Pennsylvania Department of Health
HORSHAM CENTER FOR JEWISH LIFE
Patient Care Inspection Results

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HORSHAM CENTER FOR JEWISH LIFE
Inspection Results For:

There are  154 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.
HORSHAM CENTER FOR JEWISH LIFE - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:
Based on a Medicare/Medicaid Recertification survey, State Licensure survey, Civil Rights Compliance survey and an Abbreviated survey in response to five complaints completed on March 21, 2024, it was determined that Horsham Center for Jewish Life was not in compliance with the following requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care and the 28 Pa. Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations as they relate to the Health portion of the survey.




 Plan of Correction:


483.10(g)(14)(i)-(iv)(15) REQUIREMENT Notify of Changes (Injury/Decline/Room, etc.):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(g)(14) Notification of Changes.
(i) A facility must immediately inform the resident; consult with the resident's physician; and notify, consistent with his or her authority, the resident representative(s) when there is-
(A) An accident involving the resident which results in injury and has the potential for requiring physician intervention;
(B) A significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications);
(C) A need to alter treatment significantly (that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment); or
(D) A decision to transfer or discharge the resident from the facility as specified in 483.15(c)(1)(ii).
(ii) When making notification under paragraph (g)(14)(i) of this section, the facility must ensure that all pertinent information specified in 483.15(c)(2) is available and provided upon request to the physician.
(iii) The facility must also promptly notify the resident and the resident representative, if any, when there is-
(A) A change in room or roommate assignment as specified in 483.10(e)(6); or
(B) A change in resident rights under Federal or State law or regulations as specified in paragraph (e)(10) of this section.
(iv) The facility must record and periodically update the address (mailing and email) and phone number of the resident
representative(s).

483.10(g)(15)
Admission to a composite distinct part. A facility that is a composite distinct part (as defined in 483.5) must disclose in its admission agreement its physical configuration, including the various locations that comprise the composite distinct part, and must specify the policies that apply to room changes between its different locations under 483.15(c)(9).
Observations:


Based on clinical record review and review of facility policy, it was determined that the facility failed to ensure that the physician was notified of a resident change in condition related to abnormal blood sugar levels for one of 35 resident reviewed. (Resident R648)

Findings include:

Review of facilities policy titled "Management of hypoglycemia" revealed that the resident's provider was to be notify after giving the resident an oral form of rapidly absorbed glucose or glucagon.

Review of Resident R648's clinical record revealed that the resident was admitted to the facility on September 19, 2023 with the diagnoses of dementia (progressive degenerative disease of the brain) and type 1 diabetes (failure of the body to produce insulin to enable sugar to pass from the blood stream to cells) .

Review of residents' care plan noted an intervention for resident's diagnosis of diabetes mellitius as monitor/document and report any signs or symptoms of hypoglycemia. Further review of residents' clinical record revealed special instructions to "Please call Nurse Practitioner 1st with any changes in condition immediately after notifying MD."

Review of resident's progress note on March 17, 2023 at 1:20 p.m revealed resident's blood sugar level was 61 and resident was 'feeling sick to her stomach'. Resident ate lunch and per progress note the resident's blood sugar level rose to 227 'an hour later' and 'insulin was administered. '

Further review of blood sugar levels revealed resident's blood sugar level of 23 mg/dl on March 17, 2023 at 4:24 p.m.

Review of Resident R648's Medication Administration Record (MAR) revealed Glucagon Emergency Kit 1mg administered in residents left deltoid. Progress note on March 17, 2024 at 4:53 p.m. revealed resident given food and drinks and 'supervisor was notified'.

Further review of resident R648's clinical record revealed no documented evidence that the resident's physician was notified of the resident's blood sugar levels and the need to administer Glucagon on March 17, 2024.

28 Pa Code 211.10(c) Resident care policies

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






 Plan of Correction - To be completed: 05/07/2024

Preparation and/or execution of this plan of correction does not constitute an admission or agreement by the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of Federal and State Law. The plan of correction represents the facility's credible allegation of compliance.
Resident R648's covering CRNP was notified of low blood sugar on March 18, 2024. New order to decrease mealtime insulin and notification parameters were implemented.
Current residents with insulin orders were reviewed to ensure orders included physician notification parameters.
Licensed nurses were re-educated on insulin parameter orders including physician notification.
The Director of Nursing Services/Designee will audit five residents with insulin orders weekly for three weeks, then 5 residents monthly for three months to ensure insulin parameters were followed and physician notification when necessary. Results of these audits will be reported to the QAPI Committee monthly for 3 months.


483.20(f)(5), 483.70(i)(1)-(5) REQUIREMENT Resident Records - Identifiable Information: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.
483.20(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 and interviews with staff, it was determined that the facility did not ensure residents' medical records were complete and accurately documented for one of 35 resident records reviewed (Resident R199).

Findings include:

Resident R199 was admitted to the facility on April 28, 2021, with diagnoses of high blood pressure, depression, and chronic kidney disease.

Review of 199's "Living Will" explained that the document lets the person express their wishes about life support and allows them to appoint someone to speak on their behalf when they cannot speak for themselves, in the event they become terminally ill. The documentation states the declaration must be signed including month and date, by the resident or have another person sign on their behalf and, also in the presence of at least two individuals. Further review of Resident R199 living will revealed the resident failed to specify the year it was signed and did not include the signatures of two people as witnesses.

Interview with the Director of Nursing on March 20, 2024, at 1:30 p.m. stated Resident R199's living will was not valid due to missing signatures and incomplete date.

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




 Plan of Correction - To be completed: 05/07/2024

Resident R199 no longer resides in the facility.
Current residents with Living Wills will be reviewed to ensure proper dating and signatures are in place.
Social Work, Medical Records and Admissions will be educated to look for dates and signatures on Living Wills.
Medical Records Director/Designee will audit random charts weekly x3 weeks to ensure living will is properly dated and signed findings will be reviewed at QAPI monthly x3 months.


483.60(i)(1)(2) REQUIREMENT Food Procurement,Store/Prepare/Serve-Sanitary: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.
483.60(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 observations of the Food and Nutrition Services, reviews of policies and procedures and food committee meeting minutes, and interviews with residents, it was determined that the facility failed to ensure that each resident received foods and beverages that were palatable and at safe and appetizing temperatures for five of 35 residents reviewed (Residents R123, R11, R134, R135 and R69) and in two of six nursing units. (D2 second floor, and B2 second floor

Findings include:

A review of facility documentation titled HACCP Daily Tasty Panel Chart log on March 21, 2024, stated that "recommended serving temperatures to ensures hot or cold food at of consumption: soup, sauces, gravies, vegetables 160 degrees Fahrenheit (F) to 180 degrees Fahrenheit (F), meat, poultry, seafood and eggs 145 degrees Fahrenheit (F) to 165 degrees Fahrenheit (F), and cold food below 40 degrees Fahrenheit (F) and other entrees 160 degrees Fahrenheit (F)". A review of facility policy title Food Holding Temperature Requirements: states that "food temperatures should be taken prior to service to ensure that holding temperatures".

Interview on unit D2 dining room with Resident R123 on March 19, 2024, at 12:29 p.m. revealed that most of the time food is not hot and a lot of carbs.

Interview on unit D2 dining room with Resident R111 on March 19, 2024, at 1:02 p.m. revealed that grill sandwich was just delivered to her room, and it was cold.

Interview on unit D2 dining room with Resident R134 on March 19, 2024, at 1:23 p.m. revealed that food served cold and a lot of sandwiches.

Interview on unit D2 dining room with Resident R135 on March 19, 2024, at 1:23 p.m. revealed that food sometimes comes undercooked or overcooked, cold and needs to be reheated in the microwave.

Interview on unit C1 dining room with Resident R69 on March 21, 2024, at 2 p.m. revealed that food preference are not honored.

Resident council was held on March 20, 2024, at 10:30 with alert and oriented residents (Residents R79, R41, R201, R95, R259, R89, R123 and R130) revealed that these residents were unsatisfied with the food temperature.

During lunch time observation on March 21, 2024, at 12:00 p.m. in unit D2 second floor in the small unit kitchen it was revealed that food was getting served on resident's plates without taking the temperature of each hot food in the steam table.

During lunch time observation on March 21, 2024, at 12:19 p.m. in unit B2 second floor in the small unit kitchen it was revealed that food was getting served to the resident's plates without taking the temperature of each hot food on the steam table. Also, the food was plated without lids and plate covers to keep the appropriate food temperature.

Food Service staff, Employee E13 confirmed that they didn't take temperature the food prior serving. Also, food service employee E 13, started to microwave food that was plated and sitting out without plate covers and also didn't take the temperature after heating the food.

Temperatures of the food were taken on March 21, 2024 at 12:23 p.m. with food service staff, Employee E13 and Food Manager, Employee E14 revealed that eggplant was 172 degrees Fahrenheit (F), Pasta was 152 and low sodium pasta was 119 degrees Fahrenheit (F), soup was 136 degrees Fahrenheit (F), stuffed pepper was 154 degrees Fahrenheit (F) and grill cheese sandwiched was 124 degrees Fahrenheit (F).

Food Manager took the pasta, grilled cheese sandwiches and soup to big kitchen to be reheated. Also confirmed that it was not the right temperature, that they follow from the HACCP Daily Tasty Panel Chart log. Unit B2 small kitchen staff didn't wait for the reheated food to come back from the kitchen and started to serviced food with not appropriate food temperature and send out the open food chart to resident's rooms at 12:46 p.m..

A test tray was completed on the second floor on unit B2 resident's rooms with Food Manager, Employee E14 at 12:47 p.m. it was revealed that pasta was 118 degrees Fahrenheit.

An interview with the Food Manager, Employee E14, on March 21, 2024, at approximately 12:50 p.m. confirmed that the above-mentioned food items were below the acceptable temperatures, and it shouldn't being send out and served to the residents in their rooms.

28 Pa. Code 201.14(a) Responsibility of licensee

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





 Plan of Correction - To be completed: 05/07/2024

Residents are receiving food and beverages that are palatable and at proper temperatures.
Food service workers will temp food and beverages to ensure proper temperatures prior to start of service.
All dietary staff have been re-educated on taking food and beverage temp prior to service.
Dietary manager/Designee will audit random dining rooms to ensure temps are taken weekly for 4 weeks. Findings will be reviewed at QAPI monthly x3 months.

483.60(a)(3)(b) REQUIREMENT Sufficient Dietary Support Personnel: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.
483.60(a) Staffing
The facility must employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, taking into consideration resident assessments, individual plans of care and the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment required at 483.70(e).

483.60(a)(3) Support staff.
The facility must provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.

483.60(b) A member of the Food and Nutrition Services staff must participate on the interdisciplinary team as required in 483.21(b)(2)(ii).
Observations:

Based on observation and interviews with staff and residents, it was determined that the facility did not employ sufficient staff to carry out the functions of food and nutrition services and that meals were served timely in one of three dining rooms (Second floor).

Findings include:

Observation of lunch meal service on March 18, 2024 at 12:15 p.m. revealed eighteen residents seated in the dining room waiting for lunch. All residents were offered a beverage. At 12:30 p.m., Food Service staff, Employee E17 pushed a cart into the dining room with eight bowls of soup. Seven residents were seated at a table and only one resident received a bowl of soup. At 12:45 p.m., Employee E17 pushed in a cart of eight more bowls of soup. At 12:55 p.m. the final resident received a bowl of soup. Resident R134 stated " the soup is not hot". Employee E17, picked up the bowl of soup and went into the pantry where she reheated the soup in the microwave. She brought the soup out to Resident R134 who stated, " yes, the soup was hot It's fine." Again, Employee E117 came from the pantry with eight entrees and only one resident at the table of seven was served. Ten minutes later, Employee E17 returned with eight more entrees. Resident R134 stated, "I am always last." At this time, residents were leaving the dining room without being offered chocolate parfait, the dessert listed on the menu.

An interview on March 18, 2024 at 1:10 p.m. with Employee E17 revealed that his job title was food service worker and he was responsible for delivering food from the pantry to the residents seated in the dining room.

An interview on March 18, 2024 at 1:15 p.m. with Employee E4, Registered Dietician, revealed that the food temperatures were not taken for food items on the steamtable in the pantry which was located adjacent to the dining room. Employee E4 located the food thermometer and stated that food should have been temped at point of service but the food arrived late. Employee E4 confirmed that Employee E10 should not have microwaved the soup and that soup should have been temped before serving to residents.

An interview on March 18, 2024 at 1:20 p.m. with Employee E10 revealed that her job title was Dining Concierge. The Job Overview revealed that the dining concierge is responsible for assisting the dietary department with the menu process and meeting with residents to assist with their meal selections. The dining concierge provides an overview of the meal selection process to new admissions and those who call with inquiries. The dining concierge is a hospitality professional who attends to the needs of patients/residents and helps them with the menu/meal selection process while staying at the skilled nursing facility. Interview with Employee E17 confirmed that Dining Concierge job description did not include reheating food in the microwave.

An interview on March 18, 2024 at 2:45 p.m. with Nursing Home Administrator revealed, "lunch arrived late due to not having enough staff in the dietary department due to call outs."


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

28 Pa Code 211.6(c)(d)(1) Dietary Services











 Plan of Correction - To be completed: 05/07/2024

The facility has sufficient staff to carry out the function of food and nutrition services so meals are served on time.
Staffing will be reviewed at random by facility administrator/designee to ensure adequate staffing is met to carry out all food and nutrition services.
All dietary staff have been re-educated on dining times.
Random audits of daily staffing will be reviewed by Administrator/designee weekly X4 weeks to ensure staffing needs are met. Findings will be reviewed at QAPI monthly X3 months.


483.10(g)(17)(18)(i)-(v) REQUIREMENT Medicaid/Medicare Coverage/Liability Notice: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(g)(17) The facility must--
(i) Inform each Medicaid-eligible resident, in writing, at the time of admission to the nursing facility and when the resident becomes eligible for Medicaid of-
(A) The items and services that are included in nursing facility services under the State plan and for which the resident may not be charged;
(B) Those other items and services that the facility offers and for which the resident may be charged, and the amount of charges for those services; and
(ii) Inform each Medicaid-eligible resident when changes are made to the items and services specified in 483.10(g)(17)(i)(A) and (B) of this section.

483.10(g)(18) The facility must inform each resident before, or at the time of admission, and periodically during the resident's stay, of services available in the facility and of charges for those services, including any charges for services not covered under Medicare/ Medicaid or by the facility's per diem rate.
(i) Where changes in coverage are made to items and services covered by Medicare and/or by the Medicaid State plan, the facility must provide notice to residents of the change as soon as is reasonably possible.
(ii) Where changes are made to charges for other items and services that the facility offers, the facility must inform the resident in writing at least 60 days prior to implementation of the change.
(iii) If a resident dies or is hospitalized or is transferred and does not return to the facility, the facility must refund to the resident, resident representative, or estate, as applicable, any deposit or charges already paid, less the facility's per diem rate, for the days the resident actually resided or reserved or retained a bed in the facility, regardless of any minimum stay or discharge notice requirements.
(iv) The facility must refund to the resident or resident representative any and all refunds due the resident within 30 days from the resident's date of discharge from the facility.
(v) The terms of an admission contract by or on behalf of an individual seeking admission to the facility must not conflict with the requirements of these regulations.
Observations:

Based on a review of clinical records, facility provided documentation, and interview with staff, it was determined that the facility failed to provide the required advanced notice, through a Notice of Medicare Non-Coverage (CMS 10123), regarding the termination of Medicare services for two of three residents sampled (Residents R141, R166)

Findings include:

The form "Notice of Medicare Non-Coverage (NOMNC) CMS-10123," is a notice that informs the recipient when care received from the skilled nursing facility is ending; and how to contact a Quality Improvement Organization to appeal. The Medicare provider must ensure that the notice is delivered at least two calendar days before covered services end.

Review of Resident R141's Notice of Medicare Non-Coverage (NOMNC) cms-10123 revealed that the Medicare skilled A services will end on December 11, 2023.

Review of Resident R166's Notice of Medicare Non-Coverage (NOMNC) cms-10123 revealed that the Medicare skilled A services will end on December 14, 2023.

Interview with the Nursing Home Administrator on March 21, 2024 confirmed the facility did not ensure to that notice was delivered at least two calendar days before Resident R141 and R166 covered services ended.

28 Pa Code 201.29(a) Resident rights



 Plan of Correction - To be completed: 05/07/2024

Resident R141 & Resident R166 no longer reside in the facility.
Director of Social Services/Designee will review past 3 months of Medicare notification of non-coverage to ensure NOMNC was provided.
Social Work and MDS teams were re-educated on regulation of providing NOMNC within allotted time frame.
Director of Social Work/Designee will audit 5 residents needing NOMNC weekly for 3 weeks and report findings to QAPI for 3 months.


483.25 REQUIREMENT Quality of Care:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.25 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 record review and interviews with staff, the facility failed to properly transcribe a physician order for one of four residents reviewed (Resident R105).

Finding include:

Review of Resident R105's clinical record revealed that the resident was admitted to hospice services with a diagnosis of systolic congestive heart failure (excessive body fluid caused by weakened heart muscle) on February 16, 2024. Included was a recommendation for Lorazepam 2mg/ml suspension with written instructions to take 0.5 mg (0.25ml) sublingual every 4 hours as needed for restlessness and anxiety. On February 17, 2024 the physician order was added with an end date 14 days later on March 2, 2024.

Review of Resident R105's March 2024 physician orders revealed that the order was renewed on March 15, 2024 2024 and transcribed into the MAR incorrectly as scheduled every 4 hours. Resident received a dose on March 15, 2024 at 4:00 p.m and March 16, 2024 at midnight and 4:00 a.m. Progress note on March 16, 2024 at 2:57 p.m. revealed Lorazepam order was "transcribed incorrectly." Order was discontinued.

Interview with Director of Nursing on March 19, 2024 at 1:30 p.m. confirmed order was transcribed incorrectly and that they do not have a procedure for nurses on the floor when transcribing medications.

28 Pa. Code 211.10 (c) Resident care policies

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









 Plan of Correction - To be completed: 05/07/2024

Resident R105's physician was notified of Lorazepam order and recommendation from hospice. New order was received and implemented.
Current residents receiving Lorazepam orders were reviewed to ensure order matched transcription.
Licensed Nurses were re-educated on order transcription policy.
The Director of Nursing/Designee will do random audits five residents weekly for three weeks, then 5 residents monthly for three months to ensure Lorazepam is transcribed and administered per physician orders. Results of these audits will be reported to the QAPI Committee for 3 months.


483.35(a)(1)(2) REQUIREMENT Sufficient Nursing Staff: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.
483.35(a) Sufficient Staff.
The facility must have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment required at 483.70(e).

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

483.35(a)(2) Except when waived under paragraph (e) of this section, the facility must designate a licensed nurse to serve as a charge nurse on each tour of duty.
Observations:

Based on observation, review of clinical records, and interviews with residents and staff, it was determined that the facility failed to maintain sufficient nursing staff levels to provide nursing care and services for three of 35 residents reviewed (Residents R135, R123 and R138 ).

Findings include:

Review of facility's policy "Answering the Call Light" revised September 2022, "the purpose of this procedure is to ensure timely response to the resident's request and needs. Answer the resident call system within 5-15 minutes".

An interview with Resident R135 on March 18, 2024, at 1:17 p.m. revealed that many times they must wait a long time to get change because they are short staff with nursing aides day and night shifts. Daily shift has two nurse aides and night shift has one nurse aide for 27 residents on D2 unit.

An interview with Resident R123 on March 18, 2024, at 12:49 p.m. revealed that it a one hour waiting time to get your call bell answered because it one nurse aide only for 13 residents.

An interview with Registered Nurse, unit manger, Employee E16, on March 18, 2024, at 1:20 p.m. provided nurse aides daily assignment sheet and it revealed two nursing aides on each unit D2 and C2. Also, it was reported that they always had it this way.

An interview with Resident R138 on March 19, 2024, at 11:30 a.m. revealed and observed that still need to get washed and dressed.

Observations on March 19, 2024, at 10:00 a.m., on second floor, unit C, revealed that many residents reported that only two nurse aides for one unit. Residents were still waiting to be provide morning hygiene care and dressed.

Observations on March 19, 2024, 11:30 a.m. on the second floor, C unit revealed residents still waiting to be provide morning bed bath hygiene care. Three call bells were observed on. The call bell was answered and turn off by Licensed nurse, Employee E15 on March 19, 2024 at 11:44 a.m. Employee E15 informed the residents that their nurse aide will come in soon.

Observations on March 19, 2024, at 11:35 a.m. revealed that Resident R138 was still in her hospital gown and waiting to receive assistance to use the bathroom and get morning care.

Observations on March 19, 2024, at 11:45 a.m., on second floor unit C, revealed a number of residents who were still waiting to be changed and washed up from the night.

An interview with the nurse aide, Employee E12, on March 19, 2024, at approximately 10:35 a.m. revealed that there were two nursing aides for 27 residents on C2 unit. Also reported that they were behind on resident's care because of being short staff. Also, many time they can't do resident's care or answer call bells in a timely manner because of only two nursing aides on the unit. Also, it was reported that nursing aides don't have time to take they breaks or lunch because it is a lot of work with 13 residents on their case load or other nursing aide needs to help with two-person assistant.

Resident council was held on March 20, 2024, at 10:30 a.m. with alert and oriented residents (Residents R79, R41, R201, R95, R259, R89, R123 and R130) revealed that short staff with nurse aide. Residents reported that they must wait up to an 1 hour or longer to get ready or washed up because its only two nurse aide working on each unit.

An interview with Register Nurse, unit manger Employee E16, on March 19, 2024, at approximately 2:01 p.m. revealed and confirmed that they have two nurses aides per unit for D2 unit for 27 residents and C2 unit 26 residents.


28 Pa Code: 211.12 (d)(4) Nursing services

28 Pa Code: 201.14(a) Responsibility of licensee



 Plan of Correction - To be completed: 05/07/2024

Resident 135,123 and 138 are receiving nursing care and services.
Facility is staffing to maintain required staffing ratios and PPD to meet resident needs.
Staffing will be reviewed at random by facility administrator/designee to ensure required staffing is met. Interim steps include, nursing on-call is in place, Bi-weekly orientation schedule for new hires, OT and bonuses are offered and the facility is working on implementation of a CNA program.
Random audits of daily staffing will be reviewed by Administrator/designee weekly X4 weeks to ensure staffing requirements are met. Findings will be reviewed at QAPI monthly X3 months.


483.35(g)(1)-(4) REQUIREMENT Posted Nurse Staffing Information:Least serious deficiency but affects more than a limited number of residents, staff, or occurrences. This deficiency has the potential for causing no more than a minor negative impact on the resident but is not found to be throughout this facility.
483.35(g) Nurse Staffing Information.
483.35(g)(1) Data requirements. The facility must post the following information on a daily basis:
(i) Facility name.
(ii) The current date.
(iii) The total number and the actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift:
(A) Registered nurses.
(B) Licensed practical nurses or licensed vocational nurses (as defined under State law).
(C) Certified nurse aides.
(iv) Resident census.

483.35(g)(2) Posting requirements.
(i) The facility must post the nurse staffing data specified in paragraph (g)(1) of this section on a daily basis at the beginning of each shift.
(ii) Data must be posted as follows:
(A) Clear and readable format.
(B) In a prominent place readily accessible to residents and visitors.

483.35(g)(3) Public access to posted nurse staffing data. The facility must, upon oral or written request, make nurse staffing data available to the public for review at a cost not to exceed the community standard.

483.35(g)(4) Facility data retention requirements. The facility must maintain the posted daily nurse staffing data for a minimum of 18 months, or as required by State law, whichever is greater.
Observations:

Based on observations and interview with staff, it was determined that the facility did not ensure to post nurse staffing data on a daily basis in a prominent place as required and did not provide form in a clear and understandable format.

Findings include:

Observations on March 18, 2024 at 1:00 p.m. of the main lobby revealed "Daily staffing for Monday march 18, 2024," "unit: default," "census ...1."

Review of Daily Staffing for March 12, 2024 through March 18, 2024 revealed no evidence of correct census, no minimum working hours required for RN's, LPN's and nurse aides, no evidence of actual hours worked and no documentation of call outs.

Observation of units A2, B2 and D3 on March 18, 2024 through March 21, 2024 revealed no evidence of nursing staff data.

Interview with facility's executive director, staffing coordinator, as well as administrator on March 18, 2024 and March 21, 2024 confirmed that daily staffing format was incorrectly filled out and not placed in a prominent place for residents to access.

28 Pa Code 201.14(a) Responsibility of licensee




 Plan of Correction - To be completed: 05/07/2024

Nurse staffing data was posted in prominent place in a clear format.
Schedulers were educated on placing clear staffing sheets in a prominent location.
Random audits of the staffing sheet will be reviewed by Administrator/designee on random days X4 weeks to ensure the form is posted correctly. Findings will be reviewed at QAPI monthly X3 months.

205.26(e) LICENSURE Laundry.:State only Deficiency.
(e) Equipment shall be made available and accessible for residents desiring to do their personal laundry.

Observations:


Based on observations and interviews with facility staff, it was determined that the facility did not have equipment available or accessible for residents desiring to do their own personal laundry.

Findings include:

Observations during a tour of the resident's clinical/living areas on March 19, 2024, revealed that there was no laundry equipment, washer or dryer, available for residents to do their personal laundry as required.

Interview on March 19, 2024, at approximately 1:05 p.m. with Director of Material Management, Employee E8, confirmed that there was no laundry equipment, washer or dryer, available and accessible for residents desiring to do their personal laundry. The washer and dryers for specifically for personal laundry is behind a locked door and a member of housekeeping staff washes them. Interview also revealed that they residents are not allowed in that room.

28 Pa Code: 205.26(e) Laundry




 Plan of Correction - To be completed: 05/07/2024

A washer and dryer will be made available to residents requesting to do their own laundry in a safe environment.
All residents will be asked if they would like to do their own laundry. Upon admission and semi annually residents will be asked preference for doing laundry.

211.12(f.1)(4) LICENSURE Nursing services. :State only Deficiency.
(4) Effective July 1, 2023, a minimum of 1 LPN per 25 residents during the day, 1 LPN per 30 residents during the evening, and 1 LPN per 40 residents overnight.
Observations:

Based on a review of nursing time schedules, and facility provided documentation, it was determined that the facility did not ensure to meet the minimum nursing staff to resident ratio for one of 63 shifts reviewed. (11/25/23 night shift)

Findings include:

Review of facility census data indicated that on 11/25/23, the facility census was 303, which required 7.58 LPN's during the night shift.

Review of the nursing time schedules revealed that 7.38 LPN's provided care on the night shift on 11/25/23. No additional excess higher-level staff were available to compensate this deficiency.

28 Pa Code 211.12(f)(e) Nursing services










 Plan of Correction - To be completed: 05/07/2024

Facility is staffing to maintain the required staffing ratios related to LPN's on night shift.
#2 Staffing will be reviewed by facility administrator/designee prior to night shift to ensure required ratios are met. Interim steps include, nursing on-call is in place, Bi-weekly orientation schedule for new hires, OT and bonuses are offered.
#3 Random audits of daily staffing will be reviewed by Administrator/designee weekly X4 weeks to ensure required staffing ratios are met on night shift. Findings will be reviewed at QAPI monthly X2.


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