Nursing Investigation Results -

Pennsylvania Department of Health
DUNMORE HEALTH CARE CENTER
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

DUNMORE HEALTH CARE CENTER
Inspection Results For:
There are 118 surveys for this facility. Please select a date to view the survey results.

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


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

Initial comments:

Based on a Medicare/Medicaid Recertification, State Licensure, Civil Rights Compliance and Abbreviated Complaint survey completed on January 24, 2020, it was determined that Dunmore Health Care Center was not in compliance with the following requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care and the 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.

Plan of Correction:

483.35(d)(7) REQUIREMENT Nurse Aide Peform Review-12 hr/yr In-Service:

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.

§483.35(d)(7) Regular in-service education.
The facility must complete a performance review of every nurse aide at least once every 12 months, and must provide regular in-service education based on the outcome of these reviews. In-service training must comply with the requirements of §483.95(g).

Observations:

Based on review of facility in-service education records and staff interview, it was determined that the facility failed to complete a performance review at least once every 12 months and provide individualized in-service education accordingly for five out of five sampled nurse aides (Employee 3, 4, 5, 6, and 7).

The findings include:

A review of the training records of nurse aides, Employees 3, 4, 5, 6, and 7, revealed no documented evidence that the facility had completed a performance review of these nurse aides in the last 12 months.

Review of the facility nurse aide training records revealed that nurse aide Employees 3, 4, 5, 6, and 7 were not provided regular in-service education based on the outcome of an annual performance review during the last 12 months of their employment.

The facility was unable to provide documented evidence that the above nurse aide employees had received specific in-service training based on the results of an annual performance review in the last 12 months.

An interview with the Director of Nursing on January 24, 2019, at approximately 10:30 AM, confirmed the facility did not have evidence that Employees 3, 4, 5, 6, and 7 had a performance review completed during the last 12 months.

28 Pa. Code 211.12 (c) Nursing services
Previously cited 10/30/19, 7/31/19, 12/7/18

28 Pa. Code 201.20 (a)(c)(d) Staff Development

Plan of Correction - To be completed: 02/25/2020

Facility cannot retroactively correct missing performance review. For employees 3, 4,5, and 7. Moving forward the facility will complete performance evaluations on certified nurse aides annually. Based on the outcome of the performance review the facility will ensure that CNAs receive specific in-service training.
To identify staff with the potential to be affected Human Resources will complete an audit on current certified nurse aides to determine date performance evaluations are to be completed. Moving forward the facility will complete performance evaluations on certified nurse aides annually. Based on the outcome of the performance review the facility will ensure that CNAs receive specific in-service training.
To prevent this from recurring the Nursing Home Administrator will educate DON and ADON on completion of performance evaluations and mandatory in -service required to meet the requirements for job performance.

483.10(f)(5)(i)-(iv)(6)(7) REQUIREMENT Resident/Family Group and Response:

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.

§483.10(f)(5) The resident has a right to organize and participate in resident groups in the facility.
(i) The facility must provide a resident or family group, if one exists, with private space; and take reasonable steps, with the approval of the group, to make residents and family members aware of upcoming meetings in a timely manner.
(ii) Staff, visitors, or other guests may attend resident group or family group meetings only at the respective group's invitation.
(iii) The facility must provide a designated staff person who is approved by the resident or family group and the facility and who is responsible for providing assistance and responding to written requests that result from group meetings.
(iv) The facility must consider the views of a resident or family group and act promptly upon the grievances and recommendations of such groups concerning issues of resident care and life in the facility.
(A) The facility must be able to demonstrate their response and rationale for such response.
(B) This should not be construed to mean that the facility must implement as recommended every request of the resident or family group.

§483.10(f)(6) The resident has a right to participate in family groups.

§483.10(f)(7) The resident has a right to have family member(s) or other resident representative(s) meet in the facility with the families or resident representative(s) of other residents in the facility.

Observations:

Based on review of select facility policy and minutes from Resident Council meetings and resident and staff interviews it was determined that the facility failed to put forth sufficient efforts to promptly resolve continued resident complaints/grievances expressed during Resident Council Meetings including those voiced by six of six residents attending a group meeting (Residents 17, 43, 41, 66, 37, and 63).

Findings include:

Review of the facility's current Grievance policy indicated that it is the facility's policy to provide an opportunity for residents to express concerns at any time. The facility's goal is to resolve resident and family concerns in a timely basis.

Review of the minutes from the June 6, 2019, through December 19, 2019, Resident Council meetings revealed that residents in attendance at these resident group meetings voiced their concerns regarding resident care and facility services during the meetings.

During the June 6, 2019, Resident Council meeting the residents relayed concerns that snacks and ice water are not consistently offered to them.

During the July 19, 2019, Resident Council meeting the residents relayed concerns that snacks and ice water are not consistently offered to them.

During the July 25, 2019, Resident Council meeting the residents relayed concerns with timeliness of staff response to their requests for assistance via the nurse call bell system.

During the November 19, 2019, Resident Council meeting the residents relayed concerns that ice water is not consistently offered to them.

During a group meeting held on January 22, 2020 at 10:00 a.m., with six (6) alert and oriented residents, all residents in attendance complained that the facility does not consistently offer evening snacks and does not pass fresh ice water consistently. The residents also stated that untimeliness of staff response to their call bells and meeting their needs for assistance in a timely manner remains a problem for them. The residents stated that they have repeatedly brought these particular complaints to the facility's attention without resolution to date.

The facility was unable to provide documented evidence that the facility had determined if the residents' felt that their complaints/grievances had been resolved through any efforts taken by the facility in response to the residents' expressed concerns regarding untimely staff response to call bells and delays in meeting residents' needs for assistance and consistent offering of evening snacks and distributing fresh ice water.

During an interview with the Nursing Home Administrator (NHA) and Director of Nursing (DON) on January 22, 2020, at 2:30 p.m. the NHA and DON were unable to provide documented evidence that the facility had followed-up with the residents' to ascertain the effectiveness of the facility's efforts in resolving their complaints regarding facility services.

28 Pa. Code 201.18(e)(1)(3)(4) Management
Previously cited 12/7/18, 7/31/19

28 Pa. Code 201.29(i)(j) Resident Rights
Previously cited 12/7/18, 7/31/19

Plan of Correction - To be completed: 02/25/2020

Preparation and submission of this POC is required by state and federal law. This POC does not constitute an admission for purposes of general liability, professional malpractice or any other court proceeding.
Residents 17,43,41,37,63 will be interviewed for more detail regarding their concerns. Grievances will be written as needed. Resident 66 was discharged. The facility cannot retroactively correct the lack of evidence of actions taken to respond to the grievances of snacks, water pass, and call bell untimely response. Moving forward, through the grievance procedure the Administrator/designee will provide evidence of actions taken by the facility to respond to the grievances of snacks, water pass and call bell untimely response.
To identify residents with the potential to be affected a Resident Group meeting will be held to note any other grievances. It will be given a good faith effort that any identified concerns will be resolved to resident satisfaction. Resident Group meeting will be held to provide group members the opportunity to formulate a grievance related to snacks, water pass, and call bell response time. Residents who do not regularly attend resident council that have the capability to be interviewed will be interviewed by the IDT to provide them with the opportunity to formulate a grievance related to snacks, water pass, and call bell response time.
To prevent this from recurring the NHA/designee sensitivity training will be completed with staff to explain the right of residents to express grievances without reprisal or discrimination. Re-Education will be completed by the NHA/designee to all department heads rand current staff regarding grievance procedure.
To monitor and maintain ongoing compliance Resident Group meeting will be held 2 times a month as per resident request. The beginning of the meeting will address responses by the facility of last meetings concerns to communicate facility actions to resolve the issue. Resident grievances will be reviewed weekly x4 then monthly x2 for evidence of actions taken for resolution. This will be the responsibility of the Grievance Officer/designee. The IDT will conduct 5 resident interviews weekly with resident who have the capability to be interviewed to provide them with the opportunity to formulate a grievance.
Results of the audit will be brought to QAPI for review and revision as indicated.

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

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

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

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

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

Observations:

Based on review of the facility's written agreement between the facility and the Hospice Care Agencies and staff interview, it was determined the facility failed to ensure coordination of necessary care and services for two of two sampled residents (Residents 70, 47) receiving Hospice services.

Findings include:

Review of the two hospice contracts between the facility and the Hospice agencies providing Hospice care and services to Resident 70 and Resident 47, revealed that there was no evidence that the facility designated a staff person to participate in the ongoing communication between the facility and the Hospice agency.

Interview with the nursing home director of on January 24, 2020, at approximately 9:25 a.m., confirmed that the facility did not note and identify, in their agreements with the Hospice agencies, the member of the facility's interdisciplinary team responsible for working with the hospice representative to coordinate care to the residents.

28 Pa. Code 211.12 (c)(d)(3)(5) Nursing services.
Previously cited 10/30/19

28 Pa. Code 201.21(c) Use of outside resources.

28 Pa. Code 201.18(e)(2)(3) Management.
Previously cited 7/31/19, 12/7/18

Plan of Correction - To be completed: 02/25/2020

The two Hospice contracts were updated to reflect a clinical facility designated representative to facilitate coordination of care for residents receiving hospice services.
To identify areas with the potential to be affected an audit was completed by the Nursing Home Administrator of current Hospice contracts to ensure contracts to ensure contracts reflect a clinical facility designated representative to facilitate the coordination of care for residents receiving hospice services.
To prevent this from recurring the Nursing Home Administrator re-educated Departments heads on the need for contracts to address resident needs.
To monitor and maintain compliance the Nursing Home Administrator will audit 2 hospice contracts monthly x 3 months to ensure contracts reflect a facility designated representative to facilitate the coordination of care for residents receiving hospice services. Immediate corrections will be made on any negative findings.
The results of the audits will be forwarded to the facility QAPI committee for further review and recommendations.

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 clinical record review and resident and staff interview, it was determined that the facility failed to afford residents the right to formulate advance directives (a written instruction such as a living will or durable power of attorney for health care for when the individual is incapacitated) as evidenced by two residents out of 19 residents sampled. (Residents 130 and 277).

Findings include:

A review of the clinical record revealed Resident 277 was admitted to the facility on January 16, 2020, with diagnoses that included a non-displaced fracture of the left hip, peripheral vascular disease and heart disease.

Further review of the clinical record revealed that Resident 277 elected to be a DNR (do not provide Cardio-pulmonary resuscitation, CPR, in event of the resident's breathing or heart stops). Documentation in the resident's clinical record failed to indicate whether the resident had an advance directive upon admission. The resident's clinical record did not include evidence of discussions of the resident's right to formulate an Advance Directive or how to go about formulating an Advanced Directive if the resident wished to do so.

Interview with Resident 277 on January 22, 2020, at approximately 2:00 p.m. revealed that the facility had not discussed his right to formulate an Advance Directive or how to go about formulating one if he wished to do so.

An interview with the Nursing Home Administrator on January 24, 2020, at approximately 2:00 p.m. revealed that the facility was unable to provide evidence that each resident was provided information on the right to formulate an advance directive or how to formulate an advanced directive if they wished to do so.

Resident 130 was admitted to the facility on January 14, 2020 with diagnoses, which included right leg above the knee amputation, diabetes and a colostomy (a piece of the colon is diverted to an artificial opening in the abdominal wall so as to bypass a damaged part of the colon). A review of hospital records from the resident's hospital stay prior to admission to the facility revealed two documents from the hospital; one printed on December 17, 2019, which indicated the resident was a full code and one printed on December 31, 2019, indicating that the resident was to be a DNR

A physician order dated January 14, 2020, was noted for the resident's DNR status. There was no documentation in the clinical record to determine if the resident had been offered the opportunity to formulate an advanced directive, which would ensure her wishes were carried out should she become incapacitated.

An interview with this resident on January 22, 2020, at 10:36 AM revealed that the resident stated that the faciity had not discussed formulating an advanced directive with the resident. The resident stated she would not mind if they did CPR, she just wanted to be sure she was not intubated (insertion of tube into trachea for artificial ventilation).

Following surveyor interview with the resident, the facility's social service staff member went to speak to this resident on January 22, 2020, at 3:57 p.m. and documented that the resident has no living will and would appreciate the facility's help in formulating a living will. It was noted that the resident wishes are that she would like CPR and the use of antibiotics, but does not want to be intubated.

The DON confirmed upon interview on January 23, 2020, at 10:00 a.m. that the facility was unable to provide evidence that each resident was provided information on the right to formulate an advance directive or how to formulate an advanced directive if they wished to do so.

28 Pa. Code 201.18 (b)(1)(2)(3)(e)(1) Management
Previously cited 12/7/18

28 Pa. Code 201.29 (a)(l)(2) Resident rights
Previously cited 7/31/19, 12/7/18

28 Pa. Code 211.5 (f) Clinical records
Previously cited 7/31/19, 12/7/18

Plan of Correction - To be completed: 02/25/2020

Resident # 130 and 277 were educated by Social Services on Advanced Directives and provided the opportunity to devise an advanced directive.
A new process has been implemented outlining the discussion of Advanced Directives. To identify residents with the potential to be affected Social Services/designee will complete an audit on current resident medical records to determine which residents have advanced directive present. Resident who do not have advanced directives present and have the ability to make healthcare choices will be provided education on an advanced directives and given the opportunity to formulate an one if the wish to do so.
To prevent this from recurring the DON/designee provided education to licensed nursing staff, Admissions Director and Social Services on advanced directives and offering residents who do not currently have advanced directives in place including education for residents who have the ability to make healthcare choices.
To monitor and maintain ongoing compliance social services/designee will audit 3 new admissions for presence of advance directives or evidence that the facility provided education on formulation of an advanced directive weekly x4 then monthly. Any negative findings will be immediately corrected.
Results of the audit will be brought to QAPI for review and revision as indicated.

483.10(g)(14)(i)-(iv)(15) REQUIREMENT Notify of Changes (Injury/Decline/Room, etc.):

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

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

Observations:

Based on a review of clinical records and select facility policy and staff and resident interview, it was determined that the facility failed to timely consult with the physician regarding the potential need to alter treatment due to the repeated lack of availability and administration of a medication prescribed for one resident out of 19 reviewed (Resident 63).

Findings Include:

During an interview with Resident 63 on January 22, 2020 at 11:00 a.m. the resident stated that he had not received his blood pressure medicine for the last three days. Resident 63 was unable to recall the name of the medication, however stated "it starts with an E and is 50 mg daily."

Review of Resident 63's clinical record revealed that the resident was admitted to the facility on April 11, 2019, with diagnoses that included bipolar disorder, anxiety, cardiac pacemaker insertion, hypertension and hyperlipidemia.

A quarterly Minimum Data Set assessment (MDS - standardized assessment completed at specific intervals to identify specific resident care needs) dated December 27, 2019, indicated that the resident was cognitively intact.

Review of Resident 63's current physician orders revealed an order for Eplerenone 50 mg (milligram) tablet, one tablet by mouth every day for hypertension.

Review of Resident 63's Medication Administration Record (MAR) dated January 2020, revealed that the medication was unavailable on January 19, 20, and 21, 2020 and the medication was not adminstered to Resident 63 on January 19, 20, and 21, 2020.

Review of Resident 63's clinical record revealed no evidence that the physician was made aware that the medication was not administered to the resident for the last three days.

Employee 1, LPN, was interviewed on January 22, 2020 at approximately 12:30 p.m., and stated that she had taken care of Resident 63 on January 19, 2020, and had called the pharmacy and was told the medication was on backorder. Employee 1 stated that she would call the pharmacy again to find out whereabouts the resident's medication. Employee 1 stated that she did not notify a supervisor or contact the resident's physician.

Review of the facility policy titled "Medication Shortages/Unavailable Medications" last revised by the facility January 10, 2013, revealed that if a medication is unavailable from pharmacy or a third party pharmacy, the faciity should obtain alternate physician/prescriber orders.

During an interview with the Nursing Home Administrator (NHA) and Director of Nursing (DON) on January 22, 2020, at 2:30 PM these staff members confirmed that the medication was not available and not administered for the last three days and the physician had not been consulted regarding potential alternate orders.

28 Pa. Code: 211.12 (a)(d)(1)(3)(5) Nursing services
Previously cited 12/7/18, 7/31/19

Plan of Correction - To be completed: 02/25/2020

1. Resident 63 was immediately assessed. No ill effects noted from missed doses of medication. Physician was notified. Pharmacy was notified. Medication available 1/22/20 for administration. A medication error was completed. Resident and resident representative were notified.
2. To identify residents with the potential to be affected the DON/designee will complete an audit of current resident medications on hand to ensure medications are available for administration. Any negative findings will be immediately corrected.
3. To prevent this from recurring the DON/designee will educate current licensed nursing staff on procedure for medications not available for administration.
4. To monitor and maintain ongoing compliance the DON/designee will audit 5 residents weekly x4 then monthly x2 of 5 to ensure medications are available for administration to residents. Any negative findings will be immediately corrected.
Results of the audits will be brought to QAPI for review and revision as indicated.

483.24(a)(2) REQUIREMENT ADL Care Provided for Dependent Residents:

§483.24(a)(2) A resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene;

Observations:

Based on review of clinical records and facility documentation and staff interviews, it was determined that the facility failed to provide to necessary staff assistance with bathing, for residents dependent on staff for assistance with activities of daily living, to maintain good personal hygiene for one resident out of 19 sampled (Resident 69).

Findings include:

Review of Resident 69's clinical record revealed an admission date of December 23, 2019, with diagnoses that included lymphoma, acute kidney failure, muscle weakness, and depression.

Review of Resident 69's admission Minimum Data Set (MDS - a federally mandated standardized assessment process conducted periodically to plan resident care) dated December 30, 2019, revealed that the resident required assistance of one staff for bathing needs and that it was "very important" for the resident choose between a tub bath, shower, bed bath, or sponge bath.

The facility was unable to provide documentation regarding the resident's bathing/showers for the month of December 2019.

Review of facility documentation of resident bathing for the month of January 2020, until the resident's discharge January 14, 2020, revealed that Resident 69 had not been provided a shower/full tub bath during January 2020. The resident received only bed baths/partial baths.

Further review of Resident 69's clinical record revealed no documentation indicating why the resident was not showered or provided a full tub bath during January 2020.

During an interview on January 27, 2020, at 11:00 a.m. the Nursing Home Administrator confirmed that there was no documented evidence that Resident 69 had been showered/fully bathed during Janaury 2020, or evidence that the resident had chosen to receive only bed baths.

28 Pa. Code 211.12(d)(5) Nursing services
Previously cited 12/7/18, 7/31/19

28 Pa. Code 201.29(j) Resident rights
Previously cited 12/7/18, 7/31/19

Plan of Correction - To be completed: 02/25/2020

1. Resident 69 no longer at facility.
2. To identify residents with the potential to be affected the DON/designee will complete an audit of current residents to ensure that residents have documented evidence of bathing. The IDT will complete interviews with resident who have the capability to be interviewed to ensure that they have been bathed per their preference in the last 14 days.
3. To prevent this from recurring the DON/designee will provide education to current licensed nurses and CNAs on consistent bathing of residents and accurate documentation of same.
4. To monitor and maintain ongoing compliance the IDT will complete interviews with 3 residents who have the capability to be interviewed to ensure that they have been bathed per their preference weekly x4 then monthly x2. The DON/designee will audit 3 resident records weekly to ensure residents have documented evidence of bathing weekly x4 then monthly x2 Any negative findings will be immediately corrected.
Results of the audits will be brought to AQPI for review and revision as indicated.

483.25 REQUIREMENT Quality of Care:

§ 483.25 Quality of care
Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices.

Plan of Correction - To be completed: 02/25/2020

1. Facility cannot retroactively correct issue cited. Moving forward the facility will ensure timely completion and documentation of assessments and monitoring of resident after an incident or accident. Resident 23's care plan was reviewed to ensure all safety devices are in place to decrease the resident's risk for falls
2. To identify residents with the potential to be affected current resident at risk for falls will have care plans reviewed to ensure all safety devices are in place to reduce the residents' risk for falls. Moving forward the facility will ensure timely completion and documentation of assessments and monitoring of resident after an incident or accident.
3. To prevent this from recurring the DON/designee will provide education to current licensed nursing staff on conducting a thorough investigation to include the addition of new safety interventions to decrease the resident's risk for falls. The DON/designee will provide current licensed nursing staff on performing head to toe evaluations timely for pertinent signs and symptoms of possible injury. The DON/design will provide education to current Registered Nurses on their responsibility to assess residents timely for injury after an injury or incident and notify physician as warranted.
4. To monitor and maintain ongoing compliance the DON/designee will audit of 3 incident/accidents involving falls to ensure timely head to toe evaluation completed with follow up by RN assessment and monitoring weekly x4 then monthly x2. The DON/designee will audit 3 incidents/accidents for timely implementation of new interventions to decrease the resident's risk for falls weekly x4 then monthly x2. Any negative findings will be immediately corrected.

Results of the audits will be brought to QAPI for review and revision as indicated.

483.25(b)(1)(i)(ii) REQUIREMENT Treatment/Svcs to Prevent/Heal Pressure Ulcer:

§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 of clinical records and staff interview, it was determined that the facility failed to consistently implement interventions designed to prevent pressure sore development and promote optimal healing for one of five sampled residents (Resident 2) with pressure sores.

Findings include:

A review of the clinical record revealed that Resident 2 had diagnoses, which included anxiety disorder, aphasia (inability to communicate) and dementia (a term used for the disease of the brain that causes long-term and often gradual decrease in the ability to think and remember that is severe enough effecting a persons' ability to dress, eat and bathe).

A review of Resident 2's quarterly MDS Assessment (Minimum Data Set - a federally mandated standardized assessment process completed periodically to plan resident care) dated October 11, 2019, revealed that the resident required extensive assisstance of staff for transfers and bed mobility (moving to and from lying position, turning side to side and positioning body while in bed). The assessment also indicated that the resident was at risk of developing pressure sores.

A review of a "Braden Scale" (a tool used to determine/predict pressure sore development) dated August 14, 2019, revealed that the resident received a score of 12, indicating that the resident was at high risk for pressure sore development.

A review of the resident's care plan initiated on June 8, 2016, and revised in January 2017, and December 2018, revealed that the resident was at risk for/actual skin breakdown related to: decreased mobility, weakness, incontinence, diagnosis of diabetes (elevated blood sugar) and history of groin/breast fold/buttocks redness and excoriation. Interventions planned at the time included biweekly skin checks, Braden score per protocol, incontinence products as required, monitor for skin breakdown, barrier cream to buttocks, pressure relieving cushion and turn and reposition every two hours and as needed.

A review of a nurses's note dated Janaury 4, 2020, at 11:48 a.m. revealed that a nursing aide informed the nurse of an open area on Resident 2's coccyx.

A nurses's note dated Janaury 2, 2020, at 2:44 p.m. (entered as a late entry) revealed that the nurse noted that the open area on the coccyx was an in-house acquired pressure sore measuring 1 cm (length) by 1 cm (width) by 0.1 cm (depth). The wound was described as discoloration surrounding wound with white calloused edges, small serous (thin, watery-like liquid) drainage and wound bed reddened with no odor.

Review of a "Wound Evaluation & Management Summary" dated Janaury 7, 2020, revealed that the resident was seen and treated by the wound physican. At the time, the wound physican recommended the following treatment plan: apply Hydrogel (a type of wound dressing) to wound once a day for 30 days, gauze dressing for 30 days (a dry clean dressing), specialty mattress and skin prep (a liquid-film forming that forms a protective barrier on the skin) for 30 days.

Review of the resident's "Turning Schedule" for the time period prior to the Janaury 4, 2020, when the pressure area was first found, revealed no documentation that the planned intervention to turn and reposition the resident every two hours was performed by staff, as care planned.

Review of the resident's "Treatment Administration Record " (TAR) for the period from January 8, 2020, through Janaury 23, 2020, revealed that the recommendation for skin prep was not implemented. In addition, there were no nursing entries noted during the aforementioned time frame indicating that this intervention was provided as recommended by the wound physician.

During an interview with the director of nursing (DON) on January 24, 2020, at approximately 8:35 a.m. the DON was unable to explain why there was no documentation indicating that staff turned and repositioned the resident as care planned or why the wound physican's recommendation for daily skin prep was not implemented. The DON confirmed that the resident did not receive any skin prep as recommended and that there was lack of documented evidence to demonstrate that the planned intervention to turn and reposition the resident every two hours was completed to prevent and heal pressure sore.

28 Pa. Code 211.12(a)(c)(d)(1)(3)(5) Nursing services.
Previously cited 10/30/19, 7/31/19, 12/7/18

28 Pa. Code 211.5(f) Clinical records.
Previously cited 7/31/19, 12/7/18

Plan of Correction - To be completed: 02/25/2020

1. The facility cannot retroactively correct the missing documentation for Resident 2's "turning schedule". Moving forward the facility will ensure that Resident 2's "turning schedule" has accurate documentation. Resident 2's primary care physician was notified of the wound physician's documentation and a new order was obtained to add skin prep to the resident's current order.
2. To identify residents with the potential to be affected the DON/designee will audit current residents with pressure ulcers to ensure that resident "turning schedule" have accurate documentation. The DON/designee will audit current residents with pressure ulcers who have consults with the wound physician to ensure that primary care physicians were notified of any current recommendations.
3. To prevent this from recurring the DON/designee will provide education to current CNAs on accurate documentation of resident "turning schedule". The DON/designee will provide education to current licensed nursing staff on reviewing wound physician recommendations with the primary care physician.
4. To monitor and maintain ongoing compliance the DON/designee will audit 3 residents with pressure ulcers' "turning schedule" weekly x4 then monthly x2 to ensure accurate documentation. The DON/designee with audit 3 resident records of residents with pressure ulcers who have consults with the wound physician to ensure recommendations are reviewed with the primary MD. Any negative findings will be immediately corrected.
Results of the audits will be brought to QAPI for review and revision as indicated.

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

§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 clinical record reviews and staff and resident interviews, it was determined that the facility failed to provide routine medications prescribed for one resident out of 19 sampled (Resident 63).

Findings include:

Review of Resident 63's clinical record revealed that the resident was admitted to the facility on April 11, 2019, with diagnoses that included bipolar disorder, anxiety, presence of a cardiac pacemaker, hypertension and hyperlipidemia. A quarterly Minimum Data Set assessment (MDS - standardized assessment completed at specific intervals to identify specific resident care needs) dated December 27, 2019, indicated that the resident was cognitively intact.

During an interview with Resident 63 on January 22, 2020, at 11:00 a.m. he stated that he had not received his blood pressure medicine for the last three days. Resident 63 was unable to recall the name of the medication, but said "it starts with an E and is 50 mg daily."

The resident had a current physician order, initially dated July 23, 2019, 50 milligrams (mg) of Eplerenone for high blood pressure once a day.

A review of Resident 63's Medication Administration Records (MAR) for January 2020 revealed that staff did not administer Eplerenone 50 mg to the resident on January 19, 20, or 21, 2020, because the medication was not available.

Interview with the Director of Nursing on January 22, 2020, at 1:00 p.m. confirmed that Resident 63 did not receive Eplerenone as ordered on January 19, 20, or 21, 2020, because it was unavailable.

28 Pa. Code 211.9 (a)(1)(k)Pharmacy services.
Previously cited 12/7/18, 7/31/19, 10/30/19

28 Pa. Code 211.12 (d)(1)(3)(5)Nursing services.
Previously cited 12/7/18, 7/31/19, 10/30/19

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

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

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

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

Observations:

Based on observation and staff and resident interviews it was determined that the facility failed to ensure that food was served at safe temperatures, for one (Resident 129) of 19 residents to prevent the potential for food bourne illness.

Findings include:

A review of the clinical record revealed that Resident 129 had a diagnosis of chronic kidney disease, Stage 4, and received hemodialysis three times weekly (hemodialysis - the use of an artificial kidney in which blood is removed from the body to clear waste products and toxins from the blood and then returned to the body).

Further review of the clinical record revealed that the resident went to dialysis on Tuesdays, Thursdays and Saturdays.

Observation on January 23, 2019, revealed that the resident was getting prepared for dialysis. The resident stated that she takes a lunch with her, which usually consists of a sandwich, juice and crackers. On this date she had a peanut butter and jelly sandwich, cranberry juice and crackers her lunch bag. The lunch bag did not contain a cooling device to the resident's beverage was maintained at a safe temperature. Interview with Resident 129 at that time revealed that the resident stated that she is not always provided an ice pack in her lunch bag.

Interview with the cook on January 23, 2020, revealed that residents who take a lunch to dialysis usually receive one of the following sandwiches: tuna salad, egg salad, peanut butter an jelly sandwiches an a soda or juice.

Interview with the dietary manager confirmed an ice pack was not present in this resident's lunch bag when observed on January 23, 2020, to maintain the safety and palatability of the foods and/or beverages served.

28 Pa. Code 211.6 (d)(f) Dietary services

Plan of Correction - To be completed: 02/25/2020

An ice pack was immediately placed in resident 129's lunch prior to going to dialysis.
To identify residents with the potential to be affected an audit will be completed by the Dietary Manager to identify residents who will require facility meals for dialysis. A supply of ice packs will be purchased for residents taking meals out to dialysis.
To prevent this from recurring the facility implemented a check sheet to be completed by the cook and signed off by the clinical staff to comply with safe food temperatures for food going out with the resident to dialysis. The Dietary manager will provide education to current dietary staff regarding maintaining proper food temperatures for meals going out of the facility with residents to dialysis. The Dietary Manager will provide education to current cooks and current licensed nursing staff on the new check sheet implemented.
The Dietary Manager will complete audits on one resident who requires facility meals when attending dialysis weekly x4 weeks then monthly x 2 months to ensure check sheets are completed and reflect compliance with ice packs in resident meals going out of the facility for dialysis. Any negative findings will be immediately corrected.
The results of the audits will be forwarded to the facility QAPI committee for further review and recommendations.

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

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

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

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

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

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

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

Observations:

Based on clinical record review and staff interview, it was determined that the facility failed to
to maintain complete and accurate records in accordance with accepted professional standards for one of 19 sampled residents (Resident 38).

Findings include:

The Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, 21.145 Functions of the Licensed Practical Nurse (LPN) (a) The LPN is prepared to function as a member of the health-care team by exercising sound judgement based on preparation, knowledge, skills, understandings and past experiences in nursing situations. The LPN participates in the planning, implementation and evaluation of nursing care in settings where nursing takes place. 21.148 Standards of nursing conduct (a) A licensed practical nurse shall: (5) Document and maintain accurate records.

A review of the clinical record revealed that Resident 10 was admitted to the facility with diagnoses that included anxiety, atherosclerotic cardiovascular disease (hardening and thickening of the walls of the arteries) and hypertension (elevated blood pressure).

Physician's orders dated March 25, 2019, called for staff to administer the medication metoprolol tartrate (a medication used to treat hypertension) 25 milligrams (mg) once a day and to hold the medication when the resident's systolic blood pressure is less than 100 mmHg (millimeters of mercury) or when the heart rate is less than 60 beats per minute. [Systolic blood pressure (SBP) - occurs when the heart is contracting causing maximum arterial pressure during contraction of the left ventricle of the heart and the systolic blood pressure, for example, is the first number recorded as 120/80 mmHg (the SBP is the 120 mmHg).

A review of the resident's medication administration record (MAR) for the month of Janaury 2020, revealed that nursing staff documented the resident's daily blood pressure readings, but failed to consistently document the resident's heart rate on Janaury 9, 10, 11, 12, 13, 14, 20, 21 and 22, 2020.

Interview with the director of nursing on Janaury 24, 2020, at approximately 9:26 a.m. confirmed that the nursing documentation failed to reflect that nursing staff had consistently documented the resident's heart rate on the Janaury 2020 MAR.

28 Pa. Code 211.12 (a)(c)(d)(1)(3)(5) Nursing services.
Previously cited 10/30/19, 7/31/19, 12/7/18

28 Pa. Code 211.15(f) Clinical records.
Previously cited 7/31/19,

Plan of Correction - To be completed: 02/25/2020

1. Resident 38's heart rate was immediately assessed. No ill effects noted from receiving medications with documentation of heart rate prior to administration. Physician was notified with no new orders. A medication error was completed. Resident representative were notified.
2. To identify residents with the potential to be affected the DON/designee will complete an audit of residents with orders for BP parameters to ensure appropriate documentation noted prior to administration of BP medication. Any negative findings will be immediately addressed.
3. To prevent this from recurring the DON/designee will educate current licensed nursing staff on following physician orders for BP medications with parameters and documentation prior to administration of BP medication.
4. To monitor and maintain ongoing compliance the DON/designee will audits 5 residents with BP mediation orders with parameters to ensure proper documentation of HR prior to administration of medication weekly x4 then monthly x2. Any negative findings will be immediately corrected.
Results of the audits will be brought to QAPI for review and revision as indicated.

§ 201.22(e) LICENSURE Prevention, control and surveillance of TB.:

(e) The 2-step intradermal tuberculin skin test shall be the method used for initial testing of residents and employes. If the first test is positive, the person tested shall be considered to be infected. If the first test is negative, a second test should be administered in 1--3 weeks. If the second test is positive, the person tested shall be considered to be previously infected. If the second test result is negative, the person is to be classified as uninfected.

Observations:

Based on a review of clinical records, it was determined that the facility failed to correctly administer the two-step intradermal tuberculosis skin test to obtain a baseline tuberculosis status for two of 19 residents sampled (Residents 1, 66).

Findings include:

A review of Resident 1's clinical record revealed that the resident was admitted to the facility on December 27, 2019, and was given the first step tuberculosis skin test on December 27, 2019.

According to state licensure regulations and CDC (Centers for Disease Control) guidelines the first step tuberculosis skin test is to be given upon admission and results read within 48 to 72 hours and the second tuberculosis skin test is to be administered one to three weeks after the first skin test.

The clinical record indicated that Resident 1 did not receive the second skin test as of Janaury 23, 2020.

A review of Resident 66's clinical record revealed the resident was admitted to the facility on January 14, 2020, and was given the first step tuberculosis skin test on January 14, 2020.

According to facility documentation, the first step was to be read by January 16, 2020. A review of the Janaury 2020 Mediication Administration Record revealed that staff failed to obtain the results of this first step TB skin test.

Interview with the assistant director of nursing on January 24, 2020 at approximately 12:25 p.m. verified that staff failed to give Resident 1 his second step tuberculosis skin test and failed to read Resident 177's first step tuberculosis skin test timely.

Plan of Correction - To be completed: 02/25/2020

. Resident 1 had aTB assessment completed. The physician was notified and new orders were received. Resident 66 and 277 were discharged from the facility.
2. To identify residents with the potential to be affected. The DON /designee will audit all resident admitted in the last 90 days and still reside in the facility to ensure PPDs were administered per CDC recommendations. Residents that did not have PPDs administered per CDC guidelines had TB assessments completed. Physicians were notified and orders were implemented per order.
3. The DON/designee will provide education to current licensed nursing staff on PPD administration per CDC recommendation.
4. To monitor and maintain ongoing compliance the DON/designee with audit 3 new admission records weekly x4 then monthly x2 to ensure PPD administration per CDC guidelines. Any negative findings will be immediately corrected.
Results of the audits will be brought to QAPI for review and revision as indicated.

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