Pennsylvania Department of Health
MOUNTAIN CITY NURSING & REHAB CTR
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

MOUNTAIN CITY NURSING & REHAB CTR
Inspection Results For:

There are 183 surveys for this facility. Please select a date to view the survey results.

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MOUNTAIN CITY NURSING & REHAB CTR - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:

Based on a revisit and abbreviated complaint survey completed on July 10, 2024, it was determined that Mountain City Nursing & Rehabilitation Center corrected the federal deficiencies cited during the survey of March 20, 2024, but failed to correct the deficiencies cited during the surveys of April 19, 2024, and May 31, 2024, and continued to be out of compliance with the following requirements of 42 CFR Part 483 Subpart B Requirements for Long Term Care and the 28 PA Code Commonwealth of Pennsylvania Long Term Care Licensure Regulations.

Plan of Correction:

483.12(a)(1) REQUIREMENT Free from Abuse and Neglect:

This is a more serious deficiency but is isolated to the fewest number of residents, staff, or occurrences. This deficiency results in a negative outcome that has negatively affected the resident's ability to achieve his/her highest functional status.

§483.12 Freedom from Abuse, Neglect, and Exploitation
The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms.

§483.12(a) The facility must-

§483.12(a)(1) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion;

Observations:

Based on review of clinical records, the facility's abuse prohibition policy, and select investigative reports, and interviews with staff, residents and resident representatives, it was determined that the facility failed to ensure that one resident was free from sexual abuse and resultant psychosocial harm (Resident 16) and that one resident (Resident 106) was free from physical abuse out of 11 residents sampled for abuse prohibition.

Findings include:

A review of a facility policy entitled "Pennsylvania Resident Abuse: Abuse, Neglect, and Exploitation," dated August 30, 2023, revealed that it is the policy of the facility to not tolerate abuse, neglect, mistreatment, exploitation of residents, or misappropriation of resident property by anyone. The policy defines abuse as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. It is the facility's policy to investigate all allegations, suspicions and incidents of abuse, neglect, involuntary seclusion, intimidation, exploitation of residents, misappropriation of resident property an injuries, of unknown source. The definition of sexual abuse incudes but is not limited to, non-consensual sexual contact of any type, sexual harassment. sexual coercion, or sexual assault.

A review of Resident 16's clinical record revealed the resident was admitted to the facility on April 18, 2024, with diagnoses, which included mild cognitive impairment of uncertain or unknown etiology.

A review of the resident's Admission Minimum Data Set Assessment (MDS - a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated April 24, 2024, revealed that the resident was severely cognitively impaired with a BIMS score of 7 (Brief Interview For Mental Status score of 7, a tool to assess the resident's attention, orientation and ability to register and recall new information, a score of 00-07 equates to severe cognitive impairment).

A review of Resident 91's clinical record revealed the resident was admitted to the facility on June 18, 2024, with diagnoses of hemiplegia (paralysis of one side of the body) affecting the left non dominant side due to history of a cerebral infarct (when a cluster of brain cells die due to lack of blood flow), depression and congestive heart failure (CHF occurs when the heart is unable to pump sufficiently to maintain blood flow to meet the body's needs

A review of Resident 91's admission MDS assessment dated June 24, 2024, revealed that the resident was cognitively intact with a BIMS score of 14 (scores of 13-15 equate to intact cognition).

A review of a facility investigation report dated July 6, 2024, at 6:00 PM revealed that Employee 1, a nurse aide, walked into Resident 16's room and observed Resident 16 and Resident 91 naked in Resident 16's bed.

A review of Employee 1's witness statement dated July 6, 2024 revealed that she entered Resident 16's room to give her a dinner tray and found both residents lying naked in the resident's bed. When Resident 16 saw Employee 1 she quickly sat up. The nurse aide immediately notified the nurse. The residents were quickly separated and were placed in their own rooms.

Nursing documentation dated July 6, 2024, at 10:13 PM from Employee 2 the Registered Nurse indicated Resident 91 reported that Resident 16, called him over into her room and they engaged in a sexual act.

A review of the facility investigation dated July 9, 2024, revealed statements from both residents. Employee 2, RN, obtained a statement from Resident 16, which indicated that this female resident did not remember a guy being in her room. She stated if a guy was in her room it would be her boyfriend. Resident 16 continued to state that all she did all was stay in her room and change her clothing twice. Employee 2 stated the resident had no recollection of the sexual encounter with Resident 91.

A statement was obtained from Resident 91, whose primary language is not English, and may require a translator as requested, and was translated and written by Employee 3, Licensed Practical Nurse (LPN) on July 6, 2024. According to Resident 91's statement, he observed Resident 16 in her room across the hall. Resident 91 stated that Resident 16 was naked and gestured to him to come to her room. He walked over to Resident 16's room and he climbed on top of her and had sexual intercourse with Resident 16. He stated a girl walked in while he was still engaged in sexual intercourse with Resident 16. He then stopped the sexual act, pulled his pants up and left the room and went back to his room. Resident 91 also stated Resident 16 was provoking him the prior day by talking and conversing with him.

A telephone interview conducted on July 9, 2024, at 1:26 AM with Employee 1. the nurse aide, revealed that she found both residents naked in bed in Resident 16's room on the evening of July 6, 2024, and immediately told a nurse. She stated she was very surprised because Resident 91 usually stays to himself in his room and he barely comes out. She stated he rings his call bell when he needs something. She stated she usually didn't see him conversing with Resident 16. Employee 1 stated that Resident 91 does speak to her because she is able to converse with him in his primary language. She stated on the evening of this sexual encounter Resident 91 was taken to the dayroom and staff watched him on a one-to-one basis until Resident 16 was moved to another room. Employee 1 stated Resident 16 is very social and was frequently observed walking up and down the hallway on a regular basis and often spoke to others about her boyfriend.

An interview with Resident 91 was attempted on July 9, 2024 however the resident was not available as he was out at an appointment on the day of the survey.

An interview with Resident 16 was conducted on July 9, 2024, but she was unable to recall the event and shared pictures of her boyfriend with the surveyor, that were on her dresser next to her bed in her new room.

An interview with Employee 2, RN, at 12:52 PM on July 9, 2024, revealed that the residents were both separated that evening and placed on every 15 minute security checks. Resident 16 was moved to another room in a different building of the facility (facility comprised of two separate buildings on the same campus).

A telephone interview was conducted with Resident 16's interested representative, a close friend, on July 9, 2024, at 11:46 PM. The resident's friend stated that Resident 16 is a long time friend, and she was not surprised of her actions with the male resident. The resident's friend stated that Resident 16 may have thought the male resident was her boyfriend. She stated that the resident may not want to remember what happened because she is very forgetful and may not want to accept what happened because of the loyalty she has to her boyfriend. The resident's friend stated that the resident can be very outgoing and that she wished had the opportunity to speak with facility staff to apprise them of the resident's resident's behavior and relationship with her boyfriend. The resident's representative stated that she believed that information would be necessary for the facility to explain the resident's behaviors. Resident 16's interested representative also relayed that she could never allow the resident's boyfriend to be aware of this sexual encounter because of the negative effects it would have on their relationship and also did not wish to notify the resident's daughter of the event due to the humiliation and embarrassment.

A review of the resident's admission paperwork revealed that her daughter signed the documents upon admission and remained listed as a second emergency contact. The resident's friend was listed as the primary contact.

A review of Resident 16's care plan, at the time of the survey, did not identify the significance of the resident's relationship with her boyfriend.

Neither Resident 16's or Resident 91's care plans, identified any history of sexual behaviors.

Resident 16 is cognitively impaired and did not possess the ability to consent to sex with Resident 91. A repeat BIMS score was obtained shortly after the encounter and her score was assessed at a 3 indicating severe cognitive impairment. Applying the reasonable person concept, in the case of Resident 16, who is unable to cognizantly speak for herself due to severe cognitive impairment, and the assessment of how most people would react to the situation of being sexually abused by Resident 91, Resident 16 would have been negatively affected by Resident 91's actions.

A review of Resident 106's clinical record revealed admission to the facility on May 18, 2016, with diagnoses which include dementia (a chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning) and anxiety.

A review of the resident's Quarterly Minimum Data Set Assessment dated May 2, 2024, indicated the resident was severely cognitively impaired with a BIMS score of 3.

A review of Resident 12's clinical record revealed admission to the facility on August 7, 2023, with diagnoses which included intermittent explosive disorder and epilepsy.

A review of the resident's annual Minimum Data Set Assessment dated June 7, 2024, indicated that the resident was severely cognitively impaired with a BIMS score of 3.

A facility incident report dated June 21, 2024, at 2:30 PM indicated that Resident 109, a cognitively intact resident, reported observing Resident 12 hit Resident 106 in the stomach as Resident 106 was walking in the hallway. The residents were redirected and separated and placed on increased supervision. Assessment completed and no injuries were noted.

Applying the reasonable person concept, in the case of Resident 106, who is severely cognitively impaired, and the assessment of how most people would react to the situation of being physically abused by Resident 12, Resident 106 would have suffered psychosocial harm and humiliation.

An interview with the nursing home administrator on July 9, 2024, at approximately 1:00 PM confirmed that the facility failed to ensure that Residents 16 was free from sexual abuse perpetrated by Resident 91 and Resident 106 was free from physical abuse perpetrated by Resident 12.

28 Pa. Code 201.14 (a) Responsibility of licensee

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

28 Pa. Code 201.29 (a)(c) Resident Rights

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

Plan of Correction - To be completed: 07/29/2024

Preparation and submission of this POC is required by state and federal law. This POC does not constitute an admission for purposes of general liability, professional malpractice or any other court proceeding.

Step 1
R16 and R106 had head to toe observations completed post incidents with no injuries noted. SS follow up occurred with R16 and R106 with no identified negative effects. Reportable events were submitted and facility conducted a thorough investigation.

Step 2
To identify other residents that have potential to be affected, the DON/designee will interview alert and oriented residents with a BIMs of 12 and higher related to abuse including sexual and physical to determine safety of residents. There were no negative findings.
To identify other residents that have the potential to be affected, licensed nursing completed body check on Residents with a BIMs below 12 for any signs or symptoms of abuse/physical/sexual. There were no negative findings.
To identify other residents that have the potential to be affected, the DON / designee will conduct an audit for abuse allegations in the past 30 days to determine that any negative psychosocial effects post incident where addressed with follow up based on the findings.
Step 3
To prevent this from reoccurring, the DON/designee will educate employees on the abuse policy and procedure including sexual and physical abuse.
Step 4
To monitor and maintain ongoing compliance, the DON/designee will interview 10 residents per week with a BIMs of 12 and higher related to abuse including sexual and physical to determine safety of residents.
10 residents with a BIMs below 12 will have a body audit completed to ensure no unidentified concerns are noted.
The DON / designee will audit allegations of abuse in the clinical meeting to determine if there had been identified behaviors with appropriate interventions in place to prevent the incident / behavior and if there were any identified psychosocial negative effects post incident.
The audits will be completed 5 days per week times 4 weeks and then monthly times 2. Negative findings will be addressed. Ad hoc education will be provided as needed
The results of the audits will be forwarded to QAPI committee for further review and recommendations.

483.12(b)(1)-(5)(ii)(iii) REQUIREMENT Develop/Implement Abuse/Neglect Policies:

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.

§483.12(b) The facility must develop and implement written policies and procedures that:

§483.12(b)(1) Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property,

§483.12(b)(2) Establish policies and procedures to investigate any such allegations, and

§483.12(b)(3) Include training as required at paragraph §483.95,

§483.12(b)(4) Establish coordination with the QAPI program required under §483.75.

§483.12(b)(5) Ensure reporting of crimes occurring in federally-funded long-term care facilities in accordance with section 1150B of the Act. The policies and procedures must include but are not limited to the following elements.

§483.12(b)(5)(ii) Posting a conspicuous notice of employee rights, as defined at section 1150B(d)(3) of the Act.

§483.12(b)(5)(iii) Prohibiting and preventing retaliation, as defined at section 1150B(d)(1) and (2) of the Act.

Observations:

Based on review of clinical records, the facility's abuse prohibition policy, and select investigative reports, and interviews with staff, residents, and resident representatives, it was determined that the facility failed to implement their established procedures for responding to an incident of sexual abuse of one resident (Resident 16) perpetrated by another resident (Resident 91) out of 11 residents reviewed for abuse prohibition.

Findings include:

Review of the facility policy entitled "Pennsylvania Resident Abuse: Abuse, Neglect, and Exploitation," dated August 30, 2023, revealed that it is the policy of the facility to not tolerate abuse, neglect, mistreatment, exploitation of residents, or misappropriation of resident property by anyone." The policy defines abuse as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. It is the facility's policy to investigate all allegations, suspicions and incidents of abuse, neglect, involuntary seclusion, intimidation, exploitation of residents, misappropriation of resident property an injuries, of unknown source. The definition of sexual abuse incudes but is not limited to, non-consensual sexual contact of any type, sexual harassment. sexual coercion, or sexual assault.

Procedures include Screening, Training, prevention & Identification, Protection of the Resident and Reporting. The Facility will educate its staff upon orientation and periodically thereafter regarding the facility's policy concerning abuse, neglect, mistreatment, exploitation, involuntary seclusion and/or misappropriation of property and how to handle resident-to-resident Abuse and Injuries of Unknown Source. Protection of the resident includes if the resident is injured as a result of the alleged or suspected incident, the Facility should take immediate action to treat the resident.

Staff should report all incidents immediately to their direct supervisors. Staff should not leave a resident unattended, unless it is necessary to summon assistance. Staff should not move the resident until he/she has been assessed by a nurse supervisor for possible injuries.

A nurse should perform an initial assessment of the resident. The assessment should generally include the following: range of motion (ROM); full body assessment for signs of injury; and vital signs.

The resident's attending physician should be notified if an incident has occurred requiring physician involvement. If appropriate, the facility should send the resident to the hospital for an examination.

The facility will contact the police for any allegation of misappropriation of resident property. Administrator or designee will notify police when the facility receives a complaint of, or suspect sexual abuse, serious bodily injury or suspicious death in Allegations of Sexual Abuse every effort will be made to preserve evidence on both the resident and the perpetrator.

For both the Resident and the perpetrator:

Will not be bathed or cleaned
Will not receive incontinence care
Incontinence brief will not be changed
Clothing will not to be changed
No oral care will be provided
Both resident and perpetrator will be evaluated in the ER.
Linens will be bagged and provided as evidence, if applicable
Police to be notified

A review of Resident 16's clinical record revealed that the resident was admitted to the facility on April 18, 2024, with diagnoses, which included mild cognitive impairment of uncertain or unknown etiology.

A review of the resident's Admission Minimum Data Set Assessment (MDS - a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated April 24, 2024, revealed the resident was severely cognitively impaired with a BIMS score of 7 (Brief Interview For Mental Status score of 7, a tool to assess the resident's attention, orientation and ability to register and recall new information, a score of 00-07 equates to severe cognitive impairment).

A review of Resident 91's clinical record revealed that the resident was admitted to the facility on June 18, 2024, with diagnoses of hemiplegia (paralysis of one side of the body) affecting the left non dominant side due to history of a cerebral infarct (when a cluster of brain cells die due to lack of blood flow), depression and congestive heart failure (CHF occurs when the heart is unable to pump sufficiently to maintain blood flow to meet the body's needs.

A review of Resident 91's admission MDS dated June 24, 2024, revealed that he was cognitively intact with a BIMS score of 14 (13-15 equates to intact cognition).

An investigative report date July 6, 2024, revealed that Employee 1, a nurse aide found, Resident 16 and Resident 91 naked in bed together. The residents were immediately separated.

Employee 3, Licensed Practical Nurse (LPN), translated Resident 91's statement, as English is not Resident 91 primary language. The resident's translated statement, obtained on July 6, 2024, indicated that he observed Resident 16 in her room across the hall. Resident 91 stated that Resident 16 was naked and gestured to him to come to her room. He walked, across the hall, over to Resident 16's room. He climbed on top of her and had sexual intercourse with Resident 16. He stated a girl walked in while he was still engaged in sexual intercourse with Resident 16. He then stopped the sexual act, pulled his pants up and left the room and went back to his room. Resident 91 also stated Resident 16 was provoking him the prior day by talking and conversing with him.

Nursing documentation written by Employee 2, a Registered Nurse (RN), dated July 6, 2024, at 10:13 PM AM revealed "the Administrator, DON and family was notified. The physician was notified, the family declined any medical treatment at the hospital. Agency of Aging was notified at 8:11 PM. The police was notified at 8:21. The police came in and did an investigation and talked to both parties. Head to toe assessment was completed on both residents. There is no history of either of the resident conversing prior to this. The male resident continues to be on 1:1 until tomorrow. She is moving to white building in a different room."

An interview with the nursing home administrator (NHA) and Director of Nursing (DON) on July 9, 2024 at 10:00 AM revealed that the facility notified the resident's representative, which was a close friend. The resident's daughter was listed as a contact but she was not notified since the friend is the resident's first emergency contact to be notified. The NHA and DON also confirmed that neither residents was sent to the hospital for an evaluation as per facility policy because Resident 16's representative declined to have her sent out and the physician did not want Resident 91 sent to the hospital for an evaluation.

A telephone interview with Resident 16's representative on July 9, 2024 at 11:46 PM revealed that she did not want Resident 16 sent to the hospital for an evaluation after the sexual encounter because she did not want to upset the resident. She stated that she also did not call the resident's daughter because she didn't want to get her involved because she is very busy and lives out of state. The resident's representative stated that she was very concerned about the resident's boyfriend finding out because he would be upset and the resident would not want him to know. The resident's representative stated she was not aware the facility policy required the resident to be examined at the hospital. She stated if she was knew it was facility policy she would have agreed to the transfer for an exam. The resident's representative stated that the facility told her they would examine the resident in the facility. She was concerned about the potential for sexually transmitted communicable disease and suggested testing to rule out disease. The resident's representative stated that she did not want the resident moved to another building (the facility is comprised of two buildings within the same campus) but the facility insisted it was for her safety and so she agreed.

A Focused Head to Toe Observation of Resident 16 dated July 6, 2024 at 7:46 PM completed by Employee 2, RN, in response to the sexual incident did not include documented evidence of an comprehensive examination of her entire body to identify any possible injuries to her mouth, anus, or genitalia. The resident was also not tested for potential STIs (sexually transmitted infections) until July 8, 2024. There was no evidence that the residents' clothing or bedding was preserved as evidence according to facility policy.

Interview with the NHA and DON on July 9, 2024 at 11:00AM confirmed that the residents were not sent to the hospital for evaluation according to facility policy. The NHA confirmed that the facility did not inform Resident 16's representative that it was facility policy to send the resident to the hospital for an examination and testing following sexual abuse. The NHA and DON confirmed that the facility had not followed their policy for sending the residents to the hospital and preserving evidence. The DON stated that Resident 91's physician did not want to send the resident to the hospital to be evaluated despite facility policy.

Resident 16 was transferred to another room in an another building of the facility even though the resident's representative was not in agreement with the room change and move to the other building on the facility's campus.

During a telephone interview with Employee 2, RN, on July 9, 2024, at 12:52 PM she stated that she completed the head to toe assessment on Resident 16 but verified that she did not document that she examined Resident 16's mouth, anus, or genitalia and no orders were obtained to acquire bloodwork to rule out STI. She confirmed that she had not completed a sexual assault examination and verified that she is not trained to complete that type of examination. When asked about the facility policy for preservation and collection of evidence she stated the bed linens should be washed, but stated she was unsure what was done with the resident's bedding and clothing.

Employee 2, RN also verified that she did not conduct an assessment of Resident 91 following the incident according to facility policy.

A telephone interview with Employee 1, the nurse aide, on July 9,2024 at 11:26 AM revealed she was unaware that according to facility policy she was to preserve the bed linens. She stated Resident 16 was independent and able to shower herself.

Interview via telephone with Employee 3 an LPN on July 9, 2024 at 11:34 AM confirmed that Resident 91 showered shortly after the incident. Interview with Employee 3 revealed that she was aware of the facility policy indicating that the residents should not shower, and the need for preservation of evidence but stated that since the resident was not transferred out for an examination, when he asked to shower she told the resident that it was OK.

In response to this incident the facility completed training with Employee 1 and Employee 2 on the facility's abuse policy on July 7, 2024. However, when interviewed by telephone on July 9, 2024, these employees were unaware of the facility policy and procedures for collection and preservation of evidence following a sexual incident.

Refer F600 and F726

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

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

28 Pa. Code 201.29 (a)(c)Resident Rights

28 Pa. Code 201.14(a) Responsibility of Licensee

Plan of Correction - To be completed: 07/29/2024

Step 1
The community is unable to retroactively correct the identified concern.
Step 2
To identify other residents that have potential to be affected, the DON/designee will audit incident reports from the past 30 days related to allegations of sexual abuse to verify that the policy was followed with follow up based on the findings.
Step 3
To prevent this from reoccurring, the DON/designee will educate staff on the policy for allegations of sexual abuse including appropriate actions to be taken.
Step 4
To monitor and maintain ongoing compliance, the DON/designee will interview 10 staff per week on what action steps are to be completed related to allegations of sexual abuse. The audits will be completed weekly times 4 then monthly times 2. The results of the audits will be forwarded to QAPI committee for further review and recommendations.

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 observation, review of select facility incident reports and clinical records, and staff interview, it was determined that the facility failed to provide adequate supervision and maintain an environment free of accident hazards to prevent a minor injury (a cut to the thumb) sustained by one of 11 sampled residents (Resident 65).

Findings include:

A review of clinical record revealed that Resident 65 was admitted to the facility on July 23, 2019, with diagnoses which included chronic alcoholism and hypertension.

A review of the resident's Quarterly Minimum Data Set Assessment (MDS - a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated June 10, 2024, indicated the resident was moderately cognitively impaired with a BIMS (brief screener that aids in detecting cognitive impairment) score of 8 (a score of 8-12 indicates moderate cognitive impairment).

A review of the resident's current care plan revealed that the resident did have a self-care deficit and required the assistance of one staff for bathing and was independent for ambulation and toileting.

A facility incident report dated July 3, 2024, at 6:35 PM revealed that the resident sustained a cut to his right thumb. The resident was found standing at the medication cart holding multiple used razors. The resident stated that he "had to dig them out in the shower room." The resident sustained a cut measuring 1.0 cm x 0.2 cm with a scant amount of dried blood. Resident washed hands with antibacterial soap. Right thumb flushed with normal saline and patted dry. Physician and Resident Representative notified. New physician order to cleanse right thumb with normal saline solution, apply triple antibiotic ointment, and band aid daily. STAT \ CBC, BMP, and Hepatitis Panel were ordered. Tdap Vaccine ordered. Resident placed on increased supervision. All Sharps containers (container used for disposal of used needles and other sharps to reduce risk of harm to others) were checked and changed as necessary. Sharps containers were removed from the shower rooms.

During an onsite survey on July 9, 2024, at 2:05 PM observations were conducted on the third floor which revealed the following potential accident hazards

-the sharps container was removed from the wall, but the mounted encasement that previously held the sharps container remained on the shower wall, and a razor was observed in the hollow case allowing for access of the sharp object by just placing a hand inside

-this same situation was observed in the third floor bathroom of the lounge area. The sharps container was removed from the wall, but the mounted encasement that previously held the sharps container remained on the wall, and a razor was observed in the hollow case allowing for access of the sharp object by just placing a hand inside

- observation in Room 313's bathroom revealed no sharps container, but the encasement, that previously held the container, contained two razors that were easily accessible by placing a hand inside in the case.

Observation on the second floor nursing unit revealed two razors in the encasement receptacle, that previously held the sharps container, mounted on the wall of the shower room. The director of nursing stated the facility removed the sharps container from the boxes that held them to the walls but staff continued to place the razors in that box which allowed continued access to the sharp items they contained.

Interview with the director of nursing on July 9, 2024, at approximately 2:30 PM failed to provide evidence the facility provided adequate supervision and maintained an environment free of accident hazards to prevent injury to Resident 65.

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

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

Plan of Correction - To be completed: 07/29/2024

Step 1
R65 was assessed and area has resolved.
Step 2
To identify other residents that have potential to be affected, Maintenance / designee removed all sharp mounted containers. Locks were ordered for shower.
Step 3
To prevent this from reoccurring, the DON/designee will educate the nursing staff on the process for disposing of sharps including razors and when to remove / replace sharps containers.
Step 4
To monitor and maintain ongoing compliance, the DON/designee will interview 10 nursing staff on their understanding on where to dispose of sharps including razors and when to remove / replace sharps containers. The DON / designee will complete audits for med cart sharps containers on all units to ensure sharps containers have been replaced as needed. The audits will be completed 5 days per week times 4 weeks and then monthly times 2. The results of the audits will be forwarded to QAPI committee for further review and recommendations.

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

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

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

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

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

Observations:

Based on review of select facility policy and staff interview, it was determined the facility failed to ensure that nursing staff possessed the appropriate competencies and skill sets to conduct a thorough resident assessment of residents following an incident of sexual abuse involving two out of 11 residents reviewed (Resident 16 and Resident 91)

Findings include:

A review of the facility's policy entitled "Pennsylvania Resident Abuse" last reviewed by the facility August 2023, indicated that after an allegation of sexual abuse The resident's attending physician should be notified if an incident has occurred requiring physician involvement. If appropriate, the facility should send the resident to the hospital for an examination.

The facility will contact the police for any allegation of misappropriation of resident property. Administrator or designee will notify police when the facility receives a complaint of, or suspect sexual abuse, serious bodily injury or suspicious death in Allegations of Sexual Abuse every effort will be made to preserve evidence on both the resident and the perpetrator.

The facility policy included the following procedures to be implemented for both the resident victim and the perpetrator:

Will not be bathed or cleaned
Will not receive incontinence care
Incontinence brief will not be changed
Clothing will not to be changed
No oral care will be provided
Both resident and perpetrator will be evaluated in the ER.
Linens will be bagged and provided as evidence, if applicable
Police to be notified

A review of nursing documentation in Resident 16's clinical record, dated July 6, 2024 at 10:13 PM, written by Employee 2 an RN, revealed that "Aide came to LPN stating she walked in on resident (Resident 16and another resident \ having sex. This RN went to their rooms. At this point each resident was in their separate rooms. The male resident \ said that the female resident was naked and motioning for him to come over Once the male resident came over they started to engage in sex. Once the aide came in with the meal tray they stopped and he went back to their separate rooms. The female resident \ stated that she "doesn't remember a guy being here and if there was a guy here it would be Administrator, DON and family was notified. The physician was notified, the family declined any medical treatment at the hospital. Agency of Aging was notified at 8:11 PM. The police were notified at 8:21 PM. The police came in and did an investigation and talked to both parties. Head to toe assessment was completed on both residents. There is no history of either of the resident conversing prior to this. The male resident \ continues to be on 1:1 until tomorrow. She \ is moving to white building in a different room."

Employee 2 wrote an identical entry in Resident 91's medical record.

Further review of Resident 16's clinical record revealed nursing documentation entitled "Focused Head to Toe Observation" regarding sexual occurrence dated July 6, 2024 at 7:46 PM. Employee 2 did not document the results of an examination an examination of the resident's mouth, anus, or genital areas.

The residents were not sent to the hospital for evaluation according to facility policy.

During a telephone interview with Employee 2, RN, on July 9, 2024, at 12:52 PM she stated that she completed the head to toe assessment on Resident 16. However, she verified that she did not document that she examined Resident 16's mouth, anus, or genitalia and did not obtain orders to complete bloodwork to rule out sexually transmitted diseases She confirmed that she had not performed a sexual assault examination on Resident 16 and confirmed that she is not trained to conduct that type of examination. When asked about preservation and collection of evidence, she stated the bed linens should be washed. Employee 2 stated that she was unsure what was done with the residents' bedding and clothing. Employee 2 also confirmed she did not complete or document any assessment of Resident 91.

As per the International Association of Forensic Nurses, a healthcare provider trained to conduct sexual assault exams performs a sexual assault exam. A sexual assault forensic examiner (SAFE), a sexual assault nurse examiner (SANE), or one of these types of doctors.

A review of Employee 2's records revealed that she was not trained to conduct a sexual assault forensic exam.

The DON and NHA confirmed during interview on July 9, 2024, that the residents were not sent to the hospital according to facility policy and Employee 2, RN, did not possess the necessary competencies to perform a sexual assault exam and she was not specifically trained to perform that type of sexual examination on the residents to include mouth, anus and genitalia.

28 Pa. Code 211.10 (a)(d) Resident care policies

28 Pa. Code 211.5 (f)(ii) (iii) (iv)Medical records

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

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

28 Pa. Code 201.19 (1)(3) Personnel records

Plan of Correction - To be completed: 07/29/2024

Step 1
The community is unable to retroactively correct the identified concern.
Step 2
To identify other residents that have potential to be affected, the DON/designee will audit incident reports from the past 30 days related to allegations of sexual abuse to verify if the residents were assessed by the RN appropriately based on the type of allegation of sexual abuse or if the resident(s) were sent to the ER for an examination.
Step 3
To prevent this from reoccurring, the DON/designee will complete education and written competencies related to allegations of sexual abuse with nursing staff to ensure they understand the policy.
Step 4
To monitor and maintain ongoing compliance, the DON/designee will interview 10 nursing staff per week on their understanding of the policy related to allegations of sexual abuse. The interviews will be completed 5 days per week times 4 weeks and then monthly times 2. The results of the audits will be forwarded to QAPI committee for further review and recommendations.

483.75(c)(d)(e)(g)(2)(i)(ii) REQUIREMENT QAPI/QAA Improvement Activities:

§483.75(c) Program feedback, data systems and monitoring.
A facility must establish and implement written policies and procedures for feedback, data collections systems, and monitoring, including adverse event monitoring. The policies and procedures must include, at a minimum, the following:

§483.75(c)(1) Facility maintenance of effective systems to obtain and use of feedback and input from direct care staff, other staff, residents, and resident representatives, including how such information will be used to identify problems that are high risk, high volume, or problem-prone, and opportunities for improvement.

§483.75(c)(2) Facility maintenance of effective systems to identify, collect, and use data and information from all departments, including but not limited to the facility assessment required at §483.70(e) and including how such information will be used to develop and monitor performance indicators.

§483.75(c)(3) Facility development, monitoring, and evaluation of performance indicators, including the methodology and frequency for such development, monitoring, and evaluation.

§483.75(c)(4) Facility adverse event monitoring, including the methods by which the facility will systematically identify, report, track, investigate, analyze and use data and information relating to adverse events in the facility, including how the facility will use the data to develop activities to prevent adverse events.

§483.75(d) Program systematic analysis and systemic action.

§483.75(d)(1) The facility must take actions aimed at performance improvement and, after implementing those actions, measure its success, and track performance to ensure that improvements are realized and sustained.

§483.75(d)(2) The facility will develop and implement policies addressing:
(i) How they will use a systematic approach to determine underlying causes of problems impacting larger systems;
(ii) How they will develop corrective actions that will be designed to effect change at the systems level to prevent quality of care, quality of life, or safety problems; and
(iii) How the facility will monitor the effectiveness of its performance improvement activities to ensure that improvements are sustained.

§483.75(e) Program activities.

§483.75(e)(1) The facility must set priorities for its performance improvement activities that focus on high-risk, high-volume, or problem-prone areas; consider the incidence, prevalence, and severity of problems in those areas; and affect health outcomes, resident safety, resident autonomy, resident choice, and quality of care.

§483.75(e)(2) Performance improvement activities must track medical errors and adverse resident events, analyze their causes, and implement preventive actions and mechanisms that include feedback and learning throughout the facility.

§483.75(e)(3) As part of their performance improvement activities, the facility must conduct distinct performance improvement projects. The number and frequency of improvement projects conducted by the facility must reflect the scope and complexity of the facility's services and available resources, as reflected in the facility assessment required at §483.70(e). Improvement projects must include at least annually a project that focuses on high risk or problem-prone areas identified through the data collection and analysis described in paragraphs (c) and (d) of this section.

§483.75(g) Quality assessment and assurance.

§483.75(g)(2) The quality assessment and assurance committee reports to the facility's governing body, or designated person(s) functioning as a governing body regarding its activities, including implementation of the QAPI program required under paragraphs (a) through (e) of this section. The committee must:

(ii) Develop and implement appropriate plans of action to correct identified quality deficiencies;
(iii) Regularly review and analyze data, including data collected under the QAPI program and data resulting from drug regimen reviews, and act on available data to make improvements.

Observations:

Based on review of the facility's plan of correction from the survey of April 19, 2024, and the findings of the survey ending July 10, 2024, it was determined that the facility's Quality Assurance Performance Improvement (QAPI) committee failed to develop and implement corrective action plans to prevent a continued quality deficiency related to abuse prohibition to ensure that plans designed to improve the delivery of care and services were consistently implemented to effectively deter future quality deficiencies.

Findings include:

During a standard survey completed at the facility on April 19, 2024, deficient facility practice was identified under the requirement for residents to be free from abuse and neglect. In response to this quality deficiency the facility developed a plan of correction, to include a quality assurance monitoring component to ensure that solutions were sustained. This plan was to be completed by May 14, 2024.

In response to the quality of care deficiency cited during the survey of April 19, 2024, related to the facility's failure to prevent resident abuse the facility's plan of correction was to:

Educate facility staff (interdisciplinary) on identifying behaviors and placing interventions to reduce initiating and/or receiving physical aggression.

To prevent abuse from reoccurring, the nursing home administrator (NHA)/designee educated staff on the Abuse Policy.

To monitor and maintain ongoing compliance, the director of nursing (DON)/designee reviewed progress notes five times per week times four weeks then monthly times two to identify any residents exhibiting aggressive behaviors. To monitor and maintain ongoing compliance, the DON/designee reviewed progress notes five times per week for four weeks then monthly times two to identify residents having increased behaviors that put them at risk for receiving aggression. To monitor and maintain ongoing compliance the DON/designee interviewed five interviewable residents weekly times four then monthly times two to ensure they feel safe in the facility. To monitor and maintain ongoing compliance, the DON/designee will review resident to resident incidents weekly times four then monthly times two to establish patterns of day of the week and shift.

However, during the revisit survey ending July 10, 2024, a review clinical records, facility incident reports, and staff interviews revealed that the facility failed to ensure that one resident (Resident 106) was free from physical abuse and one resident (Resident 16) was free from sexual abuse and resultant psychosocial harm out of 11 sampled residents.

The facility's quality assurance monitoring plans failed to identify the ongoing quality deficiency and sustain solutions to the identified quality deficiency to be free from abuse and neglect.

Refer F600

28 Pa. Code 211.12 (c) Nursing services

28 Pa. Code 201.18(e)(3)(4) Management

Plan of Correction - To be completed: 07/29/2024

Step 1
R16 and R106 had head to toe observations completed post incidents with no injuries noted. SS follow up occurred with R16 and R106 with no identified negative effects.
Step 2
To identify other residents that have potential to be affected, the DON/designee will interview alert and oriented residents with a BIMs of 12 and higher related to abuse including sexual and physical to determine safety of residents. Residents with a BIMs below 12 had a body audit completed with follow up based on the findings if needed. The DON / designee will conduct an audit for abuse allegations in the past 30 days to determine that any negative psychosocial effects post incident where addressed with follow up based on the findings.
Step 3
To prevent this from reoccurring, the Regional Nurse/designee will educate the NHA and DON on QAPI committee including the development and implementation of corrective action plans to prevent continued quality deficiencies related to abuse.
Step 4
To monitor and maintain ongoing compliance, the Regional Nurse/designee will audit the facilities abuse POC for implementation of corrective actions related to preventing continued quality deficiencies. The audits will be completed 5 days per week times 4 weeks and then monthly times 4. The results of the audits will be forwarded to QAPI committee for further review and recommendations.

§ 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.

Observations:

Based on a review of nurse staffing and staff interview, it was determined that the facility failed to ensure the minimum Nurse Aides (NA) staff to resident ratio was provided on the evening and night shifts for six shifts out of 14 reviewed (June 14 - June 20, 2024, and June 21- June 27, 2024).

Findings include:

A review of the facility's weekly staffing records June 14 - June 20, 2024, and June 21 - June 27, 2024, revealed that on the following dates the facility failed to provide minimum nurse aides (NA) staff of 1:12 on the day and evening shift, and 1:20 on night shift based on the facility's census.

Review of facility census data indicated that on June 14, 2024, the facility census was 232, which required 19.33 nurse aides (NA) during evening shift. Review of the nursing time schedules revealed only 17.70 NA worked the evening shift on June 14, 2024.

Review of facility census data indicated that on June 16, 2024, the facility census was 231, which required 19.25 nurse aides (NA) during evening shift. Review of the nursing time schedules revealed only 17.47 NA worked the evening shift on June 16, 2024.

Review of facility census data indicated that on June 22, 2024, the facility census was 227, which required 18.92 nurse aides (NA) during evening shift. Review of the nursing time schedules revealed only 17.83 NA worked the evening shift on June 22, 2024.

Review of facility census data indicated that on June 23, 2024, the facility census was 227, which required 18.92 nurse aides (NA) during evening shift. Review of the nursing time schedules revealed only 2.27 NA worked the evening shift on June 23, 2024.

Review of facility census data indicated that on June 23, 2024, the facility census was 227, which required 11.35 nurse aides (NA) during night shift. Review of the nursing time schedules revealed only 1.13 NA worked the night shift on June 23, 2024.

Review of facility census data indicated that on June 24, 2024, the facility census was 227, which required 18.92 nurse aides (NA) during evening shift. Review of the nursing time schedules revealed only 17.97 NA worked the evening shift on June 24, 2024.

During an interview on July 10, 2024, at approximately 2:00 PM, the administrator confirmed that the facility failed to provide a minimum nurse aide staffing ratios on the above shifts.

Plan of Correction - To be completed: 07/29/2024

Step 1
Facility can't retroactively correct
Step 2
To identify other areas of concern the facility reviewed 1 weeks' worth of schedules to review CNA staffing ratios.
Step 3
To monitor and maintain ongoing compliance, the NHA/Designee will educate staff responsible for the nursing schedule related to the required CNA ratios.
Step 4
To monitor and maintain ongoing compliance the NHA/designee will audit the nursing schedule related to CNA staffing ratios 5x's/week for 2 weeks and then weekly for 4 weeks, and monthly for 3 months. The results of the audits will be forwarded to the facility QAPI committee for further review and recommendations.

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

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

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