Pennsylvania Department of Health
JERSEY SHORE SKILLED NURSING AND REHABILITATION CENTER
Patient Care Inspection Results

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JERSEY SHORE SKILLED NURSING AND REHABILITATION CENTER
Inspection Results For:

There are  91 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.
JERSEY SHORE SKILLED NURSING AND REHABILITATION CENTER - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on a Medicare/Medicaid Recertification Survey, State Licensure Survey, and Civil Rights Compliance Survey completed on April 10, 2024, it was determined that Jersey Shore Skilled Nursing and Rehabilitation 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:


483.60(i)(1)(2) REQUIREMENT Food Procurement,Store/Prepare/Serve-Sanitary: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(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 interview, it was determined that the facility failed to store food in accordance with professional standards for food service safety and sanitation in the facility's main kitchen.

Findings include:

An observation of the facility's main kitchen on April 7, 2024, at 8:38 AM revealed the following:

A coffee station was observed with cabinets below the coffee maker with sliding doors. The tracks of the doors were filled with dried food, debris, and ground coffee.

A household refrigerator located in the preparation area was observed with a dried white substance covering the lower interior shelf of the refrigerator and dried liquid spills on the interior door.

A sliding window and wall behind a preparation table located beside the refrigerator noted above was covered with dried food splatter. A piece of equipment on a cart beside the table covered in a garbage bag was also observed with dried food splatter on the exterior of the garbage bag. A cart the piece of equipment was sitting on was covered in dust and debris as well as a dolly the cart sat on top of. A large round garbage can in the same area was uncovered with the lid leaning against the wall behind it. The flooring area around the garbage can extending behind the oven was observed with dried food and debris. Concurrent interview with Employee 5, cook, indicated the equipment under the garbage bag was an industrial mixer, which had not been used in several years.

The lower shelves of preparation tables located near the food serving line contained a buildup of dust and debris.

The wall area behind a preparation table holding the food processor was observed with dried food splatter covering the tiles on the wall, and the cabinets above the area. A sliding door cabinet under the area contained a buildup of dust and debris in the tracks of the sliding doors. A carboard box of sheet pan liners in the cabinet was observed open with the carboard box soiled with grease spots and dried food.

A large round gray garbage can was sitting beside the mixer/cart the lid was off the garbage can and sitting propped up against the wall. The floor surrounding the garbage can and extending behind the oven had significant dried debris.

Lower shelves of the preparation table area, which contains a sink, was soiled with dried spills and debris.

Several packages of bread products were observed on a rack in the dry storage area including multiple loaves of white bread, hot dog rolls, and hamburger rolls. The bread products were in clear plastic bags and there was no visible indication as to when they were placed there or when they needed to be used by. Employee 5 indicated the bread products came into the facility fresh but was not sure when they expired. Employee 5 found a carboard box from bread in the area and indicated the bread came delivered in the box, which also did not have a use by date on it but did indicate to keep the product frozen until ready to use. Employee 5 then indicated she was not sure if the bread came in fresh or frozen. There was no evidence to indicate when the bread products were pulled from the frozen state as indicated on the box, or when they needed to be used by.

Shelving units throughout the dry storage area with food products stored on them were observed with dust, debris, and dried spills on several of the shelves.

In an interview with the Nursing Home Administrator and Director of Nursing on April 8, 2024, at 2:25 PM the above findings were reviewed.

28 Pa. Code 201.14 (a) Responsibility of licensee


 Plan of Correction - To be completed: 05/27/2024

1) The coffee station and cabinets, refrigerator, sliding window and wall behind the preparation table, piece of equipment on a cart beside the table, the flooring area around the garbage can, lower shelves of preparation tables, wall behind the preparation table and cabinets above the area, sliding door cabinet, lower shelves of the preparation table and shelving units throughout the dry storage area have been cleaned by dietary staff . The garbage can lid was placed on the can and the cardboard box of sheet pan liners has been closed. The "use by" date was added to bread products by the Food Service Manager to indicate when they needed to be consumed by.

2) An audit of the kitchen will be conducted to identify any additional areas that require further cleaning as well as labeling of items to indicate when they should be used by.

3) To prevent the deficient practice from recurrence–the Food Service Manager and dietary staff will be educated on cleaning, cleaning schedules and the use of labels to indicate when food items need to be used by.

4) Audits will be conducted weekly x 4 weeks and then monthly X 2 months to validate food is stored in accordance with professional standards for food service safety and sanitation in the facility's main kitchen. Audits will be completed by the NHA/designee with trends reported through the QAPI committee.

5) Date of compliance: May 27, 2024

483.10(i)(1)-(7) REQUIREMENT Safe/Clean/Comfortable/Homelike Environment: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(i) Safe Environment.
The resident has a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

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

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

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

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

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

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

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

Based on observations and staff and resident interview, it was determined that the facility failed to provide adequate housekeeping and maintenance services to maintain a clean and orderly environment on three of three nursing units (A and B Nursing Unit, D and E Nursing Unit, C Nursing Unit; Residents 7, 27, 43, 44, 79, 84, 89, 91, 97, and 153).

Findings include:

Observation of the facility's B hall nursing unit on April 8, 2024, at 8:58 AM revealed the following environmental concerns:

At the end of the B hall nursing unit, the wallpaper was stained to the right of the heating and air conditioning unit.

The wall outside Resident 84's room had peeling, stained, and cut wallpaper. Resident 84's room was missing a closet door.

Resident 89's room was missing one of the closet doors. One handle fixture of the closet door was loose. The plastic protective cover on the lower half of the room doorway was broken and jagged.

Observation of the facility's E hall nursing unit on April 8, 2024, at 11:30 AM, revealed the following environmental concerns:

The closet door bottom brackets were broken in Resident 7's room causing the doors to swing back and forth. Resident 7 indicated that they have been "broken" and "don't work right." Resident 7's bathroom door was difficult to open and shut as the bottom portion of the door was dragging on the floor.

Resident 43's room had a large marring outside the bathroom on the wall. The marring had multiple colors inside, such as black, brown, and tan. Resident 43 indicated she was told it was "mold." The wall in front of Resident 43's bed in between dressers was marred and scraped. A ceiling tile to the right of her window was stained. The wooden faceplate on the bottom drawer of Resident 43's dresser was broken. The bottom bracket of the closet doors was broken causing the doors to swing back and forth.

One door of Resident 97's closet was broken and propped up against a shelf on the inside of her closet.

The wall in front of Resident 153's bed by his dresser was marred and scraped. Resident 153's top dresser drawer was missing the handle.

The above concerns regarding B and E halls were reviewed with the Administrator and Director of Nursing on April 8, 2024, at 2:15 PM.

Observation of Resident 91's room on the D unit on April 8, 2024, at 10:50 AM revealed the door to enter the room was all marred on the side that faces the hallway. The left corner inside the door had a buildup of dirt in it. In front of the closet there was dirt noted on the floor. There was a small plastic medicine cup noted on the floor to the left of the dresser that had the television on it. The bathroom door frame was all marred, there was used tissue on the floor of the bathroom, the toilet seat was dirty, the back of the toilet was splattered with a brown substance, and there was a small amount of brown substance on the floor to the left of the toilet.

Observation of Resident 27's room on D unit on April 8, 2024, at 11:33 AM revealed that the door to the room was all marred, the frame to the bathroom door was all marred and chipped, the bathroom floor was dirty with a build-up of dirt around the toilet, and behind the head of the bed was a buildup of dirt and dust on the floor along the cove base.

The above noted concerns regarding Resident 27's and 91's rooms were reviewed with the Nursing Home Administrator and Director of Nursing on April 8, 2024, at 2:22 PM.

Observation of the C unit on April 7, 2024, at 10:39 AM revealed a dark blue armchair in the lounge area attached to the dining room with dried smeared food and crumbs on the interior and exterior sides of the arms on the chair and the seating area.

Glass doors at the end of the hallway of the C unit, which exit to a foyer with another set of doors to an outdoor patio area, were observed with curtains on the exterior of the first set of doors to the foyer. The curtains were visibly dirty and dead bugs and cobwebs were collected at the base of the curtains. The foyer area was covered in dirt and debris, dead bugs, and cobwebs. A card table was observed folded up along the wall in the foyer area and was covered in cobwebs and dead bugs.

The above findings on C unit were reviewed with the Nursing Home Administrator and Director of Nursing on April 8, 2024, at 2:20 PM.

Observation of Resident 79's room on April 7, 2024, at 11:00 AM revealed that there were two medication cups lying on the floor by the door side of the bed near the trash can. There was red liquid in the shape of a medication cup dried on the floor beside one of the medication cups. On April 7, 2024, at 2:18 PM, the two medication cups were now placed in the Resident 79's trash can, however the dried red liquid remained on the floor. On April 8, 2024, at 9:46 AM the dried red liquid remained on Resident 79's floor. A six inch brown stain was now identified between Resident 79's bed and the bedside stand near the trash can.

Observation of Resident 44's bathroom on April 7, 2024, at 2:14 PM revealed that the molding around the bottom of Resident 44's bathroom door was marred and scuffed.

Observation of the A Wing Nursing Unit on April 7, 2024, at 2:15 PM revealed that the corner protector to the right of the A wing's double entry door was falling off the protector backing with 2 inches of the protector's backing exposed at the top.

The surveyor reviewed the above information during an interview with the Nursing Home Administrator and Director of Nursing on April 8, 2024, at 1:30 PM and April 9, 2024, at 2:00 PM.

28 Pa. Code 207.2(a) Administrators Responsibility


 Plan of Correction - To be completed: 05/27/2024

1) The wallpaper to the right of the heating and air conditioning unit on B hall was repaired by maintenance. Resident 84's wallpaper will be repaired by maintenance.
Resident 84's closet door will be replaced by maintenance.
Resident 89's closet door will be replaced by maintenance and the handle fixture will be secured.
The protective plastic cover of the lower half of Resident 89"s doorway will be replaced by maintenance.
The bottom prackets of Resident 7's closet door will be repaired and the bathroom door in the room will be repaired to insure it opens and shuts properly by maintenance.
The walls outside of Resident 43's bathroom and in front of the bed will be repaired; the ceiling tile will be replaced; the wooden faceplate on the bottom drawer of the dresser will be repaired and the bottom bracket of the closet doors will be replaced by maintenance .
Resident 97's closet door will be repaired.
The wall in front of Resident 153's bed will be repaired and the handle to the top dresser drawer will be replaced by maintenance.
The marring to Resident 91's room door facing the hallway and bathroom door frame will be repaired.
Resident 91's room and bathroom has been thoroughly cleaned by housekeeping .
The door to Resident 27's room and frame to the bathroom door will be repaired. Resident 27's room and bathroom has been thoroughly cleaned.
The dark blue armchair in the lounge area has been thoroughly cleaned by housekeeping.
The foyer area and curtains at the end of the hallway on C unit has been thoroughly cleaned and folding table removed and cleaned by housekeeping.
Resident 79's room has been thoroughly cleaned by housekeeping.
The molding around the bottom of Resident 44's bathroom door will be repaired by maintenance.
The corner protector to the right of A wing's double entry door has been repaired by maintenance.

2) Resident rooms and common areas will be observed to identify items that need repaired or additional cleaning. Corrective action will be taken upon discovery.

3) To prevent the deficient practice from recurrence–the Maintenance Director and housekeeping staff will be educated by the NHA (Nursing Home Administrator)/designee on the facility processes to maintain a clean and orderly environment.

4) Audits will be conducted weekly x 4 weeks and then monthly X 2 months to ensure maintenance of a clean and orderly environment. Audits will be completed by the NHA/designee with trends reported through the QAPI committee.

5) Date of compliance: May 27, 2024

483.45(c)(3)(e)(1)-(5) REQUIREMENT Free from Unnec Psychotropic Meds/PRN Use: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(e) Psychotropic Drugs.
§483.45(c)(3) A psychotropic drug is any drug that affects brain activities associated with mental processes and behavior. These drugs include, but are not limited to, drugs in the following categories:
(i) Anti-psychotic;
(ii) Anti-depressant;
(iii) Anti-anxiety; and
(iv) Hypnotic

Based on a comprehensive assessment of a resident, the facility must ensure that---

§483.45(e)(1) Residents who have not used psychotropic drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record;

§483.45(e)(2) Residents who use psychotropic drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs;

§483.45(e)(3) Residents do not receive psychotropic drugs pursuant to a PRN order unless that medication is necessary to treat a diagnosed specific condition that is documented in the clinical record; and

§483.45(e)(4) PRN orders for psychotropic drugs are limited to 14 days. Except as provided in §483.45(e)(5), if the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she should document their rationale in the resident's medical record and indicate the duration for the PRN order.

§483.45(e)(5) PRN orders for anti-psychotic drugs are limited to 14 days and cannot be renewed unless the attending physician or prescribing practitioner evaluates the resident for the appropriateness of that medication.
Observations:

Based on clinical record review and staff interview, it was determined that the facility failed to ensure a resident's medication regime was free from potentially unnecessary medications for one of five residents reviewed (Resident 13).

Findings include:

Clinical record review for Resident 13 revealed a physician's order dated November 1, 2023, and discontinued on March 6, 2024, for Ativan (for anxiety) 1 milligram (mg) by mouth (PO) twice daily (BID) as needed (PRN) for 60 days. On March 16, 2024, Resident 13's physician reordered the Ativan 1 mg PO BID PRN for anxiety for another 60 days.

Review of Resident 13's February, March, and April 2024 MARs (medication administration record, a form to document medication administration) revealed that there was no documentation that staff attempted non-medicinal interventions prior to administration of her PRN Ativan for 24 of the 25 administrations in February 2024, for 29 of the 36 administrations in March 2024, and for 9 of the 10 administrations in April 2024.

The surveyor reviewed the above information for Resident 13 during an interview with the Nursing Home Administrator and Director Nursing on April 8, 2024, at 2:14 PM.

28 Pa. Code 211.9(a)(1)(k) Pharmacy services

28 Pa. Code 211.10(a) Resident care policies

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


 Plan of Correction - To be completed: 05/27/2024

1) Resident 13's physician has evaluated the appropriateness of PRN Ativan.

2) Current residents receiving PRN psychotropic medications will be reviewed to validate orders extending beyond 14 days have physician evaluation documented and non-medicinal interventions are attempted prior to their use. Corrective action will be taken as needed.

3) To prevent the deficient practice from recurrence–licensed nurses will receive education by the Director of Nursing regarding requirements of PRN psychotropic drug use and attempting nonpharmacological intervention prior to administration that is reflective in documentation in the medical record.

4) Audits will be conducted weekly x 4 weeks and then monthly X 2 months to validate PRN psychotropic drug orders extending beyond 14 days are evaluated by the physician and have non-medicinal interventions attempted and documented prior to use of PRN psychotropic medications. Audits will be completed by the DON/designee with trends reported through the QAPI committee.

5) Date of compliance: May 27, 2024

483.25(g)(1)-(3) REQUIREMENT Nutrition/Hydration Status Maintenance: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(g) Assisted nutrition and hydration.
(Includes naso-gastric and gastrostomy tubes, both percutaneous endoscopic gastrostomy and percutaneous endoscopic jejunostomy, and enteral fluids). Based on a resident's comprehensive assessment, the facility must ensure that a resident-

§483.25(g)(1) Maintains acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that this is not possible or resident preferences indicate otherwise;

§483.25(g)(2) Is offered sufficient fluid intake to maintain proper hydration and health;

§483.25(g)(3) Is offered a therapeutic diet when there is a nutritional problem and the health care provider orders a therapeutic diet.
Observations:

Based on clinical record review and staff interview, it was determined that the facility failed to provide timely assessment and implement interventions to promote acceptable parameters of nutritional status for four of seven residents reviewed for nutritional concerns (Residents 46, 59, 86, and 91).

Findings include:

Review of Resident 46's clinical record revealed that the facility admitted him on March 18, 2024. Resident 46 was admitted to the facility with a diagnosis of malnutrition and needing a feeding tube for nutrition. There was no documented evidence in Resident 46's clinical record to indicate that an initial comprehensive dietary assessment was completed.

A Minimum Data Set Assessment (MDS, an assessment completed at specific intervals to determine care needs) dated March 25, 2024, indicated that the facility assessed him as being at nutritional risk and that the facility would proceed to develop a care plan regarding his risk for weight loss. There was no documented evidence in Resident 46's clinical record to indicate that the facility developed a potential for weight loss care plan or implemented interventions.

Resident 46 was weighed by nursing staff on March 20, 2024, at 120 pounds. On April 3, 2024, nursing staff weighed Resident 46 at 110 pounds, which would be an 8.3 percent loss in less than three weeks. There was no documented evidence in Resident 46's clinical record to indicate that Resident 46's nutritional needs were assessed to determine if his caloric needs were being met.

Interview with the Administrator on April 7, 2024, at 2:00 PM revealed that the facility has been without a qualified dietitian since March 8, 2024.

Once the surveyor brought up the weight loss concerns regarding Resident 46, a dietary assessment was completed on April 10, 2024, at 7:12 AM. The assessment indicated that Resident 46 only eats 0-50 percent of his meals, and he has not been getting enough calories with his current order of nutrition by feeding tube.

Interview with the Administrator on April 9, 2024, at 12:28 PM confirmed the above findings for Resident 46.

Clinical record review for Resident 59 revealed the resident was admitted from another nursing facility on January 31, 2024, with a history of significant weight loss and dementia.

A nutrition note by the registered dietitian dated February 14, 2024, at 1:30 PM indicated Resident 59 had variable weights since her admission with an initial weight on February 1, 2024, of 117.2 pounds, then 128 pounds on February 6, 104.5 pounds on February 7, and 109 pounds on February 12, 2024. The dietitian acknowledged a variance of scales utilized to obtain the weights may have a contributed to the variance in the weights, but due to the resident's history of weight loss and malnutrition, nutritional supplements were increased for the resident.

Review of Resident 59's weight record revealed the resident's weight continued to decline after the registered dietitian's note on February 14, 2024, with a weight of 100 pounds on February 26, 2024, 99.9 pounds on March 4, 2024, 97 pounds on March 18, 2024, 99 pounds on March 25, 2024, and 84.5 pounds on April 3, 2024. There was no evidence of a reweight after the April 3, 2024, weight and it was noted as "last weight, refused."

Resident 59 continued to lose weight since last noted by the registered dietitian on February 14, 2024, with a 12 pound (11 percent) severe weight loss from 109 pounds on February 12 to 97 pounds on March 11, 2024, and a 15.4 pound (15.4 percent) severe weight loss from 99.9 pounds on March 4, 2024, to April 3, 2024, residents last known weight. Resident 59's weights revealed a 32.7-pound weight loss since her admission to the facility from the weight first obtained on February 1, 2024, to the April 3, 2024, weight.

There was no evidence Resident 59 was further assessed by the dietitian or physician regarding the resident's continued weight loss since the nutrition note on February 14, 2024.

In an interview with the Nursing Home Administrator on April 9, 2024, at 2:19 PM the administrator indicated the facility has not employed a registered dietitian/nutrition professional since March 8, 2024, was currently in the recruitment phase and confirmed there was no additional information regarding nutrition interventions for Resident 59 after the resident continued to lose weight.

Clinical record review for Resident 86 revealed the following weights:

December 18, 2023, 138.0 pounds
January 5, 2024, 129.0 pounds (9 pounds, 6.5 percent weight loss in 18 days)
February 1, 2024, 131.2 pounds (6.8 pounds, 5.03 percent weight loss since December 18, 2023)
March 1, 2024, 132.0 pounds (6 pounds, 4.3 percent weight loss in 2.5 months)

Review of Resident 86's meal intakes revealed that between December 15, 2024, and March 5, 2024, staff documented he ate 25 percent of his meal 16 times, ate 0 percent of his meal twice, and refused his meal seven times. There were several meals where Resident 86 was out of the facility visiting with his family.

Review of Resident 86's physician documentation dated December 15, 2023, revealed that the resident had a poor prognosis due to stage four lung cancer with metastasis, with recent hospitalization for a pulmonary embolism. The physician's goal was to ensure that Resident 86 was supported nutritionally and identified nutritional support was of "significant importance." The physician indicated that "though (Resident 86)'s prognosis was very poor with limited survival (our) goal was to make sure that as long as (Resident 86) was alive he remains comfortable and safe."

Resident 86's physician ordered the following:

On December 15, 2023, for staff to provide a regular diet with regular texture.
On December 19, 2023, admitted Resident 86 to hospice for terminal illness of lung cancer.
On December 20, 2023, provided a house shake twice daily for inadequate oral intake.
On December 31, 2023, administer Zofran 4 milligrams every 8 hours as needed for nausea/vomiting.
On February 21, 2024, discontinue hospice services per resident request.

Review of Resident 86's registered dietitian documentation on December 19, 2023, the dietitian identified that Resident 86 had an advanced cancer diagnosis with hospice services, their intake was 78 percent, they had an elevated nutritional need, and recommended a house shake twice daily. The dietician deferred Resident 86's weekly weight monitoring secondary to their hospice status with weight loss expected, noting the dietitian was available for consultation as needed.

The facility completed Resident 86's care plan conference on December 28, 2023, and indicated that his meal intakes were 25 to 50 percent, accepted nutritional supplements, and noted no eating difficulties.

Review of Resident 86's nursing documentation revealed the following:

On December 30, 2023, Resident 86 complained of an upset stomach at 2:10 AM with ginger ale accepted.

On December 31, 2023, at 12:00 AM the facility notified the on-call physician regarding Resident 86 complaining of nausea and they ordered Zofran. At 6:05 AM, Resident 86 again complained of nausea. The facility notified hospice staff. At 5:00 PM, staff indicated that Resident 86 complained of intermittent nausea throughout the day.

On January 12, 2024, Resident 86's physician indicated that the resident reported weight loss since his cancer diagnosis and requested staff keep the resident as comfortable and pain free as possible.

On January 17, 2024, Resident 86's physician revealed that the resident complained of chest discomfort (mid-sternal regions) with swallowing liquids and solids for several months during almost every meal and had a diminished appetite. He ordered staff to start Omeprozole (for acid reflux) 40 milligrams by mouth daily and complete a barium swallow study for chest pain due to swallowing. Review of Resident 86's clinical record revealed neither the Omeprozole or barium study were ordered for Resident 86 between January 17, 2024, and March 5, 2024.

On February 12, 2024, at 4:28 AM, Resident 86 complained of feeling like "something was stuck in (his) throat and was irritating. Resident 86 was able to speak with no redness or irritation noted. He had eaten ice cream earlier with no concerns.

On March 3, 2024, 3:35 PM, Resident 86 complained of a sore throat and felt he had trouble swallowing. His physician ordered throat lozenges/cough drops and his family requested Resident 86 receive hot soup or broth, ice cream, and mashed potatoes with every meal. The kitchen was notified.

On March 5, 2024, a different dietitian noted a significant change with Resident 86 and the first time that the dietitian assessed this resident. The dietitian noted the 6 pound (4.3 percent) weight loss in 2.5 months with malnutrition included in the diagnoses since admission. The dietitian noted ongoing swallowing concerns since January 17, 2024, with the resident informing the dietitian concerns with eating most food items, particularly meats. Resident 86 also indicated that the chocolate shakes being sent are too rich at times with noted creaminess. The dietitian changed the shakes to vanilla and the timing for the shakes to be delivered with the breakfast and dinner meals. Resident 86 was also agreeable to try Gelatin plus supplements, noting he would be "open to try anything." Resident 86 indicated that he used to weight 149 to 155 pounds prior to admission with weight loss noted due to significant loss of muscle, fat, and grip strength and continued to lose weight despite eating. The dietitian informed Resident 86 that these were signs of malnutrition. The dietician identified that the facility had not ordered the Omeprozole and/or barium swallow study per the physician directive/documentation on January 17, 2024 (1.5 months prior). The dietitian indicated to monitor meal and supplement intakes/acceptance, weights, lab orders, medications, and diet texture tolerance. He also recommended a speech evaluation.

On March 5, 2024, at 4:44 PM, nursing staff approached Resident 86 regarding the physician ordered Omeprozole and barium swallow study from January 17, 2024. Resident 86 determined that he did not wish to have the Omeprozole medication and did not want the barium swallow study completed.

There was no documentation that indicated the facility's two dietitians identified, monitored, and implemented dietary interventions for Resident 86's weight loss and swallowing and intake concerns between December 19, 2023, and March 5, 2024.

This surveyor reviewed the above information during an interview with the Nursing Home Administrator and Director of Nursing on April 9, 2024, at 1:37 PM and April 9, 2024, at 2:19 PM

Clinical record review for Resident 91 revealed that the facility admitted him on January 11, 2024, with an admission weight of 185 pounds. He was on a regular diet with regular texture.

A dietary progress note dated January 12, 2024, at 2:47 PM indicated that Resident 91's intakes have been variable with increased nutritional needs for healing related to a fracture. The note indicated that a request would be made to the food service director to offer resident high protein food options. It also indicated that the registered dietician would follow Resident 91.

Review of Resident 91's documented weights revealed that he had a significant weight loss of 10 percent from January 11, 2024, when he weighed 185 pounds to March 7, 2024, where he weighed 165 pounds, and a 5 percent weight loss from January 11, 2024, where he weighed 185 pounds to February 22, 2024, where he weighed 175 pounds.

Review of Resident 91's physician orders and care plan revealed that no new interventions were initiated related to his significant weight loss.

There was no documentation that indicated the facility identified, monitored, and implemented dietary interventions for Resident 91's significant weight loss that was noted on February 22, 2024, and March 7, 2024.

This surveyor reviewed the above information related to Resident 91's weight loss during an interview with the Nursing Home Administrator and Director of Nursing on April 9, 2024, at 2:15 PM.

483.25(g)(1) Maintain acceptable parameters of nutrition
Previously cited 5/11/23

28 Pa. Code 201.14 (a) Responsibility of licensee

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


 Plan of Correction - To be completed: 05/27/2024

1) A comprehensive nutritional assessment was completed for Resident 46 by a dietitian with a plan for weight loss with interventions.
Resident 59 will be assessed by a dietitian and physician regarding her continued weight loss.
Resident 86 no longer resides in the facility thus no further corrective action can be taken.
Resident 91 will be assessed by a dietitian and physician regarding his significant weight loss.

2) Current residents who have had a noted significant weight loss will be reviewed to validate nutritional evaluations have been completed, all interventions implemented as appropriate and reweigh all residents with a loss or gain of more than five pounds since their most recent weight. Facility scales will be recalibrated by the maintenance department. Corrective action will be taken as needed.

3) To prevent the deficient practice from recurrence–the facility has hired a full-time dietitian who will receive education by the Administrator regarding timely evaluation and implementation of additional interventions for residents with noted significant weight loss. Nursing staff will be re-educated by the Director of Nursing regarding the need to reweigh a resident if a weight differs 5 or more pounds from the previous weight. The dietician will routinely monitor obtained weights to ensure timely physician notification and implementation of recommended interventions.

4) Audits will be conducted weekly x 4 weeks and then monthly X 2 months to validate timely assessment and implementation of interventions to promote acceptable parameters of nutritional status and to ensure all residents with a 5 or more pound weight difference from the previous weight are reweighed and documentation present in the medical record. Audits will be completed by the NHA/designee with trends reported through the QAPI committee.

5) Date of compliance: May 27, 2024

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 staff interview, it was determined that the facility failed to determine a resident's wishes regarding an advance directive for one of 10 residents reviewed (Resident 27).

Findings include:

Clinical record review for Resident 27 revealed that the facility admitted her on March 6, 2024, with a diagnosis of a left femoral fracture and end stage renal disease.

Clinical record review revealed her advance directive to be DNR (Do Not Resuscitate, a medical order that instructs health care providers not to intervene if a patient stops breathing or if their heart stops beating).

A Medical Practitioner Note (Physician/ Nurse practitioner) dated March 7, 2024, at 10:28 PM revealed that Resident 27 was severely lethargic and fatigued. Her neurological assessment revealed that she was alert, awake, and oriented to person only. The note further indicated that Resident 27 desired to be a DNR based on her advance directive.

Interview with the Nursing Home Administrator and Director of Nursing (DON) on April 9, 2024, at 2:12 PM revealed that they obtained Resident 27's DNR information from her discharge records that were brought with her from the hospital.

Interview with the DON on April 10, 2024, at 12:32 PM revealed that there was no advance directive located in Resident 27's chart and that she was unsure where the physician obtained the DNR information.

The facility failed to determine a resident's wishes related to her code status prior to obtaining a physician's order for her code status.

28 Pa. Code 211.5(f) Clinical records

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


 Plan of Correction - To be completed: 05/27/2024

The statements made on this plan of correction are not an admission to and do not constitute an agreement with the alleged deficiencies. To remain in compliance with all federal and state regulations, the facility has taken or will take actions set forth in the following plan of correction.

1) The facility will provide information regarding formulating an advanced directive to Resident 27's resident representative by Medical Director.

2) Current residents will be reviewed to validate that residents and/or their resident representatives have been offered an opportunity to execute an advanced directive. Corrective action will be taken if needed.

3) The facility's attending physicians and social worker will be educated by the DON (Director of Nursing)/designee regarding residents' rights to formulate an advanced directive.

4) Audits will be conducted weekly x 4 weeks and then monthly X 2 months to validate residents and/or their resident representatives have been offered an opportunity to execute advanced directives. Audits will be completed by the NHA/designee with trends reported through the QAPI committee.

5) Date of compliance: May 27, 2024

483.10(g)(17)(18)(i)-(v) REQUIREMENT Medicaid/Medicare Coverage/Liability Notice:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
§483.10(g)(17) The facility must--
(i) Inform each Medicaid-eligible resident, in writing, at the time of admission to the nursing facility and when the resident becomes eligible for Medicaid of-
(A) The items and services that are included in nursing facility services under the State plan and for which the resident may not be charged;
(B) Those other items and services that the facility offers and for which the resident may be charged, and the amount of charges for those services; and
(ii) Inform each Medicaid-eligible resident when changes are made to the items and services specified in §483.10(g)(17)(i)(A) and (B) of this section.

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

Based on clinical record review and staff interview, it was determined that the facility failed to provide the correct required notification to a resident whose payment coverage changed for two of five residents reviewed (Residents 34 and 89).

Findings include:

A review of the "Form Instructions Skilled Nursing Facility (SNF) Advanced Beneficiary Notice of Non-coverage (SNFABN) Form CMS-10055" revealed that examples of the common reasons why an extended care stay, or services may not be covered under Medicare might include the beneficiary no longer requires daily skilled care for a medical condition but wants to continue residing in the skilled nursing facility (SNF). The SNF enters a good faith estimate of the cost of the corresponding care that may not be covered by Medicare. In the blank that follows "Beginning on ...," the skilled nursing facility enters the date on which the beneficiary may be responsible for paying for care that Medicare is not expected to cover. The beneficiary selects an option box to indicate a desire to continue to receive the care or not to continue to receive the care and if there is a desire to have the bill submitted to Medicare for consideration. The beneficiary or their authorized representative must sign the signature box to acknowledge that they read and understood the notice.

The SNF must issue this notice when there is a termination of all Medicare Part A services for coverage reasons. If after issuing the NOMNC, the SNF expects the beneficiary to remain in the facility in a non-covered stay, the SNFABN must be issued to inform the beneficiary of potential liability for the non-covered stay.

Clinical record review of census information for Resident 34 revealed that the facility provided services primarily paid for by Medicare starting September 7, 2023. Resident 34's Medicare payment for services ended October 3, 2023. Resident 34 began to privately pay for his care on October 4, 2023. Resident 34 still resides in the facility. There was no documented evidence to indicate that the facility provided a CMS-10055 form to Resident 34 and/or his responsible party.

Clinical record review of census information for Resident 89 revealed that the facility provided services primarily paid for by Medicare starting January 4, 2024. Resident 89's Medicare payment for services ended February 14, 2024. Resident 89 began to privately pay for his care on February 14, 2024. Resident 89 still resides in the facility. There was no documented evidence to indicate that the facility provided a CMS-10055 form to Resident 89 and/or his responsible party.

The surveyor confirmed the above findings regarding Resident 34's and Resident 89's Medicare notices during an interview with Employee 1, medical records, on April 8, 2024, at 1:06 PM. Employee 1 indicated that she was not aware that the CMS-10055 form was to be used.

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

28 Pa. Code 201.29(a) Resident rights


 Plan of Correction - To be completed: 05/27/2024

1) Resident 34 and/or his responsible party will be provided a CMS-10055 form by the Nursing Home Administrator. Resident 89 has been discharged from the facility thus no further corrective action can be taken.

2) Current residents who have had a termination of Medicare Part A services in the last 30 days will be reviewed to determine if a SNFABN has been issued with corrective action provided upon discovery.

3) To prevent the deficient practice from recurrence–the Social Service Director and Medical Records Director will receive education by the Administrator regarding providing the correct required notification to a resident whose payment coverage has changed.

4) Audits will be conducted weekly x 4 weeks and then monthly X 2 months to validate required notification has been provided to residents whose payment coverage has changed. Audits will be completed by the NHA/designee with trends reported through the QAPI committee.

5) Date of compliance: May 27, 2024

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

Based on clinical record review and staff interview, it was determined that the facility failed to develop and implement a comprehensive person-centered care plan to maintain the highest practicable care for one of three residents reviewed (Resident 81).

Findings Include:

Clinical record review for Resident 81 revealed that he was admitted to the facility on August 27, 2023, and his primary language was Spanish. He was also able to speak in broken English (you speak English with difficulty or with a lot of mistakes).

Interview with the Nursing Home Administrator and Director of Nursing on April 9, 2024, at 2:10 PM revealed that staff communicate with Resident 81 through one employee, a licensed practical nurse, that speaks Spanish, and some staff have interpreter applications on their phones.

A Medical Practitioner (Physician or Nurse Practitioner) progress note dated March 4, 2023, at 2:33 PM revealed that Resident 81 solely speaks Spanish, but can communicate through movements such as head nods.

A Social Determinant of Health (conditions in the environment that affect a wide range of health, functioning, and quality of life outcomes and risks) progress note dated March 18, 2024, at 9:39 AM by social services revealed that Resident 81 did not need or want an interpreter to communicate with a doctor or health care staff.

A Medical Practitioner note date December 20, 2023, at 2:19 PM revealed that a discussion was held with Resident 81, and the nurse, who speaks Spanish and she communicated with him in detail regarding his code status (the type of emergent treatment a person would or would not receive if their heart or breathing stops).

Review of Resident 81's care plan revealed no care plan related to his communication deficit or interventions for the staff to utilize to improve communication with him.

Interview with the Director of Nursing on April 9, 2024, at 2:14 PM confirmed that there is not always a staff member present that speaks Spanish, and that there was no care plan in Resident 81's clinical record addressing his communication concerns or interventions for staff to utilize to communicate with him.

The facility failed to implement a person center care plan to maintain the highest practicable care for Resident 81.

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


 Plan of Correction - To be completed: 05/27/2024

1) Resident #81's care plan has been updated to reflect his communication deficit and interventions including how to utilize the language line for non english speaking patients to improve communication with him.

2) A review of current residents with communication deficits will be completed to validate their care plans are reflective of interventions including the language line for non english speaking patients to improve communication with them by the Director of Nursing.

3) To prevent the deficient practice from recurrence– licensed nurses and social services will be educated by the DON (Director of Nursing)/designee regarding the need to implement person-centered plans of care to maintain communication abilities.

4) Audits will be conducted weekly x 4 weeks and then monthly X 2 months to ensure care plans are reflective of person-centered interventions. Audits will be completed by the DON/designee with trends reported through the QAPI committee.

5) Date of compliance: May 27, 2024

483.25(a)(1)(2) REQUIREMENT Treatment/Devices to Maintain Hearing/Vision: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(a) Vision and hearing
To ensure that residents receive proper treatment and assistive devices to maintain vision and hearing abilities, the facility must, if necessary, assist the resident-

§483.25(a)(1) In making appointments, and

§483.25(a)(2) By arranging for transportation to and from the office of a practitioner specializing in the treatment of vision or hearing impairment or the office of a professional specializing in the provision of vision or hearing assistive devices.
Observations:

Based on clinical record review and staff interview, it was determined that the facility failed to provide treatment to improve hearing for one of three residents reviewed (Resident 81).

Findings include:

Clinical record review for Resident 81 revealed an audiologist (a health care professional that assesses and manages disorders of hearing) progress note from an outside provider dated March 21, 2024, at 12:20 PM that indicated his left ear was impacted with cerumen (ear wax). The note further indicated that it should be removed as soon as possible by the facility if the resident allows. The facility should follow their protocol for cerumen removal with Debrox (a medication used to treat wax build-up) as ordered by the facility physician. Resident 81 should return for a hearing exam following cerumen removal.

Clinical record review for Resident 81 revealed no evidence that the Debrox treatment to his ear was ordered or done.

Interview with the Nursing Home Administrator on April 9, 2024, at 2:10 PM confirmed that the audiologist recommendations for Resident 81, were never reviewed by his physician and the treatment was never completed.

The facility failed to implement recommended interventions to potentially improve Resident 81's hearing.

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

28 Pa. Code 211.11(d) Resident care plan

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


 Plan of Correction - To be completed: 05/27/2024

1) Resident 81 has been treated for cerumen removal with Debrox.

2) Current residents who have been seen by an audiologist in the past 90 days will be reviewed by the Director of Nursing to validate that recommendations were reviewed by the residents' physician and treatment completed if the physician was in agreement. Additional referrals will be made as appropriate.

3) To prevent the deficient practice from recurrence–Licensed nurses will be educated by the DON (Director of Nursing)/designee regarding the expectation to monitor consultant audiology and vision appointment reports upon receipt and to validate that all physician-ordered recommendations are acted upon.

4) Audits will be conducted weekly x 4 weeks and then monthly X 2 months to ensure the facility has implemented recommended interventions to potentially improve residents' hearing. Audits will be completed by the DON/designee with trends reported through the QAPI committee.

5) Date of compliance: May 27, 2024

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 clinical record review and staff interview, it was determined that the facility failed to evaluate a pressure ulcer to prevent decline and promote healing for one of two residents reviewed (Residents 27).

Findings include:

Clinical record review for Resident 27 revealed that the facility admitted her on March 6, 2024, with a closed wound to her left heel.

Review of Resident 27's skin and wound evaluation dated March 7, 2024, revealed that she had an abrasion that was present on admission and measured 2.5 centimeters (cm) x 2.0 cm with no depth. The wound bed was 100 percent covered with epithelial (a type of tissue that covers many surfaces on the inside and outside of your body). There was no slough (yellowish/white material noted on a wound bed) or eschar (dead tissue) present, and there was no drainage. It was a foam dressing and there was no additional care noted on the evaluation.

An admission MDS (Minimum Data Set, an assessment completed at intervals by the facility to determine care needs) date March 13, 2024, revealed that Resident 27 did not have any pressure ulcers.

Review of Resident 27's next skin and wound evaluation dated April 6, 2024, revealed that the wound was an abrasion on the left heel, that was present on her admission to the facility, 1.9 cm x 2.6 cm with no depth. The wound bed was now eschar but did not identify the percentage. No drainage was noted. No dressing was identified, and no additional care was noted on the evaluation form.

Review of Resident 27's care plan that was initiated on March 7, 2024, and resolved on April 9, 2024, revealed the left heel wound was identified as a deep tissue injury (DTI, persistent non-blanchable deep red, maroon or purple discoloration with intact skin due to damage of underlying soft tissue).

Interview with the Nursing Home Administrator and Director of Nursing on April 9, 2024, at 2:21 PM related to whether the wound on Resident 27's left heel was an abrasion or a pressure ulcer, revealed that they were going to have the wound specialist look at it on this same date.

On April 10, 2024, at 9:13 AM the Nursing Home Administrator provided an initial wound evaluation and management summary that was completed by the wound clinic physician that indicated the wound on Resident 27's left heel was a pressure ulcer unstageable DTI with intact skin. The wound was 1.5 cm x 2.5 cm and depth was not measurable. They also provided a skin and wound evaluation form dated April 9, 2024, that indicated the wound was a pressure ulcer on the left heel, unstageable, and 100 percent, eschar was present, indicating the pressure ulcer declined.

Review of Resident 27's treatment administration record (TAR) for March and April 2024, revealed that the staff were completing a body audit on the evening shift daily for skin observation. Review of Resident 27's clinical record revealed no documented evidence that the left heel was being assessed during the body audit.

There was no evidence that the facility completed an evaluation at least weekly on Resident 27's left heel pressure ulcer that included the location and staging, the size, drainage to include type, of odor present, and amount, pain, the color and type of tissue present, and a description of the wound bed and edges, to promote healing.

The Director of Nursing confirmed the above noted findings during a meeting on April 10, 2024, at 12:30 PM.

The facility failed to conduct an evaluation, at least weekly, to promote healing and prevent decline, of Resident 27's left heel pressure ulcer that worsened.

483.25(b)(1)(i)(ii) Treatment/svcs to Prevent/heal Pressure Ulcer
Previously cited deficiency 5/11/23 and 12/4/23

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

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

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


 Plan of Correction - To be completed: 05/27/2024

1) Resident 27's left heel pressure ulcer was restaged as a SDTI (Suspected Deep Tissue Injury) and is being evaluated at least weekly to address location, staging, size, drainage to include type, if odor present, and amount, pain, color and type of tissue present, and a description of wound bed and edges, to promote healing . The MDS from 3/13/24 was corrected to reflect a pressure ulcer.

2) Current residents with pressure ulcers have the potential to be affected. A review of current residents with pressure ulcers will be conducted to ensure weekly evaluations are completed. Corrective action will be taken if concerns are identified.

3) Licensed nurses will receive education by the Director of Nursing/designee regarding the timely identification, treatment and evaluation of pressure ulcers.

4) Audits will be conducted weekly x 4 weeks and then monthly X 2 months to ensure pressure ulcers are identified and evaluated at least weekly. Audits will be completed by the DON/designee with trends reported through the QAPI committee.

5) Date of compliance: May 27, 2024

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 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(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 clinical record review and staff interview, it was determined that the facility failed to ensure that the resident's attending physician addressed pharmacy recommendations timely and implemented accepted recommendations timely for two of five residents reviewed (Residents 50 and 80).

Findings include:

Clinical record review for Resident 50 revealed a consultant pharmacist recommendation dated February 6, 2024, for the initiation of Vitamin D3 for the resident. The recommendation was noted as accepted by the physician and signed on February 25, 2024, by the physician.

Further record review for Resident 50 revealed the resident did not receive a physician's order for the Vitamin D3 until March 6, 2024, 10 days later.

Clinical record review for Resident 80 revealed a consultant pharmacist recommendation dated October 13, 2023, to check a serum Vitamin D level on the resident due to a recent fall. The recommendation was reviewed by the physician until November 27, 2023, greater than 30 days from the date of the recommendation.

The physician did accept the recommendation for Resident 80 to obtain a serum Vitamin D level when signed on November 27, 2023, although there was no evidence the serum Vitamin D level was obtained until February 5, 2024, even though the resident had other blood lab work completed in the time frame.

A consultant pharmacy recommendation dated February 6, 2024, for Resident 80 noted the serum Vitamin D level that was obtained on February 5, 2024, with a concentration of 11 ng/mL (nanograms/milliliter) and now recommended the addition of a Vitamin D3 supplement. Review of Resident 80's lab report dated February 5, 2024, revealed Resident 80's serum Vitamin D level was identified as deficient with a level less than 20 ng/mL. Resident 80 was ordered Vitamin D3 on February 6, 2024.

The above information regarding Resident 50 and 80 was reviewed with the Nursing Home Administrator and Director of Nursing on April 9, 2024, at 2:00 PM.

28 Pa. Code 211.9 (d)(k) Pharmacy services

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


 Plan of Correction - To be completed: 05/27/2024

1) Resident 50 is receiving Vitamin D3 as ordered.
Resident 80's Vitamin D level was completed on February 5, 2024 and he is receiving vitamin D3 as ordered.

2) Current residents with pharmacist recommendations in the previous 60 days will be reviewed to validate the recommendations have been communicated to the physician and acted upon. Corrective action will be taken as needed.

3) To prevent the deficient practice from recurrence–licensed nurses will receive education by the Director of Nursing/designee regarding the need for timely physician evaluation of pharmacist recommendations and timely implementation of accepted recommendations.

4) Audits will be conducted weekly x 4 weeks and then monthly X 2 months to validate pharmacist recommendations are addressed timely by attending physicians and accepted recommendations are implemented timely. Audits will be completed by the DON/designee with trends reported through the QAPI committee.

5) Date of compliance: May 27, 2024

483.60(a)(1)(2) REQUIREMENT Qualified Dietary Staff:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
§483.60(a) Staffing
The facility must employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, taking into consideration resident assessments, individual plans of care and the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment required at §483.70(e)

This includes:
§483.60(a)(1) A qualified dietitian or other clinically qualified nutrition professional either full-time, part-time, or on a consultant basis. A qualified dietitian or other clinically qualified nutrition professional is one who-
(i) Holds a bachelor's or higher degree granted by a regionally accredited college or university in the United States (or an equivalent foreign degree) with completion of the academic requirements of a program in nutrition or dietetics accredited by an appropriate national accreditation organization recognized for this purpose.
(ii) Has completed at least 900 hours of supervised dietetics practice under the supervision of a registered dietitian or nutrition professional.
(iii) Is licensed or certified as a dietitian or nutrition professional by the State in which the services are performed. In a State that does not provide for licensure or certification, the individual will be deemed to have met this requirement if he or she is recognized as a "registered dietitian" by the Commission on Dietetic Registration or its successor organization, or meets the requirements of paragraphs (a)(1)(i) and (ii) of this section.
(iv) For dietitians hired or contracted with prior to November 28, 2016, meets these requirements no later than 5 years after November 28, 2016 or as required by state law.

§483.60(a)(2) If a qualified dietitian or other clinically qualified nutrition professional is not employed full-time, the facility must designate a person to serve as the director of food and nutrition services.
(i) The director of food and nutrition services must at a minimum meet one of the following qualifications-
(A) A certified dietary manager; or
(B) A certified food service manager; or
(C) Has similar national certification for food service management and safety from a national certifying body; or
D) Has an associate's or higher degree in food service management or in hospitality, if the course study includes food service or restaurant management, from an accredited institution of higher learning; or
(E) Has 2 or more years of experience in the position of director of food and nutrition services in a nursing facility setting and has completed a course of study in food safety and management, by no later than October 1, 2023, that includes topics integral to managing dietary operations including, but not limited to, foodborne illness, sanitation procedures, and food purchasing/receiving; and
(ii) In States that have established standards for food service managers or dietary managers, meets State requirements for food service managers or dietary managers, and
(iii) Receives frequently scheduled consultations from a qualified dietitian or other clinically qualified nutrition professional.
Observations:

Based on staff interview, it was determined that the facility failed to employ a qualified registered dietitian, in the absence of a full time certified dietary manager.

Findings include:

Interview with the Administrator on April 7, 2024, at 2:00 PM revealed that the facility has not had a qualified dietitian either full time, part time, or on a consultant basis since March 8, 2024. It was also confirmed that the facility does not have a certified dietary manager.

28 Pa Code 201.18(e)(6) Management


 Plan of Correction - To be completed: 05/27/2024

1) No specific residents were cited.

2) A qualified dietitian has been offered a position by the facility with an anticipated start date of April 30, 2024.

3) Regional Vice President will educate Nursing Home Administrators that when a qualified dietitian leaves employment at the facility, alternate dietitian services will be obtained.

4) Audits will be conducted weekly x 4 weeks and then monthly X 2 months to validate the facility employs a qualified registered dietitian. Audits will be completed by the NHA/designee with trends reported through the QAPI committee.

5) Date of compliance: May 27, 2024

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 facility staff education records and staff interview, it was determined that the facility failed to ensure that all nurse aide staff completed a minimum of 12 hours of in-service education training each year for two of four nurse aides reviewed (Employees 2 and 3).

Findings include:

During an interview with the Nursing Home Administrator (NHA) and Employee 6, human resources director, scheduler, and payroll, on April 10, 2024, at 9:30 AM the surveyor requested evidence of annual in-service education for Employee 2, nurse aide, hired January 25, 2022, and Employee 3, nurse aide, hired February 2, 2016.

Interview with the NHA and Employee 6 on April 10, 2024, at 10:00 AM confirmed that Employee 2 only completed 6.26 hours and Employee 3 only completed 3.01 hours of the required 12 hours of annual in-service education, which included dementia training, abuse prevention training, and any areas of weakness or resident special care needs in the past year.

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

28 Pa. Code 201.20(a)(d) Staff development

28 Pa. Code 211.12(c) Nursing services


 Plan of Correction - To be completed: 05/27/2024

1) Employees 2 and 3 will complete the required 12 hours of annual in-service education.

2) A review of current certified nursing aides will be completed to validate they have completed the required 12 hours of annual in-service education. Corrective action will be taken as needed.

3) To prevent the deficient practice from recurrence–the Scheduling/Payroll coordinator will receive education by the Administrator regarding the need for nurse aide staff to have completed a minimum of 12 hours of in-service education training each year.

4) Audits will be conducted weekly x 4 weeks and then monthly X 2 months to validate nurse aides have completed the required 12 hours of annual in-service education. Audits will be completed by the NHA/designee with trends reported through the QAPI committee.

5) Date of compliance: May 27, 2024

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

Observations:

Based on staff interview and documentation review, it was determined that the facility did not comply with the requirements of the Act 52 Infection Control Plan.

Findings include:

The Act 52 Infection Control Plan, states that a health care facility should develop and implement an internal infection control plan that should be established for improving the health and safety of residents and health care workers and should include a multidisciplinary committee including a representative from each of the following, if applicable, to the specific health care facility:

(i) Medical staff that could include the chief medical officer or the nursing home medical director
(ii) Administration representatives that could include the chief executive officer, the chief financial officer, or the nursing home administrator
(iii) Laboratory personnel
(iv) Nursing staff that could include a director of nursing or a nursing supervisor
(v) Pharmacy staff that could include the chief of pharmacy
(vi) Physical plant personnel
(vii) A patient safety officer
(viii) Members from the infection control team, which could include an epidemiologist.
(ix) The community, except that these representatives may not be an agent, employee, or contractor of the health care facility.

Interview with the Administrator and Employee 4, Infection Control Preventionist, on April 10, 2024, at 10:45 AM revealed that the facility had no evidence of attendance of all required committee members at the infection control meetings. Review of attendees' signatures revealed that the facility had no evidence that laboratory personnel or a community member attended the meetings.


 Plan of Correction - To be completed: 05/27/2024

1) No resident or employee was identified.

2) The facility will complete an evaluation to determine that all required mandatory committee members of the Infection Control Committee, according to Act 52, have been identified and are available for the required committee meetings.

3) To prevent the deficient practice from recurrence– The Infection Preventionist and Infection Control Team will be re-educated by the NHA (Nursing Home Administrator)/designee to Act 52 requirements for quarterly meetings to include all required mandatory members.

4) Audits will be conducted quarterly for 6 months to ensure the facility has complied with the multidisciplinary committee requirements of the Act 52 Infection Control Plan. Audits will be completed by the NHA/designee with trends reported through the QAPI committee.

5) Date of compliance: May 27, 2024

§ 211.12(f.1)(2) LICENSURE Nursing services. :State only Deficiency.
(2) Effective July 1, 2023, a minimum of 1 nurse aide per 12 residents during the day, 1 nurse aide per 12 residents during the evening, and 1 nurse aide per 20 residents overnight.

Observations:

Based on a review of nursing staffing hours and staff interviews, it was determined that the facility failed to ensure a minimum of one nurse aide per 12 residents during the day shift for 19 of 21 days reviewed, one nurse aide per 12 residents during the evening shift for nine of 21 days reviewed, and one nurse aide per 20 residents during the night shift for four of the 21 days reviewed.

Findings include:

A review of nursing care hours provided by the facility from February 1-7, 2024, March 1-7, 2-24, and April 3-9, 2024, revealed the following on day shift:

February 4, 2024, census of 95 with 7.91 NAs, required 7.92 NAs
February 7, 2024, census of 95 with 7.75 NAs, required 7.92 NAs
March 3, 2024, census of 97 with 7.38 NAs, required 8.08 NAs
March 42024, census of 98 with 7.63 NAs, required 8.17 NAs
March 5, 2024, census of 99 with 7.88 NAs, required 8.25 NAs
March 6, 2024, census of 101 with 8.25 NAs, required 8.42 NAs
March 7, 2024, census of 101 with 7.75 NAs, required 8.42 NAs
April 4, 2024, census of 94 with 7.47 NAs, required 7.83 NAs
April 8, 2024, census of 93 with 7.63 NAs, required 7.75 NAs
April 9, 2024, census of 93 with 6.75 NAs, required 7.75 NAs

A review of nursing care hours provided by the facility from February 1-7, 2024, March 1-7, 2-24, and April 3-9, 2024, revealed the following on evening shift:

February 4, 2024, census of 95 with 7.00 NAs, required 7.92 NAs
February 5, 2024, census of 94 with 6.47 NAs, required 7.83 NAs
March 4, 2024, Census of 98 with 7.44 NAs, required 8.17 NAs
March 5, 2024, census of 99 with 7.75 NAs, required 8.25 NAs
March 6, 2024, census of 101 with 8.19 NAs, required 8.42 NAs
March 7, 2024, census of 101 with 8.31 NAs, required 8.42 NAs
April 3, 2024, census of 94 with 7.69 NAs, required 7.83 NAs
April 6, 2024, census of 93 with 6.50 NAs, required 7.75 NAs
April 9, 2024, census of 93 with 7.25 NAs, required 7.75 NAs

A review of nursing care hours provided by the facility from February 1-7, 2024, March 1-7, 2-24, and April 3-9, 2024, revealed the following on night shift:

February 6, 2024, census of 95 with 4.63 NAs, required 4.75 NAs
March 1, 2024, census of 98 with 4.88 NAs, required 4.90 NAs
March 2, 2024, census of 97 with 4.69 NAs, required 4.85 NAs
April 6, 2024, census of 93 with 3.75 NAs, required 4.65 NAs

Interview with the Administrator on April 10, 2024, at 9:17 AM confirmed the above noted findings.


 Plan of Correction - To be completed: 05/27/2024

1) There were no adverse effects to residents of the facility as a result of decreased staffing ratios on February 4, 5, 6, 7, March 1, 2, 3, 4, 5, 6, 7, April 3, 4, 6, 8, and 9 of 2024.

2) The Director of Nursing and Scheduling & Payroll Manager will be re-educated on the state requirement for nurse aide to resident staffing ratios by the Administrator/designee.

3) Staffing meetings will be held 5 days a week to review HPPD (hours per patient day) from the previous day, the projected nursing aide staff ratios for the current day, as well as the upcoming week to ensure appropriate staffing levels. If projected staffing levels do not meet the minimum nurse aide requirements, the facility will reach out to current staff and local staffing agencies to enlist additional staffing to meet the requirements. Facility will continue to recruit staff through all platforms.

4) Audits of HPPD and nursing aide staff ratios will be completed weekly x4 by the NHA/designee using the PA regulatory staffing worksheet to ensure nurse aide ratios meet the state minimums. Results of the audits will be forwarded to the center QAPI committee for review and recommendations.

5) Date of compliance: May 27, 2024

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

Based on a review of nursing staffing hours and staff interview, it was determined that the facility failed to ensure a minimum of one licensed practical nurse per 40 residents during the night shift on 11 of 21days reviewed.

Findings include:

Review of nursing staff care hours provided by the facility revealed the following licensed practical nurse (LPN) scheduled for the following resident census on night shift:

February 1, 2024, 2.38 LPNs for a census of 98, required 2.45
February 2, 2024, 2.25 LPNs for a census of 95, required 2.38
February 4, 2024, 2.25 LPNs for a census of 95, required 2.38
February 5, 2024, 2.13 LPNs for a census of 94, required 2.35
March 1, 2024, 2.28 LPNs for a census of 98, required 2.45
March 2, 2024, 2.22 LPNs for a census of 97, required 2.43
March 4, 2024, 2.19 LPNs for a census of 98, required 2.45
April 4, 2024, 2.13 LPNs for a census of 93, required 2.33
April 5, 2024, 2.25 LPNs for a census of 92, required 2.30
April 6, 2024, 2.18 LPNs for a census of 93, required 2.33
April 9, 2024, 1.50 LPNs for a census of 93, required 2.33

The above findings were confirmed with the Nursing Home Administrator on April 10, 2024, at 9:17 AM.


 Plan of Correction - To be completed: 05/27/2024

1) There were no adverse effects to residents of the facility as a result of decreased staffing ratios on February 1,2, 4, 5, March 1, 2, 4, April 4, 5, 6, and 9 of 2024.

2) The Director of Nursing and Scheduling & Payroll Manager will be re-educated on the state requirement for LPN to resident staffing ratios by the Administrator/designee.

3) Staffing meetings will be held 5 days a week to review HPPD (hours per patient day) from the previous day, the projected LPN staff ratios for the current day, as well as the upcoming week to ensure appropriate staffing levels. If projected staffing levels do not meet the minimum LPN requirements, the facility will reach out to current staff and local staffing agencies to enlist additional staffing to meet the requirements. Facility will continue to recruit staff through all platforms.

4) Audits of LPN staff ratios will be completed weekly x4 by the NHA/designee using the PA regulatory staffing worksheet to ensure LPN ratios meet the state minimums. Results of the audits will be forwarded to the center QAPI committee for review and recommendations.

5) Date of compliance: May 27, 2024


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