disorder characterized by a disconnection from reality).

A behavior care plan for Resident 62, revised on December 8, 2023, indicated that the resident was on 15-minute checks for safety. However, there was no documented evidence that the resident was on 15-minute checks.

Interview with the Director of Nursing on February 8, 2024, at 1:08 p.m. confirmed that Resident 62 was no longer on 15-minute checks and that the care plan should have been revised.

A quarterly MDS assessment for Resident 78, dated November 17, 2023, revealed that the resident was cognitively intact, required partial to substantial assistance with care needs, was using supplemental oxygen, and had diagnoses that included acute and chronic respiratory failure (difficulty breathing) and chronic obstructive pulmonary disease (COPD) (a chronic lung disease making breathing difficult).

Physician's order for Resident 78, dated November 30, 2023, revealed that the resident was ordered oxygen at a flow rate of 2 liters per minute by way of a nasal canula (a small tube that delivers oxygen through the nasal passages).

A respiratory care plan for Resident 78, revised on October 17, 2023, indicated that the resident was receiving oxygen at a flow rate of 3 liters per minute by way of a nasal canula.

Interview with the Director of Nursing on February 7, 2024, at 1:52 p.m. confirmed that Resident 78's care plan should have been revised to reflect the resident's current oxygen order.

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



 Plan of Correction - To be completed: 03/27/2024

1. Resident 23 care plan has been updated to address resident having defibrillator and contact precautions being in place. Resident 62 care plan has been revised and every 15-minute checks have been resolved. Resident 78 care plan has been updated to reflect the current oxygen status ordered by physician.
2. Current resident care plans for pacemaker/defibrillator, isolation precautions and oxygen use have been reviewed to ensure care plan reflects the status of the resident.
3. The Inter Disciplinary Team has been re-educated on revising resident care plans to reflect status of the resident when changes are made to affect residents plan of care. Care plans will be reviewed at morning clinical meeting to ensure plan of care is accurate. Any newly hired Inter Disciplinary Team staff will be trained on F657 during orientation.
4. The Director of Nursing/designee will audit 5 resident care plans per week for four weeks and 5 resident care plans monthly for two months to ensure care plans reflect status of the resident. Results of audits will be reported to Quality Assurance and Performance Improvement Committee for review and recommendations.

483.25(b)(1)(i)(ii) REQUIREMENT Treatment/Svcs to Prevent/Heal Pressure Ulcer:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
§483.25(b) Skin Integrity
§483.25(b)(1) Pressure ulcers.
Based on the comprehensive assessment of a resident, the facility must ensure that-
(i) A resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable; and
(ii) A resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing.
Observations:


Based on review of clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that pressure ulcer treatments were completed as ordered for one of 37 residents reviewed (Resident 48).

Findings include:

A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 48, dated December 27, 2023, indicated that the resident was cognitively impaired, was dependent on staff for all care needs, and had a Stage 3 pressure area (full-thickness skin loss potentially extending into the subcutaneous tissue layer) to her left buttocks.

Physician's orders for Resident 48, dated October 30, 2023, included an order for the resident's left buttocks to be cleansed with soap and water and patted dry, zinc barrier cream applied to the area every shift and as needed, and to leave the wound open to air.

Review of the December 2023 Treatment Administration Record (TAR) for Resident 48 revealed no documented evidence that the treatment to her left buttocks was completed on December 17, 2023.

Interview with the Director of Nursing on February 8, 2024, at 3:02 p.m. confirmed that there was no documented evidence to indicate the treatment to Resident 48's left buttock was completed as ordered on December 17, 2023.

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




 Plan of Correction - To be completed: 03/27/2024

1. Resident 48 treatment is being completed according to physician order and documented accordingly.
2. Current residents with physician orders for completion of wound treatments have been reviewed to ensure treatments are being completed and documentation is in place to support treatment completion.
3. Licensed nursing staff have been re-educated to complete documentation when administering or completing a treatment according to facility policy. Any newly hired regular or agency licensed staff will be trained on treatment administration as ordered with completion of documentation upon completion of treatment during orientation.
4. The Director of Nursing/designee will audit ten residents a week for four weeks and then 10 residents a month for 2 months to ensure treatment documentation is completed. Results of audits will be reported to Quality Assurance and Performance Improvement Committee for review and recommendations.

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 clinical record reviews, observations, and resident and staff interviews, it was determined that the facility failed to ensure that nutritional supplements were provided as ordered for two of 37 residents reviewed (Residents 11, 29) who were at risk for weight loss.

Findings include:

A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 11, dated January 1, 2024, indicated that the resident could rarely or never understand or be understood, and was dependent on staff for eating. The resident's care plan, dated December 22, 2023, indicated that the resident had an impaired metabolic status and to provide the diet as ordered.

Physician's orders for Resident 11, dated August 2, 2023, included an order for the resident to be provided a sugar-free healthshake with breakfast, lunch, and dinner related to a risk for malnutrition.

Observations of the lunch meal on February 5, 2024, at 11:36 a.m. revealed that Resident 11 was being assisted by Licenced Practical Nurse (LPN) 2 in the dining room. There was no health shake on the lunch tray. Interview with LPN 2 at that time confirmed that the healthshake was not on the tray.

A dietary note for Resident 11, dated February 6, 2024, indicated that the resident had a 4.2-pound weight loss over the last thirty days.

Observations of the lunch meal on February 8, 2024, at 12:06 p.m. revealed that Resident 11 was being assisted by Nurse Aide 3. There was no health shake on the lunch tray. Interview with Nurse Aide 3 at the time confirmed that the health shake was not on the lunch tray.

The medication administration record (MAR) for February 2024 revealed that Resident 11 had zero percent for consumption of a health shake from the dinner meal on February 4, 2024, through the lunch meal on February 8, 2024.

A quarterly MDS assessment for Resident 29, dated December 21, 2023, indicated that the resident, was cognitively impaired and was dependent on staff for eating. The resident's care plan, dated January 5, 2024, indicated that the resident had an increased risk for malnutrition and was to be provided nutritional supplements as ordered by the physician.

Physician's orders for Resident 29, dated November 28, 2023, included an order for the resident to be provided a healthshake with lunch and dinner related to a risk for malnutrition.

Observations of the lunch meal on February 5, 2024, at 11:36 a.m. revealed that Resident 29 was being assisted by Nurse Aide 3 in the dining room. There was no health shake on the lunch tray. Interview with Nurse Aide 3 at that time revealed that the kitchen rarely sends them.

Observations of the lunch meal on February 8, 2024, at 12:06 p.m. revealed that Resident 29 was being assisted by LPN 2 in her room. There was no health shake on the lunch tray. Interview with LPN 2 at that time confirmed that the health shake was not on the lunch tray.

The MAR for February 2024 revealed that Resident 29 had zero percent consumption of the health shakes from the dinner meal on February 5, 2024, through the lunch meal on February 8, 2024.

Interview with the Dietary Manager on February 8, 2024, at 12:14 p.m. revealed that health shakes were out of stock for order and that the dietician informed him to offer a comparable supplement that was available, such as Boost, and to inform staff of the change. There was no documented evidence that this was done.

Interview with the Director of Nursing on February 8, 2024, at 2:38 p.m. confirmed that Resident 11 and Resident 29 did not receive the ordered supplement or the equivalent supplement with meals.

28 Pa. Code 211.12(d)(3)(5) Nursing Services.





 Plan of Correction - To be completed: 03/27/2024

1. Residents 11 and 29 are receiving nutritional supplements according to physician order.
2. Current residents with orders for nutritional supplements have been reviewed and are receiving supplement according to order.
3. Nursing staff have been re-educated to ensure that ordered supplement is being provided and consumption is recorded. Any newly hired regular or agency nursing staff will be trained on during orientation.
4. The Director of Nursing/designee will audit 5 residents per week for four weeks and 10 residents a month for 2 months to ensure nutritional supplement is provided. Results of audits will be reported to Quality Assurance and Performance ensuring nutritional supplements are provided as ordered Improvement Committee for review and recommendations.

483.25(i) REQUIREMENT Respiratory/Tracheostomy Care and Suctioning:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
§ 483.25(i) Respiratory care, including tracheostomy care and tracheal suctioning.
The facility must ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals and preferences, and 483.65 of this subpart.
Observations:


Based on review of clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that oxygen therapy was provided as ordered by the physician for one of 37 residents reviewed (Resident 78).

Findings include:

A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 78, dated November 17, 2023, revealed that the resident was cognitively intact, was using supplemental oxygen, and had diagnoses that included acute and chronic respiratory failure (difficulty breathing) and chronic obstructive pulmonary disease (COPD) (a chronic lung disease making breathing difficult).

Physician's orders for Resident 78, dated November 30, 2023, included an order for the resident to receive oxygen at a flow rate of 2 liters per minute by way of a nasal canula (a small tube that delivers oxygen through the nasal passages).

Observations of Resident 78 on February 5, 2024, at 10:35 a.m. and February 6, 2024, at 8:45 a.m. revealed that the resident was receiving supplemental oxygen continuously at a flow rate of 5 liters per minute by way of a nasal canula.

Interview with Licensed Practical Nurse 4 on February 7, 2024, at 8:45 a.m. confirmed that Resident 78's oxygen was set at a flow rate of 5 liters per minute by way of nasal canula, and the physician's order was for a flow rate of 2 liters per minute by way of nasal canula.

Interview with the Director of Nursing on February 7, 2024, at 10:18 a.m. confirmed that Resident 78's oxygen was being delivered at an incorrect flow rate.

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





 Plan of Correction - To be completed: 03/27/2024

1. Resident 78 is receiving oxygen according to physician order.
2. Current residents receive oxygen therapy have been reviewed and are receiving oxygen according to physician order.
3. Nursing staff have been re-educated to administer oxygen according to physician order and to check administration settings for accuracy. Any newly hired regular or agency nursing staff will be trained on administering oxygen per physician order during orientation.
4. The Director of Nursing/designee will audit 5 residents per week for four weeks and 10 residents a month for 2 months who are receiving oxygen to ensure oxygen administration is correct. Results of audits will be reported to Quality Assurance and Performance Improvement Committee for review and recommendations.

483.25(m) REQUIREMENT Trauma Informed Care: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(m) Trauma-informed care
The facility must ensure that residents who are trauma survivors receive culturally competent, trauma-informed care in accordance with professional standards of practice and accounting for residents' experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization of the resident.
Observations:


Based on clinical record reviews and staff interviews, it was determined that the facility failed to ensure that residents were assessed and received trauma-informed care to eliminate or mitigate triggers for residents with the diagnosis of Post Traumatic Stress Disorder (PTSD) (a mental and behavioral disorder that develops related to a terrifying event) for one of 37 residents reviewed (Resident 45).

Findings include:

An annual Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 45, dated November 21, 2023, revealed that the resident was cognitively intact; required moderate assistance from staff for dressing, toileting, and bathing; and had diagnoses that that included depression and PTSD. A review of Resident 45's care plan, dated December 6, 2023, indicated that the resident had a history of PTSD after surviving a traumatic event.

Interview with Resident 45 on February 5, 2024, at 11:38 a.m. revealed that a past boyfriend had physically hurt her.

There was no documented evidence that a trauma-informed assessment was completed.

Interview with the Director of Nursing on February 7, 2024, at 9:00 a.m. confirmed that there was no documented evidence that a trauma-informed care assessment was part of the medical record.

Interview with the Social Services Director on February 7, 2024, at 1:15 p.m. indicated that Resident 45 has very few memories of the traumatic event due past physical trauma and only repeats what the family have reported. The Social Services Director confirmed that the trauma informed assessment should be completed periodically to assess for changes and be documented in the medical record.

28 Pa Code 211.12(a)(d)(3)(5) Nursing Services.

28 Pa. Code 211.16(a) Social Services.





 Plan of Correction - To be completed: 03/27/2024

1. Resident 45 has had a Trauma Evaluation completed.
2. Current residents have been reviewed and residents with history of a traumatic event have had a Trauma Evaluation completed.
3. Social Service department has been re-educated on completing a Trauma Evaluation for residents with a diagnosis of post-traumatic stress disorder or have had a traumatic event. Any newly hired social service staff will be trained on completing a trauma evaluation for residents with a history of PTSD or a history of trauma during orientation.
4. The Administrator/designee will audit 5 residents per week for four weeks and 10 residents a month for 2 months to ensure a trauma informed assessment is completed when appropriate. Results of audits will be reported to Quality Assurance and Performance Improvement Committee for review and recommendations.

483.50(a)(1)(i) REQUIREMENT Laboratory Services: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.
§483.50(a) Laboratory Services.
§483.50(a)(1) The facility must provide or obtain laboratory services to meet the needs of its residents. The facility is responsible for the quality and timeliness of the services.
(i) If the facility provides its own laboratory services, the services must meet the applicable requirements for laboratories specified in part 493 of this chapter.
Observations:


Based on review of clinical records, as well as staff interviews, it was determined that the facility failed to obtain labs timely for one of four residents reviewed (Resident 62).

Findings include:

A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 62, dated November 7, 2023, revealed that she was cognitively impaired and had diagnoses that included seizure disorder (sudden, uncontrolled body movements and changes in behavior that occur because of abnormal electrical activity in the brain), anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), and psychotic disorder (a mental disorder characterized by a disconnection from reality).

The pharmacist's Medication Regimen Review for Resident 62, dated June 23, 2023, recommended lab tests for Keppra (a medication used for seizures that must be regulated by routine lab testing), Basic Metabolic Panel (a blood test that measures eight different substances in blood), Complete Blood Count (a blood test to look at overall health), Liver Function Test (a blood test to help find the cause of symptoms and monitor liver disease), and A1C (a blood test that measured your average blood sugar levels over the past three months) be completed on June 24, 2023. The form was signed by the Certified Registered Nurse Practitioner agreeing to recommendations.

A review of Resident 62's clinical record revealed that the above requested laboratory testing for Resident 62 was not completed until August 3, 2023.

Interview with the Interim Director of Nursing on February 8, 2024, at 1:05 p.m. confirmed that staff did not follow through and complete the laboratory testing in a timely manner.

28 Pa. Code 211.12(d)(3)(5) Nursing Services.





 Plan of Correction - To be completed: 03/27/2024

1. Resident 62 lab work was completed and physician aware of results.
2. Current residents with physician orders for lab work have been reviewed and lab work was completed timely.
3. Licensed nursing staff have been re-educated regarding reviewing pharmacy recommendations and scheduling labs in a timely manner according to the physician order. Completed pharmacy recommendations will be reviewed at morning clinical meeting to ensure recommendations are transcribed accurately to include laboratory testing as ordered. Any newly hired regular or agency licensed staff will be trained on reviewing pharmacy recommendations when completed and transcribing orders including labs during orientation.
4. The Director of Nursing/designee will audit 5 residents per week for four weeks and 10 residents a month for 2 months to ensure lab work was completed per pharmacy recommendation according to physician order. Results of audits will be reported to Quality Assurance and Performance Improvement Committee for review and recommendations.

483.50(a)(2)(i)(ii) REQUIREMENT Lab Srvcs Physician Order/Notify of Results: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.
§483.50(a)(2) The facility must-
(i) Provide or obtain laboratory services only when ordered by a physician; physician assistant; nurse practitioner or clinical nurse specialist in accordance with State law, including scope of practice laws.
(ii) Promptly notify the ordering physician, physician assistant, nurse practitioner, or clinical nurse specialist of laboratory results that fall outside of clinical reference ranges in accordance with facility policies and procedures for notification of a practitioner or per the ordering physician's orders.
Observations:


Based on clinical record reviews and staff interviews, it was determined that the facility failed to obtain laboratory studies as ordered by the physician for one of 37 residents reviewed (Resident 37).

Findings include:

An annual Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 37, dated November 14, 2023, indicated that the resident was cognitively impaired, required substantial assistance from staff for daily care needs, and had diagnoses that included chronic iron deficiency anemia due to blood loss.

A Certified Registered Nurse Practitioner's (CRNP) progress note for Resident 37, dated November 3, 2023, at 2:04 p.m. indicated that the resident had recent bloodwork reviewed from October 10, 2023, showing a hemoglobin (measurement of protein in the blood that carries oxygen to body organs) of 7.4 (low) and a hematocrit (measures how much of the blood consists of red blood cells) of 24.7 (low). The results were reviewed by the physician on October 10, 2023, and the physician ordered the bloodwork to be rechecked in one week.

There was no documented evidence in Resident 37's clinical record that staff obtained the bloodwork on October 17, 2023, that was ordered by the physician on October 10, 2023.

Interview with the Director of Nursing on February 7, 2024, at 1:52 p.m. confirmed that there was no documented evidence that staff obtained the bloodwork for Resident 37 as ordered by the physician on October 10, 2023.

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




 Plan of Correction - To be completed: 03/27/2024

1. Resident 37 has had no negative effects from the lab work not being completed as ordered.
2. Current resident orders have been reviewed from February 1, 2024, to ensure that lab work has been completed as ordered.
3. Licensed nursing staff have been re-educated on reviewing labs results with the physician and transcribing orders timely. Lab results will be reviewed at clinical meeting to ensure physician orders have been transcribed and completed.
4. The Director of Nursing/designee will audit 5 residents per week for four weeks 10 residents a month for 2 months ensure lab results have been reviewed with the physician and new orders have been transcribed. Results of audits will be reported to Quality Assurance and Performance Improvement Committee for review and recommendations.

483.60(i)(1)(2) REQUIREMENT Food Procurement,Store/Prepare/Serve-Sanitary: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(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 and staff interviews, it was determined that the facility failed to ensure that food was stored and served under sanitary conditions in accordance with professional standards for food service safety, and failed to ensure that food items were stored in accordance with professional standards for food service safety in three of three nursing unit pantry refrigerators (first, third, fourth floor pantries).

Findings include:

Observations inside the second floor pantry refrigerator on February 5, 2024, at 10:18 a.m. revealed a large spill of a brown, sticky, removable substance below the draws in the bottom of the refrigerator and several loose pieces of old, dried-up shredded cheese on the door of the refrigerator.

Interview with the Director of Nursing on February 5, 2024, at 10:21 a.m. confirmed that the spill and old cheese should have been cleaned up.

28 Pa. Code 211.6(f) Dietary services.



 Plan of Correction - To be completed: 03/27/2024

1. The brown sticky substance has been cleaned from the refrigerator. No residents were affected.
2. Pantry refrigerators were inspected and are clean.
3. Dietary staff have been re-educated on routine cleaning of the pantry refrigerators. The cleaning of the refrigerators has been placed on a routine cleaning schedule and a routine inspection schedule. Any newly hired dietary staff will be trained on routine cleaning and inspection of the pantries during orientation.
4. The Food Service Manager/designee will audit pantry refrigerators 3x/week for four weeks then monthly for 2 months to ensure they are clean and sanitary. Results of audits will be reported to Quality Assurance and Performance Improvement Committee for review and recommendations.

483.20(f)(5), 483.70(i)(1)-(5) REQUIREMENT Resident Records - Identifiable Information:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
§483.20(f)(5) Resident-identifiable information.
(i) A facility may not release information that is resident-identifiable to the public.
(ii) The facility may release information that is resident-identifiable to an agent only in accordance with a contract under which the agent agrees not to use or disclose the information except to the extent the facility itself is permitted to do so.

§483.70(i) Medical records.
§483.70(i)(1) In accordance with accepted professional standards and practices, the facility must maintain medical records on each resident that are-
(i) Complete;
(ii) Accurately documented;
(iii) Readily accessible; and
(iv) Systematically organized

§483.70(i)(2) The facility must keep confidential all information contained in the resident's records,
regardless of the form or storage method of the records, except when release is-
(i) To the individual, or their resident representative where permitted by applicable law;
(ii) Required by Law;
(iii) For treatment, payment, or health care operations, as permitted by and in compliance with 45 CFR 164.506;
(iv) For public health activities, reporting of abuse, neglect, or domestic violence, health oversight activities, judicial and administrative proceedings, law enforcement purposes, organ donation purposes, research purposes, or to coroners, medical examiners, funeral directors, and to avert a serious threat to health or safety as permitted by and in compliance with 45 CFR 164.512.

§483.70(i)(3) The facility must safeguard medical record information against loss, destruction, or unauthorized use.

§483.70(i)(4) Medical records must be retained for-
(i) The period of time required by State law; or
(ii) Five years from the date of discharge when there is no requirement in State law; or
(iii) For a minor, 3 years after a resident reaches legal age under State law.

§483.70(i)(5) The medical record must contain-
(i) Sufficient information to identify the resident;
(ii) A record of the resident's assessments;
(iii) The comprehensive plan of care and services provided;
(iv) The results of any preadmission screening and resident review evaluations and determinations conducted by the State;
(v) Physician's, nurse's, and other licensed professional's progress notes; and
(vi) Laboratory, radiology and other diagnostic services reports as required under §483.50.
Observations:


Based on review of clinical records, as well as resident and staff interviews, it was determined that the facility failed to maintain clinical records that were complete and accurately documented for two of 37 residents reviewed (Residents 53, 62).

Findings include:

A quarterly MDS assessment for Resident 53, dated January 12, 2024, revealed that the resident was cognitively impaired, required assistance with daily care needs, and had diagnoses that included a stroke and a Stage 3 pressure ulcer on the left middle finger.

Physician's orders for Resident 53, dated December 22, 2023, included an order for the resident's left middle finger to be cleansed with normal saline and patted dry, Bactroban 2 percent (an antibiotic ointment) applied to the wound base, secured with bordered gauze, and to be changed daily.

Review of the January and February 2024 Treatment Administration Record (TAR) for Resident 53 indicated that the resident did not receive the treatment on January 23 and 27, 2024, or February 2, and 5, 2024.

A witness statement from Licensed Practical Nurse 5 revealed that she completed Resident 53's treatment on January 23 and 27, 2024, and February 2, 2024, but did not sign it off on the TAR.

A witness statement from Licensed Practical Nurse 6 revealed that he completed Resident 53's treatment on February 5, 2024, but did not sign it off on the TAR.

Interview with the Director of Nursing on February 8, 2024, confirmed that the treatment should have been documented as completed on Residents 53's treatment record.

A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 62, dated November 7, 2023, revealed that she was cognitively impaired and had diagnoses that included seizure disorder, anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), and psychotic disorder (a mental disorder characterized by a disconnection from reality).

A social services note, dated December 28, 2023, at 2:31 p.m. revealed that Resident 62 had a care conference where it was determined that the resident's behaviors were increasing to a point that there was a concern for her safety, and that the social worker was working on finding alternate placement. However, there was no documented evidence that the social worker had attempted to find alternate placement for Resident 62.

Interview with the Social Service Director on February 8, 2024, at 10:22 a.m. revealed that she attempted to find alternative housing, but she was unable to, and that she should have documented those conversations.

28 Pa. Code 211.5(f) Clinical Records.

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




 Plan of Correction - To be completed: 03/27/2024

1. Resident 53 and 62 medical record is complete and accurate.
2. Current residents Treatment Administration Records have been reviewed and are complete and accurate. Current residents social service progress notes have been reviewed and are complete and accurate.
3. Licensed nursing staff have been re-educated on the need to sign off completion of physician ordered treatments in the Treatment Administration Record upon completion of the treatment. Social Service staff have been re-educated to document post care conference to include any attempts to find alternate placement in resident medical record.
4. The Director of Nursing/designee will audit 10 residents per week for four weeks and 10 residents a month for 2 months to ensure documentation is complete in TAR. NHA/designee will audit 5 residents social service notes per week for four weeks and 10 residents social services notes to ensure documentation is complete and accurate. Results of audits will be reported to Quality Assurance and Performance Improvement Committee for review and recommendations.

483.70(o)(1)-(4) REQUIREMENT Hospice Services: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.
§483.70(o) Hospice services.
§483.70(o)(1) A long-term care (LTC) facility may do either of the following:
(i) Arrange for the provision of hospice services through an agreement with one or more Medicare-certified hospices.
(ii) Not arrange for the provision of hospice services at the facility through an agreement with a Medicare-certified hospice and assist the resident in transferring to a facility that will arrange for the provision of hospice services when a resident requests a transfer.

§483.70(o)(2) If hospice care is furnished in an LTC facility through an agreement as specified in paragraph (o)(1)(i) of this section with a hospice, the LTC facility must meet the following requirements:
(i) Ensure that the hospice services meet professional standards and principles that apply to individuals providing services in the facility, and to the timeliness of the services.
(ii) Have a written agreement with the hospice that is signed by an authorized representative of the hospice and an authorized representative of the LTC facility before hospice care is furnished to any resident. The written agreement must set out at least the following:
(A) The services the hospice will provide.
(B) The hospice's responsibilities for determining the appropriate hospice plan of care as specified in §418.112 (d) of this chapter.
(C) The services the LTC facility will continue to provide based on each resident's plan of care.
(D) A communication process, including how the communication will be documented between the LTC facility and the hospice provider, to ensure that the needs of the resident are addressed and met 24 hours per day.
(E) A provision that the LTC facility immediately notifies the hospice about the following:
(1) A significant change in the resident's physical, mental, social, or emotional status.
(2) Clinical complications that suggest a need to alter the plan of care.
(3) A need to transfer the resident from the facility for any condition.
(4) The resident's death.
(F) A provision stating that the hospice assumes responsibility for determining the appropriate course of hospice care, including the determination to change the level of services provided.
(G) An agreement that it is the LTC facility's responsibility to furnish 24-hour room and board care, meet the resident's personal care and nursing needs in coordination with the hospice representative, and ensure that the level of care provided is appropriately based on the individual resident's needs.
(H) A delineation of the hospice's responsibilities, including but not limited to, providing medical direction and management of the patient; nursing; counseling (including spiritual, dietary, and bereavement); social work; providing medical supplies, durable medical equipment, and drugs necessary for the palliation of pain and symptoms associated with the terminal illness and related conditions; and all other hospice services that are necessary for the care of the resident's terminal illness and related conditions.
(I) A provision that when the LTC facility personnel are responsible for the administration of prescribed therapies, including those therapies determined appropriate by the hospice and delineated in the hospice plan of care, the LTC facility personnel may administer the therapies where permitted by State law and as specified by the LTC facility.
(J) A provision stating that the LTC facility must report all alleged violations involving mistreatment, neglect, or verbal, mental, sexual, and physical abuse, including injuries of unknown source, and misappropriation of patient property by hospice personnel, to the hospice administrator immediately when the LTC facility becomes aware of the alleged violation.
(K) A delineation of the responsibilities of the hospice and the LTC facility to provide bereavement services to LTC facility staff.

§483.70(o)(3) Each LTC facility arranging for the provision of hospice care under a written agreement must designate a member of the facility's interdisciplinary team who is responsible for working with hospice representatives to coordinate care to the resident provided by the LTC facility staff and hospice staff. The interdisciplinary team member must have a clinical background, function within their State scope of practice act, and have the ability to assess the resident or have access to someone that has the skills and capabilities to assess the resident.
The designated interdisciplinary team member is responsible for the following:
(i) Collaborating with hospice representatives and coordinating LTC facility staff participation in the hospice care planning process for those residents receiving these services.
(ii) Communicating with hospice representatives and other healthcare providers participating in the provision of care for the terminal illness, related conditions, and other conditions, to ensure quality of care for the patient and family.
(iii) Ensuring that the LTC facility communicates with the hospice medical director, the patient's attending physician, and other practitioners participating in the provision of care to the patient as needed to coordinate the hospice care with the medical care provided by other physicians.
(iv) Obtaining the following information from the hospice:
(A) The most recent hospice plan of care specific to each patient.
(B) Hospice election form.
(C) Physician certification and recertification of the terminal illness specific to each patient.
(D) Names and contact information for hospice personnel involved in hospice care of each patient.
(E) Instructions on how to access the hospice's 24-hour on-call system.
(F) Hospice medication information specific to each patient.
(G) Hospice physician and attending physician (if any) orders specific to each patient.
(v) Ensuring that the LTC facility staff provides orientation in the policies and procedures of the facility, including patient rights, appropriate forms, and record keeping requirements, to hospice staff furnishing care to LTC residents.

§483.70(o)(4) Each LTC facility providing hospice care under a written agreement must ensure that each resident's written plan of care includes both the most recent hospice plan of care and a description of the services furnished by the LTC facility to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, as required at §483.24.
Observations:


Based on a review of hospice contracts and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that the designated interdisciplinary team member obtained the required information from the contracted hospice provider for two of two hospice residents reviewed (Residents 32, 48).

Findings include:

An agreement between the facility and a hospice provider (provider of end-of-life services), dated January 25, 2024, indicated that the hospice provider would provide information to the facility to facilitate coordination of care that included the most recent hospice plan of care specific to each patient and a hospice benefit of elections form (a form signed to indicate that the individual waives all rights to traditional Medicare Part A payments for treatment related to the terminal illness).

Physician's orders for Resident 32, dated July 12, 2022, revealed that the resident was to receive hospice services from the facility's contracted hospice provider. As of February 8, 2024, there was no documented evidence in the resident's clinical record, or in the hospice provider's clinical record, that the facility obtained the recertification of terminal illness form and resident's hospice plan of care.

Interview with the Director of Nursing on February 8, 2024, at 1:07 p.m. confirmed that there was no documented evidence that Resident 32's clinical records and/or the hospice clinical records contained the recertification of terminal illness and resident's hospice plan of care.

Physician's orders for Resident 48, dated March 30, 2022, revealed that the resident was to receive hospice services from the facility's contracted hospice provider. As of February 8, 2024, there was no documented evidence in the resident's clinical record, or in the hospice provider's clinical record, that the facility obtained the recertification of terminal illness form and the resident's hospice plan of care.

Interview with the Director of Nursing on February 8, 2024, at 2:40 p.m. confirmed that there was no documented evidence that Resident 48's clinical records and/or the hospice clinical records contained the recertification of terminal illness and the resident's hospice plan of care.

28 Pa. Code 211.12(d)(3)(5) Nursing Services.



 Plan of Correction - To be completed: 03/27/2024

1. Resident 32 and 48 medical records have a current hospice plan of care and recertification of terminal illness form in the medical record.
2. Current resident receiving hospice benefits have been reviewed and hospice plan of care and recertification of terminal illness form are in the medical record.
3. Hospice providers have been re-educated on the need to maintain a current hospice plan of care and recertification of terminal illness in the resident medical record. Any new hospice providers will be trained on completing hospice plan of care and recertification of terminal illness.
4. The Administrator/designee will audit 5 residents per week for 4 weeks and then monthly for 2 months who are receiving hospice benefits to ensure hospice plan of care and recertification of terminal illness form is in medical record. Results of audits will be reported to Quality Assurance and Performance Improvement Committee for review and recommendations.

483.75(c)(d)(e)(g)(2)(i)(ii) REQUIREMENT QAPI/QAA Improvement Activities: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.
§483.75(c) Program feedback, data systems and monitoring.
A facility must establish and implement written policies and procedures for feedback, data collections systems, and monitoring, including adverse event monitoring. The policies and procedures must include, at a minimum, the following:

§483.75(c)(1) Facility maintenance of effective systems to obtain and use of feedback and input from direct care staff, other staff, residents, and resident representatives, including how such information will be used to identify problems that are high risk, high volume, or problem-prone, and opportunities for improvement.

§483.75(c)(2) Facility maintenance of effective systems to identify, collect, and use data and information from all departments, including but not limited to the facility assessment required at §483.70(e) and including how such information will be used to develop and monitor performance indicators.

§483.75(c)(3) Facility development, monitoring, and evaluation of performance indicators, including the methodology and frequency for such development, monitoring, and evaluation.

§483.75(c)(4) Facility adverse event monitoring, including the methods by which the facility will systematically identify, report, track, investigate, analyze and use data and information relating to adverse events in the facility, including how the facility will use the data to develop activities to prevent adverse events.

§483.75(d) Program systematic analysis and systemic action.

§483.75(d)(1) The facility must take actions aimed at performance improvement and, after implementing those actions, measure its success, and track performance to ensure that improvements are realized and sustained.

§483.75(d)(2) The facility will develop and implement policies addressing:
(i) How they will use a systematic approach to determine underlying causes of problems impacting larger systems;
(ii) How they will develop corrective actions that will be designed to effect change at the systems level to prevent quality of care, quality of life, or safety problems; and
(iii) How the facility will monitor the effectiveness of its performance improvement activities to ensure that improvements are sustained.

§483.75(e) Program activities.

§483.75(e)(1) The facility must set priorities for its performance improvement activities that focus on high-risk, high-volume, or problem-prone areas; consider the incidence, prevalence, and severity of problems in those areas; and affect health outcomes, resident safety, resident autonomy, resident choice, and quality of care.

§483.75(e)(2) Performance improvement activities must track medical errors and adverse resident events, analyze their causes, and implement preventive actions and mechanisms that include feedback and learning throughout the facility.

§483.75(e)(3) As part of their performance improvement activities, the facility must conduct distinct performance improvement projects. The number and frequency of improvement projects conducted by the facility must reflect the scope and complexity of the facility's services and available resources, as reflected in the facility assessment required at §483.70(e). Improvement projects must include at least annually a project that focuses on high risk or problem-prone areas identified through the data collection and analysis described in paragraphs (c) and (d) of this section.

§483.75(g) Quality assessment and assurance.

§483.75(g)(2) The quality assessment and assurance committee reports to the facility's governing body, or designated person(s) functioning as a governing body regarding its activities, including implementation of the QAPI program required under paragraphs (a) through (e) of this section. The committee must:

(ii) Develop and implement appropriate plans of action to correct identified quality deficiencies;
(iii) Regularly review and analyze data, including data collected under the QAPI program and data resulting from drug regimen reviews, and act on available data to make improvements.
Observations:


Based on review of the facility's plans of correction for previous surveys, and the results of the current survey, it was determined that the facility's Quality Assurance Performance Improvement (QAPI) committee failed to ensure that corrective plans to improve and/or correct quality deficiencies effectively addressed recurring deficiencies and ensured that the facility maintained compliance with nursing home regulations.

Findings include:

The facility's deficiencies and plans of correction for State Survey and Certification (Department of Health) surveys ending December 1, 2023; June 30, 2023; and March 23, 2023, revealed that the facility developed plans of correction that included quality assurance systems to ensure that the facility maintained compliance with cited nursing home regulations. The results of the current survey, ending February 8, 2024, identified repeated deficiencies related to notification of changes, developing comprehensive care plans, updating and revising care plans, providing services to maintain adequate nutrition, ensuring that food was properly stored, and ensuring that the medical record was complete and accurately documented.

The facility's plans of correction for deficiencies regarding notification of changes, cited during the survey ending December 1, 2023, revealed that the facility would complete audits and report the results of the audits to the QAPI committee for review. The results of the current survey, cited under F580, revealed that the facility's QAPI committee failed to successfully implement their plan to ensure ongoing compliance with the regulations regarding notification of changes.

The facility's plans of correction for deficiencies regarding developing comprehensive care plans, cited during the surveys ending June 30, 2023, and March 23, 2023, revealed that the facility would complete audits and report the results of the audits to the QAPI committee for review. The results of the current survey, cited under F656, revealed that the facility's QAPI committee failed to successfully implement their plan to ensure ongoing compliance with the regulation regarding the development of a comprehensive care plan to meet the care needs of residents.

The facility's plan of correction for a deficiency regarding revision of care plans, cited during the survey ending March 23, 2023, revealed that the facility would complete audits and report the results of the audits to the QAPI committee for review. The results of the current survey, cited under F657, revealed that the facility's QAPI committee was ineffective in maintaining compliance with the regulation regarding the revision of care plans to meet the care needs of residents.

The facility's plan of correction for a deficiency regarding services to maintain nutritional status, cited during the survey ending June 30, 2023, revealed that the facility developed a plan of correction that included completing audits and reporting the results of the audits to the QAPI committee for review. The results of the current survey, cited under F692, revealed that the QAPI committee was ineffective in maintaining compliance with services to maintain nutritional status.

The facility's plan of correction for a deficiency regarding labeling, storing, preparing and serving food under sanitary conditions, cited during the survey ending March 23, 2023, revealed that the facility developed a plan of correction that included completing audits and reporting the results of the audits to the QAPI committee for review. The results of the current survey, cited under F812, revealed that the QAPI committee was ineffective in correcting deficient practices related to labeling, storing, preparing and serving food under sanitary conditions.

The facility's plan of correction for a deficiency regarding complete and accurate documentation in the medical record, cited during the survey ending June 30, 2023, and March 23, 2023, revealed that the facility would complete audits and report the results of the audits to the QAPI committee for review. The results of the current survey, cited under F842, revealed that the facility's QAPI committee was ineffective in maintaining compliance with the regulation regarding complete and accurate documentation in the medical record.

Refer to F580, F656, F657, F692, F812, F842

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

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





 Plan of Correction - To be completed: 03/27/2024

1. No residents were identified regarding this deficiency.
2. Residents residing in the facility have the potential to be affected by the identified deficient practice. The Administrator/designee will continue to routinely monitor the plan of correction for compliance and address any needed interventions.
3. The Administrator will retrain members of the Quality Assurance and Performance Improvement Committee on problem identification and initiation or continuance of identified areas brought forth to the Quality Assurance Performance Improvement Committee.
4. The Quality Assurance Performance Improvement Committee will audit future plans of corrections to ensure they are compliant with all aspects of the cited deficiency. The results will be reviewed at the Quality Assurance and Performance Improvement Committee meetings.

483.80(a)(1)(2)(4)(e)(f) REQUIREMENT Infection Prevention & Control:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
§483.80 Infection Control
The facility must establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections.

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

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

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

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

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

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


Based on review of guidance from the Centers for Disease Control (CDC - the national health protection agency) and clinical records, as well as observations and staff interviews, it was determined that the facility failed to follow CDC guidelines to reduce the spread of infections and prevent cross-contamination related to Clostridioides difficile infection for one of 37 residents reviewed (Resident 38).

Findings include:

The facility's policy regarding isolation and transmission based precautions, dated January 25, 2024, indicated that contact precautions are implemented for residents known or suspected to be infected with microorganisms that can be transmitted by direct contact with the resident or indirect contact with environmental surfaces or resident-care items in the resident's environment. Staff and visitors are to don gloves and disposable gowns (also known as personal protective equipment or PPE) when entering the room and remove the PPE before leaving the room.

A quarterly Minimum Data Set (MDS) assessment (required assessment of a resident's abilities and care needs) for Resident 38, dated January 8, 2024, revealed that the resident was cognitively intact, was frequently incontinent of bowel, required assistance for staff with daily care needs, and had diagnoses that included high blood pressure and a stroke. A care plan dated January 26, 2024, indicated that the resident was in contact isolation for Clostridium difficile (C-diff, a bacteria that can cause severe diarrhea and inflammation of the colon).

Observations on February 8, 2024, at 11:23 a.m. revealed that Nurse Aide 7 and Nurse Aide 8 answered Resident 38's call bell and entered the resident's room without putting on disposable gowns. They performed incontinence care on the resident while only wearing gloves. When finished, Nurse Aide 7 discarded the soiled brief into the isolation bin and emptied the wash bin into the sink in the bathroom, removed her gloves, and assisted Nurse Aide 8 with transporting the resident into the mechanical lift to transfer resident into the wheelchair. They removed gloves but did not perform hand hygiene.

Interview with Nurse Aide 7 and Nurse Aide 8 on February 8, 2024, at 11:25 a.m. confirmed that they performed incontinence care on Resident 38 and did not wear the disposable gowns and did not wash hands with soap and water per contact isolation precautions for Clostridium difficile.

Interview with the Director of Nursing on February 8, 2024, at 1:52 p.m. confirmed that Resident 38 is on contact isolation precautions for Clostridium difficile and that the nurse aides should have worn the proper personal protective equipment when providing care to residents on isolation precautions.

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




 Plan of Correction - To be completed: 03/27/2024

1. Employee 7 and 8 have been re-educated on use of proper personal protective equipment when completing resident care.
2. Current residents on isolation have been reviewed and staff is utilizing proper personal protective equipment when completing resident care.
3. Facility staff have been re-educated on use of proper personal protective equipment when completing care for a resident with an infectious disease. All newly hired members of regular staff or agency staff will be trained on infection control and usage of appropriate personal protective equipment.
4. The Director of Nursing/designee will audit 5 residents per week for four weeks and then 5 residents a month for two months who are on isolation to ensure proper personal protective equipment is being utilized by facility staff. Results of audits will be reported to Quality Assurance and Performance Improvement Committee for review and recommendations.

§ 201.14(a) LICENSURE Responsibility of licensee.:State only Deficiency.
(a) The licensee is responsible for meeting the minimum standards for the operation of a facility as set forth by the Department and by other Federal, State and local agencies responsible for the health and welfare of residents. This includes complying with all applicable Federal and State laws, and rules, regulations and orders issued by the Department and other Federal, State or local agencies.

Observations:


Based on review of Pennsylvania state law, as well as staff interviews, it was determined that the facility failed to ensure that the multi-disciplinary infection control committee met at least quarterly.

Findings include:

The Act 52 Infection Control Plan, dated January 25, 2024, revealed that a health care facility should develop and implement an internal infection control plan that should be established for the purpose of improving the health and safety of residents and health care workers, and should include a multi-disciplinary committee including a representative from each of the following, if applicable to the specific health care facility. Applicable members included medical staff that could include the chief medical officer or the nursing home medical director, the nursing home administrator, laboratory personnel, nursing staff that could include the director of nursing or a nursing supervisor, pharmacy staff, physical plant personnel, a patient safety officer, and a community member that may not be an agent, employee or contractor of the facility.

As of February 8, 2024, the facility was unable to provide any documented evidence that the facility's multi-disciplinary infection control committee met at least quarterly.

Interview with the Director of Nursing on February 6, 2024, at 10:18 a.m. confirmed that there was no documented evidence that the facility's multi-disciplinary infection control committee met at least quarterly.






 Plan of Correction - To be completed: 03/27/2024

1. No residents were identified for this deficiency.

2. The membership of the infection control committee has been expanded to include a laboratory representative from the facility's lab provider, Penn Highlands Tyrone.

3. The Administrator will retrain the Director of Nursing and Infection Control Nurse on the requirements of H1020 to be inclusive of all required multi-disciplinary membership on the committee.

4. The Director of Nursing/designee will monitor attendance of required multi-disciplinary members for the infection control committee meetings and report findings to the Quality Assurance and Performance Improvement committee.
35 P. S. § 448.809b LICENSURE Photo Id Reg:State only Deficiency.
Law amended July 11, 2022 Act 79 2022 HB 2604

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

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


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

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


Observations:


Based on observations and staff interviews, it was determined that the facility failed to ensure that all staff displayed photo identification tags on their uniforms.

Findings include:

Observations on February 8, 2024, at 11:30 a.m. revealed that Nurse Aide 10 was not wearing her photo identification tag. Interview with her at that time confirmed that she was not wearing her photo identification tag because the facility did not give her one yet. She revealed that she worked at the facility since April 2023 then was off for maternity leave and then back to work at the facility in August 2023.

Interview with the Human Resources Director on February 8, 2024, at 3:18 p.m. revealed that new hires are given a lanyard and a plastic holder to display their name and position. The photo identifications are sent out in batches and would take no longer than two weeks after the start date. She confirmed that staff should have their new hire badge or photo identification on while working.




 Plan of Correction - To be completed: 03/27/2024

1. Employee 10 has been wearing identification badge.
2. Current staff have been monitored to ensure that they are wearing appropriate identification badges while working.
3. Facility staff have been re-educated on the need to wear identification badges while working. All newly hired members of regular staff or agency staff will be trained on H010 in orientation.
4. The Administrator/designee will audit 10 employees per week for two weeks and 10 employees every 2 weeks to ensure that they are wearing identification badges. Results of audits will be reported to Quality Assurance and Performance Improvement Committee for review and recommendations.


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