Pennsylvania Department of Health
 GROVE AT HARMONY, THE
Patient Care Inspection Results

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
GROVE AT HARMONY, THE
Inspection Results For:

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GROVE AT HARMONY, THE - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on a Medicare/Medicaid Recertification Survey, State Licensure, Civil Rights Compliance Survey, and an Abbreviated Survey in response to three complaints completed on May 3, 2024, it was determined that The Grove at Harmony was not in compliance with the following requirements of 42 CFR Part 483, Subpart B, Requirements for Long-Term Care and the 28 Pa. Code, Commonwealth of Pennsylvania Long-Term Care Licensure Regulations.


 Plan of Correction:


483.60(i)(1)(2) REQUIREMENT Food Procurement,Store/Prepare/Serve-Sanitary:This is a less serious (but not lowest level) deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents. 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 a review of facility menu, facility documents, observations, staff interviews, and resident interview, it was determined that the facility failed to comply with food safety regulations by failing to monitoring the proper cooling of foods for two days (4/27/24, and 4/28/24), and properly store utensils for one of two ice machines (Main Dining Room) creating the potential for food borne illness.

Findings include:

Review of the facility policy "Food Temperature Recording Policy" dated 2/1/24, indicated that temperatures of un-served/production foods will be taken after meal service/production and followed for six hours (if needed) after service/production for appropiate cooling. All temperature's will be recorded on the Cooling Log. Temperatures of un-served/production foods will be taken prior to the close of the Dining Services department for appropriate cooling and will be recorded on the Cooling Log. If the desired temperature of the un-served/production food is not achieved prior to the close of the dietary department, the food will be discarded.

Review of the facility menu revealed that for Week One Sunday (4/28/24), the main entrfor lunch was Yankee Pot Roast, and Week One Monday (4/29/24) the alternate main entrfor lunch was roast beef.

During an observation and interview on 4/29/24, at 9:40 a.m. in the Main Dining Room, the ice machine had a scoop that was sitting on top of the ice machine. Food Service Director (FSD) Employee E9 confirmed that the facility failed to prevent any physical contamination and or cross contamination of ice by having an ice scoop on top of the machine.

During an observation on 4/29/24, at 12:19 p.m. Resident R59 had her lunch tray in front of her, but was not eating.

During an observation on 4/29/24, at 12:19 p.m., Resident R59's meal ticket stated that she was to receive fried chicken, however, there was no fried chicken on her tray and there was a very dry, hard, and stringy appearing piece of meat.

During an interview on 4/29/24, at 12:20 p.m. Resident R59 was asked what her entrwas and she replied "I think it's left over roast beef from yesterday".

During an interview in Resident R59's room on 4/29/24, at 12:47 p.m. FSD Employee E9 confirmed that Resident R59 was served leftovers from yesterday's lunch of Yankee pot roast, and confirmed that the meat appeared to be very dry and unappetizing.

During an additional interview on 4/29/24, at 1:08 p.m. FSD Employee E9 stated that Yankee pot roast was on the menu for lunch on Sunday 4/28/24, but that it was made a day ahead on Saturday 4/27/24, then cooled, and reheated for lunch on Sunday 4/28/24. This was cooled again on 4/28/24, then reheated and reserved for lunch on Monday 4/29/24 as an alternate now called "roast beef".

During an interview on 4/29/24, at 1:10 p.m. FSD Employee E9 was asked to produce Cooling Logs to ensure that the meat had undergone proper cooling and temperature monitoring throughout its two separate occasions of cooling.

Review of the facility's "Food and Leftover Cooling Log" for April 2024 failed to ensure that any documentation for proper cooling was completed for the meat on 4/27/24, or 4/28/24 prior to being served to residents.

During an interview on 4/29/24, at 1:10 p.m. FSD Employee E9 confirmed that the facility failed to provide evidence that the meat temperature was properly monitored and cooled for two days creating the potential for food bore illness.

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

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

28 Pa. Code: 211.6(c) Dietary services.


 Plan of Correction - To be completed: 06/13/2024

The facility will ensure that the proper cooling of foods are monitored and logged correctly. The facility will ensure that the ice scoop is placed in a secured bin on the side of the ice machine with a protective cover.

The facility can not retroactively correct that the cooling log was incomplete on 4/27/24 and 4/28/24. The facility has installed a bin on the side of the ice machine for the ice scooper to be placed in. This bin has a protective cover on top to conceal the scooper.

The facility no longer retains any food served from a meal. Meaning no cooling logs will typically be needed for the purposes of food cooling.

The Nursing Home Administrator or designee will educate the food services director on federal regulation 0812. Detailing maintaining proper cooling logs for cooling foods for storage.

The Nursing Home Administrator (NHA) or designee will conduct a weekly audit times four weeks to identify that the ice scoop is stored properly and if any food needed to be cooled for storage. If so, that the cooling log was completed appropriately. The NHA or designee will


The results of these audits will be forwarded to the quality assurance and improvement committee meeting for review and frequency of audits.
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 facility policy, clinical records, and staff interview, it was determined that the facility failed to provide documentation of advanced directives or given the opportunity to formulate an advance directive (a written instruction such as a living will or durable power of attorney for health care for when the individual is incapacitated) for eight of eight residents reviewed (Resident R8, R30, R50, R67, R75, R86, R87, and R311).

Findings include:

A review of the facility policy "Advanced Directives" last reviewed 2/1/24, indicated that the facility has policies and procedures which allow the withholding of CPR (Cardiopulmonary Resuscitation - emergency life-saving procedure that is done when breathing or a heartbeat has stopped) measures from individual residents who have an Advanced Directives stating they do not want to be resuscitated. The procedures for determining when the services may be withheld must respect the resident ' s rights of self-determination. This nursing home will inform the resident of the policies and procedures upon admission or at such times as may be appropriate.

Review of Resident R8's clinical record indicated she was admitted to the facility on 4/11/23.

Review of Resident R8's MDS (Minimum Data Set, periodic assessment of resident care needs) dated 3/11/24, indicated diagnosis of hypertension (high blood pressure in the arteries), heart failure (a progressive heart disease that affects pumping action of the heart muscles), and depression.

A review of the clinical record failed to reveal an advanced directive or documentation that Resident R8 was given the opportunity to formulate an Advanced Directive.

Review of Resident R30's clinical record indicated she was admitted to the facility on 2/26/24.

Review of Resident R30's MDS dated 3/2/24, indicated diagnosis of hypertension, multiple sclerosis (a disease that affects central nervous system), and seizure disorder (a disorder in which nerve cell activity in the brain is disturbed, causing seizures.

A review of the clinical record failed to reveal an advanced directive or documentation that Resident R30 was given the opportunity to formulate an Advanced Directive.

Review of Resident R50's clinical record indicated she was admitted to the facility on 2/26/24.

Review of Resident R50's MDS dated 2/7/24, indicated diagnosis of hypertension, dementia (a group of symptoms that affects memory, thinking and interferes with daily life), and atrial fibrillation (disease of the heart characterized by irregular and often faster heartbeat).

A review of the clinical record failed to reveal an advanced directive or documentation that Resident R50 was given the opportunity to formulate an Advanced Directive.

Review of Resident R67's clinical record indicated she was admitted to the facility on 8/24/20.

Review of Resident R67's MDS dated 2/3/24, indicated diagnosis of osteoarthritis (degeneration of the joint causing pain and stiffness), depression, and peripheral vascular disease (PVD, circulatory condition in which narrowed blood vessels reduce blood flow to the limbs).

A review of the clinical record failed to reveal an advanced directive or documentation that Resident R67 was given the opportunity to formulate an Advanced Directive.

Review of Resident R75's clinical record indicated she was admitted to the facility on 9/27/21.

Review of Resident R75's MDS dated 1/21/24, indicated diagnosis of hypertension, dementia, and cerebral infarction (necrotic tissue in the brain resulting loss of blood and oxygen to the brain).

A review of the clinical record failed to reveal an advanced directive or documentation that Resident R75 was given the opportunity to formulate an Advanced Directive.

Review of Resident R86's clinical record indicated he was admitted to the facility on 10/25/23.

Review of Resident R86's MDS dated 2/27/24, indicated diagnosis of hypertension, malnutrition (lack of nutrients to the body), and dysphagia (difficulty swallowing).

A review of the clinical record failed to reveal an advanced directive or documentation that Resident R86 was given the opportunity to formulate an Advanced Directive.

Review of Resident R87's clinical record indicated she was admitted to the facility on 9/25/23.

Review of Resident R87's MDS dated 3/1/24, indicated diagnosis of depression, diabetes, and heart failure.

A review of the clinical record failed to reveal an advanced directive or documentation that Resident R87 was given the opportunity to formulate an Advanced Directive.

Review of Resident R311's clinical record indicated he was admitted to the facility on 4/18/24.

Review of Resident R311's MDS dated 4/24/24, indicated diagnosis of diabetes, hypertension, and osteomyelitis (inflammation of bone caused by infection).

A review of the clinical record failed to reveal an advanced directive or documentation that Resident R311 was given the opportunity to formulate an Advanced Directive.

During an interview on 5/2/24, at 9:17 a.m. Social Worker Employee E19 confirmed that advanced directives are not part of the documentation in the clinical record.

During an interview on 5/2/24, at 9:20 a.m. the Director of Nursing confirmed that the facility failed to provide documentation of advanced directives or given the opportunity to formulate an advance directive for eight of eight residents reviewed (Resident R8, R30, R50, R67, R75, R86, R87, and R311).

28 Pa. Code: 201.29(b)(d)(j) Resident rights.


 Plan of Correction - To be completed: 06/13/2024

The facility will provide documentation of advanced directives. If a resident does not have a preexisting advance directive, resident will be given the opportunity to create one.

The facility cannot retroactively correct the concerns identified with residents R8, R30 ,R50, R67, R86, R87, and R311. However, residents R8, R30 ,R50, R67, R86, R87, and R311 will be afforded the opportunity to form an advanced directive.

The Nursing Home Administrator or designee will educate the Social Services Director and the Admissions Director on federal regulation 0578. Detailing giving residents the opportunity to communicate an existing advance directive or being given the opportunity to form one.

The facility will audit new admissions to ensure their advance directives are on file. Or they have been given an opportunity to form one. These audits will be conducted weekly for four weeks and then monthly for three months.

The results of these audits will be forwarded to the Quality Assurance and Performance Improvement Committee for review

483.95(g)(1)-(4) REQUIREMENT Required In-Service Training for Nurse Aides: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.
§483.95(g) Required in-service training for nurse aides.
In-service training must-

§483.95(g)(1) Be sufficient to ensure the continuing competence of nurse aides, but must be no less than 12 hours per year.

§483.95(g)(2) Include dementia management training and resident abuse prevention training.

§483.95(g)(3) Address areas of weakness as determined in nurse aides' performance reviews and facility assessment at § 483.70(e) and may address the special needs of residents as determined by the facility staff.

§483.95(g)(4) For nurse aides providing services to individuals with cognitive impairments, also address the care of the cognitively impaired.
Observations:

Based on review of facility in-service documentation, personnel records, and staff interviews it was determined that the facility failed to ensure that all nurse aide staff received a minimum of twelve hours of inservice education training each year for four out of four personnel records (Nurse aide Employee E7, Nurse aide Employee E13, Nurse aide Employee E14, and Nurse aide Employee E15).

Findings include:

The certified nursing assistant job description, last reviewed on 2/1/24, indicated that Nurse aides must complete 12 hours of in-service training annually tracked from date of hire.

Review of Nurse aide (NA) Employee E7's personnel record indicated she was hired on 12/18/91. The record indicated she last received in-service training on 2/2023. Review of Nurse aide (NA) Employee E7's personnel record did not include annual inservice training on resident rights, resident confidential information, quality assurance performance improvement (QAPI), falls/incident accident, restorative care, cultural competence, and compliance and ethics in the past year. Review of Nurse aide (NA) Employee E7's personnel record did not indicate that 12 hours of inservice training was completed.

Review of Nurse aide (NA) Employee E13's personnel record indicated she was hired on 10/28/91. The record indicated she last received in-service training on 2/2023. Review of Nurse aide (NA) Employee E13's personnel record did not include annual inservice training on resident rights, resident confidential information, quality assurance performance improvement (QAPI), falls/incident accident, restorative care, cultural competence, and compliance and ethics in the past year. Review of Nurse aide (NA) Employee E13's personnel record did not indicate that 12 hours of inservice training was completed.

Review of Nurse aide (NA) Employee E14's personnel record indicated she was hired on 11/25/91. The record indicated she last received in-service training on 2/2023. Review of Nurse aide (NA) Employee E14's personnel record did not include annual inservice training on resident rights, resident confidential information, quality assurance performance improvement (QAPI), falls/incident accident, restorative care, cultural competence, and compliance and ethics in the past year. Review of Nurse aide (NA) Employee E14's personnel record did not indicate that 12 hours of inservice training was completed.

Review of Nurse aide (NA) Employee E15's personnel record indicated she was hired on 6/4/03. The record indicated she last received in-service training on 2/2023. Review of Nurse aide (NA) Employee E15's personnel record did not include annual inservice training on resident rights, resident confidential information, quality assurance performance improvement (QAPI), falls/incident accident, restorative care, cultural competence, and compliance and ethics in the past year. Review of Nurse aide (NA) Employee E15's personnel record did not indicate that 12 hours of inservice training was completed.

During an interview on 5/3/24, at 11:40 a.m. Licensed Practical Nurse (LPN) Infection Control Preventionist and staff educator Employee E16 confirmed that the facility failed to ensure that all nurse aide staff received a minimum of twelve hours of inservice education training each year for four personnel records as required.

28 Pa. Code 201.19(7) Personnel policies and procedures

28 Pa. Code 201.20(a)(d) Staff development


 Plan of Correction - To be completed: 06/13/2024

The facility will ensure that all nurse aide staff receive the required 12 hours of the required education topics every 12 months/annually.

Nursing Home Administrator/Designee will educate the Director of Human Resources on the requirements education topics for the nurse aide staff must be every 12 months/annually.

House audit will be completed by the Director of Human Resources to ensure that all nurse aide staff have had the required education topics every 12 months/ annually.

Director of Human Resources (HR) will provide the required training to the nurse aide staff every 12 months/ annually and will complete log of in-service training monthly of each staff member.

The results of the house audit will be forwarded to the Quality Assurance and Performance Improvement Committee for review. In-service logs will be brought to the Quality Assurance and Performance Improvement meeting to ensure compliance

483.95(b) REQUIREMENT Resident Rights Training: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.
§483.95(b) Resident's rights and facility responsibilities.
A facility must ensure that staff members are educated on the rights of the resident and the responsibilities of a facility to properly care for its residents as set forth at §483.10, respectively.
Observations:

Based on review of facility in-service documentation, personnel records, and staff interviews it was determined that the facility failed to ensure that nurse aide staff received annual inservice training on resident rights for four out of four personnel records (Nurse aide Employee E7, Nurse aide Employee E13, Nurse aide Employee E14, and Nurse aide Employee E15).

Findings include:

The certified nursing assistant job description, last reviewed on 2/1/24, indicated that Nurse aides must complete 12 hours of in-service training annually tracked from date of hire. Nurse aides attend mandatory inservice trainings that includes resident rights.

Review of Nurse aide (NA) Employee E7's personnel record indicated she was hired on 12/18/91. The record indicated she last received in-service training on 2/2023. Review of Nurse aide (NA) Employee E7's personnel record did not include annual inservice training on resident rights.

Review of Nurse aide (NA) Employee E13's personnel record indicated she was hired on 10/28/91. The record indicated she last received in-service training on 2/2023. Review of Nurse aide (NA) Employee E13's personnel record did not include annual inservice training on resident rights.

Review of Nurse aide (NA) Employee E14's personnel record indicated she was hired on 11/25/91. The record indicated she last received inservice training on 2/2023. Review of Nurse aide (NA) Employee E14's personnel record did not include annual inservice training on resident rights.

Review of Nurse aide (NA) Employee E15's personnel record indicated she was hired on 6/4/03. The record indicated she last received inservice training on 2/2023. Review of Nurse aide (NA) Employee E15's personnel record did not include annual inservice training on resident rights.

During an interview on 5/3/24, at 11:40 a.m. Licensed Practical Nurse (LPN) Infection Control Preventionist and staff educator Employee E16 confirmed that the facility failed to ensure that nurse aide staff received annual inservice training on resident rights for four personnel records as required.

28 Pa. Code 201.19(7) Personnel policies and procedures

28 Pa. Code 201.20(a)(d) Staff development


 Plan of Correction - To be completed: 06/13/2024

The Facility will ensure that nurse aide staff will receive annual inservice training on resident rights. Nurse aide employees E7, E13, E14 and E15 will receive the resident rights inservice training.

The Facility will complete a house audit to validate all nurse aide employees have received the annual inservice training on resident rights.

The Nursing Home Administrator or designee will re-educate the Director of Human Resources on federal regulation 0942, detailing ensuring nurse aides receive the annual inservice training on residents rights.

The Nursing Home Administrator or designee will complete an audit monthly for three months to validate Nurse Aides receive the inservice training on Resident rights.

The results of these audits will be forwarded to the Monthly Quality Assurance and Performance Improvement Committee for review and frequency of audits.

483.95 REQUIREMENT Training Requirements: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.
§483.95 Training Requirements
A facility must develop, implement, and maintain an effective training program for all new and existing staff; individuals providing services under a contractual arrangement; and volunteers, consistent with their expected roles. A facility must determine the amount and types of training necessary based on a facility assessment as specified at § 483.70(e). Training topics must include but are not limited to-
Observations:

Based on review of facility in-service documentation, personnel records, and staff interviews it was determined that the facility failed to implement and maintain an effective training program for six out of eight personnel records (LPN Employee E11, LPN Employee E12, Nurse aide Employee E7, Nurse aide Employee E13, Nurse aide Employee E14, and Nurse aide Employee E15).

Findings include:

The facility "Monthly mandatory education" schedule last reviewed 2/1/24, indicated that staff will be provided annual inservice training based on the following:
January training (abuse, neglect, elder care justice act)
February training (infection control, bloodborne pathogens, COVID-19).
March training (psychosocial needs, dementia, trauma informed care, substance abuse).
April training (customer service).
May training (resident rights, HIPAA/confidential information, cultural diversity).
June training (falls, restraints, accident, incidents)
July training (fire and safety, disasters, hazards, active shooter).
August training (restorative care, dietary and nutrition, hydration).
September (abuse, neglect, elder care justice act).
October (compliance and ethics).
November (quality assurance performance improvement).
December (infection control, bloodborne pathogens, COVID-19).

Review of Licensed Practical Nurse (LPN) Employee E11's personnel record indicated she was hired on 9/25/95. The record indicated she last received in-service training on 3/2023. Review of Licensed Practical Nurse (LPN) Employee E11's personnel record did not include annual inservice training on resident rights, resident confidential information, quality assurance performance improvement (QAPI), falls/incident accident, restorative care, cultural competence, and compliance and ethics in the past year.

Review of Licensed Practical Nurse (LPN) Employee E12's personnel record indicated she was hired on 10/3/17. The record indicated she last received in-service training on 2/2023. Review of Licensed Practical Nurse (LPN) Employee E12's personnel record did not include annual inservice training on resident rights, resident confidential information, quality assurance performance improvement (QAPI), falls/incident accident, restorative care, cultural competence, and compliance and ethics in the past year.

Review of Nurse aide (NA) Employee E7's personnel record indicated she was hired on 12/18/91. The record indicated she last received in-service training on 2/2023. Review of Nurse aide (NA) Employee E7's personnel record did not include annual inservice training on resident rights, resident confidential information, quality assurance performance improvement (QAPI), falls/incident accident, restorative care, cultural competence, and compliance and ethics in the past year.

Review of Nurse aide (NA) Employee E13's personnel record indicated she was hired on 10/28/91. The record indicated she last received in-service training on 2/2023. Review of Nurse aide (NA) Employee E13's personnel record did not include annual inservice training on resident rights, resident confidential information, quality assurance performance improvement (QAPI), falls/incident accident, restorative care, cultural competence, and compliance and ethics in the past year.

Review of Nurse aide (NA) Employee E14's personnel record indicated she was hired on 11/25/91. The record indicated she last received in-service training on 2/2023. Review of Nurse aide (NA) Employee E14's personnel record did not include annual inservice training on resident rights, resident confidential information, quality assurance performance improvement (QAPI), falls/incident accident, restorative care, cultural competence, and compliance and ethics in the past year.

Review of Nurse aide (NA) Employee E15's personnel record indicated she was hired on 6/4/03. The record indicated she last received in-service training on 2/2023. Review of Nurse aide (NA) Employee E15's personnel record did not include annual inservice training on resident rights, resident confidential information, quality assurance performance improvement (QAPI), falls/incident accident, restorative care, cultural competence, and compliance and ethics in the past year.

During an interview on 5/3/24, at 11:40 a.m. Licensed Practical Nurse (LPN) Infection Control Preventionist and staff educator Employee E16 confirmed that the facility failed to implement and maintain an effective training program for six personnel record as required.

28 Pa. Code 201.19(7) Personnel policies and procedures

28 Pa. Code 201.20(a)(d) Staff development


 Plan of Correction - To be completed: 06/13/2024

The facility will implement and maintain an effective training program for new and existing staff. The facility review employees E7, E11, E12, E 13, E14 and E15 records and provide them with required trainings.
The facility will review and update the monthly mandatory education calendar as appropriate and implement to include required education for facility employees.
The Nursing Home Administrator or Designee will re-educate the Director of Human Resources on federal regulation 0940, detailing implementing and maintaining a training program for employees.
The Director of Human Resources will implement a spreadsheet to track employee training. The Nursing Home Administrator or Designee will complete an audit monthly for three months to validate employees are receiving the required training.
These audits will be forwarded to the monthly Quality Assurance and Performance Improvement Committee for review and frequency of audits.

483.60(d)(4)(5) REQUIREMENT Resident Allergies, Preferences, Substitutes:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
§483.60(d) Food and drink
Each resident receives and the facility provides-

§483.60(d)(4) Food that accommodates resident allergies, intolerances, and preferences;

§483.60(d)(5) Appealing options of similar nutritive value to residents who choose not to eat food that is initially served or who request a different meal choice;
Observations:

Based on review of facility policy, facility documents, resident interviews, meal tray observations and staff interviews, it was determined that the facility failed to provide menu selections according to the resident's preference for five out of nine residents (Resident R21, R58, R59, R88, and R210).

Findings include:

Review of the facility policy "Meal Service Line" last reviewed on 2/1/24, indicated that the cook will be stationed at the steam table to place foods from the wells onto the plate in accordance with the menu and resident diet order. Dining Services staff will check the tray for accuracy, cover the plate, and place the tray onto the food cart to be delivered to the floor or unit. The meal service line will be supervised and checked for quality assurance by the Dining Service Manager, Assistant Manager, Supervisor, or Dietitian.

Review of facility Grievance Log dated 3/12/24, revealed that a resident voiced concern as no one had discussed food preferences with the resident.

Review of 3/12/24, Resident Council Meeting Minutes revealed that a resident voiced concern regarding dietary preferences being honored.

Review of 4/9/24, Resident Council Meeting Minutes revealed that a resident voiced concern over not receiving milk on her tray. Another resident voiced concern that the doctor changed her diet to low carbohydrate, but continues to receive a regular diet.

During an interview on 4/29/24, at 12:19 p.m. Resident R59 stated that she often does not receive food items that are on her meal ticket or menu. Resident R59 stated that she asks for additional protein foods on her tray and that this is not always honored.

During an observation on 4/29/24, at 12:19 p.m., Resident R59's meal ticket stated that she was to receive fried chicken, however, there was no fried chicken on her tray and there was a very dry, hard, and stringy appearing piece of meat.

During an interview on 4/29/24, at 12:50 p.m.. Food Service Director (FSD) Employee E9 stated that the registered dietitian visits the residents for food preferences after admission.

During a lunch meal observation on 4/30/24, the following was noted:

During an interview on 4/30/24, at 12:15 p.m. Resident R88 stated "Nobody asks what we like. You just get stuff".

During an observation on 4/30/24, at 12:19 p.m. Resident R21 had breaded chicken and buttered noodles on her meal ticket, but did not have either one of them on her tray. Resident R21 had lasagna on her tray instead.

During an observation on 4/30/24, at 12:23 p.m. Resident R58 had ice cream on her meal ticket, but she had not received it on her tray.

During an interview with Nurse Aide Employee E19 confirmed that Resident R21 and R58 did not receive the foods listed on their meal tickets as stated above.

During an interview on 4/30/24, at 12:32 p.m. Resident R210 stated "I get stuff I don't like but I just don't eat it".

During an interview on 5/3/24, at 10:46 a.m. Registered Dietitian (RD) Employee E10 stated that the FSD Employee E9 is to visit residents for food preferences. When RD Employee E10 was told the FSD Employee E9 stated that RD Employee E10 is to do the visits for food preferences, RD Employee E10 stated that she only comes into the facility once a week and not able to visit residents in a timely manner after their admission to obtain food preferences.

During an interview on 5/3/24, at 11:35 a.m. Resident R210 stated that she had never been asked about food preferences since her admission on 4/13/24, and also added "They say I am allergic to fish. But that's not true. I eat fish all the time". Resident R 210 clarified that no one from Dietary Services had ever asked her about any food allergies or preferences.

During an interview on 5/3/24, at 11:40 a.m. Nursing Home Administrator confirmed that the facility failed to provide menu selections in accordance with resident's preferences.


28 Pa Code: 211.6(a)(c ) Dietary service.


 Plan of Correction - To be completed: 06/13/2024

The facility will meet with all residents to ensure they are afforded the opportunity to learn about residents food preferences and likes and dislikes.


The facility will conduct a 30 day look back at new admissions to ensure those residents were provided the opportunity to provide the dietary department with their likes and dislikes for food and have voiced their food preferences.

The process has been implemented that food service director meets with new admissions upon admission to ask about the residents likes and dislikes. The food services director now also attends the 72 hour care conferences to inquire about likes and dislikes. Department heads also ask residents if they have been asked about their likes and dislikes during guardian angel rounds.

The Nursing Home Administrator will educate the food service director on obtaining likes and dislikes and food preferences from residents.

The Nursing Home Administrator or designee will conduct an audit of new admissions to ensure they were afforded the opportunity to voice their food preferences to the dietary department. These audits will be conducted weekly for four weeks and then monthly for three months.

The results of these audits will be forwarded to the quality assurance and improvement committee for review and frequency of audits.
483.60(a)(3)(b) REQUIREMENT Sufficient Dietary Support Personnel:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
§483.60(a) Staffing
The facility must employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, taking into consideration resident assessments, individual plans of care and the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment required at §483.70(e).

§483.60(a)(3) Support staff.
The facility must provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.

§483.60(b) A member of the Food and Nutrition Services staff must participate on the interdisciplinary team as required in § 483.21(b)(2)(ii).
Observations:

Based on review of clinical records, facility policies, facility documents, and staff interviews, it was determined that the facility failed to have sufficient dietary staff to perform essential clinical duties for six out of 12 months (November and December 2023, and January through April 2024).

Findings include:

Review of facility policy "Resident Weights", dated 2/1/24, indicated that the facility will identify residents at risk for significant weight change and ensure uniform tracking and reporting of resident weights. Monthly weights will be obtained weekly times four weeks following admission/readmission and monthly thereafter. The licensed nurse will notify the Interdisciplinary Team for further assessment.

Significant weight loss is defined as:
5% or greater in one month
7.5% or greater in three months
10% or greater in six months.

Review of Registered Dietitian's Job Description revealed that the purpose of Registered Dietitian's job position is to implement, coordinate and evaluate the medical nutrition therapy for the residents, provide resident and family education, provide nutritional assessment and consultation to assist in planning, organizing and directing the food and nutritional services of the facility. Registered Dietitian must interpret and evaluate information on a patient's chart and make recommendations for appropriate medical nutrition therapy.

Review of the clinical record indicated Resident R21 was admitted to the facility on 10/21/11.

Review of Resident R21's Minimum Data Set (MDS - a periodic assessment of care needs) dated 3/19/24, indicated diagnoses of cancer, dementia (a group of symptoms that affects memory , thinking and interferes with daily life), and chronic pain.

Review of Resident R21's clinical record conducted on 4/30/24, revealed that Resident R21 was weighed on 2/1/24 at 115 pounds which reflected a significant weight loss of 10.2% in six months, and that Resident R21 had not been weighed since the 2/1/24/ weight was obtained.

Review of Resident R21's clinical record conducted on 4/30/24, revealed that Resident R21's February weight loss was not addressed in February by the Registered Dietitian (RD) Employee E10.

Review of clinical record indicated that Resident R59 was admitted to the facility on 4/28/20.

Review of Resident 59's MDS dated 1/24/24, indicated diagnoses of diabetes (high sugar level in the blood), high blood pressure, and dysphagia (difficulty swallowing). Section K0520:- Nutritional Approaches, Therapeutic diet was "checked", indicating that "While a Resident" in the past seven days, this nutritional approach was performed.

Review of Resident R59's clinical record failed to reveal nutritional assessment documentation addressing her nutritional status and therapeutic diet captured by MDS dated 1/24/24.

During an interview on 5/2/24, at 12:59 p.m. Licensed Practical Nurse Assessment Coordinator (LPNAC) Employee E2 confirmed that the facility failed to address Resident R21's weight loss, and failed to timely assess the nutritional status of Resident R59.

During a telephone interview on 5/3/24, at 10:39 a.m. RD Employee E10 stated that she began working at the facility one year ago when the census was 70 residents, but that the census has been climbing over the past several months and is now 104. RD Employee E10 confirmed that she is the only employee who performs clinical nutrition evaluations at the facility. RD Employee E10 also stated that she comes into the facility one day per week, as she has a full time job in another facility and works part-time in a third facility. RD Employee E10 confirmed that not all nutritional evaluations are completed as required in a timely manner. RD Employee E10 also stated that since she is only in the facility one time per week she does not participate in residents' care conferences or interdisciplinary team meetings. RD Employee E10 also stated on 5/3/24, at 11:00 a.m. that she does not have enough time to address the current census in one day per week.

During an interview on 5/3/24, at 11:41 a.m. Nursing Home Administrator confirmed that the facility failed to have sufficient dietary staff to perform essential clinical duties for six out of 12 months.


28 Pa. Code: 211.6 (c) Dietary services.


 Plan of Correction - To be completed: 06/13/2024

The facility will provide sufficient dietary staffing to perform essential clinical duties.
The facility can not retroactively correct the issues identified during November and December 2023, and January through April 2024.

The facility is actively working on hiring and RD that would equate to 3 times the amount of hours the facility had previously had. An agency RD is being contacted with Healthcare Services to assume RD duties until full time in-house RD can be obtained.

The regional director of operations will educate the nursing home administrator on federal regulation 0802. Detailing providing adequate Registered Dietician staffing.

The Nursing Home Administrator will audit nutritional assessments being completed timely. These audits will be completed weekly for four weeks and then monthly for three months.

The results of these audits will be forwarded to the monthly Quality Assurance Improvement Committee Meeting for review and frequency of audits.
483.60(a)(1)(2) REQUIREMENT Qualified Dietary Staff:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
§483.60(a) Staffing
The facility must employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, taking into consideration resident assessments, individual plans of care and the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment required at §483.70(e)

This includes:
§483.60(a)(1) A qualified dietitian or other clinically qualified nutrition professional either full-time, part-time, or on a consultant basis. A qualified dietitian or other clinically qualified nutrition professional is one who-
(i) Holds a bachelor's or higher degree granted by a regionally accredited college or university in the United States (or an equivalent foreign degree) with completion of the academic requirements of a program in nutrition or dietetics accredited by an appropriate national accreditation organization recognized for this purpose.
(ii) Has completed at least 900 hours of supervised dietetics practice under the supervision of a registered dietitian or nutrition professional.
(iii) Is licensed or certified as a dietitian or nutrition professional by the State in which the services are performed. In a State that does not provide for licensure or certification, the individual will be deemed to have met this requirement if he or she is recognized as a "registered dietitian" by the Commission on Dietetic Registration or its successor organization, or meets the requirements of paragraphs (a)(1)(i) and (ii) of this section.
(iv) For dietitians hired or contracted with prior to November 28, 2016, meets these requirements no later than 5 years after November 28, 2016 or as required by state law.

§483.60(a)(2) If a qualified dietitian or other clinically qualified nutrition professional is not employed full-time, the facility must designate a person to serve as the director of food and nutrition services.
(i) The director of food and nutrition services must at a minimum meet one of the following qualifications-
(A) A certified dietary manager; or
(B) A certified food service manager; or
(C) Has similar national certification for food service management and safety from a national certifying body; or
D) Has an associate's or higher degree in food service management or in hospitality, if the course study includes food service or restaurant management, from an accredited institution of higher learning; or
(E) Has 2 or more years of experience in the position of director of food and nutrition services in a nursing facility setting and has completed a course of study in food safety and management, by no later than October 1, 2023, that includes topics integral to managing dietary operations including, but not limited to, foodborne illness, sanitation procedures, and food purchasing/receiving; and
(ii) In States that have established standards for food service managers or dietary managers, meets State requirements for food service managers or dietary managers, and
(iii) Receives frequently scheduled consultations from a qualified dietitian or other clinically qualified nutrition professional.
Observations:

Based on staff interviews, and review of the Food Service Director's Job description, it was determined that the facility failed to employ a full-time qualified Food Service Director for six of six months (November and December 2023, and January through April 2024).

Finding include:

Review of the facility's "Food Service Director's Job Description" indicated that the Food Service Director:
Must be a graduate of an accredited course in dietetic training approved by the American Dietetic Association.
Must be registered as a Food Service Director in Pennsylvania.
Must provide documentation of registry/certificate upon application for the position.

During an interview conducted at initial tour on 4/29/24, at 9:28 a.m. Food Service Director (FSD) Employee E9, stated that he was not a Certified Dietary Manager (CDM) and did not have any formal education or certificates in food service management. FSD Employee E9 stated that he has been a cook in the facility, but was promoted to FSD about six months ago. FSD Employee E9 also clarified that he is not currently enrolled in any classes to become a CDM.

During an additional interview on 4/29/24, at 9:40 a.m. FSD Employee E9 stated that the facility does employ a Registered Dietitian (RD), but that RD Employee E10 comes into the facility only one day per week.

During an interview on 4/29/24, at 1:45 p.m. Nursing Home Administrator (NHA) confirmed that Food Service Director Employee E23 did not possess the appropriate qualifications as required.


28 Pa. Code: 211.6(c)(d) Dietary services.


 Plan of Correction - To be completed: 06/13/2024

The facility will employ a full-time qualified food service director.

The facility can not retroactively employ a qualified Food Service Director for November and December 2023, and January through April 2024.

The facilities current Food Service Director will enroll in a Certified Dietary Manager program. An agency RD is being contracted with Healthcare Services to assume RD duties until full time in-house RD can be obtained.

The regional Operations Director will educate the Nursing Home Administrator on Federal Regulation 0801. Detailing the need for the facilities food services director to be a certified dietary manager and education required for position.

NHA, or designee will audit continued enrollment in Certified Dietary Manager program weekly until completion.

The results of these audits will be forwarded to the monthly Quality Assurance Improvement Committee Meeting for review and frequncy of audits.
483.25(i) REQUIREMENT Respiratory/Tracheostomy Care and Suctioning:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
§ 483.25(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 facility policy, observations, interviews, and clinical record review, it was determined that the facility failed to provide appropriate respiratory care and maintain respiratory equipment for three out of four sampled residents (Resident R3, R12, and R66).

Findings include:

The facility "Oxygen administration" policy dated 2/1/24, indicated that humidifiers should be labeled and dated with the time changed. At regular intervals, check and clean oxygen equipment, masks, tubing and nasal cannula.

Review of the clinical record indicated Resident R3 was admitted to the facility on 2/27/17.

Review of Resident R3's Minimum Data Set (MDS - a periodic assessment of care needs) dated 4/11/24, indicated active diagnosis of high blood pressure, dementia (a group of symptoms that affects memory, thinking, and interferes with daily life), and muscle weakness.

Review of a physician order dated 1/2/24, indicated to administer supplemental oxygen continuously at 2 liters per minute via a nasal cannula (a lightweight tube placed in the nostrils to deliver oxygen).

Review of a physician order dated 1/2/24, indicated to administer Ipratropium-Albuterol (a medication used to make breathing easier) 0.5-2.5 milligrams, inhale orally every six hours as needed for wheezing and/or shortness of breath.

Review of a physician order dated 4/16/24, indicated to change oxygen tubing, change humidification bottle, and cleanse oxygen filter every night shift every Saturday.

During an observation on 4/29/24, at 10:11 a.m. Resident R3 was observed receiving oxygen at 3 liters per minute via a nasal cannula. A nebulizer machine was located on Resident R3's bedside table. No date was present on the nebulizer tubing and the aerosol face mask was stored inside of an open box of gauze dressings.

During an interview on 4/29/24, at 10:39 a.m. Licensed Practical Nurse (LPN) Employee E1 confirmed there was no date on Resident R3's nebulizer tubing and the aerosol mask was improperly stored in an open box of gauze dressings.

Review of the clinical record indicated Resident R12 was admitted to the facility on 12/16/22.

Review of Resident R12's MDS dated 4/8/24, indicated diagnosis of high blood pressure, muscle weakness, and dependence on supplemental oxygen.

Review of a physician order dated 10/1/22, indicated to administer oxygen at 2 liters via a nasal cannula as needed for shortness of breath or oxygen saturation less than 90%.

Review of a physician order dated 6/4/23, indicated to change oxygen tubing, change humidification bottle, and cleanse oxygen filter every night shift every Saturday.

During an observation on 4/29/24, at 10:16 a.m. Resident R12 was observed receiving oxygen at 3 liters per minute via a nasal cannula. The humidifier bottle connected to the oxygen concentrator was empty and dated 4/14/24.

During an interview on 4/29/24, at 10:40 a.m. LPN Employee E1 confirmed that Resident R12's humidifier bottle was empty and dated 4/14/24.

Review of Resident R66's admission record indicated she was admitted on 5/17/22.

Review of Resident R66's MDS assessment (Minimum Data Set assessment: MDS -a periodic assessment of resident care needs) dated 2/7/24, indicated she had diagnoses that included chronic obstructive pulmonary disease (COPD: a disease characterized by persistent respiratory symptoms involving breathlessness, coughing, and obstructed airflow to the lungs), peripheral vascular disease (a progressive narrowing of the blood vessels impacting blood flow to the limbs), dementia (a condition characterized by memory loss and progressive or persistent loss of intellectual functioning).

Review of Resident R66's care plan dated 12/6/23, indicated that she is receiving oxygen therapy, change oxygen tubing, change humidification bottle and provide maintenance for oxygen equipment.

Review of Resident R66's physican order dated 5/17/22, indicated to administer oxygen at 2-Liters via nasal cannula every shift for Shortness of breath (SOB).

Review of Resident R66's physician order dated 4/16/24, indicated to change oxygen tubing, Change humidification bottle, cleanse oxygen filter, inspect easy foam wraps (replace if soiled of missing) every night shift every Saturday for Maintenance of oxygen equipment.

During observations on 4/29/24, at 10:19 a.m. Resident R66 was observed sitting in her room. Her oxygen nasal canula tube was above the bridge of her nose. The humidifier water bottle connected to Oxygen concentrator was observed dated 4/14/24.

During an interview on 4/29/24, at 10:20 a.m. Nurse aide (NA) Employee E7 was brought into Resident R66 room and stated: "Resident R66's water container is empty and dated 4/14/24. Its not connected to the Oxygen concentrator. Resident R66 oxygen line is dated 4/21/24. Nurses date the oxygen at night and her oxygen is not on her nose."

During an interview on 4/29/24, at 2:05 p.m. the Director of Nursing (DON) confirmed that the facility failed to provide appropriate respiratory care and maintain respiratory equipment for Residents R3, R12, and R66 as required.



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

28 Pa. Code 211.12(d)(1)(2)(3)(5) Nursing services.


 Plan of Correction - To be completed: 06/13/2024

The facility can not retroactively correct the concerns identified with residents R3, R12, and R66.

The facility will ensure that all residents are receiving appropriate respiratory care by maintaining respiratory equipment per facility oxygen administration policy. The concerns for residents R3, R12 and R66 were corrected once facility was made aware of the deficient practice.

All licensed staff will be educated on oxygen administration per facility policy, detailing maintaining respiratory equipment per policy and physician orders.

The Director of Nursing or designee will perform audits on respiratory equipment to ensure equipment is being maintained per oxygen administration policy and physician orders. 10 audits will be performed weekly for 4 weeks then monthly for 3 months.

The results of these audits will be forwarded to the monthly Quality Assurance and Performance Improvement Committee for review and frequency of audits.


483.25(g)(1)-(3) REQUIREMENT Nutrition/Hydration Status Maintenance:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
§483.25(g) Assisted nutrition and hydration.
(Includes naso-gastric and gastrostomy tubes, both percutaneous endoscopic gastrostomy and percutaneous endoscopic jejunostomy, and enteral fluids). Based on a resident's comprehensive assessment, the facility must ensure that a resident-

§483.25(g)(1) Maintains acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that this is not possible or resident preferences indicate otherwise;

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

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

Based a review of facility policy, clinical record review and staff interview, it was determined that the facility failed to make certain that weights were monitored for two of nine residents (Resident R21, and R50), failed to timely assess the nutritional status for two of four residents (Resident R21, and R59), and failed to provide nutritional supplements as ordered for weight loss for one of two residents ( Resident R50).

Findings include:

Review of facility policy "Resident Weights", dated 2/1/24, indicated that the facility will identify residents at risk for significant weight change and ensure uniform tracking and reporting of resident weights. Monthly weights will be obtained weekly times four weeks following admission/readmission and monthly thereafter. The licensed nurse will notify the Interdisciplinary Team for further assessment.

Review of facility policy " Nutriton Management", dated 2/1/24, indicated that based on a resident's comprehensive assessment, the facility will ensure that a resident maintains acceptable parameters of nutritional status, such as body weight and protein levels, unless the resident's clinical condition demonstrates that this is not possible and receives a therapeutic diet when there is a nutritional problem. Suggested parameters for evaluating significance f unplanned weight loss are:

Significant weight loss is defined as:
5% or greater in one month
7.5% or greater in three months
10% or greater in six months.

In evaluating weight loss, the dietitian will consider the resident's usual weight through adult life, and the potential for weight loss to any medical conditions.

Review of the clinical record indicated Resident R21 was admitted to the facility on 10/21/11.

Review of Resident R21's Minimum Data Set (MDS - a periodic assessment of care needs) dated 3/19/24, indicated diagnoses of cancer, dementia (a group of symptoms that affects memory , thinking and interferes with daily life), and chronic pain.

Review of Resident R21's clinical record conducted on 4/30/24, revealed that Resident R21 was weighed on 2/1/24 at 115 pounds which reflected a significant weight loss of 10.2% in six months, and that Resident R21 had not been weighed since the 2/1/24/ weight was obtained.

Review of Resident R21's clinical record conducted on 4/30/24, revealed that Resident R21's February weight loss was not addressed in February by the Registered Dietitian (RD) Employee E10.

Review of Resident R50's clinical record indicated she was admitted to the facility on 2/26/24.

Review of Resident R50's MDS dated 2/7/24, indicated diagnosis of hypertension (high blood pressure), dementia, and atrial fibrillation (disease of the heart characterized by irregular and often faster heartbeat).

Review of Resident R50 's care plan initiated on 3/28/24, indicated to monitor weights.

Review of Resident R50's progress note dated 10/28/23, at 20:58 indicate a weight of 150.5# was recorded for resident for the month of October. This alerts as a -7.5% change [ Comparison Weight 7/12/2023, 163.7 Lbs, -8.1% , -13.2 Lbs ]. Will recommend to begin 60cc TwoCal HN (thickened) BID at med pass. This will provide 240 kcal and 10gm protein a day.

Review of Resident R50's care plan initiated on 11/3/23, indicated to provide nutritional supplement as ordered.

Review of Resident R50's physician orders dated 3/2/24, reveal to weigh resident every month on the day sift.

Review of Resident R50's physician orders dated 11/19/23, reveal to give resident Two Cal (a nutritional supplement) three times a day with medication pass.

Review of Resident R50's clinical record on 5/2/24, at 10:53 a.m. indicated on residents medication administration record (MAR) that Two Cal supplement was unavailable on 4/2/24, 4/4/24, 4/24/24, and 4/27/24.

Review of Resident R50's clinical record on 5/2/24, at 10:55 a.m. indicated that resident was last weighed on 2/9/24.

During an phone interview on 5/3/24, at 10:39 a.m. Registered Dietician, Employee E10 stated that she was not made aware of the facililty not having TwoCal and would have made a recommendation to substitute with another supplement.

Review of clinical record indicated that Resident R59 was admitted to the facility on 4/28/20.

Review of Resident 59's MDS dated 1/24/24, indicated diagnoses of diabetes (high sugar level in the blood), high blood pressure, and dysphagia (difficulty swallowing). Section K0520:- Nutritional Approaches, Therapeutic diet was "checked", indicating that "While a Resident" in the past seven days, this nutritional approach was performed.

Review of Resident R59's clinical record failed to reveal nutritional assessment documentation addressing her nutritional status and therapeutic diet captured by MDS dated 1/24/24.

During an interview on 5/2/24, at 12:59 p.m. Licensed Practical Nurse Assessment Coordinator (LPNAC) Employee E2 confirmed that the facility failed to weigh Resident R21 monthly and to timely assess, and address Resident R21's weight loss, and failed to timely assess the nutritional status of Resident R59.

During a telephone interview on 5/3/24, at 10:50 a.m. RD Employee E10 confirmed that the facility failed to obtain weights monthly as per policy, that not all nutritional evaluations are completed as required in a timely manner, and failed to provide nutritional supplements as ordered for weight loss for one of two residents ( Resident R50).

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

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


 Plan of Correction - To be completed: 06/13/2024

The facility will provide sufficient dietary staffing to perform essential clinical duties.

The facility can not retroactively correct the issues identified during November and December 2023, and January through April 2024.

R21 and R50 and all in house weights are current.

R21 and R59 nutritional assessments are current.

R50 and all in house residents have all ordered supplements available to them.

The facility is actively working on hiring and RD that would equate to 3 times the amount of hours the facility has previously had. An agency RD is being contracted with Health Care Services to assume RD duties until full time in-house RD can be obtained.

The regional director of operations will educate the nursing home administrator on federal regulation 0802. Detailing providing adequate Registered Dietician staffing.

The Nursing Home Administrator will audit nutritional assessments being completed timely, timely completion of weights, and availability of ordered supplements. These audits will be completed weekly for four weeks and then monthly for three months.

The results of these audits will be forwarded to the monthly Quality Assurance Improvement Committee Meeting for review and frequncy of audits.

483.25(d)(1)(2) REQUIREMENT Free of Accident Hazards/Supervision/Devices:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
§483.25(d) Accidents.
The facility must ensure that -
§483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and

§483.25(d)(2)Each resident receives adequate supervision and assistance devices to prevent accidents.
Observations:

Based on review of facility policies, clinical records, facility documents and staff interview, it was determined that the facility failed to ensure that residents received neurological assessment after an incident involving a fall for four of nine residents (Residents R8, R12, R30, and Resident R87).

Findings include:

Review of facility policy "Falls Protocol" dated 2/1/24, indicated residents experiencing an actual fall will have an immediate assessment by nursing and medical attention will be obtained as needed. Falls that involve a possible head injury will have neurological checks performed and documented.

Review of facility policy "Neurological Checks" dated 2/1/24, indicated neurological checks shall be performed following an unwitnessed fall or known head injury. Neurological checks should be performed periodically for at least 72 hours. Neurological checks shall be documented on the designated record.

Review of the clinical record indicated Resident R8 was admitted to the facility on 2/26/24.

Review of Resident R8's MDS (Minimum Data Set, periodic assessment of resident care needs) dated 3/11/24, indicated diagnoses of hypertension (high blood pressure in the arteries), heart failure (a progressive heart disease that affects pumping action of the heart muscles), and depression.

Review of a nursing progress note dated 2/26/24, indicated Resident R8 was observed sitting on the floor beside her bed. She was unclear if she hit her head. Assisted back to bed. Neuro checks initiated.

Review of the clinical record failed to reveal a neurological assessment was performed for 72 hours following Resident R8's unwitnessed fall on 2/26/24.

During an interview on 5/3/24, at 10:51 a.m. the Assistant Director of Nursing (ADON) confirmed that the facility did not perform a neurological assessment for 72 hours after Resident R8's unwitnessed fall on 2/26/24.

Review of the clinical record indicated Resident R12 was admitted to the facility on 12/16/22.

Review of Resident R12's Minimum Data Set (MDS - a periodic assessment of care needs) dated 4/8/24, indicated diagnosis of high blood pressure, muscle weakness, and dependence on supplemental oxygen.

Review of a nursing progress note dated 4/7/24, indicated Resident R12 was found on the floor by a staff member. Four staff members were required to move Resident R12 away from the bed. Resident R12 was assessed and placed into a chair using a mechanical lift.

Review of the clinical record failed to reveal a neurological assessment was performed for 72 hours following Resident R12's unwitnessed fall on 4/7/24.

During an interview on 5/3/24, at 10:51 a.m. the Assistant Director of Nursing (ADON) confirmed that the facility did not perform a neurological assessment for 72 hours after Resident R12's unwitnessed fall on 4/7/24.

Review of a nursing progress note dated 4/23/24, indicated Resident R12 was found face down on the floor on a fall mat. Neuro checks were initiated and family and the physician were made aware of the fall.

Review of the clinical record failed to reveal a neurological assessment was performed for 72 hours following Resident R12's unwitnessed fall on 4/23/24.

During an interview on 5/3/24, at 10:51 a.m. the ADON confirmed that the facility did not perform a neurological assessment for 72 hours after Resident R12's unwitnessed fall on 4/23/24.

Review of the clinical record indicated Resident R30 was admitted to facility on 2/26/24.

Review of Resident R30's MDS (Minimum Data Set, periodic assessment of resident care needs) dated 3/2/24, indicated diagnosis of hypertension (high blood pressure in the arteries), multiple sclerosis (a disease that affects central nervous system), and seizure disorder (a disorder in which nerve cell activity in the brain is disturbed, causing seizures.

Review of a nursing progress note dated 4/27/24, indicated Resident R30 was observed face down on the floor beside her bed. Resident was turned on her back. Nursing noticed a laceration above her eye. Resident was assisted back into bed. Resident was sent to emergency room and returned with stitches on her eye brow.

Review of the clinical record failed to reveal a neurological assessment was performed for 72 hours following Resident R30's unwitnessed fall on 4/27/24.

During an interview on 5/3/24, at 10:51 a.m. the ADON confirmed that the facility did not perform neurological assessment for 72 hours after Resident R30's unwitnessed fall on 4/27/24.

Review of clinical record indicated Resident R87 was admitted to the facility on 9/25/23.

Review of Resident R87's MDS (Minimum Data Set, periodic assessment of resident care needs) dated 3/1/24, indicated diagnosis of depression, diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time), and heart failure (a progressive heart disease that affects pumping action of the heart muscles).

Review of a nursing progress note dated 3/1/24, indicated Resident R87 was found sitting on the bathroom floor. Resident stated " I slipped". Resident unable to describe how fall happened. Resident assessed. No injuries noted. Resident assisted back to bed and placed call bell within reach.

Review of the clinical record failed to reveal a neurological assessment was performed for 72 hours following Resident R87's unwitnessed fall on 3/1/24.

During an interview on 5/3/24, at 10:51 a.m. the ADON confirmed that the facility did not perform a neurological assessment for 72 hours after Resident 87's unwitnessed fall on 3/1/24.

During an interview on 5/3/24, at 10:51 a.m. the ADON confirmed that the facility failed to ensure that residents received neurological assessment after an incident involving a fall for four of nine residents (Resident R8, R12, R30, and R87).


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

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

28 Pa. Code: 207.2(a) Administrator's responsibility.

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


 Plan of Correction - To be completed: 06/13/2024

The facility can not retroactively correct the concerns identified with residents R8, R12, R30, and R87.

The facility will ensure that proper fall protocols are being performed per facility policy.

The Director of Nursing or Designee will re-educate licensed staff on fall protocol per facility policy, detailing neurological monitoring post fall.

The Director of Nursing or designee will perform an audit on all falls to ensure neurological checks are implemented per facility policy. Audits will be performed weekly for 4 weeks then monthly for 3 months.

The results of these audits will be forwarded to the monthly Quality Assurance and Performance Improvement Committee for review and frequency of audits.

483.24(a)(2) REQUIREMENT ADL Care Provided for Dependent Residents: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.
§483.24(a)(2) A resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene;
Observations:

Based on review of facility policy, clinical record review, a resident council group interview, resident and staff interviews, it was determined that the facility failed to make certain that showers were consistently provided and failed to provide adequate hygienic care for eight out of 12 sampled residents (Resident R30, R50, R63, R67 R75, R87, R311, and R312 ).

Findings include:

The facility "Flow of care" policy dated 2/1/24, indicated that residents are to have two baths or showers per week unless the resident states otherwise.

Review of Resident R30's clinical record indicated she was admitted to the facility on 2/26/24.

Review of Resident R30's MDS (Minimum Data Set, periodic assessment of resident care needs) dated 3/2/24, indicated diagnosis of hypertension (high blood pressure in the arteries), multiple sclerosis (a disease that affects central nervous system), and seizure disorder (a disorder in which nerve cell activity in the brain is disturbed, causing seizures.

Review of Resident R30's care plans dated 8/24/20, indicated to monitor skin during baths and showers as scheduled.

Review of Resident R30's shower documentation dated April 2024, indicated no showers were provided for April 2024.

Review of Resident R50's clinical record indicated she was admitted to the facility on 2/26/24.

Review of Resident R50's MDS (Minimum Data Set, periodic assessment of resident care needs) dated 2/7/24, indicated diagnosis of hypertension (high blood pressure in the arteries), dementia (a group of symptoms that affects memory, thinking and interferes with daily life), and atrial fibrillation (disease of the heart characterized by irregular and often faster heartbeat).

Review of Resident R50's shower documentation dated April 2024, indicated only two showers in April 2024 (4/9/24 and 4/23/24).

During an observation, on 4/30/24, at 1:42 p.m. Resident R50 was sitting in wheelchair with facial hair on her chin.

Review of Resident R63's admission record indicated she was admitted on 12/28/23.

Review of Resident R63's MDS assessment (Minimum Data Set assessment: MDS -a periodic assessment of resident care needs) dated 2/9/24, indicated she had diagnoses that included hyperlipidemia (elevated lipid levels within the blood), hypothyroidism (decrease in production of thyroid hormone), and chronic kidney disease (a loss of kidney function resulting in the swelling of feet, fatigue, high blood pressure and changes in urination).

Review of Resident R63's care plans dated 1/17/24, indicated to monitor skin during showers and baths.

Review of Resident R63's shower documentation dated April 2024, indicated only two showers in April 2024 (4/1/24 and 4/5/24).

During a resident interview on 4/29/24, at 10:18 a.m. Resident R63 stated the following: "i am only getting showers once a week."

Review of Resident R67's clinical record indicated she was admitted to the facility on 8/24/20.

Review of Resident R67's MDS (Minimum Data Set, periodic assessment of resident care needs) dated 2/3/24, indicated diagnosis of osteoarthritis (degeneration of the joint causing pain and stiffness), depression, and peripheral vascular disease (PVD, circulatory condition in which narrowed blood vessels reduce blood flow to the limbs).

Review of Resident R67's care plans dated 2/15/24, indicated provide a sponge bath when a full bath or shower cannot be tolerated.

Review of Resident R67's shower documentation dated April 2024, indicated no showers were provided for April 2024.

Review of Resident R67's clinical record on 5/1/24, the facility failed to provide documentation that the resident could not tolerate a shower for April 2024.

Review of Resident R75's clinical record indicated she was admitted to the facility on 9/27/21.

Review of Resident R75's MDS (Minimum Data Set, periodic assessment of resident care needs) dated 1/21/24, indicated diagnosis of hypertension, dementia (a group of symptoms that affects memory, thinking and interferes with daily life), and cerebral infarction (necrotic tissue in the brain resulting loss of blood and oxygen to the brain).

Review or Resident R75's care plans dated 4/28/24, indicated to provide a sponge bath when a full bath or shower can not be tolerated.

Review of Resident R75's shower documentation dated April 2024, indicated no showers were provided for April 2024.

Review of Resident R75's clinical record on 5/1/24, the facility failed to provide documentation that the resident could not tolerated a shower for April 2024.

During an observation, on 4/29/24, at 11:19 a.m. Resident R75 was sitting at the side of bed with facial hair on her chin.

During an interview on 5/1/24, at 9:33 a.m. Resident R75 stated she would like her facial hair trimmed and does not like it.

Review of Resident R87's clinical record indicated she was admitted to the facility on 9/25/23.

Review of Resident R87's MDS (Minimum Data Set, periodic assessment of resident care needs) dated 3/1/24, indicated diagnosis of depression, diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time), and heart failure (a progressive heart disease that affects pumping action of the heart muscles).

Review of Resident R87's care plans dated, 10/11/23 That nails should always be cut straight across, never cut corners. File rough edges with emery board.

Review of Resident R 87's shower documentation dated April 2024, indicated no shower were provided for April 2024.

During an observation, on 4/29/24, at 1:04 p.m. Resident R87 was laying in bed with facial hair on her chin, her fingernails were long with discoloration and her hair was unkempt.

During an interview on 5/1/24, at 10:03 a.m. Resident R87 stated the following, "I haven't gotten a shower for a while, I haven't gotten my hair washed and look at these fingernails, they are so long".

During an interview on 5/1/24, at 10:05 a.m. Resident R87 stated she would love to get her facial hair trimmed.

Review of Resident R311's clinical record indicated he was admitted to the facility on 4/18/24.

Review of Resident R311's MDS (Minimum Data Set, periodic assessment of resident care needs) dated 4/24/24, indicated diagnosis of diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time), hypertension, and osteomyelitis (inflammation of bone caused by infection).

Review or Resident R311's care plans dated 4/23/24, indicated to monitor skin during baths and showers as scheduled.

Review of Resident R311's shower documentation dated April 2014, indicated no showers have been provided since date of admission on 4/19/24.

During an interview on 4/29/24, at 11:30 a.m. Resident R311 stated the following. "I haven't gotten a shower since I got here".

Review of Resident R312's clinical record indicated he was admitted to the facility on 4/9/24.

Review of Resident R311's MDS (Minimum Data Set, periodic assessment of resident care needs) dated 4/15/24, indicated diagnosis of dysphagia (difficult swallowing), orthostatic hypotension (a form of low blood pressure that happens when standing up from sitting or lying down) and, hyperlipidemia (an abnormally high concentration of fats or lipids in the blood).

Review of Resident 312's care plans dated 4/9/24, indicated to monitor skin during baths and showers as scheduled.

Review of Resident R312's shower documentation dated April 2014, indicated no showers have been provided since date of admission on 4/9/24.

During a resident council group interview on 4/30/24, at 1:00 p.m. two out of eight residents voiced concerns with receiving shower twice a week.

During an interview on 5/2/24, at 9:32 a.m. Licensed Practical Nurse (LPN) Employee E5 stated: "there are shower logs in the shower rooms and the showers are documented in the computer."

During observations on 5/2/24, at 9:35 a.m. observations of the shower rooms on the 400 hall and the 200 hall found no shower logs in the shower rooms.

During an interview on 5/2/24, at 2:11 p.m. the Director of Nursing (DON) confirmed that the facility failed to make certain that showers were consistently provided and failed to provide adequate hygienic care for eight out of 12 sampled residents (Resident R30, R50, R63, R67 R75, R87, R311, and R312 ) as required.


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


 Plan of Correction - To be completed: 06/13/2024

Residents R30, R50, R63, R67, R75, R87, R311, and R312 Showers and Hygienic care have been provided.

The facility will ensure that nursing staff follow shower schedules, provide nail, and hygienic care as per plan of care.

The Facility will complete a house audit to ensure residents received showers, hair and nail care and proper hygienic care.

Nursing staff will be educated on proper shower schedules, ensuring nail and hygienic care is provided and care is appropriately documented.

The Director of Nursing or designee will perform 10 shower, nail, and hygienic care audits weekly for 4 weeks then monthly for 3 months to ensure residents are receiving appropriate hygienic care per their plan of care.

The results of these audits will be forwarded to the monthly Quality Assurance and Performance Improvement Committee for review and frequency of audits.

483.21(b)(3)(i) REQUIREMENT Services Provided Meet Professional Standards: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)(3) Comprehensive Care Plans
The services provided or arranged by the facility, as outlined by the comprehensive care plan, must-
(i) Meet professional standards of quality.
Observations:

Based on review of facility policies and job descriptions, clinical records, and staff interviews, it was determined that the facility failed to adhere to acceptable standards of practice related to participation in interdisciplinary meetings for 12 of 12 months, and completion of Nutrition Assessments by the Registered Dietitian for two of eight residents reviewed (Residents R21 and R59).

Findings include:


The Pennsylvania Code, Title 49, Chapter 21, Professional and Vocational Standards: Responsibilities of the Licensed Dietitian/ Nutritionist Section 21.711 Professional Conduct indicated that the Licensed Dietitian/ Nutritionist shall provide information which will enable patients to make their own informed decisions regarding nutrition and dietetic therapy, including the reasonable expectations of the professional relationship.

Review of facility policy "Resident Weights", dated 2/1/24, indicated that the facility will identify residents at risk for significant weight change and ensure uniform tracking and reporting of resident weights. Monthly weights will be obtained weekly times four weeks following admission/readmission and monthly thereafter. The licensed nurse will notify the Interdisciplinary Team for further assessment.

Significant weight loss is defined as:
5% or greater in one month
7.5% or greater in three months
10% or greater in six months.

Review of Registered Dietitian's Job Description revealed that the purpose of Registered Dietitian's job position is to implement, coordinate and evaluate the medical nutrition therapy for the residents, provide resident and family education, provide nutritional assessment and consultation to assist in planning, organizing and directing the food and nutritional services of the facility. Registered Dietitian must interpret and evaluate information on a patient's chart and make recommendations for appropriate medical nutrition therapy.

Review of the clinical record indicated Resident R21 was admitted to the facility on 10/21/11.

Review of Resident R21's Minimum Data Set (MDS - a periodic assessment of care needs) dated 3/19/24, indicated diagnoses of cancer, dementia (a group of symptoms that affects memory , thinking and interferes with daily life), and chronic pain.

Review of Resident R21's clinical record conducted on 4/30/24, revealed that Resident R21 was weighed on 2/1/24 at 115 pounds which reflected a significant weight loss of 10.2% in six months, and that Resident R21 had not been weighed since the 2/1/24/ weight was obtained.

Review of Resident R21's clinical record conducted on 4/30/24, revealed that Resident R21's February weight loss was not addressed in February by the Registered Dietitian (RD) Employee E10.

Review of clinical record indicated that Resident R59 was admitted to the facility on 4/28/20.

Review of Resident 59's MDS dated 1/24/24, indicated diagnoses of diabetes (high sugar level in the blood), high blood pressure, and dysphagia (difficulty swallowing). Section K0520:- Nutritional Approaches, Therapeutic diet was "checked", indicating that "While a Resident" in the past seven days, this nutritional approach was performed.

Review of Resident R59's clinical record failed to reveal nutritional assessment documentation addressing her nutritional status and therapeutic diet captured by MDS dated 1/24/24.

During an interview on 5/2/24, at 12:59 p.m. Licensed Practical Nurse Assessment Coordinator (LPNAC) Employee E2 confirmed that the facility failed to timely assess Resident R21's significant weight loss, and failed to timely assess the nutritional status of Resident R59.

During a telephone interview on 5/3/24, at 10:39 a.m. RD Employee E10 stated that she began working at the facility one year ago when the census was 70 residents, but that the census has been climbing over the past several months and is now 104. RD Employee E10 confirmed that she is the only employee who performs clinical nutrition evaluations, and addresses weight loss at the facility. RD Employee E10 also stated that she comes into the facility one day per week, as she has a full time job in another facility and works part-time in a third facility. RD Employee E10 confirmed that not all nutritional evaluations are completed as required in a timely manner. RD Employee E10 also stated that since she is only in the facility one time per week, she does not participate in residents' care conferences or interdisciplinary team meetings. RD Employee E10 also confirmed that she does not always perform admission evaluations in person but that she has completed them remotely without having spoken to the residents.

During an interview on 5/3/24, at 11:41 a.m. Nursing Home Administrator confirmed that the facility failed to adhere to acceptable standards of practice related to participation in interdisciplinary meetings for 12 of 12 months, and completion of Nutrition Assessments by the Registered Dietitian for two of eight residents reviewed (Residents R21, and R59).

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

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


 Plan of Correction - To be completed: 06/13/2024

The facility will ensure all standards of practice are adhered to involving RD participation in interdisciplinary meetings and completion of Nutrition Assessments.
The facility cannot retroactively correct the errors found with Residents R21 and R59; however, MDS has been corrected and Nutrition Assessments are up to date.

NHA will educate Registered Dietician on the policy for completion of Nutritional Assessments and policy for participating in interdisciplinary meetings.

NHA, or designee, will complete audits on Nutritional Assessments to ensure timely completion and attendance at IDT meetings weekly for one month and then monthly for three months.

The results of these audits will be forwarded to the monthly Quality Assurance and Performance Improvement Committee for review and frequency of audits.



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

Based on review of the Resident Assessment Instrument (RAI) User's Manual, clinical records, and staff interviews, it was determined that the facility failed to ensure that MDS assessments accurately reflected the resident's status for three of six sampled residents (Resident R3, R21, and R37).

Findings include:

The Resident Assessment Instrument (RAI) User's Manual, which gives instructions for completing Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2023, indicated indicated the following instructions: Section K - Swallowing/Nutritional Status: base weight on the most recent measure in the last 30 days. If the last recorded weight was taken more than 30 days prior to the Assessment Reference Date (ARD) of this assessment or previous weight is not available, weigh the resident again. Section O-Hospice care: Code residents identified as being in a hospice program for terminally ill persons where an array of services is provided for the management of terminal illness and related conditions. The hospice must be licensed by the state as a hospice provider and/or certified under the Medicare program as a hospice provider.

The facility "Resident assessment minimum data set" policy dated 2/1/24, indicated that the facility will conduct initially and periodically a comprehensive, accurate and standardized assessment of each resident's functional capacity under the direction of a designated registered nurse. The assessment will accurately reflect the resident's status assuring that each resident receives an accurate assessment by staff that are qualified to assess relevant care areas.
Review of the clinical record indicated Resident R3 was admitted to the facility on 2/27/17.

Review of Resident R3's Minimum Data Set (MDS - a periodic assessment of care needs) dated 4/11/24, indicated active diagnosis of high blood pressure, dementia (a group of symptoms that affects memory, thinking, and interferes with daily life), and muscle weakness. Review of Section K: Swallowing/Nutritional Status, Question K0200 Height and Weight indicated Resident R3's documented weight was 193 pounds. Review of the clinical record indicated Resident R3's last documented weight was 193 pounds on 2/2/24.

During an interview on 5/2/24, at 1:10 p.m. Licensed Practical Nurse Assessment Coordinator (LPNAC) Employee E2 confirmed that Resident R3's weight from 2/2/4, was used to complete her MDS dated 4/11/24, due to a more recent weight not being documented in the medical record.

Review of the clinical record indicated Resident R21 was admitted to the facility on 10/21/11.

Review of Resident R21's MDS dated 3/19/24, indicated diagnoses of cancer, dementia (a group of symptoms that affects memory, thinking and interferes with daily life), and chronic pain. Section K0200 Weight indicated Resident R21's weight was 115 pounds. Review of Resident R21's clinical record indicated Resident R21's last docuemnted weight was 115 pounds on 2/1/24

During an interview on 5/2/24, at 12:59 p.m. LPNAC Employee E2 confirmed that the facility failed to weigh Resident R21 monthly and to ensure that MDS assessments accurately reflect Resident R21's weight status.

Review of Resident R37's admission record indicated she was originally admitted on 4/1/15.

Review of Resident R37's MDS assessment (Minimum Data Set assessment: MDS -a periodic assessment of resident care needs) dated 3/1/24, indicated she had diagnoses that included schizoaffective disorder (a mental disorder in which a person experiences a combination of schizophrenia and mood disorder symptoms), dementia (loss of cognitive function, thinking, remembering, and reasoning), anxiety disorder (a medical condition creating a sense of acute fear, restlessness, and worry), and hypothyroidism (decrease in production of thyroid hormone). The assessment indicated that these diagnoses were the most recent upon review.

Review of Resident R37's care plans dated 12/11/23, indicated that Resident R37 was on hospice.

Review of Resident R37's physician order dated 12/5/23, indicated to admit to hospice.

Review of Resident R37's clinical nurse notes dated 2/1/24, 3/25/24, and 4/22/24, indicated that she was receiving hospice services.

Review of Resident R37's MDS assessment dated 3/12/24, Section O-Hospice care was left blank, indicating she was not receiving hospice services during the look back period.

During an interview on 5/1/24, at 10:48 a.m. the Licensed Practical Nurse Assessment Coordinator (LPNAC) Employee E2 confirmed that the facility failed to ensure that MDS assessments accurately reflected the resident's status for Resident R37 as required.


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

28 Pa. Code: 211.12(d)(1)(2)(3)(5) Nursing services.


 Plan of Correction - To be completed: 06/13/2024

The facility will ensure that MDS assessments accurately reflect resident's condition. ResidentsR3,R21 and R37 MDS will be corrected to reflect their current conditions.

The facility will ensure that monthly weights and hospice are captured to ensure Section K and O of the MDS can be completed correctly. A house audit on Sections K and O of the MDS will be completed to validate they are accurate.

The Regional Reimbursement Consultant or Designee will educate the Registered Dietician and LPNAC's on completing section K and section O of the MDS.

The Nursing Home Administrator or designee will audit section K and O of the MDS to ensure completion and accuracy. These audits will be conducted weekly for four weeks and then monthly for three months.

The results of these audits will be forwarded to the monthly Quality Assurance and Performance Improvement Committee for review and frequency of audits.

483.15(c)(3)-(6)(8) REQUIREMENT Notice Requirements Before Transfer/Discharge: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.
§483.15(c)(3) Notice before transfer.
Before a facility transfers or discharges a resident, the facility must-
(i) Notify the resident and the resident's representative(s) of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand. The facility must send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman.
(ii) Record the reasons for the transfer or discharge in the resident's medical record in accordance with paragraph (c)(2) of this section; and
(iii) Include in the notice the items described in paragraph (c)(5) of this section.

§483.15(c)(4) Timing of the notice.
(i) Except as specified in paragraphs (c)(4)(ii) and (c)(8) of this section, the notice of transfer or discharge required under this section must be made by the facility at least 30 days before the resident is transferred or discharged.
(ii) Notice must be made as soon as practicable before transfer or discharge when-
(A) The safety of individuals in the facility would be endangered under paragraph (c)(1)(i)(C) of this section;
(B) The health of individuals in the facility would be endangered, under paragraph (c)(1)(i)(D) of this section;
(C) The resident's health improves sufficiently to allow a more immediate transfer or discharge, under paragraph (c)(1)(i)(B) of this section;
(D) An immediate transfer or discharge is required by the resident's urgent medical needs, under paragraph (c)(1)(i)(A) of this section; or
(E) A resident has not resided in the facility for 30 days.

§483.15(c)(5) Contents of the notice. The written notice specified in paragraph (c)(3) of this section must include the following:
(i) The reason for transfer or discharge;
(ii) The effective date of transfer or discharge;
(iii) The location to which the resident is transferred or discharged;
(iv) A statement of the resident's appeal rights, including the name, address (mailing and email), and telephone number of the entity which receives such requests; and information on how to obtain an appeal form and assistance in completing the form and submitting the appeal hearing request;
(v) The name, address (mailing and email) and telephone number of the Office of the State Long-Term Care Ombudsman;
(vi) For nursing facility residents with intellectual and developmental disabilities or related disabilities, the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with developmental disabilities established under Part C of the Developmental Disabilities Assistance and Bill of Rights Act of 2000 (Pub. L. 106-402, codified at 42 U.S.C. 15001 et seq.); and
(vii) For nursing facility residents with a mental disorder or related disabilities, the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with a mental disorder established under the Protection and Advocacy for Mentally Ill Individuals Act.

§483.15(c)(6) Changes to the notice.
If the information in the notice changes prior to effecting the transfer or discharge, the facility must update the recipients of the notice as soon as practicable once the updated information becomes available.

§483.15(c)(8) Notice in advance of facility closure
In the case of facility closure, the individual who is the administrator of the facility must provide written notification prior to the impending closure to the State Survey Agency, the Office of the State Long-Term Care Ombudsman, residents of the facility, and the resident representatives, as well as the plan for the transfer and adequate relocation of the residents, as required at § 483.70(l).
Observations:

Based on facility policy review, clinical record review, and staff interviews, it was determined that the facility failed to notify the resident/resident representative and/or the representative of the Office of the State Long-Term Care Ombudsman of resident transfers, in writing, to include to include the following: the reason for the transfer or discharge, date of transfer, location of transfer, statement of the resident's appeal rights, and name, address (mailing and email), and telephone number of the Office of the State Long-Term Care Ombudsman for five of seven resident records reviewed (Resident R30, R57, R59, R75, and R87)

Findings Include:

Review of Title 42 Code of Federal Regulations Contents of the notice. The written notice specified in paragraph (c)(3) of this section must include the following:
(i) The reason for transfer or discharge;
(ii) The effective date of transfer or discharge;
(iii) The location to which the resident is transferred or discharged;
(iv) A statement of the resident's appeal rights, including the name, address (mailing and email), and telephone number of the entity which receives such requests; and information on how to obtain an appeal form and assistance in completing the form and submitting the appeal hearing request;
(v) The name, address (mailing and email) and telephone number of the Office of the State Long-Term Care Ombudsman;
(vi) For nursing facility residents with intellectual and developmental disabilities or related disabilities, the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with developmental disabilities established under Part C of the Developmental Disabilities Assistance and Bill of Rights Act of 2000 (Pub. L. 106-402, codified at 42 U.S.C. 15001 et seq.); and
(vii) For nursing facility residents with a mental disorder or related disabilities, the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with a mental disorder established under the Protection and Advocacy for Mentally Ill Individuals Act.

Review of Resident R30's clinical record indicated the resident was admitted to the facility on 2/26/24.

Review of Resident R30's MDS (Minimum Data Set, periodic assessment of resident care needs) dated 3/2/24, indicated diagnoses of hypertension (high blood pressure in the arteries), multiple sclerosis (a disease that affects central nervous system), and seizure disorder (a disorder in which nerve cell activity in the brain is disturbed, causing seizures).

Review of Resident 30's clinical record revealed that the resident was transferred to the hospital on 4/27/24 and returned to the facility on 4/27/24, same day.

Review of Resident R30's clinical record, the facility failed to include documented evidence that the facility provided a written transfer notification to the resident/resident representative and or Office of Long-Term Care Ombudsman for the hospitalization on 4/27/24.

Review of the clinical record indicated Resident R57 was admitted to the facility on 7/26/19.

Review of Resident R57's MDS dated 3/8/24, indicated diagnoses of diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time), hypertension, and stroke (an event that occurs when something blocks blood supply to part of the brain or when a blood vessel in the brain bursts).

Review of Resident 57's clinical record revealed that the resident was transferred to the hospital on 1/6/24, and returned on 1/8/24.

Review of Resident R57's clinical record, the facility failed to include documented evidence that the facility provided a written transfer notification to the resident/resident representative and or Office of Long-Term Care Ombudsman for the hospitalization on 1/8/24

Review of clinical record indicated that Resident R59 was admitted to the facility on 4/28/20.

Review of Resident 59's MDS dated 1/24/24, indicated diagnoses of diabetes, high blood pressure, and dysphagia (difficulty swallowing).

Review of Resident 59's clinical record revealed that the resident was transferred to the hospital on 12/22/23, and returned on 12/24/23.

Review of Resident R59's clinical record, the facility failed to include documented evidence that the facility provided a written transfer notification to the resident/resident representative and or Office of Long-Term Care Ombudsman for the hospitalization on 12/22/23.

Review of the clinical record indicated Resident R75 was admitted to the facility on 9/21/24.

Review of Resident R75's MDS dated 1/21/24, indicated diagnoses hypertension, dementia (a group of symptoms that affects memory, thinking and interferes with daily life), and cerebral infarction (necrotic tissue in the brain resulting loss of blood and oxygen to the brain).

Review of Resident R75's clinical record revealed that the resident was transferred to the hospital on 3/9/24 returned to the facility on 3/14/24.

Review of Resident R75's clinical record, the facility failed to include documented evidence that the facility provided a written transfer notification to the resident/resident representative and or Office of Long-Term Care Ombudsman for the hospitalization on 3/9/24.

Review of the clinical record indicated Resident R87 was admitted to the facility on 9/5/23.

Review of Resident R87's MDS dated 3/1/24, indicated diagnoses of depression, diabetes, and heart failure (a progressive heart disease that affects pumping action of the heart muscles).

Review of Resident R87's clinical record revealed that the resident was transferred to the hospital on 10/31/23 returned to the facility on 11/6/23.

Review of Resident R87's clinical record, the facility failed to include documented evidence that the facility provided a written transfer notification to the resident/resident representative and or Office of Long-Term Care Ombudsman for the hospitalization on 3/9/24.

During an interview on 5/2/24, at 9:22 a.m. Director of Nursing confirmed that the facility failed to notify the resident/resident representative and or the representative of the Office of the State Long-Term Care Ombudsman of resident transfers in writing for five of seven residents (Resident R30, R57, R59, R75, and R87).

28 Pa. Code 201.29 (a) (c.3) (2) Resident rights.


 Plan of Correction - To be completed: 06/13/2024

The facility cannot retroactively correct the concern for resident R30,R57,R59, R75 and R87,however Ombudsman will be notified of any further transfers to the hospital.

Audit's will be completed for residents that have been sent out to the hospital within the last 30 days to verify Ombudsman, resident and resident representative notification has been made.

Nursing Home Administrator/Designee will educate the Social Services Director on tracking residents who are transferred out of the facility, and federal regulation 0623 ombudsman and resident and resident representative notification.

Social Services Director/Designee will send tracking data to the Ombudsman one time per month.

Nursing Home Administrator/Designee will audit to ensure the Ombudsman,resident and resident representative is notified of transfers monthly for 2 months.

The results of these audits will be forwarded to the Quality Assurance and Performance Improvement Committee for review and frequency of audits.

483.15(c)(1)(i)(ii)(2)(i)-(iii) REQUIREMENT Transfer and Discharge Requirements: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.
§483.15(c) Transfer and discharge-
§483.15(c)(1) Facility requirements-
(i) The facility must permit each resident to remain in the facility, and not transfer or discharge the resident from the facility unless-
(A) The transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in the facility;
(B) The transfer or discharge is appropriate because the resident's health has improved sufficiently so the resident no longer needs the services provided by the facility;
(C) The safety of individuals in the facility is endangered due to the clinical or behavioral status of the resident;
(D) The health of individuals in the facility would otherwise be endangered;
(E) The resident has failed, after reasonable and appropriate notice, to pay for (or to have paid under Medicare or Medicaid) a stay at the facility. Nonpayment applies if the resident does not submit the necessary paperwork for third party payment or after the third party, including Medicare or Medicaid, denies the claim and the resident refuses to pay for his or her stay. For a resident who becomes eligible for Medicaid after admission to a facility, the facility may charge a resident only allowable charges under Medicaid; or
(F) The facility ceases to operate.
(ii) The facility may not transfer or discharge the resident while the appeal is pending, pursuant to § 431.230 of this chapter, when a resident exercises his or her right to appeal a transfer or discharge notice from the facility pursuant to § 431.220(a)(3) of this chapter, unless the failure to discharge or transfer would endanger the health or safety of the resident or other individuals in the facility. The facility must document the danger that failure to transfer or discharge would pose.

§483.15(c)(2) Documentation.
When the facility transfers or discharges a resident under any of the circumstances specified in paragraphs (c)(1)(i)(A) through (F) of this section, the facility must ensure that the transfer or discharge is documented in the resident's medical record and appropriate information is communicated to the receiving health care institution or provider.
(i) Documentation in the resident's medical record must include:
(A) The basis for the transfer per paragraph (c)(1)(i) of this section.
(B) In the case of paragraph (c)(1)(i)(A) of this section, the specific resident need(s) that cannot be met, facility attempts to meet the resident needs, and the service available at the receiving facility to meet the need(s).
(ii) The documentation required by paragraph (c)(2)(i) of this section must be made by-
(A) The resident's physician when transfer or discharge is necessary under paragraph (c) (1) (A) or (B) of this section; and
(B) A physician when transfer or discharge is necessary under paragraph (c)(1)(i)(C) or (D) of this section.
(iii) Information provided to the receiving provider must include a minimum of the following:
(A) Contact information of the practitioner responsible for the care of the resident.
(B) Resident representative information including contact information
(C) Advance Directive information
(D) All special instructions or precautions for ongoing care, as appropriate.
(E) Comprehensive care plan goals;
(F) All other necessary information, including a copy of the resident's discharge summary, consistent with §483.21(c)(2) as applicable, and any other documentation, as applicable, to ensure a safe and effective transition of care.
Observations:

Based on clinical record review and staff interview, it was determined that the facility failed to make certain that the necessary resident information was communicated to the receiving health care provider for five out of seven residents sampled with facility-initiated transfers (Residents R30, R57, R59 R75, and R87).


The findings include:

Review of Resident R30's clinical record indicated the resident was admitted to the facility on 2/26/24.

Review of Resident R30's MDS (Minimum Data Set, periodic assessment of resident care needs) dated 3/2/24, indicated diagnoses of hypertension (high blood pressure in the arteries), multiple sclerosis (a disease that affects central nervous system), and seizure disorder (a disorder in which nerve cell activity in the brain is disturbed, causing seizures).

Review of Resident 30's clinical record revealed that the resident was transferred to the hospital on 4/27/24 and returned to the facility on 4/27/24, same day.

Review of Resident R30's clinical record revealed no documented evidence that the facility had communicated specific information to the receiving health care provider for the residents transferred and expected to return, which included the resident's care plan goals, advanced directive information, specific instructions for ongoing care, resident representative information, and all information necessary to meet the resident's specific needs at the receiving facility.

Review of the clinical record indicated Resident R57 was admitted to the facility on 7/26/19.

Review of Resident R57's MDS dated 3/8/24, indicated diagnoses of diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time), hypertension, and stroke (an event that occurs when something blocks blood supply to part of the brain or when a blood vessel in the brain bursts).

Review of Resident R57's clinical record revealed that the resident was transferred to the hospital on 1/6/24, and returned on 1/8/24..

Review of Resident R57's clinical record revealed no documented evidence that the facility had communicated specific information to the receiving health care provider for the residents transferred and expected to return, which included the resident's care plan goals, advanced directive information, specific instructions for ongoing care, resident representative information, and all information necessary to meet the resident's specific needs at the receiving facility.

Review of clinical record indicated that Resident R59 was admitted to the facility on 4/28/20.

Review of Resident 59's MDS dated 1/24/24, indicated diagnoses of diabetes, high blood pressure, and dysphagia (difficulty swallowing).

Review of Resident 59's clinical record revealed that the resident was transferred to the hospital on 12/22/23, and returned on 12/24/23.

Review of Resident R59's clinical record revealed no documented evidence that the facility had communicated specific information to the receiving health care provider for the residents transferred and expected to return, which included the resident's care plan goals, advanced directive information, specific instructions for ongoing care, resident representative information, and all information necessary to meet the resident's specific needs at the receiving facility.

Review of the clinical record indicated Resident R75 was admitted to the facility on 9/21/24.

Review of Resident R75's MDS dated 1/21/24, indicated diagnoses hypertension, dementia (a group of symptoms that affects memory, thinking and interferes with daily life), and cerebral infarction (necrotic tissue in the brain resulting loss of blood and oxygen to the brain).

Review of Resident R75's clinical record revealed that the resident was transferred to the hospital on 3/9/24 returned to the facility on 3/14/24.

Review of Resident R75's clinical record revealed no documented evidence that the facility had communicated specific information to the receiving health care provider for the residents transferred and expected to return, which included the resident's care plan goals, advanced directive information, specific instructions for ongoing care, resident representative information, and all information necessary to meet the resident's specific needs at the receiving facility.

Review of the clinical record indicated Resident R87 was admitted to the facility on 9/5/23.

Review of Resident R87's MDS dated 3/1/24, indicated diagnoses of depression, and, heart failure (a progressive heart disease that affects pumping action of the heart muscles).

Review of Resident R87's clinical record revealed that the resident was transferred to the hospital on 10/31/23 returned to the facility on 11/6/23.

Review of Resident R87's clinical record revealed no documented evidence that the facility had communicated specific information to the receiving health care provider for the residents transferred and expected to return, which included the resident's care plan goals, advanced directive information, specific instructions for ongoing care, resident representative information, and all information necessary to meet the resident's specific needs at the receiving facility.

During an interview on 5/1/24, at 9:36 a.m. the Director of Nursing (DON) stated, "they send information in a packet, but they don't specifically document what they send".

During an interview on 5/1/24, at 2:03 p.m. the Director of Nursing confirmed that there was no evidence that the necessary information was communicated to the receiving health care institution or provider upon transfer for five out of five residents sampled with facility-initiated transfers (Residents R30, R57, R59, R75, and R87).


28 Pa. Code 201.29 (a) (c.3) (2) Resident rights.


 Plan of Correction - To be completed: 06/13/2024

The facility will make certain that the necessary resident information is communicated to the receiving health care provider when a resident is transferred out of the facility to another health care provider/facility.

The facility can not retroactively correct the concerns identified with residents R30, R57, R59, R75, and R87, however representative will be notified of any further transfers to the hospital.

Audit's will be completed for residents that have been sent out to the hospital within the last 30 days to verify representative notification.

Director of Nursing/Designee will educate staff on facility's policy for transfer notification that the resident and resident's family or legal representative will be notified and a treatment/care of summary of the resident will be sent to the hospital and documented in the resident's electronic medical record (EMR).

Director of Nursing/Designee will audit transfers to the hospital to ensure documentation that the resident's family member or legal representative has been notified and a treatment/care of summary of the resident has been sent to the hospital weekly for 4 weeks and monthly for 2 months.

The results of these audits will be forwarded to the Quality Assurance and Performance Improvement Committee for review and frequency of audits

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 facility policy, clinical record review and staff interviews, it was determined the facility failed to notify the physician of a change in condition for one of six residents. (Resident R30).

Findings include:

Review of facility policy "Notification of Changes" dated 2/1/24, indicated the facility will immediately inform the resident; consult with the resident's physician; and if known, notify the resident's legal representative or an interested family member when there is:
- An accident involving the resident which results in injury and has the potential for requiring physician intervention.
- A significant change in the resident ' s physical, mental, or psychosocial status
- A need to alter treatment significantly.

Review of facility policy "Protocol When to Call Physician" dated 2/1/24, indicated the physicians caring for residents in your facility was to respond in an appropriate and timely manner to changes in condition as determined by the nursing staff and to address any concerns voiced by staff, residents or family members.

Review of the clinical record indicated Resident R30 was admitted to the facility on 2/26/24.

Review of Resident R30's MDS (Minimum Data Set, periodic assessment of resident care needs) dated 3/2/24, indicated diagnoses of hypertension (high blood pressure in the arteries), multiple sclerosis (a disease that affects central nervous system), and seizure disorder (a disorder in which nerve cell activity in the brain is disturbed, causing seizures).

Review of Resident R30's progress note indicated on 4/23/24, at 8:43 p.m. that Resident R30 was noted on floor in room on the side of bed closest to window; Resident positioned faced down no injury noted at this time; range of motion tolerated per Residents toleration times four extremities. Reddend area noted on left wrist, Resident alert to self with confusion. Resident bed positioned at lowest position.

Review of Resident R30's progress note indicated on 4/23/24, at 9:05 p.m. that resident was on the floor next to bed. upon entering room resident was laying on the right side of bed on floor face down. resident was assessed for injuries and repositioned onto her back for easy transfer. no injuries noted at this time. resident had small red area to left wrist that resident stated, "that's been there." Resident R30 is alert times one and continuing on hospice. Resident R30 stated she was not in any pain. no signs or symptoms of pain or discomfort. resident transferred back into bed assist times 3. pillows placed on both sides of resident to help keep her from rolling out of bed. vitals (blood pressure, pulse, respirations) within normal limits. Afebrile (no fever). Neuros initiated. Physician notified. supervisor called husband but no answer. message left. will continue to monitor.

Review of Resident R30's progress note indicated on 4/23/24, at 10:47 p.m. that resident had an increase of pain and agitation this shift, resident was crying out, when asked she stated that she was in pain, and wanted help, also that she couldn't see, hospice notified, this nurse spoke with on call, hospice stated she will call supervisor and come out to assess resident and call before she comes. Supervisor notified, will continue to monitor.

Review of Resident R30's progress notes on 4/23/24, at 10:47 p.m. failed to have an assessment documented by a registered nurse with residents change in condition.

Review of Resident R30's progress note on 4/23/24, at 10:47 p.m. failed to include documentation of notifying the physician of change in condition when resident reported having increased pain and being unable to see after a fall.

During an Interview on 5/1/24, at 10:15 a.m. the Director of Nursing (DON) confirmed the facility failed to notify the physician of a change in condition for one of six residents (Resident R30).

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

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


 Plan of Correction - To be completed: 06/13/2024

The facility cannot retroactively notify physician for R30 change of condition.

The facility will notify physician of any resident change of condition.

All licensed clinical staff will be educated regarding physician notification with resident change of condition.

Clinical start up meeting will be enhanced to include progress notes and risk management assessments reviewed and any resident change of conditions are notified to physician.

The Director of Nursing or designee will perform audits to progress notes and risk management assessments twice weekly for 2 weeks, weekly for 2 weeks and then monthly for 3 months to ensure physician notification of resident change in condition.

The results of these audits will be forwarded to the monthly Quality Assurance and Performance Improvement Committee for review and frequency of audits.
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 facility policy, resident clinical records, and staff interviews, it was determined the facility failed to obtain a physician order for hospice services and to ensure the coordination of hospice services with facility services to meet the needs of each resident for end of life care for one of four residents (Resident R30).

Findings include:

Review of the facility's "Hospice Care Policy" dated, 2/1/24, indicated hospice care will be offered to residents, as ordered by the attending physician, to provide additional supportive care for residents with end-stage terminal illnesses. Social services or designee will obtain a physician ' s order and contact Hospice Agency. All hospice services are provided under contractual arrangements.

Review of Resident R30's clinical record indicated the resident was admitted to the facility on 2/26/24.

Review of Resident R30's MDS (Minimum Data Set, periodic assessment of resident care needs) dated 3/2/24, indicated diagnoses of hypertension (high blood pressure in the arteries), multiple sclerosis (a disease that affects central nervous system), and seizure disorder (a disorder in which nerve cell activity in the brain is disturbed, causing seizures).

Review of Resident R30's documentation from the resident's hospice provider dated 3/13/24, indicated the resident was admitted to their services on 3/13/24.

Review of Resident R30's care plan initiated 5/1/24, indicated the resident is receiving hospice care related to end stage illness.

Review of Resident R30's clinical record failed to include a completed hospice contract between the facility and hospice provider.

Review of Resident R30's physician orders dated 4/27/24, included a hospice phone number for hospice services.

Review of Resident R30's physician orders dated 3/13/24 through 5/1/24 failed to include a physician order for hospice services.

During an interview on 5/1/24, at 10:40 a.m. Director of Nursing stated, "I don ' t see an order but I will get one put in".

During an observation on 5/1/24, at 12:30 p.m. Nursing Home Administrator provided a contract which failed to identify resident name, what kind of contract and which hospice provider was contracted to provide services to Resident R30.

During an interview on 5/1/24, at 10:42 a.m. Director of Nursing confirmed the facility failed to obtain a physician order for hospice services and to ensure the coordination of hospice services with facility services to meet the needs of each resident for end of life care for one of four residents (Resident R30).

28 Pa. Code 211.2(a) Physician services

28 Pa. Code 211.11(d) Resident care plan


 Plan of Correction - To be completed: 06/13/2024

Facility cannot retroactively correct failure to obtain a physician order for hospice services and to ensure the coordination of hospice services with facility services to meet the needs of each resident for end of life care; specifically for Resident R30. The facility immediately corrected Resident R30's medical record and will ensure all new hospice admissions records are accurate and recorded.

Admissions Director, Social Services Director, and Director of Nursing will be educated on accurate contract record keeping and order entry for Hospice admissions.

The Director of Nursing or designee will complete audits of new hospice admissions to ensure accurate record keeping and documentation weekly for 4 weeks and then monthly for 3 months.

The results of these audits will be forwarded to the monthly Quality Assurance and Performance Improvement Committee for review and frequency of audits.
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 clinical record review and staff interview, it was determined that the facility failed to maintain and complete accurate documentation for two of nine residents (Resident R3 and R12).

Findings include:

Review of facility policy "Documentation" dated 2/1/24, indicated nursing documentation will provide accurate reflection of a resident condition that will meet federal and state requirements.

Review of Title 42 Code of Federal Regulations (CFR) Medical records. In accordance with accepted professional standards and practice, the facility must maintain medical records that are complete, accurately documented, readily accessible, and systematically organized.

Review of the clinical record indicated Resident R3 was admitted to the facility on 2/27/17.

Review of Resident R3's Minimum Data Set (MDS - a periodic assessment of care needs) dated 4/11/24, indicated active diagnosis of high blood pressure, dementia, and muscle weakness.

Review of a physician order dated 1/2/24, indicated to weigh patient every day shift every month starting on the 2nd day of the month.

Review of a physician order dated 1/18/24, indicated to weigh resident every day shift every Thursday. This order was discontinued on 2/11/24.

Review of Resident R3's clinical record failed to reveal that a weight was documented in the electronic medical record on 1/25/24, 2/1/24, 2/8/24, 3/2/24, and 4/2/24.

During an interview on 5/3/24, at 12:09 p.m. the Assistant Director of Nursing (ADON) provided facility documentation to indicate that Resident R3's ordered weights were documented on paper sheets dated 1/2/24, 2/2/24, 2/9/24, 3/2/24, and 4/2/24. During this interview the ADON confirmed that these weights had not be transferred to the electronic medical record and were not readily accessible for review.

Review of the clinical record indicated Resident R12 was admitted to the facility on 12/16/22.

Review of Resident R12's Minimum Data Set MDS dated 4/8/24, indicated diagnosis of high blood pressure, muscle weakness, and dependence on supplemental oxygen.

Review of a physician order dated 12/18/24, indicated to weigh resident every day shift every Thursday. This order was discontinued on 2/23/24.

Review of Resident R12's clinical record failed to reveal that a weight was documented in the electronic medical record on 2/1/24, 2/8/24, and 2/15/24. Further review of R12's clinical record failed to reveal a weight documented in the electronic medical record for February and March 2024.

During an interview on 5/3/24, at 12:09 p.m. the ADON provided facility documentation to indicate that Resident R12's ordered weights were documented on paper sheets dated 2/2/24, 2/9/24, 2/16/24, and 3/2/24. During this interview the ADON confirmed that these weights had not be transferred to the electronic medical record and were not readily accessible for review.

During an interview on 5/3/24, at 10:39 a.m. Registered Dietitian (RD) Employee E10 stated, "I come in to the facility once a week, usually on Thursdays. I do a lot of my charting remotely from home. I rely on weights being documented in the electronic medical record for my charting."

During an interview on 5/3/24, at 12:09 p.m. the ADON confirmed that the facility failed to maintain and complete accurate documentation for two of nine residents (Resident R3 and R12).


28 Pa. Code 211.5(f) Clinical Records.

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


 Plan of Correction - To be completed: 06/13/2024

The facility can not retroactively have weights on electronic medical record for R3 on 1/25/24, 2/1/24, 2/8/24, 3/2/24, 4/2/24. The facility can not retroactively have weights on the electronic medical record for R12 on 2/1/24, 2/8/24, 2/15/24.

Director of Nursing, or designee, will educate all licensed staff on the weight policy and procedure and timely process for entering weights into the Electronic Medical Record.

The facility will ensure that all weights are accessible for review on the electronic medical record.

A house audit will be completed to validate weights have been entered into the electronic record and are up to date for current residents.

The facility has transferred the weights obtained on paper sheets to the electronic medical record for residents R3 and R12.

The Director of Nursing or designee will perform 5 audits weekly for 4 weeks then monthly for 3 months to ensure weights are accessible for review on the electronic medical record.

The results of these audits will be forwarded to the monthly Quality Assurance and Performance Improvement Committee for review and frequency of audits.

483.60(i)(4) REQUIREMENT Dispose Garbage and Refuse Properly: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)(4)- Dispose of garbage and refuse properly.
Observations:

Based on facility policy, observation, and staff interview it was determined that the facility failed to properly contain and dispose of garbage in one of one outside dumpsters to prevent the potential for rodent and insect infestation.

Findings include:

Review of facility policy "Garbage and Rubbish Disposal Policy", date 2/1/24, indicated that outside dumpsters provided by the garbage pick-up services must be kept closed and free of litter around the dumpster area.

During an observation of the facility's outdoor trash receptacle on 4/29/23, at 9:32 a.m. revealed the lids/covers were not closed on the dumpster.

During an interview on 4/29/24, at 9:32 a.m. Food Service Director Employee E9 confirmed that the facility failed to properly contain and dispose of garbage in the outside trash receptacles to prevent the potential for rodent and insect infestation.


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

28 Pa. Code 207.2(a) Administrator's responsibility.


 Plan of Correction - To be completed: 06/13/2024

The facility will ensure the dumpster lid is closed at all times.

The Nursing Home Administrator or designee will educate the Dietary Staff and Housekeeping Staff on ensuring the dumpster lid is closed when not actively being used.

The Nursing Home Administrator will audit the dumpster lid daily for four weeks and then monthly for three months to ensure that the lid is closed and secured.

The results of these audits will be forwarded to the quality assurance and improvement committee meeting for review and frequency of audits.
483.60(d)(1)(2) REQUIREMENT Nutritive Value/Appear, Palatable/Prefer Temp: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(d) Food and drink
Each resident receives and the facility provides-

§483.60(d)(1) Food prepared by methods that conserve nutritive value, flavor, and appearance;

§483.60(d)(2) Food and drink that is palatable, attractive, and at a safe and appetizing temperature.
Observations:

Based on a review of facility policy, observation, resident interview, and staff interview, it was determined that the facility failed to serve food products that appeared palatable for one of four meals observed (lunch meal on 4/29/24).

Findings include:

Review of facility policy "Meal Service Line", dated 2/1/24, indicated that the facility will serve food that will be prepared by methods that conserve nutritive value, flavor, and appearance, and will be placed on trays in an attractive manner.

During an observation on 4/29/24, at 12:19 p.m. Resident R59 had her lunch tray in front of her, but was not eating.

During an observation on 4/29/24, at 12:19 p.m., Resident R59's meal ticket stated that she was to have received fried chicken, however, there was no fried chicken on her tray and there was a very dry, hard, and stringy appearing piece of meat.

During an interview on 4/29/24, at 12:20 p.m. Resident R59 was asked what her entrwas and she replied, "I think it's left over roast beef from yesterday".

During an interview in Resident R59's room on 4/29/24, at 12:47 p.m. Food Service Director (FSD) Employee E9 confirmed that Resident R59 was served leftovers from yesterday's lunch of Yankee pot roast, and confirmed that the meat appeared to be very dry and unappetizing. FSD confirmed that the facility failed to provide food products that appeared palatable for the lunch meal on 4/29/24.

Pa Code 211.6(b)(c)(d) Dietary Services.


 Plan of Correction - To be completed: 06/13/2024

The facility will serve food products that appear palatable.

The Nursing Home Administrator or designee will educate the Food Services Director on serving food that presents well and appears appetizing.

The food services director will monitor tray lines to ensure that food looks appealing and is plated in a visually pleasing manor.

Left over food will no longer be served in the facility. Which will help with food looking and tasting fresh.

The Nursing Home Administrator or designee will audit trays to ensure that they look appetizing. These audits will be conducted weekly for four weeks and then monthly for three months.

The results of these audits will be forwarded to the quality assurance and improvement committee for review and frequency of audits.
483.60(c)(1)-(7) REQUIREMENT Menus Meet Resident Nds/Prep in Adv/Followed:This is a less serious (but not lowest level) deficiency and 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(c) Menus and nutritional adequacy.
Menus must-

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

§483.60(c)(2) Be prepared in advance;

§483.60(c)(3) Be followed;

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

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

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

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

Based on observations, facility menu, resident interviews, and staff interviews it was determined that the facility failed to follow the displayed menu for one of four observed meals (lunch meal 4/30/24).

Findings include:

During an interview on 4/29/24, at 12:19 p.m. Resident R59 stated that she often does not receive food items that are on her meal ticket or menu.

Review of lunch menu for 4/30/24 revealed that the vegetable was to be broccoli cuts, and that the alternative vegetables were peas, green beans, and carrots.

During an observation in the Main Dining Room on 4/30/24, at 12:46 a.m., no residents were served broccoli, but had Winter Blend vegetables (cauliflower, carrots and broccoli) instead.

Review of Resident R9, R17, R21, R58, and R210's meal tickets all indicated that they were to have received broccoli cuts, but received Winter Blend instead.

During an interview on 4/30/24, at 1:00 p.m. Food Service Director (FSD) Employee E9 stated that he was aware that broccoli was on the menu but that he did not receive it in the food delivery so he served the Winter Blend instead. When FSD Employee E9 was asked if he had approval from the Registered Dietitian to change the menu or alert residents of the change in the menu, he replied "no".

During an interview on 4/30/24, at 1:01 p.m., FSD Employee E9 confirmed that facility failed to properly display and update the menu being served for the lunch meal on 4/30/24.

Pa Code: 211.6(a) Dietary services.


 Plan of Correction - To be completed: 06/13/2024

The facility will follow the displayed menu for meals.

The facility can retroactively correct the issue identified with the lunch meal observed on 4/30/24.

The facility has since corrected some supply chain related issues that should result in the facility getting the specific items ordered.

The facility will receive approval from the registered dietician for any menu changes that may occur in the future.

The facility will notify the residents of any menu changes that may occur in the future prior to those meals being served.

The Nursing Home Administrator or designee will educate the food service director on federal regulation 0803. Detailing approval from registered dietician on menu changes and notification to residents of any menu changes.

The Nursing Home Administrator or designee will audit menu changes to ensure that the registered dietician had approved that menu change, and that residents were made aware of that menu change prior to that meal being served. These audits will be conducted weekly for four weeks and then monthly for three months.

The results of these audits will be forwarded to the quality assurance improvement committee meeting for review and frequency of audits.
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 review of facility policy, resident clinical records and staff interview it was determined that the facility failed to obtain laboratory results and promptly report those results as per order for one out of two sampled residents (Resident R17).

Findings include:

The facility "Laboratory services" policy dated 8/2016, and last reviewed 2/1/24, indicated that laboratory studies will be obtained only when ordered by a physician. The facility will notify the physician of the results promptly and laboratory findings will be filed in the resident record. The facility will have a system to reconcile physician orders, lab orders, and results received.

Review of Resident R17's admission record indicated she was admitted on 4/4/24.

Review of Resident R17's MDS assessment (Minimum Data Set assessment: MDS -a periodic assessment of resident care needs) dated 4/10/24, indicated she had diagnoses that included major depressive disorder (a state of consistent sadness and loss of interest interfering in daily life activities), hypertension (a condition impacting blood circulation through the heart related to poor pressure), and hematuria (blood in urine).

Review of Resident R17's care plans dated 4/16/24, indicated to obtain and monitor laboratory results as ordered and report results to a physician.

Review of Resident R17's physician orders dated 4/27/24, indicated to obtain a complete blood count (CBC) one time for infection prevention.

Review of Resident R17's physician orders dated 4/27/24, indicated to obtain an urinalysis (a urine test) one time for urinary tract infection.

Review of Resident R17's CBC lab results dated 4/27/24, indicated a high white blood cell count of 10.40.

Review of Resident R17's physician orders dated 4/27/24, indicated to administer Macrobid (antibiotic) 100mg twice a day by mouth for seven days. Resident R 17 diagnosis was a urinary tract infection.

Review of Resident R17's urinalysis results dated 4/29/24, indicated that superficial bacteria does not show a urinary tract infection.

Review of Resident R17's physician notes and clinical nurse notes did not indicate a notification to the doctor about the results of the 4/29/24 urinalysis showing Resident R17 did not have an active urinary tract infection.

Review of Resident R17's April 2024 and May 2024 Medication Administration Record (MAR) indicated that she received Macrobid 100mg on 4/28/24, 4/29/24, 4/30/24, 5/1/24, and 5/2/24.

During an interview on 5/2/24, at 12:19 p.m. Registered Nurse (RN) Employee E6 confirmed that the facility failed to obtain laboratory results and promptly report those results as per order for Resident R17 as required.

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


 Plan of Correction - To be completed: 06/13/2024

The facility will ensure all laboratory values out of range or unexpected clinical values are reported to physician. The physician was notified of the urinalysis results for R17.

The facility will complete a 30 look back of labs ordered to validate the results were obtained timely and physician notification was made.

The Director of Nursing or designee will re-educate licensed nurses on obtaining labs timely and notifying the physician for laboratory values out of range or values that would be clinically unexpected.

The Director of Nursing or designee will conduct audits of laboratory results and physician notifications weekly for 4 weeks and then monthly for 3 months.

The results of these audits will be forwarded to the monthly Quality Assurance and Performance Improvement Committee for review and frequency of audits.​
483.25 REQUIREMENT Quality of 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 Quality of care
Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices.
Observations:

Based on facility policy, clinical record review, resident observation, and staff interviews, it was determined that the facility failed to follow physician's orders for one of two residents (Resident R311).

Findings include:

Review of facility policy, "Medication and Treatment Orders", dated 2/1/24 indicate each medication administered will have a corresponding and complete physician ' s order.

Review of facility policy, "Treatment and services", dated 2/1/24 indicate based on the comprehensive assessment of a resident, the facility must ensure that a resident is given the appropriate treatment and services to maintain or improve his or her abilities.

Review of Resident R311's clinical record indicated he was admitted to the facility on 4/18/24.

Review of Resident R311's Minimum Data Set (MDS, periodic assessment of resident care needs) dated 4/24/24, included diagnoses of diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time), hypertension (high blood pressure in the arteries) and osteomyelitis (inflammation of bone caused by infection).

Review of Resident R311's active physician order dated 4/19/23, indicated change PICC (a type of long catheter that is inserted through a peripheral vein, often in the arm, into a larger vein in the body used when intravenous treatment is required over a long time) line dressing every day shift, every seven days for catheter care.

Review of Resident R311's care plan, dated 4/23/24 indicated dressing change per physician order.

During an observation on 5/1/24, at 10:57 a.m. Resident R311's PICC line dressing was dated 4/23/24.

Review of Resident R311's clinical record on 5/1/24, at 12:20 p.m. failed to provide documentation from a licensed nurse that the treatment was completed and signed on the Treatment Administration Record (TAR) on 4/30/24.

During an interview on 5/1/24, at 12:38 p.m. Licensed Practical Nurse (LPN) Employee E8, confirmed the PICC line dressing was dated 4/23/24 on Resident R311's arm.

During an interview on 5/1/24, 12:47 p.m. Director of Nursing confirmed the facility failed to follow physician ' s orders for one of two residents (Resident R311).



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

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

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


 Plan of Correction - To be completed: 06/13/2024

The facility will ensure IV dressings are changed as ordered by the physician for all residents.Resident R311 IV dressing was changed once the facility was made aware of the deficient practice.

A house audit of residents with IV dressings will be completed to validate the dressing was changed as ordered by the physician.


All licensed clinical staff will be educated on following orders related to IV dressing changes.

The Director of Nursing or designee will audit all residents who require IV dressing changes to ensure that the dressing changes are being completed per physician orders. These audits will be performed weekly for 4 weeks and then monthly for three months.

The results of these audits will be forwarded to the monthly Quality Assurance and Performance Improvement Committee for review and frequency of audits.

483.15(d)(1)(2) REQUIREMENT Notice of Bed Hold Policy Before/Upon Trnsfr: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.
§483.15(d) Notice of bed-hold policy and return-

§483.15(d)(1) Notice before transfer. Before a nursing facility transfers a resident to a hospital or the resident goes on therapeutic leave, the nursing facility must provide written information to the resident or resident representative that specifies-
(i) The duration of the state bed-hold policy, if any, during which the resident is permitted to return and resume residence in the nursing facility;
(ii) The reserve bed payment policy in the state plan, under § 447.40 of this chapter, if any;
(iii) The nursing facility's policies regarding bed-hold periods, which must be consistent with paragraph (e)(1) of this section, permitting a resident to return; and
(iv) The information specified in paragraph (e)(1) of this section.

§483.15(d)(2) Bed-hold notice upon transfer. At the time of transfer of a resident for hospitalization or therapeutic leave, a nursing facility must provide to the resident and the resident representative written notice which specifies the duration of the bed-hold policy described in paragraph (d)(1) of this section.
Observations:

Based on review of facility documents, clinical records, and staff interviews, it was determined that the facility failed to notify the resident or resident's representative of the facility bed-hold policy (an agreement for the facility to hold a bed for an agreed upon rate during a hospitalization) for one of seven resident hospital transfers (Resident R57).

Findings Include:

Review of the "Admission Packet" which is provided to residents upon admission, it was indicated that before the facility transfers a resident to the hospital or the resident goes on therapeutic leave, the facility shall provide written notice to Resident or Resident Representative.

Review of the clinical record indicated Resident R57 was admitted to the facility on 7/26/19.

Review of Resident R57's Minimum Data Set (MDS - a periodic assessment of care needs) dated 3/8/24, indicated diagnoses of diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time), hypertension (high blood pressure in the arteries) and stroke (an event that occurs when something blocks blood supply to part of the brain or when a blood vessel in the brain bursts).

Review of Resident R57's clinical record revealed that the resident was transferred to the hospital on 1/6/24.

Review of Resident R57's clinical record failed to include documented evidence that the resident or the resident's representative were provided with written information about the facility's bed hold policy at the time of the transfer to the hospital on 1/6/24.

During an interview on 5/2/24, at 9:22 a.m. Director of Nursing confirmed that the facility failed to notify the resident or resident's representative of the facility bed-hold policy for Resident R57's hospital transfer.

28 Pa. Code: 201.29(b)(d)(j) Resident rights.


 Plan of Correction - To be completed: 06/13/2024

The facility cannot retroactively correct the concern for resident resident R57, however representative will be notified of the bed hold policy with any further transfers to the hospital.

Nursing Home Administrator/Designee will educate Business Office Manager and Social Services Director regarding sending written information of Bed Hold Policy to resident's representative.

Director of Nursing/Designee will educate licensed staff on the need to provide to the resident and the resident representative written notice which specified the duration of the bed-hold policy at the time of transfer.

Director of Nursing/Designee will audit transfers to the hospital to ensure documentation that the resident and resident's family member or legal representative has been notified of the bed-hold policy weekly for 4 weeks and monthly for 2 months.

The results of these audits will be forwarded to the Quality Assurance and Performance Improvement Committee for review

483.12(c)(2)-(4) REQUIREMENT Investigate/Prevent/Correct Alleged Violation: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.
§483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must:

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

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

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

Based on review of facility policy, clinical records, reports submitted to the state, and staff interviews, it was determined that the facility failed to conduct a thorough investigation to rule out abuse for one of three residents (Resident R67).

Findings include:

The facility " Abuse: Protection from Abuse" policy dated 1/23/23 and 2/1/24, indicated that the resident have the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, involuntary seclusion, neglect, and misappropriation of property. The facility shall have processes in place to include screening, training, prevention, identification, protection, investigation, reporting and response to allegations of potential or actual abuse or neglect.

The facility "Abuse Reporting and Investigation" policy dated 1/23/23 and 2/1/24, indicated that the facility will thoroughly investigate all reports of suspected or alleged abuse (mental, physical, sexual, involuntary seclusion or misappropriation of resident property), neglect or exploitation. The Department of Health will be notified of the alleged event via Electronic Event Reporting System (ERS) per regulation. Provider Bulletin 22 (PB22) will be completed and forwarded to the Department of Health within 5 working days of the incident.

Review of Resident R67's clinical record indicated she was admitted to the facility on 8/24/20.

Review of Resident R67's MDS (Minimum Data Set, periodic assessment of resident care needs) dated 2/3/24, indicated diagnosis of osteoarthritis (degeneration of the joint causing pain and stiffness), depression, and peripheral vascular disease (PVD, circulatory condition in which narrowed blood vessels reduce blood flow to the limbs).

During an interview on 4/29/24, at 1:40 p.m. Resident R67 stated that she had arranged with a certified nurse aide that she will get ready for bed around ten o'clock p.m. per her choice this past Friday or Sunday.

During an interview on 4/29/24, at 1:45 p.m. Resident R67 stated, " I'm afraid of retaliation but I'll tell you. This weekend, Friday or Sunday an aide told me that I would either have to get cleaned up now or you will have to stay wet. The aide allegedly told Resident R67, " Don ' t tell us how to do our job". Resident R67 stated, " It's scary". Resident stated that she was not ready for care to be provided at this time.

During an interview on 4/29/24, at 2:21 p.m.. the Administrator and Director of Nursing was made aware of allegation from 4/29/24.

Review of Resident R67 clinical record on 4/30/24, at 1:07 p.m. indicated that on 10/2/23, resident was upset and shaken. Resident was insulted by staff member calling her fat because her legs rub and she doesn't move. Staff member told her that she can roll over independently, but she is just too lazy too.

During an interview on 4/30/24, at 1:12 p.m. the Director of Nursing was made aware of allegation from 10/2/23.

During an interview on 5/3/24, at 12:00 p.m. the Director of Nursing failed to provide investigations for reported abuse allegations from 4/29/24 and 4/30/24.

During an interview on 5/3/24, at 2:13 p.m. the Nursing Home Administrator (NHA) confirmed that the facility failed to conduct a thorough investigation to rule out abuse for one of three residents (Resident R67) as required.



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

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


 Plan of Correction - To be completed: 06/13/2024

The facility will thoroughly conduct an investigation into any allegation of abuse to either substantiate or rule out abuse pertaining to any allegation of abuse.

The facility can not retroactively investigate the allegation of abuse identified with resident R67. However, the facility has completed an investigation into this matter and the allegation was unsubstantiated. The allegation was reported to the local state field office.

The Regional Clinical Consultant or designee will educate the facility Nursing Home Administrator, Director of Nursing, and Assistant Director of Nursing on federal regulation 0610. Detailing thoroughly investigating suspected or alleged abuse.

The Director of Nursing or designee will conduct a 30 day look back at the facilities grievance log and incident/accident log to ensure that any allegation of abuse was thoroughly investigated.

The Director of Nursing or designee will conduct an audit on the grievance log and incident/accident log to ensure that any allegation of abuse was thoroughly investigated. These audits will be conducted weekly for four weeks and then monthly for three months.

The results of these audits will be forwarded to the monthly Quality Assurance and Performance Improvement Committee for review and frequency of audits.

483.12(b)(5)(i)(A)(B)(c)(1)(4) REQUIREMENT Reporting of Alleged Violations: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.
§483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must:

§483.12(c)(1) Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures.

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

Based on review of facility policy, resident clinical record, reports submitted to the State, and staff interview it was determined that the facility failed to report two allegations of abuse for one of three sampled residents (Resident R67).

Findings include:

The facility " Abuse:Protection from Abuse" policy dated 1/23/23 and 2/1/24, indicated that the resident have the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, involuntary seclusion, neglect, and misappropriation of property. The facility shall have processes in place to include screening, training, prevention, identification, protection, investigation, reporting and response to allegations of potential or actual abuse or neglect.

The facility "Abuse Reporting and Investigation" policy dated 1/23/23 and 2/1/24, indicated that the facility will thoroughly investigate all reports of suspected or alleged abuse (mental, physical, sexual, involuntary seclusion or misappropriation of resident property), neglect or exploitation. The Department of Health will be notified of the alleged event via Electronic Reporting System (ERS) per regulation. Provider Bulletin 22 (PB22) will be completed and forwarded to the Department of Health within 5 working days of the incident.

Review of Resident R67's clinical record indicated she was admitted to the facility on 8/24/20.

Review of Resident R67's MDS (Minimum Data Set, periodic assessment of resident care needs) dated 2/3/24, indicated diagnosis of osteoarthritis (degeneration of the joint causing pain and stiffness), depression, and peripheral vascular disease (PVD, circulatory condition in which narrowed blood vessels reduce blood flow to the limbs).

During an interview on 4/29/24, at 1:40 p.m. Resident R67 stated that she had arranged with a certified nurse aide that she will get ready for bed around ten o'clock p.m. per her choice this past Friday or Sunday.

During an interview on 4/29/24, at 1:45 p.m. Resident R67 stated, " I'm afraid of retaliation but I'll tell you. This weekend, Friday or Sunday an aide told me that I would either have to get cleaned up now or you will have to stay wet. The aide allegedly told Resident R67, " Don ' t tell us how to do our job". Resident R67 stated, " It's scary". Resident stated that she was not ready for care to be provided at this time.

During an interview on 4/29/24, at 2:21 p.m. the Nursing Home Administrator (NHA) and Director of Nursing was made aware of allegation from 4/29/24.

Review of Resident R67 clinical record on 4/30/24, at 1:07 p.m. indicated that on 10/2/23, resident was upset and shaken. Resident was insulted by staff member calling her fat because her legs rub and she doesn't move. Staff member told her that she can roll over independently, but she is just too lazy too.

During an interview on 4/30/24, at 1:12 p.m. the Director of Nursing was made aware of allegation from 10/2/23.

During an interview on 5/3/24, at 12:00 p.m. the facility failed to provide evidence to indicate the abuse allegations from 4/29/24 and 4/30/24 were reported to the local State field office.

During an interview on 5/3/24, at 2:13 p.m. the Nursing Home Administrator (NHA) confirmed that the facility failed to report two allegations of abuse for one of three sampled residents (Resident R67).

28 Pa Code: 201.14 (a)(c )(e ) Responsibility of management

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



 Plan of Correction - To be completed: 06/13/2024

The facility will report allegations of abuse pertaining to residents to the local state field office.

The facility cannot retroactively report the allegations of abuse pertaining to resident R67 in a timely manner. However, the allegations of abuse pertaining to resident R67 have been reported to the local state field office.

The facility will conduct a 30 day lookback at the grievance log and Incident/Accident reports to ensure that any allegations of abuse were reported to the local state field office.

The Regional Clinical Consultant or designee will educate the facility Nursing Home Administrator, Director of Nursing, and Assistant Director of Nursing on federal regulation 0609. Detailing thoroughly investigating suspected or alleged abuse and timely reporting to the local state field office.

The Director of Nursing or designee will conduct an audit on the grievance log and incident/accident log to ensure that any allegation of abuse was reported timely to the local state field office. These audits will be conducted weekly for four weeks and then monthly for three months.

The results of these audits will be forwarded to the monthly Quality Assurance and Performance Improvement Committee for review and frequency of audits.

483.12(b)(1)-(5)(ii)(iii) REQUIREMENT Develop/Implement Abuse/Neglect Policies: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.
§483.12(b) The facility must develop and implement written policies and procedures that:

§483.12(b)(1) Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property,

§483.12(b)(2) Establish policies and procedures to investigate any such allegations, and

§483.12(b)(3) Include training as required at paragraph §483.95,

§483.12(b)(4) Establish coordination with the QAPI program required under §483.75.

§483.12(b)(5) Ensure reporting of crimes occurring in federally-funded long-term care facilities in accordance with section 1150B of the Act. The policies and procedures must include but are not limited to the following elements.

§483.12(b)(5)(ii) Posting a conspicuous notice of employee rights, as defined at section 1150B(d)(3) of the Act.

§483.12(b)(5)(iii) Prohibiting and preventing retaliation, as defined at section 1150B(d)(1) and (2) of the Act.
Observations:

Based on review of facility policy, newly hired personnel records and staff interviews it was determined that the facility failed to conduct an FBI background check on an employee prior to working on the nursing unit for one out of five personnel records (Registered Nurse Employee E6) and failed to properly screen an employment by completing a State background check prior to hire for one out of five personnel records (Dietary Aide Employee E17).

Findings include:

The facility "Abuse: Protection from Abuse" policy dated 1/23/23 and 2/1/24, indicated that the resident has the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, involuntary seclusion, neglect, and misappropriation of property. The facility shall have processes in place to include screening, training, prevention, identification, protection, investigation, reporting and response to allegation of potential or actual abuse and neglect. Our facility conducts employee background checks and will not knowingly employ any individual who has been convicted of abusing, neglecting, or mistreating individuals. Screening- protocols for conducting employment background checks; background checks include State Criminal and Federal Criminal (if applicable).

Review of Registered Nurse Employee E6's personnel record indicated she was hired on 1/23/24.

Review of Registered Nurse Employee E6's personnel record revealed resident has not lived in Pennsylvania for two consecutive years and indicated a home address that was out of the state.

Review of Registered Nurse Employee E6's personnel record did not reveal that a FBI background check and fingerprint check was completed prior to her start date of employment.

During an interview on 5/2/24, at 1:40 p.m. Human Resource Employee E18 stated, "They do not show me proof that they did the FBI background check prior to their date of hire, we just get the results sent to us".

During an interview on 5/2/24, at 2:05 p.m. the Nursing Home Administrator (NHA) confirmed that the facility failed to conduct an FBI background check on Registered Nurse Employee E6 prior to her working on the nursing unit as required.

Review of Dietary Aide Employee E17's personnel record indicated she was hired 2/16/24.

Review of Dietary Aide Employee E17's personnel record did not include a state criminal background check prior to her date of hire.

During an interview on 5/2/24, at 1:32 p.m. Human Resource Employee E18 stated, "I was off on medical leave and when I came back, I noticed it wasn ' t completed so I did it".

During an interview on 5/2/24, at 2:05 p.m. the Nursing Home Administrator (NHA) confirmed that the facility failed to properly screen Dietary Aide Employee E17 by completing a state criminal background check prior to hire as required.


28 Pa Code: 201.14(a) (c)(d)(e) Responsibility of licensee

28 Pa Code 201.18(b)(1)(2)(e)(1) Management.

28 Pa Code: 201.19 Personnel policies and procedures

28 Pa Code: 201.20 (a)(b)(c)(d) Staff development

28 Pa Code: 201.29 (d) Resident Rights


 Plan of Correction - To be completed: 06/13/2024

The facility will conduct FBI background checks and state background checks prior to hire and working on the nursing unit.
The concern identified for employee E6 and E17 can not be retroactively corrected. However both background checks where completed and are in the employees file.

The facility will conduct a 30 day look back on new hires to ensure that a state or federal background check was conducted prior to hire and prior to those employees working on the nursing unit.

The Nursing Home Administrator or designee will reeducate the Human Resources Director on federal regulation 0607 detailing conducting FBI background checks on employees prior to working on the nursing unit and completing state background checks prior to hire.

The Nursing Home Administrator will audit new hires to ensure state and federal background checks are conducted prior the new hires starting on the nursing unit. These audits will be conducted weekly for four weeks and then monthly for three months.

The results of these audits will be forwarded to the monthly Quality Assurance and Performance Improvement Committee for review and frequency of audits.

483.12(a)(1) REQUIREMENT Free from Abuse and Neglect: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.
§483.12 Freedom from Abuse, Neglect, and Exploitation
The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms.

§483.12(a) The facility must-

§483.12(a)(1) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion;
Observations:

Based on review of facility policy, clinical record review, staff interview, and facility submitted documents, it was determined that the facility failed to provide services to create an environment free from neglect for one of four residents (Resident R99).

Findings include:

Review of facility policy "Abuse: Protection From Abuse" dated 2/1/24, indicated residents have the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, involuntary seclusion, neglect, and misappropriation of property. Neglect is defined as the failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. Neglect refers to failure through inattentiveness, carelessness, or omission to provide timely, consistent, safety adequate, and appropriate services, treatment of care, including but not limited to: nutrition, medication, therapies, and activities of daily living.

Review of the clinical record indicated Resident R99 was admitted to the facility on 2/5/24.

Review of Resident R99's Minimum Data Set assessment (MDS - a periodic assessment of care needs) dated 2/12/24, indicated diagnosis of high blood pressure, hyperglycemia (high blood sugar levels in the blood), and pain in left knee.

A review of facility submitted documents dated 3/12/24, indicated that on 3/12/24, Resident R99 submitted a complaint to the facility that he had been left sitting in a soiled brief from 8:30 a.m. to 1:30 p.m. Once a statement was obtained from the resident, the facility was able to determine that Nurse Aide (NA) Employee E3 was caring for the resident during the time of occurrence. NA Employee E3 was removed from resident care until a full investigation could be completed.

Review of investigation documents dated 3/12/23, indicated Resident R99's roommate provided the following statement, "NA Employee E3 came into room around 8:30 a.m. to answer call light, only turning it off and leaving saying she would be back. Around 1:30 p.m. NA Employee E3 came back and changed him (Resident R99) and left the room. Resident R99 was cold and not dressed in his bed. At 2:30 p.m. the second shift person covered him up."

Review of investigation documents dated 3/13/24, indicated Resident R99 provided the following statement, "I put my call bell on and she (NA Employee E3) came into my room at 8:30 a.m. and turned it off and stated, "I'll be back." She never came back until 1:30 p.m. to change my brief. I sat in my poop 5 hours. She changed my brief and left me in my bed with only a brief on. I was cold and she never came back in after the 1:30 p.m. brief change. Another person answered my call light and covered me up. I feel I sat too long in my brief with poop in it."

Review of investigation documents dated 3/13/24, indicated NA Employee E3 stated that Resident R99 put his call bell on for assistance on 3/12/24, around 12:15 p.m. when lunch trays had arrived. Resident R99 requested to be changed as he had a bowel movement. NA Employee E3 did not recall Resident R99 putting on his call bell at any other time during that shift. NA Employee E3 recalled that she had checked in on Resident R99 a couple of times during her shift and he did not need assistance. The last time she checked on him was at 10:00 a.m. and his brief ws clean and dry. At 1:30 p.m. NA Employee E3 entered Resident R99's room with NA Employee E4 and changed Resident R99. He was soiled with a bowel movement and required a change of his gown and sheets. NA Employee E3 and NA Employee E4 entered another residents room and when they came out of that room there were multiple people in the hall and they were talking about the fact that Resident R99 was upset he didn ' t have a gown on or have a sheet. NA Employee E3 remembered that she had forgotten to take them back to Resident R99 after he had been changed.

During an interview on 5/3/24, at 12:12 p.m. the Assistant Director of Nursing (ADON) confirmed that the facility failed to provide services to create an environment free from neglect for one of four residents (Resident R99).


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

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

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


 Plan of Correction - To be completed: 06/13/2024

The facility will provide services to create and maintain an environment free from neglect for residents. The facility cannot retroactively correct the concern identified for resident R99. A Skin Assessment will be completed on R99 to ensure there are no skin concerns related to delayed incontinence care.

The facility will ensure resident call bells are answered timely and that incontinence care is provided residents.
A house audit will be completed to ensure no resident has skin concerns related to delayed incontinence care.

The Director of Nursing or Designee will re-educate the nursing staff, including agency and new hires on Federal tag 0600, detailing providing an environment free neglect which includes answering call bells timely and providing incontinence care.

The Director of Nursing or Designee will complete an audit weekly for four weeks then monthly for three months to validate call bells are answered timely and residents are provided incontinence care.

The results of these audits will be forwarded to the monthly Quality Assurance and Performance Improvement Committee for review and frequency of audits

51.3 (g)(1-14) LICENSURE NOTIFICATION:State only Deficiency.
51.3 Notification

(g) For purposes of subsections (e)
and (f), events which seriously
compromise quality assurance and
patient safety include, but not
limited to the following:
(1) Deaths due to injuries, suicide
or unusual circumstances.
(2) Deaths due to malnutrition,
dehydration or sepsis.
(3) Deaths or serious injuries due
to a medication error.
(4) Elopements.
(5) Transfers to a hospital as a
result of injuries or accidents.
(6) Complaints of patient abuse,
whether or not confirmed by the
facility.
(7) Rape.
(8) Surgery performed on the wrong
patient or on the wrong body part.
(9) Hemolytic transfusion reaction.
(10) Infant abduction or infant
discharged to the wrong family.
(11) Significant disruption of
services due to disaster such as fire,
storm, flood or other occurrence.
(12) Notification of termination of
any services vital to continued safe
operation of the facility or the
health and safety of its patients and
personnel, including, but not limited
to, the anticipated or actual
termination of electric, gas, steam
heat, water, sewer and local exchange
of telephone service.
(13) Unlicensed practice of a
regulated profession.
(14) Receipt of a strike notice.

Observations:

Based on review of facility policy, review of reports to the local State field office, resident clinical records and staff interview, it was determined that the facility failed to report a resident transferred to the hospital due to an accident for two out of four sampled resident records (Resident R65 and Resident R100).

Findings include:

Review of Resident R65's admission record indicated that she was originally admitted on 1/16/23.

Review of Resident R65's MDS assessment (Minimum Data Set assessment: MDS -a periodic assessment of resident care needs) dated 11/2/23, indicated she had diagnoses that included dementia (a condition characterized by memory loss and progressive or persistent loss of intellectual functioning), major depressive disorder (a state of consistent sadness and loss of interest interfering in daily life activities), and hypertension (a condition impacting blood circulation through the heart related to poor pressure). The diagnoses were current upon review.

Review of Resident R65's care plans dated 11/14/23, indicated she was at risk of falls.

Review of Resident R65's nurse progress notes dated 11/28/23, indicated that she was found on the floor between the bed and her wheelchair. Resident R65 stated she was attempting to toilet herself. Resident R65 stated her pain was a two out of ten and pain was located on her buttocks where she was sitting on the floor. New order to X-ray left hip. Resident R65 is positive for a right hip fracture. Nurse Practitioner ordered Resident R65 to be seen at the Emergency Room for evaluation. EMS notified to pick resident up. Family notified.

Review of reportable incidents and documents submitted to the local State field office did not include a notification that Resident R65 was transferred to the hospital due to fall.Review of the clinical record indicated Resident R100 was admitted to the facility on 4/5/24.

Review of Resident R100's MDS dated 4/12/24, indicated diagnosis of dementia (a group of symptoms that affects memory, thinking, and interferes with daily life), anxiety, and Cerebrovascular Accident (CVA - blood flow to the brain is interrupted due to a blocked or rupture blood vessel).

Review of Resident R100's care plan dated 4/15/24, indicated he was at risk for falls.

Review of a nursing progress note dated 4/17/24, indicated Resident R100 was found on the floor on his left side in a copious amount of blood on the floor. Resident R100 was noted to have a laceration (cut) on the bridge of his nose. The physician was notified and gave an order to send Resident R100 to the emergency room.

Review of a physician order dated 4/17/24, indicated to send Resident R100 to the emergency room for evaluation of nose.

Review of reportable incidents and documents submitted to the local State field office did not include a notification that Resident R100 was transferred to the hospital due to a fall.

During an interview on 5/1/24, at 12:47 p.m. the Director of Nursing (DON) confirmed that the facility failed to report a resident transferred to the hospital due to an accident for Resident R65 and Resident R100 as required.


 Plan of Correction - To be completed: 06/13/2024

The facility will report all resident transfers to the hospital due to an accident.

The facility can not retroactively correct the issues identified with R65 and R100. However, notifications to the local state field office have been submitted.

The facility will perform a 30 day look back to ensure that all residents transferred to the hospital due to an accident have been reported to the local state field office.

The Regional Clinical Consultant will educate the Director of Nursing, the Assistant Director of Nursing, and the Nursing Home Administrator on reporting to the local state field office when a resident is transferred to the hospital resulting from an accident.

The Director of Nursing or designee will audit transfers to the hospital to identify if the cause of these transfers was due to an accident. And if so, that these transfers where submitted to the local state field office.

The results of these audits will be forwarded to the quality assurance and improvement committee meeting for review and frequency of audits.
§ 211.6(a) LICENSURE Dietary Services.:State only Deficiency.
(a) Menus shall be planned and posted in the facility or distributed to residents at least 2 weeks in advance. Records of menus of foods actually served shall be retained for 30 days. When changes in the menu are necessary, substitutions shall provide equal nutritive value.

Observations:

Based on observations, resident interview, and staff interview, it was determined the facility failed to post menus in the facility or distribute to residents at least two weeks in advance for all nursing units of the facility (North, Northwest, South, and West).

Findings include:

Tour of the facility on 4/30/24, at 9:30 a.m., revealed no menus were posted on the nursing units.

During an interview on 4/302/4, at 12:22 p.m. Resident R90 stated that she had been given copies of the menus for the old menu cycle, but not the new spring and summer menu cycle.

During an interview on 4/30/24, at 12:30 p.m. Food Service Director Employee E9 confirmed that menus are not posted two weeks in advance as required.


 Plan of Correction - To be completed: 06/13/2024

The facility will post menus throughout the facility and on every unit in the building.

The facility can not retroactively change that the menus were only posted on some units but not all. However the facility will post the menus on every unit in the facility.

The Nursing Home Administrator will educate the food service director on state regulation 4920. Detailing posting menus on every unit in the facility and ensuring those schedules show the menus for at least the next two weeks. Also ensuring that every resident has access to see these menus.

The Nursing Home Administrator or designee will audit the menu posting to ensure the are correctly posted throughout the facility. These audits will be conducted weekly for four weeks and then monthly for three months.

The results of these audits will be forwarded to the quality assurance and improvement committee meeting for review of audits and frequency evaluation.
§ 211.12(f.1)(2) LICENSURE Nursing services. :State only Deficiency.
(2) Effective July 1, 2023, a minimum of 1 nurse aide per 12 residents during the day, 1 nurse aide per 12 residents during the evening, and 1 nurse aide per 20 residents overnight.

Observations:

Based on review nursing time schedule documents, resident council group interview and staff interviews, it was determined that the facility failed to provide a minimum of one nurse aide per 12 residents during the daylight shift for one out of 21 days (4/27/24), failed to provide the minimum of one nurse aide per 12 residents during the evening shifts for two out of 21 days (2/22/24 and 4/27/24) and failed to provide a minimum of one Nurse aide (NA) per 20 residents during the overnight shift for seven out of 21 days (2/21/24, 2/22/24, 2/23/24, 2/24/24, 4/24/24, 4/26/24 and 4/28/24).


Findings include:

During a resident council group interview on 4/30/24, at 1:00 p.m. three out of eight residents voiced concerns that the facility was short staffed.

A review of 3-week nursing staffing review (2/18/24-2/24/24, 4/18/24-5/1/24) did not include one Nurse aide (NA) per 12 residents during the day on the following dates: 4/27/24.

A review of 3-week nursing staffing review (2/18/24-2/24/24, 4/18/24-5/1/24) did not include one Nurse aide (NA) per 12 residents during the evening shifts on the following dates: 2/22/24 and 4/27/24.

A review of 3-week nursing staffing review (2/18/24-2/24/24, 4/18/24-5/1/24) did not include one Nurse aide (NA) per 20 residents during the overnight shift on the following dates: 2/21/24, 2/22/24, 2/23/24, 2/24/24, 4/24/24, 4/26/24 and 4/28/24

During an interview on 5/2/24, at 1:21 p.m. the Director of Nursing (DON) and the Nursing Home Administrator (NHA) confirmed that the facility failed to provide a minimum of one nurse aide per 12 residents during the daylight shift for one out of 21 days (4/27/24), failed to provide the minimum of one nurse aide per 12 residents during the evening shifts for two out of 21 days (2/22/24 and 4/27/24) and failed to provide a minimum of one Nurse aide (NA) per 20 residents during the overnight shift for seven out of 21 days (2/21/24, 2/22/24, 2/23/24, 2/24/24, 4/24/24, 4/26/24 and 4/28/24) as required.


 Plan of Correction - To be completed: 06/13/2024

The facility cannot correct that nurse aide staffing ratios were not met on the following dates:4/27/24, 2/21/24, 2/22/24, 2/23/24, 2/24/24, 4/24/24, 4/26/24 and 4/28/24.

The facility will ensure that nurse aide staffing ratios are met every shift.

The Regional Clinical Consultant will re-educate the Nursing Home Administrator, Director of Nursing, and HR Director/Scheduler on regulation P5510 and ensuring nurse aide staffing ratios are met each shift.

Daily shift staffing ratios will be reviewed at daily staffing meeting. The Nursing Supervisors will review shift staffing ratios on the weekends. If the facility projects to not meet staffing ratios on a given shift, the scheduler/designee will be responsible to call off duty personnel or call extra support staff to assist.

The Nursing Home Administrator/designee will audit staffing daily for four weeks and monthly for three months to ensure nurse aide staffing ratios are being met.

The results of these audits will be reported to the Quality Assurance Performance Improvement Committee for review, recommendations, and frequency of audits
§ 211.12(f.1)(4) LICENSURE Nursing services. :State only Deficiency.
(4) Effective July 1, 2023, a minimum of 1 LPN per 25 residents during the day, 1 LPN per 30 residents during the evening, and 1 LPN per 40 residents overnight.
Observations:

Based on review nursing time schedule documents, resident council group interview and staff interviews, it was determined that the facility failed to provide a minimum of one Licensed Practical Nurse (LPN) per 25 residents during the day shift for two out of 21 days (4/18/24 and 4/21/24), failed to provide a minimum of one Licensed Practical Nurse (LPN) per 30 residents during the evening shift for one out of 21 days (4/21/24) and failed to provide a minimum of one Licensed Practical Nurse (LPN) per 40 residents during the overnight shift one out of 21 days (4/23/24).


Findings include:

During a resident council group interview on 4/30/24, at 1:00 p.m. three out of eight residents voiced concerns that the facility was short staffed.

A review of 3-week nursing staffing review (2/18/24-2/24/24, 4/18/24-5/1/24) did not include a minimum of one Licensed Practical Nurse (LPN) per 25 residents during the daylight shift on the following dates: 4/18/24 and 4/21/24.

A review of 3-week nursing staffing review (2/18/24-2/24/24, 4/18/24-5/1/24) did not include a minimum of one Licensed Practical Nurse (LPN) per 30 residents during the evening shift on the following dates: 4/21/24.

A review of 3-week nursing staffing review (2/18/24-2/24/24, 4/18/24-5/1/24) did not include a minimum of one Licensed Practical Nurse (LPN) per 40 residents during the overnight shift on the following dates: 4/23/24.

During an interview on 5/2/24, at 1:21 p.m. the Director of Nursing (DON) and the Nursing Home Administrator (NHA) confirmed that the facility failed to provide a minimum of one Licensed Practical Nurse (LPN) per 25 residents during the day shift for two out of 21 days (4/18/24 and 4/21/24), failed to provide a minimum of one Licensed Practical Nurse (LPN) per 30 residents during the evening shift for one out of 21 days (4/21/24) and failed to provide a minimum of one Licensed Practical Nurse (LPN) per 40 residents during the overnight shift one out of 21 days (4/23/24) as required.


 Plan of Correction - To be completed: 06/13/2024

The facility cannot correct that LPN staffing ratios were not met on the following dates: 4/18/24 and 4/21/24

The facility will ensure that LPN staffing ratios are met every shift.

The Regional Clinical Consultant will re-educate the Nursing Home Administrator, Director of Nursing, and HR Director/Scheduler on regulation P5530 and ensuring LPN staffing ratios are met each shift.

Daily shift staffing ratios will be reviewed at daily staffing meeting. The Nursing Supervisors will review shift staffing ratios on the weekends. If the facility projects to not meet staffing ratios on a given shift, the scheduler/designee will be responsible to call off duty personnel or call extra support staff to assist.

The Nursing Home Administrator/designee will audit staffing daily for four weeks and monthly for three months to ensure LPN staffing ratios are being met.

The results of these audits will be reported to the Quality Assurance Performance Improvement Committee for review, recommendations, and frequency of audits

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