Nursing Investigation Results -

Pennsylvania Department of Health
MUNCY PLACE
Patient Care Inspection Results

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MUNCY PLACE
Inspection Results For:

There are  89 surveys for this facility. Please select a date to view the survey results.

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MUNCY PLACE - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on a Medicare/Medicaid Recertification Survey, State Licensure Survey, Civil Rights Compliance Survey, and Complaint Investigation, completed on October 15, 2021, it was determined that Muncy Place was not in compliance with the following requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care and the 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.


 Plan of Correction:


483.60(i)(1)(2) REQUIREMENT Food Procurement,Store/Prepare/Serve-Sanitary:This is a less serious (but not lowest level) deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents.  This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.60(i) Food safety requirements.
The facility must -

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

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

Based on observation and staff interview, it was determined that the facility failed to store food items and maintain equipment in a safe and sanitary manner in the facility's main kitchen.

Findings include:

A tour of the facility's main kitchen with Employee 1 (supervisor of food and nutrition) on October 12, 2021, at 8:50 AM revealed a dry food storage area with multiple expired items. These items included the following:

Golden Light Brown Pioneer Sugar Pure and Natural (two packs) that had a use by date of September 21, 2021.

Bottles of Roland Original Glaze with facility use by dates of August 13, 2021 (one bottle); June 18, 2021 (two bottles); July 16, 2021 (one bottle); and three bottles with no noted received on or use by dates.

Mild Chili Powder, Ground Oregano, Leaf Basil, Poultry Seasoning, and Ground White Pepper all with a facility use by date of August 26, 2021.

Soy Sauce with a manufacturer's stamped notice of "Best by 23Sept2021."

There was one box of 6 inch Flour Tortillas with manufacturer's information on the package to "use or freeze by Aug 17, 2021" (there were a total of 13 packs of these in this open box).

There were two packs of 10 inch Flour Tortillas with a manufacturer's information on the package to "use or freeze by Oct 6, 2021."

One box of apple butter containers with a use by date of July 6, 2021.

One bag of opened and partially used farro in a box that had no date to indicate when it was opened or when it needed to be used by.

An observation of the walk-in cooler on October 12, 2021 at 9:33 AM revealed four plastic gallons of spring water with a white and black thick substance on the gallons that flaked when touched.

There was a large bag of spinach in the walk-in freezer that was frozen and in a cardboard box. It had a use by date of August 15, 2021.

Continued observation of an additional walk-in cooler revealed a bag (no size written on it) of celery with a use by date from the manufacturer of October 2, 2021. There were also two cans of fresh-cut honey dew chunks with a manufacturer's use by date of October 8, 2021.

An upright two-doored freezer contained an open bag of what appeared to be frozen hamburger patties. There were multiple patties in the bag. There was no open date, identification sticker, or use by date identified on the bag. The freezer also had debris build-up on the bottom of each side of the freezer including the door jamb area.

These findings were reviewed with the Nursing Home Administrator via phone on October 13, 2021, at 2:11 PM.

483.60 (i) Food, Store and Serve -Sanitary
Previously cited deficiency 3/5/2020

28 Pa. Code 211.6 (c) Dietary services


 Plan of Correction - To be completed: 12/07/2021

The Facility submits this Plan of Correction under procedures established by the Department of Health in order to comply with the Department's directive to change conditions which the Department alleges is deficient under State and/or Federal Long Term Care Regulations. This Plan of Correction should not be construed as either a waiver of the facility's right to appeal or challenge the accuracy or severity of the alleged deficiencies or an admission of past or ongoing violation of State or Federal regulatory requirements.


1. All expired items were removed from the kitchen and disposed of immediately. Hamburgers were immediately dated and labeled. Debris in freezer door jamb area and debris build up on the bottom of each freezer side door was removed and cleaned.


2. Verification completed on remaining items in kitchen to assure that items are properly labeled and within the use by dates/not expired. Door Jambs cleaned and remaining kitchen equipment reviewed for cleanliness.

3. Education provided to staff on proper labeling and dating as well proper storage and checking of walk-in freezers/coolers for cleanliness.

4. Food Services manager or designee will conduct weekly audits x 3 months on food items being rotated and labeled properly as well as monitoring food usage dates. Food Services manager or designee will conduct weekly audits x 3 months to monitor cooler for spills and splashes maintaining cooler cleanliness. Results will be reported at QAPI.

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

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

Based on clinical record review and staff interview, it was determined that the facility failed to provide required notification to a resident whose payment coverage changed for two of three residents reviewed (Residents 186 and 81).

Findings include:

A review of the form "Instructions for the Notice of Medicare Non-Coverage (NOMNC) CMS-10123," (a notice that informs the recipient when care received from the skilled nursing facility is ending; and how to contact a Quality Improvement Organization (QIO) to appeal) revealed instructions that a Medicare provider must ensure that the notice is delivered at least two calendar days before Medicare covered services end. The provider must ensure that the beneficiary or their representative signs and dates the NOMNC to demonstrate that the beneficiary or their representative received the notice and understands the termination of services can be disputed. If the provider is personally unable to deliver a NOMNC to a person acting on behalf of an enrollee, then the provider should telephone the representative to advise him or her when the enrollee's services are no longer covered. Confirm the telephone contact by written notice mailed on that same date.

Issuing the Notice to Medicare Provider Non-coverage (NOMNC), form CMS-10123, to a beneficiary only conveys notice to the beneficiary of his or her right to an expedited review of a service termination and does not fulfill the facility's obligation to advise the beneficiary of potential liability for payment. A facility must still issue the SNFABN to address liability for payment.

A review of the "Form Instructions Skilled Nursing Facility (SNF) Advanced Beneficiary Notice of Non-coverage (SNFABN) Form CMS-10055" revealed that the SNF enters a good faith estimate of the cost of the corresponding care that may not be covered by Medicare. The beneficiary selects an option box to indicate a desire to continue to receive the care or not to continue to receive the care and if there is a desire to have the bill submitted to Medicare for consideration. The beneficiary or their authorized representative must sign the signature box to acknowledge that they read and understood the notice.

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

Clinical record review for Resident 186 revealed a Change in Status Notification form dated March 2, 2021, that indicated her payment source changed from Humana to private pay. The form indicated that her last covered day of the former payer was March 4, 2021, and the first date of the new status was March 5, 2021. A CMS-10123 (NOMNC) indicated that the effective date coverage would end was March 4, 2021.

The facility did not provide Resident 186 an Advanced Beneficiary Notice (SNFABN) that would provide a good faith estimate of the cost of the care that may not be covered so that she could decide if she wished to continue receiving care not paid for by Medicare and assume financial responsibility.

Interview with the Nursing Home Administrator and the Director of Nursing on October 14, 2021, at 2:30 PM revealed no evidence that the facility provided Resident 186 a SNFABN regarding potential (custodial care) costs that she would be responsible for after the last date of her Humana coverage.

Clinical record review for Resident 81 revealed that her payment coverage changed on April 15, 2021, when Medicare payment for services stopped.

Review of a CMS-10123 form indicated that Resident 81's niece was informed via telephone that the effective date Resident 81's coverage would end was April 14, 2021. This notice did not contain a dated signature; however, was stamped that "GREEN validation card used in lieu of signature." A handwritten note, "no date noted," filled the space for the representative's signature date. Review of the certified mail receipt to Resident 81's responsible party did not include any postmark seal or date; nor a date when the representative signed for the receipt of the mail. Review of a SNFABN form also indicated that Resident 81's niece was informed via telephone that the effective date Resident 81's coverage would end was April 14, 2021, and included the estimated daily room rates. This notice did not include a response from Resident 81's niece to select an option box to indicate a desire to continue to receive the care or discontinue the care; and if there was a desire to have the bill submitted to Medicare for consideration. Resident 81's niece did not sign the signature box to acknowledge that she read and understood the notice. This notice did not contain a dated signature; however, was stamped that "GREEN validation card used in lieu of signature." A handwritten note, "no date noted," filled the space for the representative's signature date.

Interview with the Nursing Home Administrator on October 15, 2021, at 12:40 PM, confirmed the above findings.

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

28 Pa. Code 201.29(a) Resident rights


 Plan of Correction - To be completed: 12/07/2021

The Facility submits this Plan of Correction under procedures established by the Department of Health in order to comply with the Department's directive to change conditions which the Department alleges is deficient under State and/or Federal Long Term Care Regulations. This Plan of Correction should not be construed as either a waiver of the facility's right to appeal or challenge the accuracy or severity of the alleged deficiencies or an admission of past or ongoing violation of State or Federal regulatory requirements.


1. Resident 186 has discharged from the facility. Resident 186 received all required notices based on her non-Medicare insurance coverage. Resident 81 RP received verbal notification as well as certified notice of change in payor. Resident 81 RP acknowledged with RP signature that notification was received and documentation of verbal conversation with RP indicates timely notice provided.

2. Facility verified all residents and/or RP of resident, in the last quarter (July-September 2021), received notification of room rates upon admission as well as notification of payor change.

3. Facility will continue to provide room rate notification upon admission to facility to resident or resident RP. Facility will provide room rate notification to resident and/or resident RP upon payor change within facility in conjunction with payor notification guidelines. Education provided to RNAC office and social workers in regard to payor change notifications. Education provided to RNAC office in regard to notification processes required in cases where certified mailings are returned to facility incomplete. RNAC will attempt to notify resident RP x 2 via phone in cases of incomplete paperwork.

4. ANHA or designee will conduct audits to ensure room rate notification are provided upon admission as well as proper notification processes upon payor change times weekly x 3 months. Results will be reported at QAPI.


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 clinical record review, observation, and staff interview, it was determined that the facility failed to implement timely interventions to prevent further accidents for one of three residents reviewed (Residents 15).

Findings include:

Clinical record review revealed a follow-up progress note dated September 8, 2021, at 3:26 PM that referred to an event where Resident 15's neck tie (bands that go around the neck to hold a trach tube in place) of his tracheostomy (an opening created at the front of the neck so a tube can be inserted into the windpipe and help with breathing) cut into his neck. The note also indicated that Resident 15 moves around in bed frequently and the movement of his neck caused the neck tie to abrade his posterior neck. The note refers to the event date of August 24, 2021.

Review of the facility's investigation into the event dated August 24, 2021, at 10:32 PM revealed that Resident 15 obtained a laceration to his neck that measured 4 centimeters (cm) in length, 3 cm in width, and a depth of 2 cm. The equipment involved was noted as the trach tie (bands that go around the neck to hold a trach tube in place). The physician was notified. The action taken indicated to continue to observe. First aid was done at this time.

There was no evidence of a new intervention to prevent further injury to Resident 15's neck until September 8, 2021, at 3:26 PM in a progress note that indicated the Director of Nursing would talk to respiratory therapy because a bariatric neck tie was ordered as a new intervention to prevent further abrading of the skin.

Interview with the Director of Nursing on October 14, 2021, at 2:45 PM revealed that the bariatric trach ties were placed on September 8, 2021, 15 days later, by respiratory therapy.

The above information was reviewed with the Nursing Home Administrator in a meeting on October 15, 2021, at 12:31 PM. The facility failed to initiate timely preventative interventions related to an accident with Resident 15.

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


 Plan of Correction - To be completed: 12/07/2021

The Facility submits this Plan of Correction under procedures established by the Department of Health in order to comply with the Department's directive to change conditions which the Department alleges is deficient under State and/or Federal Long Term Care Regulations. This Plan of Correction should not be construed as either a waiver of the facility's right to appeal or challenge the accuracy or severity of the alleged deficiencies or an admission of past or ongoing violation of State or Federal regulatory requirements.





1. Resident 15 received bariatric trach tie

2. Facility verified all residents have correct trach tie in place

3. Education provided to licensed staff to elevate to administration delays in supplies

4. Wound nurse or designee will conduct audits weekly x 3 months, to ensure correct trach tie in place. Results will be reported to QAPI



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

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

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

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

Based on review of select facility policies and procedures, clinical record review, and staff interview, it was determined that the facility failed to assess and monitor acceptable parameters of nutritional status for two of four residents reviewed for nutritional concerns (Residents 14 and 55).

Findings include:

The facility policy entitled, "Weight Change Procedure," last reviewed in December 2020, revealed that staff will weigh residents on admission, readmission, and then daily for two more days for a total of three days in a row. Dietary clinical staff will review weights after the admission or readmission, the two-week weights, and make ongoing weight assignments for the resident. All weight changes of plus or minus five pounds will be automatically reweighed immediately for accuracy. The dietitian/designee will send a fax to the physician provider regarding significant weight changes. Nursing staff will assess the resident and notify the responsible party of a weight change.

Clinical record review for Resident 14 revealed the facility admitted her on July 16, 2021. Review of weight documentation in Resident 14's electronic medical record indicated the following weights:

July 16, 2021 86 pounds
July 17, 2021 89 pounds
July 18, 2021 98.1 pounds (9.1 pound, 13.95 percent severe weight gain)
July 20, 2021 98.1 pounds
August 17, 2021 90.6 pounds, (7.5 pound, 7.65 percent severe weight loss)
September 14, 2021 98.9 pounds, (8.3 pound, 8.39 percent severe weight gain)

Further review of Resident 14's clinical record revealed there was no assessment of Resident 14's weight gain on July 18, 2021.

Review of Resident 14's nutritional note dated August 20, 2021, revealed Employee 2 (registered dietician) met with Resident 14 and Resident 14 stated that the July 20, 2021 "weight was an error." Employee 2 indicated that there were no new recommendations.

Interview with Employee 2 (registered dietician) on October 14, 2021, at 8:41 AM confirmed the facility obtained weights on Resident 14 on July 18 and July 20, 2021 by two separate staff noting the same severe weight gain of 9.1 pounds, 13.95 percent in less than a month. Employee 2 was unable to provide further documentation that the facility assessed and monitored Resident 14's severe weight fluctuations.

Clinical record review for Resident 55 revealed that the facility assessed her weight on August 2, 2021, as 167.6 pounds.

The next available weight assessment dated August 4, 2021, indicated that staff assessed her weight as 146.3 pounds. An immediate re-weight assessed her weight as 158.2 pounds (a 9.4 pound, 5.6 percent, significant weight loss). This documentation errantly noted that there was not a weight change of greater or less than five pounds.

Interview with Employee 3 (registered dietitian) and Employee 2 (registered dietitian) on October 15, 2021, at 10:41 AM verified that Resident 55's medical record contained no evidence of physician, responsible party, or registered dietitian notification in response to the significant weight loss identified on August 4, 2021.

The next available weight assessment dated August 6, 2021, indicated that staff assessed her weight as 164 pounds (a 5.8 pound weight gain from the previous assessment). This documentation again errantly noted that there was not a weight change of greater or less than five pounds. There was no evidence that staff obtained an immediate re-weight in response to this change.

A registered dietitian assessment dated August 10, 2021, referenced Resident 55's August 6, 2021, weight and determined that she had no significant changes based on one, three, and six month weight assessments. The assessment did not identify or include the weight assessment dated August 4, 2021; or identify that nursing staff had obtained assessments with greater than five pounds difference without obtaining an immediate re-weight or making the required notifications to the physician, responsible party, or dietitian.

Resident 55's clinical record indicated that she transferred to the hospital on August 8, 2021, and returned to the facility on August 16, 2021. The clinical record contained no evidence that staff obtained a weight assessment following her hospitalization until August 18, 2021.

The weight assessment dated August 18, 2021, indicated Resident 55 weighed 157.8 pounds (6.2 pound loss from the previous weight on August 6, 2021). This documentation again errantly noted that there was not a weight change of greater or less than five pounds. Resident 55's clinical record did not contain evidence that staff made notifications to Resident 55's responsible party, physician, or registered dietitian.

Registered dietitian documentation dated August 20, 2021, at 3:39 PM (four days after readmission to the facility), noted a significant weight loss in one month and a 7.5 percent in six months. The writer requested that nursing staff reassess the weight at that time, that there was only one readmission weight measured thus far. The writer submitted a recommendation to add nutritional supplements to aid in Resident 55's healing and weight loss.

The next weight assessment dated August 21, 2021, assessed Resident 55 as 155.5 pounds (an additional 2.3 pound loss from August 18, 2021; a total 8.5 pound, 5.18 significant weight loss since the date she transferred to the hospital).

Interview with Employees 2 and 3 on October 15, 2021, at 10:41 AM confirmed that Resident 55 returned to the facility on August 16, 2021; but staff failed to obtain a readmission weight until August 18, 2021 (should have been completed upon her return on August 16, 2021 and for at least two days thereafter). The interview confirmed that four days elapsed from when Resident 55 returned to the facility and when the registered dietitian completed an assessment and recommended nutritional supplements in response to her assessed weight loss.

A weight assessment dated September 29, 2021, indicated Resident 55 weighed 165.6 pounds. The next weight assessment dated October 4, 2021, indicated Resident 55 weighed 133.8 pounds (a 31.8 pound, 19.2 percent severe weight loss change from the previous weight); however, staff failed to obtain a re-weight assessment for four days (October 8, 2021) when Resident 55 was assessed as 159 pounds (a 10 pound, 5.9 percent weight loss in one month).

Interview with Employees 2 and 3 on October 15, 2021, at 10:41 AM revealed that they had Resident 55 on daily report on October 6, 2021, for the significant weight loss; however, although the nursing department was asked to obtain a re-weight on that date, it did not happen for two more days (on October 8, 2021).

Nursing documentation dated October 10, 2021, at 3:22 PM revealed that nursing staff notified Resident 55's husband that she had a significant weight gain of 5.4 percent, or 8.6 pounds, over one month per assessments obtained on September 15, 2021.

Interview with Employees 2 and 3 on October 15, 2021, at 10:41 AM confirmed that nursing staff errantly notified her husband that she had gained weight when her most recent condition indicated she was experiencing a weight loss trend.

On October 11, 2021, staff assessed Resident 55's weight as 157 pounds (a 5.19 percent significant weight loss in the one month since her weight of 165.60 pounds on September 29, 2021). Resident 55's clinical record contained no evidence of responsible party, physician, or dietitian notification immediately upon identification of this finding. Physician notification occurred three days later on October 14, 2021.

An interview with the Nursing Home Administrator and Director of Nursing on October 13, 2021, at 5:30 PM confirmed the above findings.

A physician's order dated October 14, 2021 (after the surveyor's questioning) instructed staff to provide Glucerna nutritional supplement three times a day with meals.

28 Pa. Code 211.6 (d) Dietary services

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


 Plan of Correction - To be completed: 12/07/2021

The Facility submits this Plan of Correction under procedures established by the Department of Health in order to comply with the Department's directive to change conditions which the Department alleges is deficient under State and/or Federal Long Term Care Regulations. This Plan of Correction should not be construed as either a waiver of the facility's right to appeal or challenge the accuracy or severity of the alleged deficiencies or an admission of past or ongoing violation of State or Federal regulatory requirements.



1. Weights conducted on Resident 14 and Resident 55 to obtain baseline weight


2. Facility verified weights completed on all residents. Resident weights reviewed for significant weight change

3. Staff education on Weight Change Procedure Policy

4. ANHA or designee will conduct audits weekly x 3 months to review for significant weight changes. Results will be reported at QAPI.

483.25(i) REQUIREMENT Respiratory/Tracheostomy Care and Suctioning: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(i) Respiratory care, including tracheostomy care and tracheal suctioning.
The facility must ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals and preferences, and 483.65 of this subpart.
Observations:

Based on review of select facility policies and procedures, clinical record review, observation, and resident and staff interview, it was determined that the facility failed to maintain respiratory equipment appropriately for one of one resident reviewed for oxygen use concerns (Resident 38).

Findings include:

The facility policy entitled, "BiPAP/CPAP Cleaning and Disinfection," last reviewed in January 2021, revealed that the purpose of the policy is to provide guidelines for the cleaning and disinfection of BiPAP/CPAP equipment and supplies to prevent the spread of infection. The BiPAP (Bilevel positive airway pressure is a breathing treatment for sleep apnea and other health conditions that impact breathing)/CPAP (Continuous positive airway pressure therapy is a common treatment for obstructive sleep apnea) machine should be disconnected from the power and cleaned with a sani-cloth or other approved cleaner weekly. The BiPAP/CPAP mask and circuit (including filter and tubing) will be disposed of monthly and as needed due to damage of the tubing, mask, or any of the circuit components. If the mask or tubing appears to be soiled, the mask and tubing may be cleansed with mild soap and warm water as needed and allowed to air dry. Humidifier chambers/reservoirs (if present) will be cleaned weekly with routine BiPAP/CPAP cleansing.

Observation of Resident 38's room on October 13, 2021, at 2:53 PM revealed a CPAP mask (a type of ventilator that helps people who have a health condition that causes brief pauses in breathing during sleep keep the airway open by providing a continuous stream of air through a mask) not bagged, stored in an open basket. Interview with Resident 38 on the date and time of the observation revealed that it was her opinion that staff do not always clean the mask.

Observation of Resident 38's room on October 14, 2021, at 10:53 AM revealed the CPAP mask again stored in an open basket, not bagged, potentially exposed to environmental contaminates during non-use.

Interview with Employee 4 (registered nurse) and Employee 5 (nurse aide) on October 14, 2021, at 11:29 AM confirmed that Resident 38's CPAP mask was not bagged and should be as it was exposed to surface and environmental surfaces with nothing to protect it from dust or potential contamination while not in use.

Review of Resident 38's treatment administration record (TAR, form the facility utilizes to document the completion of treatments) dated October 2021 revealed that staff initialed the cleaning of Resident 38's CPAP one time monthly (physician's order dated October 4, 2021), which included changing the CPAP filter, changing the oxygen tubing, checking the integrity and cleaning the mask, and cleaning the machine with a sani-cloth.

Interview with the Nursing Home Administrator on October 15, 2021, at 12:40 PM confirmed that there was no evidence that staff cleaned and bagged Resident 38's CPAP mask daily after use. The interview confirmed that staff should bag the mask between uses. The interview also confirmed that the facility's current policy did not instruct staff to clean and bag a CPAP mask routinely (daily).

28 Pa. Code 211.10(d) Resident care policies

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


 Plan of Correction - To be completed: 12/07/2021

The Facility submits this Plan of Correction under procedures established by the Department of Health in order to comply with the Department's directive to change conditions which the Department alleges is deficient under State and/or Federal Long Term Care Regulations. This Plan of Correction should not be construed as either a waiver of the facility's right to appeal or challenge the accuracy or severity of the alleged deficiencies or an admission of past or ongoing violation of State or Federal regulatory requirements.




1. Resident 38 respiratory equipment cleaned and properly stored in resident room

2. Facility verified proper storage of all CPAP and BiPAP equipment in resident rooms.

3. Education to licensed staff on BiPAP/CPAP Cleaning and Disinfection policy. Education on storage of CPAP equipment provided to licensed staff.

4. DON or designee will conduct audits to ensure proper storage of CPAP/BiPAP equipment. Audits will be conducted weekly x 3 months with results being reported at 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, staff interviews, and review of other documents provided by the facility, it was determined that the facility failed to ensure each resident is provided with the necessary behavioral health care in a timely manner to attain or maintain the highest practicable mental and psychosocial well-being for one resident reviewed (Resident 6).

Findings include:

Review of the facility's investigation related to Resident 6's fall dated July 15, 2021, indicated he fell out of bed as he thought he was going to get electrocuted from a sink with running water. A progress noted dated July 16, 2021, at 9:45 AM revealed that the nurse spoke with the Nurse Practitioner to notify her that the resident continued to complain of being electrocuted. The note suggest that the resident may be having numbness and tingling and asked if the resident could benefit from trying gabapentin (a medication used to treat nerve pain). A new order was received from the nurse practitioner on July 16, 2021, for Gabapentin 300 milligrams (mg) for neuropathy (weakness, numbness, and pain from nerve damage).

Clinical record review for Resident 6 revealed a progress note dated July 19, 2021, at 9:44 AM that was a follow-up note to a fall that occurred on July 18, 2021, at 7:30 AM. The note stated that Resident 6's physician would be asked for a referral for Resident 6 to be seen by MediTelecare (psych services by TeleMed).

A physician's progress note dated July 29, 2021, at 11:54 AM revealed that resident was weak and tired first thing in the morning. He initiated Melatonin (a medication used to help with insomnia) 3 mg at bedtime.

A progress note dated September 2, 2021, at 2:30 PM revealed that Resident 6 was talking to people that were not there. He was thinking there were two guys in his closet.

A progress note dated September 7, 2021, at 10:35 AM revealed that a fax was sent to the PA-C (Physician's Assistant -Certified) regarding Resident 6's family concern that he is becoming depressed and would like a therapeutic intervention. Please advise with a plan of care. A progress noted dated September 7, 2021, at 1:51 PM indicated a return fax was received from the PA-C with new orders for Prozac (a medication used to treat depression) 20 mg daily.

A progress note dated September 7, 2021, at 2:00 PM revealed a fax was sent to the PA-C indicating that the family does not want the resident on Prozac, and they are requesting that the resident see someone like a psychiatrist or therapist. A progress note dated September 7, 2021, at 3:48 PM indicated a return fax from the PA-C was received with new orders for a psychology consult.

A physician's progress note dated September 9, 2021, at 12:18 PM revealed that the resident was being seen for lethargy and staff report some hallucinations last week where he was worried someone would come in his window and get him. A new order for Zoloft was initiated by the PA-C and he also indicated that a referral for psychology was already placed.

A progress note dated September 11, 2021, at 11:03 PM revealed that Resident 6 was having delusions. He was thinking something, or someone was in his closet and that they are going to get him. He made staff open the closet doors to feel safe.

A progress note dated September 12, 2021, at 6:58 PM revealed that Resident 6 was angry and convinced people were stealing from him and trying to hurt him.

A progress noted dated September 20, 2021, at 11:50 PM revealed that Resident 6 has been having some visual hallucinations, but they have not really been distressing him much.

Interview with the Nursing Home Administrator on October 14, 2021, at 11:10 AM revealed that Resident 6 was not seen by MediTelecare at that time because the PA-C refused the request for him to be seen. She provided an email dated July 7, 2021, at 10:40 AM, that was sent to the nurse practitioner from the Social Services Coordinator. The Social Services Coordinator indicated that she had asked for MediTelecare to see Resident 6, but the request was declined. There was no evidence that Resident 6's physician or the PA-C were approached again requesting MediTelecare to see Resident 6 after the progress note of July 19, 2021, that indicated they would ask for a referral.

An email dated September 16, 2021, at 12:08 PM provided to the surveyor from the Nursing Home administrator revealed that the social services coordinator informed the Nursing Home Administrator that the outpatient psych service would not allow her to make the appointment for Resident 6 that the resident has to call form himself and that the PA-C would not write the referral to MediTelecare because their attendance was inconsistent.

A progress noted dated October 4, 2021, at 10:10 AM revealed that Resident 6 was noted on the floor on October 3, 2021 at 8:30 PM. Resident 6 was noted to be hallucinating, felt enemies were in his closet and trying to get in his window to cut and kill him. The note indicated that a MediTelecare consult for paranoia would be done.

A progress note dated October 4, 2021, at 11:48 AM revealed that the PA-C was consulted related to Resident 6's increased depression, hallucinations, and paranoia and a new order was received for MediTelecare services for medication management and counseling.

Further clinical record review revealed that the Resident 6 was not seen by behavioral health services until October 11, 2021, after a request was sent to MediTelecare services on October 4, 2021, indicating that it was an emergency referral related to him hallucinating and paranoia.

Interview with the Nursing Home Administrator on October 15, 2021, at 12:31 PM confirmed the above noted findings related to Resident 6's behavioral health.

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


 Plan of Correction - To be completed: 12/07/2021

The Facility submits this Plan of Correction under procedures established by the Department of Health in order to comply with the Department's directive to change conditions which the Department alleges is deficient under State and/or Federal Long Term Care Regulations. This Plan of Correction should not be construed as either a waiver of the facility's right to appeal or challenge the accuracy or severity of the alleged deficiencies or an admission of past or ongoing violation of State or Federal regulatory requirements.


1. Resident 6 currently receiving behavioral health services via Meditelicare

2. Facility verified that all residents with an order for behavioral health services are currently receiving services.

3. Education provided to social services and licensed staff in regards to referral process for behavioral health consultations.

4. Social services or designee will conduct audits weekly x 3 months to review for appropriate behavioral health referrals. Results to be reported at QAPI.


483.45(g)(h)(1)(2) REQUIREMENT Label/Store Drugs and Biologicals:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.45(g) Labeling of Drugs and Biologicals
Drugs and biologicals used in the facility must be labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable.

483.45(h) Storage of Drugs and Biologicals

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

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

Based on review of select facility policies and procedures, observation, and staff interview, it was determined that the facility failed to store medications securely on one of three nursing units (Second Floor West), dispose of expired medications on one of three nursing units (First floor medication room), and for one of 18 residents sampled (Resident 49).

Findings include:

Observation on October 12, 2021, at 11:43 AM and October 13, 2021, at 8:40 AM revealed a tube of Venelex wound dressing ointment with no cap (used to promote wound healing and treatment of pressure ulcers) on Resident 49's overbed table next to his bed. The insert noted warnings for "external use only, avoid contact with eyes, keep out of reach of children," and "keep tightly closed."

Interview with the Director of Nursing on October 14, 2021, at 2:30 PM confirmed Resident 49 was unable to self-administer the wound dressing treatment and it should not be stored at his bedside.

Observation of the medication cart on the 2 West Nursing Unit labeled "Odd" on October 14, 2021, at 10:35 AM revealed that the 2nd big drawer contained liquid medications. The bottom of the drawer was noted with dried liquid spillage on the bottom and some areas were sticky form liquid medication spillage. Observation of the cart labeled "Even" on the 2 West unit revealed that the 2nd big drawer with all the liquid medications stored in it had dried liquid spillage on the bottom and some areas were sticky. This was confirmed with Employee 6, Licensed practical Nurse.

The Director of Nursing and Nursing and Nursing Home Administrator were made aware of the concerns with the medication carts located on the 2 West Unit in a meeting on October 14, 2021, at 2:45 PM.

Observation of the first floor nursing unit medication storage room on October 14, 2021, at 9:00 AM with Employee 7 (registered nurse) revealed a 32-ounce bottle of Liquid Fiber with FOS (fiber supplement with prebiotics, compounds that induce the growth or activity of beneficial microorganisms such as bacteria and fungi) that expired on June 12, 2021. Interview with Employee 7 on the date and time of the observation confirmed that this fiber medication was available for resident use while stored with other stock medications.

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

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


 Plan of Correction - To be completed: 12/07/2021

The Facility submits this Plan of Correction under procedures established by the Department of Health in order to comply with the Department's directive to change conditions which the Department alleges is deficient under State and/or Federal Long Term Care Regulations. This Plan of Correction should not be construed as either a waiver of the facility's right to appeal or challenge the accuracy or severity of the alleged deficiencies or an admission of past or ongoing violation of State or Federal regulatory requirements.



1. Resident 49 Venelex wound dressing ointment in locked medication treatment cart. Medication carts on 2 west unit cleaned. Stock liquid high fiber disposed of.


2. Verified all ordered resident Venelex wound dressing ointment locked in medication treatment cart. Verified all treatment carts are free of spillage of liquid medications. Verified stock medications in medication rooms are within date.

3. Education provided to licensed staff on Venelex wound dressing ointment storage. Education to licensed staff on protocol for medication cart cleanliness. Education provided to licensed staff on monitoring of expiration dates on stock liquid high fiber in medication room.

4. Quality Assurance Nurse or designee will conduct audits weekly x 3 months on medication cart cleanliness as well as stock liquid high fiber expiration dates. Results will be reviewed at QAPI.



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