Pennsylvania Department of Health
SUSQUEHANNA HEALTH AND WELLNESS CENTER
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

SUSQUEHANNA HEALTH AND WELLNESS CENTER
Inspection Results For:

There are 239 surveys for this facility. Please select a date to view the survey results.

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SUSQUEHANNA HEALTH AND WELLNESS CENTER - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:
Based on a Medicare/Medicaid Recertification survey, State Licensure survey, and Civil Rights Compliance survey and complaint survey completed on August 22, 2024 , it was determined that Susquehanna Health and Wellness Center was not in compliance with the following requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care Facilities and the 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.

Plan of Correction:

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

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

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

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

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

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

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

Observations:

Based on clinical record reviews and staff interviews, it was determined that the facility failed to notify the resident and resident's representative, in writing, regarding the reason for hospitalization for five of 56 residents reviewed (Residents 18, 36, 38, 77, 85).

Findings include:

A quarterly Minimum Data Set (MDS) assessment (a federally-mandated assessment of a resident's abilities and care needs) for Resident 18, dated June 17, 2024, indicated that the resident was cognitively impaired, required assistance from staff for his daily care needs, and had diagnoses that included dementia.

A nursing note for Resident 18, dated June 11, 2024, revealed that the resident was transferred to the hospital for evaluation of abdominal pain and to have his indwelling urinary catheter flushed or replaced. He was admitted to the hospital with a urinary tract infection.

There was no documented evidence that a written notice of Resident 18's transfer to the hospital was provided to the resident's responsible party regarding the reason for transfer.

A quarterly MDS assessment for Resident 36, dated July 23, 2024, indicated that the resident was understood and able to understand others, required substantial to moderate assist from staff for his personal care needs, and had diagnoses that included dementia.

A nursing note for Resident 36, dated June 7, 2024, at 6:41 a.m., revealed that the resident had an unwitnessed fall resulting in a possible right arm fracture. The physician was notified, and the resident was sent to the emergency room for evaluation.

A nursing note for Resident 36, dated July 4, 2024, at 10:46 p.m., revealed that the resident had a significant change in condition. The certified registered nurse practitioner was notified, and the resident was sent to the emergency room for evaluation.

There was no documented evidence that a written notice of Resident 36's transfers to the hospital were provided to the resident or the resident's representative regarding the reason for transfer.

A quarterly MDS assessment for Resident 38, dated May 21, 2024, indicated that the resident was severely cognitively impaired, was dependent on staff for personal care needs, and had diagnoses that included idiopathic epilepsy (a genetic seizure disorder).

A nursing note for Resident 38, dated May 7, 2024, at 2:40 p.m., revealed that the resident had a seizure and was not responding to treatments provided and his condition was worsening; therefore, he was transferred to the emergency room for evaluation.

A nursing note for Resident 38, dated June 21, 2024, at 6:34 a.m., revealed that the resident's feeding tube came out of his body. The physician was notified, and the resident was sent to the emergency room for evaluation.

There was no documented evidence that a written notice of Resident 38's transfers to the hospital were provided to the resident or the resident's representative regarding the reason for transfer.

A quarterly MDS assessment for Resident 77, dated May 2, 2024, indicated that the resident was moderately cognitively impaired, required assistance from staff for personal care needs, and had diagnoses that included dementia and heart failure.

A nursing note, dated June 24, 2024, at 7:46 p.m. revealed that Resident 77 was found coughing and wheezing, was flushed, and had an oxygen saturation (amount of oxygen in the blood) in the 70's (normal 95-100 percent). The physician was notified, and the resident was transferred to the hospital.

There was no documented evidence that a written notice of Resident 77's transfer to the hospital was provided to the resident or the resident's representative regarding the reason for transfer.

A quarterly MDS assessment for Resident 85, dated May 16, 2024, indicated that the resident was severely cognitively impaired, required assistance from staff for personal care needs, and had diagnoses that included dementia, seizure disorder, and a stroke.

A nursing note, dated July 27, 2024, at 10:10 a.m. revealed that Resident 85 was observed lying in bed with his eyes closed with right-sided facial droop and facial edema (swelling). The resident stated, "I don't feel well," and the physician was notified and an order was received to send him to the hospital for evaluation and treatment.

A nursing note, dated July 27, 2024, at 12:28 p.m. revealed that Resident 85 was admitted to the hospital with a diagnosis of encephalopathy (a condition that causes brain dysfunction).

There was no documented evidence that a written notice of Resident 85's transfer to the hospital was provided to the resident or the resident's representative regarding the reason for transfer.

Interview with the Nursing Home Administrator on August 20, 2024, at 3:48 p.m. confirmed that the facility did not provide a written notice to the residents or their responsible party when a resident was transferred to the hospital.

28 Pa. Code 201.25 Discharge Policy.

28 Pa. Code 201.29(f)(g) Resident Rights.

Plan of Correction - To be completed: 10/09/2024

1. Social Service Director spoke with resident representatives for residents R36, R38, R77 and R85 regarding hospital transfers and transfer letter and there were no concerns noted. For resident R18 messages were left and no return call received.
2. Residents with transfers out in the month of August were reviewed to ensure that a copy of the transfer letter was reviewed with them and mailed to their representative.
3. Education was completed by the DON/designee with the licensed nurses and social services regarding notice requirements before transfer/discharge.
4. An audit will be completed for notice requirements before transfer/discharge weekly for 4 weeks and monthly for 2 months by the DON/designee. The results of the audits will be reviewed by the Quality Assessment and Assurance committee for the need to complete further audits.

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

�483.20(f)(5) Resident-identifiable information.
(i) A facility may not release information that is resident-identifiable to the public.
(ii) The facility may release information that is resident-identifiable to an agent only in accordance with a contract under which the agent agrees not to use or disclose the information except to the extent the facility itself is permitted to do so.

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

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

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

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

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

Plan of Correction - To be completed: 10/09/2024

1. R94 had the task for the alert bracelet resolved. R98 no longer resides in the facility and R112 has had no further choking incidents.
2. Residents with task for alert bracelets have been audited for accuracy. Residents refusing or cancelling their own appointments will have documentation to reflect the cancelled appointments and residents with incidents requiring assessment will be audited to ensure that the assessment is documented in the progress notes and/or forms.
3. The DON/designee will educate the licensed nurses on the need to accurately document per the facility documentation policy.
4. The DON/designee will audit changes with 5 residents to ensure that it is reflected in the progress notes weekly for 4 weeks and monthly 2 months. The results of the audits will be reviewed by the Quality Assessment and Assurance committee for the need to complete further audits.

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

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

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

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

Observations:

Based on review of policies, as well as observations and staff interviews, it was determined that the facility failed to ensure that food was stored and served in accordance with professional standards for food service safety and failed to effectively sanitize dishes during mechanical dishwashing.

Findings include:

The facility's policy for food storage, dated June 1, 2024, revealed that leftover food was to be stored in covered containers or wrapped carefully and securely, and each item was to be clearly labeled and dated before being refrigerated.

Observations of the walk-in refrigerator and dry storage area on August 19, 2024, at 8:45 a.m. revealed that there were two Styrofoam containers that contained cooked eggs/omelets that were not dated or labeled, and one gallon of corn syrup that was open without a lid.

Interview with the Dietary Manager on August 19, 2024, at 8:45 a.m. confirmed that staff should have labeled and dated the Styrofoam containers of eggs and she was not sure why there was no lid on the gallon of corn syrup in the dry storage area.

Observations in the main kitchen on August 19, 2024, at 8:45 a.m. and August 21, 2024, at 1:17 p.m. revealed that there was a fan on top of the ice machine that had dust accumulation on the blades and cage and was blowing towards the food prep/service area, and 51 one clear cups had a white, removable residue on the inside of them.

The facility's policy regarding pot and pan washing, dated June 1, 2024, indicated that pots and pans were to be sanitized in the third sink using warm water and bleach or sanitizer to provide no less than 50 parts per million (PPM) chlorine in solution for one minute.

Observations on August 21, 2024, at 1:30 p.m. revealed that Dietary Aide 6 was washing metal pans and scoops using the three-compartment sink. She washed and rinsed the pans and scoops in the first and second sinks and then placed them in the third sink to sanitize, removing them in a couple seconds.

Interview with the Dietary Manager on August 21, 2024, at 1:25 p.m. and 1:44 p.m. confirmed that the fan was dirty and needed cleaned, the clear cups had a build up of white residue in them, and that Dietary Aide 6 should have left the items soak in the sanitizing solution for a longer period of time.

28 Pa. Code 211.6(f) Dietary Services.

Plan of Correction - To be completed: 10/09/2024

1. Immediate education was completed with staff on food storage and three compartment sinks. The items that were undated and opened were discarded. The pans were washed and re-sanitized. The cups were delimed and the fan was removed.
2. The Food Service Director/Designee will conduct an initial kitchen sanitation audit and make corrections as needed.
3. The Food Service Director/Designee will in-service the dietary staff on food storage requirements, dating/labeling of food, kitchen sanitation and the three compartment sink requirements
4. The Food Service Director/Designee will conduct kitchen sanitation audits weekly for 4 weeks and monthly for 2 months. The Food Service Director/Designee will review results of the audits to identify/track trends or patterns. The Food Service Director/Designee will report results at the monthly Quality Assurance and Performance Improvement Meeting for further review and/or recommendations

483.60(d)(1)(2) REQUIREMENT Nutritive Value/Appear, Palatable/Prefer Temp:

�483.60(d) Food and drink
Each resident receives and the facility provides-

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

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

Observations:

Based on observations and interviews with residents and staff, it was determined that the facility failed to serve food that was palatable to residents.

Findings include:

Interviews on August 19, 2024, with Resident 28 at 12:17 p.m. and Resident 56 at 12:22 p.m. revealed that the food was "terrible" and "a little rough."

The posted menu for August 20, 2024, revealed that the lunch meal was chicken teriyaki, fluffy steamed rice, seasoned broccoli, and sherbet.

Observations in the kitchen on August 20, 2024, at 11:57 p.m. revealed that a test tray was placed on the lunch meal cart going to the A wing. The cart arrived on the unit at 11:59 p.m., and the last resident was served and eating at 12:15 p.m. At 12:15 p.m. the temperature of the chicken teriyaki was 131.7 degrees Fahrenheit (F) and was dry, and the temperature of the seasoned broccoli was 134.7 degrees F and it was mushy.

Interview with the Dietary Manager on August 20, 2024, at 12:15 p.m. confirmed that the chicken appeared dry and the broccoli was mushy and over-cooked.

28 Pa. Code 201.18(b)(1)(3)(e)(1) Management.

Plan of Correction - To be completed: 10/09/2024

Immediate education was completed with cook on preparing vegetables and meat to preserve palatability on 8/19/24.
2. The Food Service Director/Designee will provide education to the cooks regarding food palatability and proper food temperatures.
3. The Food Service Director/Designee will conduct a test tray four times a week and 4 random food satisfaction audits weekly for 4 weeks and monthly for 2 months to ensure food is palatable and served at the proper temperature.
4. The Food Service Director/Designee will review results of the audits to identify/track trends or patterns. The Food Service Director/Designee will report results at the monthly Quality Assurance and Performance Improvement Meeting for further review and/or recommendations.

483.45(f)(2) REQUIREMENT Residents are Free of Significant Med Errors:

The facility must ensure that its-
�483.45(f)(2) Residents are free of any significant medication errors.

Plan of Correction - To be completed: 10/09/2024

1. R8's physician extender and the resident representative were notified of the missed insulin. R8 is receiving insulin as ordered. R56's physician extender and resident representative were notified of medication error. Resident was assessed with no concerns noted. R56 is receiving insulin as ordered.
2. Residents with orders to hold insulin based on blood sugar parameters will be completed for the last 7 days to ensure that insulin was held if parameters met and any concerns will be reported to the attending physician. Residents with orders for insulin will have their EMARs reviewed for the last 7 days to ensure that their insulin was administered as ordered with follow up to physician if needed.
3. Education will be completed by the DON/designee regarding administering insulins as ordered by the physician.
4. The DON/designee will audit medication administration records for 5 residents requiring insulin for insulin administration documentation weekly for 4 weeks and monthly for 2 months. The results of the audits will be reviewed by the Quality Assessment and Assurance committee for the need to complete further audits.

483.25(d)(1)(2) REQUIREMENT Free of Accident Hazards/Supervision/Devices:

�483.25(d) Accidents.
The facility must ensure that -
�483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and

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

Observations:

Based on clinical record reviews, observations, and staff interviews, it was determined that the facility failed to ensure that each resident received assistance devices to prevent accidents for two of 56 residents reviewed (Residents 109, 125) and failed to protect the safety of other residents from violence from two of 56 residents reviewed (Residents 52, 85).

Findings include:

A comprehensive Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 109, dated May 15, 2024, revealed that the resident was cognitively intact and required extensive assistance for daily care needs including transfers and locomotion.

Observations of Resident 109 on August 19, 2024, at 12:28 p.m. revealed that the resident was sitting in a wheelchair while being transported to her room by Nurse Aide 2. There were no footrests on her wheelchair to prevent her feet from dragging during the transport. An interview with Nurse Aide 2 revealed that he did not know if she had leg rests or not and did not know if she needed them.

An interview with the Director of Nursing on August 19, 2024, at 4:38 p.m. confirmed that footrests should have been used when transporting residents in their wheelchairs.

A quarterly MDS for Resident 125, dated June 17, 2024, revealed that the resident was understood and able to understand others, required partial to moderate assistance of staff for personal hygiene needs, used a manual wheelchair for mobility, and had diagnoses that included a stroke.

Observation of Resident 125 on August 20, 2024, at 11:35 a.m. revealed that she was sitting in her wheelchair being transported the length of a long hallway to her bedroom by Activities Aide 3. There were no footrests on the resident's wheelchair to prevent her feet from dragging during the transport. An interview with Activities Aide 3 at the time of the observation revealed that she was unsure if footrests were to be on the wheelchair when transporting a resident.

Interview with the Director of Nursing on August 29, 2024, at 5:05 p.m. confirmed that footrests should have been used when transporting the resident in her wheelchair.

A quarterly MDS assessment a mandated assessment of a resident's abilities and care needs for Resident 52, dated, dated August 5, 2024, revealed that the resident was usually understood and was always able to understand others, was dependent on staff for personal hygiene care, and had diagnosis that included Parkinson's disease and schizophrenia.

Care plan for Resident 52, dated March 2, 2022, revealed that the resident had behavior symptoms including hitting himself and others, being resistive with care, running his wheelchair into other people and objects, and inappropriate comments and yelling at others. Staff were to redirect or assist to remove the resident from situations or individuals that cause visual or verbal irritation as allowed, and to monitor the resident while in common areas for aggression including verbal or physical. A care plan, dated May 24, 2022, indicated that the resident had difficulty communicating related to mental retardation. Staff were to maintain his safety and anticipate and meet his needs.

A nurse's note for Resident 52, dated June 25, 2024, at 10:53 a.m. revealed that the resident went up to a female resident who was sitting in the hall and attempted to hit her in the face, the resident was able to block him, and then he hit her on the chin with a closed fist. An investigation revealed that the female resident involved was Resident 167 and that the incident did not cause any harm to her. A nurse's note, dated June 25, 2024, at 11:21 a.m., revealed that the resident was sitting in the hall and when another resident went past him, he hit the other resident on the right shoulder. An investigation revealed that the other resident involved was Resident 17 and that the incident did not cause any harm to him. A nurse's note, dated July 25, 2024, at 3:30 p.m., revealed that the resident was rolling himself out of the activity room and while going past a female resident he reached out and punched her in the arm. An investigation revealed that female resident involved was Resident 167 and that the incident did not cause any harm to her.

Interview with the Director of Nursing on August 22, 2024, at 2:54 p.m. revealed that Resident 52 did have physical altercations with other residents as identified above and that staff were to monitor the resident's emotions and stimuli and remove him from potentially aggressive situations; however, his intellectual disabilities made it difficult to determine when his behaviors would occur, making it difficult to prevent.

A quarterly MDS assessment for Resident 85, dated May 16, 2024, revealed that the resident was cognitively impaired; had physical, verbal, and other behaviors not directed towards others that occurred that occurred one to three days; rejected care; and had diagnoses that included dementia and a stroke.

A care plan for Resident 85, dated August 14, 2024, revealed that the resident was at risk for behaviors symptoms of hitting doors and walls; rejection of care; elopement; wandering into other resident rooms; urinating in inappropriate places; lying in beds; changes in mood related to anxiety, depression delusions, and cognitive loss; verbal and physical agitation (hitting, kicking, pushing, cursing, screaming) towards others; and unwanted interactions with other residents. Interventions included to encourage the resident to a private area where he may openly express his feelings regarding why he was angry and upset; offer opportunities for free expression through creative activities; a psychiatric referral as needed; redirect resident to his own room when expressing and appearing tired; redirect to the bathroom when observed urinating in inappropriate places; redirect and validate resident to ensure safety of self and others; staff to be aware that the resident sits within groups due to protection/safety of peers; use a consistent approach when providing care; assess for physical/environmental changes that may participate changes in mood; discuss feelings regarding current situation; offer choices to enhance sense of control; validate feelings of loss; medications as ordered; allow resident time to respond to directions or requests; be aware of resident personal space; close observation/supervision while in public space; gain the resident's attention before speaking or touching; give the resident a clear and concise explanation of anything about to occur; if behavioral intervention strategies are not working leave (if safe to do so) and reapproach later; keep at the nurse's station so there is a space between residents and redirect him when needed; monitor the resident while approaching other residents and redirect; provide diversional activities; remove from public area when behavior was disruptive/unacceptable; medication review as needed; monitor for resident's increase in voice, body positioning, and other indicators of reactions while near others; monitor surroundings for stimulation of others; and redirect the resident while in other's personal space.

A nursing note, dated June 9, 2024, at 9:49 p.m. revealed Resident 85 struck Resident 111 in the left arm and left cheek. The resident's were immediately separated, and Resident 111's skin was assessed and found to be without redness, bruising, or disruption in integrity. Resident 85 was placed under direct and close supervision to maintain safety of all residents. An interdisciplinary note, dated June 10, 2024, indicated that Resident 85's behaviors were escalating and the resident was to have close observation/supervision while in common areas and a complete comprehensive medication review completed by psychiatry. A physician's order, dated June 11, 2024, included an order for the resident to receive 2.5 milligrams (mg) of Zyprexa (antipsychotic) twice a day.

A nursing note, dated June 21, 2024, at 9:47 p.m. revealed that Resident 85 walked over to Resident 26 and punched her in the left shoulder. The residents were separated and Resident 26 was assessed with no injuries found. Resident 85's care plan was updated June 22, 2024, to include that he was to be monitored while approaching other residents and to redirect him.

A nursing note, dated June 24, 2024, at 6:15 p.m. revealed that Resident 85 hit Resident 99 in the left leg and attempted to hit another resident and a staff member. Resident 85 was re-directed from the other residents and Resident 99 was assessed and had no injuries. Resident 85's care plan was updated on June 25, 2024, to include that he was to be redirected while in other's personal space.

A nursing note, dated July 12, 2024, at 12:18 p.m., revealed that Resident 85 was being verbally aggressive towards another resident in the dayroom and proceeded to hit Resident 70 on her left arm. The residents were separated and Resident 70 was assessed to have no injuries. Resident 85's care plan was updated on July 12, 2024, to keep him at the nurse's station so there was a space between residents and to redirect him when needed.

A nursing note and witness statements, dated July 14, 2024, at 6:15 a.m. revealed that Resident 85 entered Resident 97's room and punched her in the arm. The residents were separated and there were no injuries noted to either resident. There was no documented evidence that any changes were made to Resident 85's plan of care.

A nursing note, dated July 17, 2024, at 9:24 p.m. revealed that Resident 85 and Resident 34 were arguing and exchanged curse words, and Resident 34 hit Resident 85 and then Resident 85 hit Resident 34. This happened a few times and the licensed practical nurse was notified. The residents were separated and there were no injuries noted. A physician's order, dated July 17, 2024, included an order to increase the Zyprexa to 5 mg twice a day, and his care plan was updated to include to monitor him for an increase in his voice, body positioning, and other indicators of reactions while near others. Physician's orders, dated July 19, 2024, included orders to discontinue the Zyprexa and start Risperdal Consta ER intramuscularly every two weeks.

A nursing note, dated July 20, 2024, at 3:45 p.m., revealed that Resident 85 was agitated throughout the shift; received Ativan as needed, which was ineffective; was pacing up the halls and approaching other residents, yelling and agitated; and while under supervision abruptly punched Resident 110 on her back. The residents were separated and an order was received to administer 0.5 mg of Haldol (antipsychotic) intramuscularly (injection in the muscle) one time, which was ineffective. Resident 85 continued to approach other residents and while attempting to re-direct Resident 85, he began to strike staff on three occasions. A physician's order was received to send the resident to the hospital.

A nursing note, dated July 21, 2024, at 5:35 p.m. revealed that Resident 85 approached Resident 159 at the end of the hall and a verbal argument began. Staff went down the hallway to intervene and Resident 85 pushed Resident 159 from the back, knocking him onto his hands and knees before staff could get there. The residents were separated and there were no injuries noted. There was no documented evidence that any changes were made to Resident 85's plan of care.

Following the above incidents, there was no documented evidence that Resident 85's care-planned behavior interventions were revised when they were not effective, and no evidence that an individualized behavior management plan was developed in an attempt to prevent Resident R85's behaviors from affecting the safety of all other residents.

Interview with Registered Nurse 1 on August 22, 2024, at 12:16 p.m. revealed that Resident 85 would curse, stand over residents like he was going to hit them, would become aggressive and hit other residents, and anything could set him off. Staff would place him on one-to-one observations, adjust his medications, try activities, and re-direct him, but you could be talking to him one minute and the next minute he would go off.

Interview with the Director of Nursing on August 22, 2024, at 2:52 p.m. revealed that the facility tried interventions, but Resident 85 was very impulsive and continued to hit other residents. She indicated that they tried activities, adjusting his medications, and one-to-one observations, but he still hit others.

28 Pa. Code 211.10(c)(d) Resident Care Policies.

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

Plan of Correction - To be completed: 10/09/2024

1. R109 and R125 had footrests placed on their wheelchairs to be utilized during transports. R52 is followed by Vital Psych Services and recently had a medication adjustment and is placed on 1:1 when he becomes agitated. R85 is currently receiving hospice services and is physically incapable of striking out at others.
2. Residents in wheelchairs that are unable to self-propel have been evaluated by therapy and footrests were provided. Residents exhibiting behaviors toward other residents will be evaluated and followed by Vital Psych Services to manage their behaviors. Their care plans will be reviewed for appropriate interventions.
3. Education will be completed by social services/designee for the nursing staff on managing residents with difficult behaviors. Residents with behaviors will be reviewed by the IDT to determine if behavioral interventions need to be adjusted.
4. The Social Service Director/designee will audit 5 residents with behaviors to ensure appropriate interventions to manage those behaviors weekly for 4 weeks and monthly for 2 months. The results of the audits will be reviewed by the Quality Assessment and Assurance committee for the need to complete further audits.

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 review of clinical records, as well as staff interviews, it was determined that the facility failed to ensure that physicians orders were followed for three of 56 residents reviewed (Residents 104, 112, 139).

Findings include:

A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) assessment for Resident 104, dated June 14, 2024, indicated that the resident was understood and able to understand others, was dependent on staff for personal hygiene care, and had diagnoses that included cancer and anxiety.

Physician's orders for Resident 104, dated June 29, 2024, and August 5, 2024, included an order for the resident to receive 150 milligrams (mg) of Depo-Provera (a medication containing hormones that has been found effective in reducing offensive sexual behavior) intramuscularly one time a day every seven days for impulse disorder.

Review of the Medication Administration Record (MAR) for Resident 104 for July 2024 revealed no documented evidence that the resident was administered the Depo-Provera injection as ordered on July 13, 20, and 27, 2024, and August 3, 6, and 20, 2024.

Interview with the Director of Nursing on August 22, 2024, at 4:12 p.m. confirmed that there was no documented evidence that Resident 104 was administered Depo-Provera as ordered on the above-mentioned dates.

Hospital discharge papers for Resident 112, dated July 17, 2024, revealed that the resident was admitted to the hospital with congestive heart failure and that she required intravenous (IV) Lasix (diuretic) to remove excess fluid. Resident 112's care plan for congestive heart failure, dated July 17, 2024, indicated that the resident should be weighed per the physician's orders.

Physician's orders for Resident 112, dated July 18 ,2024, included an order for the resident to be weighed daily and to notify the physician if there was a 2-pound weight gain in one day or a 5-pound weight gain in one week.

Resident 112's weight record for July and August 2024 revealed that the resident was not weighed on July 21, 27, 2024, and August 4, 5, 7, 8, 2024.

On August 9, 2024, Resident 112 weighed 106.8 pounds and on August 11 the resident weighed 111 pounds. There was no documented evidence that the physician was notified of the 4.2-pound weight gain.

On August 15, 2024, Resident 112 weighed 105.6 pounds and on August 16 the resident weighed 108 pounds. There was no documented evidence that the physician was notified regarding the 2.4-pound weight gain in one day.

Interview with Registered Nurse Supervisor 1 on August 21, 2024, at 11:39 a.m. revealed that she was not notified about Resident 112's weight gains and therefore the physician was not notified. She stated that night shift should have notified her of the weight gains so that she could have notified the physician.

Interview with the Director of Nursing on August 21, 2024, at 4:42 p.m. confirmed that staff should have weighed Resident 112 and notified the physician as ordered.

A quarterly Minimum Data Set (MDS) assessment (a federally-mandated assessment of a resident's abilities and care needs) for Resident 139, dated July 1 2024, indicated that the resident was alert and oriented, had respiratory failure, and was received an antibiotic.

Physician's orders for Resident 139, dated June 30, 2024, included an order for the resident to receive 100 milligrams (mg) of Doxycycline (an antibiotic) two times a day for seven days for a respiratory tract infection.

Review of Resident 139's Medication Administration Record (MAR) for July 2024 revealed that the resident did not receive 100 mg of Doxycycline on July 1, 2024, at 9:00 a.m. and 8:00 p.m. as ordered.

Interview with the Nursing Home Administrator on August 21, 2024, at 3:23 p.m. confirmed that Resident 139 missed two doses of Doxycycline on July 1, 2024, and did not receive the antibiotic as ordered by the physician.

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

Plan of Correction - To be completed: 10/09/2024

1. R104 is receiving DepoProvera as ordered. R112's physician changed resident to weekly weights. The dietician assessed the resident and will follow as needed. Weights are obtained as per order. R139's provider was notified on 7/2/24 that resident missed 2 doses of doxycycline on 7/1/24 with no new orders to extend the antibiotic.
2. Residents with orders for daily weight will be reviewed to ensure weight is obtained and physician notified if parameters are not met. Residents with orders for antibiotics and DepoProvera injections will be reviewed to ensure medications are administered as ordered.
3. Education will be completed by the DON/designee for licensed nurses on following physician orders and notification to the physician as ordered by the physician.
4. The DON/designee will audit 10 residents weekly for 4 weeks and monthly for 2 months to ensure that medications are given as ordered. The dietician will audit residents with daily weights weekly for 4 weeks and monthly for 2 months to ensure that weights are obtained and follow up is completed per parameters. The results of the audits will be reviewed by the Quality Assessment and Assurance committee for the need to complete further audits.

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 review of facility policies, clinical records, and staff interviews, it was determined that the facility failed to develop a comprehensive care plan that included specific and individualized interventions to address the care needs of residents for six of 56 residents reviewed (Residents 8, 25, 27, 38, 53, 120).

Findings include:

A facility policy for Comprehensive Person-Centered Care Plans, dated June 1, 2024, included that the interdisciplinary team, in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each person. The comprehensive, person-centered care plan was to be developed within seven days of the completion of the required MDS assessment (admission, annual or change in significant status), and no more than 21 days after admission. Assessments of residents are ongoing and care plans are revised as information about the resident and the resident's condition change.

A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 8, dated July 17, 2024, revealed that the resident was cognitively impaired, was dependent on staff for personal care needs, and had diagnoses that included diabetes.

Physician's orders for Resident 8, dated August 16, 2024, included an order to administer 33 units of Toujeo SoloStar (long-acting insulin used to lower blood sugar) insulin once a day.

There was no documented evidence that a care plan was developed to address Resident 8's individual care and treatment needs related to her diabetes diagnosis and diabetes medication use.

Interview with the Director of Nursing on August 20, 2024, at 5:09 p.m. revealed that a care plan to address the care needs of Resident 8's diabetes diagnosis and diabetes medication use was not developed and should have been.

An admission MDS assessment for Resident 25, dated July 18, 2024, revealed that the resident was understood and able to understand others, was dependent on staff for personal hygiene care, had an indwelling catheter (a small tube inserted into the bladder to drain urine), had diagnoses that included renal insufficiency, and was receiving hospice services.

Physician's orders for Resident 25, dated July 20, 2024, included an order for the resident to have a 16 French (indicates a size) foley catheter (type of an indwelling catheter).

Interview with the Director of Nursing on August 20, 2024, at 12:47 p.m. revealed that Resident 25 required enhanced barrier precautions (infection control intervention designed to reduce transmission of multidrug-resistant organisms that requires gown and glove use during high contact resident care activities) because of her indwelling catheter; however, a care plan to address the care needs associated with enhanced barrier precautions related to her indwelling catheter was not developed and should have been.

An annual MDS for Resident 27, dated June 7, 2024, indicated that the resident was cognitively intact. Physician's orders for Resident 27, dated August 14, 2024, included an order for the resident to receive 1 gram of Vancomycin (antibiotic) through her Peripherally Inserted Central Catheter (PICC- a long thin tube inserted through a vein in the arm and passed to the larger veins near the heart that can be used for a prolonged period of time) for osteomyelitis (bone infection).

Resident 27's care plan, dated May 2, 2022, revealed that it did not include any information or interventions related to the resident's PICC line, infection with antibiotic treatment, or enhanced barrier precautions.

An interview with the Director of Nursing on August 20, 2024, at 12:48 p.m. confirmed that Resident 27's care plan did not include anything regarding the resident's infection, PICC line, antibiotic treatment, or Enhanced Barrier Precautions and it should have.

A quarterly MDS assessment for Resident 38, dated May 21, 2024, revealed that the resident was cognitively impaired, was dependent on staff for all care needs, had an indwelling catheter, and had diagnoses that included neurogenic bladder.

Physician's orders, dated June 21, 2024, included an order for the resident to have a 16 French foley catheter for neuromuscular dysfunction of his bladder.

Observations of Resident 38's room on August 19, 2024, at 11:30 a.m. revealed that the resident was lying in bed with a foley catheter drainage bag hanging on his bed. A sign was posted on the door to his room indicating that enhanced barrier precautions were required when providing care to the resident. Resident 38's care plan did not include anything regarding enhanced barrier precautions related to the indwelling catheter.

An admission MDS assessment for Resident 53 dated June 8, 2024, revealed that the resident was understood and able to understand others, was independent with personal hygiene care, had an indwelling catheter, and had diagnosis that included Parkinson's disease (brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination).

Physician's orders for Resident 53, dated July 1, 2024, included for the resident to have a 16 French suprapubic catheter (tube that is used to drain urine from the bladder through a cut in the abdomen) for urinary retention.

Observations of Resident 53's room on August 19, 2024, at 11:30 a.m. revealed that the resident sitting in bed with a urinary catheter drainage bag attached to his leg. A sign was posted on the door to his room indicating that enhanced barrier precautions were required when providing care to the resident. Resident 53's care plan did not include anything regarding enhanced barrier precautions related to the indwelling catheter.

Interview with the Director of Nursing on August 20, 2024, at 12:47 p.m. revealed that Residents 38 and 53 did require enhanced barrier precaution because of their indwelling catheters; however, care plans to address the care needs associated with enhanced barrier precautions related to their indwelling catheters were never developed and should have been.

A quarterly MDS for Resident 120, dated July 15, 2024, revealed that the resident was cognitively intact and that he was on a blood thinner. Physician's orders for Resident 120, dated June 21, 2024, included an order for the resident to receive 5 milligrams (mg) Apixaban (blood thinner) two times per day.

Resident 120's care plan, dated June 21, 2024, did not include any information or interventions related to the use of a blood thinner.

Interview with the Director of Nursing on August 20, 2024 at 12:48 p.m. revealed that Resident 120's care plan did not included anything regarding the resident's use of Apixaban and it should have.

28 Pa. Code 201.24(e)(4) Admission Policy.

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

Plan of Correction - To be completed: 10/09/2024

1. The care plan for resident R8 was immediately updated to include the diagnosis of Diabetes, R25, R27, R38, and R53 had enhanced Barrier Precautions added to their plan of care and R27 had their infection and PICC line added to their plan of care. R120 had their anticoagulant immediately to their plan of care.
2. Residents with diagnosis of Diabetes, residents requiring enhanced barrier precautions and residents receiving anticoagulants or with infections and/or PICC lines have had their care plans updated to reflect their current condition.
3. Education was completed by the DON/designee with the licensed nurses and interdisciplinary team to ensure that care plans are updated timely with any changes.
4. The Social Services Director/designee will audit 8 residents care plans weekly to ensure that residents with diabetes, anticoagulants infections and/or PICC lines or requiring enhanced barrier precautions are appropriately care planned. The results of the audits will be reviewed by the Quality Assessment and Assurance committee for the need to complete further audits.

483.20(g) REQUIREMENT Accuracy of Assessments:

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

Plan of Correction - To be completed: 10/09/2024

1. Residents R28, R52, R53, R91, R94, R139 and R162 identified with inaccurate MDSs had modifications completed.
2. A review of MDSs was completed for the 2 weeks prior to survey end (8/6-8/22) to ensure accuracy for catheters, medications, non-invasive mechanical ventilator, alarms and discharge destination.
3. The MDS department has been re-educated on accurately completing MDS section H for catheters and incontinence, section N for high-risk medications, Section O for non-invasive mechanical ventilation, Section P for alarms, and Section A2105 Discharge Status.
4. The MDS department/designee will complete accuracy audits on 5 random MDSs per week for 4 weeks and monthly for 2 months to ensure section A, H, N, O, and P have been completed correctly. The results of the audits will be reviewed by the Quality Assessment and Assurance committee for the need to complete further audits.

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 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(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 reviews, observations, and staff interviews, it was determined that the facility failed to provide care in a manner that maintained dignity for one of 56 residents reviewed (Resident 48).

Findings include:

An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 48, dated August 6, 2024, indicated that the resident was understood and able to understand others, required substantial to moderate assistance with personal hygiene care, and had diagnoses that included diabetes.

Observations of Resident 48 on August 19, 2024, at 11:00 a.m. revealed that she was lying in her bed with many long, white hairs protruding from under her chin. An interview with Resident 48 at that time revealed that she does not like having the long hair on her chin because it sometimes gets caught on her blankets and pulls her skin.

Observations of Resident 48 on August 21, 2024, at 7:47 a.m. and on August 22, 2024, at 12:07 p.m. revealed that the resident continued to have many long, white hairs protruding from under her chin.

Review of Resident 48's clinical record, including nurses' notes and nurse aide documentation, revealed no evidence that the resident was offered or refused to have her facial hair removed.

Interview with the Director of Nursing on August 22, 2024, at 12:10 p.m. revealed that staff should have provided Resident 48 care that included removing her visible facial hair.

28 Pa. Code 201.29(c) Resident Rights.

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

Plan of Correction - To be completed: 10/09/2024

1. Resident R48 had their facial hairs removed
2. Current residents were audited for unwanted facial hair with grooming completed as needed.
3. The DON/designee will educate the nursing staff on providing facial hair removal with am care for those residents that prefer to be hair free. The care plans for those residents that prefer to keep their facial hair will have their care plans updated.
4. DON/designee will complete weekly audits of facial hair for 4 weeks and monthly for 2 months. The results of the audits will be reviewed by the Quality Assessment and Assurance committee for the need to complete further audits.

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.

Observations:

Based on review of established infection control guidelines, facility policy, and residents' clinical records, as well as observations and staff interviews, it was determined that the facility failed to follow infection control guidelines from the Centers for Medicare/Medicaid Services (CMS) and the Centers for Disease Control (CDC) to reduce the spread of infections and prevent cross-contamination for three of 56 residents reviewed (Residents 25, 77, 94).

Findings include:

CDC guidance on isolation precautions and Implementation of Personal Protective Equipment (PPE) use in Nursing Homes to Prevent Spread of Multidrug-Resistant Organisms (MDRO's - bacteria that have become resistant to certain antibiotics, and these antibiotics can no longer be used to control or kill the bacteria), dated July 12, 2022, indicates that MDRO transmission is common in skilled nursing facilities, contributing to substantial resident morbidity and mortality and increased healthcare costs. Enhanced Barrier Precautions (EBP) are an infection control intervention designed to reduce transmission of resistant organisms that employs targeted gown and glove use during high contact resident care activities. CMS updated its infection prevention and control guidance effective April 1, 2024. The recommendations now include the use of EBP during high-contact care activities for residents with chronic wounds or indwelling medical devices, regardless of their MDRO status, in addition to residents who have an infection or colonization with a CDC-targeted or other epidemiologically important MDRO when contact precautions do not apply.

The facility's policy regarding Enhanced Barrier Precautions (EBP), dated June 1, 2024, indicated that precautions are used as an infection prevention and control intervention to reduce the spread for multi-drug resistant organisms (MDRO's) to residents. EBP's are indicated for residents with wounds and/or indwelling medical devices regardless of MDRO colonization. EBP's remain in place for the duration of the resident's stay or until resolution of the wound or discontinuation of the indwelling medical device that places them at increased risk. Signs are posted on the door or wall outside the resident room indicating the type of precautions and PPE required.

An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 25, dated July 18, 2024, revealed that the resident was understood and able to understand others, was dependent on staff for personal hygiene care, had an indwelling catheter (a small tube inserted into the bladder to drain urine), and had diagnosis that included renal insufficiency.

Physician's orders, dated July 20, 2024, included for the resident to have a 16 French (indicates a size) foley catheter (type of an indwelling catheter).

Observations of Resident 25 on August 20, 2024, at 10:25 p.m. revealed that the resident was lying in bed with a urinary drainage bag hanging on the left side of her bed. There was no sign posted on her door or wall alerting staff and visitors of the resident's need for EBP.

A significant change MDS assessment for Resident 77, dated August 6, 2024, revealed that the resident was cognitively intact and had a nephrostomy (procedure that creates an artificial opening in the skin and kidney to allow urine to drain from the kidney).

Physician's orders, dated July 2, 2024, included an order for the resident to have her nephrostomy site cleaned with normal saline (solution of water and salt) and gauze applied every day shift. A care plan, dated July 12, 2024, indicated that the resident was to use nephrostomy tubes related to kidney stones.

Observations on August 20, 2024, at 12:52 p.m. revealed that there was no sign posted on her door or wall alerting staff and visitors of the resident's need for EBP.

A quarterly MDS assessment for Resident 94, dated July 10, 2024, revealed that the resident was cognitively impaired, required assistance from staff for daily care needs, and had diagnoses that included dementia and a stroke.

A wound note, dated August 13, 2024, revealed that Resident 94 had a vascular wound (wound caused by poor circulation) on her left foot.

Physician's orders, dated August 13, 2024, included orders for the resident's left foot be cleaned with normal saline, Medi-Honey (honey based wound treatment) and Calcium Alginate with Silver (absorbent dressing used to prevent infection) applied, and covered with a dry dressing every day.

Observations of Resident 94 during a dressing change on August 20, 2024, at 11:34 a.m. revealed that the resident had a vascular wound on her left foot. There was no sign posted on her door or wall alerting staff and visitors of the resident's need for EBP.

Interview with the Director of Nursing on August 20, 2024, at 12:47 p.m. confirmed that Resident 25, 77, and 94 did require EBP because of their indwelling catheter, nephrostomy, and vascular wound and that a sign should have been posted on their door alerting staff to this; however, a sign was never posted.

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

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

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

Plan of Correction - To be completed: 10/09/2024

1. R25, R77 and R94 were immediately placed on enhanced barrier precautions.
2. An audit was conducted for residents requiring enhanced barrier precautions to ensure that PPE and EBP signage was in place.
3. Education will be completed by the DON/designee for the licensed nurses regarding enhanced barrier precautions and residents that require the precautions.
4. The DON/designee will audit 5 residents that require enhanced barrier precautions weekly for 4 weeks and monthly for 2 months to ensure that precautions are being followed and appropriate PPE is available. The results of the audits will be reviewed by the Quality Assessment and Assurance committee for the need to complete further audits.

483.45(g)(h)(1)(2) REQUIREMENT Label/Store Drugs and Biologicals:

�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 policies, as well as observations and staff interviews, it was determined that the facility failed to label medications with the date they were opened in one of two medication rooms reviewed (A unit) and in two of four medication carts reviewed (A and B unit).

Findings include:

The facility's policy regarding medication storage/labeling, dated June 1, 2024, indicated that multi-dose vials that have been opened or accessed are dated and discarded within 28 days unless the manufacturer specifies a shorter or longer date for the open vial.

An undated package insert for Tubersol (used to test for tuberculosis - a bacterial infection) revealed that once entered/opened, the vial was to be discarded after 30 days.

Observations in the medication room refrigerator on the A unit on August 22, 2024, at 12:18 p.m. revealed that an opened vial of Tubersol was not properly labeled with the date it was opened.

An interview with Registered Nurse 1 at that time confirmed that the opened vial of Tubersol was not properly labeled with the date it was opened and should have been.

Manufacturer's instructions for Basaglar (insulin) pen, dated November 2023, revealed that the pen should be thrown away after 28 days of use, even if it still has insulin left in it.

Manufacturer's instructions for Humalog (insulin) pen, dated August 2023, revealed that the pen should be thrown away after 28 days of use, even if it still has insulin left in it.

Manufacturer's instructions for Lyumjev (insulin) pen, dated October 2022, revealed that the pen should be thrown away after 28 days of use, even if it still has insulin left in it.

Observations of the North B cart revealed an open and undated Basaglar pen for Resident 93, an opened and undated Lumjev pen for Resident 58, and an opened and undated Humalog pen for Resident 58.

Interview with Licensed Practical Nurse 4 on August 21, 2024, at 8:04 a.m. revealed that the Basaglar, Humalog, and Lyumjev pens were not dated when opened and that they should have been.

Physician's orders for Resident 2, dated July 31, 2024, included orders for the resident to receive Lyumjev Kwikpen (insulin lispro- fact acting insulin) subcutaneously (beneath the skin) with meals based on a sliding scale (amount of insulin based on blood sugar results), and was to give 2 units of Lyumjev for a blood sugar of 150-200 milligrams per deciliter (mg/dL).

Observations during the medication pass on August 21, 2024, at 7:49 a.m. revealed that Licensed Practical Nurse 5 administered 2 units of Lyumjev to Resident 2 for a blood sugar result of 180 mg/dL and the Lyumjev Kwikpen was not dated when opened.

Interview with Licensed Practical Nurse 5 at that time confirmed that the Lyumjev Kwikpen was not dated when opened and should have been.

Interview with the Director of Nursing on August 21, 2024, at 10:38 a.m. confirmed that the insulin pens should have been dated when opened.

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

Plan of Correction - To be completed: 10/09/2024

1. The 3 undated insulin pens and undated Tubersol solution were replaced and discarded.
2. An audit was completed of the medication carts and medication refrigerators to ensure that medications with shortened expiration dates when opened are dated when opened.
3. Education will be completed by the DON/designee for the licensed nurses on the policy for dating medications with shortened expiration dates when opened.
4. The DON/designee will audit 6 medication carts and medication refrigerators to ensure medications are dated weekly for 4 weeks and monthly for 2 months. The results of the audits will be reviewed by the Quality Assessment and Assurance committee for the need to complete further audits.

483.45(a)(b)(1)-(3) REQUIREMENT Pharmacy Srvcs/Procedures/Pharmacist/Records:

�483.45 Pharmacy Services
The facility must provide routine and emergency drugs and biologicals to its residents, or obtain them under an agreement described in �483.70(g). The facility may permit unlicensed personnel to administer drugs if State law permits, but only under the general supervision of a licensed nurse.

�483.45(a) Procedures. A facility must provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident.

�483.45(b) Service Consultation. The facility must employ or obtain the services of a licensed pharmacist who-

�483.45(b)(1) Provides consultation on all aspects of the provision of pharmacy services in the facility.

�483.45(b)(2) Establishes a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation; and

�483.45(b)(3) Determines that drug records are in order and that an account of all controlled drugs is maintained and periodically reconciled.

Observations:

Based on facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to maintain accountability for controlled medications (drugs with the potential to be abused) for three of 56 residents reviewed (Residents 36, 94, 116).

Findings include:

A facility policy for medication administration, dated June 1, 2024, indicated that the individual administering a medication initials the resident's MAR on the appropriate line after giving each medication and before administering the next ones.

A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 36, dated July 23, 2024, indicated that the resident was understood and able to understand others, required substantial to maximum assistance for his daily care needs, and had diagnoses that included dementia.

Physician's orders for Resident 36, dated June 15, 2024, and July 17, 2024, included to administer 50 milligrams (mg) of Tramadol (a controlled medication use to treat pain) every eight hours as needed for right shoulder or right wrist pain.

Review of the controlled drug administration records (tracks each dose of a controlled medication) for Resident 36, dated April 13, 2024, and June 25, 2024, indicated that 50 mg of Tramadol was signed out as administered on June 15, 2024, at 3:15 p.m.; June 18, 2024, at 1:30 p.m.; June 19, 2024, at 5:00 p.m.; and July 19, 2024, time unreadable.

Review of the Medication Administration Records (MAR's) for Resident 36, dated June and July 2024, revealed no documented evidence that the signed-out doses of Tramadol were administered on the above-mentioned dates and times.

Interview with the Director of Nursing on August 22, 2024, at 1:06 p.m. confirmed that there was no documented evidence that the signed-out doses of Tramadol were administered to Resident 36 on the above-mentioned dates and times.

A quarterly MDS assessment for Resident 94, dated July 23, 2024, indicated that the resident was understood and able to understand others, required substantial to maximum assistance for his daily care needs, and had diagnoses that included dementia.

Physician's orders for Resident 94, dated June 1, June 18, July 3, and July 17, 2024, included an order to administer 0.25 mL of 2 mg/ml of Ativan every six hours as needed for anxiety/shortness of breath.

Review of the controlled drug administration records for Resident 94 for June and July 2024 revealed that 0.25 mL of 2 mg/ml of Ativan was signed out as administered on June 10 at 3:13 a.m., June 18 at 3:30 a.m., June 20 at 1:00 a.m., and July 3, 2024, at 10:00 p.m.

Review of the MAR's for Resident 94 for June and July 2024 revealed that there was no documented evidence the signed-out doses of Ativan were administered on the above-mentioned dates and times.

Interview with the Director of Nursing on August 22, 2024, at 1:06 p.m. confirmed that there was no documented evidence the signed-out doses of Ativan for Resident 94 were administered on the above-mentioned dates and times.

A quarterly MDS assessment for Resident 116, dated July 4, 2024, indicated that the resident was understood and able to understand others, was dependent on staff for daily care needs, and had diagnosis that included stroke.

Physician's orders for Resident 116, dated July 31, 2024, included for the resident to receive 0.25 milliliters (ml) of Ativan 2mg/ml solution every six hours as needed for anxiety for 14 days.

Review of the controlled drug administration records for Resident 116, dated August 4, 2024, indicated that 0.25 ml of Ativan 2 mg/ml solution was signed out as administered on August 13, 2024, no time recorded, and on August 14, 2024, at 8:00 p.m.

Review of the MAR for Resident 116, dated August 2024, revealed no documented evidence that the signed-out doses of Ativan were administered on the above-mentioned dates and times.

Interview with the Director of Nursing on August 22, 2024, at 1:06 p.m. confirmed that there was no documented evidence that the signed-out doses of Ativan were administered on the above-mentioned dates and times.

28 Pa. Code 211.9(h) Pharmacy Services.

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

Plan of Correction - To be completed: 10/09/2024

1. Resident R36 was assessed for pain with no concerns noted. R94 and R116 are receiving their Ativan as ordered by the physician.
2. An audit will be conducted of residents EMAR's to controlled substance logs for the last 7 days with follow up and notification to attending physician if necessary.
3. Education will be completed by the DON/designee for the licensed nurses regarding documentation of controlled substances, and documentation of administration in the residents EMAR.
4. The DON/designee will audit controlled substance records to the EMAR weekly for 4 weeks and monthly for 2 months. The results of the audits will be reviewed by the Quality Assessment and Assurance committee for the need to complete further audits.

483.25(i) REQUIREMENT Respiratory/Tracheostomy Care and Suctioning:

� 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 clinical record reviews, observations, and staff interviews, it was determined that the facility failed to obtain physician's orders for the administration of oxygen for one of 56 residents reviewed (Resident 139).

Findings include:

A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 139, dated July 1, 2024, revealed that the resident was cognitively intact, had medical diagnoses that included heart failure and respiratory failure, and used oxygen. The resident's care plan, dated March 7, 2024, revealed that staff were to administer oxygen as ordered by the physician.

Observations on August 19, 2024, at 12:11 p.m. revealed that Resident 139 was receiving oxygen via nasal cannula (tube that delivers oxygen) set at a flow rate of 2.0 liters per minute.

There was no documented evidence that a physician's order was received for the administration of oxygen.

Interview with the Nursing Home Administrator on August 21, 2024, at 3:23 p.m. confirmed that there was no physician's order for Resident 139 to receive oxygen.

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

Plan of Correction - To be completed: 10/09/2024

1. Resident R139's physician was immediately contacted, and an order was obtained for their oxygen.
2. Residents requiring oxygen have been audited to ensure that oxygen orders have been obtained by the physician.
3. Education will be completed by the DON/designee for the licensed nurses that a physician order is required for the use of oxygen.
4. The DON/designee will audit 5 residents requiring oxygen for the presence of an order weekly for 4 weeks and monthly for 2 months. The results of the audits will be reviewed by the Quality Assessment and Assurance committee for the need to complete further audits.

483.20(c) REQUIREMENT Qrtly Assessment at Least Every 3 Months:

�483.20(c) Quarterly Review Assessment
A facility must assess a resident using the quarterly review instrument specified by the State and approved by CMS not less frequently than once every 3 months.

Observations:

Based on review of the Resident Assessment Instrument User's Manual and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that Quarterly Minimum Data Set assessments were completed within the required timeframe for seven of 56 residents reviewed (Residents 21, 26, 64, 70, 98, 139, 148).

Findings include:

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 residents' abilities and care needs), dated October 2019, indicated that the completion date for a quarterly assessment is the Assessment Reference Date (ARD - the last day of an assessment's look-back period) plus 14 days. A quarterly assessment is due every 92 days (ARD of most recent assessment + 92 days).

A quarterly MDS assessment for Resident 21, with an ARD of May 10, 2024, was completed on May 27, 2024, which was three days late.

A quarterly MDS assessment for Resident 26, with an ARD of May 10, 2024, was completed on May 27, 2024, which was three days late.

A quarterly MDS assessment for Resident 64, with an ARD of May 13, 2024, was completed on May 28, 2024, which was one day late.

A quarterly MDS assessment for Resident 70, with an ARD of May 13, 2024, was completed on May 28, 2024, which was two days late.

A quarterly MDS assessment for Resident 98, with an ARD of May 9, 2024, was completed on May 24, 2024, which was one day late.

A quarterly MDS assessment for Resident 139, with an ARD of May 9, 2024, was completed on May 24, 2024, which was one day late.

A quarterly MDS assessment for Resident 148, with an ARD of May 24, 2024, was completed on June 9, 2024, which was two days late.

An interview with Nursing Home Administrator on August 22, 2024, at 3:29 p.m. confirmed that the quarterly MDS assessments listed above were not completed within the required time frames.

28 Pa. Code 211.5(f) Clinical Records.

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

Plan of Correction - To be completed: 10/09/2024

1. Residents with late Quarterly assessments cannot be retroactively corrected.
2. A review of the facility Minimum Data Set Final Validation reports was reviewed for the 2 weeks prior to the survey (8/6 � 8/22/24) end and no additional late quarterly assessments were identified.
3. The MDS department has been re-educated on the timing requirements for completion of quarterly assessments.
4. The MDS department/designee will complete weekly audits for 4 weeks and monthly for 2 months of 5 random quarterly MDS' to ensure timely completion. The results of the audits will be reviewed by the Quality Assessment and Assurance committee for the need to complete further audits.

483.20(b)(1)(2)(i)(iii) REQUIREMENT Comprehensive Assessments & Timing:

�483.20 Resident Assessment
The facility must conduct initially and periodically a comprehensive, accurate, standardized reproducible assessment of each resident's functional capacity.

�483.20(b) Comprehensive Assessments
�483.20(b)(1) Resident Assessment Instrument. A facility must make a comprehensive assessment of a resident's needs, strengths, goals, life history and preferences, using the resident assessment instrument (RAI) specified by CMS. The assessment must include at least the following:
(i) Identification and demographic information
(ii) Customary routine.
(iii) Cognitive patterns.
(iv) Communication.
(v) Vision.
(vi) Mood and behavior patterns.
(vii) Psychological well-being.
(viii) Physical functioning and structural problems.
(ix) Continence.
(x) Disease diagnosis and health conditions.
(xi) Dental and nutritional status.
(xii) Skin Conditions.
(xiii) Activity pursuit.
(xiv) Medications.
(xv) Special treatments and procedures.
(xvi) Discharge planning.
(xvii) Documentation of summary information regarding the additional assessment performed on the care areas triggered by the completion of the Minimum Data Set (MDS).
(xviii) Documentation of participation in assessment. The assessment process must include direct observation and communication with the resident, as well as communication with licensed and nonlicensed direct care staff members on all shifts.

�483.20(b)(2) When required. Subject to the timeframes prescribed in �413.343(b) of this chapter, a facility must conduct a comprehensive assessment of a resident in accordance with the timeframes specified in paragraphs (b)(2)(i) through (iii) of this section. The timeframes prescribed in �413.343(b) of this chapter do not apply to CAHs.
(i) Within 14 calendar days after admission, excluding readmissions in which there is no significant change in the resident's physical or mental condition. (For purposes of this section, "readmission" means a return to the facility following a temporary absence for hospitalization or therapeutic leave.)
(iii)Not less than once every 12 months.

Plan of Correction - To be completed: 10/09/2024

1. Identified residents with late comprehensive assessment cannot be corrected.
2. A review of the facility Minimum Data Set Final Validation reports was reviewed for the 2 weeks prior to the survey (8/6 � 8/22/24) end and no additional late comprehensive assessments were identified.
3. The MDS department has been re-educated on the timing requirements for completion of comprehensive assessments.
4. The MDS department/designee will complete weekly audits of new admission MDSs for 4 weeks and monthly for 2 months to ensure timely completion. The results of the audits will be reviewed by the Quality Assessment and Assurance committee for the need to complete further audits.

483.10(e)(4)-(6) REQUIREMENT Choose/Be Notified of Room/Roommate Change:

�483.10(e)(4) The right to share a room with his or her spouse when married residents live in the same facility and both spouses consent to the arrangement.

�483.10(e)(5) The right to share a room with his or her roommate of choice when practicable, when both residents live in the same facility and both residents consent to the arrangement.

�483.10(e)(6) The right to receive written notice, including the reason for the change, before the resident's room or roommate in the facility is changed.

Observations:

Based on clinical record reviews and observations, as well as resident and staff interviews, it was determined that the facility failed to ensure that in preparation for room changes each resident received written notice, including the reason for the change, before the resident's room or roommate was changed for one of 56 residents reviewed (Resident 139).

Findings include:

Review of Resident 139's clinical record and quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 139, dated July 1, 2024, revealed that the resident could understand others and make herself understood and was cognitively intact.

A social service note, dated August 12, 2024, at 9:45 a.m., revealed that Resident 139 toured the A-unit, was introduced to several nursing staff on the unit, and was in agreement with the room at that time.

A facility census report revealed that Resident 139 was moved from the B-wing to a room on the A unit on August 12, 2024. There was no documented evidence that Resident 139 was provided a written notice prior to the room change, including the reason for the change.

Observations and interview with Resident 139 on August 19, 2024, at 12:12 p.m. revealed that she was moved from the B-unit to the A-unit and did not know the reason why she had to move.

Interview with the Nursing Home Administrator on August 21, 2024, at 3:23 p.m. confirmed that there was no documented evidence that Resident 139 was provided a written notice regarding the room change and the reason for the move.

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

28 Pa. Code 201.29(a) Resident Rights.

Plan of Correction - To be completed: 10/09/2024

1. Social Service completed follow up with R139 to ensure the current room is satisfactory.
2. A 30 day look back of room/roommate changes was completed to ensure documentation of notification.
3. Education was completed by the Administrator with department managers regarding documentation of room/roommate changes.
4. The NHA/designee will audit room/roommate changes weekly for appropriate documentation weekly for 4 weeks and monthly for 2 months. The results of the audits will be reviewed by the Quality Assessment and Assurance committee for the need to complete further audits.

483.10(e)(3) REQUIREMENT Reasonable Accommodations Needs/Preferences:

�483.10(e)(3) The right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents.

Observations:

Based on a review of clinical records, as well as staff interviews, it was determined that the facility failed to determine a resident's preference for bathing for one of 56 residents reviewed (Resident 48).

Findings include:

An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 48, dated August 6, 2024, indicated that the resident was understood and able to understand others; required substantial to moderate assistance with personal hygiene care; had a preference that was was very important to her to choose between a tub bath, shower, bed bath, or sponge bath; and had diagnoses that included diabetes.

Review of the care plan for Resident 48, dated August 2, 2024, revealed that the resident required assist of one staff for bathing; however, it did not indicate if the resident preferred showers, tub baths or bed baths.

Interview with the Director of Nursing on August 22, 2024, at 2:10 p.m. revealed that there was no documented evidence that Resident 48's shower preferences were identified to enable staff to provide her bathing preference.

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

Plan of Correction - To be completed: 10/09/2024

1. Resident R48 had their bathing preferences updated in their plan of care
2. Residents with specific bathing preferences will have their bathing preferences updated in their plan of care. (or this one, Residents' bathing records will be reviewed to ensure that documentation accurately reflects the care they are receiving. Corrections will be made as indicated.)
3. The DON/designee will educate the licensed staff on updating plans of care for residents with specific bathing preferences.
4. DON/designee will audit bathing preferences for those residents with specific requests weekly for 4 weeks and monthly for 2 months to ensure residents needs are being met. The results of the audits will be reviewed by the Quality Assessment and Assurance committee for the need to complete further audits.

51.3 (g)(1-14) LICENSURE NOTIFICATION:

51.3 Notification

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

Observations:

Based on a review of clinical records as well as staff interviews, it was determined that the facility failed to notify the Department of Health of a choking episode and a fall requiring hospitalization.

Findings included:

A speech therapy note for Resident 112, dated July 27, 2024, indicated that the resident had a choking episode and required the Heimlich maneuver on July 26, 2024.

Interview with the Director of Nursing on August 20, 2024, at 12:28 p.m. revealed that she did not report Resident 112's choking episode to the Department of Health because she was not aware it needed reported.

A nursing note for Resident 112, dated July 13, 2024, revealed that the resident fell in her room and a large lump above her eyebrow, and her left wrist was swollen. The resident was kept in position until EMS arrived to transport her to the hospital.

Interview with the Director of Nursing on August 20, 2024, at 3:04 p.m. revealed that she did not report Resident 112's fall and transfer out because she was admitted to the hospital for congestive heart failure and not the fall.

Plan of Correction - To be completed: 10/09/2024

1. R112 had an event report submitted for the choking incident requiring the Heimlich and the fall with the transfer out.
2. A review will be completed of incidents for the prior 30 days to ensure that event reports were submitted.
3. Education will be completed for the nursing management team on reportable events
4. The DON/designee will audit 5 incidents per week for 4 weeks and monthly for 2 months to ensure that event reports are completed as per regulation. The results of the audits will be reviewed by the Quality Assessment and Assurance committee for the need to complete further audits.

� 201.14(a) LICENSURE Responsibility of licensee.:

(a) The licensee is responsible for meeting the minimum standards for the operation of a facility as set forth by the Department and by other Federal, State and local agencies responsible for the health and welfare of residents. This includes complying with all applicable Federal and State laws, and rules, regulations and orders issued by the Department and other Federal, State or local agencies.

Observations:

Based on review of Pennsylvania state law, as well as staff interviews, it was determined that the facility failed to ensure that the multi-disciplinary infection control committee met at least quarterly.

Findings include:

The Act 52 Infection Control Plan, dated January 25, 2024, revealed that a health care facility should develop and implement an internal infection control plan that should be established for the purpose of improving the health and safety of residents and health care workers, and should include a multi-disciplinary committee including a representative from each of the following, if applicable to the specific health care facility. Applicable members included medical staff that could include the chief medical officer or the nursing home medical director, the nursing home administrator, laboratory personnel, nursing staff that could include the director of nursing or a nursing supervisor, pharmacy staff, physical plant personnel, a patient safety officer, and a community member that may not be an agent, employee, or contractor of the facility.

As of August 22, 2024, the facility was unable to provide documented evidence that the facility's multi-disciplinary infection control committee met at least quarterly for one of one quarter reviewed.

Interview with the Infection Preventionist on August 22, 2024, at 2:35 p.m. confirmed that there was no documented evidence that the facility's multi-disciplinary infection control committee met at least quarterly for one of one quarter reviewed.

Plan of Correction - To be completed: 10/09/2024

P1020 Responsibility of licensee
1. The Infection Preventionist will keep documentation that the facility's multi-disciplinary infection control committee will meet at least quarterly
2. Education was completed with Infection Preventionist regarding the requirement of multi-disciplinary infection control committee meeting at least quarterly.
3. The Administrator/designee will audit the infection control committee meeting monthly for 3 months. The results of the audits will be reviewed by the Quality Assessment and Assurance committee for the need to complete further audits.

� 211.10(d) LICENSURE Resident care policies.:

(d) The policies shall be designed and implemented to ensure that the resident receives proper care to prevent pressure sores and deformities; that the resident is kept comfortable, clean and well-groomed; that the resident is protected from accident, injury and infection; and that the resident is encouraged, assisted and trained in self-care and group activities.

Observations:

Based on observations and staff interviews, it was determined that the facility failed to ensure that there was a written policy in place for the use of footrests on wheelchairs during transportation.

Findings include:

Observation of Resident 109 on August 19, 2024, at 12:28 p.m. revealed that the resident was sitting in a wheelchair while being transported to her room by Nurse Aide 2. There were no footrests on her wheelchair to prevent her feet from dragging during the transport. An interview with Nurse Aide 2 revealed that he did not know if she had leg rests or not, or if she needed them.

An interview with the Director of Nursing on August 19, 02024 at 4:38 p.m. confirmed that the facility did not have a policy regarding the use of footrests on wheelchairs for transportation.

Plan of Correction - To be completed: 10/09/2024

1. The facility policy for Assistive Devices was updated to include the use of footrests for residents that do not self-propel.
2. The DON/designee educated the nursing staff on the updated policy
3. The DON/designee will audit 5 transports in the facility weekly for 4 weeks and monthly for 2 months to ensure compliance with the updated policy.
4. The results of the audits will be reviewed by the Quality Assessment and Assurance committee for the need to complete further audits.

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

(2) Effective July 1, 2023, a minimum of 1 nurse aide per 12 residents during the day, 1 nurse aide per 12 residents during the evening, and 1 nurse aide per 20 residents overnight.

Plan of Correction - To be completed: 10/09/2024

1. CNA ratios for the dates noted in the survey cannot be corrected as this is a past event.
2. Calculation of shift CNA ratios will be completed and reviewed daily for accuracy by the scheduler.
3. The facility has developed internal incentives to retain and attract new staff. Agency staff are being utilized in an effort to reach daily shift ratios. The scheduler will look ahead for a minimum of 1 week at projected staffing patterns to enable more time to achieve appropriate CNA ratios as needed.
4. CNA ratios will be audited by scheduler and DON daily for 4 weeks, then 3 days per week x 2 months or until substantial compliance is achieved. Results will be reported to QAPI committee

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

(4) Effective July 1, 2023, a minimum of 1 LPN per 25 residents during the day, 1 LPN per 30 residents during the evening, and 1 LPN per 40 residents overnight.

Plan of Correction - To be completed: 10/09/2024

LPN ratios for the dates noted in the survey cannot be corrected as this is a past event.
2. Calculation of shift LPN ratios will be completed and reviewed daily for accuracy by the scheduler.
3. The facility has developed internal incentives to retain and attract new staff. Agency staff are being utilized in an effort to reach daily shift ratios. The scheduler will look ahead for a minimum of 1 week at projected staffing patterns to enable more time to achieve appropriate LPN ratios as needed.
4. LPN ratios will be audited by scheduler and DON daily for 4 weeks, then 3 days per week x 2 months or until substantial compliance is achieved. Results will be reported to QAPI committee.

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

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

Plan of Correction - To be completed: 10/09/2024

. The PPD cannot be corrected as this it is an event in the past.
2. The PPD will be completed and reviewed daily for accuracy by the scheduler.
3. The facility continues to develop a recruitment plan to attract nursing staff. The facility scheduler, DON, HR and NHA will meet daily to review compliance with ratios. In the event of call offs, every effort to contact regular full-time and part-time staff as well a PRN and agency staff will be made by facility personnel.
4. PPD will be monitored daily by the scheduler and DON/designee. Facility compliance with PPD will be monitored through the monthly QAPI process. Ratios will be monitored daily by the scheduler and/or DON/designee. Audits of PPD will be completed by the DON/designee daily X 4 weeks then 3 times per week X two months or until substantial compliance is achieved. The results of the audits will be reviewed at the monthly QA meeting.

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