Pennsylvania Department of Health
JULIA POUND CARE CENTER
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

JULIA POUND CARE CENTER
Inspection Results For:

There are 94 surveys for this facility. Please select a date to view the survey results.

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

Initial comments:

Based on a Medicare/Medicaid Recertification survey, State Licensure survey, and Civil Rights Compliance survey completed on July 11, 2024, it was determined that Julia Pound 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:

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

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.

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

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

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

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

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

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

Observations:

Based on facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to maintain accountability for controlled medications (drugs with the potential to be abused) for two of 37 residents reviewed (Residents 67, 80).

Findings include:

A facility policy for medication administration, dated January 11, 2023, indicated that the individual that administers the medication dose records the administration on the resident's MAR directly after the medication is given.

A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 67, dated May 11, 2024, indicated that the resident was cognitively intact, was dependent on staff for her daily care needs, and had diagnoses that included urinary tract infection and paraplegia (paralysis that occurs in the lower half of the body).

Physician's orders for Resident 67, dated November 22, 2023, included an order for the resident to receive 5 milligrams (mg)/325 mg of Hydrocodone-Acetaminophen (a narcotic pain medication) every eight hours as needed for pain.

Review of the controlled drug record (a form that accounts for each tablet/pill/dose of a controlled drug) for Resident 67, dated April 2024 and May 2024, indicated that 5 mg/325 mg of hydrocodone-acetaminophen was signed out as administered on April 4 at 6:50 p.m., April 11 at 11:15 p.m., April 18 at 9:00 a.m., April 18 at 10:45 p.m., May 2 at 10:14 p.m., and May 22 at 2:00 a.m.

Review of the Medication Administration Record (MAR) for Resident 67, dated April 2024, and May 2024, revealed no documented evidence that the signed-out doses of hydrocodone-acetaminophen were administered on the above-mentioned dates and times.

Interview with the Director of Nursing on July 11, 2024, at 3:18 p.m. confirmed that there was no documented evidence that the signed-out doses of hydrocodone-acetaminophen were administered to Resident 67 on the above-mentioned dates and times.

An admission MDS assessment for Resident 80, dated June 21, 2024, indicated that the resident was cognitively impaired, required substantial to maximum assist for daily care needs, and had diagnoses that included dementia.

Physician's orders for Resident 80, dated June 21, 2024, included for the resident to receive 0.5 mg of Lorazepam (an anti-anxiety medication) oral concentrate every six hours as needed for anxiety or restlessness.

Review of the controlled drug record for Resident 80, dated June 2024, revealed that on June 22 at 1:30 p.m. the amount of Lorazepam remaining in the resident's Lorazepam medication bottle was 29 ml. On June 22, 2023, at 5:30 p.m. after 0.25 ml of Lorazepam was administered, there was 14 ml of Lorazepam left in the resident's Lorazepam medication bottle.

Review of the resident's MAR, dated June 2024, revealed no documented evidence that a dose of Lorazepam was administered on June 22, 2024, between 1:30 p.m. and 5:30 p.m.

Review of a facility incident investigation related to missing narcotics, dated June 22, 2024, revealed that there was no documented evidence to account for the 14.75 ml of missing Lorazepam for Resident 80 identified on June 22 at 5:30 p.m.

Review of the controlled drug record for Resident 80, dated June and July 2024, indicated that 0.5 mg of Lorazepam was signed out as administered on July 2 at 7:24 p.m., July 5 at 12:35 a.m., and July 5 at 6:35 a.m.

Review of Resident 80's MAR, dated July 2024, revealed no documented evidence that 0.5 mg of Lorazepam was administered on that above-mentioned dates and times.

Interview with the Director of Nursing on July 9, 2024, at 3:30 p.m. confirmed that an investigation was completed that revealed there was no accountability for the 14.75 ml of Lorazepam missing from Resident 80's Lorazepam medication bottle on June 22. An interview with the Director of Nursing on July 10, 2024, at 10:14 a.m. confirmed that there was no documented evidence that the signed-out doses of Lorazepam were administered to Resident 80 on July 2 at 7:24 p.m. and July 5 at 12:35 a.m. and 6:35 a.m.

28 Pa. Code 211.9(h) Pharmacy Services.

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

Plan of Correction - To be completed: 08/29/2024

The Medication Administration record for resident 67 was reviewed to ensure that administered doses of as needed controlled substances were signed off in the Electronic Medication Administration record and on the Controlled Substance accountability form. Resident 80 was discharged from the facility.

A facility audit was completed for residents currently receiving as needed controlled substances to validate that administered as needed controlled substances were signed off on the controlled drug accountability form and the Electronic Medication Administration record.

Director of Nursing/Designee provided education to licensed staff on their responsibility to sign off administered as needed controlled substances on the Controlled Substance Accountability form and the Electronic Medication Administration Record. Director of Nursing/Designee provided education to licensed staff on the facility policy for Controlled Substances.

Director of Nursing/Designee will audit five residents receiving as needed controlled substances to validate proper accoutability of controlled substances and that administrations were signed off on the Controlled Substance Accountability form and the Electronic Medication Administration Record. Any dicprencies with controlled substance accountability identified in these audits will be investigated immediately to rule out potential misappropriation. These audits will be completed weekly for 4 weeks, then monthly for two months. The results of these audits will be reviewed at Quality Assurance meetings.

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

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

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

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

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

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

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

Observations:

Based on review of clinical records, as well as resident and staff interviews, it was determined that the facility failed to maintain clinical records that were complete and accurately documented for one of 37 residents reviewed (Resident 60).

Findings include:

A significant Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 60, dated June 14, 2024, revealed that the resident was cognitively intact, was clearly understood and able to understand others, required assistance with care needs, had an indwelling catheter (a thin, flexible tube inserted into the bladder to drain urine from the bladder), had a urinary tract infection (infection involving any part of the urinary system including the kidney, ureters, bladder and urethra) in the last 30 days, and had a diagnosis that included neurogenic bladder (bladder lacks control due to nerve or muscle problems).

Clinical record review for Resident 60 revealed that she had a care plan, dated February 12, 2024, for an indwelling catheter that included an intervention to provide catheter care every shift.

Interview with Resident 60 on July 11, 2024, at 12:59 p.m. revealed that she was admitted to the hospital for a bad urinary tract infection and said the hospital stated it was because of bad catheter care. She stated that the nurse aides do good catheter care, but it is difficult because her legs are contracted, and they have to pull them apart to clean her.

Review of the daily nurse aide charting for Resident 60 on day shift through the months of April, May, June and July of 2024 revealed that there was no documented evidence that catheter care was completed on April 3, April 4, April 5, April 6, April 11, April 14, April 24, April 28, April 29, April 30, May 1, May 3, May 7, May 25, May 28, May 30, May 31, June 1, June 3, June 24, June 25, June 27, June 28, June 30, July 7, and July 9, 2024.

Review of the daily nurse aide charting for Resident 60 on evening shift through the months of April, May, June and July of 2024 revealed that there was no documented evidence that catheter care was completed on April 5, April 13, April 25, May 6, May 8, May 28, June 1, June 20, June 22, June 30, July 2, July 6, and July 7, 2024.

Review of the daily nurse aide charting for Resident 60 on night shift through the months of April, May, June and July of 2024 revealed that there was no documented evidence that catheter care was completed on April 13, April 25, May 3, May 6, May 8, May 9, May 10, May 12, May 13, May 19, May 20, June 6, June 9, June 20, and June 21, 2024.

Interview with the Director of Nursing on July 11, 2024, at 3:01 p.m. confirmed there was no documented evidence that catheter care was completed for Resident 60 on the above stated dates and shifts.

28 Pa. Code 211.5(f) Clinical Records.

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

Plan of Correction - To be completed: 08/29/2024

Validation of completion of catheter care every shift for resident 60 was completed. A review of the medical record for resident 60 was completed to ensure that the task for completion of catheter care is scheduled in the nurse's aides electronic charting system every shift.

A facility audit of residents with indwelling catheters was completed to ensure that the task for completion of catheter care every shift is included in the nurse's aides electronic charting system.

Director of Nursing/Designee provided follow up education to all nursing staff on their responsibility to complete catheter care every shift and their responsibility to document the completion of catheter care in the medical record.

Director of Nursing/Designee will audit 5 residents with indwelling catheters to validate completion of catheter care every shift is completed and documented in the medical record. These audits will be completed weekly x 4 weeks, then monthly for 2 months. The results of these audits will be reviewed at Quality Assurance Meetings.

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

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

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

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

Observations:

Based on review of policies, observations, and staff interviews, it was determined that the facility failed to ensure that nutritional drinks in the medication room and pantry were not expired (Crossroads).

Findings include:

The facility policy regarding food storage, dated March 13, 2024, revealed that food is stored under safe and sanitary conditions to prevent injury and food-borne illness.

Observations in the Crossroads medication room on July 10, 2024, at 8:30 a.m. revealed that there were nine Nepro nutritional milkshakes (a protein drink generally used for dialysis residents) that expired in June 2024.

Observations in the Crossroads pantry refrigerator on July 10, 2024, at 8:51 a.m. revealed that there were nine Nepro nutritional milkshakes that expired in May 2024.

Interview with the Dietary Manager on July 10, 2024, at 8:58 a.m. confirmed that 18 expired Nepro nutritional milkshakes were in circulation on the Crossroads unit and should have been previously discarded.

28 Pa code 211.6(f) Dietary Services.

Plan of Correction - To be completed: 08/29/2024

1. All items that were expired were thrown out immediately.
2. All refrigerators in the medication room, satellite kitchens and main kitchens were inspected for other items out of date. The results were no other items were identified in that audit.
3. The Dietary Director and Director of Nursing will educate staff on proper audits of food that are out of date and the proper disposal. The Dietary Director and/or Designee will monitor those areas for continued compliance.
4. An audit of all food items will take place two times a week for four weeks. Audits will then take place one time a week for four weeks with all findings reported to the Quality Assurance Committee to ensure compliance.

483.10(c)(6)(8)(g)(12)(i)-(v) REQUIREMENT Request/Refuse/Dscntnue Trmnt;Formlte Adv Dir:

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

§483.10(c)(6) The right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.

§483.10(c)(8) Nothing in this paragraph should be construed as the right of the resident to receive the provision of medical treatment or medical services deemed medically unnecessary or inappropriate.

§483.10(g)(12) The facility must comply with the requirements specified in 42 CFR part 489, subpart I (Advance Directives).
(i) These requirements include provisions to inform and provide written information to all adult residents concerning the right to accept or refuse medical or surgical treatment and, at the resident's option, formulate an advance directive.
(ii) This includes a written description of the facility's policies to implement advance directives and applicable State law.
(iii) Facilities are permitted to contract with other entities to furnish this information but are still legally responsible for ensuring that the requirements of this section are met.
(iv) If an adult individual is incapacitated at the time of admission and is unable to receive information or articulate whether or not he or she has executed an advance directive, the facility may give advance directive information to the individual's resident representative in accordance with State law.
(v) The facility is not relieved of its obligation to provide this information to the individual once he or she is able to receive such information. Follow-up procedures must be in place to provide the information to the individual directly at the appropriate time.

Observations:

Based on review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to address and document the opportunity to formulate advance directives and failed to document in the resident's clinical record the resident's decision to accept or decline assistance to formulate advance directives for one of 37 residents reviewed (Resident 70).

Findings include:

The facility's policy regarding advance directives (instructions regarding the provision of health care and life sustaining measures when the resident is incapacitated), dated March 13, 2024, indicated that if the resident does not have an advance directive, facility staff must inform the resident or resident representative of their right to establish one as set forth in the laws of the state and provide assistance if the resident wishes to execute one or more directive(s). Facility staff must document in the resident's medical record these discussions and any advance directive(s) that the resident executes.

A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 70, dated May 10, 2024, revealed that the resident was cognitively intact, was understood and able to understand others, and required assistance with care needs.

An admission checklist for Resident 70, dated September 25, 2023, indicated that the resident did not have advance directives and that information on advance directives were given to the resident. However, there was no documented evidence in the resident's clinical record that assistance was offered to formulate advance directives, and there was no documented evidence as to the resident's decision to accept or decline assistance to formulate advance directives.

Interview with the Nursing Home Administrator on July 10, 2024, at 11:03 a.m. confirmed that there was no documented evidence in Resident 70's clinical record that assistance was offered to formulate advance directives, and there was no documented evidence as to the resident's decision to accept or decline assistance to formulate advance directives.

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

Plan of Correction - To be completed: 08/29/2024

A. Resident 70 and resident representative were provided with and educated on Advance Directives by Social Service.
B. The Social Worker or designee will complete an audit of current residents to verify Advance Directives or education related to Advance Directives have completed in the most recent quarter.
C. The Nursing Home Administrator or designee will provide education to Social Services and Admission Director on F578 and the Advance Directives policy.
D. The Admission Director or designee will conduct weekly audits on 5 random residents x's 4 weeks and then 4 residents monthly x 2 months to determine if advance directives were reviewed during weekly care conference and upon admission. Audit findings will be forwarded to the Quality Assurance Performance Improvement team for review and recommendations.
E. Date of completion is scheduled for 8/29/2024.

483.10(i)(1)-(7) REQUIREMENT Safe/Clean/Comfortable/Homelike Environment:

§483.10(i) Safe Environment.
The resident has a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

The facility must provide-
§483.10(i)(1) A safe, clean, comfortable, and homelike environment, allowing the resident to use his or her personal belongings to the extent possible.
(i) This includes ensuring that the resident can receive care and services safely and that the physical layout of the facility maximizes resident independence and does not pose a safety risk.
(ii) The facility shall exercise reasonable care for the protection of the resident's property from loss or theft.

§483.10(i)(2) Housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior;

§483.10(i)(3) Clean bed and bath linens that are in good condition;

§483.10(i)(4) Private closet space in each resident room, as specified in §483.90 (e)(2)(iv);

§483.10(i)(5) Adequate and comfortable lighting levels in all areas;

§483.10(i)(6) Comfortable and safe temperature levels. Facilities initially certified after October 1, 1990 must maintain a temperature range of 71 to 81°F; and

§483.10(i)(7) For the maintenance of comfortable sound levels.

Observations:

Based on observations and staff interviews, it was determined that the facility failed to provide a clean, homelike environment for one of 37 residents reviewed (Resident 27).

Findings include:

The facility's policy titled housekeeping department operations, dated March 13, 2024, revealed that the policy objective was to provide a safe, clean environment for residents.

A comprehensive Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 27, dated July 3, 2024, revealed that the resident was cognitively intact, required assistance with most daily care needs, and had diagnoses that included heart failure and osteoarthritis (a type of arthritis that effects the bone).

Observations of Resident 27 sitting in his wheelchair on July 8, 2024, at 11:42 a.m. and July 9, 2024, at 12:18 p.m. revealed that there was a moderate accumulation of removable dust/debris on the wheels and the metal supports under the chair.

Interview with Housekeeper 1 on July 9, 2024, at 2:05 p.m. confirmed that Resident 27's wheelchair was cleaned in June as per their documented cleaning process. However, she also confirmed that the wheelchairs are also cleaned as needed and that Resident 27's wheelchair had a heavy layer of dirt and debris and should have been clean.

Interview with the Licensed Practical Nurse 2 on July 9, 2024, at 2:08 p.m. confirmed that Resident 27's wheelchair had an accumulation of removable dust/debris on the wheels and the metal supports under the chair.

Interview with the Nursing Home Administrator on July 9, 2024, at 3:00 p.m. confirmed that the removable dust, dirt and debris on Resident 27's wheelchair should not have been there, and it should have been cleaned.

28 Pa. Code 201.29(j) Resident Rights.

28 Pa. Code 207.2(a) Administrator's Responsibility.

Plan of Correction - To be completed: 08/29/2024

1. The wheelchair in question was cleaned immediately and returned to the resident.
2. An audit of all other wheelchairs and ambulation device were audited to ensure cleanliness.

3. Staff education to be completed regarding a safe/clean/comfortable and homelike environment for members of the environmental services staff and nursing staff.

4. Audits to be completed on every neighbohood two times/week for two weeks. Then audits will resume one time a week for four weeks. All findings will be reported to the Quality Assurance committee.

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

§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 facility policies, clinical records, and investigation documents, as well as staff interviews, it was determined that the facility failed to ensure that residents were free from abuse from a resident who wanders for one of 37 residents reviewed (Resident 64).

Findings include:

The facility's policy for abuse, dated March 13, 2024, indicated each resident is provided with a safe environment where they are not subject to mental, physical, verbal, and sexual abuse. Residents must not be subjected to abuse by anyone, including but not limited to facility staff, other residents, consultants or volunteers, staff of other agencies, serving the resident, family members, or legal guardians, friends, or other individuals. Abuse was defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Willful meant the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm.

A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 64, dated March 26, 2024, indicated that the resident was understood and could understand others, had no behaviors, required assistance with daily care needs, and had diagnoses that included dementia and bipolar disease (a mental health condition that causes extreme mood swings).

An annual MDS assessment for Resident 78, dated June 24, 2024, indicated that the resident was usually understood and could usually understand others, had no behaviors, required partial to maximum assistance with daily care needs, and had diagnoses that included dementia. A review of the clinical record for Resident 78 revealed that he had episodes of being loud and verbally aggressive, wandered in and out of other residents' rooms, and wore a wanderguard (a device that allows caregivers to monitor the activity of high risk or wandering residents who are cognitively impaired).

A nurse's note for Resident 78, dated July 4, 2024, at 4:15 a.m. revealed that he was in Resident 64's room. He was witnessed to be almost on top of Resident 64, threatening to kill him.

A nurse's note for Resident 64, dated July 4, 2024, at 4:49 a.m., revealed that staff heard Resident 64 screaming. A nurse witnessed Resident 64 in bed with Resident 78 standing over him, yelling at him, and Resident 64 reported that Resident 78 was hitting him and put his hands around his neck.

A nurse's note for Resident 64, dated July 4, 2024, at 4:59 a.m., revealed that at 3:50 a.m. staff performed a physical assessment on Resident 64 after Resident 78 was near him, and that Resident 64 was observed to have reddened areas around his neck and chest. Resident 64 was reported stating, "I don't want to see that man near me, I don't want to see him ever again."

A statement from Registered Nurse 3 regarding the incident on July 4, 2024, revealed that Resident 64 reported to her that Resident 78 "jumped on me and hit me all over my body, my legs, trunk, and face. He had his hands around my neck. I was asleep and then I was being attacked."

Interview with the Director of Nursing on July 11, 2024, at 1:45 p.m. confirmed that they did not have a plan in place for Resident 78's wandering other than the wanderguard because it is a behavior that you cannot stop. The Director of Nursing also confirmed that Resident 78 did hit and threatened to kill Resident 64.

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

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

28 Pa. Code 201.29(j) Resident Rights.

Plan of Correction - To be completed: 08/29/2024

Resident 78 was discharged from the facility on 07/04/2024. Resident 68 was assessed following the incident and remained in the facility. A safety assessment was completed to ensure resident 68's safety. Follow up care for emotional support was provided. A plan of care was developed to include supportive interventions for resident 68 following the incident.

A facility audit was completed for residents with aggressive or wandering behaviors to ensure the plan of care is developed and includes interventions to mitigate these behaviors.

Director of Nursing/Designee provided follow up education to nursing staff on the facility policy for Abuse/Neglect. Licensed staff were provided follow up education on their responsibility to develop and revise residents plan of care immediately to include interventions to address any aggressive or wandering behaviors.

Director of Nursing/Designee will audit the plan of care for five residents with active aggressive or wandering behaviors to ensure appropriate development of a behavior care plan is completed and includes interventions to mitigate these behaviors. These audits will occur weekly for four weeks, then monthly for two months. The results of these audits will be reviewed at Quality Assurance meetings.

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

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

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

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

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

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

Observations:

Based on clinical record reviews and staff interviews, it was determined that the facility failed to notify the resident and legal guardian in writing regarding the reason for hospitalization for four of 37 residents reviewed (Residents 23, 36, 46, 67).

Findings include:

A significant Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 23, dated June 24, 2024, indicated that the resident was cognitively impaired, required assistance from staff for her daily care needs, and had diagnoses that included dementia.

Nursing notes for Resident 23, dated June 16, 2024, at 10:30 a.m. and 4:56 p.m., revealed that the resident was unresponsive, then vomited bright red blood and clots. She was transferred to the hospital and admitted with GI (gastro-intestinal) bleeding.

There was no documented evidence that a written notice of Resident 23's transfer to the hospital was provided to the resident's responsible party regarding the reason for transfer.

A quarterly MDS assessment for Resident 36, dated April 24, 2024, indicated that the resident was cognitively intact, usually understood and was usually able to understand others, and required assistance from staff for her daily care needs. She had diagnoses listed in her clinical record that included muscular dystrophy and non-Alzheimer's dementia.

Nursing notes for Resident 36, dated June 4, 2024, at 6:04 p.m., revealed that the resident complained of chest pain and difficulty breathing and was transferred to the hospital emergency room.

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

Interview with the Nursing Home Administrator on July 10, 2024, at 2:07 p.m. confirmed that the facility did not provide a written notice to Resident 36's responsible party when the resident was transferred to the hospital with the reason for transfer.

A significant MDS assessment for Resident 46, dated May 23, 2024, indicated that the resident was cognitively impaired, usually understood and was usually able to understand others, and required assistance from staff for her daily care needs. She had diagnoses listed in her clinical record that included anxiety, depression, schizoaffective disorder, and dementia.

Nursing notes for Resident 46, dated April 29, 2024, at 1:15 p.m., revealed that the resident had an increase in behaviors and resistance to care and was transferred to the hospital to behavioral health.

There was no documented evidence that a written notice of Resident 46's transfer to the hospital was provided to the resident's responsible party regarding the reason for transfer.

Interview with the Nursing Home Administrator on July 10, 2024, at 8:56 a.m. confirmed that the facility did not provide a written notice to Resident 46's responsible party when the resident was transferred to the hospital with the reason for transfer.

A quarterly MDS assessment for Resident 67, dated May 11, 2024, indicated that the resident was cognitively intact, was dependent on staff for her daily care needs, and had diagnoses that included urinary tract infection and paraplegia (paralysis that occurs in the lower half of the body).

Nursing note for Resident 67, dated April 25, 2024, at 11:24 a.m., revealed that the resident had increased swelling in her legs. The physician was notified, and the resident was transferred to the hospital for evaluation.

Nursing note for Resident 67, dated May 1, 2024, at 7:45 a.m., revealed that the resident was complaining of severe abdominal pain. The physician examined the resident at her bedside and gave orders to send her to the hospital for evaluation and treatment.

There was no documented evidence that a written notice of Resident 67's transfer to the hospital was provided to the resident's responsible party regarding the reason for transfer.

Interview with the Nursing Home Administrator on July 10, 2024, at 12:32 p.m. confirmed that the facility did not provide a written notice to the resident or the resident's responsible party when a resident was transferred to the hospital.

28 Pa. Code 201.25 Discharge Policy.

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

Plan of Correction - To be completed: 08/29/2024

A. Resident 23, 36, 46, and 67 representative provided with transfer/discharge notice.
B. The Admission Director or designee will conduct an audit on current resident's transfer out of facility in the last 30 days to ensure transfer/discharge notices are provided.
C. The Nursing home Administrator or designee will provide re-education to the Admissions Director and licensed nursing staff on F623 and facility Transfer/Discharge Policy.
D. The Nursing Home Administrator or designee will conduct weekly audits on up to 4 resident transfers out of facility x's 4 weeks and then 4 residents transfer out of facility monthly x 2 months to ensure transfer notices are provided. Audit findings will be forwarded to the Quality Assurance Performance Improvement team for review and recommendations.
E. Date of completion is scheduled for 8/29/2024

483.15(d)(1)(2) REQUIREMENT Notice of Bed Hold Policy Before/Upon Trnsfr:

§483.15(d) Notice of bed-hold policy and return-

§483.15(d)(1) Notice before transfer. Before a nursing facility transfers a resident to a hospital or the resident goes on therapeutic leave, the nursing facility must provide written information to the resident or resident representative that specifies-
(i) The duration of the state bed-hold policy, if any, during which the resident is permitted to return and resume residence in the nursing facility;
(ii) The reserve bed payment policy in the state plan, under § 447.40 of this chapter, if any;
(iii) The nursing facility's policies regarding bed-hold periods, which must be consistent with paragraph (e)(1) of this section, permitting a resident to return; and
(iv) The information specified in paragraph (e)(1) of this section.

§483.15(d)(2) Bed-hold notice upon transfer. At the time of transfer of a resident for hospitalization or therapeutic leave, a nursing facility must provide to the resident and the resident representative written notice which specifies the duration of the bed-hold policy described in paragraph (d)(1) of this section.

Plan of Correction - To be completed: 08/29/2024

A. Resident 23, 36, 46, and 67 were provided notices of bed hold policy prior to transfer.
B. The Admission Director or designee will conduct an audit on current resident's bed hold in the last 30 days to ensure bed hold notices are provided.
C. The Nursing home administrator or designee will provide re-education to the Admissions Director and licensed nursing staff on F625 and facility Bed hold Policy.
D. The Nursing Home Administrator or designee will conduct weekly audits on up to 4 resident x's 4 weeks and then 4 residents monthly x 2 months to ensure bed hold notices are provided. Audit findings will be forwarded to the Quality Assurance Performance Improvement team for review and recommendations.
E. Date of completion is scheduled for 8/29/2024.

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

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

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

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

Plan of Correction - To be completed: 08/29/2024

1. Residents R103, R104, R105, had no ill effects as a result of the Minimum Data Set assessments closed late.

2. Minimum Data Set assessments that have been completed in the past 30 days will be audited to ensure timely closure.

3. The Interdisciplinary team will be educated regarding proper closure of Minimum Data Set assessments.

4. A random audit of 5 Minimum Data Set Assessments will be completed weekly for 4 weeks and then monthly for 2 months to ensure timely closure. Audit results will be forwarded to the Quality Assurance Process Improvement committee for review.

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 the Resident Assessment Instrument User's Manual and clinical records, as well as staff interviews, it was determined that the facility failed to complete accurate Minimum Data Set assessments for two of 37 residents reviewed (Residents 60, 64).

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, revealed that Section N0415F (Antibiotic Medications - medications used to treat infections) was to be coded if the resident took the medication during the seven-day look-back period.

Physician's orders for Resident 60, dated June 8, 2024, included an order for the resident to receive one gram of Ceftazidime (antibiotic medication) intravenously (administration of fluids and/or medications directly into a person's vein) every eight hours for seven days for a urinary tract infection (infection involving any part of the urinary system including the kidney, ureters, bladder and urethra).

Resident 60's Medication Administration Record for June 2024 revealed that the resident was administered Ceftazidime during the seven-day look-back assessment period.

A significant change Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 60, dated June 14, 2024, revealed that N0415F was not coded, indicating she did not receive an antibiotic medication during the seven-day look-back assessment period.

The RAI User's Manual, dated October 2023, indicated that Section B0700 (make self-understood) should be coded with either clearly understood, usually understood, sometimes understood, or rarely/never understood. Section C0100 (should brief interview for mental status be conducted) should be completed if the resident is at least sometimes understood verbally, in writing, or using another method. Section C0100 was to be coded No (0) or Yes (1) to determine whether a Brief Interview for Mental Status (BIMS) (an assessment to determine a resident's cognitive status) should be attempted with the resident. The instructions for determining if a BIMS interview should be attempted indicated that if the resident was at least sometimes understood (verbally or in writing) then the BIMS interview was to be attempted with the resident and coded in Sections C0200 through C0500. If the resident was rarely/never understood, then the BIMS interview was not to be attempted, and a Staff Assessment of Mental Status was to be completed instead and coded in Sections C0600 through C1000.

A quarterly MDS assessment for Resident 64, dated March 26, 2024, revealed that Section B0700 was coded clearly understood and Section C0100 was coded (no) indicating that a BIMS interview was not to be attempted.

An interview with the Registered Nurse Assessment Coordinator (RNAC- a registered nurse who is responsible for the completion of MDS assessments) confirmed on July 11, 2024, at 2:13 p.m. that the assessments for Residents 60 and 64 were coded incorrectly.

28 Pa. Code 211.5(f) Clinical Records.

Plan of Correction - To be completed: 08/29/2024

1. Residents 60 & 64 had no ill effects from inaccurate coding on the Minimum Data Set
2. Current residents who have had an MDS in the past 7 days will be reviewed to ensure that 1) N0415 Antibiotic is coded correctly 2) B0700 (Make self-understood) will be reviewed and if it is coded with at least sometimes understood then C0100 should be coded Yes and Brief Interview for Mental Status (BIMS) was attempted. If any inaccuracies are noted a corrected MDS will be corrected and submitted.
3. Social Service, RNAC, and Licensed Nurses will be educated regarding proper coding of Section B as noted in the Resident Assessment Instrument (RAI) manual.
4. An Audit will be conducted weekly for 4 weeks and then monthly for 2 months to ensure that 1) N0415 Antibiotic is coded correctly 2) B0700 (Make self-understood) will be reviewed and if it is coded with at least sometimes understood then C0100 should be coded Yes and Brief Interview for Mental Status (BIMS) was attempted. Results will be forwarded to the Quality Assessment Process Improvement Committee.

483.21(b)(1)(3) REQUIREMENT Develop/Implement Comprehensive Care Plan:

§483.21(b) Comprehensive Care Plans
§483.21(b)(1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at §483.10(c)(2) and §483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following -
(i) The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under §483.24, §483.25 or §483.40; and
(ii) Any services that would otherwise be required under §483.24, §483.25 or §483.40 but are not provided due to the resident's exercise of rights under §483.10, including the right to refuse treatment under §483.10(c)(6).
(iii) Any specialized services or specialized rehabilitative services the nursing facility will provide as a result of PASARR recommendations. If a facility disagrees with the findings of the PASARR, it must indicate its rationale in the resident's medical record.
(iv)In consultation with the resident and the resident's representative(s)-
(A) The resident's goals for admission and desired outcomes.
(B) The resident's preference and potential for future discharge. Facilities must document whether the resident's desire to return to the community was assessed and any referrals to local contact agencies and/or other appropriate entities, for this purpose.
(C) Discharge plans in the comprehensive care plan, as appropriate, in accordance with the requirements set forth in paragraph (c) of this section.
§483.21(b)(3) The services provided or arranged by the facility, as outlined by the comprehensive care plan, must-
(iii) Be culturally-competent and trauma-informed.

Observations:

Based on review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that baseline care plans included the information and instructions needed to provide person-centered care for two of 37 residents reviewed (Residents 25, 35).

Findings include:

The facility's policy regarding care plans, dated March 13, 2024, indicated that a baseline care plan is person-centered care plan designed to include the resident's basic healthcare information needed to care for the resident. It must be completed within forty-eight hours of admission and include initial goals based on admission orders, physician orders, dietary orders, therapy services, social services, address resident health and safety concerns, and identify needs for supervision, behavioral interventions, and assistance with care as necessary. The comprehensive care plan, which is derived from the baseline care plan and is triggered by care area assessments, will be entered into the electronic health record system.

A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 25, dated June 9, 2024, revealed that the resident was moderately cognitively impaired and received a diuretic (water pill).

Physician's orders for Resident 25, dated June 7, 2024, included an order to administer 40 milligrams (mg) of Furosemide water pill) daily. A review of the resident's Medication Administration Record (MAR) for July 2024 revealed she received Furosemide from July 1 through July 11, 2024.

There was no documented evidence that a care plan was developed to address Resident 25's individual care needs related to receiving a diuretic.

An interview with the Director of Nursing on July 10, 2024, at 1:00 p.m. confirmed that a care plan to address Resident 25's use of a diuretic was not developed.

An admission MDS assessment for Resident 35, dated June 30, 2024, revealed that the resident was cognitively intact, experienced hallucinations, required assistance from staff for care needs, had diagnoses that included dementia, and was receiving supplemental oxygen.

Physician's orders for Resident 35, dated June 24, 2023, included that the resident receive 3 milliliters (ml) of ipratropium albuterol (medication to treat wheezing and shortness of breath) every six hours as needed for shortness of breath.

Physician's orders for Resident 35, dated June 30, 2023, included that the resident receive four liters of supplemental oxygen as needed for shortness of breath at bedtime and while sleeping during the day.

Nurse's note for Resident 35, dated June 24, 2024, at 9:31 p.m., revealed that the resident was admitted to the facility at 1:00 p.m. with a diagnosis of dementia with behavior disturbance, has intermittent confusion, and was reporting that a mouse was in her pants. She was heard to have upper airway wheezes (high-pitched whistling sound made while breathing) and shortness of breath when lying flat.

Nurse's note for Resident 35, dated July 1, 2024, revealed that the resident was using supplemental oxygen, was short of breath with exertion, and was yelling out that rats were in her bed.

There was no documented evidence that a care plan was developed to address Resident 35's individual care and treatment needs related to her dementia with hallucinations or her altered respiratory status with the use of supplemental oxygen.

Interview with the Director of Nursing on July 11, 2024, at 1:40 p.m. confirmed that a care plan to address the care needs related to Resident 35's dementia with hallucinations or her altered respiratory status with the use of supplemental oxygen was not developed and should have been.

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

Plan of Correction - To be completed: 08/29/2024

The plan of care for resident 25 was reviewed and immediately developed to include the ordered diuretic medication. The plan of care for resident 35 was reviewed and immediately developed to include care needs related to dementia and hallucinations and altered respiratory status with the need for supplemental oxygen. Resident 35 was subsequently discharged from the facility.

An audit of all current resident care plans for individualized interventions for residents receiving diuretic medications, residents with dementia and hallucinations, and residents with altered respiratory status receiving supplemental oxygen.

Director of Nursing/Designee provided education to licensed staff on the facility policy on implementing a comprehensive care plan to meet the residents' medical, nursing, mental, and psychosocial needs. This education included licensed staff's responsibility to implement resident centered care plans and interventions for residents with new orders for diuretic medications, residents with new diagnoses of dementia and hallucinations, and residents with new altered respiratory status receiving supplemental oxygen. Licensed staff were educated on making timely revisions to the residents' care plan as the residents medical, nursing, mental, and psychosocial needs change.

Director of Nursing/Designee will audit five random residents care plans for individualized interventions for residents needs, including diuretic medications, dementia with hallucinations, and altered respiratory status with the need for supplemental oxygen. These audits will be completed weekly over four weeks, then monthly for an additional two months. The results of these audits will be reviewed at Quality Assurance meetings.

483.21(b)(2)(i)-(iii) REQUIREMENT Care Plan Timing and Revision:

§483.21(b) Comprehensive Care Plans
§483.21(b)(2) A comprehensive care plan must be-
(i) Developed within 7 days after completion of the comprehensive assessment.
(ii) Prepared by an interdisciplinary team, that includes but is not limited to--
(A) The attending physician.
(B) A registered nurse with responsibility for the resident.
(C) A nurse aide with responsibility for the resident.
(D) A member of food and nutrition services staff.
(E) To the extent practicable, the participation of the resident and the resident's representative(s). An explanation must be included in a resident's medical record if the participation of the resident and their resident representative is determined not practicable for the development of the resident's care plan.
(F) Other appropriate staff or professionals in disciplines as determined by the resident's needs or as requested by the resident.
(iii)Reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments.

Observations:

Based on review of clinical records, as well as staff interviews, it was determined that the facility failed to ensure that care plans were updated to reflect changes in care needs for one of 37 residents reviewed (Resident 60).

Findings include:

A significant Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 60, dated June 14, 2024, revealed that the resident was cognitively intact, was clearly understood and able to understand others, required assistance with care needs, had a foley catheter (a thin, flexible tube inserted into the bladder to drain urine from the bladder), had a urinary tract infection (infection involving any part of the urinary system including the kidney, ureters, bladder and urethra) in the last 30 days, and had a diagnosis that included neurogenic bladder (bladder lacks control due to nerve or muscle problems).

Physician's orders for Resident 60, dated February 24, 2024, indicated that the resident was ordered 50 milligrams of Nitrofurantoin daily every Monday, Wednesday, and Friday for history of recurrent urinary tract infections.

Clinical record review for Resident 60 revealed that she had a care plan, dated June 11, 2024, for recurrent urinary tract infections related to neurogenic bladder.

There was no documented evidence that the care plan was revised to reflect Resident 60's need for a long-term antibiotic related to her history of recurrent urinary tract infections.

Interview with the Director of Nursing on July 11, 2024, at 2:13 p.m. confirmed that Resident 60's care plan was not revised to reflect the need for long-term antibiotic related to her history of recurrent urinary tract infections and it should have been.

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

Plan of Correction - To be completed: 08/29/2024

The care plan for resident 60 was immediately developed to include the use of long-term antibiotic use related to a history of recurrent urinary tract infections.

An audit of all current resident's care plans was completed for any resident who receives long term antibiotic therapy related to a history of recurrent urinary tract infections.

Director of Nursing/Designee provided education to licensed staff on the facility policy on implementing a comprehensive care plan to meet the residents' medical, nursing, mental, and psychosocial needs. This education included licensed staff's responsibility to make timely revisions to a resident's plan of care for any resident who is newly ordered long term antibiotic therapy related to a history of recurrent urinary tract infections.

Director of Nursing/Designee will audit new physicians' orders to ensure long term antibiotic therapy related to a history of recurrent urinary tract infections has been added to each resident's plan of care. These audits will be completed weekly over four weeks, then monthly for an additional two months. The results of these audits will be reviewed at Quality Assurance meetings.

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.

Plan of Correction - To be completed: 08/29/2024

Medication Administration records were reviewed for Resident 62. Physician was notified of identified blood pressure medication administrations outside of ordered parameters. The blood pressure medication for resident 62 was discontinued. The physician was notified of two administrations of an incorrect dose of as needed Lorazepam for resident 80. An RN assessment of resident 80 was completed and no adverse outcomes were identified. Resident 80 was subsequently discharged from the facility.

A whole house audit of residents receiving blood pressure medications was completed for any administrations of blood pressure medications outside of ordered physician parameters. A whole house audit of residents receiving as needed Lorazepam was completed to ensure administered doses were accurate according to the physician's orders.

Director of Nursing/Designee provided education to Licensed staff on their responsibility to administer medications in accordance with physician orders; this includes administering blood pressure medications according to physician ordered parameters and administering as needed Ativan according to the prescribed dosage. Licensed staff were provided education on the facility policy for Medication Administration.

Director of Nursing/Designee will audit five residents to ensure accurate medication administration has occurred according to physicians' orders for drug dosage and paramters. These audits will be completed weekly for four weeks, then monthly for two months. The results of these audits will be reviewed at the Quality Assurance meetings.

483.70(o)(1)-(4) REQUIREMENT Hospice Services:

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

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

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

§483.70(o)(4) Each LTC facility providing hospice care under a written agreement must ensure that each resident's written plan of care includes both the most recent hospice plan of care and a description of the services furnished by the LTC facility to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, as required at §483.24.

Plan of Correction - To be completed: 08/29/2024

1. Resident 8 had their re-evaluation for continued hospice service eligibility (recertification/certification) signed immediately.
2. An audit was conducted on 7/14/2024 to ensure eligibility for hospice services were present for residents who were under hospice care while residing in the facility.

3. The Nursing Home Administrator (NHA) educated current hospice providers on the Federal regulation of 849 that hospice certification/recertification must be present on the chart and signed in the order of two in the initial 90-day periods and one every 60 day thereafter. The hospice providers are to provide a list of residents on their case load along with the dates of recertification to the Nursing Home Administrator/designee to ensure the recertifications are signed by the physician.

4. An audit will be completed weekly for four weeks, then monthly for two months. All findings will be reviewed at the weekly risk meeting in addition to the Quarterly Quality Assurance Process Improvement Committee.

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 plans of correction for previous surveys, and the results of the current survey, it was determined that the facility's Quality Assurance Performance Improvement (QAPI) committee failed to correct quality deficiencies and ensure that plans to improve the delivery of care and services effectively addressed recurring deficiencies.

Findings include:

The facility's deficiencies and plans of corrections for a State Survey and Certification (Department of Health) survey ending August 13, 2023, and a complaint investigation survey ending May 29, 2024, revealed that the facility developed plans of correction that included quality assurance systems to ensure that the facility-maintained compliance with cited nursing home regulations. The results of the current survey, ending July 11, 2024, identified repeated deficiencies related to a failure to ensure the accuracy of Minimum Data Set (MDS) assessments, resident records being complete and accurate, and hospice services.

The facility's plan of correction for a deficiency regarding the accuracy of assessment, cited during the survey ending August 13, 2023, revealed that the facility would complete audits and report the results of the audits to the QAPI committee for review. The results of the current survey, cited under F641, revealed that the facility's QAPI committee failed to successfully implement their plan to ensure ongoing compliance with regulations regarding accuracy of assessments.

The facility's plan of correction for a deficiency regarding a failure ensure that the medical records were complete and accurate, cited during the survey ending on May 29, 2024, revealed that the facility would complete audits and report the results of the audits to the QAPI committee for review. The results of the current survey, cited under F842, revealed that the QAPI committee was ineffective in maintaining compliance with the regulation regarding complete and accurate medical records.

The facility's plan of correction for a deficiency regarding hospice records, cited during the survey ending August 13, 2023, revealed that the facility would complete audits and report the results of the audits to the QAPI committee for review. The results of the current survey, cited under F849, revealed that the facility's QAPI committee failed to successfully implement their plan to ensure ongoing compliance with regulations regarding hospice services and records.

Refer to F641, F842, F849.

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

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

Plan of Correction - To be completed: 08/29/2024

New plans of correction identifying root cause were developed and implemented for cited repeat deficient practices.

Executive Director provided follow up education to the interdisciplinary team on the facility Quality Assurance Process Improvement policy. This education included review of the principles, key components, and structure of the Quality Assurance Performance Improvement process.

Executive Director/Designee will audit the Quality Assurance Process to ensure monitoring and review of the Plan of Correction and validate evidence of compliance for deficient practices. These audits will be conducted during quarterly Quality Assurance Process improvement meetings for three quarters.

§ 201.14(a) LICENSURE Responsibility of licensee.:

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

Observations:

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

Findings include:

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

As of July 11, 2024, the facility was unable to provide documented evidence that the facility's multi-disciplinary infection control committee met at least quarterly for three of four quarters.

Interview with the Director of Nursing on July 11, 2024, at 1:45 p.m. confirmed that there was no documented evidence that the facility's multi-disciplinary infection control committee met at least quarterly for three of four quarters.

Plan of Correction - To be completed: 08/29/2024

A meeting of the Multi-disciplinary infection control committee was held on July 25, 2024. A sign in sheet and documentation of the meeting was completed.

Multi-disciplinary infection control meetings will occur quarterly. Sign in sheets will be utilized to validate attendee's participation. Attendees who are not able to attend in person will be provided options for attendance via call-in. Call in attendees will be designated on the meeting sign in sheet.

Director of Nursing provided follow up education to the Assistant Director of Nursing on the requirement to have a multi-disciplinary Infection Control Committee, (which includes the following; Medical Director, Nursing Home Administrator, Laboratory Personnel, Director of Nursing or Nursing Supervisor, Pharmacy Staff, Physical Plant Personnel, a Patient Safety officer, and a community member that may not be an agent, employee, or a contractor of the facility) and the requirement for the multi-disciplinary infection control committee to meet at least quarterly for three of four quarters. Assistant Director of Nursing was provided education on the requirement to maintain documentation of the meeting and attendance of participants via a meeting sign in sheet.

Director of Nursing will audit the documentation from the Infection Control Committee meetings to ensure the sign in sheet and the documentation of the meeting is completed.

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