Pennsylvania Department of Health
AVENTURA AT CREEKSIDE
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

AVENTURA AT CREEKSIDE
Inspection Results For:

There are 117 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.


AVENTURA AT CREEKSIDE - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:
Based on an abbreviated complaint survey completed on May 16, 2024, it was determined that Aventura at Creekside 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:

483.60(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 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 dietary department and the resident unit food storage area.

Findings include:

Food safety and inspection standards for safe food handling indicate that everything that comes in contact with 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).

During a tour of the unit resident pantry area in the presence of the food service manager on May 16, 2024, at 11:30 a.m., observation of the resident refrigerator revealed that the bottom of the unit was damaged and the vent was covered with dirt, debris, and rust.

Food was splattered inside and debris/dust was observed behind the microwave.

Observation revealed food splatter on the garbage can. There was no lid on the can and the trash was overflowing. The wall behind the garbage can was splattered with food. The pantry floor was stained with a reddish-brown substance.

Observations of the dietary department during lunch tray line service on May 16, 2024, at 11:55 a.m., revealed the following unsanitary practices with the potential to introduce contaminants into food and increase the potential for food-borne illness, was identified:

Four, 4-ounce shakes were observed inside a stainless steel pan that were not labeled with a thaw or discard date as indicated by the manufacturer's instructions (manufacturer notes a 14-day shelf life after thawing). The dietary manager reported that the shakes should be dated when staff pull them from the freezer and confirmed that the actual pull date/thaw date was unknown.

The cook was observed serving bacon, lettuce, and tomato (BLT) sandwiches that were the planned lunch and used his gloved hands to pick up the toast, then the lettuce, tomato, and bacon but then touched other kitchen surfaces without performing hand hygiene and changing his gloves. The cook/server did not change his gloves or perform hand hygiene during the lunch tray assembly and continued to use his gloved hands to pick up food for the residents' trays.

Further observations of the tray line area revealed that the surfaces of the resident meal trays showed significant evidence of wear, such as deep scratches and non-slip surfaces worn away, which inhibit proper cleaning and sanitizing due to the surface breaks and deterioration.

An interview with the food service manager on May 16, 2024, at 12:11 p.m., confirmed sanitary conditions should be maintained in the kitchen and pantries to prevent foodborne illness.

28 Pa. Code 201.18 (e)(2.1) Management

28 Pa. Code 211.6 (f) Dietary Services

Plan of Correction - To be completed: 06/11/2024

1) In the resident pantry, the refrigerator was replaced with a new unit. The microwave was cleaned inside and out. The garbage can was cleaned and a lid was placed on the unit and the floor was cleaned in the pantry room. The 4 thawed, undated, 4 ounce shakes were discarded.
2) Resident meal trays were ordered to replace the ones identified with signs of significant wear.
3) Dietary staff were reeducated on proper dating of thawed food items, according to manufacturers instructions. Cooks were reeducated on proper hand hygiene prior to handling food items. Dietary and housekeeping staff were reinstructed on proper cleaning/disinfection techniques utilized within the facility.
4) The Administrator will audit/monitor that any thawed food items are dated appropriately. The Administrator will also monitor that items identified in the pantry are cleaned as necessary. The Dietary Manager/Designee will monitor the tray line to assure that proper hand hygiene is performed (as necessary) before handling food items. This Administrators monitoring will be weekly for 4 weeks. The Dietary Managers monitoring will be 4 x week for 4 weeks.
Results will be reviewed by the QA Committee for 2 months, then reevaluated

483.10(a)(1)(2)(b)(1)(2) REQUIREMENT Resident Rights/Exercise of Rights:

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(a) Resident Rights.
The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility, including those specified in this section.

§483.10(a)(1) A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the resident.

§483.10(a)(2) The facility must provide equal access to quality care regardless of diagnosis, severity of condition, or payment source. A facility must establish and maintain identical policies and practices regarding transfer, discharge, and the provision of services under the State plan for all residents regardless of payment source.

§483.10(b) Exercise of Rights.
The resident has the right to exercise his or her rights as a resident of the facility and as a citizen or resident of the United States.

§483.10(b)(1) The facility must ensure that the resident can exercise his or her rights without interference, coercion, discrimination, or reprisal from the facility.

§483.10(b)(2) The resident has the right to be free of interference, coercion, discrimination, and reprisal from the facility in exercising his or her rights and to be supported by the facility in the exercise of his or her rights as required under this subpart.

Observations:

Based on a review of grievances filed with the facility and the minutes from Residents' Council meetings and resident and staff interviews, it was determined that the facility failed to provide care in a manner and environment that promotes each resident's quality of life by failing to respond timely to residents' requests for assistance, including experiences reported by three out of the 10 residents sampled (Residents 11, 17, and 50).

Findings include:

A review of resident council meeting minutes dated February 22, 2024, revealed that residents voiced concerns of waiting 35 - 40 minutes for staff to answer their call bells. The meeting minutes indicated that residents in attendance also indicated that there are not enough nurse aides on the floor to provide timely care to residents.

A grievance form filed on behalf of a resident dated March 22, 2024, revealed that the resident had been waiting for nursing staff to assist him to the restroom, but staff did not respond timely. After waiting for a response, the resident's family member went to find staff assistance and observed nursing staff on their cell phones. The grievance indicated that nursing staff were educated about answering call bells in a timely manner.

A review of resident council meeting minutes dated April 23, 2024, revealed that residents in attendance indicated that nurse aides at night are not answering residents' calls for assistance.

A grievance filed following the Resident Council meeting dated April 23, 2024 indicated that nursing staff are not answering the call bells in a timely manner, there are not enough nurses to do a medication administration pass in the evening, and showers are not being offered in the evenings due to staffing issues. The grievance indicated that staff were educated regarding answering call bells in a timely manner, medication passes, and showering residents. There was no documented evidence at the time of the survey ending May 16, 2024, that the facility had reviewed the adequacy of nurse staffing or nurse staff assignments to ensure that sufficient nursing staff was available to provide timely care based on the needs of the residents.

A grievance dated May 15, 2024, revealed that Resident 17 complained that she rang her call bell at 11:30 AM but staff told her that they could not provide her care until lunch was done being served in the dining room.

During an interview on May 16, 2024, at 11:25 AM, Resident 17 stated that she waits on average 20 minutes for staff to respond to her call bell rings for assistance. She explained that two days ago she waited two hours for staff assistance and filed a grievance with the facility. Resident 17 stated that she was very upset because she had feces in her brief and needed staff to help with care. Resident 17 explained that long wait times for staff to provide care are an ongoing problem at the facility. She expressed anger and frustration about the wait times for care. Resident 17 stated that there are very few staff on duty and when they take a break, there is no one left to assist the residents with care on the unit.

During an interview on May 16, 2024, at 1:15 PM, Resident 50 indicated that she waits about 20 minutes for staff to respond to her call bell rings when she needs care or assistance. She explained that the wait times seem to be the worst during the night shift. Resident 50 indicated that the long wait times have been an issue for herself and other residents for the last two to three months.

During an interview on May 16, 2024, at 1:45 PM, Resident 11 indicated that it takes staff about 15 minutes to respond to his call bell rings for care or assistance. He explained that when the facility is short on staff, he waits about 30 minutes for assistance. Resident 11 indicated that in the morning, during breakfast, the wait times are the longest.

During an interview on May 16, 2024, at approximately 5:30 PM, the Nursing Home Administrator (NHA) verified that all residents at the facility should be treated with dignity and respect. The NHA was unable to explain why residents are reporting untimely staff responses to residents' requests for assistance, which is negatively affecting their quality of life in the facility.

28 Pa. Code 201.18 (e)(1)(4) Management

28 Pa. Code 201.29 (a) Resident Rights

Plan of Correction - To be completed: 06/11/2024

1) On 05/17/24, Residents 11, 17 and 50 had skin assessments performed on them to assess for any ill effect for their complaints of delayed care. No concerns were identified.
2) Resident Council minutes and Grievance concerns for the past 3 months, were reviewed to identify additional residents with similar concerns. No other resident was identified.
A system change was placed into effect where the Director of Nursing and Assistant Director of Nursing will receive a copy of the Resident Council minutes after the meeting each month, to timely identify any concerns and then act on them.
3) The Director of Nursing performed staff education to nursing personnel, on Resident Rights and the timely performance of resident care, when residents ring for assistance. The nursing scheduler was given a copy of the Department of Heath's Staffing Calculation tool and educated on how to properly utilize it. By the scheduler utilizing this tool, they can readily identify and correct any staffing need, before they occur. Resident Council minutes and concerns will continue to be reviewed at the monthly QA meeting to help assure sustained results.
4) The Administrator will review all grievances and Resident Council minutes for similar concerns. This monitoring will be 4 x week for 4 weeks.

483.10(e)(2) REQUIREMENT Respect, Dignity/Right to have Prsnl Property:

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

§483.10(e)(2) The right to retain and use personal possessions, including furnishings, and clothing, as space permits, unless to do so would infringe upon the rights or health and safety of other residents.

Observations:

Based on observations, review of clinical records and staff interviews, it was determined that the facility failed to conduct meal service in a manner respectful of each resident's personal dignity for two residents observed during meals (Residents 61 and 68), failed to maintain a respectful environment as evidenced by observation of staff conduct and behaviors and as reported by two residents (Resident 50 and 17) and failed to ensure that resident maintained a dignified personal appearance for two of the 10 residents sampled (Residents 29 and 66).

Findings include:

A clinical record review revealed that Resident 29 was admitted to the facility on April 12, 2024. A review of an initial Minimum Data Set assessment (MDS - a federally mandated standardized assessment process conducted periodically to plan resident care) dated April 18, 2024 revealed that Resident 29 is moderately cognitively impaired with a BIMS score of 12 (Brief Interview for Mental Status- a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 8-12 indicates cognition is moderately impaired).

Clinical record review revealed that Resident 61 was admitted to the facility on November 18, 2013. A quarterly MDS assessment dated February 20, 2024, revealed that the resident was dependent on staff assistance to eat.

Resident 66 was admitted to the facility on April 2, 2024. An initial MDS assessment dated April 5, 2024, revealed that the resident is moderately cognitively impaired with a BIMS score of 10.

A clinical record review revealed that Resident 68 was admitted to the facility on July 15, 2016. A quarterly MDS assessment dated May 3, 2024, revealed that the resident was dependent on staff assistance to eat.

An observation in the facility dining room on May 16, 2024, at 12:05 PM revealed Resident 29 wearing a brown t-shirt. Small white dandruff-like flakes were observed on the front and shoulders of the shirt and there was a hole in the left arm of the shirt. Resident 29 was also wearing a bright yellow bracelet that indicated the resident was a "fall risk" in black letters.

An observation in the facility dining room on May 16, 2024, at 12:07 PM revealed Resident 66 was wearing a bright yellow bracelet that indicated the resident was a "fall risk" in black letters.

An observation in the facility dining room on May 16, 2024, at 12:12 PM revealed Resident 68, seated in a wheelchair, while Resident 61 was fed by a staff member. Resident 68's meal tray was on the table in front of her, but she was not able to feed herself and watched while Resident 61 was being fed. After 12 minutes, Resident 68 staff fed Resident 61 and provided an opportunity to eat her meal.

An observation in the facility dining room on May 16, 2024, at 5:01 PM revealed Resident 29 in the same brown shirt. White dandruff-like flakes remained visible on his shoulders and chest.

An observation in the facility dining room on May 16, 2024, at 5:24 PM revealed that meal trays were placed on a table in front of Residents 61 and 68. At the same table, a third tray was placed in front of another resident, who began eating. Residents 61 and 86 were observed waiting with their food trays in front of them. Approximately 10 minutes passed before they were assisted by staff to eat their meal.

During an interview on May 16, 2024, at 1:15 PM, Resident 50 stated that she regularly hears staff swearing. She explained that she doesn't know who they are talking to, but it makes her upset when she hears it outside of her bedroom. Resident 50 state that she hears staff say "f*ck you" and "go f*ck yourself."

An observation on May 16, 2024, at 4:52 PM in the resident dining room revealed residents seated and waiting for their evening meal. Staff were observed talking to each other near the entrance to the facility kitchen. This surveyor overheard a staff member saying, "I'll f*cking leave right now," loud enough to be heard across the dining room by the residents and others present in the dining room.

During an interview on May 16, 2024, at 11:25 AM, Resident 17 stated that the nurse aides will curse when they are talking to people, and it bothers her to hear that language. Resident 17 stated that she hears them say "f*ck" and "shit," and she does not like to hear those curse words.

During an interview on May 16, 2024, at approximately 6:00 PM, the Director of Nursing (DON) and Nursing Home Administrator (NHA) indicated that Residents 29 and 66 were wearing yellow fall risk bracelets since admission from the hospital, which the facility staff should have removed. The NHA and DON confirmed that residents should not have to watch other residents consume their meals while they wait for assistance and staff should not be using foul language in the presence of residents.

28 Pa. Code 201.29(a) Resident rights

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

Plan of Correction - To be completed: 06/11/2024

1) Residents 61 and 68 had no ill effect from the delay in eating with assist. Residents 29 and 66 had the hospital Fall Risk bracelets removed from their wrist.
2) A system change was placed into effect, assuring that all residents requiring assistance will feeding will not have to wait to eat, once their tray is brought out. The Dietician and Dietary Manager revised the order that meals are prepared and served. Trays for those residents requiring assistance are now prepared after independent residents, increasing the likelihood of staff being free to immediately help those residents requiring assistance.
All residents were visualized to assure that any hospital identification bracelet was removed and replaced with the facility's identification band.
3) The Director of Nursing and Assistant Director of Nursing educated/reeducated nursing staff on: a) the feeding assistance changes, setting up independent eaters first and then assisting/feeding those that require staff assistance, b) removing any other facilities resident identification bracelets on admission to this facility, c) the use of inappropriate language (cursing) within the facility, d) dressing residents appropriately in clothes that are not excessively worn (torn) or soiled. Dietary staff were also educated on the revisions to the resident meal serving order.
4) The Director of Nursing/Designee will monitor to assure that residents are: a) not waiting for assistance to eat, once the tray is brought out; b) that other facility identification bracelets are not being utilized on the resident; c) that staff interactions with each other and the residents are not inappropriate with profanity being used; d) that residents are dressed appropriately in clothes that are not torn/worn. This monitoring will be 4 x week for 4 weeks.
Results will be reviewed by the QA Committee for 2 months, then reevaluated.

483.10(i)(1)-(7) REQUIREMENT Safe/Clean/Comfortable/Homelike Environment:

§483.10(i) Safe Environment.
The resident has a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

The facility must provide-
§483.10(i)(1) A safe, clean, comfortable, and homelike environment, allowing the resident to use his or her personal belongings to the extent possible.
(i) This includes ensuring that the resident can receive care and services safely and that the physical layout of the facility maximizes resident independence and does not pose a safety risk.
(ii) The facility shall exercise reasonable care for the protection of the resident's property from loss or theft.

§483.10(i)(2) Housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior;

§483.10(i)(3) Clean bed and bath linens that are in good condition;

§483.10(i)(4) Private closet space in each resident room, as specified in §483.90 (e)(2)(iv);

§483.10(i)(5) Adequate and comfortable lighting levels in all areas;

§483.10(i)(6) Comfortable and safe temperature levels. Facilities initially certified after October 1, 1990 must maintain a temperature range of 71 to 81°F; and

§483.10(i)(7) For the maintenance of comfortable sound levels.

Observations:

Based on observation and resident and staff interviews it was determined that the facility failed to provide housekeeping services to maintain a clean and orderly environment in three of the three nursing halls.

Findings include:

During a facility tour on May 16, 2024, an observation of the resident activity room at 11:11 AM revealed crumbs, food, and paper debris on the floor.

An observation in the hallway outside the activity room at 11:12 AM revealed two three-inch clumps of hair on the floor. During another observation at 5:06 PM, the clumps of hair were still in the hallway outside the activity room.

An observation of the nursing station at 11:14 AM revealed a brown substance splattered on the handrail and on the wall above the handrail. A buildup of dirt and debris was observed on the surface of the handrail extending along the nursing station. Multiple dried tan liquid stains were observed on the wall across from the nursing station.

An observation of resident room #127 at 11:18 AM revealed used tissues and food debris on the floor, under the window side bed, and near the exit.

An observation of the resident day room at 11:20 AM revealed three dead black winged insects on the floor. Dirt and debris was observed on the floor next to the exit to the day room, and along the threshold to the room. A gap was visible in the corner of the door, allowing light to be seen through the bottom of the back door.

An observation of resident room #138 at 11:22 AM revealed pink droplet stains on the floor and dirt and debris on the floor along the wall to the right of the entrance. Tiles in the resident's bathroom were stained with multiple brown, black, and tan discolorations.

During an interview on May 16, 2024, at 11:25 AM, Resident 17 stated that the facility staff only lightly clean, but not thoroughly. She explained that there is still dirt on her room floor after staff cleaned the area. Resident 17 stated that she hates looking at her bathroom floor because it is very stained and discolored.

An observation of resident room #132 at 11:40 AM revealed a three-foot-by-one inch gash in the wall, exposing white drywall.

An observation of resident room #111 at 11:45 AM revealed brown and tan stains or discoloration on the molding strip measuring 3 feet along the bottom of the floor. A small red stain was visible on the floor, with drops of the red substance around the stain.

During an interview on May 16, 2024, at approximately 5:30 PM, the Nursing Home Administrator (NHA) confirmed that the facility is to be maintained in a clean and orderly manner.

28 Pa. Code 201.18 (e)(2.1) Management

28 Pa. Code 201.29 (a) Resident Rights

Plan of Correction - To be completed: 06/11/2024

1) All areas identified were cleaned or repaired as needed
2) A walk thru was performed on the remaining areas to identify any similar concerns. Any area identified was cleaned/repaired as appropriate. A new system will also be placed into effect with the Department Heads. Each Department Head will be assigned areas to monitor on a weekly basis. The days and times of these Ambassador Rounds will be random, assuring the chances for compliance. Any issues identified during these rounds, will be discussed during stand-up or stand-down meetings.
3) On 06/ /24 Housekeeping and Maintenance staff were educated by the Maintenance Director on proper cleaning methods.
4) The Administrator will perform walk throughs to identify any similar concerns. This monitoring will be 4 x week for 4 weeks.
Results will be reviewed by the QA Committee for 2 months, then reevaluated

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 a review of clinical records and select incident reports, and staff interviews, it was determined that the facility failed to provide nursing services consistent with professional standards of practice by failing to demonstrate that a registered nurse promptly assessed a resident displaying possible signs and symptoms of a potential change in condition for one resident (Resident 38) out of 15 sampled residents sampled.

Findings include:

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.

An incident report completed by Employee 2, a Registered Nurse (RN), dated May 10, 2024, at 2:17 p.m., revealed that Resident 38 had an unwitnessed fall and was found face down on the floor. The resident was assessed and had sustained a small bump to his right forehead. Resident was placed back into bed and neuro-checks initiated. Ambulance called due to medical condition. Resident was confused and appeared jaundice [is a condition where your skin, the whites of your eyes and mucous membranes (like the inside of your nose and mouth) turn yellow. Many medical conditions can cause jaundice, like hepatitis, gallstones, and tumors].

A nurses' progress note completed by Employee 2, dated May 10, 2024, at 2:19 p.m., revealed that the resident was found face down on the floor in his room on the right side of his bed. Bed was in the lowest position; wheelchair was on the left side of the bed near the window. Resident was wearing a nonskid sock. Continent of bowel and bladder and call bell was within reach. A small bump noted on his right forehead, cold compress applied. Neuro-checks started, and the resident was confused, not following commands, pupils pinpoint, sluggish, BUE (bilateral upper extremity) weakness noted. Nurse aide stated that before this happened that resident wasn't acting right and went back to his bed after lunch. Resident self-transfers and was moaning, and color was brownish yellow. Temperature at 98 degrees Fahrenheit, pulse 70, respirations 26, blood pressure 148/100, pulse OX 95 % room air. Physician was notified with new orders were obtained to transfer to the emergency department for evaluation due to changes in condition.

A review of a witness statement completed by Employee 3, a Nurse Aide (NA), dated May 10, 2024, no time noted, indicated that at around 1:30 p.m., Resident 38's color "wasn't right" and that the resident "wasn't acting like himself" and seemed more confused than normal and reported it to the RN Supervisor.

A review of a witness statement completed by Employee 4, a Nurse Aide (NA), dated May 10, 2024, at 3:30 p.m., indicated that he walked into the room to tend to Resident 38's roommate and heard a "groan" and then a "thud" coming from Resident 38's side of the room. I yelled over to ask the resident if he was okay, and he did not answer but groaned. Employee 4 indicated that he looked behind the curtain and saw the resident on the floor and quickly yelled to the LPN (licensed practical nurse). The RN Supervisor, LPN, and NA arrived and put the resident back into bed to be assessed. Employee 4 recalled that Resident 38 was very "yellow-skinned" more than usual and wasn't acting himself.

There was no documented evidence that prior to the resident's fall on May 10, 2024, and in response to Employee 3's report to the RN Supervisor that Resident 38 appeared to show signs and symptoms of a change in condition, that the RN supervisor had promptly assessed the resident's status and condition.

An interview with the Director of Nursing (DON) on May 16, 2024, at 5:20 p.m., confirmed that there was no evidence of a prompt assessment of Resident 38 by professional nursing staff of signs and symptoms of a change in resident condition.

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

28 Pa. Code 211.5 (f) Medical records

Plan of Correction - To be completed: 06/11/2024

1) The facility is unable to retroactively correct cited issue.
2) No additional resident could be identified to be at risk for similar incident.
3) Registered Nurses and Licensed Practical Nurses were educated / reeducated on the importance of timely nursing assessment upon learning of a potential resident change in condition.
4) The Director of Nursing/Designee will review resident nursing notes in the daily clinical meeting, to assure that a nursing assessment was performed on any resident change in condition. This monitoring will be 4 x week for 4 weeks.
Results will be reviewed by the QA Committee for 2 months, then reevaluated.

483.25(g)(1)-(3) REQUIREMENT Nutrition/Hydration Status Maintenance:

§483.25(g) Assisted nutrition and hydration.
(Includes naso-gastric and gastrostomy tubes, both percutaneous endoscopic gastrostomy and percutaneous endoscopic jejunostomy, and enteral fluids). Based on a resident's comprehensive assessment, the facility must ensure that a resident-

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

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

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

Observations:

Based on a review of clinical records and select facility policy and staff interviews it was determined that the facility failed to consistently and accurately monitor resident weights to timely identify changes in nutritional parameters for two residents out of 15 sampled (Residents 51 and 47).

Findings included:

Review of facility policy entitled "Weight Policy and Procedure Facility Guidelines", provided by the facility on May 16, 2024, indicated that monthly weights would be documented in the resident's electronic medical record and that nursing needs to ensure completion of weekly weights. Discontinuation of weekly weights should occur once stabilization has been determined by the Dietitian and Interdisciplinary Team. A progress note by the Dietitian needs to reflect the stabilization and return to monthly weights. Weekly weights should not go on for months at a time unless truly clinically indicated. Weight accuracy issues require problem solving. Dietitians need to drive the re-weight process and re-weights are to be completed by the following day and documented in the electronic medical record the same day. The threshold for significant unplanned and undesired weight loss will be based on the following criteria as follows; 1 month (30 days) - 5% weight loss, 3 months (90 days) - 7.5% weight loss, and 6 months (180 days) - 10% weight loss. The Dietitian should be contacting the Physician and Responsible Party to discuss significant weight changes and completed in a timely manner and documented in the clinical record.

A review of the clinical record revealed that Resident 51 was admitted to the facility on May 17, 2017, with diagnoses that included aphasia [a comprehension and communication (reading, speaking, or writing) disorder resulting from damage or injury to the specific area in the brain], diabetes, and muscle weakness.

Resident 51's current recorded weights revealed the following:

12/12/2023 2:12 p.m. - 137.4 -pounds
1/22/2024 9:22 a.m. - 133.4-pounds
2/7/2024 2:25 p.m. - 122.2 - pounds
2/8/2024 10:32 a.m. - 123.0 - pounds

A progress note in the clinical record completed by the facility's remote (completes work off-site) Registered Dietitian (RD) on February 8, 2024, at 2:13 p.m., revealed that the resident's new monthly weight was 123-pounds and on 1/22/2024 the resident's weight was 133.4-pounds (loss of 10.4-pounds or 7.8% in 17-days), 11/14/2023 weight was 139.8-pounds, and 8/4/2023 weight was 143.4-pounds that indicated a (-10.4-pound or 7.8%) loss x 1 month, a (-16.8-pound -12%) loss x 3 months, and a (-20.4-pound, -14.2%) loss x 6 months. The RD noted that the resident's weight loss was significant, undesirable, and unplanned. The RD noted that the "Weight loss could likely be related to previous positive COVID-19 on 1/1/2024 and slight decrease in oral intakes noted in one month. Consumes mainly 50-100% most meals. Resident also noted to be on diuretic therapy Lasix [a medication used to remove extra fluid from the body to prevent fluid overload and cardiac distress] 20 mg daily related to history of edema (swelling) and weight fluctuations may occur. Spoke to resident and she really enjoys and has good acceptance of ensure plus supplement; will increase ensure plus (high calorie nutrition supplement) to three times per day (350kcals, 16g pro) per 8oz shake for added nutrition support. Food preferences obtained and on file. Advanced directives: long term tube feeding/hydration indicated. Will also add resident to weekly weights so close monitoring can continue. RP/IDT/MD aware of weight loss. Will continue to make new recommendations PRN (as needed) and follow up with nutrition POC (plan of care)."

However, the facility failed to obtain weekly weights as recommended by the RD on February 8, 2024. The resident's weights were noted on 2/19/2024 12:16 p.m. - 125.0 - pounds and the next weight approximately three weeks later on 3/15/2024 4:39 p.m. - 123.6 - pounds

A weight change progress note completed by the remote RD dated March 19, 2024, at 12:20 p.m., revealed that the resident's weight loss was significant and would adjust supplement orders as per Resident 51's preference and to "continue to monitor weekly weights."

Resident 51's next record weights were noted 11 days later on 3/26/2024 11:08 a.m. as 106.6 - pounds (entry struck out on April 1, 2024, at 7:35 a.m., by the remote Registered Dietitian) and then on 3/29/2024 6:14 p.m. -122.8 - pounds

The facility failed to ensure that weekly weights were completed to monitor Resident 51's weight status for further weight loss following a significant weight loss.

A review of Resident 47's clinical record revealed that she was admitted to the facility on August 8, 2023, with diagnoses that included protein-calorie malnutrition, history of breast cancer, muscle weakness, and depression.

Resident 47's recorded weights were as follows:

1/19/2024 09:20 a.m. -145.6 - pounds
2/5/2024 09:10 a.m. - 127.2 -pounds
2/9/2024 11:08 a.m. - 126.2 - pounds
2/19/2024 12:18 p.m. - 128.0 - pounds
3/15/2024 4:39 p.m. - 131.0 - pounds
3/18/2024 2:29 p.m. - 128.8 -pounds
3/26/2024 5:58 p.m. -127.6 - pounds
4/9/2024 6:33 p.m. - 129.0 - pounds

A review of the resident's weight record revealed that January 19, 2024, the resident weighed 145.6-pounds, and on February 5, 2024, the resident weighed 127.2-pounds, representing an 18.4-pound or 12.6% significant weight loss in seventeen days. No reweight completed to confirm the weight change.

A nutrition weight change progress note completed by the remote RD dated February 9, 2024, revealed that the resident had an undesirable, and unplanned significant weight loss and was likely related to a slight decrease in oral intakes and previous antibiotic therapy. The remote RD noted "Resident usually consumes 75-100%, now consuming 50-75% most meals over seven days. Tried calling the resident's phone number, but unavailable at this time and a message left for the resident's son. Physician and interdisciplinary team aware of weight loss and goal to deter further weight loss. Fortified foods (increased calorie and protein dietary meal plan) were added to meals and Ensure Plus (a high calorie supplement) was added daily for nutrition support. Food preferences on file and resident to be weighed weekly for close monitoring."

Resident 47's weight record failed to reveal that the resident was weighed weekly as planned for close nutrition monitoring following the signficiant weight loss and that reweights were timely obtained to confirm weight changes.

An interview with the DON on May 16, 2024, at 5:30 p.m., confirmed that the facility failed to ensure that weekly weights were obtained as planned for Residents 51 and 47 to monitoring their weight status following a signfiicant weight loss.

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

Plan of Correction - To be completed: 06/11/2024

1) Residents 47 and 51 weights have stabilized. According to facility policy and physician order, both residents have been made monthly weights as of 04/09/2024.
2) All resident weights were reviewed then compaired with their respective previous month, to determine any potential additional weight loss/gain. Any identified issues were addressed at the time of discovery.
3) Nursing staff were reeducated on facility weight and reweight policies. Staff were also reeducated on proper Physician and family notification upon resident change in conditions.
4) The Director of Nursing/Designee will review resident weights to assure completion as ordered and determine need for follow-up. This monitoring will be weekly for 4 weeks.
Results will be reviewed by the QA Committee for 2 months, then reevaluated.

483.20(f)(5), 483.70(i)(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(i) Medical records.
§483.70(i)(1) In accordance with accepted professional standards and practices, the facility must maintain medical records on each resident that are-
(i) Complete;
(ii) Accurately documented;
(iii) Readily accessible; and
(iv) Systematically organized

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

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

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

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

Observations:

Based on review of clinical records and staff interview, it was determined that the facility failed to maintain accurate and complete clinical records, according to professional standards of practice, by failing to ensure that a resident's clinical record included details related to injuries sustained post incidents with changes in medical status for one out of 15 sampled residents (Resident 38).

Findings include:

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 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 38's clinical record revealed that the resident was admitted to the facility September 28, 2026, with diagnoses to include muscle weakness, unsteadiness on feet, multiple rib fractures to the right side, and symbolic dysfunction [refers to the breakdown in communication caused by misinterpretation or misunderstanding of symbols that can significantly impact one's ability to effectively communicate and understand others].

A review of Resident 38's comprehensive person-centered plan of care that was initiated on September 28, 2016, identified that the resident required extensive assistance with activities of daily living (ADLs) and was a potential risk for falls related to non-compliance with safety interventions. Planned interventions included extensive assistance with personal hygiene and dressing, assist of one-person with transfers, assist with tasks as needed, and observe and report any changes in cognitive status.
An annual Minimum Data Set assessment (MDS - a federally mandated standardized assessment process conducted at specific intervals to plan resident care) dated March 1, 2024, revealed that the resident was cognitively intact with a BIMS score of 13 (Brief Interview for Mental Status, a tool to assess the resident's attention, orientation, and ability to register and recall new information).

A review of a nurse's progress note completed by Employee 1, a Registered Nurse (RN), dated April 15, 2024, at 6:22 a.m., indicated that the resident was assessed and an abrasion to left shin and a small laceration above left eyebrow. Blood already clotting when found by staff. Resident not on blood thinners. No LOC suspected. Resident sitting with back against right side of bed with drops of blood toward HOB (head of bed). Resident denied discomfort, pupils equal and reactive, hand grasps strong and equal, ROM (range of motion) of lower extremities at baseline with no pain/deformity noted on palpation of joints of lower extremities and upper extremities. Non-skid socks on and resident stated that he fell when he tried to go from his bed to his wheelchair. Stated that he did not ring his bell beforehand but did ring bell once he sat himself up from laying on the floor. Physician made aware of fall with new orders for Vaseline to laceration on forehead and xeroform to abrasions shins. Neuro-checks and every 15-minute checks initiated.
Further review of nurses' progress notes dated April 15, 2024, at 1:37 p.m., revealed that Resident 38 was transferred to the emergency department (ED) for evaluation, resident congested with bilateral decreased breath sounds, nonproductive cough noted. Oxygen (O2) saturation at 88% on room air. O2 via nasal canula at 2 liters and 92% after O2 (oxygen) applied. Responsible party, daughter, notified of transfer and will meet the resident at the ED. Resident was awake and responsive to staff on transfer.

A review of the resident's hospital history and physical examination from trauma surgery dated April 15, 2024, at 2:21 p.m., revealed that Resident 38 present to the emergency department as a Level 2 trauma [(Potentially Life Threatening): A Level of Trauma evaluation for a patient who meets mechanism of injury criteria with stable vital signs pre-hospital and upon arrival], and recusitation preformed by trauma team after a fall that occurred sometime overnight at the nursing facility and was reported that they \ found him with a black eye at 5:30 a.m., but did not call the ambulance. They \ indicated that the resident was more lethargic than usual and indicated that he had a positive head strike. Resident was admitted with mild bibasilar atelectisis [A condition where lungs collapse partially or completely. Mild cases show no signs and symptoms, but might develop breathing difficulty when it spreads.].

The facility failed to ensure that licensed nursing staff accurately documented the findings of injuries sustained post fall in Resident 38's clinical record, such as the resident's sustained head trauma to the left side of forhead and abrasion to the left lower leg.

An interview with the Director of Nursing (DON) on May 16, 2024, at 6:25 p.m., confirmed that the facility failed to ensure that licensed nursing staff accurately recorded findings of injuries sustained post fall and event details in Resident 38's clinical record.

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

Plan of Correction - To be completed: 06/11/2024

1) The facility is unable to retroactively correct the cited issue.
2) No other resident could be immediately identified to be at risk for similar occurrence.
3) Licensed nurses were educated/reeducated on timely nursing assessments, upon potential identified Changes in Condition. Nursing Assistants were also instructed to also report any changes, they identified to the Director of Nursing or Assistant Director of Nursing upon discovery. Any potential Change in Condition identified on the daily report sheet will be discussed at the next stand-up/stand-down meeting.
4) The Director of Nursing/Designee will monitor the daily report sheets to determine potential Changes in Condition and timely nurse assessment follow up and if there was a nurses note placed in the residents permanent record regarding the changes and all actions taken. This monitoring will be 4 x week for 4 weeks.
Results will be reviewed by the QA Committee for 2 months, then reevaluated.

§ 201.14(c) LICENSURE Responsibility of licensee.:

(c) The licensee through the administrator shall report as soon as possible, or, at the latest, within 24 hours to the appropriate Division of Nursing Care Facilities field office serious incidents involving residents as set forth in § 51.3 (relating to notification). For purposes of this subpart, references to patients in § 51.3 include references to residents.

Observations:

Based on a review clinical records and interviews with residents and facility staff it was determined that the facility failed to report transfers/admission to the hospital due to injuries or accidents to the State Licensing Agency, PA Department of Health for one of seven sampled residents for one resident out of 15 sampled residents (Resident 38).

Findings included:

A review of Resident 38's clinical record revealed that the resident was admitted to the facility September 28, 2026, with diagnoses to include muscle weakness, unsteadiness on feet, multiple rib fractures to the right side, and symbolic dysfunction [refers to the breakdown in communication caused by misinterpretation or misunderstanding of symbols that can significantly impact one's ability to effectively communicate and understand others].

A nurse's progress note dated April 15, 2024, at 6:22 a.m., indicated that the resident was assessed and an abrasions to left shin and a small laceration above left eyebrow. Blood already clotting when found by staff. Resident not on blood thinners. No LOC suspected. Resident sitting with back against right side of bed with drops of blood toward HOB (head of bed). Resident denied discomfort, pupils equal and reactive, hand grasps strong and equal, ROM (range of motion) of lower extremities at baseline with no pain/deformity noted on palpation of joints of lower extremities and upper extremities. Non-skid socks on and resident stated that he fell when he tried to go from his bed to his wheelchair. Stated that he did not ring his bell beforehand but did ring bell once he sat himself up from laying on the floor. Physician made aware of fall with new orders for Vaseline to laceration on forehead and Xeroform to abrasions shins. Neuro-checks and every 15-minute checks initiated.

Nurses' progress notes dated April 15, 2024, at 1:37 p.m., revealed that Resident 38 was transferred to the emergency department (ED) for evaluation, it was noted that the resident was congested with bilateral decreased breath sounds, nonproductive cough noted. Oxygen (O2) saturation at 88% on room air. O2 via nasal canula at 2 liters and 92% after O2 (oxygen) applied. Responsible party, daughter, notified of transfer and will meet the resident at the ED. Resident was awake and responsive to staff on transfer.

The facility failed to report this incident, fall with potential injury, that required transfer to emergency department, to the State Licensing Agency, PA Department of Health.

A review of Resident 38's clinical record nurses progress notes completed by a Registered Nurse (RN) dated May 10, 2024, at 2:19 p.m., revealed that the resident was found face down on the floor in his room on the right side of his bed. Bed was in the lowest position; wheelchair was on the left side of the bed near the window. Resident was wearing a nonskid sock. Continent of bowel and bladder and call bell was within reach. A small bump noted on his right forehead, cold compress applied. Neuro-checks started, and the resident was confused, not following commands, pupils pinpoint, sluggish, BUE (bilateral upper extremity) weakness noted. Nurse aide stated that before this happened that resident wasn't acting right and went back to his bed after lunch and that the resident self-transfers and was moaning, and color was brownish yellow. Temperature at 98 degrees Fahrenheit, pulse 70, respirations 26, blood pressure 148/100, pulse OX 95 % room air. Physician was notified with new orders obtained to transfer to the emergency department for evaluation due to changes in condition.

The facility failed to report this incident, fall with potential injury, that required transfer to emergency department, to the State Licensing Agency, PA Department of Health.

An interview with the Director of Nursing (DON) on May 16, 2024, at 6:00 p.m., revealed that the incidents that occurred on April 15, 2024, and May 10, 2024, that required Resident 38 to be transferred to the emergency department and admitted to the hospital for treatment should have been reported to the State Survey Agency.

Plan of Correction - To be completed: 06/11/2024

1) The facility will enter an Event Detail for the incident on 04/15/2024 on resident 38.
2) The Director of Nursing reviewed the previous 30 days of incident reports to determine if there were any transports to the hospital as the result of an accident or injury, within the facility. None could be identified. All falls will be reviewed by the Falls Committee to determine if appropriate interventions were put into place and if appropriate action was taken. Incidents will also be reviewed at the monthly QA meeting.
3) Licensed Nurses were reeducated on Department of Health reporting guidelines and what qualifies/requires reporting (i.e. any transfer to the hospital, regardless if the person was admitted).
4) The Director of Nursing/Designee will review resident Fall incidents with resulting transport to the hospital, to determine if an Event Detail was submitted. This monitoring will be weekly for 4 weeks.
Results will be reviewed by the QA Committee for 2 months, then reevaluated.

§ 211.12(f.1)(2) LICENSURE Nursing services. :

(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.

Plan of Correction - To be completed: 06/11/2024

1) The facility is unable to retroactively correct the cited issue.
2) The facility will review the upcoming schedule to assure CNA staffing requirements are met.
3) The facility's nursing scheduler was educated on regulated staffing requirements. The nursing scheduler was given a copy of the Department of Heath's Staffing Calculation tool and educated on how to properly utilize it. By the scheduler utilizing this tool, they can readily identify and correct any staffing need, before they occur. In the absence of facility staff to cover any shortage, agency staff will be utilized.
4) The Director of Nursing/Designee will monitor to assure that required CNA staffing ratios/requirements are met. This monitoring will occur 4 x week for 4 weeks.
Results will be reviewed by the QA Committee for 2 months, then reevaluated.

§ 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.

Observations:

Based on review of nursing time schedules and staff interviews, it was determined that the facility failed to provide a minimum of one licensed practical nurse (LPN) per 30 residents during the evening shift and failed to provide a minimum of one LPN per 40 residents during the night shift on two out of 42 shifts reviewed (May 9, 2024, and May 15, 2024).

Findings include:

Review of facility census data indicated that on May 9, 2024, the facility census was 73, which required 1.83 LPNs on the night shift.

Review of the nursing time schedules, and time punch documentation revealed 1.60 LPNs worked on the night shift on May 9, 2024.

No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on May 15, 2024, the facility census was 72, which required 2.40 LPNs on the evening shift.

Review of the nursing time schedules, and time punch documentation revealed 2.13 LPNs worked on the evening shift on May 15, 2024.

No additional excess higher-level staff were available to compensate this deficiency.

An interview with the Director of Nursing (DON) on May 16, 2024, at 6:17 p.m., confirmed that the facility did not meet the state minimum nursing ratios for LPNs required.

Plan of Correction - To be completed: 06/11/2024

1) The facility is unable to retroactively correct the cited issue.
2) The facility will review the upcoming schedule to assure LPN staffing requirements are met.
3) The facility's nursing scheduler was educated on regulated staffing requirements. The nursing scheduler was given a copy of the Department of Heath's Staffing Calculation tool and educated on how to properly utilize it. By the scheduler utilizing this tool, they can readily identify and correct any staffing need, before they occur. In the absence of facility staff to cover any shortage, agency staff will be utilized.
4) The Director of Nursing/Designee will monitor to assure that required LPN staffing ratios/requirements are met. This monitoring will occur 4 x week for 4 weeks.
Results will be reviewed by the QA Committee for 2 months, then reevaluated.

§ 211.12(i)(1) LICENSURE Nursing services.:

(1) Effective July 1, 2023, the total number of hours of general nursing care provided in each 24-hour period shall, when totaled for the entire facility, be a minimum of 2.87 hours of direct resident care for each resident.

Observations:

Based on a review of nurse staffing and resident census and staff interview, it was determined that the facility failed to consistently provide minimum general nursing care hours to each resident daily.

Findings include:

A review of the facility's staffing levels revealed that on the following dates the facility failed to provide minimum nurse staffing of 2.87 hours of general nursing care to each resident:

May 9, 2024 - 2.85 direct care nursing hours per resident
May 12, 2024 - 2.66 direct care nursing hours per resident

An interview with the Director of Nursing (DON) on May 16, 2024, at 6:30 p.m., confirmed the facility failed to consistently provide minimum general nursing care hours to each resident daily.

Plan of Correction - To be completed: 06/11/2024

1) The facility is unable to retroactively correct the cited issue.
2) The facility will review the upcoming schedule to assure that 2.87 staffing requirement, per resident per day, is met.
3) The facility's nursing scheduler was educated on regulated staffing requirements. The nursing scheduler was given a copy of the Department of Heath's Staffing Calculation tool and educated on how to properly utilize it. By the scheduler utilizing this tool, they can readily identify and correct any staffing need, before they occur. In the absence of facility staff to cover any shortage, agency staff will be utilized.
4) The Director of Nursing/Designee will monitor to assure that required 2.87 staffing requirement, per resident per day, is met. This monitoring will occur 4 x week for 4 weeks.
Results will be reviewed by the QA Committee for 2 months, then reevaluated.

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