Pennsylvania Department of Health
ABINGTON MANOR
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

ABINGTON MANOR
Inspection Results For:

There are 111 surveys for this facility. Please select a date to view the survey results.

Surveys don't appear on this website until at least 41 days have elapsed since the exit date of the survey.


ABINGTON MANOR - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:

Based on a Medicare/Medicaid Recertification, State Licensure, and Civil Rights Compliance Survey completed on November 15, 2024, it was determined that Abington Manor was not in compliance with the following requirements of 42 CFR Part 483 Subpart B Requirements for Long Term Care Facilities and the 28 PA Code Commonwealth of Pennsylvania Long Term Care Licensure Regulations.

Plan of Correction:

483.25(b)(1)(i)(ii) REQUIREMENT Treatment/Svcs to Prevent/Heal Pressure Ulcer:

This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.

§483.25(b) Skin Integrity
§483.25(b)(1) Pressure ulcers.
Based on the comprehensive assessment of a resident, the facility must ensure that-
(i) A resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable; and
(ii) A resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing.

Observations:

Based on review of clinical records and select facility reports, observations and staff and resident interviews it was determined the facility failed to consistently implement measures planned to promote healing, prevent worsening and the development of pressure sores for two residents out of 23 residents sampled (Residents 204 and Resident 1).

Findings include:

According to the US Department of Health and Human Services, Agency for Healthcare Research & Quality, the pressure ulcer best practice bundle incorporates three critical components in preventing pressure ulcers: Comprehensive skin assessment, standardized pressure ulcer risk assessment and care planning and implementation to address the areas of risk.

The American College of Physicians (ACP) is a national organization of internists, who specialize in the diagnosis, treatment, and care of adults. The largest medical-specialty organization and second-largest physician group in the United States) Clinical Practice Guidelines indicate that the treatment of pressure ulcers should involve multiple tactics aimed at alleviating the conditions contributing to ulcer development (i.e. support surfaces, repositioning and nutritional support); protecting the wound from contamination and creating and maintaining a clean wound environment; promoting tissue healing via local wound applications, debridement and wound cleansing; using adjunctive therapies; and considering possible surgical repair.

Review of the facility policy entitled "Prevention of Pressure Injuries", last reviewed September 26, 2024, indicated the facility will review and select medical devices with consideration to the ability to minimize tissue damage, including size, shape, its application, and ability to secure the device, monitor regularly for comfort and signs of pressure-related injury, and consult current clinical practice guidelines for prevention measures associated with specific devices. Additionally, monitoring of area(s) will include evaluation, report, and documentation of potential changes in the skin, and a review of interventions and strategies for effectiveness on an ongoing basis.

A review of the clinical record revealed that Resident 1 was admitted to the facility on May 10, 2023, with diagnoses that included dementia (loss of thinking, remembering, and reasoning skills), aphasia (a language disorder that affects the ability to speak and understand what others say), and contracture (a permanent tightening of the muscles, tendons, skin, and surrounding tissues that causes the joints to shorten and stiffen) of the right elbow.

A Quarterly Minimum Data Set assessment (MDS- a federally mandated standardized assessment process conducted at specific intervals to plan resident care) dated August 12, 2024, revealed the resident was severely cognitively impaired and was dependent on staff for all activities of daily living, and was at risk for pressure sore development.

A review of Resident 1's care plan initiated October 24, 2021, and last revised on November 1, 2024, revealed the resident was at risk for alteration in skin integrity related to impaired mobility and incontinence. Planned interventions included pressure reducing cushion to chair/wheelchair, sheepskin to protect back in chair and bed, observe for changes in skin condition and report abnormalities, encourage/assist to get out of bed as tolerated, encourage/assist to reposition, encourage/assist to float heels as able when in bed, pressure reduction/relieving mattress on bed, use pillows and/or positioning devices as needed, administer preventative skin treatment per physician orders, and diet and supplement per physician order.

Further review of Resident 1's care plan initiated March 5, 2019, and last revised November 1, 2024, revealed the resident was at risk for skin breakdown related to contractures, decreased activity, impaired cognition, impaired sensation, incontinence, limited mobility, shear/friction risks. Planned interventions included off load/float heels while in bed with "heels up" device, weekly skin assessment by licensed nurse, apply barrier cream after incontinence care, and provide skin preventative skin care (lotions, barrier cream).

A review of the facility's investigation report dated September 29, 2024, at 3:38 p.m., revealed the nurse aide, Employee 4 who was providing morning care to Resident 1 identified an open area to the resident's right antecubital (area inside of the elbow). According to the investigation report, the resident's right arm is contracted, and the resident had elbow protectors in place. The area measured 4 cm x 4 cm (no depth identified) and treatment was initiated as ordered by the physician. Employee 4 indicated she noticed the elbow pad was very tight, so she removed it and noticed the open area.

A review of Resident 1's clinical record did not identify orders and/or interventions for the application of elbow protectors however, a review of Resident 1's Documentation Survey Report dated September 2024 indicated the resident had Geri-sleeves (protective sleeve to prevent injury) to bilateral arms which were to be removed for care. According to the report, the Geri-sleeves were documented as provided each shift as ordered.

The resident was identified to have an elbow protector present that was applied by staff despite no documented physicians order or care plan directive for its use. There was also no skin assessment conducted for the potential risks associated with the use of the elbow protector.

The facility failed to implement interventions to prevent the development of a pressure ulcer for a resident with identified contractures.

A review of Resident 204's clinical record revealed the resident was admitted to the facility on November 6, 2024, with diagnoses that included end stage kidney disease, anxiety, shortness of breath, and need for palliative care (end of life care).

A review of the resident's care plan initiated November 6, 2024, identified a focus area related to skin breakdown with planned interventions which included enhanced barrier precautions related to a wound, observe for changes in skin condition and report abnormalities, encourage and assist as needed to turn and reposition; use assistive devices as needed, encourage/assist to float heels as able when in bed, use lift sheet as tolerate to prevent friction/shear, administer treatment per physician orders, and report evidence of infection such as purulent drainage (thick yellow/green drainage), swelling, localized heat, or increased pain.

A review of Resident 204's clinical record revealed documentation dated November 6, 2024, at 12:46 a.m., which revealed the resident was admitted to the facility with a Stage 3(sores that have broken completely through the top two layers of the skin and into the fatty tissue below) pressure ulcer on the right buttock and coccyx that measured 8. 5cm x 5cm x 0. 1cm with slough tissue (dead tissue) in the wound bed, and an intact blister on the right lower back which measured 1. 5cm x 2. 5cm x 0 cm.

Review of a Skin and Wound note dated November 7, 2024, at 3:56 p.m., completed by the wound care consultant indicated the pressure area on Resident 204's sacrum (coccyx) was a DTI (deep tissue injury to underlying tissue below the skin's surface that results from prolonged pressure in an area of the body. Like a pressure sore, a deep tissue injury restricts blood flow in the tissue causing the tissue to die) with a scant amount of serosanguineous (drainage which is yellowish with small amount of blood), 50% granulation (new tissue) and 50% epithelial (healing tissue). No measurements were documented. The area on the resident's right lower back was identified as incontinence associated dermatitis which measured 3 cm x 1cm x 0. 2cm, treatment recommendations were made and implemented by the facility.

Review of Skin and Wound note dated November 14, 2024, at 11:48 p.m., completed by the wound care consultant indicated the DTI on the sacrum continued to have a scant amount of serosanguineous drainage, 30% epithelial tissue, 30% granulation tissue, and 40% eschar (dead tissue). No measurements were documented. According to the documentation, the "sacral wound has worsened greatly since last evaluation" and was identified as a potential "Kennedy Ulcer" (a dark sore that develops rapidly during the final stages of person's life and is often unavoidable). No additional recommendations were identified.

Skin assessments were documented on November 7, 2024, and November 14, 2024, however, there were no wound measurements recorded for Resident 204's sacral pressure area to evaluate whether the pressure ulcer was healing, worsening, or remaining unchanged. Facility policy indicates that wounds would be monitored to determine any potential changes. The lack of consistent wound measurements had the potential to prevent accurately evaluating the effectiveness of the treatment plan and adjusting interventions as necessary.

Observation of Resident 204 on November 13, 2024, at approximately 11:00 a.m. revealed there was an alternating air mattress on the resident's bed, her heels were elevated, and the resident was without evidence of pain/discomfort. However, Resident 204 declined to allow the surveyor to observe her sacral pressure ulcer.

Interview with the Director of Nursing on November 15, 2024, at approximately 2:10 p.m., confirmed there was no evidence the facility thoroughly evaluated Resident 204's sacral pressure ulcer for worsening and/or improvement. The DON further confirmed the facility failed to implement interventions to prevent the development of Resident 1's pressure.

28 Pa. Code 201.14(a) Responsibility of licensee

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

28 Pa. Code 211.5(f)(ix) Clinical records

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

Plan of Correction - To be completed: 01/07/2025

1. Resident #204 no longer resides in the facility. Resident #1 antecubital pressure ulcer continues to show improvement and elbow protector is no longer in use.

2.Residents with any open areas will have a completed wound observation with measurements and appropriate interventions added as indicated.

3.DON/designee will educate all licensed staff on wound observation form and preventative interventions.

4.DON/designee will monitor any residents with new skin alterations in morning clinical meeting weekly for 4 weeks and then monthly for 2 months to ensure appropriate form and interventions are completed/followed. The results of the audit will be presented by the NHA/designee monthly at the facilities QAPI meeting for review and recommendation.

483.20(g) REQUIREMENT Accuracy of Assessments:

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

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

Observations:

Based on a review of clinical records, the Resident Assessment Instrument, and staff interview, it was determined that the facility failed to ensure that the Minimum Data Set Assessments accurately reflected the status of two residents out of 20 sampled (Residents 69 and 79).

Findings include:

According to the Resident Assessment Instrument (RAI) User's Manual (an assessment tool utilized to gather definitive information on a resident's strengths and needs, which must be addressed in an individualized care plan, and the RAI also assists staff to evaluate goal achievement and revise care plans accordingly by enabling the facility to track changes in the resident's status) dated October 2024, Section O, Special Treatments, Procedures, and Programs O 0110 J1 Dialysis, indicates facilities will code peritoneal or renal dialysis, which occurs at the nursing home or at another facility, and record treatments of hemofiltration, slow continuous ultrafiltration (SCUF), continuous arteriovenous hemofiltration (CAVH), and continuous ambulatory peritoneal dialysis (CAPD) in this item. Intravenous (IV) medication and blood transfusions administered during dialysis are considered part of the dialysis procedure.

A clinical record review revealed Resident 69 was admitted to the facility on October 22, 2024.

A review of an admission Minimum Data Set assessment (MDS-a federally mandated standardized assessment process conducted periodically to plan resident care) Section O 0110. Special Treatments, Procedures, and Programs, J1, Dialysis completed for Resident 69, dated October 28, 2024, indicated he received dialysis treatments while a resident at the facility.

Further clinical record review revealed no other documented evidence that Resident 69 received dialysis services while a resident at the facility.

During an interview on November 13, 2024, at approximately 9:30 AM, the Director of Nursing (DON) confirmed that Resident 69 was not currently receiving dialysis services and has not received dialysis treatments as a resident at the facility. The DON confirmed the facility coded Resident 69's MDS assessment dated October 28, 2024, in error as related to dialysis services. The MDS was coded as the resident receiving dialysis despite no physician order.

A clinical record review revealed Resident 79 was admitted to the facility on October 8, 2024.

A review of an admission MDS Section N Medications N0350, Insulin, dated October 10, 2024, indicated Resident 79 received three insulin injections in the last seven days.

Further clinical record review revealed no other documented evidence that Resident 79 was administered any insulin injections in the last seven days. The MDS was coded as the resident receiving insulin despite no physician order.

During an interview on November 13, 2024, at approximately 9:30 AM, the DON confirmed that Resident 79 did not receive insulin as indicated in Resident 79's MDS assessment dated October 28, 2024. The DON indicated Resident 79's MDS assessment dated October 28, 2024, was coded in error as it relates to insulin.

28 Pa. Code 211.5(f)(i) Medical records.

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

Plan of Correction - To be completed: 01/07/2025

1. Coding error was corrected on MDS for resident 79

2. MDS nurse did house audit of most recent MDS's sections N0300, N0350, and O-0110 JI

3. Director of clinical assessments will educate MDS nurses on MDS accuracy of sections N0300, N0350, and O-0110 JI.

4. MDS nurse/designee will audit sections N0300, N0350, and O-0110 JI weekly on 5 MDS's. (for 4 weeks and then monthly for 2 months?) The results of the audit will be presented by the NHA/designee monthly at the facilities QAPI meeting for review and recommendation.

483.20(f)(5), 483.70(h)(1)-(5) REQUIREMENT Resident Records - Identifiable Information:

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

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

Observations:

Based on review of clinical records and resident and staff interview, it was determined the facility failed to ensure the clinical record was accurately documented, according to professional standards of practice, reflecting the administration of medication for one resident out of 23 sampled (Resident 204).

Findings included:

The Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, 21.145 Functions of the Licensed Practical Nurse (LPN) (a) The LPN is prepared to function as a member of the health-care team by exercising sound judgement based on preparation, knowledge, skills, understandings, and past experiences in nursing situations. The LPN participates in the planning, implementation, and evaluation of nursing care in settings where nursing takes place. 21.148 Standards of nursing conduct (a) A licensed practical nurse shall: (5) Document and maintain accurate records.

According to the American Nurses Association Principles for Nursing Documentation, nurses document their work and outcomes and provide an integrated, real-time method of informing the health care team about the patient status. Timely documentation of the following types of information should be made and maintained in a patient's EHR (electronic health record) to support the ability of the health care team to ensure informed decisions and high-quality care in the continuity of patient care:

Assessments
Clinical problems
Communications with other health care professionals regarding the patient
Communication with and education of the patient, family, and the patient's designated support person and other third parties.

A review of Resident 204's clinical record revealed that the resident was admitted to the facility on November 6, 2024, with diagnoses that included end stage kidney disease, anxiety, shortness of breath, and need for palliative care.

A physician order dated November 6, 2024, was noted for Morphine Sulfate solution 20mg/mL give 0.5 mL by mouth every hour as needed for shortness of breath or pain for 14 days.

A review of Resident 204's Medication Administration Record (MAR) dated November 2024 failed to specify the circumstances under which the narcotic medication should be administered for either pain or shortness of breath.

An interview the Director of Nursing (DON) on November 15, 2024, at approximately 2:00 PM confirmed the facility failed to specify when narcotic medication may need to be administered to Resident 204. The DON further confirmed that there should have been two separate orders to identify if the resident required the ordered narcotic medication for shortness of breath or pain.

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

Plan of Correction - To be completed: 01/07/2025

1.The order for resident 204 was updated and corrected for two separate orders.

2.Facility house audit conducted for residents receiving same medication has 2 separate orders in place.

3.DON/designee will educate licensed nurses on pain management policy.

4.DON/designee will audit order listing report at clinical meeting weekly for 4 weeks and then monthly for 2 months to ensure same medications have 2 separate orders.

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

§483.60(i) Food safety requirements.
The facility must -

§483.60(i)(1) - Procure food from sources approved or considered satisfactory by federal, state or local authorities.
(i) This may include food items obtained directly from local producers, subject to applicable State and local laws or regulations.
(ii) This provision does not prohibit or prevent facilities from using produce grown in facility gardens, subject to compliance with applicable safe growing and food-handling practices.
(iii) This provision does not preclude residents from consuming foods not procured by the facility.

§483.60(i)(2) - Store, prepare, distribute and serve food in accordance with professional standards for food service safety.

Observations:

Based on observation and staff interview, it was determined that the facility failed to maintain acceptable practices for the storage and service of food to prevent the potential for contamination and microbial growth in food, which increased the risk of food-borne illness in the food and nutrition services department.

Findings include:

Food safety and inspection standards for safe food handling indicate that everything that encounters food must be kept clean and food that is mishandled can lead to foodborne illness. Safe steps in food handling, cooking, and storage are essential in preventing foodborne illness. You cannot always see, smell, or taste harmful bacteria that may cause illness according to the USDA (The United States Department of Agriculture, also known as the Agriculture Department, is the U.S. federal executive department responsible for developing and executing federal laws related to food).

Initial tour of the food and nutrition services department in the presence of the foodservice director on November 12, 2024, at 8:40 AM revealed the following food storage concerns with the potential to increase the potential for food-borne illness:

There were 14 four-ounce thawed nutritional beverage shakes on the shelf in the refrigerator which were not dated with a thaw or discard date. The manufacturer label indicated to use within 14 days of thawing.

There were two bags of frozen vegetables on the shelf in the freezer which were not dated.

Interview with the food service director at the time of the observations confirmed that acceptable practices for food storage were to be followed and all food items were to be properly dated to ensure safety and quality.

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

Plan of Correction - To be completed: 01/07/2025

1. 14 four-ounce thawed nutritional beverages shakes and 2 bags of frozen vegetables have been dated and stored.

2.Dietary manager/designee will confirm that all current food items are properly dated and stored.

3. NHA/designee will educate all dietary staff on acceptable practices for food storage including ensuring items are dated.

4.Dietician/designee will audit food storage 3x week for 4 weeks and then monthly for 2 months to ensure all food is properly dated and stored. The results of the audit will be presented by the NHA/designee monthly at the facilities QAPI meeting for review and recommendation.

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

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

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

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

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

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

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

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

Observations:

Based on a review of clinical records, select facility policies, and staff interview, it was determined the facility failed to ensure that the resident's drug regimen was free of unnecessary antibiotic medications for one out of 23 residents sampled (Resident 90).

Findings included:

A review of the facility policy titled Antibiotic Stewardship, last reviewed by the facility on September 26, 2024, revealed that antibiotics will be prescribed and administered to residents under the guidance of the facility's antibiotic stewardship program and in conjunction with the facility's general policy for medication utilization and prescribing. The policy indicates if a resident is admitted from an emergency department, acute care facility, or other care facility, the admitting nurse will review discharge and transfer paperwork for current antibiotic or anti-infective orders. The policy also indicates culture and sensitivity (urine culture is a method to grow and identify bacteria that may be in the urine. The sensitivity test helps select the best medicine to treat the infection) laboratory results will be communicated to the prescriber as soon as available to determine if antibiotic therapy should be started, continued, modified, or discontinued.

A clinical record review revealed a culture laboratory result report dated October 21, 2024, at 6:32 PM, indicating Resident 90's urine showed growth of Klebsiella oxytoca ESBL (extended-spectrum beta-lactamase) producing organisms of greater than 100,000 colonies/ml and Enterococcus species of greater than 100,000 colonies/ml. The susceptibility report indicated Klebsiella oxytoca ESBL is resistant to ceftriaxone (a class of medicines known as cephalosporin antibiotics). The report did not indicate if Enterococcus species identified in Resident 90's urine were susceptible or resistant to cephalosporin antibiotics.

A community provider progress notes dated October 22, 2024, at 10:51 AM indicated Resident 90 was started on Rocephin (Ceftriaxone) for a symptomatic urinary tract infection and can be discharged on an oral antibiotic.

A clinical record review revealed Resident 90 was admitted to the facility on October 22, 2024, with diagnoses that included a myocardial infarction (a condition where the blood flow to the heart is reduced or stopped).

An admission notes dated October 23, 2024, indicated Resident 90 was transferred and admitted to the facility on October 22, 2024. The note indicated a review of Resident 90's hospital course, which included a community provider section indicating Resident 90's urine analysis was concerning for a urinary tract infection, and a urine culture was sent, though pending at the time of discharge. Resident 90 was started on ceftriaxone (a cephalosporin class of antibiotics) while a patient and was discharged on Cephalexin/Keflex. She was able to urinate independently, and she was deemed medically ready for discharge on October 22, 2024.

The culture laboratory report dated October 21, 2024, did not indicate if the identified organisms were susceptible or resistant to Cephalexin/Keflex (another type of cephalosporin antibiotic).

A physician's order for Cephalexin capsule 500 mg with directions to give one capsule by mouth four times a day for infection for five days was initiated on October 23, 2024, at 6:00 AM and discontinued on October 23, 2024.

Another physician's order for Cephalexin capsule 500 mg with directions to give one capsule by mouth four times a day for infection for five days was initiated on October 23, 2024, at 12:00 PM and discontinued on October 28, 2024.

A medication administration record dated October 2024 revealed Resident 90 received twenty doses of Cephalexin capsule 500 mg between October 23, 2024, and October 28, 2024.

There was no documented evidence the resident had experienced any symptoms of a urinary tract infection, such as fever, chills, mental changes/confusion, fatigue, nausea/vomiting, pressure in the lower part of the pelvis, or increased urination, from her admission on October 22, 2024, through the course of her prescribed antibiotic course on October 28, 2024.

During an interview on November 15, 2024, at approximately 10:00 AM, Employee 3, Certified Registered Nurse Practitioner (CRNP), confirmed the culture laboratory report did not indicate if the identified organisms were susceptible or resistant to Cephalexin/Keflex (another type of cephalosporin antibiotics). Employee 3, CRNP, was not able to provide documented evidence indicating the necessity for Resident 90 to receive Cephalexin 500 mg.

During an interview on November 15, 2024, at approximately 10:30 AM, the Director of Nursing (DON) confirmed it is the facility's responsibility to ensure the resident's drug regimen was free of unnecessary antibiotic drugs. The DON confirmed that Resident 90's culture laboratory report dated October 21, 2024, did not indicate if the identified organisms were susceptible or resistant to the cephalexin antibiotic medication. The DON was not able to provide documented evidence indicating the necessity for Resident 90 to receive Cephalexin 500 mg.

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

28 Pa. Code 211.9 (k) Pharmacy services.

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

Plan of Correction - To be completed: 01/07/2025

1.Facility can't retroactively correct non-compliance.

2.Facility house audit will be conducted to review residents receiving antibiotics to ensure antibiotic stewardship is followed.

3.DON/designee will educate licensed nurses and practitioners on antibiotic stewardship policy.

4.Infection Control/designee will audit all new antibiotic orders including new admissions weekly for 4 weeks and then monthly for 2 months to ensure antibiotic stewardship is followed. The results of the audit will be presented by the NHA/designee monthly at the facilities QAPI meeting for review and recommendation.

483.25 REQUIREMENT Quality of Care:

§ 483.25 Quality of care
Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices.

Observations:

Based on clinical record review, review of select facility policy, and staff interview, it was determined the facility failed to provide quality care as evidenced by the facility failure to ensure physician orders were followed for the administration of medications for two of 23 sampled residents (Residents 64 and 6).

Findings include:

A review of the facility policy titled "Administering Medications" last reviewed by the facility September 26, 2024, indicated that medications are administered within one hour of their prescribed time. The individual (licensed nurse) administering the medication initials the resident's Medication Administration Record (MAR) on the appropriate line after giving each medication and before administering the next medication.

A review of the clinical record reveal that Resident 64 was admitted to the facility on January 30, 2021, with diagnoses to include diabetes mellitus (a metabolic disorder in which the body has high sugar levels for a prolonged period), and COPD (chronic obstructive pulmonary disease- an ongoing lung condition caused by damage to the lungs).

A current physician's order initially dated September 9, 2023, indicated Accu-checks (a test to check blood glucose levels) BID (twice daily) every morning and at bedtime for diabetes mellitus.

A review of Resident 64's November 2024 Medication Administration Record (MAR) revealed that on November 7, 2024, the morning Accu-check for 6:00 A.M. for Resident 64 was not completed.

A current physician's order initially dated July 27, 2023, indicated that Lantus Solostar Solution Pen injector 100 Units/ML (insulin) Inject 30 units subcutaneously (injection given in the fatty tissue, just under the skin) one time a day for elevated blood glucose related to diabetes mellitus.

A review of Resident 64's November 2024 Medical Administration Record (MAR) revealed that on November 7, 2024, Resident 64 did not receive the prescribed dose of insulin ordered at 06:00 A.M.

A current physician's order initially dated December 5, 2022, indicated Spiriva Respimat Aerosol Solution 2.5 MCG/ACT (inhaler), 2 puffs, inhale orally in the A.M. for COPD.

A review of Resident 64's November 2024 Medication Administration Record (MAR) revealed that on November 7, 2024, Resident 64 did not receive the prescribed dose of the inhaler ordered at 06:00 A.M.

A current physician's order initially dated June 11, 2024, indicated Systane Ultra PF Ophthalmic Solution 0.4-0.3% (an eye drop solution) instill 1 drop in both eyes four times a day for dry eyes.

A review of Resident 64's November 2024 Medication Administration Record (MAR) revealed that on November 7, 2024, Resident 64 did not receive the prescribed eye drops ordered at 06:00 A.M.

A current physicians order initially dated July,13, 2023, indicated Pregabalin Capsule (nerve pain medication) 50 mg, give one capsule by mouth two times per day for neuropathy (a term for nerve damage that can occur anywhere in the body).

A review of Resident 64's November 2024 Medication Administration Record (MAR) revealed that resident 64 did not receive the prescribed medication ordered at 06:00 A.M.

A review of the clinical record revealed that Resident 6 had diagnoses which include diabetes mellitus and cerebral infarction (stroke).

A current physician order initially dated October 7, 2023, indicated Basaglar KwikPen 100 Units/ML solution (insulin) inject 20 units subcutaneously once daily for a diagnosis of diabetes mellitus.

Review of Resident 6's November 2024 Medication Administration Record (MAR) revealed that on November 12, 2024, the resident did not receive the prescribed dose of insulin which was ordered to be administered at 6:30 AM.

An interview with the Director of Nursing (DON) on November 14, 2024, at 1:00 P.M. confirmed the facility failed to follow physician orders and administer physician ordered medications as prescribed for Resident 64 and Resident 6. Specifically, the facility did not administer prescribed medications, including blood glucose monitoring, insulin, inhalers, and other scheduled medications, at the designated times. These failures resulted in residents not receiving necessary treatments as ordered.

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

Plan of Correction - To be completed: 01/07/2025

1. Nurses received medication error reports and were disciplined per facility policy.

2.Facility house audit conducted to review medication administration record to ensure administration and documentation completed.

3.DON/designee will educate licensed nurses on Medication Administration policy.

4.DON/designee will audit medication administration record at clinical meeting weekly for 4 weeks and then monthly for 2 months to ensure administration and documentation of medications are complete. The results of the audit will be presented by the NHA/designee monthly at the facilities QAPI meeting for review and recommendation.

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

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

Observations:

Based on observation, clinical record review, select facility policy, facility investigation reports, and staff interviews, it was determined the facility failed to implement a person-centered fall prevention plan of care for one resident out of 23 sampled (Resident 96).

Findings include:

A review of facility policy entitled Managing Falls and Fall Risk, last reviewed by the facility on September 26, 2024, revealed it is the facility's policy to identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to minimize complications from falling. The policy indicates facility staff will identify pertinent interventions to try to prevent subsequent falls and to address the risks of clinically significant consequences of falling.

A clinical record review revealed Resident 96 was admitted to the facility on October 11, 2024, with diagnoses that include heart failure (a condition that occurs when the heart is unable to pump enough blood and oxygen to the body's organs) and pneumonia (a lung infection that causes the air sacs in the lungs to fill with fluid or pus, making it difficult to breathe).

A care plan focus indicating Resident 96 is at risk for falls due to altered mobility and antidepressant medication use was initiated on October 11, 2024. Interventions implemented to minimize his risk of falls included encouraging transfer and slowly changing positions, assistance with transfers and ambulation as needed, and reinforcing the need to call for assistance.

A fall risk form dated October 15, 2024, revealed Resident 96 is at moderate risk for falling with a history of prior falls and overestimating or forgetting his limitations.

A review of facility incidents revealed Resident 96 experienced a fall event on the following dates:

October 15, 2024
October 20, 2024
October 27, 2024
November 6, 2024
November 8, 2024

A review of Resident 96's fall incident report dated November 8, 2024, revealed Resident 96 fell while being assisted in the bathroom when a nurse aide left him to gather hygiene supplies.

A review of a witness statement dated November 8, 2024, revealed Employee 2, Nurse Aide (NA), indicated he took Resident 96 to the bathroom. Employee 2, NA, indicated he left the bathroom while Resident 96 was holding the grab assist bars to get the resident a clean brief. Employee 2, NA, indicated that he heard a thump.

The fall incident report dated November 8, 2024, revealed Resident 96 explained he was holding the grab assist bars when he lost his balance and fell to the ground.

A skin observation tool dated November 9, 2024, revealed Resident 96 was observed with a skin tear on his right elbow measuring 5.5 cm x 1.5 cm x 0.1 cm and reopened a surgical incision on his face measuring 2.0 cm x 0.1 cm x 0.1 cm.

A review of Resident 96's care plan revealed a new intervention was implemented on November 9, 2024, to minimize his risk for falling. The new intervention indicated staff will always stay with the resident while in the bathroom, initiated on November 9, 2024.

During an observation on November 12, 2024, at 11:20 AM Employee 1, NA, assisted Resident 96 to the bathroom. Employee 1, NA, left Resident 96 in the bathroom unattended while she gathered supplies for hygiene. Employee 1, NA, returned to the bathroom and assisted the resident without incident.

During an interview on November 14, 2024, at approximately 12:00 PM, Employee 1, NA, confirmed Resident 96 had a fall prevention intervention in place to always remain with the resident while in the bathroom.

During an interview on November 15, 2024, at approximately 10:30 AM, the Director of Nursing (DON) confirmed it is the facility's responsibility to ensure staff implement interventions developed on each resident's comprehensive person-centered care plan. The DON confirmed Resident 96's care plan included an intervention for staff to always remain with the resident while in the bathroom.

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

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

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

Plan of Correction - To be completed: 01/07/2025

1. Individual education done with CNA regarding resident 96 care plan and following interventions.

2. House staff audit will be done to ensure staff are familiar with the care plan and where to locate interventions.

3. DON/designee will educate all licensed staff on care plans and following interventions.

4. RN Management will audit 2 staff per shift to ensure weekly for 4 weeks and then monthly for 2 months to ensure staff are following the care plan as ordered. The results of the audit will be presented by the NHA/designee monthly at the facilities QAPI meeting for review and recommendation.

483.10(h)(1)-(3)(i)(ii) REQUIREMENT Personal Privacy/Confidentiality of Records:

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

§483.10(h) Privacy and Confidentiality.
The resident has a right to personal privacy and confidentiality of his or her personal and medical records.

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

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

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

Observations:

Based on review of clinical records, facility written procedures, and resident and staff interview, it was determined the facility failed to ensure that mail was delivered unopened to two of 23 residents interviewed (Residents 64 and 20).

Findings include:

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

Review of a facility written procedure regarding residents' rights indicated that residents have the right to personal privacy which includes that mail must be delivered to residents within 24 hours and be unopened. Mail can be opened and read if a person requests it.

A review of the clinical record reveal that Resident 64 was admitted to the facility on January 30, 2021, with diagnoses to include diabetes mellitus (a metabolic disorder in which the body has high sugar levels for a prolonged period), and essential hypertension (abnormally high blood pressure that is not a result of a medical condition).

A review of a quarterly Minimum Data Set Assessment (MDS - a federally mandated standardized assessment completed at specific times to identify resident care needs) dated October 10, 2024, revealed the resident was cognitively intact with a BIMS score of 15 (brief interview for mental status, a tool to assess the resident's attention, orientation, and ability to register and recall new information, a score of 13 to 15 equates to cognitively intact).

During an interview on November 13, 2024, at 8:43 A.M. Resident 64 stated he does not receive his incoming mail unopened. Resident 64 also stated he does not always receive his mail opened, but it has happened on more than one occasion. During this interview it was also revealed there have been instances where the mail he receives is not in the sender's envelope.

A review of the clinical record revealed Resident 20 was admitted to the facility on October 15, 2020, with diagnoses to include diabetes mellitus and depression.

A review of a quarterly Minimum Data Set Assessment dated October 31, 2024, revealed the resident was cognitively intact with a BIMS score of 15.

During an interview on November 13, 2024, at 11:30 A.M. Resident 20 stated that at times staff open her mail before it is delivered to her. Resident 20 stated the mail seems to be opened without her permission when the mail is from a "medical place" such as a letter for an appointment or provided service.

During an interview on November 15, 2024, at approximately 9:00 A.M., the Nursing Home Administrator (NHA) confirmed that residents have the right to personal privacy and to receive their mail unopened. The NHA failed to provide documented evidence that Resident 20 and Resident 64 received their mail unopened as required to ensure resident privacy.

28 Pa. Code 201.29(a) Resident rights.

Plan of Correction - To be completed: 01/07/2025

1. NHA communicated to Resident 64 and 20 that going forward all mail addressed to them will be delivered unopened.

2. NHA will interview residents in the resident council meeting regarding mail delivery.

3. NHA will educate receptionists, activities, and BOM on not opening resident mail that is addressed to them.

4. NHA will interview 3 residents weekly for 4 weeks and then monthly for 2 months to ensure their mail is being delivered unopened. The results of the audit will be presented by the NHA/designee monthly at the facilities QAPI meeting for review and recommendation.

§ 211.12(f.1)(3) LICENSURE Nursing services. :

(3) Effective July 1, 2024, a minimum of 1 nurse aide per 10 residents during the day, 1 nurse aide per 11 residents during the evening, and 1 nurse aide per 15 residents overnight.

Plan of Correction - To be completed: 01/07/2025

1. The facility will provide staffing at a minimum of 1 nurse aid per 10 residents during the day, 1 nurse aid per 11 residents during the evening, and 1 nurse aid per 15 residents overnight to meet the needs of the residents. The facility Administrator, Director of Nursing, and Nursing Scheduler will review the nursing schedule and deployment sheets daily Monday-Friday, to include projected weekend ratios, to validate appropriate direct resident care ratios. Adjustments will be made as necessary.

2. Schedule is completed daily and staffed with a minimum of 1 nurse aid per 10 residents during the day, 1 nurse aid per 11 residents during the evening, and 1 nurse aid per 15 residents overnight. When absences occur, every effort is made to replace staff.

3. The Administrator, the Nursing Management team, and the nursing scheduler will be re-educated concerning minimum CNA ratios and the appropriate response to unplanned variations in ratios. Ratios will be audited by the Nursing Home Administrator/designee during the daily review of nursing schedules and deployment sheets to ensure that correct CNA ratios are maintained.

4. The Administrator/designee will present the results of these audits at the Quality Assurance and Performance Committee monthly for further review and recommendations.

§ 211.12(f.1)(4) LICENSURE Nursing services. :

(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.

Plan of Correction - To be completed: 01/07/2025

1.The facility will provide staffing at 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 to meet the needs of the residents. The facility Administrator, Director of Nursing, and Nursing Scheduler will review the nursing schedule and deployment sheets daily Monday-Friday, to include projected weekend ratios, to validate appropriate direct resident care ratios. Adjustments will be made as necessary.

2.Schedule is completed daily and staffed with 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. When absences occur, every effort is made to replace staff.

3.The Administrator, the Nursing Management team, and the nursing scheduler will be re-educated concerning minimum LPN ratios and the appropriate response to unplanned variations in hours. Ratios will be audited by the Nursing Home Administrator/designee during the daily review of nursing schedules and deployment sheets to ensure that correct LPN ratios are maintained.

4.The Administrator/designee will present the results of these audits at the Quality Assurance and Performance Committee monthly for further review and recommendations.

§ 211.12(i)(2) LICENSURE Nursing services.:

(2) Effective July 1, 2024, the total number of hours of general nursing care provided in each 24-hour period shall, when totaled for the entire facility, be a minimum of 3.2 hours of direct resident care for each resident.

Plan of Correction - To be completed: 01/07/2025

1. The facility will provide staffing at a minimum of 3.2 hour per patient day to meet the needs of the residents. The facility Administrator, Director of Nursing, and Nursing Scheduler will review the nursing schedule and deployment sheets daily Monday through Friday, to include projected weekend hours, to validate appropriate direct resident care hours. Adjustments will be made as necessary.

2.Schedule is completed daily and staffed with a minimum of 3.2 PPD. When absences occur, every effort is made to replace staff.

3.The Administrator, the Nursing Management team, and the nursing scheduler will be re-educated concerning minimum nursing staffing hours and the appropriate response to unplanned variations in hours. Direct care hours will be audited by the Nursing Home Administrator/designee during the daily review of nursing schedules and deployment sheets to ensure that 3.2 hours of direct resident care is maintained.

4.The Administrator/designee will present the results of these audits at the Quality Assurance and Performance Committee monthly for further review and recommendations.

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