Pennsylvania Department of Health
HERITAGE CARE CENTER
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

HERITAGE CARE CENTER
Inspection Results For:

There are 184 surveys for this facility. Please select a date to view the survey results.

Surveys don't appear on this website until at least 41 days have elapsed since the exit date of the survey.


HERITAGE CARE CENTER - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:
Based on an Abbreviated Survey in response to a complaint and an incident, completed on August 15, 2024, it was determined that Heritage Care 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:

483.12(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;

Plan of Correction - To be completed: 09/20/2024

- All facility staff will be directly in-serviced by LW Consulting on the F600 Freedom from Abuse regulation.
- Therapy staff will be performing therapy evaluations on all residents who have not been evaluated in the last 60 days to update their transfer statuses in the residents Kardex.
- DON, or designee, will audit the resident Kardex records to ensure they accurately reflect the residents transfer status for all existing residents.
- DON, or designee, will monitor the resident Kardex bi-weekly x 2 weeks, weekly x 2 weeks and monthly thereafter to ensure that all resident Kardex records accurately reflect the resident's current status.
- DON, or designee, will in-service all direct care staff on how to find the resident Kardex information and transfer statuses.
- Results of all in-services, evaluations and monitoring will be reported to the QAPI committee at the next scheduled meeting.

- Direct in-service was completed on 8/26/2024

Correction for this resident
- All direct care staff has been inserviced on the kardex, how to navigate the kardex to find resident transfer status and the importance of following the directed transfer status.
-All RN's and LPN's have been in-serviced on accidents and incidents- investigating and reporting, as well as the facility requirements for documenting falls.
-All direct care staff has been in-serviced on the transfer status of the affected resident and that she is to only be transferred via a hoyer lift.

- All direct care staff has been in-serviced on providing the proper care during the changing of incontinence products on this resident, maintaining safety precautions on her injured shoulder and providing care with an assist of 2.

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.

Plan of Correction - To be completed: 09/20/2024

- All staff will attend a directed in-service on F 684 provided by LW Consulting, Inc.
- DON, or designee, will in-service all direct care staff on the Kardex (location of, use of, transfer status, etc) to ensure that all transfer statuses of residents is followed at all times.
- DON, NHA and Director of Rehab will review all current residents to ensure accuracy with their current transfer status within the Kardex.
- DON, or designee, will monitor the Kardex to ensure all new admissions have a valid transfers status, as well as any changes made to existing residents are accurate and monitor 3 random residents during transfers and bed mobility bi-weekly x 2, weekly x 2 and monthly thereafter.
- Resident R1's Kardex record accurately reflects her current transfer status.
- All in-services, reviews, audits and monitoring will be reviewed with the QAPI committee at the next scheduled meeting.
-DON, or designee, will interview 5 residents weekly x 3 and monthly there after on the quality of care they are receiving, level of assistance from staff and if there are any care concerns to ensure all residents are satisfied with the services and care provided to them.
-All C.N.A's will complete a competency on the proper use of a mechanical lift/hoyer and bed mobility to ensure they are capable of safely transferring all residents per their transfer status.
Directed In-Service was completed on 8/26/2024 by LW Consulting.

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

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

§483.12(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 facility documents, facility policy, clinical records, and staff interviews, it was determined that the facility failed to implement written policies and procedures to conduct a thorough investigation of an incident to rule out neglect for one of two residents (Resident R1) involving a fall sustained while receiving care.

Findings include:

Review of facility policy "Abuse and Neglect- Clinical Protocol", review date undetermined, indicated that neglect is defined as "the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress".

Review of the facility policy "Abuse, Neglect, Exploitation or Misappropriation- Reporting and Investigating", review date undetermined, indicated that "All reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation or resident property are reported to local, state and federal agencies (as required by current regulation) and thoroughly investigated by facility management, Finding of all investigations are documented and reported".

Review of the facility job description for "Certified Nursing Assistant", indicated that the purpose of the job position is to provide each resident with routine daily nursing care and services in accordance with the resident's assessment and care plan and as may be directed by your supervisor in accordance with the requirements of the policies and procedures of this facility in accordance with current federal, state, and local standards governing the facility. Job duties include assisting with lifting, turning, moving, positioning, and transporting residents into and out of beds, chairs, bathtubs, wheelchairs, lifts, etc.

Review of Resident R1's admission record indicated she was admitted to the facility on 6/10/24.

Review of Resident R1's Minimum Data Set (MDS) assessment (mandated assessment of a resident's abilities and care needs) dated 6/17/24, indicated diagnoses Vitamin C deficiency, and generalized edema (fluid accumulation that affects the whole body.

Review of Resident R1's admission record indicated additional diagnoses of muscle wasting and atrophy (decrease in size).

Review of documentation provided by the facility dated 8/1/24, stated the following: Resident R1 was admitted to the facility on 6/10/24. On 7/29/24 the resident was given a shower and as two nurse aides stood her to dress her in the shower room by standing her up at grab bar. Resident R1's legs gave out and she was assisted to the ground resulting in a fall. Description of Follow-up Action: The resident was immediately assessed by the registered nurse, and she was lifted off the floor. Vital signs were at baseline. No bruising or injuries noted. Doctor and POA (power of attorney- a person who is legally named to act on someone else's behalf) notified. Fall protocol initiated. Increased pain was found in the left arm over the next day. CRNP (Certified Registered Nurse Practitioner) notified of increased pain and came to assess the resident. CRNP gave orders for the resident to be sent out to the ER (emergency room) for possible trauma to the left bicep. On 7/31/24 it was founded that Resident R1's left shoulder was dislocated. They attempted to place shoulder back into place but were unsuccessful. Resident was sent back to the facility with orders for Resident R1 to follow up with ortho (orthopedic- a doctor who treats injuries involving muscles, bones, joints, ligaments, and tendons). Upon investigation it was found that the resident should have been lifted by a mechanical lift for transfers. All of the nursing staff will be re-educated on checking the Task list for transfer requirements prior to moving the resident. Resident R1 had a follow-up appointment with her previous surgeon, and she is scheduled to undergo surgery to replace shoulder.

During an interview on 8/15/24, at 11:58 a.m. Resident R1 confirmed that she had her surgery to repair her shoulder. State Agency informed Resident R1 of awareness of fall in the shower room. Resident R1 replied that she first fell a few days prior when "An aide was changing my diaper and rolled me onto my side and pushed me too hard and I went over the side of the bed. I tried to brace myself with my arm and hurt my arm. I kept complaining of pain and they sent me to the ER a couple of days later (7/30/24). The CT scan (computed tomography- a medical imaging technique used to obtain detailed internal images of the body) showed my arm was out of socket and they tried twice to put it back in with no success so I needed surgery on Friday (8/2/24). I'm just pissed that this all had to happen. It's been inconvenient going back and forth (for treatment)".

Review of Resident R1's medical record did not reveal any documentation regarding Resident R1's account of the fall that occurred when she was rolled out of the bed prior to her fall in the shower room.

During an interview on 8/15/24, at 12:52 p.m. Nursing Home Administrator (NHA) stated that Resident R1 did fall out of bed on 7/22/24.

During an additional interview on 8/15/24, at 12:55 p.m. NHA confirmed that this fall was not documented in Resident R1's medical record and that the fall was not investigated.

During an interview on 8/15/24, at 3:45 p.m. the Nursing Home Administrator and the Director of Nursing confirmed that the facility failed to implement written policies and procedures to ensure a complete and thorough investigation of an incident involving the potential for neglect for one of two residents (Resident R1) involving a fall sustained while receiving care on 7/22/24.

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

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

Plan of Correction - To be completed: 09/20/2024

- NHA will file a late reportable on this resident's fall on 7/22/2024 to the PA Event Reporting site.
- DON, or designee, will in-service direct care staff on the facility policy and procedure for "Abuse, Neglect, Exploitation or Misappropriation- Reporting and Investigating", "Accidents and Incidents- Investigating and Reporting" and "Assessing Falls and Their Causes".
- DON, or designee, will audit the facility falls in the last 30 days to ensure they have been properly documented and are accurately completed per the facility policy and procedures.
- DON, or designee, will monitor all facility falls bi-weekly x 2, weekly x 2 and monthly thereafter to ensure regulatory compliance, as well as compliance with the facility policies and procedures.
Social Worker, or designee, will interview 5 residents on staff care, staff assistance and the maintaining of weight bearing statuses weekly x 2 weeks and monthly thereafter to ensure residents are receiving proper care.
- The late reportable, in-service's and monitoring will be reported to QAPI at the next scheduled meeting.
-All C.N.A's will complete a competency on mechanical lift/hoyer use, bed mobility and resident transfers to show they can properly transfer residents according to their transfer status.

UPDATE ON RESIDENT R1- resident is still in facility and is currently
participating in skilled therapy. She has an ortho follow up on 9/18 and currently has a nwb status to the injured shoulder until she follows up with her dr.

483.12(c)(2)-(4) REQUIREMENT Investigate/Prevent/Correct Alleged Violation:

§483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must:

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

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

§483.12(c)(4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken.

Observations:

Based on review of facility documents, facility policy, clinical records, and staff interviews, it was determined that the facility failed to conduct a thorough investigation of an incident to rule out neglect for one of two residents (Resident R1) involving a fall sustained while receiving care.

Findings include:

Review of facility policy "Abuse and Neglect- Clinical Protocol", review date undetermined, indicated that neglect is defined as "the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress".

Review of the facility policy "Abuse, Neglect, Exploitation or Misappropriation- Reporting and Investigating", review date undetermined, indicated that "All reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation or resident property are reported to local, state and federal agencies (as required by current regulation) and thoroughly investigated by facility management, Finding of all investigations are documented and reported".

Review of the facility job description for "Certified Nursing Assistant", indicated that the purpose of the job position is to provide each resident with routine daily nursing care and services in accordance with the resident's assessment and care plan and as may be directed by your supervisor in accordance with the requirements of the policies and procedures of this facility in accordance with current federal, state, and local standards governing the facility. Job duties include assisting with lifting, turning, moving, positioning, and transporting residents into and out of beds, chairs, bathtubs, wheelchairs, lifts, etc.

Review of Resident R1's admission record indicated she was admitted to the facility on 6/10/24.

Review of Resident R1's Minimum Data Set (MDS) assessment (mandated assessment of a resident's abilities and care needs) dated 6/17/24, indicated diagnoses Vitamin C deficiency, and generalized edema (fluid accumulation that affects the whole body.

Review of Resident R1's admission record indicated additional diagnoses of muscle wasting and atrophy (decrease in size).

Review of documentation provided by the facility dated 8/1/24, stated the following: Resident R1 was admitted to the facility on 6/10/24. On 7/29/24 the resident was given a shower and as two nurse aides stood her to dress her in the shower room by standing her up at grab bar. Resident R1's legs gave out and she was assisted to the ground resulting in a fall. Description of Follow-up Action: The resident was immediately assessed by the registered nurse, and she was lifted off the floor. Vital signs were at baseline. No bruising or injuries noted. Doctor and POA (power of attorney- a person who is legally named to act on someone else's behalf) notified. Fall protocol initiated. Increased pain was found in the left arm over the next day. CRNP (Certified Registered Nurse Practitioner) notified of increased pain and came to assess the resident. CRNP gave orders for the resident to be sent out to the ER (emergency room) for possible trauma to the left bicep. On 7/31/24 it was founded that Resident R1's left shoulder was dislocated. They attempted to place shoulder back into place but were unsuccessful. Resident was sent back to the facility with orders for Resident R1 to follow up with ortho (orthopedic- a doctor who treats injuries involving muscles, bones, joints, ligaments, and tendons). Upon investigation it was found that the resident should have been lifted by a mechanical lift for transfers. All of the nursing staff will be re-educated on checking the Task list for transfer requirements prior to moving the resident. Resident R1 had a follow-up appointment with her previous surgeon, and she is scheduled to undergo surgery to replace shoulder.

During an interview on 8/15/24, at 11:58 a.m. Resident R1 confirmed that she had her surgery to repair her shoulder. State Agency informed Resident R1 of awareness of fall in the shower room. Resident R1 replied that she first fell a few days prior when "An aide was changing my diaper and rolled me onto my side and pushed me too hard and I went over the side of the bed. I tried to brace myself with my arm and hurt my arm. I kept complaining of pain and they sent me to the ER a couple of days later (7/30/24). The CT scan (computed tomography- a medical imaging technique used to obtain detailed internal images of the body) showed my arm was out of socket and they tried twice to put it back in with no success so I needed surgery on Friday (8/2/24). I'm just pissed that this all had to happen. It's been inconvenient going back and forth (for treatment)".

Review of Resident R1's medical record did not reveal any documentation regarding Resident R1's account of the fall that occurred when she was rolled out of the bed prior to her fall in the shower room.

During an interview on 8/15/24, at 12:52 p.m. Nursing Home Administrator (NHA) stated that Resident R1 did fall out of bed on 7/22/24.

During an additional interview on 8/15/24, at 12:55 p.m. NHA confirmed that this fall was not documented in Resident R1's medical record and that the fall was not investigated.

During an interview on 8/15/24, at 3:45 p.m. the Nursing Home Administrator and the Director of Nursing confirmed that the facility failed to conduct a thorough investigation of an incident to rule out neglect for one of two residents (Resident R1) involving a fall sustained while receiving care on 7/22/24.

28 Pa Code: 201.18 (e)(1)(2) Management

28 Pa Code: 201.29 (a )(c)(d) Resident Rights

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

Plan of Correction - To be completed: 09/20/2024

- DON, or designee, will be in-servicing all direct care staff on the facility policy and procedure for "Accidents and Incidents- Investigating and Reporting".
- NHA, or designee, will in-service the IDT team on the facility policy and procedure for "Accidents and Incidents- Investigating and Reporting"
- DON, or designee, will audit all current resident falls in the last 30 days to ensure that they have been completed in compliance with the facility policy and procedures.
- DON, or designee, will monitor all facility falls bi-weekly x 2 weeks, weekly x 2 weeks and monthly thereafter to ensure all fall investigations are completed in accordance with regulatory compliance and the facility policy and procedure.
- In-services and monitoring will be discussed with the QAPI committee at the next scheduled meeting.

483.20(g) REQUIREMENT Accuracy of Assessments:

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

Observations:
Based on a review of Resident Assessment Instrument (RAI) User's Manual, clinical records, and staff interviews, it was determined that the facility failed to ensure that MDS assessments accurately reflected the resident's status for one of two residents (Resident R1).

Findings include:

The Resident Assessment Instrument (RAI) User's Manual, which gives instructions for completing Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs),dated October 2023, indicated the following instructions:

-Observation (Look-Back, Assessment) Period is the time period over which the resident's condition or status is captured by the MDS assessment. Most MDS items themselves require an observation period, such as 7 or 14 days, depending on the item. Since a day begins at 12:00 a.m. and ends at 11:59 p.m., the observation period must also cover this time period. A standard 7-day look-back period counts back from and includes the Assessment Reference Date (ARD+6 previous days).
-Section C: Resident interview should be conducted because the resident is at least sometimes understood verbally, in writing, or using another method, and if an interpreter is needed, one is available.

Review of Resident R1's admission record indicated she was admitted to the facility on 6/10/24.

Review of Resident R1's MDS assessment dated 6/17/24, indicated diagnoses Vitamin C deficiency, and generalized edema (fluid accumulation that affects the whole body.

Review of Resident R1's admission record indicated additional diagnoses of muscle wasting and atrophy (decrease in size).

Review of the MDS assessment completed on 10/16/23, Section B: Hearing, Speech, and Vision, question B0700 measures the resident's "ability to express ideas and wants" indicated that Resident R1 is "understood", and question B0800 measures the resident's "ability to understand others" indicated that Resident R1 "understands". Review of Section C: Cognitive Patterns, Question C0100 indicated that Resident R41 is rarely/never understood, and the BIMS (brief interview for mental status) assessment was not completed.

State Agency (SA) conducted an interview on 8/15/24, at 11:58 a.m. with Resident R1 regarding a recent fall and surgery. Resident R1 was very clear in her speech, and answered questions appropriately The following is part of the conversation: "An aide was changing my diaper and rolled me onto my side and pushed me too hard and I went over the side of the bed. I tried to brace myself with my arm and hurt my arm. I kept complaining of pain and they sent me to the ER a couple of days later (7/30/24). The CT scan (computed tomography- a medical imaging technique used to obtain detailed internal images of the body) showed my arm was out of socket and they tried twice to put it back in with no success so I needed surgery on Friday (8/2/24). I'm just pissed that this all had to happen. It's been inconvenient going back and forth (for treatment).

Review of medical records and interviews with staff confirmed that Resident R1's account of events were accurate.

During an interview on 8/15/24, at 12:40 p.m. Director of Nursing (DON) was informed of discrepancy between MDS answer that resident is rarely/never understood, and the clarity of the interview that had just occurred between SA and Resident R1. DON stated that typically a Social Worker would conduct that part of the interview that would be utilized to fill out Section C of the MDS, and BIMS score, however there was a gap in coverage with Social Workers and the RNAC (registered nurse assessment coordinator) was completing this section during this time.

During an interview on 8/15/24, at 12:42 p.m. RNAC Employee E7 confirmed that she had completed Section C on the above mentioned MDS completed on 6/17/24. When SA explained the discrepancy between MDS answer that resident is rarely/never understood, and the clarity of the interview that had just occurred between State Agency and Resident R1, RNAC Employee E7 stated it depends on how much medication she has had.

During an interview on 8/15/24, at 2:01 p.m. Physical Therapy (PT) Employee E4 stated that she is familiar with Resident R1. When asked about her mental status, PT Employee E4 stated that Resident R1's medication can make her mental status "fuzzy" sometimes, but that Resident R1 can "absolutely" make her needs known, and is understood.

During an interview on 11/22/23, at 11:30 a.m. the Nursing Home Administrator and DON confirmed that Residents R1 is cognitively intact, and should have had BIMS assessments completed, and that the facility failed to ensure that MDS assessments accurately reflected the resident's status for one of two residents.

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

Plan of Correction - To be completed: 09/20/2024

- Social Worker, Social Work Assistant and RNAC's will be in-serviced on the RAI manual and importance of accurate assessments by the NHA, or designee. RNAC's recently underwent training on dashing MDS's and the importance of accurate completion by our corporate reimbursement specialist.
- NHA, or designee, will review all current residents to ensure that they have a BIMS assessment in their record.
- NHA, or designee, will monitor all new admissions to ensure that there is a completed BIMS assessment in their chart within the regulated time period and that the BIMS assessment is completed accurately in regards to residents current condition bi-weekly x 2, weekly x 2 and monthly thereafter.
- All education, audits and monitors will be discussed with the QAPI team at the next scheduled meeting.

Resident R1 had a BIMS completed on 8/15 with a score of 15, which reflects her current cognitive status.

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, resident interview, and staff interviews, it was determined that the facility failed to document and/or institute interventions for a fall for one of two residents (Residents R1).

Findings include:

Review of the facility job description for "Certified Nursing Assistant", indicated that the purpose of the job position is to provide each resident with routine daily nursing care and services in accordance with the resident's assessment and care plan and as may be directed by your supervisor in accordance with the requirements of the policies and procedures of this facility in accordance with current federal, state, and local standards governing the facility. Job duties include assisting with lifting, turning, moving, positioning, and transporting residents into and out of beds, chairs, bathtubs, wheelchairs, lifts, etc.

Review of Resident R1's admission record indicated she was admitted to the facility on 6/10/24.

Review of Resident R1's Minimum Data Set (MDS) assessment (mandated assessment of a resident's abilities and care needs) dated 6/17/24, indicated diagnoses Vitamin C deficiency, and generalized edema (fluid accumulation that affects the whole body.

Review of Resident R1's admission record indicated additional diagnoses of muscle wasting and atrophy (decrease in size).

Review of documentation provided by the facility dated 8/1/24, stated the following: Resident R1 was admitted to the facility on 6/10/24. On 7/29/24 the resident was given a shower and as two nurse aides stood her to dress her in the shower room by standing her up at grab bar. Resident R1's legs gave out and she was assisted to the ground resulting in a fall. Description of Follow-up Action: The resident was immediately assessed by the registered nurse, and she was lifted off the floor. Vital signs were at baseline. No bruising or injuries noted. Doctor and POA (power of attorney- a person who is legally named to act on someone else's behalf) notified. Fall protocol initiated. Increased pain was found in the left arm over the next day. CRNP (Certified Registered Nurse Practitioner) notified of increased pain and came to assess the resident. CRNP gave orders for the resident to be sent out to the ER (emergency room) for possible trauma to the left bicep. On 7/31/24 it was founded that Resident R1's left shoulder was dislocated. They attempted to place shoulder back into place but were unsuccessful. Resident was sent back to the facility with orders for Resident R1 to follow up with ortho (orthopedic- a doctor who treats injuries involving muscles, bones, joints, ligaments, and tendons). Upon investigation it was found that the resident should have been lifted by a mechanical lift for transfers. All of the nursing staff will be re-educated on checking the Task list for transfer requirements prior to moving the resident. Resident R1 had a follow-up appointment with her previous surgeon, and she is scheduled to undergo surgery to replace shoulder.

During an interview on 8/15/24, at 11:58 a.m. Resident R1 confirmed that she had her surgery to repair her shoulder. State Agency informed Resident R1 of awareness of fall in the shower room. Resident R1 replied that she first fell a few days prior when "An aide was changing my diaper and rolled me onto my side and pushed me too hard and I went over the side of the bed. I tried to brace myself with my arm and hurt my arm. I kept complaining of pain and they sent me to the ER a couple of days later (7/30/24). The CT scan (computed tomography- a medical imaging technique used to obtain detailed internal images of the body) showed my arm was out of socket and they tried twice to put it back in with no success so I needed surgery on Friday (8/2/24). I'm just pissed that this all had to happen. It's been inconvenient going back and forth (for treatment)".

Review of Resident R1's medical record did not reveal any documentation regarding Resident R1's account of the fall that occurred when she was rolled out of the bed prior to her fall in the shower room.

During an interview on 8/15/24, at 12:52 p.m. Nursing Home Administrator (NHA) stated that Resident R1 did fall out of bed on 7/22/24.

During an additional interview on 8/15/24, at 12:55 p.m. NHA confirmed that this fall was not documented in Resident R1's medical record and that the fall was not investigated.

During an interview on 8/15/24, at 3:45 p.m. the Nursing Home Administrator and the Director of Nursing confirmed that the facility failed to document and/or institute interventions for a fall sustained on 7/22/24, for one of two residents (Resident R1).

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

28 Pa. Code 201.29(d) Resident rights.

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

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

Plan of Correction - To be completed: 09/20/2024

- DON, or designee, will in-service all direct care staff on the facility policy and procedure on "Falls-Clinical Protocol" and "Accidents and Incidents- Investigating and Reporting".
- DON, or designee, will review all falls within the last 30 days to ensure that the facility policy and procedure, as well as all state and federal regulations, were followed. Any issues identified will be reported to the appropriate reporting agency.
- DON, or designee, will monitor all falls bi-weekly x 2, weekly x 2 and monthly thereafter for accurate investigation and reporting, per the facility policy and procedures.
-All C.N.A's will complete a competency to ensure proper us technique for transfers on the mechanical lift/hoyer, bed mobility, transfer to and from wc.
-DON, or designee, will review the last 30 days of documentation in all current residents to ensure that all falls have been properly investigated and reported.
- All education, audits, reporting and monitors will be reviewed with the QAPI committee at the next scheduled meeting.

483.25(e)(1)-(3) REQUIREMENT Bowel/Bladder Incontinence, Catheter, UTI:

§483.25(e) Incontinence.
§483.25(e)(1) The facility must ensure that resident who is continent of bladder and bowel on admission receives services and assistance to maintain continence unless his or her clinical condition is or becomes such that continence is not possible to maintain.

§483.25(e)(2)For a resident with urinary incontinence, based on the resident's comprehensive assessment, the facility must ensure that-
(i) A resident who enters the facility without an indwelling catheter is not catheterized unless the resident's clinical condition demonstrates that catheterization was necessary;
(ii) A resident who enters the facility with an indwelling catheter or subsequently receives one is assessed for removal of the catheter as soon as possible unless the resident's clinical condition demonstrates that catheterization is necessary; and
(iii) A resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible.

§483.25(e)(3) For a resident with fecal incontinence, based on the resident's comprehensive assessment, the facility must ensure that a resident who is incontinent of bowel receives appropriate treatment and services to restore as much normal bowel function as possible.

Observations:
Based on review of facility policy, clinical records, and staff interviews it was determined that the facility failed to ensure that the physician order indicated a catheter size for a urinary catheter (insertion of a tube into the bladder to remove urine) for one of two residents (Residents R2).

Findings include:

Review of facility policy "Indwelling Catheter Insertion", review date undetermined, indicated that a physician's order should be present, and that the size of the catheter and the amount of sterile water sued to inflate the balloon should be documented.

Review of admission record indicated that Resident R2 was admitted on 6/27/24.

Review of Resident R2's Minimum Data Set Assessment (MDS, periodic assessment of resident care needs) dated 6/30/24, indicated diagnoses of obstructive uropathy (restriction in the flow of urine), difficulty swallowing, and pain. Section H - Bladder and Bowel indicated the utilization of an indwelling catheter.

Review of Resident R2 's physician order dated 6/27/24, indicated to perform catheter care every shift, and to empty catheter every shift, but did not have a physician's order regarding the size of the foley catheter and balloon.

During an interview on 9/15/24, at 9:50 a.m., the Director of Nursing confirmed the facility failed to ensure that the physician order indicated a catheter size for the use urinary catheter and balloon as required for one of two resident (Resident R2).

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

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

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

Plan of Correction - To be completed: 09/20/2024

- DON, or designee, will in-service all RN's and LPN's on the facility policy and procedure for "Indwelling Catheter Insertion".
- All residents with a catheter during the complaint survey had their order updates to reflect catheter/balloon size in the physcians order.
- DON, or designee, will review all admissions since the complaint survey to ensure that if they have a catheter, their physicians order states the catheter and balloon size.
- DON, or designee, will monitor all new admissions bi-weekly x 2, weekly x 2 and monthly thereafter to ensure that all admissions with catheters have physicians orders that reflect the catheter and balloon size.
- All educations, audits and monitoring will be reviewed with the QAPI committee at the next scheduled meeting.

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 facility policies, observations and staff interview it was determined that the facility failed to store all drugs and biologicals in a safe, secure, and orderly manner for one of two nursing units (Second floor).

Findings include:

Review of the facility policy "Storage of Medications" review date undetermined, indicated that only persons authorized to prepare and administer medications have access to locked medications. Compartments (including, but not limited to drawers, cabinets, rooms, refrigerators, carts, and boxes) containing drugs and biologicals are locked when not in use. Unlocked medication carts are not left unattended.

During an observation and interview on 8/15/24, at 11:44 a.m. the door to the Second Floor medication room was propped open, and contained a treatment cart containing medications that was unlocked. Assistance Director of Nursing Employee E8 Employee confirmed that the facility failed to store all drugs and biologicals in a safe, and secure manner for one of two nursing units (Second Floor).

28 Pa Code: 211.9 (a) Pharmacy services.

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

Plan of Correction - To be completed: 09/20/2024

- DON, or designee, will in-service all RN's and LPN's on the facility policy and procedures for "Storage of Medications" and "Security of Med Cart".
- DON, or designee, will monitor 50% of facility storage rooms to ensure compliance with the facility policy and procedures for medication storage security bi-weekly x 2, weekly x 2 and monthly thereafter.
- DON, or designee, will monitor 50% of facility medication and treatment carts to ensure compliance with the facility policy and procedures for medication storage security bi-weekly x 2, weekly x 2 and monthly thereafter.
- All education and monitoring will be reviewed with the QAPI committee at the next scheduled meeting.
-All med carts and storage room were checked to ensure they were secured after notification from the surveyor of the identified issue by the facility ADON and Unit Managers.

35 P. S. § 448.809b LICENSURE Photo Id Reg:

Law amended July 11, 2022 Act 79 2022 HB 2604

(1) The photo identification tag shall include a recent
photograph of the employee, the employee's first name, the
employee's title and the name of [the health care facility or
employment agency.] any of the following:
(i) The health care facility.
(ii) The health system.
(iii) The employment agency.
(iv) The fictitious name of an entity under
subparagraph (i), (ii) or (iii) which is registered with
the Department of State under 54 Pa.C.S. Ch. 3 (relating
to fictitious names) or a successor statute.

(2) The title of the employee shall be as large as possible
in block type and shall occupy a one-half inch tall strip as
close as practicable to the bottom edge of the badge.

(3) Titles shall be as follows:
(i) A Medical Doctor shall have the title "Physician."
(ii) A Doctor of Osteopathy shall have the title
"Physician."
(iii) A Registered Nurse shall have the title
"Registered Nurse."
(iv) A Licensed Practical Nurse shall have the title
"Licensed Practical Nurse."
(v) All other titles shall be determined by the
department. Abbreviated titles may be used when the title
indicates licensure or certification by a Commonwealth
agency.

(4)A notation, marker or indicator included on an identification badge that differentiates employees with the same first name is considered acceptable in lieu of displaying an employee's last name.

Observations:
Based on observations, and staff interviews, it was determined that the facility failed to make certain that staff members displayed identification badges to include a name, title, and a photo as required for five of five employees (Employee E3, E4, E5, E7 and E9).

Finding include:

Review of the Photo Identification Tag Regulation indicates that staff must wear a photo identification tag that shall include a recent photograph of the employee, the employee's first name, the employee's title and the name of the health care facility or employment agency.

During an observation and interview on 8/15/24, at 11:14 a.m. Physical Therapist Employee E4, Occupational Therapist Employee E5, and Physical Therapy Assistant Employee E9 displayed name tags with name and title, but no photo. Physical Therapy Employee E4 stated that the name tags were given to them without a photo.

During an observation and interview on 8/15/24, at 11:48 a.m. Nurse Aide (NA) Employee E3 displayed a name tag with name, and title but no photo. NA Employee E3 stated that the name tag was given without a photo.

During an observation and interview on 8/15/24, at 12:42 a.m. Registered Nurse Assessment Coordinator (RNAC) Employee E7 displayed a name tag with name, and title but no photo. RNAC Employee E7 stated that the name tag was given without a photo

During an interview on 8/15/24, at 3:45 a.m. the Nursing Home Administrator confirmed that the facility failed to make certain that Employees E3, E4,E5, E7, and E9 properly wore photo identification tags with the require information displayed as required.

Plan of Correction - To be completed: 09/20/2024

- NHA, or designee, will in-service HR director on the PA state regulations for the requirement of Photo Identification on employee name badges.
- HR director, or designee, will ensure that all current employee have name badges with their photo, name and position per state regulation.
- NHA, or designee, will monitor all new hires to ensure they have proper identification in accordance with the PA state regulation for Photo ID's bi-weekly x 2, weekly x 2 and monthly thereafter.
-NHA, or designee, will audit staff to ensure they are wearing proper facility issued identification bi-weekly x 2, weekly x w and monthly thereafter.
- All education, audit and monitor will all be reviewed with the QAPI committee at the next scheduled meeting.

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