Pennsylvania Department of Health
 MAPLE WINDS HEALTHCARE AND REHABILITATION, LLC
Patient Care Inspection Results

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MAPLE WINDS HEALTHCARE AND REHABILITATION, LLC
Inspection Results For:

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MAPLE WINDS HEALTHCARE AND REHABILITATION, LLC - 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 June 5, 2024, it was determined that Maple Winds Healthcare and Rehabilitation 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:


483.60(c)(1)-(7) REQUIREMENT Menus Meet Resident Nds/Prep in Adv/Followed:This is a less serious (but not lowest level) deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents. 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(c) Menus and nutritional adequacy.
Menus must-

§483.60(c)(1) Meet the nutritional needs of residents in accordance with established national guidelines.;

§483.60(c)(2) Be prepared in advance;

§483.60(c)(3) Be followed;

§483.60(c)(4) Reflect, based on a facility's reasonable efforts, the religious, cultural and ethnic needs of the resident population, as well as input received from residents and resident groups;

§483.60(c)(5) Be updated periodically;

§483.60(c)(6) Be reviewed by the facility's dietitian or other clinically qualified nutrition professional for nutritional adequacy; and

§483.60(c)(7) Nothing in this paragraph should be construed to limit the resident's right to make personal dietary choices.
Observations:


Based on review of the facility's written menus, as well as observations and staff interviews, it was determined that the facility failed to follow their planned menu.

Findings include:

A facility's policy regarding menu management, dated May 6, 2024, revealed that menus were to be posted on menu boards located in the dining room and hallway. Temporary changes to the menu will be posted daily on the menu boards. To ensure consistency, all meals served will strictly adhere to the pre-approved menus.

The facility's written and posted weekly menu for the lunch meal on June 3, 2024, revealed that the residents were to receive bread with margarine.

Observations during the lunch meal on June 3, 2024, at 12:08 p.m. revealed that the residents did not receive bread or margarine for the lunch meal.

Interview with the Dietary Manager on June 3, 2024, at 12:58 a.m. revealed that a new cook eliminated the bread from the menu for lunch and she did not know why, but the residents should have been provided bread and margarine with their meal.

28 Pa. Code 211.6(a) Dietary Services.

28 Pa. Code 201.29(j) Resident Rights.


 Plan of Correction - To be completed: 07/16/2024

Immediate education was provided to cook by the Dietary Manager regarding the importance of following the facility planned menu.

Any resident who receives a meal has the ability to be affected by this alleged deficient practice.

Baseline random audit of recently served meals has been completed to ensure the facility menu was followed and residents received food items as per posted menus.

Dietary staff re-educated on the importance of following the facility planned menu and serving all items listed on posted menu boards.

The Dietary Manager/designee will audit random resident meals to ensure items served match posted menu weekly times three weeks and then monthly times two months and then reviewed by the Quality Assurance Performance Improvement Committee for results, areas of improvement and/or continuation of audits.

Results of these audits will be reviewed in Quality Assurance and Performance Improvement times three months or until substantial compliance is noted.


483.25 REQUIREMENT Quality of Care: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.
§ 483.25 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 facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that physician's orders for were followed for three of 27 residents reviewed (Residents 11, 27, 35) and failed to ensure that neurological checks were completed following an unwitnessed fall for one of 27 residents reviewed (Resident 13).

Findings include:

A facility policy related to physician's orders, dated May 6, 2024, indicated that medications, treatments, and care is provided to residents upon written and/or verbal order.

A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 11, dated May 2, 2024, revealed that the resident was understood and could understand others, required assistance with daily care needs, received insulin, and had diagnoses that included diabetes.

Physician's orders for Resident 11, dated October 18, 2023, included an order for the resident to receive 44 units of Glargine insulin (a long-acting insulin) subcutaneously (injected just under the skin) daily at bedtime and hold if blood sugar is less than 150 milligrams per deciliter (mg/dl).

A review of Resident 11's Medication Administration Record (MAR) for April 2024 revealed that the resident's bedtime blood sugar was 118 mg/dl on April 17, 2024; 148 mg/dl on April 24, 2024; 146 mg/dl on April 26, 2024; and 123 mg/dl on April 30, 2024. Glargine insulin was documented on the MAR as having been administered on the above stated dates.

Interview with the Director of Nursing on June 5, 2024, at 10:15 a.m. confirmed that Glargine insulin was administered to Resident 11 on the above stated dates and should not have been.

A facility policy related to falls, dated May 6, 2024, revealed that resident falls were reported, their causes identified when possible, and timely interventions were established to help reduce the probability of repeated incidents.

A quarterly MDS assessment for Resident 13, dated May 14, 2024 revealed that the resident was able to make herself understood and understood others, was moderately cognitively impaired, and required assistance from staff for personal care needs.

A licensed practical nurse's note for Resident 13, dated February 21, 2024, indicated that she was found lying on her fall mats on her back with her legs extended in front of her.

A review of Resident 13's medical chart revealed no documented evidence that neurological checks were completed for the unwitnessed fall on February 21, 2024.

Interview with the Director of Nursing on June 5, 2024, at 9:19 a.m. confirmed that neurological checks should be completed after unwitnessed falls, and was unable to find them for Resident 13 for the fall occurring on February 21, 2024.

An admission MDS assessment for Resident 27, dated May 15, 2024, revealed that the resident was cognitively impaired and required extensive assistance for daily care needs.

Physician's orders for Resident 27, dated May 24, 2024, included an order for the resident to have a treatment for a skin tear on her left forearm. A review of Resident 27's Treatment Administration Record (TAR) for May 2024 revealed no documented evidence that the treatment for the skin tear on Resident 27's left forearm was completed as ordered by the physician.

Interview with the Director of Nursing on June 4, 2024, at 11:30 a.m. confirmed that treatments for the skin tear on Resident 27's left forearm were not completed as ordered.

A quarterly MDS assessment for Resident 35, dated March 8, 2024, revealed that the resident was understood and could understand others, required assistance with daily care needs, and had one fall with injury.

A nurse's note for Resident 35, dated May 14, 2024, revealed that the resident had an unwitnessed fall at bedside, the resident was assessed, and neurological checks (a neurological examination is the assessment of sensory neuron and motor responses, especially reflexes, to determine whether the nervous system is impaired) were to be completed.

A review of Resident 35's medical chart revealed no documented evidence neuro checks were completed for the unwitnessed fall on May 14, 2024.

Interview with the Director of Nursing on June 5, 2024, at 10:15 a.m. confirmed that neuro checks should be completed after unwitnessed falls.

A facility policy for Bowel Protocol, dated May 6, 2024, revealed that a resident should have a soft, formed bowel movement every third day or sooner.

Physician's orders for Resident 35, dated November 30, 2023, included an order for the resident to receive a 5 mg tablet of Dulcolax (a laxative that stimulates bowel movements) by mouth as needed for constipation on Day 3 with no bowel movement and a Dulcolax suppository 10 mg rectally as needed for constipation on Day 4 with no bowel movement.

Nurse's note for Resident 35, dated April 10, 2024, revealed the resident's last bowel movement was April 4, 2024, and there was no documented evidence that bowel protocol was administered.

Interview with Director of Nursing on June 5, 2024, at 12:53 p.m. revealed that the bowel protocol was not initiated for Resident 35 on Day 3 and Day 4 with no bowel movement and should have been.

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




 Plan of Correction - To be completed: 07/16/2024

Resident 11 assessed with no noted concerns related to his Glargine insulin being administered on April 17, 2024; April 24, 2024; April 26, 2024 and April 30,
2024.

Resident 11's physician notified of Glargine insulin being administered on April 17, 2024; April 24, 2024; April 26, 2024 and April 30,
2024.

Resident 13 assessed with no noted concerns related to neurological checks not being completed after unwitnessed fall on February 21, 2024.

Resident 13's physician notified of neurological checks not being completed after her unwitnessed fall on February 21, 2024.

Resident 27 assessed with no noted concerns related to skin tear treatment not being completed as per physician's order on May 24, 2024.

Resident 27's physician notified of skin tear treatment not being completed as per physician's order on May 24, 2024.

Resident 35 assessed with no noted concerns related to neurological checks not being completed after unwitnessed fall on February 21, 2024.

Resident 35's physician was notified of neurological checks not being completed after her unwitnessed fall on February 21, 2024.

Resident 35 assessed with no noted concerns related to bowel protocol not being initiated on Day 3 and Day 4 with no bowel movement after having last bowel movement on April 4, 2024.

Resident 35's physician notified of bowel protocol not being initiated on Day 3 and Day 4 with no bowel movement after having last bowel movement on April 4, 2024.

Any resident with a physician order that specifies parameters related to receiving/holding insulin has the ability to be affected by this alleged deficient practice.

A whole house audit on residents with physician orders with specific parameters to receive/hold insulin was completed to ensure insulin was administered and/or held as per parameters/physician orders.

Any resident who has an unwitnessed fall has the ability to be affected by this alleged deficient practice.

A whole house audit on residents with recent unwitnessed fall incidents was completed to ensure neurological checks were completed after his/her unwitnessed fall and present in the resident's clinical record.

Any resident who has a skin tear has the ability to be affected by this alleged deficient practice.

A whole house audit on residents with recent skin tears was completed to ensure his/her skin tear treatment was completed as per physician orders and documentation of completion of skin tear treatment order was present in the resident's treatment administration record.

Any resident who has a physician order for bowel protocol has the ability to be affected by this alleged deficient practice.

A whole house audit on residents recently having no bowel movement on Day 3 and Day 4 was completed to ensure bowel protocol was administered as per physician orders.

Licensed nursing staff, including agency licensed staff, re-educated to administer insulin to residents and/or hold insulin for residents as per physician parameters/physician orders.

Licensed nursing staff, including agency licensed staff, re-educated on the need to complete neurological checks on residents having an unwitnessed fall including the need to ensure neurological checks are placed and present in the resident's clinical record.

Licensed nursing staff, including agency licensed staff, re-educated on the need to complete skin tear treatments as per physician orders including the need to ensure documentation of skin tear treatment is recorded in the resident's treatment administration record.

Licensed nursing staff, including agency licensed staff, re-educated on the need to administer bowel protocol as per physician orders for residents not having bowel movement on Day 3 and Day 4 as per physician orders.

The Director of Nursing/designee will audit medication administration records for residents who are to receive insulin to ensure resident insulin was administered/held as per physician parameters/physician orders weekly times six weeks and then monthly times two months and then reviewed by the Quality Assurance Performance Improvement Committee for results, areas of improvement and/or continuation of audits.

Results of these audits will be reviewed in Quality Assurance and Performance Improvement times four months or until substantial compliance is noted.

The Director of Nursing/designee will audit medication administration records for residents who are to have unwitnessed falls to ensure resident neurological checks are completed and present in resident's clinical record weekly times six weeks and then monthly times two months and then reviewed by the Quality Assurance Performance Improvement Committee for results, areas of improvement and/or continuation of audits.

Results of these audits will be reviewed in Quality Assurance and Performance Improvement times four months or until substantial compliance is noted.

The Director of Nursing/designee will audit treatment administration records for residents with recent skin tears to ensure resident's skin tear treatment order is completed as per physician order and documentation of completed skin tear treatment is present in resident's treatment administration record weekly times six weeks and then monthly times two months and then reviewed by the Quality Assurance Performance Improvement Committee for results, areas of improvement and/or continuation of audits.

Results of these audits will be reviewed in Quality Assurance and Performance Improvement times four months or until substantial compliance is noted.

The Director of Nursing/designee will audit medication administration records of residents not having bowel movement on Day 3 and Day 4 to ensure resident's bowel protocol was administered as per physician orders weekly times six weeks and then monthly times two months and then reviewed by the Quality Assurance Performance Improvement Committee for results, areas of improvement and/or continuation of audits.

Results of these audits will be reviewed in Quality Assurance and Performance Improvement times four months or until substantial compliance is noted.


483.45(c)(1)(2)(4)(5) REQUIREMENT Drug Regimen Review, Report Irregular, Act On: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(c) Drug Regimen Review.
§483.45(c)(1) The drug regimen of each resident must be reviewed at least once a month by a licensed pharmacist.

§483.45(c)(2) This review must include a review of the resident's medical chart.

§483.45(c)(4) The pharmacist must report any irregularities to the attending physician and the facility's medical director and director of nursing, and these reports must be acted upon.
(i) Irregularities include, but are not limited to, any drug that meets the criteria set forth in paragraph (d) of this section for an unnecessary drug.
(ii) Any irregularities noted by the pharmacist during this review must be documented on a separate, written report that is sent to the attending physician and the facility's medical director and director of nursing and lists, at a minimum, the resident's name, the relevant drug, and the irregularity the pharmacist identified.
(iii) The attending physician must document in the resident's medical record that the identified irregularity has been reviewed and what, if any, action has been taken to address it. If there is to be no change in the medication, the attending physician should document his or her rationale in the resident's medical record.

§483.45(c)(5) The facility must develop and maintain policies and procedures for the monthly drug regimen review that include, but are not limited to, time frames for the different steps in the process and steps the pharmacist must take when he or she identifies an irregularity that requires urgent action to protect the resident.
Observations:


Based on a review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to respond timely to pharmacy recommendations for four of 27 residents reviewed (Residents 3, 11, 35, 36) and failed to obtain completed pharmacy recommendations for physician review for two of 27 residents reviewed (Residents 10, 29).

Findings include:

The facility's policy for drug regimen review, dated May 6, 2024, indicated that a drug regimen review is performed by a licensed pharmacist for every resident each month. The pharmacist will report any medication irregularities and recommendations to the attending physician on a pharmacy review sheet. The physician will respond to the pharmacist's recommendation on the review sheet, and it will be returned to the facility to be acted upon. The review sheet will be filed in the resident's chart in the physician progress section and will be kept in the chart for one full year.

A quarterly Minimum Data Set (MDS) (assessment of a resident's abilities and care needs) for Resident 3, dated April 12, 2024, revealed that the resident was cognitively intact, was dependent on staff for daily care needs, received insulin (a medication preperation of the hormone insulin), and had a diagnosis of diabetes (disease causing high blood sugar levels).

A pharmacy review sheet for Resident 3, dated March 5, 2024, included a recommendation that a correction needed to be made to Resident 3's orders due a change in insulin dose at bedtime. There was no documented evidence that the pharmacy recommendation was addressed timely by the physician.

Interview with the Director of Nursing on June 5, 2024, at 1:34 p.m. confirmed that the pharmacy recommendation for Resident 3 on March 5, 2024, was not addressed timely by the physician.

A quarterly MDS assessment for Resident 11, dated May 2, 2024, revealed that the resident was understood and could understand others, required assistance with daily care needs, received insulin and controlled pain medication, and had diagnoses that included diabetes.

Review of a pharmacy review sheet for Resident 11, dated March 5, 2024, revealed a recommendation that the resident may be due for blood work related to drug therapy. However, there was no documented evidence that the pharmacy recommendations were addressed timely by the physician.

Interview with the Director of Nursing on June 5, 2024, at 1:34 p.m. confirmed that the pharmacy recommendations for Resident 11 on March 5, 2024, were not addressed timely by the physician and should have been.

A quarterly Minimum Data Set (MDS) (assessment of a resident's abilities and care needs) for Resident 35, dated March 8, 2024, revealed that the resident was cognitively impaired, was dependent on staff for daily care needs, and received an antianxiety medication (a drug used to treat anxiety) and an antidepressant medication (a drug used to treat depression).

Progress notes for Resident 35, dated March 5, 2024; April 12, 2024; and May 13, 2024, revealed that a pharmacy review was done and recommendations were made. However, there was no documented evidence that the pharmacy recommendations were addressed timely by the physician.

Interview with the Director of Nursing on June 5, 2024, at 1:34 p.m. confirmed that the pharmacy recommendations for Resident 35 on March 5, 2024; April 12, 2024; and May 13, 2024, were not addressed timely by the physician and they should have been.

An annual MDS assessment for Resident 36, dated May 14, 2024, revealed that the resident was cognitively intact, was dependent on staff for daily care needs, and was receiving an antianxiety medication (used to control anxiety) and a medication for insomnia (used to control sleep).

Review of a pharmacy recommendation for Resident 36, dated March 5, 2024, revealed a recommendation that it may be appropriate to discontinue one of the medications for anxiety and insomnia and that a correction was made to Resident 3's orders. However, there was no documented evidence that the pharmacy recommendations were addressed timely by the physician.

Interview with the Director of Nursing on June 5, 2024, at 1:34 p.m. confirmed that the pharmacy recommendations for Resident 36 on March 5, 2024, were not addressed timely by the physician and they should have been.

A significant change MDS assessment for Resident 10, dated May 2, 2024, revealed that the resident was understood and could understand others, was dependent for care needs, received controlled pain medication, and had diagnoses that included atrial fibrillation (irregular heart rhythm).

A progress note for Resident 10, dated February 19, 2024, revealed that a pharmacy review was done and that recommendations were made. However, there was no documented evidence that the pharmacy recommendations were received for the physician to review.

Interview with the Director of Nursing on June 5, 2024, at 1:34 p.m. confirmed that the pharmacy recommendations for Resident 10 on February 19, 2024, were not obtained for the physician to review and should have been.

A quarterly MDS assessment for Resident 29, dated April 25, 2024, revealed that the resident was understood and could understand others and was receiving controlled pain medication, antipsychotic medications (used to treat mental health disorders), antidepressant medications (used to treat depression) and anticoagulant medications (used to treat or prevent blood clots).

A progress note for Resident 29, dated March 5, 2024, revealed that a pharmacy review was done and recommendations were made. However, there was no documented evidence that the pharmacy recommendations were obtained for physician review.

Interview with the Director of Nursing on June 5, 2024, at 1:34 p.m. confirmed that the pharmacy recommendations for Resident 29 on March 5, 2024, were not obtained for physician review and they should have been.

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


 Plan of Correction - To be completed: 07/16/2024

Resident 3 assessed with no ill effects and/or no noted concerns with not having her March 5, 2024 pharmacy recommendation addressed timely by her physician.

Resident 3's pharmacy review sheet recommendation, dated March 5, 2024, was reviewed and addressed by her physician and the review sheet has been filed in her clinical record.

Resident 11 assessed with no ill effects and/or no noted concerns with not having his March 5, 2024 pharmacy recommendation addressed timely by his physician.

Resident 11's pharmacy review sheet recommendation, dated March 5, 2024, was reviewed and addressed by his physician and the review sheet has been filed in his clinical record.

Resident 35 assessed with no ill effects and/or no noted concerns with not having her March 5, 2024; April 12, 2024 and May 13, 2024 pharmacy recommendations addressed timely by her physician.

Resident 35's pharmacy review sheet recommendations, dated March 5, 2024; April 12, 2024 and May 13, 2024 were reviewed and addressed by her physician and the review sheets have been filed in her clinical record.

Resident 36 assessed with no ill effects and/or no noted concerns with not having his March 5, 2024 pharmacy recommendations addressed timely by his physician.

Resident 36's pharmacy review sheet recommendations, dated March 5, 2024, were reviewed and addressed by his physician and the review sheet has been filed in his clinical record.

Resident 10 assessed with no ill effects and/or no noted concerns with not having her February 19, 2024 pharmacy recommendations addressed timely by her physician.

Resident 10's pharmacy review sheet recommendations, dated February 19, 2024, were reviewed and addressed by her physician and the review sheet has been filed in her clinical record.

Resident 29 assessed with no ill effects and/or no noted concerns with not having her March 5, 2024 pharmacy recommendations addressed timely by her physician.

Resident 29's pharmacy review sheet recommendations, dated March 5, 2024, were reviewed and addressed by her physician and the review sheet has been filed in her clinical record.

Any resident receiving medications has the ability to be affected by this alleged deficient practice.

Current pharmacy recommendations were audited to ensure physician reviewed and accepted or declined recommendations within thirty days of recommendation ensuring timely responses to pharmacy consultant reports and review sheets have been filed in resident clinical records.

Licensed nursing staff, including agency licensed staff, were re-educated on addressing pharmacy consultant reports timely.

Director of Nursing has arranged to verify the number of residents with pharmacy recommendations and the number of residents without pharmacy recommendations with the consulting pharmacist monthly after receiving the pharmacy consultant reports electronically and has created a routine monthly audit to verify current pharmacy consultant report recommendations have been addressed timely within the preceding thirty days.

The Director of Nursing/Designee will audit residents with pharmacy consultant reports to ensure recommendations were addressed timely and filed in resident clinical record monthly times four months until resolved.

Findings from audits will be reviewed by the Quality Assurance Performance Improvement Committee for recommendations and/or resolution at its regularly scheduled meetings times four months for results, areas of improvement and/or continuation of audits.


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 review of 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 four of 27 residents reviewed (Residents 2, 11, 29, 34).

Findings include:

The facility's policy regarding medication administration, dated May 6, 2024, revealed that all medications were ordered, acquired, and administered in accordance with Pennsylvania State Regulations as governed by the Centers of Medicare and Medicaid Services, and in accordance with all policies and procedures of the facility. If a medication was to be administered at a specific time, the specific time may be based upon resident's choice.

A significant change Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 2, dated May 7, 2024, revealed that the resident was understood and could understand others, had complaints of pain rated as a 5 out of 10 on a pain scale, and was receiving controlled pain medication. A care plan, dated November 1, 2023, revealed that Resident 2 had pain related to rhabdomyolysis (muscle injury where muscles break down).

Physician's orders for Resident 2, dated February 29, 2024, included an order for the resident to receive 5 milligrams (mg) of Oxycodone (an opioid pain medication) immediate release every eight hours as needed for moderate to severe pain for a pain scale rating of 6 to 10 for 14 days. Physician's orders for Resident 2, dated March 15, 2024, included an order for the resident to receive 5 mg of Oxycodone immediate release every eight hours as needed for pain. Physician's orders for Resident 2, dated March 29, 2024, included an order for the resident to receive 5 mg of Oxycodone immediate release every six hours as needed for chronic pain.

Review of the controlled drug record (a form that accounts for each tablet/pill/dose of a controlled drug) for Resident 2 for March 2024 through June 2024 indicated that a dose of Oxycodone was signed out on March 3, 2024, at 10:19 a.m.; March 28, 2024, at 3:35 p.m.; April 1, 2024, at 6:30 a.m.; April 15, 2024, at 6:30 a.m.; April 29, 2024, at 6:30 a.m.; May 1, 2024, at 6:30 a.m.; May 9, 2024, at 6:30 a.m.; May 29, 2024, at 6:30 a.m.; and June 2, 2024, at 6:30 a.m.

However, a review of Resident 2's MAR and nursing notes revealed no documented evidence that the signed-out doses of Oxycodone were administered to the resident on the above stated dates and times.

Interview with the Director of Nursing on June 5, 2024, at 10:15 a.m. confirmed that there was no documented evidence in Resident 2's clinical records to indicate that the signed-out doses of Oxycodone were administered to the resident on the above stated dates and times.

A quarterly MDS assessment for Resident 11, dated May 2, 2024, revealed that the resident was understood and could understand others, had complaints of pain rated a 7 out of 10 on a pain scale, and was receiving controlled pain medication.

Current physician's orders for Resident 11 included an order for the resident to receive 5-325 milligrams (mg) of Hydrocodone-acetaminophen (an opioid pain medication) every four hours as needed for a pain scale of 4 to 10.

Review of the controlled drug record for Resident 11 for March and May 2024 indicated that a dose of Hydrocodone-acetaminophen was signed out on March 8, 2024, at 1:00 a.m. and on May 14, 2024, at 9:40 a.m.

However, a review of Resident 11's MAR and nursing notes revealed no documented evidence that the signed-out doses of Hydrocodone-acetaminophen were administered to the resident on the above stated dates and times.

Interview with the Director of Nursing on June 5, 2024, at 10:15 a.m. confirmed that there was no documented evidence in Resident 11's clinical records to indicate that the signed-out doses of Hydrocodone-acetaminophen were administered to the resident on the above stated dates and times.

A quarterly MDS assessment for Resident 29, dated April 25, 2024, revealed that the resident was understood and could understand others, had complaints of pain rated a 7 out of 10 on a pain scale, and was receiving controlled pain medication.

Physician's orders for Resident 29, dated January 21, 2024, included an order for the resident to receive 50 mg of Tramadol (an opioid pain medication) every eight hours as needed for moderate to severe pain.

Review of the controlled drug record for Resident 29 for March and June 2024 indicated that a dose of Tramadol was signed out on March 17, 2024, at 11:27 a.m. and on June 3, 2024, at 12:05 a.m.

However, a review of Resident 29's MAR and nursing notes revealed no documented evidence that the signed-out doses of Tramadol were administered to the resident on the above stated dates and times.

Interview with the Director of Nursing on June 5, 2024, at 3:55 p.m. confirmed that there was no documented evidence in Resident 29's clinical records to indicate that the signed-out doses of Tramadol were administered to the resident on the above stated dates and times.

A quarterly MDS assessment for Resident 34, dated February 5, 2024, revealed that the resident was understood and could understand others, was cognitively impaired, had complaints of pain rated as an 8 out of 10 on a pain scale, and was receiving controlled pain medication.

Physician's order for Resident 34, dated February 28, 2024, included an order for the resident to receive 50 milligrams (mg) of Tramadol every six hours as needed for moderate to severe pain for a pain scale rating of 4 to 10.

Review of the controlled drug record (a form that accounts for each tablet/pill/dose of a controlled drug) for Resident 34 for March 2024 through June 2024 indicated that a dose of Tramadol was signed out on March 4, 2024, at 7:30 p.m.; March 15, 2024, at 9:00 p.m.; March 17, 2024, at 9:00 p.m.; and May 28 ,2024, at 9:00 p.m.

Review of Resident 34's MAR and nursing notes revealed no documented evidence that the signed-out doses of Tramadol were administered to the resident on the above stated dates and times.

Interview with the Director of Nursing on June 5, 2024, at 10:15 a.m. confirmed that there was no documented evidence in Resident 34's clinical records to indicate that the signed-out doses of Tramadol were administered to the resident on the above stated dates and times.

28 Pa. Code 211.9(a)(h) Pharmacy Services.

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



 Plan of Correction - To be completed: 07/16/2024

Resident 2 assessed with no noted concerns with her pain and/or her pain medications.

Licensed Nursing Staff documented late entries on Resident 2's Medication Administration Records to correct missing documentation of Oxycodone immediate release that was administered to Resident 2 on March 3, 2024 at 10:19 a.m.; March 28, 2024 at 3:35 p.m.; April 1, 2024 at 6:30 a.m.; April 15, 2024 at 6:30 a.m.; April 29, 2024, at 6:30 a.m.; May 1, 2024 at 6:30 a.m.; May 9, 2024 at 6:30 a.m.; May 29, 2024 at 6:30 a.m. and June 2, 2024 at 6:30 a.m. as per her physician orders and as per her entries on her controlled drug records.

Resident 11 assessed with no noted concerns with his pain and/or his pain medications.

Licensed Nursing Staff documented late entries on Resident 11's Medication Administration Records to correct missing documentation of Hydrocodone-acetaminophen that was administered to Resident 11 on March 8, 2024 at 1:00 a.m. and on May 14, 2024 at 9:40 a.m. as per his physician orders and as per his entries on his controlled drug records.

Resident 29 assessed with no noted concerns with her pain and/or her pain medications.

Licensed Nursing Staff documented late entries on Resident 29's Medication Administration Records to correct missing documentation of Tramadol that was administered to Resident 29 on March 17, 2024 at 11:27 a.m. and on June 3, 2024 at 12:05 a.m. as per her physician orders and as per her entries on her controlled drug records.

Resident 34 assessed with no noted concerns with his pain and/or his pain medications.

Licensed Nursing Staff documented late entries on Resident 34's Medication Administration Records to correct missing documentation of Tramadol that was administered to Resident 34 on March 4, 2024 at 7:30 p.m.; March 15, 2024 at 9:00 p.m.; March 17, 2024 at 9:00 p.m. and May 28, 2024 at 9:00 p.m. as per his physician orders and as per his entries on his controlled drug records.

Any resident having a physician order to receive a controlled pain medication has the ability to be affected by this alleged deficient practice.

Facility audit completed to ensure Medication Administration Records of residents who recently received Oxycodone has recorded documentation of medication administration of his/her controlled medication and matches documentation of his/her controlled medication on resident's controlled drug record.

Facility audit completed to ensure Medication Administration Records of residents who recently received hydrocodone-acetaminophen has recorded documentation of medication administration of his/her controlled medication and matches documentation of his/her controlled medication on resident's controlled drug record.

Facility audit completed to ensure Medication Administration Records of residents who recently received Tramadol has recorded documentation of medication administration of his/her controlled medication and matches documentation of his/her controlled medication on resident's controlled drug record.

Licensed nursing staff, including agency licensed staff, were re-educated on maintaining accountability for controlled medications, including the importance of providing routine and emergency drugs to residents with accurate documentation of controlled medication administration on both medication administration records and controlled drug records ensuring an accurate reconciliation of controlled medications.

Director of Nursing created a new facility process of Medication Administration Error and Medication Administration Documentation Education and Discipline Process to include routine weekly reviews of medication administration and documentation on medication administration records and controlled drug records to identify needs for education and disciplines to licensed nurses.


Director of Nursing/Designee will complete random audits of residents receiving controlled pain medications including Oxycodone, Hydrocodone-acetaminophen and Tramadol to ensure accurate documentation of administered controlled pain medications on both medication administration records and corresponding controlled drug records by licensed nurses weekly times eight weeks then monthly times four months until noted substantial compliance. Director of Nursing will conduct a thorough investigation of audit findings of noted discrepancies between resident medication administration records and controlled drug records to rule out any resident misappropriation and ensure medication accountability.


Findings from audits will be reviewed by the Quality Assurance Performance Improvement Committee for recommendations and/or resolution at its regularly scheduled meetings times six months for results, areas of improvement and/or continuation of audits.


483.10(e)(3) REQUIREMENT Reasonable Accommodations Needs/Preferences: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(e)(3) The right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents.
Observations:


Based on clinical record reviews, observations, and staff interviews, it was determined that the facility failed to provide reasonable accommodation of a resident's needs by failing to ensure that the call bell was within reach for one of 27 residents reviewed (Resident 35).

Findings include:

A Quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 35, dated March 8, 2024, indicated that the resident was sometimes understood and could sometimes understand, was cognitively impaired, and required maximum assistance for transfers and toileting. The resident's current care plan indicated that the resident had decreased mobility and that staff were to ensure the call bell was within reach, and the resident was to have her bed and chair alarms on and operational while she was in her bed or chair.

Observations of Resident 35 on June 3, 2024, at 10:31 a.m. revealed that the resident was lying in bed, and the call bell was in her nightstand drawer with the drawer closed and was not within her reach. The resident's bed alarm was unplugged at this time.

Interview with Licensed Practical Nurse (LPN) 1 at that time revealed that Resident 35 could use her call bell and that it should have been placed within her reach. LPN 1 also indicated that the resident was to have a bed alarm while in bed and that it currently was not plugged in and functioning as it should have been.

Interview with Director of Nursing on June 6, 2024, at 9:01 a.m. confirmed that the bed alarm should have been plugged in and functioning and the call bell should have been within reach.

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




 Plan of Correction - To be completed: 07/16/2024

Resident 35's call bell was immediately placed within her reach.

Resident 35's bed alarm was immediately plugged back in and confirmed to be functioning.

Immediate education was provided to Licensed Practical Nurse 1 by the Director of Nursing regarding the importance of ensuring resident call bells are within reach and resident bed alarms are plugged in and functioning.

Any resident who utilizes a call bell has the ability to be affected by this alleged deficient practice.

A whole house audit on residents who utilize call bells was completed to ensure his/her call bell was within reach and available for use.

Any resident who has a bed alarm has the ability to be affected by this alleged deficient practice.

A whole house audit on residents who have bed alarms was completed to ensure his/her bed alarm was plugged in and functioning.

Direct care staff, including agency direct care staff, were re-educated on the importance of ensuring call bells are within resident reach and available for use and the importance of ensuring resident bed alarms are plugged in and functioning.

The Director of Nursing/designee will randomly audit placement and availability of call bells weekly times four weeks and then monthly times two months and then reviewed by the Quality Assurance Performance Improvement Committee for results, areas of improvement and/or continuation of audits.

Results of these audits will be reviewed in Quality Assurance and Performance Improvement times three months or until substantial compliance is noted.

The Director of Nursing/designee will randomly audit bed alarms and their operational status weekly times four weeks and then monthly times two months and then reviewed by the Quality Assurance Performance Improvement Committee for results, areas of improvement and/or continuation of audits.

Results of these audits will be reviewed in Quality Assurance and Performance Improvement times three months or until substantial compliance is noted.


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 maintain advance directives as part of the clinical record for one of 27 residents reviewed (Resident 29).

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 May 6, 2024, indicated that upon admission residents and/or their responsible party are asked if an advanced directive or living will exists. If an advanced directive or living will exists, it is reviewed and placed in the resident's chart. If an advanced directive or living does not exist, the resident and/or their responsible party are asked if they wish to complete one. Advanced directives are reviewed with the residents as needed by social worker and acknowledgment forms are filed in the resident's medical record.

A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 29, dated April 25, 2024, revealed that the resident was cognitively impaired, required assistance with care needs, and had diagnoses that included cerebral infarction (lack of blood supply to the brain resulting in brain death to parts of the brain) and depression (a mood disorder).

There was no documented evidence that advance directives were addressed with Resident 29 and maintained as part of her clinical record.

Interview with the Director of Nursing on June 5, 2024, at 1:00 p.m. confirmed the there was no documented evidence that advance directives were addressed with Resident 29 and maintained as part of her clinical record.

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




 Plan of Correction - To be completed: 07/16/2024

Social Worker met with Resident 29's representative to discuss advance directives. Advance Directives Acknowledgement of Explanation Form has been completed and placed in Resident 29's medical record.

Any resident admitted to the facility has the ability to be affected by this alleged deficient practice.

A whole house audit was completed to discuss/address residents' health care wishes including advance directives and complete a facility Advance Directives Acknowledgement of Explanation Form.

Nursing Home Administrator re-educated Social Worker on the facility Advance Directives Policy and the facility Advance Directives Acknowledgement of Explanation Form.

Social Worker was also educated on the importance of determining upon admission whether the resident has an advance directive and, if not, determining whether the resident wishes to formulate an advance directive and to provide information in a manner easily understood by the resident or resident's representative about the right to refuse medical or surgical treatment and formulate an advanced directive. If the resident or the resident's representative has executed one or more advance directive(s), or executes one upon admission, the Social Worker will obtain copies of these documents and place them in the resident's medical record. Social Worker will complete an Advance Directives Acknowledgement of Explanation Form upon admission and place the form in the resident's medical record.

Social Worker educated on the importance of periodically re-assessing the resident for decision-making capacity and/or the need to invoke a healthcare agent or representative if the resident is determined not to have decision-making capacity and/or the need to identify the primary decision-maker.

Social Worker educated on the importance of reviewing existing health care wishes and whether the resident wishes to change or continue these instructions at routine care plan conference meetings and with care plan reviews and document and communicate the resident's choices to the interdisciplinary team and to the staff responsible for the resident's care, including direct care staff and physician.

Nursing Home Administrator/designee will randomly audit advance directives of residents weekly times four weeks and then monthly times three months and then reviewed by the Quality Assurance Performance Improvement Committee for results, areas of improvement and/or continuation of audits.

Results of these audits will be reviewed in Quality Assurance and Performance Improvement times four months or until substantial compliance is noted.


483.12(b)(1)-(5)(ii)(iii) REQUIREMENT Develop/Implement Abuse/Neglect Policies:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
§483.12(b) The facility must develop and implement written policies and procedures that:

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

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

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

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

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

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

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


Based on review of policies and personnel files, as well as staff interviews, it was determined that the facility failed to ensure that the status of nursing licenses was checked with the State Board of Nursing for one of two nurses reviewed (Licensed Practical Nurse 2) and failed to complete a Nurse Aide Registry verification for one of three nurse aides reviewed (Nurse Aide 3).

Findings include:

The facility's policy regarding abuse, neglect or mistreatment, dated May 6, 2024, indicated that potential employees must pass the pre-employment screening process to be hired at the facility. Potential employees must pass a criminal background check inquiring for a history of abuse, neglect, or mistreatment of residents as defined by the requirements of federal regulations. This search includes attempting to obtain information from previous employers and/or current employers, and checking with the appropriate licensing boards and registries.

The personnel file for Licensed Practical Nurse 2 revealed a start date of February 10, 2019. However, there was no documented evidence until July 12, 2019, that her license was verified with the state board prior to her working.

The personnel file for Nurse Aide 3 revealed a start date of March 26, 2024. However, there was no documented evidence that the nurse aide's standing on the Pennsylvania Nurse Aide Registry was verified.

Interview with the Human Resources Director on June 5, 2024, at 10:40 a.m. confirmed that Licensed Practical Nures 2's start date was February 10, 2019, and her license was not verified with the State Board of Nursing until July 12, 2019. She also confirmed that Nurse Aide 3 had a start date of March 26, 2024, and did not have a registry verification completed prior to her start date.

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

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




 Plan of Correction - To be completed: 07/16/2024

Nurse Aide Registry verification completed and placed into Nurse Aide 3 personnel file.

Any resident admitted to the facility has the ability to be affected by this alleged deficient practice.

A whole house audit of nurse aide registry verifications was completed to ensure a certified nurse aide registry verification was present in each nurse aide employee personnel file.

A whole house audit of licensed nurse verifications was completed to ensure a State Board of Nursing License Verification was present in each licensed nurse employee file.

Human Resources Director was re-educated on the importance of ensuring that the status of nursing licenses and the status of certified nurse aides are verified via checking with the State Board of Nursing and/or the Nurse Aide Registry and are completed for potential employees to be eligible to pass the pre-employment screening process prior to being hired at the facility.

Human Resources Director also re-educated on the importance of ensuring potential employees pass a criminal background check and the importance of the need to attempt to obtain information from previous employers and/or current employers to inquire for a history of abuse, neglect or mistreatment of residents as defined by the requirements of federal regulations.

Nursing Home Administrator/designee will audit random employee personnel files weekly times six weeks and then monthly times four months and then reviewed by the Quality Assurance Performance Improvement Committee for results, areas of improvement and/or continuation of audits.

Results of these audits will be reviewed in Quality Assurance and Performance Improvement times six months or until substantial compliance is noted.


483.21(b)(2)(i)-(iii) REQUIREMENT Care Plan Timing and Revision: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.
§483.21(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 a resident's care plan was updated/revised to reflect the resident's specific care needs for three of 27 residents reviewed (Residents 13, 29, 43).

Findings include:

A quarterly Minimum Data Set (MDS) (assessment of a resident's abilities and care needs) for Resident 13, dated May 14, 2024 revealed that the resident was able to make herself understood and understood others, was moderately cognitively impaired, required assistance from staff for personal care needs, and had a mechanically altered therapeutic diet. A care plan for Resident 13, dated June 21, 2022, revealed that she had an impaired nutritional status and required a mechanically altered therapeutic diet with thickened liquids that was to be provided as ordered.

Physician's orders for Resident 13, dated May 9, 2024, included orders for the resident tor receive a carbohydrate controlled, mechanically soft textured diet, with thin consistency liquids, and may have salads per speech therapy.

A nutrition note for Resident 13, dated May 15, 2024, indicated that the previous diet of mechanical soft with nectar thick liquids was changed to thin liquids on May 9, 2024.

Interview with The Director of Nursing on June 5, 2024, at 1:45 p.m. confirmed that Resident 13's care plan should have been revised to reflect the current diet orders of May 9, 2024.

A quarterly MDS assessment for Resident 29, dated April 25, 2024, revealed that the resident was understood and could 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), and had a diagnosis of neuromuscular dysfunction of the bladder (bladder lacks control due to nerve or muscle problems).

A physician's order for Resident 29, dated March 22, 2024, indicated that the resident was ordered an 18 French (size of catheter), 5-15 milliliter (ml) balloon (size of balloon used to secure in place once inserted) Foley catheter. A care plan for Resident 29, dated January 16, 2024, indicated that the resident had a 16 French, 10 ml balloon Foley catheter.

Observations of Resident 29 on June 5, 2024, at 2:22 p.m. revealed that the resident had an 18 French, 5-15 ml balloon foley catheter in place.

Interview with The Director of Nursing on June 5, 2024, at 3:55 p.m. revealed that Resident 29's care plan should have been revised to reflect the correct size of Foley catheter ordered and it was not.

A baseline care plan for Resident 43, dated May 15, 2024, revealed that the resident was receiving antibiotics through a Peripherally Inserted Central Catheter or PICC line (type of long tube that is inserted through a vein, often in the arm, into a larger vein in the body, used when intravenous treatment is required over a long period).

Physician's orders for Resident 43, dated May 17, 2024, included an order that the PICC line was discontinued and able to be removed.

Observations of Resident 43 on June 3, 2024, at 12:22 p.m. revealed that the resident no longer had a PICC line in place and was no longer receiving antibiotics.

Interview with Resident 43 on June 3, 2024, at 12:25 p.m. revealed that the resident stopped receiving antibiotics and had the PICC line removed two days after being admitted to the nursing facility,

Interview with The Director of Nursing on June 4, 2024, at 3:39 p.m. revealed that Resident 43's care plan should have been revised to reflect that the resident was no longer receiving antibiotics and had the PICC line removed.

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

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



 Plan of Correction - To be completed: 07/16/2024

Resident 13's care plan was revised to reflect her current diet orders.

Resident 29's care plan was revised to reflect her correct size of Foley catheter matching her physician's order.

Resident 43 no longer resides in the facility.

Any resident who is ordered a mechanically altered therapeutic diet has the ability to be affected by this alleged deficient practice.

A whole house audit of residents receiving a mechanically altered therapeutic diet was completed to ensure his/her care plan has been revised to reflect current diet order.
Any resident who has a Foley catheter has the ability to be affected by this alleged deficient practice.

A whole house audit of residents who have a Foley catheter was completed to ensure his/her care plan has the correct Foley catheter size included in the care plan.
Any resident who receives antibiotics and/or has a peripherally inserted central catheter line has the ability to be affected by this alleged deficient practice.

A whole house audit of residents who recently received antibiotics and completed a course of antibiotic regimen was completed to ensure his/her care plan has been updated to include no longer receiving antibiotics.
A whole house audit of residents who recently had his/her peripherally inserted central catheter line removed was completed to ensure his/her care plan has been updated to include the removal of the peripherally inserted central catheter.

Licensed nursing staff, including agency licensed nursing staff, re-educated on the importance of updating/revising resident care plans to reflect resident specific care needs including residents who receive a mechanically altered therapeutic diet and/or diet order changes, residents who have a Foley catheter including Foley catheter size, residents who no longer receive antibiotics due to discontinuation or completion of antibiotics and/or residents who have recently had a removal of his/her peripherally inserted central catheter line.

Licensed Practical Nurse Assessment Coordinator will routinely review order summary reports to ensure resident care plans are updated/revised with changes, new orders and/or discontinued orders that reflect a change to resident's current plan of care.

Interdisciplinary Care Plan Team will continue to review care plans upon resident admissions, at regularly scheduled care plan conferences and as needed to ensure individualized, person-centered care needs are included and up to date in resident care plans.

The Director of Nursing/designee will audit care plans for residents who receive a mechanically altered therapeutic diet to ensure care plan reflects current diet orders weekly times eight weeks and then monthly times three months and then reviewed by the Quality Assurance Performance Improvement Committee for results, areas of improvement and/or continuation of audits.

Results of these audits will be reviewed in Quality Assurance and Performance Improvement times five months or until substantial compliance is noted.

The Director of Nursing/designee will audit care plans for residents who have a Foley catheter weekly times eight weeks and then monthly times three months and then reviewed by the Quality Assurance Performance Improvement Committee for results, areas of improvement and/or continuation of audits.

Results of these audits will be reviewed in Quality Assurance and Performance Improvement times five months or until substantial compliance is noted.

The Director of Nursing/designee will audit care plans for residents who recently have stopped receiving antibiotics and residents who have had his/her peripherally inserted central catheter removed weekly times eight weeks and then monthly times three months and then reviewed by the Quality Assurance Performance Improvement Committee for results, areas of improvement and/or continuation of audits.

Results of these audits will be reviewed in Quality Assurance and Performance Improvement times five months or until substantial compliance is noted.

Licensed Practical Nurse Assessment Coordinator/designee will conduct random audits of resident care plans to ensure that all person-centered care needs are included/updated to reflect the resident current care needs weekly times eight weeks and then monthly times three months and then reviewed by the Quality Assurance Performance Improvement Committee for results, areas of improvement and/or continuation of audits.

Results of these audits will be reviewed in Quality Assurance and Performance Improvement times five months or until substantial compliance is noted.



483.21(b)(3)(i) REQUIREMENT Services Provided Meet Professional Standards: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.
§483.21(b)(3) Comprehensive Care Plans
The services provided or arranged by the facility, as outlined by the comprehensive care plan, must-
(i) Meet professional standards of quality.
Observations:


Based on review of Pennsylvania's Nursing Practice Act, clinical records, and staff interviews, it was determined that the facility failed to ensure that a professional (registered) nurse assessed a resident after a fall for one of 27 residents reviewed (Resident 13).

Findings include:

The Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, 21.11 (a)(1)(2)(4) indicated that the registered nurse was to collect complete and ongoing data to determine nursing care needs, analyze the health status of individuals and compare the data with the norm when determining nursing care needs, and carry out nursing care actions that promote, maintain, and restore the well-being of individuals.

A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 13, dated May 14, 2024, revealed that the resident was able to make herself understood and understood others, was moderately cognitively impaired, and required assistance from staff for personal care needs.

A licensed practical nurse's note for Resident 13, dated February 21, 2024, indicated that the resident was out of bed on the floor between her bed and the wall. Upon entering her room, she was lying on her left side, legs extended in front of her, and her hands reaching in the air.

A fall investigation, dated February 17, 2024, at 9:00 p.m., revealed that a comment was added to the note section of the investigation by a registered nurse stating, "Resident was assessed status post fall and agree with the assessment done by the nurse on duty." The fall investigation was privileged and confidential and was not part of the medical record.

There was no documented evidence in the clinical record that Resident 13 was assessed by a registered nurse following her fall on February 17, 2024.

Interview with the Director of Nursing on June 4, 2024, at 12:58 p.m. confirmed that there was no documented evidence in the clinical record of a registered nurse assessment at the time of Resident 13's fall on February 17, 2024.

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




 Plan of Correction - To be completed: 07/16/2024

Registered Nurse documented late entry in Resident 13's clinical record to document fall assessment that was completed on Resident 13 on February 17, 2024 at 9:00 p.m.

Any resident who has a fall incident has the ability to be affected by this alleged deficient practice.

A whole house audit on registered nurse fall assessments was completed to ensure assessment was completed with each fall incident.

Registered Nurses, including agency Registered Nurses, re-educated on the importance of completing a registered nurse fall assessment in the clinical record with each resident fall incident.

Director of Nursing created a new facility process of daily Supervisor Audits, including audits of Registered Nurse charting/documentation, and educated Registered Nurse Supervisors individually on the new daily audit process and the importance of daily compliance. Daily Supervisor Audits will be signed and submitted to the Director of Nursing daily for review.


The Director of Nursing/designee will audit completion of a registered nurse fall assessment of residents having fall incidents weekly times twelve weeks and then monthly times six months and then reviewed by the Quality Assurance Performance Improvement Committee for results, areas of improvement and/or continuation of audits.

Results of these audits will be reviewed in Quality Assurance and Performance Improvement times nine months or until substantial compliance is noted.


483.25(b)(1)(i)(ii) REQUIREMENT Treatment/Svcs to Prevent/Heal Pressure Ulcer: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(b) Skin Integrity
§483.25(b)(1) Pressure ulcers.
Based on the comprehensive assessment of a resident, the facility must ensure that-
(i) A resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable; and
(ii) A resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing.
Observations:


Based on review facility policy and clinical records, as well as staff interviews, it was determined that the facility failed to follow treatment recommendations for one of six residents reviewed (Resident 6).

Findings include:

A facility policy regarding pressure ulcer prevention and management, dated May 6, 2024, revealed that a wound care nurse consult would include assessment and finding, which may include stage, measurements, appearance, and treatment recommendations in the consult report.

A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 6, dated March 27, 2024, indicated that the resident was usually understood and could usually understand others, was dependent on staff for care, and was at risk for a pressure ulcer (skin breakdown caused by prolonged, unrelieved pressure).

Physician's orders for Resident 6, dated May 15, 2024, included an order for the resident to have his right heel cleansed, patted dry, Medihoney (wound ointment) applied, then covered with bordered gauze once daily and as needed for a pressure wound.

A skin and wound note for Resident 6, dated May 30, 2024, at 1:05 p.m. revealed that the resident was seen by the wound consultant, who recommended to change the frequency of the right heel dressing to twice a day and as needed.

As of June 5, 2024, there was no documented evidence that Resident 6's wound care was completed twice a day as recommended by the wound consultant.

Interview with the Director of Nursing on June 5, 2024, at 3:06 p.m. and 3:32 p.m. confirmed that the Registered Nurse Supervisor who completed rounds with the wound consultant did not update the order, and the treatment was not completed twice daily as recommended by the wound consultant and should have been.

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



 Plan of Correction - To be completed: 07/16/2024

Resident 6 assessed with no ill effects and/or noted concerns related to his wound order not being updated nor his wound treatment not being completed twice daily as recommended by the wound consultant.

Immediate one to one re-education was provided to the Registered Nurse Supervisor by the Director of Nursing on the need to review wound consultant recommendations for treatment orders with resident's physician, update the treatment orders as recommended by the wound consultant after approval by resident's physician and treatment completed as recommended by the wound consultant.

Any resident who has a physician order for a wound treatment has the ability to be affected by this alleged deficient practice.

A whole house audit on residents with recent wound consultant recommendations for treatment orders was completed to ensure resident's treatment orders were updated after physician review and approval as recommended by the wound consultant and treatment completed as recommended by the wound consultant.

Licensed nursing staff, including agency licensed staff, re-educated on the need to review wound consultant recommendations for treatment orders with resident's physician and subsequently update the treatment orders as recommended by the wound consultant after approval by resident's physician and ensure wound treatment completed as recommended by the wound consultant.

Director of Nursing created a new facility process of weekly Supervisor Audits, including audits of wound documentation and wound treatment orders, and educated Registered Nurse Supervisors individually on the new weekly audit process and the importance of daily compliance. Weekly Supervisor Audits will be signed and submitted to the Director of Nursing weekly for review.


The Director of Nursing/designee will conduct random audits of wound consultant recommendations for treatment orders to ensure treatment orders were reviewed with the resident's physician, updated as per wound consultant recommendations after physician approval and treatment completed as recommended by the wound consultant weekly times six weeks and then monthly times three months and then reviewed by the Quality Assurance Performance Improvement Committee for results, areas of improvement and/or continuation of audits.

Results of these audits will be reviewed in Quality Assurance and Performance Improvement times five months or until substantial compliance is noted.




483.25(c)(1)-(3) REQUIREMENT Increase/Prevent Decrease in ROM/Mobility: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(c) Mobility.
§483.25(c)(1) The facility must ensure that a resident who enters the facility without limited range of motion does not experience reduction in range of motion unless the resident's clinical condition demonstrates that a reduction in range of motion is unavoidable; and

§483.25(c)(2) A resident with limited range of motion receives appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion.

§483.25(c)(3) A resident with limited mobility receives appropriate services, equipment, and assistance to maintain or improve mobility with the maximum practicable independence unless a reduction in mobility is demonstrably unavoidable.
Observations:


Based on review of clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that contracture management services were provided as care planned for one of 27 residents reviewed (Resident 25).

Findings include:

A Quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 25, dated March 20, 2024, revealed that the resident was able to make herself understood and was able to understand others, was dependent on staff for her daily care needs, and had diagnoses that included hemiplegia (muscle weakness or partial paralysis on one side of the body).

Occupational Therapy orders for Resident 25, dated January 10, 2024, included an order for the resident to have passive range of motion (when someone physically moves or stretches a part of your body) to all joints in her left hand twice a day. A care plan for Resident 25, dated May 1, 2024, revealed that the resident was on a restorative nursing program for range of motion.

Nursing tasks for Resident 25 included that the resident was to have passive range of motion to all joints in her left hand scheduled twice a day. Documentation for this task revealed that the resident only received passive range of motion one time per day on May 8, 9, 10, 11, 12, 18, 19, 20, 28, 30, and June, 1, 2024.

An interview with Occupational Therapist 4 on June 4, 2024, at 2:59 p.m. revealed that passive range of motion programs for restorative nursing is recommended by therapy. The recommendations are then reviewed by the Director of Nursing, scheduled to be completed twice a day by nursing staff, and added to the care plan by the Licensed Practical Nurse Assessment Coordinator. Recommendations for Resident 25 included passive range of motion twice a day.

Interview with the Director of Nursing on June 6, 2024, at 10:18 a.m. confirmed that there was no documented evidence to confirm that Resident 25 received passive range of motion twice a day per the recommendations and should have.

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



 Plan of Correction - To be completed: 07/16/2024

Resident 25 assessed with no ill effects and/or noted concerns related to her not having passive range of motion to all joints in her left hand twice a day on May 8, 2024; May 9, 2024; May 10, 2024; May 11, 2024; May 12, 2024, May 18, 2024; May 19, 2024; May 20, 2024; May 28, 2024; May 30, 2024 and June 1,
2024.

Resident 25's physician notified of resident not receiving passive range of motion to all joints in her left hand twice a day on May 8, 2024; May 9, 2024; May 10, 2024; May 11, 2024; May 12, 2024, May 18, 2024; May 19, 2024; May 20, 2024; May 28, 2024; May 30, 2024 and June 1,
2024.

Any resident who has a passive range of motion program for restorative nursing recommended by therapy has the ability to be affected by this alleged deficient practice.

A whole house audit on residents with a restorative nursing passive range of motion program was completed to ensure the resident received correct frequency of his/her passive range of motion restorative program as recommended by therapy and was documented correctly in his/her clinical chart.

Direct care staff, including agency direct care staff, were re-educated on the importance of ensuring contracture management services are provided as care planned including the importance of residents receiving the correct frequency of his/her passive range of motion restorative nursing program as recommended by therapy and documentation entered into his/her clinical chart.

Director of Nursing created a new facility process for routine weekly review of resident nursing restorative programs and accompanying documentation. Lead Certified Nurses Aide/Certified Nurse Aide Trainer will conduct routine weekly audits of resident nursing restorative programs, including documentation frequency.


The Director of Nursing/designee will conduct random audits of passive range of motion restorative programs to ensure restorative program is completed and documented as per scheduled frequency recommended by therapy weekly times four weeks and then monthly times two months and then reviewed by the Quality Assurance Performance Improvement Committee for results, areas of improvement and/or continuation of audits.

Results of these audits will be reviewed in Quality Assurance and Performance Improvement times three months or until substantial compliance is noted.


483.45(g)(h)(1)(2) REQUIREMENT Label/Store Drugs and Biologicals: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.
§483.45(g) Labeling of Drugs and Biologicals
Drugs and biologicals used in the facility must be labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable.

§483.45(h) Storage of Drugs and Biologicals

§483.45(h)(1) In accordance with State and Federal laws, the facility must store all drugs and biologicals in locked compartments under proper temperature controls, and permit only authorized personnel to have access to the keys.

§483.45(h)(2) The facility must provide separately locked, permanently affixed compartments for storage of controlled drugs listed in Schedule II of the Comprehensive Drug Abuse Prevention and Control Act of 1976 and other drugs subject to abuse, except when the facility uses single unit package drug distribution systems in which the quantity stored is minimal and a missing dose can be readily detected.
Observations:


Based on observations and staff interviews, it was determined that the facility failed to ensure that medications were properly secured in the medication cart.

Findings include

A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 244, dated May 28, 2024 revealed that the resident understood others and was understood, was cognitively intact, required assistance from staff for personal care needs, and has a diagnosis of gout (a build up of uric acid that causes pain and inflammation).

Observations on June 3, 2024, at 10:49 a.m. revealed that there was a round white pill on the floor of Resident 244's room.

Physician orders for Resident 244, dated May 13, 2024, included an order for the resident to be administered 100 milligrams (mg) of Allopurinol in the morning for gout.

Interview with Licensed Practical Nurse 5 on June 3, 2024, at 10:59 a.m. confirmed the white pill with 349 IJ was identified as Allopurinol (a medication used to treat gout), and Resident 244 was currently prescribed the medication.

Interview with the Director of Nursing on June 3, 2024, at 2:06 p.m. confirmed that the medication should have been labeled and secured, not on the resident's floor.

28 Pa. Code 211.9(a)(1) Pharmacy Services.

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


 Plan of Correction - To be completed: 07/16/2024

Round white pill on the floor of Resident 244's room was immediately removed.

Any resident receiving medications has the ability to be affected by this alleged deficient practice.

A whole house audit was completed to ensure no medication/loose pills were found unlabeled and unsecured on resident floors.

Licensed Nursing Staff, including Agency Licensed Staff, were re-educated on ensuring medications are properly secured in the medication cart.

The Director of Nursing/designee will audit observations of medication carts to ensure medications are labeled and secured and will audit observations of resident rooms to ensure medication/loose pills are not observed on the floor weekly times three weeks and then monthly times two months and then reviewed by the Quality Assurance Performance Improvement Committee for results, areas of improvement and/or continuation of audits.

Results of these audits will be reviewed in Quality Assurance and Performance Improvement times three months or until substantial compliance is noted.


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 facility policy, clinical record reviews, and staff interviews, it was determined that the facility failed to ensure that clinical records were complete and accurately documented for one of 27 residents reviewed (Resident 13).

Findings include:

The facility's policy regarding nursing documentation, dated May 6, 2024, revealed that all documentation confirms that care was provided. Documentation identifies the resident's status, clinical findings and interventions. It is the staff's responsibility in documentation, which acts as proof that care was provided. All documentation was to be done in the electronic record Point Click Care (PCC).

A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 13, dated May 14, 2024, revealed that the resident was able to make herself understood and understood others, was moderately cognitively impaired, and required assistance staff for personal care needs.

A licensed practical nurse's note for Resident 13, dated February 21, 2024, indicated that she was lying on her fall mats on her back, with legs extended in front of her.

A fall investigation, dated February 21, 2024, at 6:45 p.m., revealed that Resident 13 was found sitting on the floor in her room with her alarm sounding. The investigation was privileged and confidential, and not part of the clinical record. The notes section of the investigation revealed that the registered nurse was present during the fall assessment and the resident was able to tolerate passive range of motion to the bilateral lower extremity. The bilateral lower extremities were equal in length, and no internal or external rotation was noted.

There was no documented evidence that a registered nurse assessment was documented in the clinical record.

Interview with the Director of Nursing on June 4, 2024, at 12:58 p.m. confirmed that the resident was assessed by a registered nurse and confirmed that there was no documentation of the assessment in the clinical record.

28 Pa. Code 211.5(f) Clinical Records.



 Plan of Correction - To be completed: 07/16/2024

Registered Nurse documented late entry in Resident 13's clinical record to document fall assessment that was completed on Resident 13 on February 21, 2024 at 6:45 p.m.

Any resident who has a fall incident has the ability to be affected by this alleged deficient practice.

A whole house audit on documentation of registered nurse fall assessments for recent fall incidents was completed to ensure documentation of fall assessment was present in the medical record.

Registered Nurses, including agency Registered Nurses, re-educated on the importance of ensuring clinical records are complete and accurately documented including documenting registered nurse fall assessments in the medical record.

The Director of Nursing/designee will audit documentation of registered nurse fall assessments in the medical records weekly times six weeks and then monthly times four months and then reviewed by the Quality Assurance Performance Improvement Committee for results, areas of improvement and/or continuation of audits.

Results of these audits will be reviewed in Quality Assurance and Performance Improvement times six months or until substantial compliance is noted.


483.75(c)(d)(e)(g)(2)(i)(ii) REQUIREMENT QAPI/QAA Improvement Activities: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.
§483.75(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 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 State Survey and Certification (Department of Health) survey ending June 1, 2023, 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 June 5, 2024, identified repeated deficiencies related to failure to develop resident care plans, failure to provide quality of care, failure to maintain complete and accurate medical records, and failure to maintain a complete and accurate accounting of controlled medications.

The facility's plans of correction for deficiencies regarding developing and implementing comprehensive care plans, cited during the survey ending June 1, 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 F656, revealed that the facility's QAPI committee failed to successfully implement their plan to ensure ongoing compliance with the regulation regarding developing and implementing comprehensive care plans.

The facility's plan of correction for a deficiency regarding quality of care, cited during the survey ending June 1, 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 F684, revealed that the facility's QAPI committee was ineffective in maintaining compliance with the regulation regarding quality of care.

The facility's plan of correction for a deficiency regarding failure to maintain a complete and accurate accounting of controlled medications, cited during the survey ending June 1, 2023, revealed that the facility developed a plan of correction that included completing audits and reporting the results of the audits to the QAPI committee for review. The results of the current survey, cited under F755, revealed that the facility's QAPI committee failed to maintain compliance with the regulation regarding maintaining a complete and accurate accounting of controlled medications.

The facility's plan of correction for a deficiency regarding the accuracy of residents' clinical records, cited during the survey ending June 1, 2023, revealed that the facility developed a plan of correction that included completing audits and reporting the results of the audits to the QAPI committee for review. The results of the current survey, cited under F842, revealed that the facility's QAPI committee failed to maintain compliance with the regulation regarding maintaining accurate clinical records.

Refer to F656, F684, F755, F842

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

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



 Plan of Correction - To be completed: 07/16/2024

Nursing Home Administrator met with the Interdisciplinary Team Facility Directors to review the current outstanding deficiencies and the facility plan to correct these deficiencies to maintain compliance with nursing home regulations.

Current facility residents have the ability to be affected by this alleged deficient practice.

Quality Assurance Performance Improvement Committee Meetings will increase in frequency to monthly to ensure quality care is being delivered to the residents residing at the facility and cited deficiencies including recurring deficiencies are being effectively addressed and corrected.

Nursing Home Administrator re-educated Quality Assurance Performance Improvement Committee members on the importance of facility and interdisciplinary team collaboration to correct cited facility deficiencies and ensure plans of correction improve the delivery of care and services to residents and effectively address recurring deficiencies, including developing and implementing person-centered, comprehensive resident care plans, providing utmost quality of care, maintaining complete and accurate accounts of controlled medications and maintaining accurate resident clinical records.

Interdisciplinary Team Facility Directors will attend weekly meetings held by the Nursing Home Administrator to review progress and compliance of the current plan of correction audit process. Concerns and suggestions will be provided and reviewed as needed upon review of outstanding deficiency audits to ensure that improvements are being made and the facility is moving forward and progressing in its quality care being delivered to the residents residing at the facility. Weekly meetings will continue until facility compliance is established.

Results from audits will be reviewed by the Quality Assurance Performance Improvement Committee for recommendations and/or resolution at monthly meetings times nine months for results, areas of improvement and/or continuation of audits.


483.95(g)(1)-(4) REQUIREMENT Required In-Service Training for Nurse Aides: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.
§483.95(g) Required in-service training for nurse aides.
In-service training must-

§483.95(g)(1) Be sufficient to ensure the continuing competence of nurse aides, but must be no less than 12 hours per year.

§483.95(g)(2) Include dementia management training and resident abuse prevention training.

§483.95(g)(3) Address areas of weakness as determined in nurse aides' performance reviews and facility assessment at § 483.70(e) and may address the special needs of residents as determined by the facility staff.

§483.95(g)(4) For nurse aides providing services to individuals with cognitive impairments, also address the care of the cognitively impaired.
Observations:


Based on review of policies and personnel files, as well as staff interviews, it was determined that based on nurse aides' hire dates, the facility failed to ensure that nurse aides completed at least 12 hours of inservice education for one of five nurse aides reviewed (Nurse Aide 6).

Findings include:

The facility's policy regarding nurse aide inservice training, dated May 6, 2024, indicated that the facility will maintain an ongoing educational program for the development and improvement of skills of the facility's personnel, including at a minimum, annual in-service training. Certified Nursing Assistants are required to complete at a minimum 12 hours total annually.

Nurse aide education records revealed that based on their hire dates Nurse Aide 6 did not have at least 12 hours of education annually as follows:

Nurse Aide 6's hire date was May 18, 2018, and inservice records revealed that she had no annual education completed between May 2022 and May 2024.

Interview with the Human Resources Director on June 5, 2024, at 10:40 a.m. confirmed that Nurse Aide 6 did not have the required 12 hours of annual education based on her hire date.

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

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

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



 Plan of Correction - To be completed: 07/16/2024

Twelve hours of required annual education was completed with Nurse Aide 6 and documented in her employee personnel in-service education record.

Any resident admitted to the facility has the ability to be affected by this alleged deficient practice.

A whole house audit of certified nursing assistant in-service education records was completed to ensure a minimum of twelve hours annual in-service training was completed and present in each certified nursing assistant employee personnel in-service education record.

Nursing Home Administrator re-educated Human Resources Director and Director of Nursing on the importance of ensuring that based on nurse aides' hire dates, the facility must ensure that nurse aides complete at least twelve hours of annual in-service education.

Nursing Home Administrator/designee will randomly audit certified nursing assistant in-service education records weekly times nine weeks and then monthly times two months and then reviewed by the Quality Assurance Performance Improvement Committee for results, areas of improvement and/or continuation of audits.

Results of these audits will be reviewed in Quality Assurance and Performance Improvement times four months or until substantial compliance is noted.






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