Pennsylvania Department of Health
MILFORD HEALTHCARE AND REHABILITATION CENTER
Patient Care Inspection Results

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MILFORD HEALTHCARE AND REHABILITATION CENTER
Inspection Results For:

There are  126 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.
MILFORD HEALTHCARE AND REHABILITATION 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 August 15, 2024, it was determined that Milford Healthcare and Rehabilitation Center was not in compliance with the following requirements of 42 CFR Part 483 Subpart B Requirements for Long Term Care Facilities and the 28 PA Code Commonwealth of Pennsylvania Long Term Care Licensure Regulations.


 Plan of Correction:


483.60(i)(4) REQUIREMENT Dispose Garbage and Refuse Properly: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)(4)- Dispose of garbage and refuse properly.
Observations:

Based on observation and staff interview, it was determined that the facility failed to properly dispose of garbage and refuse.

Findings include:

Observation on August 13, 2024, at 10:20 AM in the presence of the food service director revealed that the facility's dumpster, containing bags of garbage, was not covered. One of the two lids on the dumpster was observed open. There were food containers and debris scattered on the ground surrounding the dumpster.

Interview with the food service director at this time confirmed that the dumpster lid was to be kept closed and that the area surrounding the dumpster should be maintained in a sanitary manner.

28 Pa Code 201.8 (e)(2.1) Management


 Plan of Correction - To be completed: 09/18/2024

1. The dumpster was immediately covered, and the surrounding area was cleaned up on August 13, 2024. All garbage and debris were properly disposed of, and the area was thoroughly inspected to ensure it was restored to a sanitary condition.

2. An inspection of all waste disposal areas, including all dumpsters and refuse containers on the facility grounds, was conducted. New dumpsters were ordered and they now have a new and heavier lid that will assist with staying secured and closed.

3. The NHA educated the Food Service Director and Environmental Services staff on the importance of maintaining all waste disposal areas in a sanitary condition. This training emphasized the requirement to keep dumpster lids closed at all times and to promptly address any spills or scattered debris.


4. The environmental director or designee will conduct daily audits of all waste disposal areas to ensure area is free of debris and in a sanitary condition. Audits will ensure dumpster lids are secure and closed when not in use. Audits will be completed daily x4 weeks then monthly x2 months. Audits will be reviewed in QAPI.

483.25 REQUIREMENT Quality of Care:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
§ 483.25 Quality of care
Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices.
Observations:

Based on clinical record review, observation, and staff interviews, it was determined the facility failed to ensure care and services are provided in accordance with professional standards of practice that will meet each resident's physical, mental, and psychosocial needs for one of 16 residents reviewed (Residents 51).

Findings include:

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

Review of Resident 51's clinical record revealed admission to the facility on December 6, 2023, with diagnoses that included dementia (a chronic disorder of the mental processes caused by brain disease, and marked by memory disorders, personality changes, and impaired reasoning).

Review of an incident report dated July 2, 2024, indicated the resident had a skin tear on her right shin measuring approximately 7cm centimeters x 6cm.

A review of the resident's physicians orders revealed an order for a wanderguard bracelet (a bracelet that triggers alarms and can lock monitored doors to prevent the resident leaving unattended) due to the resident's risk of elopement.

Further review of the physician's order revealed no indication of where the bracelet was to be placed on the resident or to check the resident's skin below bracelet routinely.

A review of a nursing progress note dated July 14, 2024, revealed the area on resident's right shin had worsened due to swelling and the wanderguard bracelet digging into the skin on the right shin above the ankle.

There was no documented evidence the facility staff assessed that the placement of the wanderguard was appropriate after the resident developed skin tear. The facility failed to monitor the resident's skin where the wanderguard was placed resulting in worsening of the resident's wound.

An interview with the Nursing Home Administrator, and the Director of Nursing on August 15, 2024, at 11:10 AM, confirmed the facility failed to evaluate and assess the resident's wanderguard placement had to prevent further injury to Resident 51's skin.


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

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






 Plan of Correction - To be completed: 09/18/2024

1. The facility can not retroactively correct. The wanderguard bracelet was immediately removed from Resident 51's right shin, and the resident's skin was assessed by the nursing staff and treated per MD. A new properly positioned wanderguard bracelet was applied to an area less prone to injury. A care plan update was made to include specific instructions for monitoring the placement of the wanderguard and assessing the skin underneath at least once per shift.

2. DON/designee conducted an audit for residents currently using a wanderguard bracelet to ensure proper placement and to assess any potential skin issues. Care plans/orders were updated to include specific monitoring instructions.

3. DON/designee educated nursing staff on the facility's policy regarding the use of wanderguard bracelets . Education included guidelines on proper placement, routine skin assessments, and the documentation of these assessments. Training also provided on how to properly apply and monitor wanderguard bracelets to prevent skin damage.

4. DON or designee will perform random weekly audits on residents with wanderguard bracelets to ensure there is daily monitoring on the placement of the wanderguard along with skin checks underneath at least once per shift. Audits will also include ensuring care plans are in place showing placement, and skin checks. Audits will be completed weekly x4 weeks then monthly x2 months. Audits will be reviewed in QAPI.
483.10(g)(14)(i)-(iv)(15) REQUIREMENT Notify of Changes (Injury/Decline/Room, etc.):This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
§483.10(g)(14) Notification of Changes.
(i) A facility must immediately inform the resident; consult with the resident's physician; and notify, consistent with his or her authority, the resident representative(s) when there is-
(A) An accident involving the resident which results in injury and has the potential for requiring physician intervention;
(B) A significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications);
(C) A need to alter treatment significantly (that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment); or
(D) A decision to transfer or discharge the resident from the facility as specified in §483.15(c)(1)(ii).
(ii) When making notification under paragraph (g)(14)(i) of this section, the facility must ensure that all pertinent information specified in §483.15(c)(2) is available and provided upon request to the physician.
(iii) The facility must also promptly notify the resident and the resident representative, if any, when there is-
(A) A change in room or roommate assignment as specified in §483.10(e)(6); or
(B) A change in resident rights under Federal or State law or regulations as specified in paragraph (e)(10) of this section.
(iv) The facility must record and periodically update the address (mailing and email) and phone number of the resident
representative(s).

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

Based on review of select facility policy and clinical records, and staff interview, it was determined the facility failed to timely notify the physician and the resident's representative of an incident with the potential to require physician intervention for one resident out of 16 sampled (Resident 115).

Findings include:

A review of the facility Change in Resident's Condition or Status Policy last reviewed, June 2024, revealed it is the policy of the facility to promptly notify the resident, his or her attending physician, and resident representative of changes in the resident's medical/mental condition and/or status.

A review of the clinical record revealed Resident 115 was discharged from the facility to the hospital on July 27, 2024, and readmitted to the facility on August 7, 2024, with diagnoses which included a urinary tract infection, cerebral infarction (stroke), and seizures. A Midline catheter (a long, thin, flexible tube that is inserted into a vein in the upper arm to safely administer medication or fluids into the bloodstream) was present in the resident's arm upon readmission to the facility.

A nurses note dated August 12, 2024, at 5:38 PM noted the Midline catheter was assessed after the flush showed leaking around the dressing. The Midline catheter was dislodged. It was removed and measured eight centimeters. Further it was noted the tubing was intact. The area was cleansed and dressed with a dry sterile dressing and Tegaderm (dressing used to protect catheter sites) was applied.

A late entry nurses note dated August 14, 2024 (two days after the incident), noted the physician was notified that the Midline catheter was dislodged, removed, and was intact.

Further review of the clinical record revealed no documented evidence the resident's resident representative was notified of the dislodgement and discontinuation of the Midline catheter.

An interview with the Director of Nursing (DON) on August 14, 2024, at approximately 11:00 AM failed to provide documented evidence the facility timely notified the resident's attending physician of the dislodgement and removal of the resident's Midline catheter. The DON confirmed there was no documented evidence the resident's resident representative was notified of the dislodgement and removal of the Midline catheter.


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









 Plan of Correction - To be completed: 09/18/2024

1-Facility cannot retroactively correct. The physician was notified immediately upon identification of the deficiency. The resident's representative was informed of the incident during the correction process. Late entry in resident #115 EHR chart added showing notification for incident that occurred on August 12, 2024.



2. DON/Designee will complete a comprehensive audit of the last 30 days of clinical record to ensure that current residents who experienced changes in condition had their physician and representatives notified promptly. Any discrepancies found were addressed immediately, with notifications made as required. DON/ADON/RN supervisors will be trained on running a 24 hour nursing summary report to ensure compliance. The Director of Nursing/designee will be responsible for reviewing these reports and following up on any missed notifications.

3. DON/Designee will educate licensed nursing staff on the facilities policy of notification with change in condition. Education will also emphasis on timely notification as well as documenting both the notification to the physician and to the resident's responsible party in the residents EHR.

4. The DON/designee will conduct random weekly audits of resident charts to ensure compliance with notification to MD and RP with change in conditions. Audits will be conducted weekly x 4 weeks than monthly x 2 weeks. Audits will be reviewed in QAPI.


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 a review of clinical records, and staff interview, it was determined the facility failed to address a resident's skin condition on the comprehensive care plan for one out of 16 sampled residents (Resident 23).

Findings include:

A review of the clinical record revealed Resident 23 was admitted to the facility on May 15, 2023, with diagnoses which include congestive heart failure, cerebrovascular accident (CVA- stroke, interruption in the flow of blood to cells in the brain), and rheumatoid arthritis.

A physician order dated June 27, 2024, noted an order to apply Zinc to buttocks every shift for skin protectant/moisture barrier.

A wound progress note dated August 1, 2024, indicated the resident's sacrum (large, triangle-shaped bone in the lower spine that forms part of the pelvis) was assessed and was noted to have MASD (Moisture-associated skin damage caused by prolonged exposure to various sources of moisture, including urine or stool, or perspiration) of the epidermis resulting from prolonged exposure to various sources of moisture and potential irritants measuring 3 cm (centimeters) x 5 cm x 0.1 cm. The area is open with light serous exudate (clear, thin, watery plasma that is a normal part of wound healing). The treatment plan was to apply Zinc ointment twice daily for 30 days. Further recommendations included, limit sitting to 60 minutes, off-load wound, reposition per facility protocol, turn side to side in bed every one to two hours if able.

A wound progress note dated August 8, 2024, indicated that the MASD on the resident's sacrum now measures 3 cm x 4 cm x 0.1 cm. the area is open with light serous exudate and noted to be improved. The dressing treatment plan was to continue to apply Zinc ointment twice daily for 30 days. Further the recommendations were to continue to limit sitting to 60 minutes, off-load wound, reposition per facility protocol, turn side to side in bed every one to two hours if able.

A review of Resident 23's comprehensive plan of care (a tool used to organize aspects of patient care) conducted during the survey on August 14, 2024, revealed the resident's care plan did not address the resident's moisture associated skin disorder, treatment, and specific interventions to prevent recurrence.

Interview with the Director of Nursing on August 14, 2024, at approximately 10:30 AM confirmed the resident received treatment for the MASD, and the MASD was not addressed on the resident's care plan along with preventative measures to address the resident's identified risk factors to promote optimal healing and prevent recurrence.



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


 Plan of Correction - To be completed: 09/18/2024

1. The comprehensive care plan for Resident 23 was updated to include the resident's MASD diagnosis, the current treatment plan, and specific interventions, including the application of Zinc ointment, repositioning schedules, off-loading pressure, and limiting sitting time. A care conference was held with the interdisciplinary team to review and update the care plan and ensure interventions are appropriate to meet the needs of the resident.

2. DON/Designee will audit current residents with skin conditions to ensure that their care plans are accurate and reflect their diagnoses, treatments, and preventive interventions. The facility implemented a weekly interdisciplinary team (IDT) review of resident care plans, focusing on residents with high-risk conditions such as skin issues. During these reviews, the team will ensure care plans are comprehensive, up-to-date, and include specific interventions for identified risks.

3. The NHA/designee will educate the IDT on the weekly skin risk meeting implemented which will review resident care plans, focusing on residents with high-risk conditions such as skin issues. During these reviews, the team will be educated to ensure care plans are comprehensive, up-to-date, and include specific interventions for identified risks. The DON/designee will educate the licensed nursing staff on care planning and the importance updating comprehensive care plans to include aspects of resident care, particularly in response to new orders, treatments, or changes in condition, and interventions and preventative measures.

4. The DON or designee will conduct weekly audits to ensure weekly risk meetings are completed and that residents' care plans are updated reflecting any skin conditions and or other high-risk factors as well as appropriate interventions to meet the plan of care provided. Audits will be completed weekly x4 weeks than monthly x 2 months. Audits will be reviewed in QAPI.

483.25(b)(1)(i)(ii) REQUIREMENT Treatment/Svcs to Prevent/Heal Pressure Ulcer:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
§483.25(b) Skin Integrity
§483.25(b)(1) Pressure ulcers.
Based on the comprehensive assessment of a resident, the facility must ensure that-
(i) A resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable; and
(ii) A resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing.
Observations:

Based on review of clinical records, select facility reports, observations and staff interview it was determined the facility failed to consistently provide care and services to to prevent the development and/or worsening of pressure sores and promote healing for one resident out of 16 residents sampled (Resident 6).

Findings include:

According to the US Department of Health and Human Services, Agency for Healthcare Research & Quality, the pressure ulcer best practice bundle incorporates three critical components in preventing pressure ulcers: Comprehensive skin assessment, Standardized pressure ulcer risk assessment and care planning and implementation to address the areas of risk.

The American College of Physicians (ACP) is a national organization of internists, who specialize in the diagnosis, treatment, and care of adults. The largest medical-specialty organization and second-largest physician group in the United States) Clinical Practice Guidelines indicate that the treatment of pressure ulcers should involve multiple tactics aimed at alleviating the conditions contributing to ulcer development (i.e. support surfaces, repositioning and nutritional support); protecting the wound from contamination and creating and maintaining a clean wound environment; promoting tissue healing via local wound applications, debridement and wound cleansing; using adjunctive therapies; and considering possible surgical repair.

A review of Resident 6's clinical record revealed that the resident was admitted to the facility was on June 10, 2022, with diagnoses that included end stage renal disease with dependence on renal dialysis, diabetes, amputation of bilateral legs above the knees and obesity.

A review of Resident 6's care plan initiated August 29, 2023, revealed the resident was at risk for alteration in skin integrity related to impaired mobility, incontinence, and history of scratching, with interventions which included encourage and assist to reposition, encourage resident to remove stump socks at bedtime, provide preventative skin care after each incontinent episode and as needed, pressure reduction device on chair, encourage/assist to suspend/float upper legs to keep stumps off pressure surface, and administer preventative skin treatment per physician orders.

Review of a facility investigation dated August 3, 2024, at 8:00 PM, revealed that Resident 6 had a wound that was identified in the left groin. According to the event description, the area was a small hole in patient's groin. Slight bleeding was noted. No pain was indicated. The wound tunneled about a half inch inwards, but diameter was too small to pack. Wound was cleansed with normal saline solution and covered with a dry dressing, Further it was indicated a pending assessment will be completed by treatment team.

Review of Change in Condition Evaluation form dated August 3, 2024, at 10:01 PM, indicated that Resident 6 stated she did not scratch the site accidentally and she was unaware it was there. The physician was notified and ordered the resident to be seen by treatment team.

The facility failed to provide evidence that Resident 6's tunneling wound acquired on August 3, 2024, was evaluated by the facility's treatment team. There was no evidence that the wound was evaluated for size, drainage, or condition of surrounding tissue.

According to additional tracking/monitoring of the wound completed by the DON, the open area on Resident 6's left groin was stable, and as of August 12, 2024, the wound measurements were less than 0.1cm x less than 0.1cm and had no depth or drainage. The form further indicated that the resident would be seen by wound care consultant on August 15, 2024.

An interview with the Director of Nursing on August 14, 2024, at approximately 11 AM indicated that the initial description of the wound was based on "perception" and the initial nurse's evaluation of the wound was inaccurate.

On August 14, 2024, at approximately 2:30 PM, the Director of Nursing presented surveyor with a paper Wound Evaluation Flow Sheet which was not found in the resident's clinical records initially dated August 3, 2024, which indicated that the wound measured less than 0.1cm x less than 0.1cm and had no depth, despite the documentation that the wound tunneled approximately a half inch. According to the wound evaluation form completed by the Director of Nursing, the wound did not have drainage, and the surrounding tissue was WNL (within normal limits).

Observation of Resident 6's left groin on August 15, 2024, at approximately 8:45 AM, in the presence of Employee 1, registered nurse, revealed an open area which measured approximately 1cm x 1cm with visible depth. Employee 1 did not have depth measuring tool at time of observation. The wound bed was deep red, and surrounding tissue was excessively moist with white substance that appeared fungal in the skin folds. There was no treatment in place at time of observation.

Review of wound care consultant evaluation completed on August 15, 2024, revealed that the full thickness(damage extends past the epidermis and dermis, and into the subcutaneous tissue, muscle, bone, or tendons) wound in the left groin measured 0.5cm x 1cm x 0.5cm with a moderate amount of serous (clear) drainage, and 100% granulation (healthy) tissue. Recommendation to discontinue current treatment of dry dressing to wound and apply alginate calcium (highly absorbent and non-occlusive dressing that forms a soft gel when in contact with wound drainage) daily with a gauze island with boarder for 30 days.

Interview with the Director of Nursing on August 15, 2024, at approximately 2:10 PM, confirmed that the facility failed to properly assess Resident 6's pressure area and implement interventions to prevent worsening and promote healing in a timely manner.

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




 Plan of Correction - To be completed: 09/18/2024

1. Facility can not retroactively correct. The wound care provider/wound team reassessed Resident #6 and documented the wound's size, depth, drainage, and surrounding tissue condition into the resident's clinical record. The resident's care plan was revised to include specific interventions to monitor and manage the wound effectively, frequency of skin assessments and wound evaluations will
Be completed weekly or more as needed.



2. The DON/designee conducted an audit on current residents with pressure sores and or those at risk for developing pressure sores to ensure their wounds are being properly assessed, documented, and treated per plan of care. For residents with existing wounds, the wound care team reviewed each wound, updated treatment plans as necessary, and ensured all findings were accurately documented in the clinical records. Care plans were reviewed and updated to reflect current interventions and preventive measures. The facility has a new wound provider called Vohra who is scheduled to come out weekly to round and assess residents with skin impairments.

3. The NHA will educate the DON/ADON as well as the wound care nurse on ensuring skin conditions have weekly assessments completed with a focus on the importance of comprehensive skin assessments, accurate and timely documentation of wound conditions, and the implementation of appropriate interventions to prevent and treat pressure sores. Specific training was provided on the use of wound assessment tools, including accurate measurement of wound dimensions and assessment of wound depth and surrounding tissue.

4. The Director of Nursing (DON) or designee will conduct random audits weekly of residents with pressure sores or skin impairments to ensure weekly assessments are complete by wound team verifying that wounds are being properly assessed, documented, and treated according to the plan of care. care plans will be audited to ensure plan of care reflects care plan in place. Audits will be conducted weekly x4 weeks then monthly x2 months. Audits will be reviewed in QAPI.
483.25(h) REQUIREMENT Parenteral/IV Fluids: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(h) Parenteral Fluids.
Parenteral fluids must be administered consistent with professional standards of practice and in accordance with physician orders, the comprehensive person-centered care plan, and the resident's goals and preferences.
Observations:

Based on review of clinical records and select facility policy, staff and resident interviews it was determined the facility failed to ensure that a physician ordered intravenous (IV- medication is administered through needle or tube inserted into a vein) medication, an antibiotic, was timely administered as prescribed for one resident out of 16 sampled (Resident 115).

Findings include:

Review of the facility policy titled "Administering Medications" last reviewed by the facility on June 24, 2024, indicated that medications are administered in a safe and timely manner and as prescribed. It indicated that medications are administered in accordance with prescriber orders, including any required time frame. Medication errors are documented, reported, and reviewed by the QAPI (Quality Assurance and Performance Improvement) committee to inform process changes and/or the need for additional staffing. Prescribed medications are to be administered within one hour of their prescribed time, unless otherwise specified.

Review of Resident 115's clinical record revealed that the resident was readmitted to the facility on August 7, 2024, with a Midline Catheter [tube placed into a vein in the upper arm to provide vascular access and for IV (intravenous- method to deliver fluids or medications directly into a vein using a needle or tube) treatments] and diagnoses to include urinary tract infection and sepsis (extreme immune response to infection that can lead to tissue damage, organ failure, or death if not treated right away).

A physician order dated August 8, 2024, at 12:44 PM was noted for Ceftazidime (an antibiotic used to treat bacterial infections) 1000 MG intravenously two times per day for urinary tract infection for three days.

Review of a Scheduling Detail Report dated August 8, 2024, noted that the first dose was to be administered on August 8, 2024, at 10:00 PM.

Review of Resident 115's Medication Administration Record dated August 8, 2024, through August 11, 2024, revealed that the physician ordered intravenous antibiotic medication, Ceftazidime, was not administered to the resident on August 8, 2024, at 10:00 PM as prescribed.

A nurse progress note dated August 8, 2024, noted that the scheduled 10:00 PM dose was not administered due to awaiting delivery from pharmacy.

Interview with the Director of Nursing (DON) on August 15, 2024, at 12:00 PM, confirmed that the facility failed to timely administer the first dose of the IV antibiotic therapy prescribed for Resident 115, and failed to notify the attending physician of the missed dose on August 8, 2024.

Refer F755

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

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

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


 Plan of Correction - To be completed: 09/18/2024

1. Facility can not retroactively correct. The missed dose of Ceftazidime was administered as soon as the medication was delivered. Resident 115 had a medication error incident report completed. It was noted for resident 115 that there was no negative outcomes based on this medication error.

2. DON/designee did a 30 day look back on residents who were ordered an antibiotic IV to review their administration to ensure medication was administered timely and per physicians order. This look back showed no other medication error. The facility will collaborate with the contracted pharmacy to establish more effective communication channels to prevent delays in medication delivery. This will include:
- Review of the E-Kit and inventory and adding into E-kit antibiotic IV mediations.
-utilization of back of pharmacy if needed.


3. The DON/designee will educate licensed nursing staff on the facilities policy called "Administering Medications". Specific education will be provided to licensed staff on the following:
-The Immediate notification of the attending physician if a prescribed medication cannot be administered as scheduled.

-Documentation and the importance of timely administration of medications and the proper procedure for reporting and documenting missed doses.

- the use of the Back up pharmacy if necessary and or utilizing the E-kit and understanding the inventory of what is on hand and communicating this with the MD.

4. The DON/Designee will conduct weekly audits of Medication Administration Records (MARs) for residents who receive and have orders for IV antibiotics to ensure compliance with timely medication administration. Audits will be conducted weekly x4 weeks then monthly x2 months. Audits will be reviewed in QAPI.
483.25(l) REQUIREMENT Dialysis: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(l) Dialysis.
The facility must ensure that residents who require dialysis receive such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences.
Observations:

Based on observations, clinical record review and staff interview it was determined that the facility failed to ensure the ready availability of necessary emergency supplies for a resident receiving hemodialysis for one of 16 residents sampled. (Resident 6)

Findings include:

According to the National Kidney Foundation patients receiving hemodialysis (a machine filters wastes, salts and fluid from your blood when your kidneys are no longer healthy enough to do this work adequately) should keep emergency care supplies on hand.

A review of Resident 6's clinical record revealed that the resident was admitted to the facility was on June 10, 2022, with diagnoses that included end stage renal disease (a chronic kidney disease that occurs when the kidneys can no longer function properly) and dependence on renal dialysis.

Review of the resident's current plan of care, dated June 11, 2022, and last revised May 22, 2024, revealed that the resident required dialysis related to end stage renal failure along with a care planned approach to have emergency clamp kept at bedside for access site, check access site daily fistula/graft/catheter left forearm for signs of infection, and observe thrill and bruit and document findings, report abnormal findings to physician.

Observation conducted on August 13, 2024, at 11:55 AM revealed that there were no emergency supplies available in the resident's room or on the resident's wheelchair.

Interview with Employee 2, registered nurse, on August 13, 2024, at 11:58 AM, confirmed that no emergency supplies for Resident 6's dialysis access site were available in the resident's room or on her wheelchair. Employee 2 further confirmed that the emergency supplies were to be available at the bedside.

Interview with the Director of Nursing on August 15, 2024, at approximately 1:45 PM confirmed the facility failed to ensure the ready availability of necessary emergency supplies at the resident's bedside and that the care plan reflected the required plan of care for the dialysis access site in the event of an emergency.

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


 Plan of Correction - To be completed: 09/18/2024

1. On August 13, 2024, emergency supplies, including the necessary clamp for the dialysis access site, were immediately placed at Resident 6's bedside and attached to the resident's wheelchair. The resident's care plan was reviewed and confirmed to ensure it accurately reflects the requirement for emergency supplies to be available at all times. The care plan was updated to include clear instructions for the placement and maintenance of these supplies.

2. DON/designee audited current residents in house who receive dialysis to ensure emergency kits were/are available at all times. Facility also established an order that populates to the MAR/TAR that has a sign off for daily checks to confirm the presence and condition of these supplies.

3. DON/designee will educated licensed nursing staff on the importance of ensuring the availability of emergency supplies for residents receiving hemodialysis are available. Training will include daily monitoring system that will be implemented whereby nursing staff will check that all necessary emergency supplies are present at the bedside and on the wheelchairs of residents receiving hemodialysis. This will be documented in the MAR/TAR.

4. The DON/Designee will conduct weekly audits on residents who are receiving hemodialysis to ensure an emergency kit is at bedside and on/in wheelchair. Audits will also be completed on ensuring an order is in place and being signed off daily by licensed staff on checking emergency kit and placement of emergency kit. Audits will be conducted weekly and than monthly x2 months. Audits will be reviewed in QAPI.

483.40 REQUIREMENT Behavioral Health Services: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.
§483.40 Behavioral health services.
Each resident must receive and the facility must provide the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. Behavioral health encompasses a resident's whole emotional and mental well-being, which includes, but is not limited to, the prevention and treatment of mental and substance use disorders.
Observations:

Based on clinical record review and staff interviews, it was determined that the facility failed to ensure each resident received the necessary behavioral health care in a timely manner to attain or maintain the highest practicable mental and psychosocial well-being for one of 15 residents sampled (Resident 59).

Findings include:

A review of Resident 59's clinical record revealed the resident was admitted to the facility on May 18, 2024, with diagnoses including unspecified dementia (a loss of cognitive functioning that can make it difficult for someone to perform daily activities).

Further review of Resident 59's clinical record revealed that the resident exhibited behaviors, including making statements regarding suicidal ideations.

Review of Resident 59's care plan, initiated by the facility on May 18, 2024, did not indicate that the resident had a behavioral problem. The resident's care plan did not address the resident's specific behavioral problems or symptoms that were noted in the nursing documentation.

Review of a Psychological evaluation dated June 6, 2024, indicated that Resident 59 was making statements of wanting to kill herself. Recommendations indicated that Resident 59 would benefit from continued psychological services.

A review of a nursing progress note dated August 13, 2024, revealed the resident had told her daughter she wanted to kill herself. Further review of the resident's clinical record revealed that the physician was made aware of these statements, however social services, and psychological services were not made aware of these statements.

The facility failed to update to the resident's care plan to address the mental health needs of the resident after she was voicing thoughts of harming herself.

During an interview with the Nursing Home Administrator (NHA), on August 15, 2024, at approximately 10:00 AM, the NHA was unable to provide evidence that Resident 59 was being provided psychological services to maintain the highest practicable level of mental and psychosocial wellbeing.


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

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



 Plan of Correction - To be completed: 09/18/2024

1. Facility cannot retroactively correct. Upon identification of the deficiency, Resident 59's care plan was immediately updated to address her mental health needs, including her expressed suicidal ideations. The care plan now includes specific interventions for monitoring and managing her behavioral health symptoms. Social services and psychological services were promptly notified and consulted. Resident 59 was referred to a psychologist, in which she refused to be seen that week. ongoing psychological support was initiated to address her mental and psychosocial well-being.


2. The Social worker/DON/designee will review incident reports/notes within the last 30 days related to behavioral health to ensure that appropriate actions were taken, and care plans were updated accordingly. Facility initiated a mandatory notification procedure for social services, psychological services, and the interdisciplinary team whenever a resident exhibits behaviors indicating a potential mental health crisis.

3. NHA/designee will educate nursing staff and social services on Immediate documentation of the resident's behavior in the clinical record and notification of the physician, social services, and psychological services. Education will also include updating care plans to reflect current behavioral health needs and interventions. NHA will educate social services to conduct a prompt evaluation and coordinate with the psychology team to ensure that the resident receives timely and appropriate mental health care.

4. The DON/designee will audit incident reports/notes weekly related to behavioral health to ensure that appropriate actions were taken, and care plans were updated accordingly. Audits will be completed weekly x4 weeks then monthly x 2 months. Audits will be reviewed in QAPI.
483.45(a)(b)(1)-(3) REQUIREMENT Pharmacy Srvcs/Procedures/Pharmacist/Records: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 Pharmacy Services
The facility must provide routine and emergency drugs and biologicals to its residents, or obtain them under an agreement described in §483.70(g). The facility may permit unlicensed personnel to administer drugs if State law permits, but only under the general supervision of a licensed nurse.

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

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

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

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

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

Based on review of clinical records and staff interview it was determined that the facility failed to provide pharmacy services to assure timely receiving of a prescribed antibiotic medication for one resident out of 16 residents reviewed (Resident 115).

Findings include:

Review of clinical record revealed that Resident 115, was readmitted to the facility on August 7, 2024, with diagnoses to include urinary tract infection and sepsis (extreme immune response to infection that can lead to tissue damage, organ failure, or death if not treated right away).

A physician order dated August 8, 2024, at 12:44 PM was noted for Ceftazidime (an antibiotic used to treat bacterial infections) 1000 MG intravenously (a method of administering a substance, such as medicine or fluid, into a vein through a needle or tube) two times per day for urinary tract infection for three days.

Review of a Scheduling Detail Report dated August 8, 2024, noted that the first dose was to be administered on August 8, 2024, at 10:00 PM.

Review of Resident 115's Medication Administration Record dated August 8, 2024, through August 11, 2024, revealed that the physician ordered intravenous antibiotic medication, Ceftazidime, was not administered to the resident on August 8, 2024, at 10:00 PM as prescribed.

Interview with the director of nursing on August 15, 2024, at 12:00 PM confirmed the facility failed to timely provide Resident 115's first dose of intravenous antibiotic medication as prescribed because it was not available in the facility as the facility's pharmacy did not timely deliver the antibiotic drug.

Refer F694

28 Pa. Code 211.9 (a)(l)(d)(k) Pharmacy Services.

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



 Plan of Correction - To be completed: 09/18/2024


1. Facility can not retroactively correct. The missed dose of Ceftazidime was administered as soon as the medication was delivered. Resident 115 had a medication error incident report completed. It was noted for resident 115 that there was no negative outcomes based on this medication error.

2. DON/designee did a 30 day look back on residents who were ordered an antibiotic IV to review their administration to ensure medication was administered timely and per physicians order. This look back showed no other medication error. The facility will collaborate with the contracted pharmacy to establish more effective communication channels to prevent delays in medication delivery. This will include:
- Review of the E-Kit and inventory and adding into E-kit antibiotic IV mediations.
-utilization of back of pharmacy if needed.


3. The DON/designee will educate licensed nursing staff on the facilities policy called "Administering Medications". Specific education will be provided to licensed staff on the following:
-The Immediate notification of the attending physician if a prescribed medication cannot be administered as scheduled.
-Documentation and the importance of timely administration of medications and the proper procedure for reporting and documenting missed doses.
- the use of the Back up pharmacy if necessary and or utilizing the E-kit and understanding the inventory of what is on hand and communicating this with the MD.

4. The DON/Designee will conduct weekly audits of Medication Administration Records (MARs) for residents who receive and have orders for IV antibiotics to ensure compliance with timely medication administration. Audits will be conducted weekly x4 weeks then monthly x2 months. Audits will be reviewed in QAPI.
§ 211.6(a) LICENSURE Dietary Services.:State only Deficiency.
(a) Menus shall be planned and posted in the facility or distributed to residents at least 2 weeks in advance. Records of menus of foods actually served shall be retained for 30 days. When changes in the menu are necessary, substitutions shall provide equal nutritive value.

Observations:

Based on observation and resident and staff interviews, it was determined the facility failed to post facility menus in the facility or distribute to residents at least two weeks in advance for two of two nursing units (First Floor and Second Floor).

Findings include:

Observation during tour of the First and Second Floor Nursing Units on August 13, 2024, at approximately 10:00 AM revealed that a menu for the day was posted on a bulletin board on each nursing unit.

During a group interview on August 14, 2024, at 10:30 AM with Residents 20, 54, 40, 43, 32, and 29, the residents revealed that they were aware of the posted daily menu but were not provided with two weeks of the facility menu and that the facility did not post two weeks of the facility menu.

Interview with the food service director on August 14, 2024, at approximately 1:00 PM confirmed that menus were not posted two weeks in advance or distributed to residents two weeks in advance as required.


 Plan of Correction - To be completed: 09/18/2024

1. Facility can not retroactively correct.


2. The facility immediately began posting the daily menu along with the complete two-week menu cycle on bulletin boards located on the First and Second Floor Nursing Units on August 14, 2024. Copies of the two-week menu were distributed to all residents on both nursing units on the same day to ensure they have access to future meal planning.

3. The NHA will educate The Food Service Director on ensuring that two-week menus are posted on all nursing unit bulletin boards and distributed to residents no later than two weeks prior to the start of each menu cycle.


4. The Food Service Director or designee will conduct weekly audits to ensure that two-week menus are consistently posted and distributed on time. Audits will be completed weekly x4 weeks then monthly x2 months. Audits will be reviewed in QAPI.

§ 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 nurse staffing and staff interview, it was determined the facility failed to ensure the minimum licensed practical nurse staff to resident ratio was provided on each shift for 11 shifts out of 63 reviewed.

Findings include:

A review of the facility's weekly staffing records revealed that on the following dates the facility failed to provide minimum licensed practical nurse (LPN) staff of 1:40 on the night shift based on the facility's census.

July 1, 2024- 1.63 LPNs on the night shift, versus the required 1.70 for a census of 68.
July 2, 2024- 1.65 LPNs on the night shift, versus the required 1.68 for a census of 67.
July 5, 2024- 1.0 LPNs on the night shift, versus the required 1.60 for a census of 64.
July 6, 2024- 1.0 LPNs on the night shift, versus the required 1.60 for a census of 64.
July 21, 2024- 1.0 LPNs on the night shift, versus the required 1.65 for a census of 66.
July 23, 2024- 1.0 LPNs on the night shift, versus the required 1.60 for a census of 64.
August 8, 2024- 1.0 LPNs on the night shift, versus the required 1.55 for a census of 62.
August 9, 2024- 1.0 LPNs on the night shift, versus the required 1.55 for a census of 62.
August 10, 2024- 1.0 LPNs on the night shift, versus the required 1.55 for a census of 62.
August 11, 2024- 1.0 LPNs on the night shift, versus the required 1.55 for a census of 62.
August 12, 2024- 1.0 LPNs on the night shift, versus the required 1.50 for a census of 60.

No additional excess higher-level staff were available to compensate for this deficiency.

An interview with the Nursing Home Administrator on August 15, 2024, at 10:00 AM confirmed the facility had not met the required LPN to resident ratios on the night shift on the above dates.


 Plan of Correction - To be completed: 09/18/2024

1. Facility can not retroactively correct.

2. Facility can not retroactively correct, Facility will continue to recruit and retain LPN staff through a variety of services.

3. NHA/Designee will educate the scheduler and IDT on the staffing Ratios.

4.DON or designee will conduct review of staffing deployment assignments daily to ensure the staffing ratio is being met for a period of 4 weeks and a weekly review x 2 months. Results of the audit will be presented for review and recommendations at the monthly QAPI meeting.

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