Nursing Investigation Results -

Pennsylvania Department of Health
MORRISONS COVE HOME
Patient Care Inspection Results

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
MORRISONS COVE HOME
Inspection Results For:

There are  60 surveys for this facility. Please select a date to view the survey results.

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MORRISONS COVE HOME - 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 a Civil Rights Compliance survey completed on March 24, 2022, it was determined that Morrisons Cove Home 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:


483.10(f)(4)(ii)-(v) REQUIREMENT Right to Receive/Deny Visitors:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
483.10(f)(4) The resident has a right to receive visitors of his or her choosing at the time of his or her choosing, subject to the resident's right to deny visitation when applicable, and in a manner that does not impose on the rights of another resident.
(ii) The facility must provide immediate access to a resident by immediate family and other relatives of the resident, subject to the resident's right to deny or withdraw consent at any time;
(iii) The facility must provide immediate access to a resident by others who are visiting with the consent of the resident, subject to reasonable clinical and safety restrictions and the resident's right to deny or withdraw consent at any time;
(iv) The facility must provide reasonable access to a resident by any entity or individual that provides health, social, legal, or other services to the resident, subject to the resident's right to deny or withdraw consent at any time; and
(v) The facility must have written policies and procedures regarding the visitation rights of residents, including those setting forth any clinically necessary or reasonable restriction or limitation or safety restriction or limitation, when such limitations may apply consistent with the requirements of this subpart, that the facility may need to place on such rights and the reasons for the clinical or safety restriction or limitation.
Observations:


Based on a review of facility policies, guidance from the Centers for Medicare and Medicaid Services, as well as resident, resident representatives and staff interviews, it was determined that the faciltiy failed to ensure that the residents were provided unrestricted visitation.

Findings include:

The facility's policy for visitation, dated April 9, 2021, indicated that the facility would document screening for all visitors. The visitor would be escorted to and from the resident's room or designated visitation area and remain there for the duration of the visit. The visitor would complete the education form regarding "how to safely visit a nursing home resident." Scheduling a visit is recommended but not required with normal visiting hours from 8:00 a.m. to 4:00 p.m.

The Centers for Medicare and Medicaid Services Memorandum QSO-20-39 revised on November 12, 2021 indicated that facilities must allow indoor visitation at all times and for all residents as permitted under the regulations. While previously acceptable during the Public Health Emergency (PHE), facilities can no longer limit the frequency or length of visits for residents, the number of visitors, or require advance scheduling of visits. Although there is no limit on the number of visitors that a resident can have at one time, visits should be conducted in a manner that adheres to the core principles of COVID-19 infection prevention and does not increase risk to other residents. Facilities should ensure that physical distancing can still be maintained during peak times of visitation (e.g., lunch time, after business hours, etc.). Also, facilities should avoid large gatherings (e.g., parties, events) where large numbers of visitors are in the same space at the same time and physical distancing cannot be maintained. During indoor visitation, facilities should limit visitor movement in the facility. For example, visitors should not walk around different halls of the facility. Rather, they should go directly to the resident's room or designated visitation area. Facilities may contact their local health authorities for guidance or direction on how to structure their visitation to reduce the risk of COVID-19 transmission. If a resident's roommate is unvaccinated or immunocompromised (regardless of vaccination status), visits should not be conducted in the resident's room, if possible. For situations where there is a roommate and the health status of the resident prevents leaving the room, facilities should attempt to enable in-room visitation while adhering to the core principles of infection prevention. If the nursing home's county COVID-19 community level of transmission is substantial to high, all residents and visitors, regardless of vaccination status, should wear face coverings or masks and physically distance at all times. In areas of low to moderate transmission, the safest practice is for residents and visitors to wear face coverings or masks and physically distance, particularly if either of them is at increased risk for severe disease or are unvaccinated. If the resident and all of their visitors are fully vaccinated and the resident is not moderately or severely immunocompromised, they may choose not to wear face coverings or masks and to have physical contact. Visitors should wear face coverings or masks when around other residents or healthcare personnel, regardless of vaccination status.

The facility's admission packet, undated, indicated that each resident has the right to say who may or may not have access to the nursing faciltiy for the purpose of visiting with them.

An interview with a group of residents on March 22, 2022, at 1:00 p.m. revealed that their families have to make an appointment to visit. Visitors and residents have to meet in the room on the first floor and may only visit for 30 minutes. The residents indicated that they would like to visit with their families in their rooms and be able to visit longer.

The facility's automated phone message that informed resident representatives of the facility's COVID (disease caused by a virus which can cause severe illness) updates indicated that as of March 1, 2022, the facility was in green status (no residents with COVID) and for source control measures (infection control prevention measures to prevent the spread of infection) they were directed to coordinate visits ahead of time by calling the activity director.

Interview with Resident Family Member 1 on March 22, 2022, at 4:17 p.m. indicated that to visit he had to call and set up a visitation time and that the scheduled appointment is 30 minutes to one hour long. The facility's procedure was to bring his mother from her to a room down to the first floor room to visit.

Interview with Resident Family Member 2 on March 22, 2022, at 4:56 p.m. indicated that she had to schedule appointments to visit. The facility was usually able to fit her into the schedule but her visits were usually only 30 minutes long. Resident Family Member 2 also has two siblings who live over two hours away and they only had 30 minute visitations. When visiting, they do not go to her room, her mother is brought down to the first floor to visit. Resident Family Member 2 indicated that it would be nice if she could visit in her mother's room once in a while, which would make it more personable for her. It would also be easier to visit if she did not have to make an appointment. She was told that she could visit on the weekends as long as they had enough staff to take her mother down to the first floor room to visit.

Interview with Resident Family Member 3 on March 2, 2022, at 5:25 p.m. indicated that she had to schedule visits ahead of time and that the visits used to be 30 minutes. Lately, the facility was more lenient and left her stay for an hour. She visits with her mother on the first floor and is not allowed in her room except when she was really ill. Resident Family Member 3 stated that she used to like to sit with her mother during meals, but they no longer bring her to the dining room.

Interview with the Director of Activities, on March 22, 2022, at 2:59 p.m. indicated that they encourage scheduled visitation. They provide a quiet visitation area and visitors can go up to the floor. The scheduled visits are for about 30 minutes due to the attention spans of the residents.

Interview with the Nursing Home Administrator on March 22, 2022, at 2:26 p.m. and again at 3:10 p.m. indicated that they do have some scheduled visits, but visitors can come unannounced, and visits are not denied.

28 Pa. Code 201.29(a) Resident Rights






 Plan of Correction - To be completed: 05/16/2022

The facility has updated the visitation policy to ensure residents are provided unrestricted visitation while maintaining the core principles of infection prevention as outlined in QSO-20-39. A visitor's log will be created and maintained. The residents will be updated via a Resident Council meeting and the responsible parties for all residents will be updated via letter with the facility's automated phone message updated with the policy changes and visitor log. All staff including new hires and agency will be educated on the updated visitation policy. Weekly audits will be conducted times four weeks by Administrator or designee and then reviewed by the Quality Assurance Performance Improvement Committee for ease of visitation and support of infection control core principles.
483.80(i)(1)-(3)(i)-(x) REQUIREMENT COVID-19 Vaccination of Facility Staff: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.
483.80(i)
COVID-19 Vaccination of facility staff. The facility must develop and implement policies and procedures to ensure that all staff are fully vaccinated for COVID-19. For purposes of this section, staff are considered fully vaccinated if it has been 2 weeks or more since they completed a primary vaccination series for COVID-19. The completion of a primary vaccination series for COVID-19 is defined here as the administration of a single-dose vaccine, or the administration of all required doses of a multi-dose vaccine.

483.80(i)(1) Regardless of clinical responsibility or resident contact, the policies and procedures must apply to the following facility staff, who provide any care, treatment, or other services for the facility and/or its residents:
(i) Facility employees;
(ii) Licensed practitioners;
(iii) Students, trainees, and volunteers; and
(iv) Individuals who provide care, treatment, or other services for the facility and/or its residents, under contract or by other arrangement.

483.80(i)(2) The policies and procedures of this section do not apply to the following facility staff:
(i) Staff who exclusively provide telehealth or telemedicine services outside of the facility setting and who do not have any direct contact with residents and other staff specified in paragraph (i)(1) of this section; and
(ii) Staff who provide support services for the facility that are performed exclusively outside of the facility setting and who do not have any direct contact with residents and other staff specified in paragraph (i)(1) of this section.

483.80(i)(3) The policies and procedures must include, at a minimum, the following components:
(i) A process for ensuring all staff specified in paragraph (i)(1) of this section (except for those staff who have pending requests for, or who have been granted, exemptions to the vaccination requirements of this section, or those staff for whom COVID-19 vaccination must be temporarily delayed, as recommended by the CDC, due to clinical precautions and considerations) have received, at a minimum, a single-dose COVID-19 vaccine, or the first dose of the primary vaccination series for a multi-dose COVID-19 vaccine prior to staff providing any care, treatment, or other services for the facility and/or its residents;
(iii) A process for ensuring the implementation of additional precautions, intended to mitigate the transmission and spread of COVID-19, for all staff who are not fully vaccinated for COVID-19;
(iv) A process for tracking and securely documenting the COVID-19 vaccination status of all staff specified in paragraph (i)(1) of this section;
(v) A process for tracking and securely documenting the COVID-19 vaccination status of any staff who have obtained any booster doses as recommended by the CDC;
(vi) A process by which staff may request an exemption from the staff COVID-19 vaccination requirements based on an applicable Federal law;
(vii) A process for tracking and securely documenting information provided by those staff who have requested, and for whom the facility has granted, an exemption from the staff COVID-19 vaccination requirements;
(viii) A process for ensuring that all documentation, which confirms recognized clinical contraindications to COVID-19 vaccines and which supports staff requests for medical exemptions from vaccination, has been signed and dated by a licensed practitioner, who is not the individual requesting the exemption, and who is acting within their respective scope of practice as defined by, and in accordance with, all applicable State and local laws, and for further ensuring that such documentation contains:
(A) All information specifying which of the authorized COVID-19 vaccines are clinically contraindicated for the staff member to receive and the recognized clinical reasons for the contraindications; and
(B) A statement by the authenticating practitioner recommending that the staff member be exempted from the facility's COVID-19 vaccination requirements for staff based on the recognized clinical contraindications;
(ix) A process for ensuring the tracking and secure documentation of the vaccination status of staff for whom COVID-19 vaccination must be temporarily delayed, as recommended by the CDC, due to clinical precautions and considerations, including, but not limited to, individuals with acute illness secondary to COVID-19, and individuals who received monoclonal antibodies or convalescent plasma for COVID-19 treatment; and
(x) Contingency plans for staff who are not fully vaccinated for COVID-19.

Effective 60 Days After Publication:
483.80(i)(3)(ii) A process for ensuring that all staff specified in paragraph (i)(1) of this section are fully vaccinated for COVID-19, except for those staff who have been granted exemptions to the vaccination requirements of this section, or those staff for whom COVID-19 vaccination must be temporarily delayed, as recommended by the CDC, due to clinical precautions and considerations;
Observations:


Based on facility policy, standards established by the Centers for Medicare and Medicaid Services, as well as employee vaccination data and staff interviews, it was determined that the facility failed to implement policies and procedures to ensure that all staff were vaccinated for COVID-19.

Findings include:

The facility's policy entitled "CMS Vaccine Mandate-COVID-19 addendum," undated, revealed that effective February 26, 2022, all individuals must receive one dose of a single vaccine or all doses of multidose vaccine series (fully vaccinated), or have been granted an exemption, or have been identified as appropriate for a temporary delay per the CDC guidance.

According to the CMS Memorandum QSO-22-07-ALL, dated December 28, 2021, CMS published an Interim Final Rule, entitled "Medicare and Medicaid Programs; Omnibus COVID-19 Health Care Staff Vaccination." It indicated that within 60 days after the issuance of the memorandum, if the facility demonstrated that less than 100 percent of all staff had received at least one dose of a single dose vaccine or all doses of a multiple dose vaccine series or have been granted a qualifying exemption or identified as having a temporary delay as recommended by the CDC the facility was noncompliant under the rule.

At the time of the survey start date March 21, 2022, the facility did not meet the requirement of staff being fully vaccinated, being granted an exemption, or being identified as appropriate for a temporary delay per the CDC guidance.

Review of facility's employee vaccination status information revealed that as of March 21, 2022, the vaccination rate of employees who were fully vaccinated was 71.2 percent.

The facility failed to provide evidence that Nurse Aides 5, 6 and 7; Registered Nurse 8; and Licensed Practical Nurse 9 were fully vaccinated, had been granted a qualifying exemption, or were identified as having a temporary delay.

Interview with Special Projects Employee 10 on March 22, 2022, at 3:22 p.m. and March 24, 2022, at 8:30 a.m. confirmed that the employees who were listed were currently working at the facility, and that not all staff were vaccinated against the COVID-19 virus and/or had a medical or nonmedical exception approved as of March 22, 2022.

28 Pa. Code 201.14 (a) Responsibility of Licensee

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



 Plan of Correction - To be completed: 05/16/2022


Nurse Aides 5, 6 and 7 as well as Registered Nurse 8 and Licensed Practical Nurse 9 were immediately notified by Human Resources, on 03/23/2022, that they were out of compliance with the CMS Memorandum dated December 28, 2021 and The Village at Morrisons Cove's Mandatory COVID-19 Vaccination Policy Addendum.
In accordance with the VMC's policy and timeline, these staff were given until Sunday, March 27, 2022 to produce proof of full vaccination, as defined by CMS Memorandum QSO-22-07-ALL, or submit and have approved a religious or medical exemption completed and signed by a licensed practitioner. Per VMC Mandatory COVID-19 Vaccination Policy, these staff were informed that if they did not comply by the given date, their employment with the VMC would cease at that time.
All employees were in compliance as of Thursday, 03/24/2022.
The Human Resource personnel, including the Special Projects Coordinator, HR Generalist, Intake Coordinator or designee will conduct weekly audits of the COVID-19 Mandatory Staff Vaccination spread sheet to monitor those employee who, per recommendation of the CDC, are temporarily delayed in receiving the vaccination.
The Special Projects Coordinator will orchestrate a facility wide education requirement including an depth explanation of The Village at Morrison's Cove's vaccination policy and CMS guidelines. This education will include in person discussions with each department manager and staff as well as vaccination handouts and additional copies of the updated policy with the addendum.

The Human Resource department will continue to update the staff vaccination spreadsheet, policy binder, vaccination card binder and exemption binder on a daily/weekly basis as needed. Audit findings, and compliance will be reported to the Quality Assurance Performance Improvement Committee monthly times three.

483.60(d)(1)(2) REQUIREMENT Nutritive Value/Appear, Palatable/Prefer Temp: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.
483.60(d) Food and drink
Each resident receives and the facility provides-

483.60(d)(1) Food prepared by methods that conserve nutritive value, flavor, and appearance;

483.60(d)(2) Food and drink that is palatable, attractive, and at a safe and appetizing temperature.
Observations:


Based on review of facility policies and Resident Council meeting minutes, as well as observations and interviews with residents and staff, it was determined that the facility failed to serve food that was at palatable temperatures.

Findings include:

The facility's policy regarding meal quality and temperatures, revised January 2022, indicated that food and drinks were to be palatable, attractive, and served at a safe and appetizing temperature to ensure residents' satisfaction and to meet nutrition and hydration needs.

Resident Council meeting minutes, dated January 10 and February 11, 2022, revealed that there were concerns hot foods were served cold.

During an interview with a group of residents on March 22, 2022, at 12:54 p.m., the residents indicated that hot foods for all meals were served cold.

Observations in the kitchen on March 23, 2022, at 11:26 a.m. revealed that a test tray was placed on the lunch meal cart going to the second floor. The cart arrived on the unit at 11:28 a.m., and the last resident was served and eating at 11:50 a.m. The test tray temperatures were taken at that time and the temperature of the sauerkraut and pork was 118 degrees Fahrenheit (F), the mashed potatoes were 126 degrees F, and the milk was 54 degrees F. The sauerkraut and mashed potatoes tasted lukewarm, and the cold milk also tasted lukewarm. The food items were not palatable at those temperatures.

Interview with the Interim Dietician on March 23, 2022, at 1:42 p.m. confirmed that the food served to the residents was to be palatable.

28 Pa. Code 201.18(b)(1)(2)(e) Management

28 Pa. Code 211.6(c) Dietary services




 Plan of Correction - To be completed: 05/16/2022

All residents will be encouraged to utilize the dining rooms for meal services.

All dietary and nursing staff including new hires and agency will be educated on the timeliness of cart delivery and meal service times. Dietary staff will pre-heat plates to maintain hot food temperatures and pre-chill cold beverages to ensure milk and juice palatability.

The Dietary Manager or designee will complete test trays on the nursing units weekly time four. The resident members of Resident Council will be interviewed for auditing of the palatability of the meals monthly times three. All audits then will be reviewed by the Quality Assurance Performance Improvement Committee for results, areas of improvement and/or continued audits.

483.45(a)(b)(1)-(3) REQUIREMENT Pharmacy Srvcs/Procedures/Pharmacist/Records:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
483.45 Pharmacy Services
The facility must provide routine and emergency drugs and biologicals to its residents, or obtain them under an agreement described in 483.70(g). The facility may permit unlicensed personnel to administer drugs if State law permits, but only under the general supervision of a licensed nurse.

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

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

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

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

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


Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to maintain accountability for controlled medications (drugs with the potential to be abused) for one of 34 residents reviewed (Resident 21).

Findings include:

The facility's policy regarding controlled substance disposal, dated April 21, 2021, indicated that the destroying/disposal of a controlled medication should include two licensed nurses and the disposal was to be documented on the accountability record representing that dose.

A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 21, dated December 23, 2021, revealed that the resident was cognitively impaired, had frequent pain, received pain medication routinely, and received an opioid (a controlled pain medication). Physician's orders, dated July 9, 2018, included an order for the resident to receive a 25 micrograms (mcg) Fentanyl (a narcotic pain patch) patch to be applied every 72 hours for pain control related to multiple sclerosis (disease that affects central nervous system) and chronic pain.

The resident's Medication Administration Record (MAR) for January, February and March 2022 revealed that a Fentanyl patch was applied to the resident on January 13, 16, and 19; February 3, 9, 15, and 27; and March 2 and 20, 2022, at 5:00 p.m. A controlled drug count record (tracks each dose of a controlled medication) for Resident 21's Fentanyl patches revealed that one patch was signed out on the controlled drug log on January 13, 16, and 19; February 3, 9, 15, and 27; and March 2, and 20, 2022. There was no documented evidence that two staff members signed that the old patch was destroyed after removal on these dates.

Interview with Licensed Practical Nurse 2 on March 23, 2022, at 3:58 p.m. revealed that licensed staff removed the old Fentanyl patches and were to destroy them with a witness.

Interview with the Director of Nursing on March 23, 2022, at 1:32 p.m. revealed that he thought two nurses were not required to sign when a Fentanyl patch was removed and destroyed.

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

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



 Plan of Correction - To be completed: 05/16/2022

Resident 21's fentanyl controlled drug record did not contain the appropriate signatures for destruction.

A whole house audit was conducted to assure staff are maintaining accountability for controlled medication with emphasis on the destruction of medications.

All licensed staff including new hires and agency will be re-educated on the facility's controlled substance disposal policy.

Weekly audits times four will be conducted by the Director of Nursing or designee then reviewed by the Quality Assurance Performance Improvement Committee for results, area of improvement and/or continued audits.

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 a review of facility policies and clinical records, as well as observations and resident and staff interviews, it was determined that the facility failed to ensure that an order for antianxiety medication was provided as ordered for one of 34 residents reviewed (Resident 36), and failed to ensure that the physician's order was followed for ear wax treatment for one of 34 residents reviewed (Resident 68).

Findings include:

The facility's policy for controlled substances, dated April 9, 2022, indicated that an accurate accountability of inventory of all controlled drugs is maintained at all times. When a controlled medication is administered, the licensed nurse administering the medication immediately enters the following information: date and time of administration, amount administered, remaining quantity, and the initials of the nurse after the medication is actually administered. When a controlled medication is removed from the container for administration, any unused partial tablets or portions of single dosage ampules are to be destroyed, and the disposal documented on the accountability record on the line representing that dosage.

The facility's policy for unavailable medications, dated April 9, 2022, indicated that the facility must make every effort to ensure that medications are available to meet the needs of each resident. The physician is to be notified of the unavailability of a medication, the circumstances and optional therapy.

A Quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 36, dated January 13, 2022, indicated that he was confused and required limited assistance of one for bed mobility and transfers.

The diagnosis record for Resident 36, dated February 7, 2020, included dementia (impairment of brain functions such as memory loss and judgement), borderline personality disorder, bipolar disorder (mood swings from depressive lows to manic highs), and generalized anxiety.

Physician's orders for Resident 36, dated October 27, 2021, included an order for a 0.5 milligram (mg) tablet of Ativan to be given by mouth three times a day for anxiety.

Physician's orders for Resident 36, dated February 11, 2022, included an order to decrease the Ativan to two times a day and to give 1/2 tablet (0.25 mg) by mouth in the morning at 6:00 a.m. for anxiety.

The Medication Administration Record (MAR) for Resident 36 for February 2022 indicated that the 0.25 mg of Ativan at 6:00 a.m. was not administered on February 13-17, 2022 (four days).

A nursing note, dated February 14, 2022, indicated that the pharmacy was called in regards to not receiving the 0.25 mg of ativan yet. The pharmacy indicated that they had not received a new order or script. The order was printed and faxed to pharmacy. A nursing note, dated February 18, 2022, indicated that pharmacy was again called regarding the 0.25 mg Ativan that had not arrived yet. Pharmacy staff indicated that they had the script but did not know why it had not been sent. In addition, she indicated the Ativan would be sent on the first run today.

Interview with the Nursing Home Administrator on March 23, 2022, at 1:22 p.m. confirmed that the physician should have been notified when the Ativan was not available. She also confirmed that there was no documented evidence that the physician was updated.

The Medication Administration Record (MAR) for Resident 36 for February, 2022, indicated that 0.25 mg of Ativan was administered at 6:00 a.m. on February 12, 2022, and February 21 through March 21, 2022, and that 0.5 mg of Ativan was also administered at 12:00 p.m. and 8:00 p.m. on those dates. Resident 36's controlled medication record for Ativan, dated as received on February 18, 2022, indicated that the pharmacy provided 30 tablets of Ativan 0.5 mg and that on February 18, 19, and 20, 2022, the licensed staff removed one tablet for the 6:00 a.m. dose (instead of the ordered 0.25 mg).

Resident 36's controlled drug medication log, undated when received, indicated that 60 tablets of Ativan 0.5 mg was received from pharmacy and that the first dose removed was on February 8, 2022. The record further indicated that on February 12 and February 21 through March 21, 2022, a 0.5 mg tablet was removed for the 6:00 a.m. dose instead of the ordered 0.25 mg.

Resident 36's second controlled drug medication log, also dated February 18, 2022, indicated that 15 of the 0.5 mg Ativan tablets were sent with a label indicating "30 actual quantity" (1/2 of a 0.5 mg tablet was equal to a 0.25 mg dose) were received. The controlled medication log further indicated that from March 7, 2022, at 8:00 p.m. through March 22, 2022, at 12:00 p.m., staff removed 0.25 mg of Ativan for the 12:00 p.m. and 8:00 p.m. doses instead of the ordered 0.5 mg.

The card for each controlled medication indicated that the doses present were accurate on a daily basis and that there was no disposal of any partial tablets.

Interview with the Nursing Home Administrator on March 24, 2022, at 2:19 p.m. confirmed that the controlled medication removal forms revealed that the incorrect doses were removed for Resident 36 on the dates mentioned.

A comprehensive Significant Change MDS assessment for Resident 68, dated February 2, 2022, indicated that he was alert but confused, able to make himself understood and could understand, required extensive assistance for hygeine, and had minimal difficulty with hearing and used a hearing aide.

Interview and observations with the Resident 68 on March 23, 2022, at 5:53 p.m. revealed that he was hard of hearing but did not use his hearing aides because his ears were full of wax and they did not work.

A physician's order for Resident 68, dated March 3, 2022, included an order for Debrox Solution, install six drops in each ear every morning and evening for excess ear wax and to flush each ear after three days of administration of the Debrox.

The MAR for Resident 68 for March, 2022, indicated that the Debrox was administered in the morning on March 4, 5, and 6; in the evening on March 3; in the morning and evening on March 4; and in the morning only on March 5 and 6, and that his ear irrigation was done on the evening of March 4, after the third dose of Debrox, instead of after the sixth dose as ordered.

Interview with Nurse Aide 4 on March 23, 2022, at 6:15 p.m. indicated that the resident did have problems with his ears being full of wax and that when he used his hearing aides you would see wax on them. Nurse Aide 4 also indicated that the nurses knew about the ear wax.

Interview with the Director of Nursing on March 24, 2022, at 11:08 a.m. confirmed that Resident 68's ears were irrigated after the third dose of Debrox instead of being done after the sixth dose as ordered. The Director of Nursing also confirmed that Resident 68 received only five of the six ordered doses of Debrox.

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



 Plan of Correction - To be completed: 05/16/2022

Resident 36's controlled drugs and controlled drug medication cards were reviewed on sight and confirmed with the facility's pharmacy to be accurate at the time of the review. Resident 68's had an assessment by a registered nurse on March 25, 2022. The findings were reviewed with the physician and a new order for debrox wax treatment was ordered.

A whole house audit was conducted to confirm all narcotic medications are current on hand with zero outstanding medications at the time of the audit. A controlled drug medication cards have been reviewed to confirm accuracy of usage. A house wide audit was also conduct an all current debrox orders to confirm the appropriate irrigation schedule. A transcription error was completed for the licensed staff involved.

All licensed nursing staff including new hires and agency will be re-educated on the facility's policy for controlled substances and unavailable medications. The facility's order template for debrox wax treatment has been updated to improve ease of use and compliance. All licensed staff including new hires and agency will be educated on how to use and interpret the order template.

Weekly audits will be conducted times four weeks by the Director of Nursing or designee and then reviewed by the Quality Assurance Performance Improvement Committee for results, areas of improvement and/or continued audits.

483.20(g) REQUIREMENT Accuracy of Assessments:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.20(g) Accuracy of Assessments.
The assessment must accurately reflect the resident's status.
Observations:


Based on review of the Resident Assessment Instrument User's Manual and clinical records, as well as staff interviews, it was determined that the facility failed to complete accurate Minimum Data Set assessments for two of 34 residents reviewed (Residents 4, 17).

Findings include:

The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which gives instructions for completing Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2019, revealed that Section N was to record the number of days during the last seven days (or since admission/entry or reentry if less than seven days) that specific types of medications were received by the resident. Section N0410B was to indicate how many days the resident received an antianxiety during the seven-day review period.

Physician's orders for Resident 4, dated December 30, 2021, included an order for the resident to receive 0.5 milligrams (mg) of Ativan (an antianxiety) every six hours, and the resident's Medication Administration Record (MAR) for December 2021 revealed that he received Ativan every six hours from December 24 to 30, 2021. However, an annual MDS assessment, with an Assessment Reference Date (ARD - the last day of the assessment's review period) of February 8, 2022, revealed that Section N0410B was coded with a zero (0), indicating that the resident did not receive an antianxiety during the review period.


The RAI User's Manual, which gives instructions for completing Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2019, revealed that if a motion alarm was used, then Section P0200D was to be coded as (0) not used, (1) used less than daily, or (2) used daily.

A physician's order for Resident 17, dated November 22, 2021, included orders for the resident to use a motion alarm in the bathroom doorway and the resident's Treatment Administration Record (MAR) for December 2021 revealed that a motion alarm was used during December 1 through 31, 2021. However, a quarterly MDS assessment for Resident 17, dated December 21, 2021, revealed that Section P0200D was coded with a (0), indicating that the resident did not use a motion alarm.

Interview with the Nursing Home Administrator on March 24, 2022, at 2:46 p.m. confirmed that Section N0410B of Resident 4's MDS assessment of February 8, 2022, should have been coded (7) for daily use of an antianxiety and Section P0200D of Resident 17's MDS assessment of December 21, 2021, should have been coded (2) for daily use of a motion alarm.

28 Pa. Code 211.5(f) Clinical records.



 Plan of Correction - To be completed: 05/16/2022

Residents 4 and 17 have had corrections made the Minimum Data Set (MDS) assessment in regards to the coding for anti-anxiety medication and motion alarm use.

A whole house audit has been conducted to ensure complete and accurate medication and alarm information is appropriately identified.

Registered Nurse Assessment Coordinators (RNAC) will review the MDS 3.0 Training via CMS.gov specifically section I/N/L and section P to ensure accurate coding.

Weekly audits of the completed assessments will be conducted by the Director of Nursing or designee and then reviewed by the Quality Assurance Performance Improvement Committee for results, areas of improvement and/or continued audits.

483.25(c)(1)-(3) REQUIREMENT Increase/Prevent Decrease in ROM/Mobility:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.25(c) Mobility.
483.25(c)(1) The facility must ensure that a resident who enters the facility without limited range of motion does not experience reduction in range of motion unless the resident's clinical condition demonstrates that a reduction in range of motion is unavoidable; and

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

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


Based on a review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that physician's orders for splint application were followed for one of 34 residents reviewed (Resident 52).

Findings include:

The facility's policy for application of splints or braces, dated April 9, 2021, indicated that after the application of the splint, the time is to be noted. If the resident is unable to have the device applied, the reason is to be documented. Upon removal of the splint/brace the procedure is to be documented.

A Quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 52, dated January 31, 2022, indicated that he was confused, required extensive assistance of one for dressing and hygiene, and had impaired range of motion of both upper extremities. He had no behaviors such as rejection of care noted.

The diagnosis record for Resident 52, dated April 27, 2017, included contracture (tightening of muscles, tendons and skin) which causes joints to be stiff of the left hand.

Physician's orders for Resident 52, dated February 10, 2022, indicated that the left palm guard was to be put on with PM care and off with AM care and that a skin check was to be done before and after the palm guard was worn each day.

Resident 52's splint application record indicated that on February 27 and 28, 2022, and March 12, 13, 14, 2022, the splint was off for third shift. There was no documented evidence that the palm guard was applied or why it was not applied as ordered on the noted dates.

Interview with the Director of Nursing on March 23, 2022, at 3:56 p.m. confirmed that there was no documentated evidence of why the splint was not on during the third shift as per the physician's order, and he further indicated that there should be documentation to indicate the reason why it was not applied and/or refused.

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




 Plan of Correction - To be completed: 05/16/2022

Resident 52 was screened by the therapy department on March 25, 2022 related to use of the left palm guard. The resident was subsequently placed on therapy services for occupational therapy.

A whole house audit was conducted to ensure physician's orders for splint application were being followed appropriately.

All nursing staff including new hires and agency will be re-educated on the facility's policy for application of splints or braces to include notification when orders are not followed and appropriate documentation. Resident splint orders are noted in the resident's kardex with the splint schedules noted in the Point of Care documentation. Employees will be re-educated to check all kardexs with confirmed schedules at the start of every shift.

Weekly audits will be conducted times four weeks by the Director of Nursing or designee and then reviewed by the Quality Assurance Performance Improvement Committee for results, areas of improvement and/or continued audits.

483.25(d)(1)(2) REQUIREMENT Free of Accident Hazards/Supervision/Devices: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(d) Accidents.
The facility must ensure that -
483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and

483.25(d)(2)Each resident receives adequate supervision and assistance devices to prevent accidents.
Observations:


Based on review of clinical records and observations, as well as staff interviews, it was determined that the facility failed to ensure that the resident environment was free from accident hazards, and that each resident received adequate supervision and assistance devices to prevent accidents, by failing to ensure that interventions to prevent injuries related to bruising were in place for one of 34 residents reviewed (Resident 77).

Findings include:

A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 77, dated February 11, 2022, indicated that the resident was cognitively impaired and required limited assistance from staff for bed mobility.

An accident/injury investigation for Resident 77, dated November 26, 2021, revealed that the resident acquired a 2.0 x 1.0 centimeter (cm) bruise under the right eye. The resident was unaware of the bruise or how it occurred. The intervention to prevent further bruising was to pad the grab bars. A care plan and physician's order, dated November 29, 2021, indicated that the resident was to have padded bilateral grab bars to assist with repositioning in bed.

Observations on March 21, 2022, at 12:30 p.m. revealed that Resident 77 was in her bed with bilateral grab bars that were not padded.

Interview with Nurse Aide 3 on March 21, 2022, at 12:33 p.m. confirmed that Resident 19 was to have padded grab bars.

Interview with the Nursing Home Administrator on March 22, 2022, at 3:14 p.m. confirmed that Resident 77's grab bars should have been padded according to the care plan and physician's order.

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



 Plan of Correction - To be completed: 05/16/2022

Resident 77's grab bar was padded immediately upon being brought to the attention of the unit staff on March 21, 2022.

A whole house audit was conducted to identify and correct any concerns related to ordered and care planned grab bar interventions.

A nursing staff including new hires and agency will be re-educated on the facility's policy for Incident-Investigating, Reporting and Implementing Corrective Action/s.Education will include the expectation that a review of the resident kardexs at the beginning of every shift to confirm ordered safety interventions.

Weekly audits times four will be reviewed by the Director of Nursing or designee then reviewed by the Quality Assurance Performance Improvement Committee for results, areas of improvement and/or continued audits.

483.60(d)(4)(5) REQUIREMENT Resident Allergies, Preferences, Substitutes: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(d) Food and drink
Each resident receives and the facility provides-

483.60(d)(4) Food that accommodates resident allergies, intolerances, and preferences;

483.60(d)(5) Appealing options of similar nutritive value to residents who choose not to eat food that is initially served or who request a different meal choice;
Observations:


Based on clinical record reviews, observations, and staff interviews, it was determined that the facility failed to ensure that residents were not served foods that were intolerable for one of 34 residents reviewed (Resident 53).

Findings include:

A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 53, dated January 31, 2022, revealed that the resident was cognitively impaired, could understand and be understood, and was independent to eat after meal set-up. Physician's orders dated January 23, 2022, revealed that the resident was to receive a cardiac healthy diet with mechanical soft texture, was lactose intolerant, and was not to receive chocolate milk or cheese. A care plan, dated January 24, 2022, indicated that the resident was lactose intolerant and was to avoid milk, cheese and chocolate.

Interview with Resident 53 on March 21, 2022, at 1:05 p.m. revealed that when she ate certain meals she would get very bad diarrhea and was not sure what it was from, and that it had been going on for awhile.

Observations of Resident 53 during the dinner meal on March 23, 2022, at 5:34 p.m. revealed that Nurse Aide 1 took Resident 53's tray into her room and her dinner tray included a cheese steak and a cookies and cream dessert. The resident's meal ticket, dated March 23, 2022, indicated that the resident was lactose intolerant, was not to have chocolate or cheese, and had allergies to dairy.

Interview with Nurse Aide 1 on March 23, 2022, at 5:42 p.m. revealed that she was not aware that the resident was lactose intolerant and should not have received the cheese steak.

Interview with the Nursing Home Administrator on March 23, 2022, at 6:19 p.m. confirmed that Resident 53 should not have received the cheese steak and dessert, and that both items contained cheese and/or milk.

Pa Code: 211.6 (b) Dietary services.

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




 Plan of Correction - To be completed: 05/16/2022

Resident 53 was served the incorrect diet on the evening of March 23, 2022 but did not consume the dairy items. The foods were substituted and a review of the April bowel records notes zero episodes of loose/diarrhea stools.

A whole house audit was conducted to confirm ordered allergy/food intolerances are accurate in the Dining Services ticket system.

All dietary staff including new hires will be re-educated on the process for following the recommended dietary requirements and preferences for resident meals. All nursing staff including new hires and agency will be educated on following and confirming the dietary orders and the items being served to the residents.

Weekly tray audits will be completed by the Dietary Manager times four weeks and then reviewed by the Quality Assurance Performance Improvement Committee for results, areas of improvement and/or audits.


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