Pennsylvania Department of Health
MONROEVILLE POST ACUTE
Patient Care Inspection Results

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MONROEVILLE POST ACUTE
Inspection Results For:

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MONROEVILLE POST ACUTE - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:
Based on a Medicare/Medicaid Recertification, State Licensure,Civil Rights Compliance, and Abbreviated Survey in response to nine complaints completed on December 20, 2024, it was determined that Monroeville Post Acute was not in compliance with the following requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care and the 28 Pa. Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.


 Plan of Correction:


483.60(i)(1)(2) REQUIREMENT Food Procurement,Store/Prepare/Serve-Sanitary:This is a less serious (but not lowest level) deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents.  This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
§483.60(i) Food safety requirements.
The facility must -

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

§483.60(i)(2) - Store, prepare, distribute and serve food in accordance with professional standards for food service safety.
Observations:
Based on facility policy review, observations, and staff interview, it was determined that the facility failed to restrain hair and failed to perform handing washing to prevent the potential for cross contamination in the Kitchen.

Findings include:

Review of facility policy "Preventing Foodborne Illness - Employee Hygiene and Sanitary Practices" reviewed 11/1/24, indicated food and nutritional services employees follow appropriate hygiene and sanitary procedures to prevent the spread of foodborne illness. Employees must wash their hands after handling soiled equipment or utensils. Hair nets or caps and/or beard restraints are worn when cooking, preparing, or assembling food to keep hair from contacting exposed food, clean equipment, utensils, and linens.

Review of facility policy "Policies and Procedures - Infection Prevention and Control" reviewed 11/1/24, indicated the facility adopted infection prevention and control policies and procedures intended to help maintain a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections.

During an observation in the Kitchen on 12/18/24, between 11:30 a.m. and 12:30 p.m., the following was observed:

-At 11:33 a.m. Kitchen Aide Employee E5 was observed gathering food items for the dinner meal prep with a hair net that did not cover her two braided buns on the back of her head.
-At 11:34 a.m. Kitchen Aide Employee E6 was observed working tray line assembly without a beard guard on.
-At 12:15 p.m. Cook Employee E16 was observed placing soiled dishes in the dishwasher, and without washing her hands putting the clean dishes away.

During an interview on 12/18/24, at 11:35 a.m., Kitchen Aide Employee E5 confirmed she did not have the hair net fully covering her hair.

During an interview on 12/18/24, at 12:15 p.m., Cook Employee E16 confirmed she failed to wash her hands in between soiled and clean dishes.

During an interview on 12/18/24, at 12:20 a.m., Dietary Manager Employee E7 confirmed the facility failed to properly restrain hair in hair nets and beard guards and failed to prevent cross contamination by not washing hands in between soiled and clean dishes.

During an observation of the First Floor nutrition room on 12/17/24, at 2:08 p.m., the following was observed:
-A glass mason jar with what appeared to be soup in it, with no name and no date.
-A partially consumed bottle of strawberry lemonade, with no name and no date, that felt swollen.
-A take-out food container with a resident room number on it, with no date.
-One large box of rice cereal, open and undated.
-One large box of raisin bran cereal, open and undated.
-Two bags of tortilla chips, open and undated, with only the top of the bag folded over.
-One package of chocolate sandwich cookies, open to air, with no name or date.

During an interview on 12/20/24, at approximately 1:00 p.m., the Nursing Home Administrator and the Director of Nursing confirmed the facility failed to restrain hair and failed to perform handing washing to prevent the potential for cross contamination in the Main Kitchen and failed to properly label food items in one of two nutrition rooms.

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


 Plan of Correction - To be completed: 01/28/2025

Kitchen staff are now being observed with proper hair and beard nets on at all times in the kitchen as well dishes being put away and cleaned properly. Food item not dates are now dated properly and closed properly to keep. Food items are labeled appropriately as of 12-30-24. Employees E5,E6,E7 and E16 will be educated by the CDM or designee on: being observed with proper hair and beard nets on at all times in the kitchen as well dishes being put away and cleaned properly, food item not dates are now dated properly and closed properly to keep and food items being labeled appropriately. Audits will be completed 3 times a week for 4 weeks then monthly thereafter to ensure that kitchen staff are being observed with proper hair and beard nets on at all times in the kitchen as well dishes being put away and cleaned properly, food item not dates are now dated properly and closed properly to keep and food items being labeled appropriately. Results of this audit will be taken to the monthly quality assurance meeting and reviewed for accuracy.
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 clinical record review, staff interview, and observation, it was determined that the facility failed to provide an environment and care to promote dignity for each resident's quality of life for two of 16 sampled residents (Resident R47 and R36).

Findings:

Review of facility policy "Dignity" reviewed 11/1/24, indicated each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem.

The "Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual," which provides instructions and guidelines for completing required Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2023, indicated that a BIMS (Brief Interview of Mental Status) is a brief screener that aids in detecting cognitive impairment. Scores from a BIMS assessment suggests the following distributions:
13 - 15: cognitively intact
8 - 12: moderately impaired
0 - 7: severe impairment

Review of the clinical record revealed Resident R47 was admitted to the facility on 6/19/24.

Review of the Minimum Data Set (MDS - a mandated assessment of a resident's abilities and care needs) dated 9/26/24, included diagnoses of dementia (a group of symptoms that affects memory, thinking and interferes with daily life) and muscle wasting. Review of Section C: Cognitive Patterns, indicated severe cognitive impairment. Review of Section G:, revealed physical impairments of both the upper and lower extremities on both sides of the body, and that Resident R47 was dependent on staff for both upper and lower body dressing.

During an observation on 12/17/24, at 9:37 a.m. Resident R47 was in the hallway, dressed in a sweater and athletic shoes. Resident R47 did not have any clothing on her lower body, and the brief was visible.

During an interview on 12/17/24, at 9:40 a.m. Unit Manager Employee E3 confirmed that Resident R47 had no clothing on the lower body.

During an interview on 12/20/24, at Nurse Aide Employee E4 stated, when asked if Resident R47 was able to put her clothing or shoes on, or take them off, stated, "No, not at all."

Review of the clinical record revealed Resident R36 was admitted to the facility on 5/28/24.

Review of the MDS dated 9/3/24, included diagnoses of Myelopathy (an injury to the spinal cord symptoms can include pain, difficulty walking loss of bowel and bladder control) and cervical vertebra fractures (commonly called a broken neck). Review of Section C: Cognitive Patterns, indicated, intact cognition with a BIMS Score of 14. Review of Section GG 0130 Functional Abilities and Goals: revealed Resident R36 was dependent for bed and chair mobility.

During an interview on 12/18/24, at 10:56 a.m. Resident R36 stated one night in 10/24 (unable to recall exact date) his call light repeatedly activated on its own. A staff member entered his room and said, "you touch that thing one more time and you're getting in the hoyer and going to the television room for the rest of the night". At approximately 1:30 a.m. staff got Resident R36 out of bed and placed him in the television room until approximately 7:30 a.m. Resident R36 asked facility staff for a supervisor and he contacted the police from his cell phone. He reported the police informed him he needs to work this out with the facility, and he did not get to see the facility supervisor. Resident R36 stated he was informed the day after the incident, there was a malfunction with his call light that was repaired.

During an interview on 12/18/24, with the Nursing Home Administrator (NHA) a request was made for work orders and repairs to the call system for the month of 10/24. The NHA confirmed the TELS (electronic work order system) was not functioning during this time and there are no records available for review.

During review of facility reported incidents and the facility complaint and grievance files for the months of September, October, November and December, there is no record of the event.

During an interview on 12/19/24, at approximately 2:21 p.m., the NHA and Director of Nursing (DON) confirmed they were unaware of this event reported by Resident R36. The NHA and DON confirmed that an investigation, report, and follow up will be conducted.

During an interview on 12/20/24, at approximately 1:00 p.m. the Nursing Home Administrator and the Director of Nursing confirmed the facility failed to provide an environment and care to promote dignity for each resident's quality of life for two of sixteen residents.

28 Pa. Code 201.29(j) Resident rights.


 Plan of Correction - To be completed: 01/28/2025

A deficiency was cited for dignity. R 47 was immediately dressed. R 36 had allegations of neglect that were brought to our attention on 12/19. R36 was immediately interviewed and a report was generated in the State ERS. Investigation was conducted and no AP was able to be identified. Resident's with a BIMS of 13 or above were interviewed in that hallway for neglect, care, and isolation concerns. No further issues were identified or alleged. All residents have the potential to be affected by this deficiency. All bedside staff will be educated on the Resident's right for dignity. Grievances and electronic documentation will be monitored 3 times a week for 4 weeks to identify any potential reportable allegations or complaints, by the DON, or designee. Then monitoring will be conducted weekly for 3 months. Rounding visual survey will be completed 3 times a week for 4 weeks for failure to maintain dignity by the DON, or designee. Then monitoring will be conducted weekly for 3 months. The corrective action shall be completed by January 28, 2025. Results of this audit will be taken to the monthly quality assurance meeting and reviewed for accuracy.


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

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

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

§483.70(n)(4) Each LTC facility providing hospice care under a written agreement must ensure that each resident's written plan of care includes both the most recent hospice plan of care and a description of the services furnished by the LTC facility to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, as required at §483.24.
Observations:
Based on review of facility policy, resident clinical records and staff interview, it was determined that the facility failed to maintain hospice records for three out of five residents receiving hospice services (Resident R2, R72, and R92).

Findings include:

The facility "Hospice Services Agreement" policy dated 8/28/23, indicated that the facility will participate in hospice care as an approach for terminally ill residents. The facility must ensure that the hospice services meet professional standards and principles that apply to individuals providing services in the facility.

Review of facility policy "Hospice Program" reviewed 3/15/24 and 11/1/24, indicated hospice services are available ro residents at the end of life. Collaborating with hospice representatives and coordinating staff participation in the hospice care planning, communicating with hospice representatives and other healthcare providers participating in the provision of care for the terminal illness, related conditions to ensure quality of care for the resident, and ensuring the facility communicates with the hospice medical director, the resident's attending physician, and other practitioners participating in the provision of care to the resident as needed to coordinate the hospice care with the medical care provided by other physicians. The following information must be obtained from the hospice service:

-the most recent plan of care, specific to each resident.
-hospice election form
-physician certification and recertification of the terminal illness specific to each resident
-names and contact information for hospice personnel involved in the hospice care of each resident
-instructions on how to access the hospice's 24 hour on-call system
-hospice medication information
-hospice physician and attending physician (if any) orders specific to each resident.

Review of Resident R2's admission record indicated she was admitted on 10/7/19.

Review of Resident R2's MDS assessment (MDS-Minimum Data Set assessment: periodic assessment of resident care needs) dated 11/9/24, indicated she had diagnoses that included Cerebral Palsy (group of neurological disorders that affect a person's ability to move, maintain balance, and control their muscles). The MDS assessment Section O-0110 Special treatments indicated an "x" for hospice services.

Review of Resident R2's care plan dated 12/1/24, indicated she had hospice services.

Review of Resident R2's physician order dated 11/9/24, indicated to admit to hospice.

Review of a practitioner progress note dated 12/9/24, indicated Resident R2 is on hospice services.

Review of Resident R2's hospice records did not include the hospice election documentation signed by Resident R2's Representative, hospice visit documents after 11/9/24, and hospice plan of care documents dated after 11/9/24.

Reivew of Resident R72's admission record indicated she was admitted on 7/20/22.

Review of Resident R72's MDS dated 10/24/24, indicated diagnoses of high blood pressure, dementia (group of symptoms affecting memory, thinking and social abilities), and anxiety.

Review of Resident R72's physician order dated 10/21/24, indicated admit to hospice.

Review of Resident R72's care plan dated 7/17/23, indicated she had hospice services.

Review of Resident R72's hospice record did not include the hospice election documentation signed by Resident R72 or representative, hospice visit documentation, medications, hospice providers, and current hospice plan of care.

Reivew of Resident R92's admission record indicated he was admitted on 9/8/22.

Review of Resident R92's MDS dated 12/13/24, indicated diagnoses of high blood pressure, dementia and hemiplegia (paralysis of one side of the body) following cerebral infarction (blood flow to the brain is obstructed by a blood clot resulting in death of brain cells) affecting left side.

Review of Resident R92's physician order dated 8/30/24, indicated admit to hospice.

Review of Resident R92's care plan dated 10/18/24, indicated he had hospice services.

Review of Resident R92's hospice record did not include the hospice election documentation signed by Resident R92 or representative, hospice visit documentation, medications, hospice providers, and current hospice plan of care.

During an interview on 12/20/24, at 12:30 p.m. the Director of Nursing (DON) confirmed that the facility failed to maintain hospice records for Residents R2, R72, and R92 as required.

28 Pa Code: 211.5(f)(h) Clinical records.

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



 Plan of Correction - To be completed: 01/28/2025

Residents R2, R72, R92 have had their hospice records obtained and placed in their hospice binders. All other like residents will have their hospice binders updated as their records can be obtained. All hospice liasons will be educated, by the DON or designee, on the facility Hospice Services expectations for maintaining the hospice binders. The hospice liasons will provide the education to their healthcare staff. These hospice binders will be audited weekly for 4 weeks and then quarterly for compliance by the DON or designee. Results of this audit will be taken to the monthly quality assurance meeting and reviewed for accuracy.
483.20(f)(5), 483.70(h)(1)-(5) REQUIREMENT Resident Records - Identifiable Information:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
§483.20(f)(5) Resident-identifiable information.
(i) A facility may not release information that is resident-identifiable to the public.
(ii) The facility may release information that is resident-identifiable to an agent only in accordance with a contract under which the agent agrees not to use or disclose the information except to the extent the facility itself is permitted to do so.

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

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

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

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

§483.70(h)(5) The medical record must contain-
(i) Sufficient information to identify the resident;
(ii) A record of the resident's assessments;
(iii) The comprehensive plan of care and services provided;
(iv) The results of any preadmission screening and resident review evaluations and determinations conducted by the State;
(v) Physician's, nurse's, and other licensed professional's progress notes; and
(vi) Laboratory, radiology and other diagnostic services reports as required under §483.50.
Observations:
Based on review of facility policies and clinical records and staff interview, it was determined that the facility failed to make certain that medical records on each resident are complete and accurately documented for two of six residents (Resident R106 and R42).

Findings include:

Review of facility policy "Charting and Documentation" dated 3/15/2024, indicated "Documentation of procedures and treatments shall include care-specific details and shall include at a minimum, whether the resident refused the procedure/treatment, signature, and title of individual documenting.

Review of Resident R106's clinical record indicated the resident was admitted to the facility on 11/8/24.

Review of Resident R106's Minimum Data Set (MDS - a periodic assessment of care needs) dated 11/15/24, indicated diagnoses of pressure ulcer (PU) of sacral region, pressure ulcer of left hip (open wound with tissue damage), paraplegia (paralysis of the lower half of the body) and severe protein calorie malnutrition (not enough protein and calories are consumed and/or metabolized).

Review of a physician order dated 11/12/24, cleanse left hip with NSS and pack with Dakins solution and apply santyl and cover with optifoam dressing every day shift and PRN for unstageable PU.

Review of Resident R106's Treatment Administration Record (TAR), daily entires from 12/1/24 through 12/18/24, revealed no entries made for the left hip treatment on 12/2, 12/5, 12/7, 12/10, 12/11, 12/12, 12/13, and 12/15.

Review of a physician order dated 12/9/24 cleanse left buttock with NSS and apply Xeroform and cover with optifoam dressing every day shift and PRN for abrasion.

Review of Resident R106's Treatment Administration Record (TAR), daily entires from 12/1/24 through 12/18/24, revealed no entries made for the left buttock treatment on 12/11, 12/13, and 12/15.

During an interview on 12/19/24 at 1:45 p.m., The Director of Nursing (DON) confirmed the above findings and that the facility failed to make certain that medical records were complete and accurately documented for one of four residents (Resident R106).

Review of Resident R42's clinical record indicated the resident was admitted to the facility on 3/2/23, and readmitted on 6/25/24.

Review of Resident R42's MDS dated 10/2/24, included diagnoses of hemiplegia (paralysis on one side of the body) and post-surgical infection.

Review of hospital discharge paperwork dated 6/18/24, indicated the removal of Resident R42's gastrostomy tube (a feeding tube inserted through the wall of the abdomen directly into the stomach).

Review of Resident R42's physician and nurse practitioner progress notes from July 2024, through December 2024, included information of current nighttime tube feedings in each of the notes.

During a interview on 12/19/24, at 1:00 p.m., the DON confirmed that the provider progress notes failed to accurately represent Resident R42's current health status.

During an interview on 12/20/24, at approximately 1:00 p.m., the Nursing Home Administrator and the DON confirmed that the facility failed to make certain that medical records on each resident are complete and accurately documented for two of six residents.

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



 Plan of Correction - To be completed: 01/28/2025

There is no way to retroactively chart on missing documentation. All residents have the potential to be affected by this deficiency. All RN/LPN will be educated on the Charting and Documentation policy by the staff development coordinator. The DON will educate the providers on properly documenting the current health status of our residents. R106 and R42's EHR will be audited three times a week by the DON or designee, for 4 weeks, for completion and accuracy along with 4 random residents. Then audits will be conducted weekly for 3 months. This deficiency will be corrected by January 28, 2025. Results of this audit will be taken to the monthly quality assurance meeting and reviewed for accuracy.
483.60(f)(1)-(3) REQUIREMENT Frequency of Meals/Snacks at Bedtime:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
§483.60(f) Frequency of Meals
§483.60(f)(1) Each resident must receive and the facility must provide at least three meals daily, at regular times comparable to normal mealtimes in the community or in accordance with resident needs, preferences, requests, and plan of care.

§483.60(f)(2)There must be no more than 14 hours between a substantial evening meal and breakfast the following day, except when a nourishing snack is served at bedtime, up to 16 hours may elapse between a substantial evening meal and breakfast the following day if a resident group agrees to this meal span.

§483.60(f)(3) Suitable, nourishing alternative meals and snacks must be provided to residents who want to eat at non-traditional times or outside of scheduled meal service times, consistent with the resident plan of care.
Observations:
Based on review of facility policy and interview with residents and staff, it was determined that the facility failed to routinely offer or make available evening snacks as desired by nine of ten oriented residents (Residents R500, R501, R502, R503, R504, R505, R507, R508, and R509).

Findings include:

A review of facility policy "Snacks (Between Meal and Bedtime), Serving" dated 3/15/24. Indicates the purpose is to provide the resident with adequate nutrition. Facility staff report any problems or complaints made by the resident related to the snack. Report other information in accordance with the facility policy and professional standards of practice.

Review of facility Snack Audits conducted during the months of August and September 2024 revealed only the volume and itemized list of snacks that were delivered to the nursing units.

During a resident group interview on 12/17/24, at 10:30 a.m., nine of ten residents in attendance stated that they are not consistently offered a nourishing evening snack and there are not enough snacks for those who request them (Residents R500, R501, R502, R503, R504, R505, R507, R508, and R509). The residents in attendance expressed frustration about not having snacks and the alternative is purchasing snacks from the vending machine. The residents reported they no longer share this at the Resident Council Meeting as they fell it's a waste of time as there has been no improvement with snack availability.

During an interview on 12/19/24, at approximately 2:15 p.m., the Nursing Home Administrator and Director of Nursing were unable to explain why residents are reporting the facility does not have enough evening snacks. The Director of Nursing confirmed it is the facility's policy to offer and serve residents a nourishing snack in accordance with their needs, preferences, and requests at bedtime.

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


 Plan of Correction - To be completed: 01/28/2025

NHA has assured that residents are getting evening snacks as 12-30-24 to all residents including R500,R501,R502,R503,R504,R505,R507,R508 and R509. CDM will be educated by the NHA on the importance of having evening snacks available as well as the DON for Nursing to be on passing the snack timely and frequently. Resident satisfaction interviews will be conducted to ascertain if receipt of evening snacks is occurring by the NHA. Audits will be completed 3 times a week for 4 weeks then monthly thereafter by the CDM or designee to ensure evening snacks are available and being passed frequently. Results of this audit will be taken to the monthly quality assurance meeting and reviewed for accuracy.
483.35(a)(1)(2) REQUIREMENT Sufficient Nursing Staff:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
§483.35(a) Sufficient Staff.
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 §483.71.

§483.35(a)(1) The facility must provide services by sufficient numbers of each of the following types of personnel on a 24-hour basis to provide nursing care to all residents in accordance with resident care plans:
(i) Except when waived under paragraph (e) of this section, licensed nurses; and
(ii) Other nursing personnel, including but not limited to nurse aides.

§483.35(a)(2) Except when waived under paragraph (e) of this section, the facility must designate a licensed nurse to serve as a charge nurse on each tour of duty.
Observations:
Based on review of facility policy, resident observations, resident and staff interviews, and grievance review, it was determined that the facility failed to have sufficient nursing staff to provide nursing and related services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of 17 of 17 residents (Residents R10, R16, R59, R105, R27, R36, R318, R500, R501, R502, R503, R504, R505, R506, R507, R508, and R509.

Findings include:

Review of the facility policy "Call System" dated 11/1/24, indicated calls for assistance are answered as soon as possible.

During an observation on 12/16/24, at 2:40 p.m., the call light for Resident R59 was noted to be alarming.

During an interview on 12/16/24, at 2:46 p.m. Resident R59 was asked why she needed help, and she responded that she was thirsty, and hadn't had a drink.

During an observation on 12/16/24, at 2:51 p.m. Registered Nurse (RN) Employee was observed walking by Resident R59's room door and looking inside. When it appeared that she noted the State Agency (SA) in the room, stopped abruptly, looked up at the call light, and backed up to enter the room to assist the resident.

During a resident group interview on 12/17/24, at 10:30 a.m.,, ten of ten residents in attendance stated it often takes one hour or more for call lights to be answered (Residents R500, R501, R502, R503, R504, R505, R506, R507, R508, and R509).

During an interview on 12/17/24, at 11:54 a.m., Resident R105, when asked if she felt the facility maintained sufficient staff, stated, "No" and further stated that "call lights take forever."

During an interview on 12/17/24, at 12:00 p.m., Resident R27, when asked about call light response, stated it could be very long.

During an interview on 12/17/24, at 2:34 p.m., Resident R318, when asked if he felt the facility maintained sufficient staff, stated, "They are low on staffing, have a skeleton crew."

During an interview on 12/17/24, at 2:38 p.m. Resident R319, when asked if she felt the facility maintained sufficient staff, stated, "No." Resident R319 proceeded to describe long waits for call light responses, long waits for prescribed medications, and the need to go to the nurses' station for assistance as staff who stated they would assist her when answering the call light never returned to do so.

During an interview on 12/18/24, at 10:30 a.m. Resident R10, when asked if she felt call lights are answered timely. Resident R10 laughed and asked, "are you serious, it takes forever to get help".

During an interview on 12/18/24, at 10:40 a.m. Resident R16, when asked to detail call light response time, she asked, "is this a joke". "You must plan ahead for what you need, you can find yourself waiting up to an hour or more for help."

During an interview on 12/18/24, at 10:56 a.m. Resident R36, when asked his thoughts on call light response. "I waited 5 hours once to be cleaned after soiling myself." "You're lucky if it takes less than an hour to get help."

During an interview on 12/20/24, at approximately 1:00 p.m. the Nursing Home Administrator and the Director of Nursing confirmed that the facility failed to have sufficient nursing staff to provide nursing and related services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of 17 of 17 residents.


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

28 Pa. Code 201.18(e)(6) Management.

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

28 Pa. Code: 211.12(a)(c)(d)(1)(2)(3)(4) Nursing services.


 Plan of Correction - To be completed: 01/28/2025

Education will be provided on appropriate call bell response protocol to all bedside staff by the staff development coordinator. Call bell audits will be conducted to monitor call bell response times for 3 days a week for 4 weeks. Resident satisfaction monitoring interviews will be conducted by the DON to assure call bells are being answered in a timely manner. Then weekly for 3 months, by the DON, or designee. The Activities Director will have Resident Council agree to an acceptable call bell response time. This will be completed by January 28, 2025.Results of this audit will be taken to the monthly quality assurance meeting and reviewed for accuracy.
483.10(i)(1)-(7) REQUIREMENT Safe/Clean/Comfortable/Homelike Environment:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
§483.10(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 observations and resident and staff interviews it was determined that the facility failed to provide a clean and homelike environment on one of six nursing units (One East nursing unit) and for two of two residents (Residents R35 and R4).

Findings include:

During an observation on 12/20/24, at 11:00 a.m., of the One East nursing unit (Room of R4 and R35) the ceiling tile above the toilet revealed a large brown colored stain.

During an interview on 12/20/24, at 11:05 a.m., Resident R35 stated "The ceiling leaks down the wall and onto the floor." "It's been going on for a long time."

During an interview on 12/20/24 at 11:05 a.m., Resident R4 stated "They changed the tile 3 times and it keeps happening."

During an interview on 12/20/24 at 11:30 a.m., The Nursing Home Administrator confirmed the above findings and that the facility failed to provide a clean, comfortable homelike environment on One East nursing.


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

28 Pa. Code: 201.29(k) Resident rights.



 Plan of Correction - To be completed: 01/28/2025

Ceiling leak will be fixed on 1-3-25 by a contracted vendor. Facility Maintenance Director will be responsible for replacing ceiling tiles after the leak is fixed. A vendor receipt will be provided at the time of the repair. Maintenance Director will be educated by the NHA on making repairs timely to ensure a safe homelike environment. Audits will completed by the NHA or designee 3 times a week times 4 weeks then monthly thereafter to ensure a safe homelike environment is present in the facility. Results of this audit will be taken to the monthly quality assurance meeting and reviewed for accuracy.
483.45(g)(h)(1)(2) REQUIREMENT Label/Store Drugs and Biologicals: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.
§483.45(g) Labeling of Drugs and Biologicals
Drugs and biologicals used in the facility must be labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable.

§483.45(h) Storage of Drugs and Biologicals

§483.45(h)(1) In accordance with State and Federal laws, the facility must store all drugs and biologicals in locked compartments under proper temperature controls, and permit only authorized personnel to have access to the keys.

§483.45(h)(2) The facility must provide separately locked, permanently affixed compartments for storage of controlled drugs listed in Schedule II of the Comprehensive Drug Abuse Prevention and Control Act of 1976 and other drugs subject to abuse, except when the facility uses single unit package drug distribution systems in which the quantity stored is minimal and a missing dose can be readily detected.
Observations:
Based on review of facility policy, observations, and staff interview, it was determined that the facility failed to make certain that medications were properly stored and/or disposed of in one of two medication rooms (First Floor medication room).

Findings include:

Review of facility policy "Medication Labeling and Storage" dated 11/1/24, stated that if the facility has discontinued, outdated, or deteriorated medications or biologicals, the dispensing pharmacy is contacted for instructions regarding returning or destroying these items.

During an observation of the First Floor medication room on 12/16/24, at 2:05 p.m. the following was observed:
-(1) vacutainer with an expiration date of 5/31/23.
-(2) vacutainers with an expiration date of 11/30/23.
-(34) vacutainers with an expiration date of 2/29/24.
-(6) vacutainers with an expiration date of 3/31/24.
-(10) vacutainers with an expiration date of 4/30/24.
-(6) vacutainers with an expiration date of 8/31/24.
-(5) vacutainers with an expiration date of 9/30/24.
-(1) I.V. start kit with an expiration date of 2/29/24.
-(6) Bacterial collection culture bottles with an expiration date of 11/6/24.
-(6) Bacterial collection culture bottles with an expiration date of 11/13/24.
-(4) Glucose monitoring control solutions with an expiration date of 9/22/24.
-(1) Package of wound vacuum dressing with an expiration date of 2/29/24.

During an interview on 12/16/24, at 2:36 p.m. Unit Manager Employee E3 confirmed the above observations.

During an interview on 12/20/24, at approximately 1:00 p.m. the Nursing Home Administrator and the Director of Nursing confirmed that the facility failed to make certain that medications were properly stored and/or disposed of in one of two medication rooms.


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

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

28 Pa. Code: 211.9 (a)(1) Pharmacy services.

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


 Plan of Correction - To be completed: 01/28/2025

This deficiency has not affected any residents. Both medroom 1 and medroom 2 have been audited for expired supplies by the Unit Managers. Expired supplies have been disposed of. The DON will educate the unit managers and central supply coordinator on inspecting for expiration before stocking supplies on the unit and the Medication Labeling and Storage Policy. Audits will be conducted 3 times a week, for 4 weeks, by the DON or designee, to monitor for expired products. Then audits will be conducted weekly for 3 months. This will be completed by January 28, 2025. Results of these audits will be taken to the monthly quality assurance meeting and reviewed for accuracy.
483.25(i) REQUIREMENT Respiratory/Tracheostomy Care and Suctioning:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
§ 483.25(i) Respiratory care, including tracheostomy care and tracheal suctioning.
The facility must ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals and preferences, and 483.65 of this subpart.
Observations:
Based on review of facility policy, clinical record review, observations, and staff interview, it was determined that the facility failed to provide respiratory care/oxygen services consistent with professional standards of practice for one of four residents reviewed (Resident R106).

Findings include:

Review of facility policy, titled "Oxygen Administration", with a review date of 3/15/24, purpose is to provide guidelines for safe oxygen administration. This includes verification of a physician order for oxygen or facility protocol, portable oxygen, regulator checking equipment and periodic assessment.

The "Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual," which provides instructions and guidelines for completing required Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2023, indicated that a BIMS (Brief Interview of Mental Status) is a brief screener that aids in detecting cognitive impairment. Scores from a BIMS assessment suggests the following distributions:
13 - 15: cognitively intact
8 - 12: moderately impaired
0 - 7: severe impairment

Review of Resident R106's clinical record indicates admission to the facility on 11/8/24.

Review of Resident R106's Minimum Data Set (MDS - a periodic assessment of care needs) dated 11/15/24, indicated diagnoses of pressure ulcer (PU) of sacral region, pressure ulcer of left hip (open wound with tissue damage), paraplegia (paralysis of the lower half of the body) and severe protein calorie malnutrition (not enough protein and calories are consumed and/or metabolized). Review of Section C: Cognitive Patterns, indicated, intact cognition with a BIMS Score of 15.

During an interview with Resident on 12/16/24 at 11:00 a.m., resident was actively using oxygen. With an oxygen concentrator (uses a process to create a purer oxygen from ambient air). in his room and two e-cylinder (portable oxygen tanks) at his bed side.

During a second interview of Resident R106 on 12/18/24, at 10:00 a.m., Resident R106 was not wearing oxygen. He reported the two e-cylinders were empty and the concentrator only works for a short time before it alarms. Resident R106 reported that he intermittent has difficulty breathing and his concerned with the condition of the existing oxygen equipment.

During an interview on 12/18/24, at approximately 10:15 a.m., Employee E1, confirmed the portable oxygen e-cylinders in Resident R106 room were empty and the oxygen concentrator needed replaced. Employee E1, removed the empty oxygen e-cylinders and had a replacement concentrator placed in Resident R106's room.

During an interview on 12/19/24, at approximately 2:00 p.m., the Director of Nursing (DON) confirmed the facility failed to provide respiratory care/oxygen services consistent with professional standards of practice for one of four residents reviewed (Resident R106).

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

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


 Plan of Correction - To be completed: 01/28/2025

Regarding the deficiency for R106, the empty oxygen cylinders were removed immediately by E1. The oxygen concentrator was immediately replaced by E1 as well. A whole house audit and visual survey will be done for all residents on oxygen. The Respiratory Therapists will be educated on our Oxygen Storage Policy. Audits will be conducted for oxygen storage and concentrator function, 3 times a week for 4 weeks by the DON, or designee. Then audits will be conducted weekly for 3 months. This will be completed by January 28, 2025. Results of this audit will be taken to the monthly quality assurance meeting and reviewed for accuracy.
483.12(c)(2)-(4) REQUIREMENT Investigate/Prevent/Correct Alleged Violation:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
§483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must:

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

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

§483.12(c)(4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken.
Observations:
Based on review of facility policy and clinical records and staff interview, it was determined that the facility failed to make certain allegations of abuse, neglect, exploitation, or mistreatment are thoroughly investigated and the results of all investigations are reported to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within five working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken for one of four residents reviewed. (Resident R166).

A review of the facility "Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating" policy dated 11/1/24, indicated that the facility will thoroughly investigate all allegations of abuse/neglect and will report to the Administrator and other officials as required.

A review of Resident R166's admission record indicated the resident was admitted on 11/6/24, with diagnoses that included fracture of the cervical (neck) vertebrae, high blood pressure, and pain. Resident R166 discharged to home on 11/22/24.

A review of Resident R166 Minimum Data Set assessment (MDS-a periodic assessment of resident care needs) dated 11/12/24, indicated that the diagnoses were current upon review and the resident was alert, oriented, and cognitively intact.

A review of a nurse progress note dated 11/21/22, indicated Resident R166 had a high level of pain while a resident at the facility.

A review of a facility grievance form dated 11/12/24, indicated Resident R166 stated the nursing staff was giving her a hard time about giving the resident pain medication. The night nurse refused to give the pain medication, stating "I have 30 other residents to take care of." The grievance form indicated the facility would investigate the staff roster and description of the alleged perpetrator. This concern was signed as received by the Director of Nursing (DON).

There was no documented evidence that the facility investigated the alleged incident of neglect for Resident R166.

During an interview on 12/17/24, at 2:00 p.m. the Director of Nursing (DON) confirmed that the facility failed to investigate an alleged incident of neglect for Resident R166.

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

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

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

28 Pa. Code: 201.20 (b) Staff development.




 Plan of Correction - To be completed: 01/28/2025

On 12/30, the allegation was reported to the State ERS as a matter of neglect when reviewing the citation. The AP was identified and the allegation of neglect was unsubstantiated. A thorough investigation has been completed, regarding the event cited in annual survey. All residents have the potential to be affected by this deficiency. A whole house audit was conducted of grievances to ensure that no allegations were unreported, nor lacked a thorough investigation. The Regional Director of Clinical Services educated the DON and NHA on thorough investigations for reporting. Grievances and EHR will be audited 3 times a week for four weeks, for any potential reportable allegations and need for investigation, by the DON or designee. It will then be audited weekly for 3 months for compliance. Date of completion is January 28, 2025. Results of these audits will be reviewed at the monthly quality assurance meeting for accuracy.
483.12(b)(5)(i)(A)(B)(c)(1)(4) REQUIREMENT Reporting of Alleged Violations:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
§483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must:

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

§483.12(c)(4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken.
Observations:
Based on review of facility policy, resident record, investigation documents, and staff interview, it was determined that the facility failed to report an allegation of neglect for one of four sampled residents (Resident R166).

Findings include:

A review of the facility "Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating" policy dated 11/1/24, indicated that the facility will thoroughly investigate and report all allegations of abuse/neglect and will report to the Administrator and other officials as required.

A review of Resident R166's admission record indicated the resident was admitted on 11/6/24, with diagnoses that included fracture of the cervical (neck) vertebrae, high blood pressure, and pain. Resident R166 discharged to home on 11/22/24.

A review of Resident R166's Minimum Data Set assessment (MDS -a periodic assessment of resident care needs) dated 11/12/24, indicated that the diagnoses were current upon review and the resident was alert, oriented, and cognitively intact.

A review of a nurse progress note dated 11/21/22, indicated Resident R166 had a high level of pain while a resident at the facility.

A review of a facility grievance form dated 11/12/24, indicated Resident R166 stated the nursing staff was giving her a hard time about giving the resident pain medication. The night nurse refused to give the pain medication, stating "I have 30 other residents to take care of." This concern was signed as received by the Director of Nursing (DON).

A review of reports submitted to the local state field office did not include Resident R166's allegation of neglect.

During an interview on 12/17/24, at 2:00 p.m. the Director of Nursing (DON) confirmed that the facility failed to report Resident R166's allegation of neglect as required.

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

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



 Plan of Correction - To be completed: 01/28/2025

R166 was interviewed upon receipt of the grievance. Resident had realized that she was not due for her opioid during the interview by the DON, ADON, and NHA. On 12/30, it was reported to the State ERS as a matter of neglect when reviewing the citation. The AP was identified and the allegation of neglect was unsubstantiated. All residents have the potential to be affected by this deficiency. A whole house audit was conducted of grievances to ensure that no allegations were unreported. The Regional Director of Clinical Services educated the DON and NHA on reporting of alleged violations. Grievances and EHR will be audited 1 time a week for four weeks, for any potential reportable allegations, by the DON or designee. It will then be audited weekly for 3 months for compliance. Results of these audits will be reviewed at the monthly quality assurance meeting for accuracy.
483.10(g)(5)(i)(ii) REQUIREMENT Required Postings:Least serious 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 has the potential for causing no more than a minor negative impact on the resident.
§483.10(g)(5) The facility must post, in a form and manner accessible and understandable to residents, resident representatives:
(i) A list of names, addresses (mailing and email), and telephone numbers of all pertinent State agencies and advocacy groups, such as the State Survey Agency, the State licensure office, adult protective services where state law provides for jurisdiction in long-term care facilities, the Office of the State Long-Term Care Ombudsman program, the protection and advocacy network, home and community based service programs, and the Medicaid Fraud Control Unit; and
(ii) A statement that the resident may file a complaint with the State Survey Agency concerning any suspected violation of state or federal nursing facility regulation, including but not limited to resident abuse, neglect, exploitation, misappropriation of resident property in the facility, and non-compliance with the advanced directives requirements (42 CFR part 489 subpart I) and requests for information regarding returning to the community.
Observations:

Based on observations and staff interview, it was determined that the facility failed to post contact information for the Medicaid Fraud Unit and Adult Protective Services as required, on two of two (first and second floor) nursing units.

Findings include:

Observations conducted on December 17, 2024, at 9:30 a.m., on the first and second floor nursing units, revealed the facility did not have the Medicaid Fraud Unit contact information posted or accessible to residents.

Observations conducted on December 17, 2024, at 9:30 a.m., on the first and second floor nursing units, revealed the facility did not have the Adult Protective Services contact information posted or accessible to residents.

During interview, on December 17, 2024, at 2:40 p.m., the Nursing Home Administrator confirmed that the Adult Protective Services and Medicaid Fraud Unit contact information was not posted in areas available to residents and visitors.

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

28 Pa. Code: 201.18(e) Management.






 Plan of Correction - To be completed: 01/28/2025

Medicaid and Medicare Fraud required posting was posted on 12-20-24 by the NHA. All adult Protective Services information was posted by the NHA on 12-20-24. NHA will be educated by the RDO on having the required postings up for resident and visitor informed information. A one time audit was completed by the NHA. A monthly audit will be completed thereafter. Results of this audit will be taken to the monthly quality assurance meeting and reviewed for accuracy.
483.10(g)(10)(11) REQUIREMENT Right to Survey Results/Advocate Agency Info:Least serious 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 has the potential for causing no more than a minor negative impact on the resident.
§483.10(g)(10) The resident has the right to-
(i) Examine the results of the most recent survey of the facility conducted by Federal or State surveyors and any plan of correction in effect with respect to the facility; and
(ii) Receive information from agencies acting as client advocates, and be afforded the opportunity to contact these agencies.

§483.10(g)(11) The facility must--
(i) Post in a place readily accessible to residents, and family members and legal representatives of residents, the results of the most recent survey of the facility.
(ii) Have reports with respect to any surveys, certifications, and complaint investigations made respecting the facility during the 3 preceding years, and any plan of correction in effect with respect to the facility, available for any individual to review upon request; and
(iii) Post notice of the availability of such reports in areas of the facility that are prominent and accessible to the public.
(iv) The facility shall not make available identifying information about complainants or residents.
Observations:
Based on observation, resident group interview and staff interview, it was determined that the facility failed to post notice of the availability of survey results in a prominent location on two of two nursing units (first and second floors).

Findings include:

During an observation on 12/17/24, at 9:40 a.m. no signage was identified indicating survey results are available.

During a resident group interview on 12/17/24, at 10:30 a.m. 10 out of 10 residents agreed that they were unaware of the location of the survey results (Residents R500, R501, R502, R503, R504, R505, R506, R507, R508, and R509).

During an interview on 12/17/24, at 2:40 p.m. the Nursing Home Administrator, confirmed the facility failed to post notice of the location of survey results in the facility.

28 Pa. Code 201.13(g) Issuance of license.


 Plan of Correction - To be completed: 01/28/2025

Survey results were posted by the NHA with the proper signage throughout the facility for residents and visitors to view. NHA will be educated by the RDO on having the required survey results up to date and the signage posted for where to find the survey results in the facility. A one time audit was completed by the NHA. A monthly audit will be completed thereafter. Results of this audit will be taken to the monthly quality assurance meeting and reviewed for accuracy.
483.10(g)(13) REQUIREMENT Posting/Notice of Medicare/Medicaid on Admit:Least serious 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 has the potential for causing no more than a minor negative impact on the resident.
§483.10(g)(13) The facility must display in the facility written information, and provide to residents and applicants for admission, oral and written information about how to apply for and use Medicare and Medicaid benefits, and how to receive refunds for previous payments covered by such benefits.
Observations:
Based on observations and staff interview, it was determined the facility failed to display written information on applying for Medicare and Medicaid benefits and receiving refunds for previous payments covered by Medicare and Medicaid on two of two nursing units (first and second floor).

Findings include:

Observations conducted on 12/17/24, at 9:30 a.m., on the first and second floor nursing units, revealed the facility failed to include information on how to apply for Medicare and Medicaid benefits and receiving refunds for previous payments covered by Medicare and Medicaid .

During interview, on 12/17/24, at 2:40 p.m., the Nursing Home Administrator confirmed the facility failed to display written information on applying for Medicare and Medicaid benefits and receiving refunds for previous payments covered by Medicare and Medicaid on two of two nursing units (first and second floor).

28 Pa. Code: Resident rights.


 Plan of Correction - To be completed: 01/28/2025

Medicare/Medicaid signage was posted per the regulation by the NHA on 12-20-24 so residents and visitors can be informed of the application and its process. NHA will be educated by the RDO on having the required postings up for resident and visitor informed information. A one time audit was completed by the NHA. A monthly audit will be completed thereafter. Results of this audit will be taken to the monthly quality assurance meeting and reviewed for accuracy.
483.95(a) REQUIREMENT Communication Training:Least serious deficiency but affects more than a limited number of residents, staff, or occurrences. This deficiency has the potential for causing no more than a minor negative impact on the resident but is not found to be throughout this facility.
§483.95(a) Communication.
A facility must include effective communications as mandatory training for direct care staff.
Observations:
Based on review of facility policy, personnel in-service training records, and staff interview, it was determined that the facility failed to provide training on Effective Communication for four of ten staff members (Employee E9, E10, E11, E12).

Findings include:

Review of the facility policy, "In-Service Training" dated 11/1/24, indicated all staff are required to participate in regular in-service education.

Review of the facility ' s previous policy "Inservice Training" dated 9/1/23, indicated the facility will provide in-service training for all personnel on a regularly scheduled basis. All mandatory in-services must be completed annually as a condition of employment.

Review of facility provided documents and training records revealed the following staff members did not have documented training on Effective Communication.

Nurse Aide (NA) Employee E9 had a hire date of 7/5/11, failed to have Effective Communication in-service education between 7/5/23, and 7/5/24.

NA Employee E10 had a hire date of 10/20/22, failed to have Effective Communication in-service education between 10/20/23, and 10/20/24.

Registered Nurse Employee E11 had a hire date of 9/15/14, failed to have Effective Communication in-service education between 9/15/23, and 9/15/24.

Licensed Practical Nurse (LPN) Employee E12 had a hire date of 9/25/19, failed to have Effective Communication in-service education between 9/25/23, and 9/25/24.

During an interview on 12/20/24, at approximately 1:00 p.m. the Nursing Home Administrator and the Director of Nursing confirmed that the facility failed to provide training on Effective Communication for four of ten staff members.

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

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

28 Pa Code: 201.20 (a)(c) Staff development.


 Plan of Correction - To be completed: 01/28/2025

Employees E9, E10,E11 and E12 will have required communication trainings before 1-28-2025 according to their hire dates. Staff educator or designee will be educated on the required trainings that staff have to have according to hire date. A one time audit will be completed for each employee to assure the training is completed and will be audited monthly thereafter. Results of this audit will be taken to the monthly quality assurance meeting and reviewed for accuracy.
483.95(b) REQUIREMENT Resident Rights Training:Least serious deficiency but affects more than a limited number of residents, staff, or occurrences. This deficiency has the potential for causing no more than a minor negative impact on the resident but is not found to be throughout this facility.
§483.95(b) Resident's rights and facility responsibilities.
A facility must ensure that staff members are educated on the rights of the resident and the responsibilities of a facility to properly care for its residents as set forth at §483.10, respectively.
Observations:
Based on review of facility policy, personnel in-service training records, and staff interview, it was determined that the facility failed to provide training on Resident Rights for four of ten staff members (Employee E9, E13, E14, E15).

Findings include:

Review of the facility policy, "In-Service Training" dated 11/1/24, indicated all staff are required to participate in regular in-service education.

Review of the facility ' s previous policy "Inservice Training" dated 9/1/23, indicated the facility will provide in-service training for all personnel on a regularly scheduled basis. All mandatory in-services must be completed annually as a condition of employment.

Review of facility provided documents and training records revealed the following staff members did not have documented training on Resident Rights.

Nurse Aide (NA) Employee E9 had a hire date of 7/5/11, failed to have Resident Rights in-service education between 7/5/23, and 7/5/24.

Licensed Practical Nurse (LPN) Employee E13 had a hire date of 11/29/22, failed to have Resident Rights in-service education between 11/29/23, and 11/29/24.

LPN Employee E14 had a hire date of 8/25/22, failed to have Resident Rights in-service education between 8/25/23, and 8/25/24.

Therapy Employee E15 had a hire date of 10/16/06, failed to have Resident Rights in-service education between 10/16/23, and 10/16/24.

During an interview on 12/20/24, at approximately 1:00 p.m. the Nursing Home Administrator and the Director of Nursing confirmed that the facility failed to provide training on Resident Rights for four of ten staff members.

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

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

28 Pa Code: 201.20 (a)(c) Staff development.


 Plan of Correction - To be completed: 01/28/2025

Employees E9,E13,E14,E15 will have the required Resident Rights training before 1-28-2025 according to their hire date. Staff educator or designee will be educated on the required trainings that staff have to have according to hire date. A one time audit will be completed for each employee to assure the training is completed and will be audited monthly thereafter. Results of this audit will be taken to the monthly quality assurance meeting and reviewed for accuracy.
483.95(d) REQUIREMENT QAPI Training:Least serious deficiency but affects more than a limited number of residents, staff, or occurrences. This deficiency has the potential for causing no more than a minor negative impact on the resident but is not found to be throughout this facility.
§483.95(d) Quality assurance and performance improvement.
A facility must include as part of its QAPI program mandatory training that outlines and informs staff of the elements and goals of the facility's QAPI program as set forth at § 483.75.
Observations:
Based on review of facility policy, personnel in-service training records, and staff interview, it was determined that the facility failed to provide training on Quality Assurance and Performance Improvement (QAPI) for six of ten staff members (Employee E9, E10, E11, E12, E13, and E14).

Findings include:

Review of the facility policy, "In-Service Training" dated 11/1/24, indicated all staff are required to participate in regular in-service education.

Review of the facility ' s previous policy "Inservice Training" dated 9/1/23, indicated the facility will provide in-service training for all personnel on a regularly scheduled basis. All mandatory in-services must be completed annually as a condition of employment.

Review of facility provided documents and training records revealed the following staff members did not have documented training on QAPI.

Nurse Aide (NA) Employee E9 had a hire date of 7/5/11, failed to have QAPI in-service education between 7/5/23, and 7/5/24.

NA Employee E10 had a hire date of 10/20/22, failed to have QAPI in-service education between 10/20/23, and 10/20/24.

Registered Nurse Employee E11 had a hire date of 9/15/14, failed to have QAPI in-service education between 9/15/23, and 9/15/24.

Licensed Practical Nurse (LPN) Employee E12 had a hire date of 9/25/19, failed to have QAPI in-service education between 9/25/23, and 9/25/24.

LPN Employee E13 had a hire date of 11/29/22, failed to have QAPI in-service education between 11/29/23, and 11/29/24.

LPN Employee E14 had a hire date of 8/25/22, failed to have QAPI in-service education between 8/25/23, and 8/25/24.

During an interview on 12/20/24, at approximately 1:00 p.m. the Nursing Home Administrator and the Director of Nursing confirmed that the facility failed to provide training on QAPI for six of ten staff members.

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

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

28 Pa Code: 201.20 (a)(c) Staff development.


 Plan of Correction - To be completed: 01/28/2025

Employees E9,E10,E11,E12,E13 and E14 will have required QAPI trainings before 1-28-2025 according to their hire date. Staff educator or designee will be educated on the required trainings that staff have to have according to hire date. A one time audit will be completed for each employee to assure the training is completed and will be audited monthly thereafter. Results of this audit will be taken to the monthly quality assurance meeting and reviewed for accuracy.
483.95(f)(1)(2) REQUIREMENT Compliance and Ethics Training:Least serious deficiency but affects more than a limited number of residents, staff, or occurrences. This deficiency has the potential for causing no more than a minor negative impact on the resident but is not found to be throughout this facility.
§483.95(f) Compliance and ethics.
The operating organization for each facility must include as part of its compliance and ethics program, as set forth at §483.85-

§483.95(f)(1) An effective way to communicate the program's standards, policies, and procedures through a training program or in another practical manner which explains the requirements under the program.

§483.95(f)(2) Annual training if the operating organization operates five or more facilities.
Observations:
Based on review of facility policy, personnel in-service training records, and staff interview, it was determined that the facility failed to provide training on Compliance and Ethics for two of ten staff members (Employee E9 and E13).

Findings include:

Review of the facility policy, "In-Service Training" dated 11/1/24, indicated all staff are required to participate in regular in-service education.

Review of the facility ' s previous policy "Inservice Training" dated 9/1/23, indicated the facility will provide in-service training for all personnel on a regularly scheduled basis. All mandatory in-services must be completed annually as a condition of employment.

Review of facility provided documents and training records revealed the following staff members did not have documented training on Compliance and Ethics.

Nurse Aide (NA) Employee E9 had a hire date of 7/5/11, failed to have Compliance and Ethics in-service education between 7/5/23, and 7/5/24.

Licensed Practical Nurse (LPN) Employee E13 had a hire date of 11/29/22, failed to have Compliance and Ethics in-service education between 11/29/23, and 11/29/24.

During an interview on 12/20/24, at approximately 1:00 p.m. the Nursing Home Administrator and the Director of Nursing confirmed that the facility failed to provide training on Compliance and Ethics for two of ten staff members.

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

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

28 Pa Code: 201.20 (a)(c) Staff development.


 Plan of Correction - To be completed: 01/28/2025

Employees E9 and E13 will have the required Compliance and Ethics trainings before 1-28-2025 according to their hire date. Staff educator or designee will be educated on the required trainings that staff have to have according to hire date. A one time audit will be completed for each employee to assure the training is completed and will be audited monthly thereafter. Results of this audit will be taken to the monthly quality assurance meeting and reviewed for accuracy.
483.95(i) REQUIREMENT Behavioral Health Training:Least serious deficiency but affects more than a limited number of residents, staff, or occurrences. This deficiency has the potential for causing no more than a minor negative impact on the resident but is not found to be throughout this facility.
§483.95(i) Behavioral health.
A facility must provide behavioral health training consistent with the requirements at §483.40 and as determined by the facility assessment at §483.71.
Observations:
Based on review of facility policy, personnel in-service training records, and staff interview, it was determined that the facility failed to provide training on Behavioral Health for two of ten staff members (Employee E9, E13, and E15).

Findings include:

Review of the facility policy, "In-Service Training" dated 11/1/24, indicated all staff are required to participate in regular in-service education.

Review of the facility ' s previous policy "Inservice Training" dated 9/1/23, indicated the facility will provide in-service training for all personnel on a regularly scheduled basis. All mandatory in-services must be completed annually as a condition of employment.

Review of facility provided documents and training records revealed the following staff members did not have documented training on Behavioral Health.

Nurse Aide (NA) Employee E9 had a hire date of 7/5/11, failed to have Behavioral Health in-service education between 7/5/23, and 7/5/24.

Licensed Practical Nurse (LPN) Employee E13 had a hire date of 11/29/22, failed to have Behavioral Health in-service education between 11/29/23, and 11/29/24.

Therapy Employee E15 had a hire date of 10/16/06, failed to have Behavioral Health in-service education between 10/16/23, and 10/16/24.

During an interview on 12/20/24, at approximately 1:00 p.m. the Nursing Home Administrator and the Director of Nursing confirmed that the facility failed to provide training on Behavioral Health for three of ten staff members.

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

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

28 Pa Code: 201.20 (a)(c) Staff development.


 Plan of Correction - To be completed: 01/28/2025

Employees E9,E13, and E15 will have the required Behavioral health training before 1-28-2025 according to their hire date. Staff educator or designee will be educated on the required trainings that staff have to have according to hire date. A one time audit will be completed for each employee to assure the training is completed and will be audited monthly thereafter. Results of this audit will be taken to the monthly quality assurance meeting and reviewed for accuracy.
§ 211.12(i)(2) LICENSURE Nursing services.:State only Deficiency.
(2) Effective July 1, 2024, the total number of hours of general nursing care provided in each 24-hour period shall, when totaled for the entire facility, be a minimum of 3.2 hours of direct resident care for each resident.

Observations:
Based on review of nursing time schedules and staff interviews it was determined that the facility administrative staff failed to provide the minimum number of general nursing hours to each resident in a 24 hour period on seven of 21 days (11/27/24, 11/28/24, 11/29/24, 11/30/24, 12/8/24, 12/9/24, and 12/12/24).

Findings include:

Review of the nursing schedules and census information for 11/23/24, through 12/13/24, revealed that the facility failed to meet the following:

-11/27/24, Census 124. PPD 3.15.
-11/28/24, Census 124. PPD 2.93.
-11/29/24, Census 125. PPD 2.98.
-11/30/24, Census 124. PPD 3.16.
-12/08/24, Census 116. PPD 3.03.
-12/09/24, Census 115. PPD 3.02.
-12/12/24, Census 114. PPD 3.16.

During an interview on 12/20/24, at approximately 1:00 p.m. the Nursing Home Administrator and the Director of Nursing confirmed that the facility failed to provide the minimum number of general nursing hours to each resident in a 24-hour period on seven of 21 days.


 Plan of Correction - To be completed: 01/28/2025

Facility will provide the required minimum amount of nursing hours to each resident in a 24 our period. Past missed PPDs cannot be rectified. NHA will educate scheduler/staffing coordinator on the required minimum amount of nursing hours that need to be given to each resident in a 24 our period. Audits via daily staffing meeting forms will be conducted 3 times a week for 4 weeks then monthly thereafter to ensure that required minimum amount of nursing hours are provided to each resident in a 24 our period. Efforts to obtain and maintain staff will be conducted by recruitment efforts such as indeed adds, calling candidates through Workday, taking walk in interviews and job fairs. Results of this audit will be taken to the monthly quality assurance meeting and reviewed for accuracy.

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