Pennsylvania Department of Health
ACCELERATE SKILLED NURSING AND REHABILITATION WILLOW GROVE
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

ACCELERATE SKILLED NURSING AND REHABILITATION WILLOW GROVE
Inspection Results For:

There are 108 surveys for this facility. Please select a date to view the survey results.

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ACCELERATE SKILLED NURSING AND REHABILITATION WILLOW GROVE - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:

Based on a Medicare/Medicaid Recertification Survey, Civil Rights Compliance Survey, State Licensure Survey, and an Abbreviated Survey in response to 4 complaints completed on August 15, 2024, it was determined that Accelerate Skilled Nursing and Rehabilitation Willow Grove was not in compliance with the 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 related to the health portion of the survey process.

Plan of Correction:

483.25(h) REQUIREMENT Parenteral/IV Fluids:

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(h) Parenteral Fluids.
Parenteral fluids must be administered consistent with professional standards of practice and in accordance with physician orders, the comprehensive person-centered care plan, and the resident's goals and preferences.

Observations:

Based on observations, review of facility policies, clinical record reviews and interviews with residents and staff, it was determined that the facility failed to provide care and assessments consistent with professional standards of practice related to intravenous therapy for three of four residents reviewed for intravenous therapy (Residents R5, R58 and R265).

Findings include:

Review of facility policy, "Assessment of the Patient Receiving IV Therapy [intravenous therapy - therapy that delivers liquid substances directly into a vein]" dated September 2022, revealed, "Assess vascular access device function by aspirating for a blood return and flushing prior to each intermittent use (intermittent medication administration) and as clinically indicated with continuous infusions. Assess the catheter insertion site and surrounding area for redness, tenderness, swelling, and drainage by visual inspection and palpation through the intact dressing. Recommended minimum assessment of midlines and central venous access devices is once every 24 hours. Measure the external length of the midline or central venous access device and compare to the length documented at insertion, during each dressing change and when catheter dislodgement is suspected. Measure upper arm circumference when clinically indicated to assess the presence of edema and possible deep vein thrombosis. Measure 10 cm above the insertion site."

Review of facility policy, "Dressing Change for Vascular Access Devices" dated August 2012, revealed, "Central venous access devices ... dressings are changed every 7 [seven] days and PRN [as needed]."

Observation, on August 12, 2024, at 11:15 a.m. revealed that Resident R5 had a PICC line (peripherally inserted central catheter - a thin soft tube inserted in a vein in the arm with the tip of the tube positioned in a large vein that carries blood to the heart) in his right upper arm; the dressing was dated August 5, 2024. Interview, at the time of the observation, Resident R5 stated that he received antibiotic therapy daily through his PICC line and that the line was recently changed due to dislodgement.

Review of Resident R5's Admission MDS (Minimum Data Set - a mandatory periodic resident assessment tool), dated July 28, 2024, revealed that the resident was admitted to the facility on July 21, 2024, and had diagnoses including osteomyelitis (bone infection) of the left ankle and foot. Continued review revealed that the resident had a surgical wound and was receiving IV medications and antibiotics.

Review of progress notes for Resident R5 revealed a nursing note, dated July 21, 2024, at 8:59 p.m. which indicated that the resident had a PICC line in his right upper arm that was "inserted prior to being admitted."

Review of Medication Administration Records (MARs) for Resident R5 revealed a physician's order, dated July 22, 2024, for ceftriaxone (antibiotic medication) two grams, administer intravenously every 24 hours for infection until August 25, 2024. Continued review revealed that the medication was initiated on July 22, 2024, as prescribed and that the medication continued to be administered at the time of the survey.

Continued review of progress notes for Resident R5 revealed a practitioner note, dated August 7, 2024, at 8:21 a.m. which indicated that the resident's PICC line was replaced on August 6, 2024, due to dislodgement.

Further review of Resident R5's clinical record, including physician orders, progress notes and MARs revealed that there was no indication that the resident's PICC line dressing was changed at any time between July 21, 2024, through August 5, 2024, a period of over two weeks. There were no physician orders or MAR documentation to indicate if the PICC line was flushed or what type of flush solution should be used. There was no indication on the MARs or progress notes of any PICC line assessments measurements, such as arm circumference and external catheter length.

Observation on August 13, 2024, at 8:55 a.m., revealed that Resident R58 had a PICC line in her right upper arm; the dressing was dated August 7, 2024. Interview, at the time of the observation, Resident R58 stated that her PICC line was used for chemotherapy (treatment for cancer) and that during her first week of admission to the facility, nursing staff did not flush her PICC line to maintain its's patency.

Review of Resident R58's Admission MDS, dated July 29, 2024, revealed that the resident was admitted to the facility on July 24, 2024, and had diagnoses including cancer and Hodgkin Lymphoma (type of cancer that affects the immune system and white blood cells). Continued review revealed that the resident had IV access and received chemotherapy.

Review of progress notes revealed a practitioner note, dated July 25, 2024, at 8:57 a.m., which indicated that Resident R58 had a double lumen PICC line to her right upper extremity and for nursing staff to maintain the PICC line for use at chemotherapy.

Review of MAR's for Resident R58 revealed a physician's order, dated July 30, 2024, to flush the resident's PICC line with sodium chloride 0.9% solution, use ten milliters intravenously every twelve hours for patency. Continued review revealed that there no indication that the resident's PICC line was flushed between July 24 through July 29, 2024. Continued review of the MARs revealed that on July 30 and 31, 2024 at 8:00 p.m. that the flushes were not administered and to "see nurses note."

Review of eMAR (electronic MAR) notes, dated July 30, 2024, at 9:46 p.m. revealed that the flush was not administered due to "Medication on order." Continued review revealed another eMAR note, dated July 31, 2024, at 9:26 p.m. which indicated that the flush was not administered due to "On order."

Continued review of MARs for Resident R58 revealed a physician's order, dated July 30, 2024, to change the resident's PICC dressing weekly. MARs indicated that the dressing was changed on July 30 and August 6, 2024. Review of eMAR notes, dated July 30, 2024, revealed that the PICC dressing was changed and that "site remains unremarkable." Review of eMAR notes from August 7, 2024, at 8:54 a.m. revealed that PICC dressing was "changed." There was no indication on the MARs or progress notes of any PICC line assessments measurements, such as arm circumference and external catheter length.

Observation on August 12, 2024, at 10:17 a.m. revealed that Resident R265 had a PICC line in her right upper arm; the dressing was dated August 7, 2024.

Review of Resident R265's Admission Assessment, dated August 7, 2024, at 3:00 p.m. revealed that the resident was admitted to the facility on August 7, 2024, with a diagnosis of right knee septic arthritis (infection of the knee), that she requires intravenous antibiotics and has a PICC line in her right upper arm.

Review of progress notes for Resident R265 revealed a practitioner note, dated August 7, 2024, at 12:41 p.m. which indicated that the resident required intravenous cefazolin (antibiotic medication) every eight hours through September 12, 2024, related to right knee septic arthritis and for "nursing to maintain PICC line."

Review of Resident R265's MARs revealed physician's orders, dated August 7 and 13, 2024, for cefazolin (antibiotic medication) two grams, administer intravenously every eight hours for acute bacterial arthritis until September 12, 2024. Continued review revealed that the medication was initiated on August 7, 2024, as prescribed and that the medication continued to be administered at the time of the survey.

Continued review of MARs and physician orders for Resident R265 revealed that there were no orders for PICC line flushes, PICC line dressing changes or PICC line assessments/measurements.

Interview on August 15, 2024, at 12:33 p.m. Employee E3, Regional Nurse, confirmed that PICC line care was not provided in accordance with professional practice standards for Residents R5, R58 and R265.

Pa Code 211.10(d) Resident care policies

Pa Code 211.12(d)(1) Nursing services

Pa Code 211.12(d)(5) Nursing services

Plan of Correction - To be completed: 10/02/2024

Resident R5, R58, and R265 orders were reviewed to ensure the physician orders related to intravenous therapy are in for monitoring placement and maintenance for current residents.
The Director of Nursing or designee will conduct an Initial audit to be completed on patients with IV therapy orders.
The Director of Nursing or designee will conduct education to licensed nursing staff to ensure that orders are in place related to intravenous therapy. Competencies for licensed nursing staff on IV placement and maintenance to be completed.
Director of Nursing or designee to conduct Random audits of 5 MARs to be completed weekly x 4 weeks and then monthly x 2 to ensure nursing staff is recording proper documentation and is providing proper care. The director of Nursing or designee will report all findings to be discussed in QAPI meeting x 3 months.

483.80(a)(3) REQUIREMENT Antibiotic Stewardship Program:

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

§483.80(a)(3) An antibiotic stewardship program that includes antibiotic use protocols and a system to monitor antibiotic use.

Plan of Correction - To be completed: 10/02/2024

Resident 5, 16, 56, 266, and 265 assessments will be completed to have infection assessment completed
An initial audit will be conducted to determine if any current residents had an assessment completed for reported infections. If an assessment was not initiated one will be opened. The facility will re-establish an effective antibiotic stewardship program for residents with present infections.
DON or designee will provide education to licensed nursing staff on monitoring for new infections/antibiotics ordered by the physician to ensure infection assessment is completed and the NPE will be re-educated to ensure a monthly Antibiotic Stewardship program is maintained in QAPI.
The Director of Nursing/designee will conduct weekly random audits x 4 weeks and then monthly x 2 to ensure that current residents have an infection assessment completed and to ensure compliance related to the monthly Antibiotic Stewardship program is reviewed in QAPI. Results of the audit will be reported to the Quality Assurance Performance Improvement Committee x 3 monthly.

483.80(a)(1)(2)(4)(e)(f) REQUIREMENT Infection Prevention & Control:

§483.80 Infection Control
The facility must establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections.

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

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

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

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

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

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

Plan of Correction - To be completed: 10/02/2024

Residents 5, 16, and 56 were updated to be included in the infection surveillance
An initial audit was completed to determine if current residents needed to be placed on infection surveillance for the last two weeks. If not present on the infection surveillance, the facility will update to include the resident identified. An initial audit of PA-PSRS for any unreported qualifying infection will be determined, if unreported the facility will ensure entered in PA-PSRS.
DON or designee will provide education to licensed nursing staff on monitoring for new infections/antibiotics ordered by the physician to ensure infection surveillance is updated.
The Director of Nursing/designee will conduct weekly random audits x 4 weeks and then monthly x 2 to ensure that current residents are placed on the infection surveillance report. Results of the audit will be reported to the Quality Assurance Performance Improvement Committee x 3 monthly. DON or designee will audit monthly x 3 the PA-PSRS reporting by the IP and ensure it is presented in the Infection Control Committee prior to QAPI. Results of the audit will be reported to the Quality Assurance Performance Improvement Committee x 3 monthly.

483.45(c)(1)(2)(4)(5) REQUIREMENT Drug Regimen Review, Report Irregular, Act On:

§483.45(c) Drug Regimen Review.
§483.45(c)(1) The drug regimen of each resident must be reviewed at least once a month by a licensed pharmacist.

§483.45(c)(2) This review must include a review of the resident's medical chart.

§483.45(c)(4) The pharmacist must report any irregularities to the attending physician and the facility's medical director and director of nursing, and these reports must be acted upon.
(i) Irregularities include, but are not limited to, any drug that meets the criteria set forth in paragraph (d) of this section for an unnecessary drug.
(ii) Any irregularities noted by the pharmacist during this review must be documented on a separate, written report that is sent to the attending physician and the facility's medical director and director of nursing and lists, at a minimum, the resident's name, the relevant drug, and the irregularity the pharmacist identified.
(iii) The attending physician must document in the resident's medical record that the identified irregularity has been reviewed and what, if any, action has been taken to address it. If there is to be no change in the medication, the attending physician should document his or her rationale in the resident's medical record.

§483.45(c)(5) The facility must develop and maintain policies and procedures for the monthly drug regimen review that include, but are not limited to, time frames for the different steps in the process and steps the pharmacist must take when he or she identifies an irregularity that requires urgent action to protect the resident.

Observations:
Based on a review of clinical records, review of facility policy and facility documentation, and staff interviews, it was determined the facility failed to implement a complete drug regimen review process for three of three residents reviewed (Resident R16, R5 and R270).

Findings Include:

Review of the facility policy, "Medication Monitoring, Medication Regimen Review (MRR) and Reporting" revealed that the Drug Regimen Review is a thorough evaluation of the medication regiment of a resident. And that the resident-specific MRR recommendations and findings are documented and acted upon by the nursing care center and/or physician.

Review of Resident R16's clinical record revealed that resident was admitted on July 24, 2024, with diagnoses including glaucoma (condition where the eye's optic nerve, which provides information to the brain, is damaged with or without raised intraocular pressure. If untreated, this will cause gradual vision loss).

A review of the July 31, 2024, pharmacy recommendation for Resident R16 revealed the following recommendation:
Resident is currently receiving the following ophthalmic medications with their respective administration times:

Latanoprost - 9:00 p.m.
Rhopressa - 9:00 p.m.
Brimonidine - 9:00 a.m., 5:00 p.m.
Dorzolamide/Timolol - 1:00 p.m., 5:00 p.m.
Artificial Tears - 9:00 a.m., 1:00 p.m., 5:00 p.m., 9:00 p.m.

"When ophthalmics are administered at the same time please be sure to separate administration of each ophthalmic agent by at least 5 minutes."

Further review of Resident R16's physician orders did not reveal any changes in the timing of the ophthalmic agents prescribed or order to separate each agent by at least 5 minutes.

Interview with the Director of Nursing (DON) on August 14, 2024, at 1:00 p.m. where these recommendations and current physician orders were reviewed, confirmed that the pharmacy recommendations were not implemented for Resident R16's opthalmic agents.

Review of Resident R5's Admission MDS (Minimum Data Set - a mandatory periodic resident assessment tool), dated July 28, 2024, revealed that the resident was admitted to the facility on July 21, 2024, and had diagnoses including heart attack and coronary artery disease (damage in the heart's major blood vessels).

Clinical record review for Resident R5 revealed a medication regimen review, dated July 24, 2024. The pharmacist recommended that the facility should monitor the resident for signs and symptoms of bleeding/bruising and thromboembolism (blood clot) due to the resident's use of Aspirin and Clopidogrel (blood thinning medications). The physician reviewed the recommendations on July 25, 2024, and noted that they agreed with the recommendation.

Review of July 2024 and August 2024's physician orders for Resident R5 revealed that there were no orders added to reflect the pharmacist's recommendations.

Review of physician orders for Resident R270 revealed that the resident was admitted to the facility on August 6, 2024, and had diagnoses including anxiety disorder (intense, excessive, persistent worry or fear) and stroke accident (damage to the brain from interruption of its blood supply). Continued review revealed that the resident was prescribed Aspirin daily for coronary artery disease and Lorazepam every six hours as needed for anxiety.

Clinical record review for Resident R270 revealed a medication regime review, dated August 8, 2024. The pharmacist recommended that the facility should monitor the resident for signs and symptoms of bleeding/bruising and thromboembolism due to the resident's use of Aspirin. The pharmacist also recommended that the facility should monitor the resident's behavior and side effects, as well as add a stop date, due to the resident's use of Lorazepam. The physician reviewed the recommendations on August 8, 2024, and noted that they agreed with the recommendations.

Further review of August 2024 physician orders for Resident R270 revealed that there were no orders added to reflect the pharmacist's recommendations.

Interview on August 14, 2024, at 1:47 p.m. the Director of Nursing confirmed that the pharmacist's recommendations for Residents R5 and R270 were not implemented.

28 Pa. Code 211.9 (k) Pharmacy services.

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

Plan of Correction - To be completed: 10/02/2024

Resident 16 orders for separate administration of each ophthalmic agent by at least 5 minutes. Resident 5 and 270 orders were updated to include monitoring for signs and symptoms of bleeding/bruising and blood clots. Resident 270 orders were updated to ensure behaviors are monitored and a 14-day stop date was in place for Lorazepam.
An initial audit will be completed for the last 30 days of pharmacy recommendations of current residents are reviewed by the physician and orders written if indicated.
Licensed nursing staff will be re-educated by the DON/designee to ensure that all resident pharmacy recommendations are reviewed by the physician and orders written if indicated.
DON/Designee will perform audits weekly x 4 and then monthly x 2 to ensure that all pharmacy recommendations are reviewed by the physician and orders written if indicated. Results of the audit will be reported to the Quality Assurance Performance Improvement Committee x 3 monthly.

483.35(a)(3)(4)(c) REQUIREMENT Competent Nursing Staff:

§483.35 Nursing Services
The facility must have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment required at §483.70(e).

§483.35(a)(3) The facility must ensure that licensed nurses have the specific competencies and skill sets necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care.

§483.35(a)(4) Providing care includes but is not limited to assessing, evaluating, planning and implementing resident care plans and responding to resident's needs.

§483.35(c) Proficiency of nurse aides.
The facility must ensure that nurse aides are able to demonstrate competency in skills and techniques necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care.

Observations:

Based on observations, review of the Pennsylvania Nurse Practice Act, clinical record reviews, review of personnel files and interviews with residents and staff, it was determined that the facility failed to assure that nursing staff possess the competencies and skill sets necessary to provide nursing and related services to meet the residents' needs for five of five personnel files reviewed for competency evaluations (Employees E11, E12, E13, E14 and E15) and for four of four residents reviewed for intravenous therapy (Residents R5, R58, R265 and R266.)

Findings include:

Review of the Pennsylvania Nurse Practice Act for Registered Nurses (RNs), 49 Pa Code 21.12, revealed that, "Performing venipuncture and administering and withdrawing intravenous fluids are functions regulated by this section, and these functions may not be performed unless: ... (3) The registered nurse who administers parental fluids, drugs or blood has had instruction and supervised practice in administering parental fluids, blood or medications into the vein."

Review of the Pennsylvania Nurse Practice Act for Licensed Practical Nurses (LPNs), 49 Pa Code 21.145, revealed that, "An LPN may only perform the IV therapy functions for which the LPN possesses the knowledge, skill and ability to perform in a safe manner."

Review of the Facility Assessment, dated reviewed July 1, 2024, revealed that, "Staff training/education and competencies are necessary to provide support and care needed for the facility's short term resident population." Continued review revealed that required competencies include: activities of daily living, privacy, range of motion, transfers, mechanical lifts and infection control practices. Further review revealed that the facility provides resident care and services including: mobility and fall prevention, bowel and bladder programs, skin and wound care, mental health services, medication administration including administration of intravenous medications, pain management, management of medical conditions, nutrition services and psychosocial support.

Review of Employee E11's personnel file revealed that the employee was hired by the facility on July 16, 2024, as a nurse aide.

Review of Employee E12's personnel file revealed that the employee was hired by the facility on July 16, 2024, as a registered nurse.

Review of Employee E13's personnel file revealed that the employee was hired by the facility on July 9, 2024, as a licensed practical nurse.

Review of Employee E14's personnel file revealed that the employee was hired by the facility on July 2, 2024, as a nurse aide.

Review of Employee E15's personnel file revealed that the employee was hired by the facility on May 21, 2024, as a registered nurse.

Continued review of personnel files for Employees E11, E12, E13, E14 and E15 revealed no evidence that the employees received any skills competency evaluations to ensure competency of hands-on skills and techniques necessary to care for residents' needs.

Observation, on August 12, 2024, at 11:15 a.m. revealed that Resident R5 had a PICC line (peripherally inserted central catheter - a thin soft tube inserted in a vein in the arm with the tip of the tube positioned in a large vein that carries blood to the heart) in his right upper arm. Interview, at the time of the observation, Resident R5 stated that he received antibiotic therapy daily through his PICC line.

Review of Medication Administration Records (MARs) for Resident R5 revealed a physician's order, dated July 22, 2024, for ceftriaxone (antibiotic medication) two grams, administer intravenously every 24 hours for infection until August 25, 2024. Continued review revealed that the medication was initiated on July 22, 2024, as prescribed and that the medication continued to be administered at the time of the survey.

Observation on August 13, 2024, at 8:55 a.m., revealed that Resident R58 had a PICC line in her right upper arm. Interview, at the time of the observation, Resident R58 stated that her PICC line was used for chemotherapy (treatment for cancer).

Review of MAR's for Resident R58 revealed a physician's order, dated July 30, 2024, to flush the resident's PICC line with sodium chloride 0.9% solution, use ten milliters intravenously every twelve hours for patency.

Observation on August 12, 2024, at 10:17 a.m. revealed that Resident R265 had a PICC line in her right upper arm.

Review of Resident R265's MARs revealed physician's orders, dated August 7 and 13, 2024, for cefazolin (antibiotic medication) two grams, administer intravenously every eight hours for acute bacterial arthritis until September 12, 2024. Continued review revealed that the medication was initiated on August 7, 2024, as prescribed and that the medication continued to be administered at the time of the survey.

Observation on August 13, 2024, at 9:10 a.m. Resident R266 had a PICC line in her right upper arm. Interview, at the time of the observation, Resident R266 stated that her PICC line was being used for antibiotic therapy.

Review of Resident R266's MARs revealed physician's orders, dated August 7, 2024, for piperacillin-sod-tazobactam (antibiotic medication), administer intravenously every eight hours for osteomyelitis (bone infection) for 14 days. Continued review revealed that the medication was initiated on August 8, 2024, and that the medication continued to be administered at the time of the survey.

Interview on August 14, 2024, at 2:15 p.m. the Director of Nursing confirmed that she was unable to provide any evidence of skills competency evaluations for Employees E11, E12, E13, E14 and E15. Continued interview revealed that she was unable to provide any evidence of IV skills trainings and competency evaluations for Employees E12, E13 and E15.

Interview on August 15, 2024, at 12:33 p.m. Employee E3, Regional Nurse, revealed that the facility had four residents who required intravenous therapy at the time of the survey. Employee E3, Regional Nurse, was unable to provide any documentation at the time of the survey of skills competency evaluations to ensure competency of hands-on skills and techniques necessary to care for residents' needs for Employees E11, E12, E13, E14 and E15.

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

28 Pa. Code 201.20(d) Staff development

Plan of Correction - To be completed: 10/02/2024

Employees 11, 12, 13, 14, and 15 will have IV skills training and competency evaluations completed.
An initial audit is to be conducted for current Licensed Nurses to ensure IV skills training and competency evaluation have been completed.
DON or designees will ensure that all new hires have completed IV skills training and that competency evaluation is completed upon orientation. NPE will ensure that yearly IV skills training and competencies are completed for license nurses and aides. Any gaps identified should be addressed through additional training or mentoring. Audits will be conducted weekly x 4 and then monthly x 2 months.
Director of Nursing or designee to conduct Random audits of new hires for completion of IV skills training and competency evaluation and that yearly competencies are placed in the employee files. The director of Nursing or designee will report all findings to be discussed in QAPI meeting x 3 months.

483.15(c)(3)-(6)(8) REQUIREMENT Notice Requirements Before Transfer/Discharge:

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

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

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

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

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

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

Observations:

Based on review of facility documentation and interviews with staff, it was determined that the facility failed to notify the Office of the State Long-Term Care Ombudsman of facility-initiated emergency transfers and discharges as required.

Findings include:

Documentation of notification to the Office of the State Long-Term Care Ombudsman of facility-initiated emergency transfers and discharges for the past three months was requested on August 15, 2024, at 12:45 p.m. from Employee E1, Nursing Home Administrator (NHA).

Interview with NHA on August 15, 2024, at 1:50 p.m. confirmed that the facility did not send the notification to the Office of the State Long-Term Care Ombudsman of facility-initiated emergency transfers and discharges for the past three months. She indicated that this function will be done by the new social worker going forward.

28 Pa. Code 201.14(a) Responsibility of licensee

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

Plan of Correction - To be completed: 10/02/2024

NHA or designee will educate the social services director on notification to the office of the state long-term care ombudsman for facility-initiated emergency transfers and discharges.
The past 3 months of transfers and discharges were sent to the Office of the State Long-Term Care Ombudsman.
Audits will be conducted at random x3 months to ensure timely tracking and notification are sent to the Office of the State Long-Term Care Ombudsman.
NHA or designee will report all findings to be discussed in QAPI meeting x 3 months.

483.21(a)(1)-(3) REQUIREMENT Baseline Care Plan:

§483.21 Comprehensive Person-Centered Care Planning
§483.21(a) Baseline Care Plans
§483.21(a)(1) The facility must develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. The baseline care plan must-
(i) Be developed within 48 hours of a resident's admission.
(ii) Include the minimum healthcare information necessary to properly care for a resident including, but not limited to-
(A) Initial goals based on admission orders.
(B) Physician orders.
(C) Dietary orders.
(D) Therapy services.
(E) Social services.
(F) PASARR recommendation, if applicable.

§483.21(a)(2) The facility may develop a comprehensive care plan in place of the baseline care plan if the comprehensive care plan-
(i) Is developed within 48 hours of the resident's admission.
(ii) Meets the requirements set forth in paragraph (b) of this section (excepting paragraph (b)(2)(i) of this section).

§483.21(a)(3) The facility must provide the resident and their representative with a summary of the baseline care plan that includes but is not limited to:
(i) The initial goals of the resident.
(ii) A summary of the resident's medications and dietary instructions.
(iii) Any services and treatments to be administered by the facility and personnel acting on behalf of the facility.
(iv) Any updated information based on the details of the comprehensive care plan, as necessary.

Observations:

Based on observations, review of facility policies, clinical record review and interviews with residents and staff, it was determined that the facility failed to develop a baseline care plan that includes the instructions needed to provide effective and person-centered care within 48 hours of admission for two of four residents reviewed for intravenous therapy (therapy that delivers liquid substances directly into a vein) (Residents R5 and R58).

Findings include:

Review of facility policy, "Person-Centered Care Plan" dated last revised October 24, 2022, revealed, "A baseline care plan must be developed within 48 hours and include the minimum healthcare information necessary to properly care for a patient."

Observation, on August 12, 2024, at 11:15 a.m. revealed that Resident R5 had a PICC line (peripherally inserted central catheter - a thin soft tube inserted in a vein in the arm with the tip of the tube positioned in a large vein that carries blood to the heart) in his right upper arm. Interview, at the time of the observation, Resident R5 stated that he received antibiotic therapy daily through his PICC line.

Review of Resident R5's Admission MDS (Minimum Data Set - a mandatory periodic resident assessment tool), dated July 28, 2024, revealed that the resident was admitted to the facility on July 21, 2024, and had diagnoses including osteomyelitis (bone infection) of the left ankle and foot. Continued review revealed that the resident had a surgical wound and was receiving IV medications and antibiotics.

Review of progress notes for Resident R5 revealed a nursing note, dated July 21, 2024, at 8:59 p.m. which indicated that the resident had a PICC line in his right upper arm that was "inserted prior to being admitted."

Review of Medication Administration Records (MARs) for Resident R5 revealed a physician's order, dated July 22, 2024, for ceftriaxone (antibiotic medication) two grams, administer intravenously every 24 hours for infection until August 25, 2024. Continued review revealed that the medication was initiated on July 22, 2024, as prescribed and that the medication continued to be administered at the time of the survey.

Review of Resident R5's care plan revealed that a care plan that includes instructions for the care and maintenance of the resident's PICC line was not initiated until August 12, 2024.

Observation on August 13, 2024, at 8:55 a.m., revealed that Resident R58 had a PICC line in her right upper arm. Interview, at the time of the observation, Resident R58 stated that her PICC line was used for chemotherapy (treatment for cancer).

Review of Resident R58's Admission MDS, dated July 29, 2024, revealed that the resident was admitted to the facility on July 24, 2024, and had diagnoses including cancer and Hodgkin Lymphoma (type of cancer that affects the immune system and white blood cells). Continued review revealed that the resident had IV access and received chemotherapy.

Review of progress notes revealed a practitioner note, dated July 25, 2024, at 8:57 a.m., which indicated that Resident R58 had a double lumen PICC line to her right upper extremity and for nursing staff to maintain the PICC line for use at chemotherapy.

Review of Resident R58's care plan revealed that a care plan that includes instructions for the care and maintenance of the resident's PICC line was not initiated until August 12, 2024.

Interview on August 15, 2024, at 12:33 p.m. Employee E3, Regional Nurse, confirmed that baseline care plans were not developed within 48 hours of admission for Residents R5 and R58 related to their PICC lines.

Pa Code 211.10(d) Resident care policies

Pa Code 211.12(d)(5) Nursing services

Plan of Correction - To be completed: 10/02/2024

Residents Resident 5 and Resident 58 care plans are updated.
Initial audit will be conducted to determine if the facility's current residents who were admitted in the last 2 weeks did not have a Baseline Care Plan present. If not present, a care plan will be added.
DON or designee will review the facility policy, "Person-Centered Care Plan" with the nursing staff to ensure that baseline care plans explicitly include instructions for providing effective and person-centered care for residents requiring intravenous therapy within 48 hours of admission.
DON or designees will provide training to emphasize the importance of developing and implementing a baseline care plan within 48 hours of admission, and how to incorporate instructions for intravenous therapy into the plan.
DON or designess will perform audits weekly x4 then monthly x 2 to ensure that the baseline care plan includes initial goals for the resident, a list of current medications, dietary instructions, and services and treatments to be administered by the facility and personnel acting on behalf of the facility. The plan will reflect changes to approaches, as necessary, resulting from significant changes in condition or needs, occurring prior to the development of the comprehensive care plan. DON or designee will report all findings to be discussed in QAPI meeting x 3 months.

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 a review of clinical records, facility policies and documentation, and interviews with staff, it was determined that the facility failed to develop and implement comprehensive person-centered plans of care in a timely manner, for two of 21resident records reviewed (Residents R16 and R27).

Findings include:

Review of facilities policy, Person Centered Care Plan, revised October 24, 2022, revealed that a comprehensive, individualized care plan will be developed within seven days after completion of the comprehensive assessment (admission, annual or significant change) and review and revise the care plan after each assessment.

Review of Resident R16's clinical record revealed that resident was admitted on July 24, 2024. Further review of Resident R16's Admission MDS (Minimum Data Set- assessment of resident's needs) dated July 31, 2024, section title "Health Conditions", revealed that Resident R16 had shortness of breath or trouble breathing when lying flat.

Observation Resident R16 conducted on August 12, 2024, at 11:30 a.m. revealed that Resident R16 was wearing a nasal cannula connected to an oxygen concentrator. Resident R16 indicated that she usually has the oxygen on to help her breathe.

Review of R16's physician's orders revealed an August 11, 2024, order to continue supplemental oxygen to maintain saturation greater than 92%.

Interview on August 14, 2024, at 1:40 p.m. with Employee E10, Registered Nurse, confirmed that the resident was to receive continuous oxygen, and that she had just check her saturation level which was over 92%.

Interview with the Director of Nursing (DON) on August 14, 2024, at 1:45 p.m. confirmed that the resident had an order for oxygen and was receiving oxygen but had no care plan developed for oxygen therapy.

Review of Resident R27's clincial record revealed that resident was admitted on August 1, 2024. Review of R27's physician order, dated August 2, 2024, revealed the following treatment orders; " Sacrum: Cleanse with wound cleanser, apply Medi-honey, cover with Border gauze, every day shift for pressure wound; left elbow: cleanse with wound cleanser, apply adaptic, cover with gauze, and wrap with kling., every day shift for abrasion; left forearm: cleanse with wound cleanser, apply adaptic, Calcium alginate, cover with gauze and wrap with kling., every day shift for skin tear; right forearm: cleanse with wound cleanser, apply adaptic and wrap with kling, every day shift for abrasion; right heel: cleanse with wound cleanser, apply Betadine, cover with gauze and wrap around with kling, every day shift for deep tissue injury (DTI)".

On August 14, 2024, at 9:47 a.m., observed that, a Licensed Nurse, E21, administered pressure wound treatment to the Sacrum of R27 as ordered.

Reviewed Resident R27's clinical records revealed that there was no care plan developed for wound treatments for Resident R27.

On August 14, 2024, at 10:20 a.m., interviewed the Unit Manager, Registered Nurse, E22, and confirmed the finding.

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

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

Plan of Correction - To be completed: 10/02/2024

Residents 16 and Resident 27 care plans updated.
DON or Designee to complete a house wide audit to identify and correct residents with current IV therapy, wounds, and respiratory concerns that have not been addressed on the care plan and are not yet due for an assessment.
DON or designees will provide training to emphasize the importance of developing and implementing a comprehensive care plan within 7 days after completion of the comprehensive assessment, and how to incorporate measurable objectives and timeframes into the plan.
DON or Designee to complete random weekly audits for 4 weeks then monthly x 2 for 3 residents reviewing any triggered items identified on the MDS to ensure care plans are in place. All findings and education to be discussed during the QAPI meeting x 3 months.

483.24(a)(2) REQUIREMENT ADL Care Provided for Dependent Residents:

§483.24(a)(2) A resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene;

Observations:

Based on staff interviews, review of facility policy and the review of clinical records, it was determined that the facility failed to ensure that activities of daily living related to bathing was provided for one out of 26 residents reviewed (Resident R48).

Findings include:

Review of the facility policy, "Activities of Daily Living," with a revision date of May 1, 2023, indicated that when patients are assessed upon admission, quarterly and with a significant change to identify their status of activities of daily living, their inability to perform activities of daily living, their risk of decline in any activity of daily living and the resident's ability to improve in the identified activity of daily living (e.g. bathing, showering, toileting, eating, walking, transferring). The policy also indicated that adl (activities of daily living) care will be recorded in the resident's medical record, is reflective of the care provided by nursing staff, will be documented as close to the time that the care was provided and documented on every shift by thee nursing assistant.

Review of Resident R48's August 2024 physician orders indicated that the resident was admitted into the facility on June 3, 2024 with diagnoses of chronic kidney disease (the gradual loss of kidney function); hypertension (high blood pressure); chronic pain syndrome; cerebral infarction ( a stroke) and encephalopathy (a term used to describe damage or disease that affects that brain).

During an interview with the resident's wife on August 15, 2024 at 10:30 a.m. the resident' wife reported that it took the facility 3 weeks to provide her husband a shower when he was admitted into the facility. Review of the residents shower record from July 25, 2024 through August 14, 2024 did not document that the resident was offered to take a shower or tub bath and if so, what his response was. Bed bath's were recorded on the following days for the year, 2024: 7/28 7/30 7/31; 8/4; 8/6 ;8/9; 8/13.

During an interview with the Unit Manager (Employee E23)on August 15, 2024 at 3:34 p.m. Employee E23 reported that the resident is scheduled for showers on Wednesday and Saturdays. During the interview no additional evidence in the clinical record could be provided to show evidence that the resident had been offered showers on his assigned 2 shower days a week or any other days of the week.

28 Pa. Code 211,12(d)(1)(5) Nursing services

Plan of Correction - To be completed: 10/02/2024

Resident 48 shower schedule was reviewed and updated per preference to ensure completed as assigned.
Initial audit of current residents to ensure that shower schedules are being completed as per their schedule in POC
The Director of Nursing or designee will conduct education to nursing staff to ensure that current residents' showers are completed as scheduled.
Director of Nursing or designee to conduct Random audits of 5 MARs to be completed weekly x 4 weeks and then monthly x 2 to ensure nursing staff are completing shower schedules. The director of Nursing or designee will report all findings to be discussed in QAPI meeting x 3 months.

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 observations, review of facility policies, clinical record review and interviews with staff, it was determined that the facility failed to obtain and follow physician orders related to diet, urinary catheters and wound care for two of 26 residents reviewed (Residents R168 and R265).

Findings include:

Observation on August 12, 2024, at 10:17 a.m. revealed that Resident R265 had a dressing on her right knee; the dressing was dated August 9, 2024, at 8 p.m.

Review of Resident R265's Admission Assessment, dated August 7, 2024, at 3:00 p.m. revealed that the resident was admitted to the facility on August 7, 2024, with a diagnosis of right knee septic arthritis (infection of the knee).

Review of physician's orders for Resident R265, revealed an order, dated August 9, 2024, to cleanse right knee surgical incision with normal saline, pat dry, then apply clean dry dressing daily; monitor for any signs or symptoms of infection or drainage from suture site.

Continued observation and interview on August 12, 2024, at 10:51 a.m. revealed that Employee E4, licensed nurse, confirmed that the dressing on Resident R265's right knee was dated August 9, 2024, at 8 p.m. and that the dressing was prescribed by the physician to be changed daily. Employee E4, licensed nurse, then proceeded to complete the dressing change for the resident.

Review of the August 2024 physician orders for Resident R168 was admitted into the facility for respite care services with diagnosis that includes the following: cerebral vascular disease; malnutrition and dementia; and the need for mechanically altered diet/thickened liquids.

Continued review of the resident' August 2024 physician ordered included a physician's order dated August 2024 for the resident to have a puree texture diet with thick liquids that are nectar consistency (a liquid consistency that is reserved for individuals who difficulty swallowing. The consistency is easily pourable and comparable to apricot nectar or thicker cream soups).

During an observation in the resident's room on August 12, 2024 at 1:15 p.m. The resident was observed eating her lunch on her bedside table. Next to her lunch, a white styrophome cup was observed filled with water with a lid and a straw inserted. Employee E5 (licensed nurse) came to the room to remove the cup and confirmed that the resident should not have had the water served to her.

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

Plan of Correction - To be completed: 10/02/2024

Resident 265 orders were reviewed to ensure the correct treatment was in place and Resident 168's physician orders were reviewed for thickened liquid to ensure appropriate for the present dietary order.
The Director of Nursing or designee will conduct an Initial audit of current patients with dietary thickened liquid orders and communication to aides are provided on POC and wound care orders.
The Director of Nursing or designee will conduct education to nursing staff to ensure that current dietary restrictions related to thickened liquids and wound care are being followed per physician orders.
The Director of Nursing or designee will conduct Random visual audits of residents' wound treatments per physician orders are completed weekly x 3 weeks and then monthly x 2 to ensure nursing staff is recording proper documentation related to wound care and those with dietary restrictions for thickened liquids. The Director of Nursing or designee will report all findings to be discussed in QAPI meeting x 3 months.

483.25(l) REQUIREMENT Dialysis:

§483.25(l) Dialysis.
The facility must ensure that residents who require dialysis receive such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences.

Observations:

Based on staff interviews and the review of clinical records, it was determined that the facility failed to maintain complete and accurate records related to dialysis communication for one of one dialysis residents reviewed (Resident R48).

Findings include:

Review of Resident R48's clinical record revealed that the resident was admitted to the facility on July 22, 2024, and that Resident R48 had diagnoses of End-Stage Renal Disease (a medical condition in which a person's kidneys cease functioning on a permanent basis leading to the need for a regular course of long-term dialysis or a kidney transplant to maintain life).

Review of Resident R48's physician order, dated July 26, 2024, revealed that Resident R48 received dialysis treatment at an outpatient dialysis facility on Mondays, Wednesdays, and Fridays on 7/29/24; 8/5/24; and 8/7/24.

Review of Resident R48's Hemodialysis Communication Record revealed that on July 29, 2024, and on August 5, 2024, it was lacking all the information to be completed by licensed nurse for dialysis patient prior to dialysis treatment, and all the information to be completed by licensed nurse for dialysis patient's post dialysis treatment. Resident R48's Hemodialysis Communication Record also revealed that on August 7, 2024, it was lacking all the information to be completed by licensed nurse for dialysis patient's post dialysis treatment.

Interview with the licensed nurse of second floor, Employee E21, on August 13, 2024, at 11:10 a.m., confirmed lack of communication with dialysis center.

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

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

Plan of Correction - To be completed: 10/02/2024

Resident R48's dialysis communication has been updated to include missing information.
An initial audit will be conducted of current dialysis patients for the last 30 days to ensure communication records have been completed by the licensed nursing staff.
The Director of Nursing or designee will conduct education to licensed nursing staff who were educated on the policy related to dialysis communication.
Director of Nursing or designee to conduct Random audits of dialysis patients to be completed weekly x 3 weeks and then monthly x 2 to ensure nursing staff is completing the documentation pre/post dialysis. The director of Nursing or designee will report all findings to be discussed in QAPI meeting x 3 months.

483.35(d)(7) REQUIREMENT Nurse Aide Peform Review-12 hr/yr In-Service:

§483.35(d)(7) Regular in-service education.
The facility must complete a performance review of every nurse aide at least once every 12 months, and must provide regular in-service education based on the outcome of these reviews. In-service training must comply with the requirements of §483.95(g).

Observations:

Based on a review of facility documentation and interviews with staff, it was determined that the facility failed to complete performance reviews for three of three nurse aides personnel files reviewed related to performance reviews as required (Employees E16, E17 and E18).

Findings include:

Review of facility documentation pertaining to current employees, revealed that Employee E16 was hired by the facility as a nurse aide on July 8, 2002; Employee E17 was hired as a nurse aide on April 19, 2022; and Employee E18 was hired as a nurse aide on December 30, 2019.

On August 13, 2024, at 11:54 a.m. annual performance reviews for Employees E16, E17 and E18 were requested from the Nursing Home Administrator and Director of Nursing.

Interview on August 14, 2024, 10:06 a.m. the Nursing Home Administrator revealed that the facility had not completed any performance reviews for any staff, including Employees E16, E17 and E18.

28 Pa. Code 201.19(2) Personnel policies and procedures

Plan of Correction - To be completed: 10/02/2024

Employees 16, 17, and 18 annual evaluations will be completed.
Initial audit to be completed for any outstanding yearly performance reviews for current nurse aides and placed in the employee's personal file.
NHA, DON, and NPE were educated on ensuring nurse aides receive an annual performance review and will provide regular in-service education based on the outcome of these reviews.
Audits will be completed monthly x 4 weeks then monthly x 2 for nurse aide's performance reviews. About 3-4 performance reviews will be completed monthly for nurse aides. NPE or designee will report all findings to be discussed in QAPI meeting x 3 months.

483.45(f)(1) REQUIREMENT Free of Medication Error Rts 5 Prcnt or More:

§483.45(f) Medication Errors.
The facility must ensure that its-

§483.45(f)(1) Medication error rates are not 5 percent or greater;

Observations:

Based on observations, review of clinical records, and interviews with facility staff, it was determined that the facility failed to ensure that it was free of medication error rate of five percent or greater for one of three residents observed during medication administration. (Resident R220)

Findings include:

Observations conducted of medication administration on August 12, 2024, 9:20 a.m., with Registered Nurse , Employee E9, revealed that Resident R220 ordered " Metoprolol Tartrate Oral Tablet 25 MG (Metoprolol Tartrate), Give 1 tablet by mouth two times a day for Tachycardia; Rosuvastatin Calcium Oral Tablet 20 MG (Rosuvastatin Calcium), Give 1 tablet by mouth one time a day for HLD; Sertraline HCl Oral Tablet 100 MG (Sertraline HCl), Give 1 tablet by mouth one time a day for depression.

Registered Nurse , Employee E9, did not administered the medications listed above to Resident R220. Employee E9 stated that the Metoprolol Tartrate Oral Tablet 25 MG, Rosuvastatin Calcium Oral Tablet 20 MG, and Sertraline HCl Oral Tablet 100 MG were not available at that time. (Metoprolol Tartrate is a beta blocker used to treat a variety of conditions, including high blood pressure, chest pain, and irregular heartbeats. Rosuvastatin is a class of medications called Statins, which works by slowing the production of cholesterol in the body to decrease the amount of cholesterol that may build up on the walls of the arteries and block blood flow to the heart, brain, and other parts of the body. Sertraline is an antidepressant used to treat major depressive disorder, obsessive-compulsive disorder, panic disorder, post-traumatic stress disorder, and social anxiety disorder).

Review of nursing progress notes for R220, dated August 12, 2024, 11:24 a.m., related with the non-administration of Sertraline HCl Oral Tablet 100 MG indicated as follows: "Sertraline HCl Oral Tablet 100 MG (Sertraline HCl), Give 1 tablet by mouth one time a day for depression, not available, pharmacy called and will be delivered at 1 p.m.- run".

Review of nursing progress notes for R220, dated August 12, 2024, 11: 25 a.m., related with the non-administration of Rosuvastatin Calcium Oral Tablet 20 MG indicated as follows: "; Rosuvastatin Calcium Oral Tablet 20 MG (Rosuvastatin Calcium), Give 1 tablet by mouth one time a day for HLD, Meds not available, pharmacy called and will be delivered at 1 p.m.- run".

Review of nursing progress notes for R220, dated August 12, 2024, 11: 29 a.m., related with the non-administration of Metoprolol Tartrate Oral Tablet 25 MG indicated as follows: " Metoprolol Tartrate Oral Tablet 25 MG (Metoprolol Tartrate), Give 1 tablet by mouth two times a day for Tachycardia, not given, Meds not available, Nurse Practitioner notified, pharmacy called and will be delivered at 1 p.m.- run".

Review of Medication Administration Record(MAR) of R 220, revealed that passing on of medications Sertraline HCl Oral Tablet 100 MG, Rosuvastatin Calcium Oral Tablet 20 MG, and Metoprolol Tartrate Oral Tablet 25 MG were scheduled for administration at 9:00 a.m. of the day.

At the time of the observation, interviewed Employee E9, and confirmed the above findings.

The facility incurred a medication error rate of 11.54%.

28 Pa Code 211.12(d)(1)(2)(5) Nursing Services

Plan of Correction - To be completed: 10/02/2024

Resident 220's physician was made aware of the pending delivery and administered when medications were available.
An initial audit of the current residents for the last 3 days to determine if any other resident had missing medications, if any medications are identified the physician and pharmacy will be notified.
Licensed nursing staff will be re-educated by the Director of Nursing or designee on Pharmacy services procedure. Licensed nursing staff will be re-educated on Pharmerica pyxis location, access, and contents.
The Director of Nursing/designee will conduct weekly random audits x 4 weeks and then monthly x 2 to ensure no medications were missed, if any missed doses are identified, the pharmacy and physician will be notified.Results of the audit will be reported to the Quality Assurance Performance Improvement Committee x 3 monthly.

483.80(d)(1)(2) REQUIREMENT Influenza and Pneumococcal Immunizations:

§483.80(d) Influenza and pneumococcal immunizations
§483.80(d)(1) Influenza. The facility must develop policies and procedures to ensure that-
(i) Before offering the influenza immunization, each resident or the resident's representative receives education regarding the benefits and potential side effects of the immunization;
(ii) Each resident is offered an influenza immunization October 1 through March 31 annually, unless the immunization is medically contraindicated or the resident has already been immunized during this time period;
(iii) The resident or the resident's representative has the opportunity to refuse immunization; and
(iv)The resident's medical record includes documentation that indicates, at a minimum, the following:
(A) That the resident or resident's representative was provided education regarding the benefits and potential side effects of influenza immunization; and
(B) That the resident either received the influenza immunization or did not receive the influenza immunization due to medical contraindications or refusal.

§483.80(d)(2) Pneumococcal disease. The facility must develop policies and procedures to ensure that-
(i) Before offering the pneumococcal immunization, each resident or the resident's representative receives education regarding the benefits and potential side effects of the immunization;
(ii) Each resident is offered a pneumococcal immunization, unless the immunization is medically contraindicated or the resident has already been immunized;
(iii) The resident or the resident's representative has the opportunity to refuse immunization; and
(iv)The resident's medical record includes documentation that indicates, at a minimum, the following:
(A) That the resident or resident's representative was provided education regarding the benefits and potential side effects of pneumococcal immunization; and
(B) That the resident either received the pneumococcal immunization or did not receive the pneumococcal immunization due to medical contraindication or refusal.

Plan of Correction - To be completed: 10/02/2024

Residents will be offered pneumococcal vaccination per physician orders and residents preferences. Residents 46 and 37 were not identified on our sample list provided. The facility does have a policy in place for pneumococcal vaccination: IC601 Pneumococcal Vaccination.
An initial audit will be conducted to determine if current residents are eligible to be provided a pneumococcal vaccination per physician orders and resident preferences.
Infection Preventionist will be re-educated on ensuring to offer current residents the preference of a pneumococcal vaccination.
The Director of Nursing/designee will conduct weekly random audits x 4 weeks and then monthly x 2 to ensure pneumococcal vaccinations are being offered. Results of the audit will be reported to the Quality Assurance Performance Improvement Committee x 3 monthly.

483.90(g)(1)(2) REQUIREMENT Resident Call System:

§483.90(g) Resident Call System
The facility must be adequately equipped to allow residents to call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area from-

§483.90(g)(1) Each resident's bedside; and
§483.90(g)(2) Toilet and bathing facilities.

Observations:

Based on observations and staff interviews, it was determined that the facility failed to ensure that resident bathrooms were equipped with the appropriate call bell system for 3 out of 25 residents reviewed (Rooms 100,102 and 104)

Findings include:

During interview with the maintenance assistance, Employee E24 and the Nursing Home Administrator (NHA) on August 14, 2023 at 3:54 p.m. it was reported that the call bell system has been broken for the following rooms: 116, 100 102, 104, and 104. Rooms 100, 102 and 104 were confirmed to be currently occupied by residents.

Continued interview with the maintenance assistance and the NHA revealed that all three residents were provided with a handheld call bell system with a lanyard attached so that they can wear it around their neck.

During an observation in rooms 100 (Resident 315), 102 (Resident 26) and 104 (Resident R51) on August 14, 2024, at 11:00 a.m. the above referenced rooms were toured and the call bell system in the bathroom of each room also did not work to ensure that when the residents are utilizing that bathroom, they have a means to contact nursing staff for assistance should they not have their handheld call bell system with them or around their neck.

During a discussion with the Nursing Home Administrator and the Regional Nurse on August 15, 2024, at 5:30 p.m. the need for a separate call bell system in the bathroom for residents was discussed.

28 Pa. Code 205.67(j) Electric requirements for existing construction

Plan of Correction - To be completed: 10/02/2024

The resident call system was fixed on 8/ 29/24.
An initial whole house audit of the resident's call bell system-both bathroom and bedside will be completed to ensure function by the Maintenance Director or designee.
NHA and or designee will ensure to educate facility employees on reporting concerns in the TELS system to prioritize for maintenance.
Weekly audits x 4 and then monthly x 2 are to be conducted at random locations to ensure the call bell system is working. NHA or designee will report all findings to be discussed in QAPI meeting x 3 months.

483.95 REQUIREMENT Training Requirements:

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

Observations:

Based on review of personnel files, facility documentation and interviews with staff, it was determined that the facility failed to ensure that an effective training program was maintained as required for five of ten staff reviewed related to training (Employees E20, E18, E11, E14 and E15).

Findings include:

Review of the Facility Assessment, dated reviewed July 1, 2024, revealed that, "Staff training/education and competencies are necessary to provide support and care needed for the facility's short term resident population." Continued review revealed that required training topics include: effective communications; resident's rights; abuse, neglect and exploitation; infection control; and identification of resident changes in condition.

Review of facility documentation pertaining to current employees, revealed that Employee E20 was hired by the facility as a licensed practical nurse on May 28, 2019, Employee E18 was hired as a nurse aide on December 30, 2019, Employee E11 was hired as a nurse aide on July 16, 2024, Employee E14 was hired as a nurse aide on July 2, 2024, and Employee E15 was hired as a registered nurse on May 21, 2024.

Personnel records pertaining the trainings completed by Employees E20, E18, E11, E14 and E15 were requested from the Nursing Home Administrator and Director of Nursing on August 13, 2024, at 11:54 a.m.

Review of Employee E20's personnel file revealed that no annual trainings had been completed by the employee between August 14, 2023, through August 13, 2024.

Review of Employee E18's personnel file revealed that the employee had completed eight trainings between August 14, 2023, through August 13, 2024, that included: gait belt, hand hygiene, personal protective equipment, sliding board transfers, weighing patients, measuring patient height, protecting residents from assault and abuse, protecting resident's rights and dementia training. There was no documentation available for review at the time of the survey to indicate that the employee completed 12 hours of annual trainings or that training was completed on topics such as accident prevention, restorative nursing techniques, emergency preparedness, fire prevention, communication, QAPI (Quality Assurance Performance Improvement), ethics and behavioral health, as required.

Review of Employee E11's personnel file revealed that no documentation was available for review at the time of the survey related to abuse training, as required.

Review of Employee E14's personnel file revealed that no documentation was available for review at the time of the survey related to training for dementia, restorative nursing techniques, emergency preparedness, QAPI, ethics and behavioral health, as required.

Review of Employee E15's personnel file revealed that no documentation was available for review at the time of the survey related to abuse training, as required.

Interview on August 14, 2024, at 2:15 p.m. the Director of Nursing confirmed that the above items were not provided in the personnel files for Empoyees E20, E18, E11, E14 and E15.

28 Pa Code 201.19(7) Personnel policies and procedures

28 Pa Code 201.20(a)(1-6) Staff development

28 Pa Code 201.20(b) Staff development

28 Pa Code 201.20(d) Staff development

Plan of Correction - To be completed: 10/02/2024

Employees E20, E18, E11, E14, and E15 annual training will be completed and placed in the employee's personnel file.
An initial audit of present employees to report annual training NHA or designee will provide education to staff on ensuring educations are completed on Healthstream timely.
NPE will be educated on reviewing current staff proficiency on annual educations to be completed. Educations that are not available on Healthstream will be completed by the NPE or designee.
NPE or designee will do monthly audits x 4 weeks then monthly x 2 to ensure current staff are receiving mandatory educations. NHA or designee will report all findings to be discussed in QAPI meeting x 3 months.

§ 201.19(2) LICENSURE Personnel policies and procedures.:

(2) Employee performance evaluations, including documentation of any monitoring, performance, or disciplinary action related to the employee.

Observations:

Based on a review of facility documentation and interviews with staff, it was determined that the facility failed to complete performance reviews for staff as required for two of two licensed nurse personnel files reviewed related to performance reviews (Employees E19 and E20).

Findings include:

Review of facility documentation pertaining to current employees, revealed that Employee E19 was hired by the facility as a registered nurse on December 22, 2011, and Employee E20 was hired as a licensed practical nurse on May 28, 2019.

On August 13, 2024, at 11:54 a.m. annual performance reviews for Employees E19 and E20 were requested from the Nursing Home Administrator and Director of Nursing.

Interview on August 14, 2024, 10:06 a.m. the Nursing Home Administrator revealed that the facility had not completed any performance reviews for any staff, including Employees E19 and E20.

Plan of Correction - To be completed: 10/02/2024

Employees 19 and 20 will have their performance reviews completed and placed in the personal employee files.
Initial audit for current Licensed Nurse's performances to be reviewed and if not completed will be updated.
NHA or designee will provide education to facility leadership on ensuring performance evaluations are completed for all staff.
Monthly audits of employee yearly reviews completed x 4 weeks then monthly will be completed to ensure staff are receiving performance reviews. NPE or designee will report all findings to be discussed in QAPI meeting x 3 months.

§ 211.9(j.1) (1) - (5) LICENSURE Pharmacy services.:

(j.1) The facility shall have written policies and procedures for the disposition of medications that address all of the following:
(1) Timely and safe identification and removal of medications for disposition.
(2) Identification of storage methods for medications awaiting final disposition.
(3) Control and accountability of medications awaiting final disposition consistent with standards of practice.
(4) Documentation of actual disposition of medications to include the name of the individual disposing of the medication, the name of the resident, the name of the medication, the strength of the medication, the prescription number if applicable, the quantity of medication and the date of disposition.
(5) A method of disposition to prevent diversion or accidental exposure consistent with applicable Federal and State requirements, local ordinances and standards of practice.

Observations:

Based on clinical record review and staff interview, it was determined that the facility failed to provide a disposition and count of unused medications at discharge for three of three closed records reviewed. Residents (R63, R166 and R62).

Findings include:

Review of R63's clinical record revealed that this resident was admitted to the facility on July 3, 2024, and discharged to the hospital on July 16, 2024. Further review of the closed clinical record revealed that there was no documentation to indicate the method of disposition or quantity of the resident's medications at discharge.

Review of the closed clinical record for Resident R166 revealed that this resident was admitted to the facility on July 1, 2024, and was discharged home with home care services. Further review of the closed clinical record revealed that there was no documentation to indicate the method of disposition or quantity of the resident's medications at discharge.

Review of the closed clinical record for Resident R62 revealed that this resident was admitted on March 19, 2021, and expired on June 26, 2024, in the facility. Further review of the closed clinical record revealed that there was no documentation to indicate the method of disposition or quantity of the resident's medications at discharge.

An electronic request was sent on August 16, 2024, at 1:05 p.m. to the Nursing Home Administrator and Employee E3, Regional Nurse, requesting the disposition of medications at discharge for Resident R63, R166 and R62, with no response by 3:30 p.m.

In an interview with the Nursing Home Administrator at 3:05 p.m. on August 15, 2024, she indicated that they were unable to locate these medication dispositions and the above findings were confirmed that the facility had failed to document the disposition of these resident's medications upon discharge/death.

Plan of Correction - To be completed: 10/02/2024

Residents 62, 63, and 166 had disposition records available for review at the time of the survey
Initial audit to be completed of the last 2 weeks of current residents to ensure disposition of medications have been completed for any discharged residents.
DON or designee will provide education to the licensed nursing staff on completing a record of disposition upon discharge.
DON or designee will do random audits x 4 weeks and then monthly x 2 to ensure that licensed nurses are completing medication disposition upon discharge of residents. DON or designee will report all findings to be discussed in QAPI meeting x 3 months.

§ 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.

Observations:

Based on review of nursing staff schedules, punch reports and interviews with staff, it was determined that the facility failed to maintain required staffing ratios, including one nurse aide per 10 residents during the day shift, on one of fourteen days reviewed (July 7, 2024).

Findings include:

Review of facility census data revealed that on July 7, 2024, the facility census was 70, which required 52.5 hours of nurse aides during the day shift. Review of the nursing time schedules and punch reports revealed 50.08 hours of nurse aide care was provided during the shift. No additional excess higher-level staff were available to compensate this deficiency.

Staffing calculations, nursing staff schedules and staff punch reports were reviewed with the Nursing Home Administrator on August 15, 2024, at 12:33 p.m. The Nursing Home Administrator confirmed that the required staffing ratios for nurse aides was not met on the above date.

Plan of Correction - To be completed: 10/02/2024

1) Nurse aide staffing ratios will be reviewed for the last 7 days to evaluate if nurse aide ratios are met.
3) The nursing admin and scheduler will be re-educated on the new July 1 nurse staffing and PPD requirements.
4) Weekly audit of nurse aid ratios will be conducted for 4 weeks then monthly x 2 by NHA/designee to ensure nurse aid ratios are met. Tracking and trends are to be submitted to the QAPI committee.

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