Pennsylvania Department of Health
MURRYSVILLE REHABILITATION AND WELLNESS CENTER
Patient Care Inspection Results

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MURRYSVILLE REHABILITATION AND WELLNESS CENTER
Inspection Results For:

There are  167 surveys for this facility. Please select a date to view the survey results.

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MURRYSVILLE REHABILITATION AND WELLNESS CENTER - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:
Based on a Medicare/Medicaid Recertification Survey, Civil Rights Compliance Survey, State Licensure Survey and an Abbreviated survey in response to two complaints, completed on April 5 2024, it was determined that Murrysville Rehabilitation and Wellness Center, was not in compliance with the requirements of 42 CFR Part 483, Subpart B, Requirements for Long-Term Care Facilities and the 28 PA Code, Commonwealth of Pennsylvania Long-Term Care Licensure Regulations.


 Plan of Correction:


483.60(i)(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 a review of facility policies, observations, and staff interviews, it was determined that the facility failed to properly label and date food products, and to properly segregate damage food in the Main Kitchen, creating the potential for food-borne illness.

Findings include:

Review of facility policy "Food Storage", dated 1/1/24, indicated that all foods will be dated at time of receipt and be inventoried using in the FIFO method (first in first out).Damaged, spoiled or recalled products will be segregated and held in a designated area.

During an observation and interview on 4/1/24, at 9:15 a.m. in the tray line refrigerator in the Main Kitchen, a tray of cups were filled with juice and covered in plastic but did not have a date on them. Food Service Director (FSD)Employee E13 confirmed that the juices were not labeled and dated.

During an observation and interview on 4/1/24, at 9:17 a.m. in the walk-in freezer in the Main Kitchen, a plastic bag of cookie dough was observed without a date, and a plastic bag of bread was observed without a date. FSD Employee E13 confirmed that the above products did not contain a date.

During an observation and interview on 4/1/24, at 9:20 a.m. in the dry storage area of the Main Kitchen an opened, unsealed bag of rice was located and found to have to be no label or date. FSD Employee E13 confirmed that the rice was unsealed, and labeled and dated.

During an observation on 4/2/24, at 11:05 a.m. in the dry storage area of the Main Kitchen, the following items were found without dates: six cans of pickles, three cans of northern beans, three cans of salsa, 11 cans of diced peaches, and two cans of chocolate pudding.

During an observation on 4/2/24, at 11:05 a.m. in the dry storage area of the Main Kitchen, a can of diced white potatoes was found to have a large dent on the side of and top of the can.

During an interview on 4/2/24, at 11:35 a.m. FSD Employee E13 confirmed that facility failed to properly date cans, and remove the damaged can from the usable inventory.

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

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

28 Pa. Code: 211.6(c) Dietary services.


 Plan of Correction - To be completed: 04/29/2024

1. The tray of juice, cookie dough, bread, rice, 6 cans of pickles, 3 cans of northern beans, 3 cans of salsa, 11 cans of diced peaches, 2 cans of chocolate pudding and the dented can of diced potatoes were disposed of.
2. The facility will label and date all food items properly moving forward and have a designated area for dented cans to be returned to the vendor.
3. The dietary staff will be re-educated by the dietary manager/designee on the facility policy for food labeling and dating and dented cans.
4. The dietary manager/designee will audit labeling and dating of food daily for 2 weeks, 2 times a week for 2 weeks, and then weekly for 3 months to ensure that food is being stored properly. Outcomes will be reported to the Quality Assurance Performance Improvement Committee for review and recommendations.

483.10(f)(5)(i)-(iv)(6)(7) REQUIREMENT Resident/Family Group and Response:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
483.10(f)(5) The resident has a right to organize and participate in resident groups in the facility.
(i) The facility must provide a resident or family group, if one exists, with private space; and take reasonable steps, with the approval of the group, to make residents and family members aware of upcoming meetings in a timely manner.
(ii) Staff, visitors, or other guests may attend resident group or family group meetings only at the respective group's invitation.
(iii) The facility must provide a designated staff person who is approved by the resident or family group and the facility and who is responsible for providing assistance and responding to written requests that result from group meetings.
(iv) The facility must consider the views of a resident or family group and act promptly upon the grievances and recommendations of such groups concerning issues of resident care and life in the facility.
(A) The facility must be able to demonstrate their response and rationale for such response.
(B) This should not be construed to mean that the facility must implement as recommended every request of the resident or family group.

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

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

Based on review of facility policy, resident council minutes, group interview, resident interviews, and staff interviews it was determined that the facility failed to respond to resident concerns and grievances identified during resident council minutes for three of three months (January 2024 through March 2024).

Findings include:

Review of the facility policy "Grievances", dated 1/1/24, indicated that the facility will support each resident's right to voice grievances and to assure that after receiving a complaint/grievance, the facility actively seeks a resolution and keeps the resident appropriately appraised of its progress toward resolution. Grievances may include a formal, written grievance process or a resident's verbalized complaint to facility staff.

Review of Resident Council Meeting/Food Committee dated 1/4/24, stated:
Is your hot food being delivered to you hot? No.

Review of Resident Council Meeting/Food Committee dated 2/1/24, stated:
Is your hot food being delivered to you hot? Hot foods are coming to the rooms cold but only if they are the last few rooms being served. Also mentioned that they are sitting on the carts for long period of time before being served.

Review of Resident Council Meeting/Food Committee dated 3/7/24, stated:
Is your hot food being delivered to you hot? No. Food sitting on carts on the floor for a while before being served to the residents.

During an interview on 4/1/24, at 10:01 a.m. Resident R40 stated that the food is cold.

During a group interview on 4/2/24, at 1:00 p.m. five of 11 residents stated that the food that should be hot is served cold.

During an interview on 4/3/24, at 11:45 a.m. Food Service Director Employee E13 confirmed that the facility has failed to address resident concerns regarding receiving cold food as meal trays are not being passed promptly after being delivered to the nursing unit.

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

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

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


 Plan of Correction - To be completed: 04/29/2024

1. Resident Council Meeting/Food Committee dated 1/4/24will be addressed by the Nursing Home Administrator/designee.
2. The facility will sustain resolution and prevent continued resident complaints that are expressed during resident council meetings.
3. The Nursing Home Administrator and Social Service Director will be re-educated on the facility grievance policies by the Regional Nursing Home Administrator/designee. Grievances will be reviewed at the daily stand up meeting.
4. The Nursing Home Administrator/designee will audit the grievance log monthly for three months to ensure grievances addressed and resolved. Outcomes will be reported to the Quality Assurance Performance Improvement Committee for review and recommendations.

483.70(e)(1)-(3) REQUIREMENT Facility Assessment: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.
483.70(e) Facility assessment.
The facility must conduct and document a facility-wide assessment to determine what resources are necessary to care for its residents competently during both day-to-day operations and emergencies. The facility must review and update that assessment, as necessary, and at least annually. The facility must also review and update this assessment whenever there is, or the facility plans for, any change that would require a substantial modification to any part of this assessment. The facility assessment must address or include:

483.70(e)(1) The facility's resident population, including, but not limited to,
(i) Both the number of residents and the facility's resident capacity;
(ii) The care required by the resident population considering the types of diseases, conditions, physical and cognitive disabilities, overall acuity, and other pertinent facts that are present within that population;
(iii) The staff competencies that are necessary to provide the level and types of care needed for the resident population;
(iv) The physical environment, equipment, services, and other physical plant considerations that are necessary to care for this population; and
(v) Any ethnic, cultural, or religious factors that may potentially affect the care provided by the facility, including, but not limited to, activities and food and nutrition services.

483.70(e)(2) The facility's resources, including but not limited to,
(i) All buildings and/or other physical structures and vehicles;
(ii) Equipment (medical and non- medical);
(iii) Services provided, such as physical therapy, pharmacy, and specific rehabilitation therapies;
(iv) All personnel, including managers, staff (both employees and those who provide services under contract), and volunteers, as well as their education and/or training and any competencies related to resident care;
(v) Contracts, memorandums of understanding, or other agreements with third parties to provide services or equipment to the facility during both normal operations and emergencies; and
(vi) Health information technology resources, such as systems for electronically managing patient records and electronically sharing information with other organizations.

483.70(e)(3) A facility-based and community-based risk assessment, utilizing an all-hazards approach.
Observations:

Based on clinical record review, staff interview and a review of the facility's assessment it was determined that the facility failed to implement and document a complete facility wide assessment, which identified the specific resources necessary to care for a resident using a LifeVest for eight out of eight months (September 2023 through April 2024 )

Findings include:

Review of facility policy "Facility Assessment", dated 7/24/23, indicated that the purpose of the assessment is to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. Use this assessment to make decisions about your direct care staff needs, as well as your capabilities to provide services to the residents in the facility.

Review of facility "Facility Assessment Tool", dated 9/28/23, indicated that the intent of the facility assessment is for the facility to evaluate its resident population and identify the resources needed to provide the necessary person-centered care and services the residents require. Using a competency-based approach focuses on ensuring that each resident is provided care that allows the resident to maintain or attain their highest practicable physical, mental, and psychosocial well-being.

Review of the clinical record revealed that Resident R56 was admitted to the facility on 7/7/23.

Review of Resident R56's MDS (Minimum Data Set, periodic assessment of resident care needs) dated 3/13/24, indicated diagnoses of heart failure (a progressive heart disease that affects pumping action of the heart muscles), hypertension (high blood pressure in the arteries) and, coronary artery disease (damage or disease in the heart's major blood vessels).

Review of Resident R56's physician orders revealed an order written on 10/5/23, that indicated, LifeVest (A LifeVest is a wearable defibrillator worn by patients at risk for sudden cardiac arrest) to wear at all times, may remove for hygiene and skin checks.

Review of Resident R56's physician orders revealed an order written on 10/5/23, that indicated, check function Q shift (every shift) and, change batteries every 24 hours. Place removed battery on the charger (every night shift)

Review of the Facility Assessment dated 9/23/23, failed to include the use of a LifeVest as a condition that requires complex medical care and management routinely cared for in the facility.

During an interview on 4/3/24, at 10:26 a.m. the Director of Nursing confirmed the facility failed to implement and document a complete facility wide assessment, which identified the specific resources necessary to care for its specific resident population.

28 Pa. Code: 207.2(a) Administrator's responsibility.


 Plan of Correction - To be completed: 04/29/2024

1. The facility immediately modified and updated the facility assessment to include "lifeVest" services are provide to ensure the accuracy of our facility-based and community-based risk assessment that utilizing an all-hazards approach.
2. The LNHA was re-educated by the Regional NHA/designee on the correct way to utilize our facility assessment.
3. The LNHA/designee will audit the facility assessment weekly for 4 weeks, biweekly for 2 months then monthly for 1 month to determine if modifications need made.
4. Outcomes will be reported to the Quality Assurance Performance Improvement Committee for review and recommendations.

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 review of clinical records and staff interviews, it was determined that the facility failed to implement a bowel protocol as ordered (Resident R11), notify a physician of abnormal glucose readings (Resident R14), provide necessary care and treatment for Resident R60' s pacemaker, and ensure timely follow-up for a resident's appointment as ordered (Resident R62) for 4 out of 29 residents. (Residents R11, R14, R60, R62)

Review of facility's policy, "Transfer to Appointment Outside the Facility, policy interpretation" dated 1/1/24, indicated the facility will verify that a physician order for an appointment/consult is present. Notify the appropriate office of the appointment by the next business day. Arrange for transportation as appropriate. Enter the appointment on the consultation/appointment log.

Review of the facility "Bowel Protocol" policy dated 1/1/24, indicated it is the facility's policy to prevent constipation. The resident's bowel movements will be monitored daily by 11-7 supervisor. Residents who have not had a bowel movement in three days are identified and considered at risk for constipation. Nursing staff will encourage the resident to increase ingestion of fluids. Resident will continue to be monitored by nursing for bowel movements following each step of the protocol and document results as appropriate. First, nursing staff will provide prune juice to residents and will document acceptance on MAR (Medication Administration Record). Second, if no results from Milk of Magnesia (MOM-is a laxative that is thought to work by drawing water to the intestines, to assist with a bowel movement) within 24 hours of administration, then administer a Bisacodyl suppository (laxative used to treat constipation) rectally at bedtime. If no results from suppository after 12 hours, administer a fleet enema (liquid medicine used to help you have a bowel movement) .

The facility "Nursing Care of the Diabetic Resident" policy, last reviewed on 1/1/24, indicated the facility will assist the resident to establish balance between diet, exercise, and insulin to prevent recurrence of hyperglycemia/hypoglycemia. The facility will recognize, assist and document the treatment of complications commonly associated with diabetes.

Review of the clinical record revealed that Resident R11 was admitted to the facility on 4/13/22.

Review of Resident R11's MDS (Minimum Data Set, periodic assessment of resident care needs) dated 2/13/24, indicated diagnoses of constipation, anxiety, and developmental disorders of scholastics skills (significant disability of learning that cannot be solely accounted for by mental retardation, visual acuity, or inadequate schooling).

Review of Resident R11's "Documentation Survey Report v2 Oct-23" failed to indicate that Resident R11 had a bowel movement from 10/23/23, though 10/26/23. A total of four days.

Review of Resident R11's clinical record failed to indicate Resident R11 was provided prune juice as per the facility's bowel protocol.

Review of Resident R11's physician order dated 8/11/23, indicated to administer 30 ml of Magnesium Hydroxide Suspension (also known as MOM, laxative that is thought to work by drawing water to the intestines, to assist with a bowel movement) 400 MG/5ML by mouth as needed for constipation, Give on day three of no bowel movement.

Review of Resident R11's physician order dated 8/11/24, indicated to insert one Bisacodyl suppository 10mg rectally as needed for constipation.

Review of Resident R11's physician order dated 8/11/23, indicated to insert one applicatorful of Fleet Enema 7-19 GM/118ML rectally as needed for constipation.

Review of Resident R11's progress note dated 10/25/23, indicated KUB (kidney, ureter, and bladder x-ray) results show moderate amount of stool in the colon and rectum. It was indicated the resident had a mild colonic ileus (occurs when your colon can't move to push food and waste out of your body, resulting in buildup and potential blockage of food material). It was indicated the Nurse Practitioner was notified and ordered to "give MOM (Milk of Magnesia) and if ineffective follow facility bowel protocol."

Review of Resident R11's "Radiology Report" dated 10/25/23, revealed there was a moderate amount of stool in colon and rectum. It was indicated the resident had a mild colonic ileus. It was observed in handwriting that a Nurse Practitioner gave a verbal order to give "MOM tonight- if ineffective give suppository in morning."

Review of Resident R11's October MAR indicated the resident was administered 30 ml of Magnesium Hydroxide Suspension 400 MG/5ML by mouth as needed for constipation on 10/25/24, at 5:55 p.m. that was ineffective.

Review of Resident R11's clinical record failed to indicate the bowel protocol was followed as ordered. Review of the clinical record failed to indicated the resident was administered a suppository or enema on 10/26/23, after the MOM was ineffective.

During an interview on 4/2/24, at 2:39 p.m. the Director of Nursing confirmed the facility failed to implement the bowel protocol as ordered for Resident R11.

Review of Resident R14's admission record indicated he was admitted on 1/4/23, with diagnoses that included diabetes (metabolic disorder impacting organ function related to glucose levels in the human body), hypertension (when the pressure in your blood vessels is too high), and major depressive disorder.

Review of Resident R14's quarterly MDS assessment (MDS-Minimum Data Set assessment: periodic assessment of resident care needs) dated 2/22/24 , indicated that the diagnoses were current upon review.

Review of Resident R14's physician order's dated 3/23/23, indicated to administer insulin (Insulin Lispro) Inject as per sliding scale: 70 - 150 = 0 if less than 70 notify MD follow hypoglycemic protocol;
151 - 200 = 3 units;
201 - 250 = 6 units;
251 - 300 = 9 units;
301 - 350 = 12 units;
351 - 400 = 15 units;
401+ = 18 units if greater than 401 give 18 units and notify MD, subcutaneously with meals related to type 2 diabetes mellitus.

Review of Resident R14's blood glucose monitoring documentation from March 2024 to May 2024, indicated the following abnormal glucose levels:
2/26/24-66
3/29/24-407
3/31/24- 528

Review of Resident R14's clinical nurse notes, physician notes, and Certified Registered Nurse Practitioner (CRNP) documentation did not include a notification to the physician about the abnormal glucose levels on 2/24/24, 3/29/24 & 3/31/24.

During an interview on 4/4/24, at 11:00 a.m. the Assistant Director of Nursing Employee E21 confirmed that the failed to notify a physician of Resident R14's abnormal glucose readings as per physician's order.

Review of the clinical record revealed that Resident R60 was admitted to the facility on 11/27/23.

Review of Resident R60's MDS dated 1/10/24, indicated diagnoses of heart failure (a progressive heart disease that affects pumping action of the heart muscles), hypertension (high blood pressure in the arteries) and, anemia (too little iron in the body causing fatigue).

Review of Resident R60's physician orders revealed an order written on 2/9/24, that indicated, consult cardiology for pacemaker (a small battery-operated device that helps the heartbeat in a regular rhythm) management.

Review of Resident R60's clinical record indicate that the facility failed to have active physician orders for a cardiologist appointment for the management of resident' s pacemaker.

During an interview on 4/2/24, at 1:32 p.m. with the appointment scheduler, Employee E7, confirmed that the cardiologist office advised the facility to use the pacemaker app on residents' phone to perform a pacemaker check, however the resident does not have his phone.

During an interview on 4/3/24, at 10:09 a.m. with the Director of Nursing confirmed that the facility failed to provide a plan of care on how the facility will check resident R60's pacemaker.

Review of Resident R60's physician orders revealed an order written on 2/9/24, indicated, schedule appointment for Enteroscopy (a procedure used to examine the small bowel).

Review of Resident R60's clinical record indicate that the facility failed to have an active physician order for a follow up appointment for an Enteroscopy.

During an interview on 4/3/24, at 10:09 a.m. with the Director of Nursing confirmed that the facility failed to schedule an appointment for an Enteroscopy, for Resident R60, that was ordered by the physician.

Review of the clinical record revealed that Resident R62 was admitted to the facility on 6/17/21.

Review of Resident R62's MDS dated 3/7/24, indicated diagnoses high blood pressure, anemia (deficiency of healthy red blood cells in blood), and polyneuropathy (damage to multiple peripheral nerves).

Review of Resident R62's progress note dated 3/18/24, stated Nurse Partitioner, Employee E23 was in facility and wrote new order for bilateral lower extremity arterial/venous dopplers (ultrasound is a noninvasive test that can be used to measure the blood flow through your blood vessels.) for pain and swelling.

Review of Resident R62's physician order dated 3/18/23, indicated to obtain arterial doppler on 3/20/24, for bilateral lower extremities due to pain and swelling.

Review of Resident R62's physician order dated 3/18/23, indicated to obtain venous doppler on 3/20/24, for bilateral lower extremities due to pain and swelling.

Review of Resident R62's progress note dated 3/21/24, entered by RN Supervisor, Employee E22 indicated the results of venous lower duplex study was completed and revealed a possible complete total occlusion on the right femoral artery.

Review of Resident R62's physician order dated 3/22/24, indicated to consult vascular due to abnormal dopplers.

Review of Resident R62's physician order dated 3/22/24, indicated to fax referral and test results to vascular consult. They will call to set up the appointment for vascular consult.

During an interview on 4/1/24, at 11:19 a.m. Resident R62 stated "both my legs are painful, it's been ongoing for a while."

During an interview on 4/2/24, at 1:31 p.m. Scheduler, Employee E7 stated once the Vascular doctor received the referral, they were supposed to call to schedule an appointment. It was indicated the RN supervisor would have it in their office if the appointment was made. She indicated she was unsure if things needed to be faxed, were faxed, and if appointment was scheduled. It was indicated she would have to follow-up with the RN supervisor.

During an interview on 4/2/24, at 1:40 p.m. RN Supervisor, Employee E22 stated, I personally have not received a call back and confirmed Resident R62 currently had no appointment scheduled. RN, Supervisor Employee E22 confirmed it had been 11 days since Resident R11 was ordered a vascular consult due to abnormal doppler results.

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

28 Pa. Code 201.29(a) Resident rights.

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

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


 Plan of Correction - To be completed: 04/29/2024

R11 is stable and moving bowels independently and is regular-physician notified and reviewed of bowel protocol.
R14 medical record has been updated to reflect the fluctuation of blood sugars-physician notified and reviewed of fluctuating blood sugars. She is stable with no ill effects. No additional changes have been indicated.
R60 is stable and an appt. is scheduled for 4/8/24 for an enteroscopy check. R60 was sent to the Cardiologist 4/23/24 to check pacemaker.
R62 appointment is made for 5/14/24 for resident to evaluate Doppler results.
MD reviewed the results of all diabetic residents with abnormal blood sugar & presence of parameter orders
A review has been completed of all residents for an appropriate bowel protocol regimen.
A review has been completed on all ordered appointments to ensure that they are all scheduled.
One time audit by DON/Designee of physicians orders on 4/16/24 for assurance of follow up on changes of conditions and appointments.
DON/designee will educate the licensed staff on Quality of Care as well as specific areas of deficient practices in the citation.
Weekly audit x 4 by DON/designee for assurance of follow up on changes of conditions and appointments as well as specific to areas of deficient practices-bowel protocol-blood sugar protocol-appointments made as ordered-follow-up appointments for abnormal test results.
DON/ designee will submit report of compliance to QAPI on compliance of quality of care x one month.


483.12(c)(2)-(4) REQUIREMENT Investigate/Prevent/Correct Alleged Violation: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.
483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must:

483.12(c)(2) Have evidence that all alleged violations are thoroughly investigated.

483.12(c)(3) Prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress.

483.12(c)(4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken.
Observations:

Based on review of facility policies, clinical record reviews and staff interviews, it was determined that the facility failed to initiate a thorough investigation for accidents or incidents included statements for three of five residents (Residents R11, R45, and R76).

Findings include:

The facility "Accidents and Incidents-Investigating and Reporting" policy dated 1/1/24, indicated all accidents or incidents occurring on our premises must be investigated and reported to the administrator. Regardless of how minor an accident or incident, injuries of unknown origin, it must be reported to the nursing supervisor and included on the facility 24-hour report. It was indicated a witness statement must be obtained immediately.

Review of the clinical record indicated that Resident R11 was admitted to the facility on 4/13/22, with diagnoses which included bipolar disorder (a serious mental illness characterized by extreme mood swings), anxiety, and developmental disorders of scholastics skills (significant disability of learning that cannot be solely accounted for by mental retardation, visual acuity, or inadequate schooling). A review of Resident R45's Minimum Data Set (MDS- a periodic assessment of resident care needs), dated 2/3/24, indicated the diagnoses remained current.

Review of Resident R11's progress note dated 2/26/24, stated a nurse aide reported that he caught Resident R11 eating shaving cream from the canister.

Review of Resident R11's investigation it was indicated a nurse aide who was not named reported that "he caught resident eating shaving cream from canister." The facility failed to obtain a witness statement from the nurse aide who found the resident eating shaving cream.

During an interview on 4/3/24, at 10:38 a.m. the Nursing Home Administrator confirmed the facility failed to obtain a witness statement from the nurse aide that found Resident R11 eating shaving cream as required. The NHA confirmed the facility failed to conduct a complete investigation for Resident R11 as required.

Review of the clinical record indicated that Resident R45 was admitted to the facility on 7/17/21, with diagnoses which included opioid and alcohol abuse, chronic viral Hepatitis C and major depressive disorder. A review of Resident R45's MDS, dated 3/6/24, indicated the diagnoses remained current.

Review of Resident R45 nurse progress notes dated 3/20/24 indicated that at 8:44 p.m. resident was frantically searching for something in a panic state, Resident R45 stated, "I can't find her Suboxone". Nurse found 3 Suboxone films in room that resident was hoarding.

During an interview 4/4/24 at 12:15 p.m. Assistant Director of Nursing (ADON) confirmed the facility did no investigation related to the medication error.

Review of the clinical record indicated that Resident R76 was admitted to the facility on 1/27/23, with diagnoses which included major depression disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), insomnia (trouble falling and/or staying asleep), schizoaffective disorder (a mental health disorder that is marked by a combination of symptoms, such as hallucinations (an experience in which you see, hear, feel, or smell something that does not exist), depression or mania (mental state of elevated or intense mood and behavior). A review of Resident R76's Minimum Data Set (MDS- a periodic assessment of resident care needs), dated 2/7/24, indicated the diagnoses remained current.

Review of Resident R76 nurse progress notes dated 3/24/24 indicated that at 4:13 p.m. Resident R76 was observed outside facility, police notified, escorted back into the building. Complete head to toe assessment performed, no injuries. MD and sister notified.

During an interview 4/2/24, at 11:30 a.m. ADON and Director of Nursing (DON) confirmed the facility did not conduct a complete elopement investigation on Resident R76 as required.

28 Pa Code: 201. 14(a) Responsibility of licensee
28 Pa Code: 201. 18 (b)(1)(3) Management
28 Pa Code: 211.10 (d) Resident care policies
28 Pa Code: 211.12 (d)(3) Nursing services


 Plan of Correction - To be completed: 04/29/2024

R11 is stable and has had no ill effects from incident. R45 is stable and has had no ill effects from incident. A medication error has been completed according to policy. R 76 is stable and has had no ill effects from incident.
One time audit by DON/Designee of all nurses notes on 4/16/24 for assurance that all incidents contain a thorough investigation and followed up according to policy.
DON/Designee has educated nursing staff on proper and thorough incident & accident reporting to the required agencies. and follow up. R11's and R76's families and physicians were notified of the incident at the time the incident happened. R45's is her own responsible and the MD was notified.
Weekly audit x 4 on 5 Residents by DON/designee to audit for any unreported Incidents or Accidents. These audits will include that a thorough investigation processes was completed.
DON/ designee will submit report of compliance to QAPI x one month on compliance with reporting Incidents and accidents and follow up occurring according to policy.

483.10(i)(1)-(7) REQUIREMENT Safe/Clean/Comfortable/Homelike Environment:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
483.10(i) Safe Environment.
The resident has a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

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

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

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

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

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

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

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

Based on review of facility policy, observations, resident council group interview, and staff interviews, it was determined that the facility failed to maintain a clean, safe, homelike environment for five out of 12 residents (Resident R33, R25, R70, R80, and Resident R81).

Findings include:

The facility "Resident Environment" policy dated 1/1/24, indicated it is the facility policy to provide an environment that is safe, clean, comfortable and homelike.

During a resident council group interview on 4/2/24, at 1:00 p.m. two residents voiced that the facility was not clean and homelike.

During an observation and interview on 4/4/24, at 9:54 a.m. Resident R70's bathroom baseboard was observed hanging off the wall. Nurse Aide, Employee E2 confirmed Resident R70's bathroom baseboard was hanging off the wall.

During an observation and interview on 4/4/24, at 9:57 a.m. Resident R80's bathroom baseboard was observed broken and hanging off the wall. Resident R80's curtain was observed to be dirty. Nurse Aide, Employee E2 confirmed Resident R80's curtains were dirty and the bathroom baseboard was hanging off the wall.

During an observation and interview on 4/4/24, at 11:42 a.m. Resident R25's wall had an area that was approximatley three inches by 12 inches, that had been plastered, but not painted. Maintenance Director Employee E14 confirmed that Resident R25's wall had not been properly sanded and painted.

During an observation and interview on 4/4/24, at 11:43 a.m. Resident R33's wall had an area that was approximately 18 inches by six inches, that had been plastered, but not painted. Maintenance Director Employee E14 confirmed that Resident R33's wall had not been properly sanded and painted.

During an observation and interview on 4/4/24, at 11:45 a.m. Resident R81's wall behind his head board had a hole that was approximately two inches by three inches, and an area of the wall in Resident R46's bathroom was approximatley two inches by two inches that had been plastered, but not painted. Maintenance Director Employee E14 confirmed that the wall behind Resident R81's bed had a hole that had not been repaired, and that a wall in Resident R81's bathroom that had not been properly sanded and painted.

28 Pa. Code:207.2(a) Administrator's responsibility.

28 Pa. Code: 201.29(j) Resident rights.


 Plan of Correction - To be completed: 04/29/2024

1) An immediate assessment of the areas identified was undertaken resulting in needed materials being ordered such as paint, dry wall, cove base etc. The areas identified were repaired.
2) The both the nursing staff and maintenance department were re-organized and re-educated in a manner that will allow for better identification of home like environment issues in a more timely manner inclusive of ongoing whole house audits to assure that those areas needing repair are identified and addressed in a timely manner.
3) Audits will be conducted by the Maintenance Department and/or designee weekly for one month, bi weekly for one month the monthly for one month.
4) Results will be discussed at the monthly quality assurance and performance improvement and safety meeting

483.10(g)(14)(i)-(iv)(15) REQUIREMENT Notify of Changes (Injury/Decline/Room, etc.):This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.10(g)(14) Notification of Changes.
(i) A facility must immediately inform the resident; consult with the resident's physician; and notify, consistent with his or her authority, the resident representative(s) when there is-
(A) An accident involving the resident which results in injury and has the potential for requiring physician intervention;
(B) A significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications);
(C) A need to alter treatment significantly (that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment); or
(D) A decision to transfer or discharge the resident from the facility as specified in 483.15(c)(1)(ii).
(ii) When making notification under paragraph (g)(14)(i) of this section, the facility must ensure that all pertinent information specified in 483.15(c)(2) is available and provided upon request to the physician.
(iii) The facility must also promptly notify the resident and the resident representative, if any, when there is-
(A) A change in room or roommate assignment as specified in 483.10(e)(6); or
(B) A change in resident rights under Federal or State law or regulations as specified in paragraph (e)(10) of this section.
(iv) The facility must record and periodically update the address (mailing and email) and phone number of the resident
representative(s).

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

Based on facility policy, clinical record review and staff interviews, it was determined the facility failed to notify the physician of a change in condition for one of three residents. (Resident R56)

Findings include:

Review of facility policy "Notification of Changes" dated 7/24/23, indicated the facility will immediately inform the resident; consult with the resident's physician; and if known, notify the resident's legal representative or an interested family member when there is:
- An accident involving the resident which results in injury and has the potential for requiring physician intervention.
- A significant change in the resident ' s physical, mental, or psychosocial status
- A need to alter treatment significantly.

Review of the clinical record indicated Resident R56 was admitted to the facility on 7/7/23.

Review of Resident R56's MDS (Minimum Data Set, periodic assessment of resident care needs) dated 3/13/24, indicated diagnoses of heart failure (a progressive heart disease that affects pumping action of the heart muscles), hypertension (high blood pressure in the arteries) and, coronary artery disease (damage or disease in the heart's major blood vessels).

Review of Resident R56's physician orders revealed an order written on 10/5/23, that indicated, LifeVest (A LifeVest is a wearable defibrillator worn by patients at risk for sudden cardiac arrest) to wear at all times, may remove for hygiene and skin checks.

Review of Resident R56's physician orders revealed an order written on 10/5/23, that indicated, check function Q-shift (every shift) and, change batteries every 24 hours. Place removed battery on the charger (every night shift)

Review of Resident R56's progress note indicated on 3/29/24, at 1:13 p.m. that nursing contacted customer service of LifeVest and notified regarding malfunction with residents vest. Customer service stated malfunction was noted and a replacement was being sent.

Review of Resident R56's progress notes on 3/29/24, failed to include documentation of notifying the physician of change in condition.

During an Interview on 4/3/24, at 10:26 a.m. the Director of Nursing (DON) confirmed the facility failed to notify the physician of a change in condition for one of three residents. (Resident R56)

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

28 Pa. Code 201.14(c)(e) Responsibility of licensee.

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


 Plan of Correction - To be completed: 04/29/2024

R 56 is stable and life vest is functioning. R 56's physician was notified of change in condition. Licensed nurses are checking placement and function q shift.
One time audit by DON/Designee of all nurses notes on 4/16/24 for assurance of MD change of condition notification completed
Weekly audit will be done x 4 by DON/designee for assurance of MD notification of all changes.
DON/Designee has educated licensed staff on Notification and change of condition and physician notification.
DON/Designee will submit a report of compliance to QAPI with MD notification for a period of one month.

483.12(b)(5)(i)(A)(B)(c)(1)(4) REQUIREMENT Reporting of Alleged Violations: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.
483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must:

483.12(c)(1) Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures.

483.12(c)(4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken.
Observations:

Based on review of facility policy, resident record, investigation documents, resident interveiw, and staff interview, it was determined that the facility failed to report allegation of neglect and report an allegation of verbal abuse for two out of four sampled residents (Resident R40 and Resident R69).

Findings include:

The facility "Abuse protection" policy dated 1/1/24, indicated that the resident has the right to be free from verbal, sexual, physical, and mental abuse.

The facility "Abuse reporting and investigation" policy dated 1/1/24, indicated that the facility will thoroughly investigate all reports of suspected or alleged abuse. The Department of Health will be notified of the alleged event by the Administrator per regulation.

Review of Resident R40's admission record indicated he was admitted on 6/16/22, with diagnoses that included hypertension (a condition impacting blood circulation through the heart related to poor pressure), diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time), and difficulty walking.

Review of Resident R40's MDS assessment (Minimum Data Set assessment: MDS -a periodic assessment of resident care needs) dated 2/3/24, indicated that the diagnoses were current upon review.

During an interview on 4/2/24, at 11:40 a.m. Resident R40 stated that a nurse aide had told him in the past that Resident R40 had reminded her of John Wayne Gacy (a convicted serial killer and sex offender), and that another aide told one of her coworkers who had asked her for assistance moving Resident R40 that "I'm not helping roll him over. He's too fucking fat", while in front of Resident R40.

During an interview on 4/2/24, at 11:50 a.m. Resident R40's allegation of verbal abuse reported to the Nursing Home Administrator (NHA).

Review of Resident R69's admission record indicated she was admitted on 6/27/23, with diagnoses that included hypertension, anxiety disorder (a medical condition creating a sense of acute fear, restlessness, and worry), and dementia (a condition characterized by memory loss and progressive or persistent loss of intellectual functioning).

Review of Resident R69's MDS assessment dated 3/13/24, indicated that the diagnoses were current upon review.

Review of Resident R69's grievance statement dated 2/4/24, indicated an allegation that staff removed Resident R69 call bell from her reach. The staff person stated Resident R69 "doesn't need to be ringing it." The facility investigated and were unable to identify an allege perpetrator.

Review of reports submitted to the local state field office did not include Resident R69's allegation of neglect.

During a resident council group interview on 4/2/24, at 1:00 p.m. Resident R69 stated that staff once answered her call bell and disconnected it.

During an interview on 4/2/24, at 2:52 p.m. the Director of Nursing (DON) confirmed that the facility failed to report Resident R69's allegation of neglect as required.

Review of reports submitted to the local state field office from 4/1/24 through 4/4/24 did not include Resident R40's allegation of verbal abuse.

During an interview on 4/4/24, at 2:39 p.m. NHA confirmed that the facility failed to report Resident R40's allegation of verbal abuse within 24 hours to the local state field office as required.

28 Pa Code: 201.14 (a) Responsibility of Management.

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


 Plan of Correction - To be completed: 04/29/2024

R 40 has been provided emotional support and has been stable. DOH reportable submitted
R 69 has been provided emotional support and has been stable. DOH reportable submitted.
One time audit by Social Services Director of all interviewable Residents for any unreported abuse.
DON/Designee has completed education with nursing staff on proper reporting, identification and investigation of abuse. This education includes resident abuse, neglect and that call bells need to remain in reach.
Weekly audit of 5 Residents x 4 weeks by Social Service Director to identify any potential abuse
Social Service Director will submit report of compliance to QAPI concerning identifying abuse x I month.

483.15(a)(1)-(7) REQUIREMENT Admissions Policy: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.
483.15(a) Admissions policy.
483.15(a)(1) The facility must establish and implement an admissions policy.

483.15(a)(2) The facility must-
(i) Not request or require residents or potential residents to waive their rights as set forth in this subpart and in applicable state, federal or local licensing or certification laws, including but not limited to their rights to Medicare or Medicaid; and
(ii) Not request or require oral or written assurance that residents or potential residents are not eligible for, or will not apply for, Medicare or Medicaid benefits.
(iii) Not request or require residents or potential residents to waive potential facility liability for losses of personal property.

483.15(a)(3) The facility must not request or require a third party guarantee of payment to the facility as a condition of admission or expedited admission, or continued stay in the facility. However, the facility may request and require a resident representative who has legal access to a resident's income or resources available to pay for facility care to sign a contract, without incurring personal financial liability, to provide facility payment from the resident's income or resources.

483.15(a)(4) In the case of a person eligible for Medicaid, a nursing facility must not charge, solicit, accept, or receive, in addition to any amount otherwise required to be paid under the State plan, any gift, money, donation, or other consideration as a precondition of admission, expedited admission or continued stay in the facility. However,-
(i) A nursing facility may charge a resident who is eligible for Medicaid for items and services the resident has requested and received, and that are not specified in the State plan as included in the term ''nursing facility services'' so long as the facility gives proper notice of the availability and cost of these services to residents and does not condition the resident's admission or continued stay on the request for and receipt of such additional services; and
(ii) A nursing facility may solicit, accept, or receive a charitable, religious, or philanthropic contribution from an organization or from a person unrelated to a Medicaid eligible resident or potential resident, but only to the extent that the contribution is not a condition of admission, expedited admission, or continued stay in the facility for a Medicaid eligible resident.

483.15(a)(5) States or political subdivisions may apply stricter admissions standards under State or local laws than are specified in this section, to prohibit discrimination against individuals entitled to Medicaid.

483.15(a)(6) A nursing facility must disclose and provide to a resident or potential resident prior to time of admission, notice of special characteristics or service limitations of the facility.

483.15(a)(7) A nursing facility that is a composite distinct part as defined in 483.5 must disclose in its admission agreement its physical configuration, including the various locations that comprise the composite distinct part, and must specify the policies that apply to room changes between its different locations under paragraph (c)(9) of this section.
Observations:

Based on review of facility policy, resident records, admissions documentation and staff interview it was determined that the facility failed to provide a comprehensive review of resident admission rights and maintain admission documentation for one out of out three sampled records (Resident R4).

Finding include:

The facility "Admissions documents: statement of resident rights" last reviewed 1/1/24, indicated that the facility shall protect and promote the rights of each resident. The resident has the right to be informed and participate in his or her treatment. The resident has the right to be informed before or at the time of admission of the facilities policies and procedures.

Review of Resident R4 admission record indicated he was admitted on 12/29/23.

Review of Resident R4 MDS assessment (Minimum Data Set assessment: MDS -a periodic assessment of resident care needs) dated 1/5/24, indicated that he was admitted with diagnosed that included lung cancer, chronic obstructive pulmonary disease (COPD: a disease characterized by persistent respiratory symptoms involving breathlessness, coughing, and obstructed airflow to the lungs), hypertension (a condition impacting blood circulation through the heart related to poor pressure), and chronic kidney disease (a loss of kidney function resulting in the swelling of feet, fatigue, high blood pressure and changes in urination). The assessment indicted that the diagnoses were still current.

Review of Resident R4 physician orders dated 12/29/23, indicated to admit to the skilled nursing care facility.

Review of Resident R4's admission packet (no date) did not indicate a signature from Resident R4 or a representative's signature, a date for review of the admission packet, or indicate that Resident R4 resident rights were reviewed.

Review of Resident R4 Nurse practitioner note dated 1/2/24, indicated that Resident R4 did not have the capacity to make medical decisions.

Review of Resident R4's clinical nurse notes and admission documents did not indicate that Resident R4 or his representative reviewed resident rights and the admission packet.

During an interview on 4/2/24, at 10:05 a.m. the Admissions coordinator Employee E5 confirmed that the facility failed to provide a comprehensive review of resident admission rights and maintain admission documentation for Resident R4 as required.

28 Pa Code: 201.18 (b)(2) Management.

28 Pa Code: 201.24 (a) Admission policy.

28 Pa Code: 201.19 (i) Resident rights.


 Plan of Correction - To be completed: 04/29/2024

The facility will provide a comprehensive review of resident admission rights and maintain admission documentation.

Admission documentation was immediately presented and signed by Resident R4's brother (POA).A whole in-house audit was completed to verify that residents right were presented to all current residents.
The Admission Director or Designee was reeducated on the facilities policy and procedures for "Admissions" detailing a comprehensive review of resident admission rights and maintain admission documentation.
The Admission Director or Designee will complete an audit of new admission packets weekly for four weeks then weekly for three months to validate resident rights have been presented and understood and dated properly.
The results of these audits will be forwarded to the monthly Quality Assurance and Performance Improvement Committee for review and frequency of audits.

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

Based on a review of clinical records, and staff interview, it was determined that the facility failed to ensure that a comprehensive resident care plan was complete for resident care needs related to a Life Vest (a wearable defibrillator designed to protect residents from sudden cardiac death) for one of five residents (Resident R56).

Findings include:

Review of facility's policy "MDS/RAI/Care Planning" dated 7/24/23, indicated the resident assessment instrument (RAI) and care planning process provide a tool for an interdisciplinary approach to plan the care of the resident. The purpose of the RAI is to incorporate the identified medical, nursing, nutritional, rehabilitative, and psychosocial needs of each resident into interventions and goals to meet those needs.

Review of the clinical record revealed that Resident R56 was admitted to the facility on 7/7/23.

Review of Resident R56's MDS (Minimum Data Set, periodic assessment of resident care needs) dated 3/13/24, indicated diagnoses of heart failure (a progressive heart disease that affects pumping action of the heart muscles), hypertension (high blood pressure in the arteries) and, coronary artery disease (damage or disease in the heart's major blood vessels). Resident R56's MDS assessment section C0200 Brief Interview for Mental Status ("BIMS", a screening test that aides in detecting cognitive impairment). The BIMS total score suggests the following distributions: 13-15: cognitively intact, 8-12: moderately impaired, 0-7: severe impairment. Resident R56's BIMS score was a fifteen, indicating Resident R56 was cognitively intact.

Review of Resident R56's physician orders revealed an order written on 10/5/23, that indicated, LifeVest (A LifeVest is a wearable defibrillator worn by patients at risk for sudden cardiac arrest) to wear at all times, may remove for hygiene and skin checks.

Review of Resident R56's physician orders revealed an order written on 10/5/23, that indicated, check function Q-shift (every shift) and, change batteries every 24 hours. Place removed battery on the charger (every night shift)

Review of Resident R56's progress note indicated on 9/20/23, at 2:05 p.m. that nursing was called to PT (physical therapy) gym by certified nursing assistant (CNA). PT stated resident went unresponsive. Stated resident started to stare and answering therapist and then PT layed resident on back on the table. LifeVest did not go off. Battery needed changed. Patient unresponsive for less than 10 seconds. MD notified. Ordered resident to be sent to hospital.

Review of Resident R56's care plan, dated on 9/20/23, revealed that the facility failed to ensure that the resident received education on the ability to care for and manage his LifeVest, which includes battery management, independently was not care planned.

During an observation on 4/2/24, at 9:15 a.m. resident demonstrated where to put his LifeVest battery to charge, stated when he changes the battery and how to tell if the battery is charging/charged. Resident stated, "I do not allow anyone to touch my LifeVest, I do it all myself."

During an interview on 4/3/24, at 10:26 a.m. the Director of Nursing (DON) confirmed that the facility failed to ensure that a comprehensive resident care plan was complete for resident care needs related to a Life Vest for one of five residents (Resident R56)

28 Pa. Code: 211.11(a) Resident care plan.


 Plan of Correction - To be completed: 04/29/2024

R 56 care plan has been amended and reviewed to reflect his independence with the life vest. R56 is stable.
One time audit by DON/Designee of all Residents who perform any independent care for an appropriate plan of care.
Weekly audit of 5 Residents x 4 by DON/Designee to identify any residents that perform independent care for appropriate plan of care.
DON/Designee has completed education with licensed staff on appropriate care planning.
DON/Designee will submit report of compliance to QAPI on compliance with care plans x one month.

483.21(b)(3)(i) REQUIREMENT Services Provided Meet Professional Standards:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.21(b)(3) Comprehensive Care Plans
The services provided or arranged by the facility, as outlined by the comprehensive care plan, must-
(i) Meet professional standards of quality.
Observations:

Based on the review of facility job descriptions, clinical records, and staff interviews, it was determined that the facility failed to follow standards of professional practice for one of six residents (Resident R25).

Findings include:

Review of Title 42 Code of Federal Regulations (CFR) Medical records. In accordance with accepted professional standards and practice, the facility must maintain medical records that are complete, accurately documented, readily accessible, and systematically organized.

Review of the facility document "Staff Nurse RN (Registered Nurse) Job Description" indicated that facility RN must:
Chart nurse's notes in an informative, relevant, concise, and descriptive manner that reflects the care provided to the resident, as well as the resident's response to care.
Develop a nursing care plan, individualizing the care, revises the plan as necessary.
Routinely assesses the total needs of the residents and adjust care plans as needed.
Reviews care plan daily to ensure that appropriate care is being provided.
Interact/communicate with residents, staff, and visitors in a courteous manner.
Acts as a positive representative of the facility.
Ensure that all residents are treated fairly, and with kindness, dignity, and respect.
Must possess the ability to deal tactfully with personnel, resident, family members, visitors, government agencies/personnel, and the general public.
Must be able to relate information concerning a resident's condition.

Review of the facility document LPN (Licensed Practical Nurse) Job Description" indicated that the facility LPN must:
Ensure that nurse's notes are charted in an informative and descriptive manner that reflects the care provided to the resident, as well as the resident's response to the care.
Maintain established nursing objectives and standards.
Administer professional services such as catheterization as required.
Ensure that resident care plans are reviewed for appropriate resident goals, problems, approaches, and revisions based on nursing needs.
Must possess the ability to deal tactfully with personnel, residents, family members, visitors, government agencies or personnel, and the general public.
Must be knowledgeable of nursing and medical procedures, as well as laws, regulations, and guidelines that pertain to nursing care facilities.

Review of the clinical record indicated Resident R25 was admitted to the facility on 10/28/22.

Review of Resident R25's Minimum Data Set (MDS) (assessment of a resident's abilities and care needs) dated 2/5/24, indicated diagnoses of Post Traumatic Stress Disorder (PTSD- a disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event), benign prostatic hyperplasia (an enlarged prostate gland that may contribute to difficulty urinating), and high blood pressure.

Review of the nursing progress notes for Resident R25 dated 5/7/23, stated the following: "After treatment to penis was completed by this nurse and during dressing change to right lower leg, resident stated that he was talking to a female from the VA (Veterans Affairs) and was telling her about a staff member in this facility that he trusts to take care of his penis dressing. He stated that this nurse took good care of his dressings and that he got a hard on with this nurse was rubbing his penis up and down while cleaning it. He stated that it felt good his pecker got as hard as a rock."

Review of the above note did not reveal that any of the language was in quotation marks to suggest that Resident R25 had verbalized these words.

Review of the clinical record revealed a care plan for Resident R25 dated 5/7/23 that stated the following: "He got a hard on with this nurse rubbing his penis up and down, it felt so good his penis got as hard as a rock."

Review of the above note did not reveal that any of the language was in quotation marks to suggest that Resident R25 had verbalized these words.

During an interview on 4/4/24, at 9:15 a.m. RN Supervisor Employee E1 confirmed that the facility failed to follow professional standards of practice for one of six residents reviewed (Resident R25).

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

28 Pa. Code 211.12(d)(1)(2)(5) Nursing services

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


 Plan of Correction - To be completed: 04/29/2024

R 25 has been is stable and has been discharged to a Veterans facility.
One time audit by DON/Designee of all nurses notes on 4/16/24 for assurance of identification of any documentation that does not meet Standards of professional practice and that resident's inappropriate verbalization can be in the record in quotation marks exactly as it was said. Also, staff was educated on who to report these verbalizations to so the resident can receive appropriate care.
DON/Designee has educated licensed nursing staff on proper documentation with Standards of professional practice and instructed that inappropriate verbalization is not acceptable in reposts.
DON/Designee will complete a weekly audit x 4 weeks to identify any documentation that does not meet Standards of professional practice.
DON/ designee will submit report of compliance to QAPI on compliance with Standards of professional practice x one month.


483.24(a)(2) REQUIREMENT ADL Care Provided for Dependent Residents: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.
483.24(a)(2) A resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene;
Observations:

Based on facility policy clinical record review and staff interviews, it was determined that the facility failed to make certain that residents receive assistance with nail care for one of two residents (Resident R53).

Findings include:

Review of the facility policy "Nail Care", last reviewed 1/1/24, indicated that resident's finger nails will be cleaned and trimmed as needed or requested.

Review of the clinical record indicated Resident R53 was admitted to the facility on 12/6/19, with diagnoses of hemiplegia (paralysis of one side of body) affecting the right dominant side, and polyneuropathy (damage to multiple peripheral nerves).

Review of Resident R53's MDS assessment (Minimum Data Set- a periodic assessment of resident needs) dated 2/22/24, indicated the diagnoses remained current and that Resident R53 requires assistance with ADL's (activities of daily living).

Review of Resident R53's Kardex (documentation system that enables nurses to write, organize, and easily reference key patient information that shapes their nursing care plan) report on 4/1/24, it was indicated to ensure the resident is well groomed.

During an observation and interview on 4/1/24, at 10:12 a.m. Resident R53 nails were observed to be long. Resident R53 indicated he would like his nails clipped.

During an observation and interview on 4/2/24, at 11:41 a.m. Resident R53 indicated he still needed his nails clipped. Resident R53's nail were observed to be long. Nail clippers were located on the resident's bedside table.

During an interview on 4/2/24, at 11:45 a.m. Nurse Aide, Employee E4 confirmed Resident R53's nails were long and needed clipped.

During an interview on 4/2/24, at 11:47 a.m. Registered Nurse Supervisor, Employee E1 confirmed the facility failed to make certain that residents receive assistance with nail care for one of two residents (Resident R53).

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

28 Pa. Code: 211.12(d)(1)(2)(3)(5) Nursing services.


 Plan of Correction - To be completed: 04/29/2024

R53 nails have been cleaned and trimmed.
One time audit by DON/Designee of all Residents nails for cleanliness and appropriate nail length.
Weekly audit of 5 Residents x 4 by DON/Designee to identify any residents that need nail care.
DON/Designee has educated nursing staff on appropriate nail care.
DON/Designee will submit report of compliance to QAPI on compliance with nail care x 1 for one month.


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 review of facility policy, clinical record review, observation, and staff interview, it was determined that the facility failed to provide services and treatment to prevent further limitations in range of motion for one of two residents who had limitations in range of motion (Resident R81).

Findings include:

Review of facility policy "Resident Screening for Therapy Services Best Practices", dated 1/1/24, indicated that skilled therapy services may be necessary to improve a patient's condition, to maintain the patient's current condition, or to slow further deterioration of the patient's condition. Thus, therapists must document the skilling need of the therapy services and support that therapy interventions are reasonable and medically necessary. Walking clinical rounds are conducted to observe positioning for comfort, posture, function, mobility, adaptive equipment use, ability to feed oneself, grooming/hygiene needs, etc. Review of previously established care includes evaluation of wheelchair to ensure sizing is appropriate, and mobility, comfort, and function is optimal.

Review of Resident 81's admission record indicated he was admitted to the facility on 1/5/23.

Review of Resident 81's MDS (Minimum Data Set, periodic assessment of resident care needs) dated 3/6/24, indicated diagnoses of cerebral vascular accident (an event that occurs when something blocks blood supply to part of the brain or when a blood vessel in the brain bursts), Parkinson's disease (a disorder of the central nervous system that affects movement, often including tremors), and weakness.

Review of Resident R81's clinical record revealed a physician order dated 1/11/24, to be out of bed in Broda Chair (a type of high back wheelchair that tilts) with abductor wedge (a type of pillow placed between the legs to stabilize the hips), and a pillow behind the left back.

During an observation on 4/1/24, at 1:21 p.m. Resident R81 was observed in his Broda Chair without an abductor wedge in between his legs or a pillow behind his back as ordered.

During an interview on 4/1/24, at 1:28 p.m. Certified Occupational Therapy Assistant (COTA) Employee E12 confirmed that the facility failed to provide Resident R81 with an abductor wedge, and pillow behind his left back in accordance with the physician's orders.

28 Pa. Code 211.10(c): Resident care policies.
28 Pa. code 211.12(d)(1): Nursing services.


 Plan of Correction - To be completed: 04/29/2024

One time audit by DON/Designee of all Residents with adaptive equipment and positioning devices for use.
R81 is stable and his care plan has been updated to reflect appropriate positioning devices.
DON/Designee will in-service Licensed nursing staff and therapy staff on appropriate use and monitoring positioning devices and equipment.
Weekly audit of 5 Residents x 4 by DON/Designee of adaptive equipment of positioning device for use.
DON/Designee will submit report of compliance to QAPI on compliance with adaptive equipment and positioning device x one month.

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 facility policy, clinical records and staff interviews, it was determined that the facility failed to make certain each resident received adequate supervision and assistance to prevent accidents for one of five residents (Resident R11).

Findings include:

Review of the facility "MDS/RAI/Care Planning" policy last reviewed 1/1/24, indicated the facility must develop a written plan of care individualized for each resident, which identifies through his/her strengths, problems and needs.

Review of Resident R11's admission record indicated Resident R11 was admitted on 4/13/22.

Review of Resident R11's MDS assessment (Minimum Data Set Assessment: A periodic assessment of resident care needs) dated 2/3/24, indicated she was admitted with the following diagnoses that included bipolar disorder (a serious mental illness characterized by extreme mood swings), anxiety, and developmental disorders of scholastics skills (significant disability of learning that cannot be solely accounted for by mental retardation, visual acuity, or inadequate schooling). Resident R11's MDS assessment section C0200 Brief Interview for Mental Status ("BIMS", a screening test that aides in detecting cognitive impairment). The BIMS total score suggests the following distributions: 13-15: cognitively intact, 8-12: moderately impaired, 0-7: severe impairment. Resident R11's BIMS score was a "00" indicating Resident R11 was severely cognitively impaired.

Review of Resident R11's "Follow-Up" summary dated 10/25/23, indicated Resident R11 had a small bowel obstruction in the past related to the ingestion of foreign objects.

Review of Resident R11's progress note dated 2/26/24, stated a nurse aide reported that he caught Resident R11 eating shaving cream from the canister.

Review of Resident R11's investigation it was indicated the unnamed nurse aide reported that "he caught resident eating shaving cream from canister." It was indicated the shaving cream was removed from the bedside drawer. "All care products removed from bedside drawers." Poison control was notified and instructed to give resident water to help dilute the shaving cream. The resident was provided a glass of water and consumed it. It was indicated "all hygiene items placed in basin on top shelf in closet." 2

Review of the "Event Report" the facility submitted to the Department of Health on 2/27/24, at 1:41 p.m. it was indicated Resident R11 with a BIMS of 0 was observed consuming shaving cream. It was estimated the resident consumed one mouth full. It was indicated the room was searched for any other unacceptable items. It stated Resident R11 "has a tendency to roam the building and pick up items not belonging to him."

Review of Resident R11's "1-Month" physician follow-up summary dated 3/21/24, indicated Resident R11 has a history of ingesting foreign substances.

Review of Resident R11's care plan on 4/1/24, failed to include interventions to prevent the resident from ingesting foreign objects and substances.

During an interview on 4/3/24, at 9:54 a.m. Dietician, Employee E8 stated Resident R11 "has PICA (an eating disorder where a person compulsively eats things that aren ' t food and don ' t have any nutritional value or purpose), we have to be really careful, he will drink anything, eat anything." Dietician, Employee E8 indicated Resident R11 "came from poor home environment" and his "brother was feeding him alcohol and popsicle sticks." It was indicated the facility was aware.

During an interview on 4/3/24, at 9:59 a.m. Registered Nurse (RN), Employee E3 indicated she is aware of Resident R11's history of ingesting foreign objects and substances. RN, Employee E3 stated his personal care items including his body wash and shampoo are located in his bedside drawer.

During an observation on 4/3/24, at 10:02 a.m.
the following was observed in Resident R11's room:
-One 2 fluid (fl.) ounce (oz.) shampoo bottle on the bedside table
-One 2 fl. oz. shampoo body wash on dresser
-One tube of Antifungal cream with 1% Clotrimazole (medication used to treat yeast infections) in dresser drawer
-One 2.5 oz. tube of Triad butt paste in night stand drawer located beside the resident's bed
-One 4 oz. tube of skin protective with zinc oxide in night stand drawer located beside the residnet's bed
-Five markers on top of the resident's dresser

During an interview on 4/3/24, at 10:06 a.m. Director of Central Supply, Employee E7 confirmed the above observation and stated "oh no, he shouldn't have that in here or access to it." She stated, "that's why I have to keep my office locked." Director of Central Supply, Employee E7's office and storage of the facility's supply was located across Resident R11's room.

During an interview on 4/3/24, at 10:24 a.m. the Director of Nursing confirmed the facility failed to failed to make certain each resident received adequate supervision and assistance to prevent accidents for one of five residents (Resident R11).

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

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

28 Pa. Code 201.29(a)(c)(d) Resident rights


 Plan of Correction - To be completed: 04/29/2024

R11 is stable. R11 room has been inspected and is free of accident hazards.
Physician was notified at the time of the incident. No diagnosis of PICA has been identified in files. Staff educated on the acceptable items allowed in his room. Room and drawer checks every shift to assure safety. Care plan updated. One time audit by DON/Designee of all Residents bed side stands and rooms for inappropriate storage of items that could be a hazard.
DON/Designee will in-service Nursing staff on appropriate storage of items that could be hazardous or pose risk to residents.
Weekly audit of 5 Residents x 4 by DON/Designee on bed stands and rooms for inappropriate storage of items that could be a hazard.
DON/Designee will submit report of compliance to QAPI on compliance with bedside stands and storage x one month.

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 a review of clinical record, and staff interview, it was determined that the facility failed to ensure a resident was offered sufficient fluid intake to maintain proper hydration and health for one of seven residents (Resident R55).

Findings include:

Review of the "Hydration Guideline" policy dated 1/1/24, stated residents will be monitored for decreased oral fluids intake and hydration status. Interventions will be initiated to prevent dehydration. It was indicated the facility must ensure residents sufficient fluid intake to maintain hydration and health. It was indicated the facility staff must offer a variety of fluids based on resident preference.

Review of the clinical record revealed that Resident R55 was admitted to the facility on 1/21/19.

Review of Resident 55's MDS (Minimum Data Set, periodic assessment of resident care needs) dated 3/25/21, indicated diagnoses of constipation, depression, and adult failure to thrive (happens when an older adult has a loss of appetite, eats and drinks less than usual, loses weight, and is less active than normal).

During an observation on 4/1/24, at 10:18 a.m. Resident R55's lips were observed cracked and dry. Resident R55 complained of a dry mouth. No water was observed at the bedside available to the resident.

During an interview on 4/1/24, at 11:12 a.m. Registered Nurse, Employee E3 confirmed the facility failed to offer sufficient fluid intake to maintain proper hydration and health for Resident R55.

During an interview on 4/1/24, at 11:32 Nurse Aide, Employee E4 confirmed she failed to provide Resident R55 with fresh water this morning.

28 Pa. Code: 201.18(b)(1)(e)(1) Management
28 Pa. Code: 201.12(d)(1)(3)(5) Nursing services


 Plan of Correction - To be completed: 04/29/2024

R 55 is stable and labs reflect appropriate hydration.
One time audit by DON/Designee of all Residents for appropriate water pass and water is placed at bedside.
Weekly audit of 5 Residents x 4 by DON/Designee for appropriate water pass and water placement.
DON/Designee will educate nursing staff on water pass and hydration.
DON/Designee will submit report of compliance to QAPI on compliance with water pass x1 for one month.

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 facility policy, observations, staff interviews, and clinical record review, it was determined that the facility failed to provide oxygen as ordered for one of four residents (Resident R55).

Findings include:

Review of undated and unsigned "Staff Nurse (RN)" job description indicated the Registered Nurse is responsible for the interpretation and execution of physician orders.

Review of the clinical record revealed that Resident R55 was admitted to the facility on 1/21/19.

Review of Resident 55's MDS (Minimum Data Set, periodic assessment of resident care needs) dated 2/21/24, indicated diagnoses of constipation, depression, and adult failure to thrive (happens when an older adult has a loss of appetite, eats and drinks less than usual, loses weight, and is less active than normal).

Review of Resident R55's physician's order dated 3/27/24, indicated to administer two liters of oxygen continuously every shift for shortness of breath.

During an observation on 4/1/24, at 11:10 a.m. Resident R55 was observed lying in bed without oxygen as ordered.

During an interview and observation on 4/1/24, at 11:24 p.m. Registered Nurse, Employee E3 confirmed Resident R55 was not receiving his oxygen as ordered.

During an interview on 4/1/24, at 2:53 a.m. the Director of Nursing and Nursing Home Administrator confirmed that the facility failed to provide oxygen as ordered for one of four residents (Resident R55).

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

28 Pa. Code 211.12(d)(1)(2)(5) Nursing services

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


 Plan of Correction - To be completed: 04/29/2024

R55 is stable and his oxygen order has been clarified to reflect his usage of.
One time audit by DON/Designee of all Residents with oxygen are utilized as per order
DON/Designee will educate nursing staff on oxygen ordering and appropriate use.
Weekly audit of 5 Residents x 4 by DON/Designee for appropriate oxygen order and utilized as per order.
DON/Designee will submit report of compliance to QAPI on oxygen use x one month.

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 review of facility policy, clinical record review, resident interview, and staff interviews it was determined that the facility failed to develop and implement a person-centered care plan that supports the behavioral health care needs for one of three residents (Resident R11), and that the facility failed to provide on-going, necessary behavioral healthcare services to a resident to maintain the highest practicable mental and psychosocial well-being for one of three residents (Resident R33), the discontinuation of behavioral healthcare services preceded an attempt of suicide for one resident (Resident R33), and also failed to offer psychiatric services for one resident (Resident R33) after an attempt of suicide.

Findings include:

Review of the facility "MDS/RAI/Care Planning" policy last reviewed 1/1/24, indicated the facility must develop a written plan of care individualized for each resident, which identifies through his/her strengths, problems and needs.

Review of Title 42 Code of Federal Regulations (CFR) -Providing behavioral health care services is an integral part of the person-centered environment. This involves the interdisciplinary approach to care, with qualified staff that demonstrate the competencies and skills necessary to provide appropriate services to the resident. Individualized approaches to care (including direct care and activities) are provided as part of a supportive physical, mental, and psychosocial environment, and are directed toward understanding, preventing, relieving, and/or accommodating a resident's distress or loss of abilities

Review of Resident R11's admission record indicated Resident R11 was admitted on 4/13/22, with diagnoses that included bipolar disorder (a serious mental illness characterized by extreme mood swings), anxiety, and developmental disorders of scholastics skills (significant disability of learning that cannot be solely accounted for by mental retardation, visual acuity, or inadequate schooling).

Review of Resident R11's MDS assessment (Minimum Data Set Assessment: A periodic assessment of resident care needs) dated 2/3/24, indicated the diagnoses were current. Resident R11's MDS assessment section C0200 Brief Interview for Mental Status ("BIMS", a screening test that aides in detecting cognitive impairment) indicated the BIMS total score suggests the following distributions: 13-15: cognitively intact, 8-12: moderately impaired, 0-7: severe impairment. Resident R11's BIMS score was a "00" indicating Resident R11 was severely cognitively impaired.

Review of Resident R11's "Follow-Up" summary dated 10/25/23, indicated Resident R11 had a small bowel obstruction in the past related to the ingestion of foreign objects.

Review of Resident R11's progress note dated 2/26/24, stated a nurse aide reported he caught Resident R11 eating shaving cream from the canister.

Review of Resident R11's "1-Month" physician follow-up summary dated 3/21/24, indicated Resident R11 has a history of ingesting foreign substances.

Review of Resident R11's care plan on 4/1/24, failed to include interventions to prevent the resident from ingesting foreign objects and substances.

During an interview on 4/3/24, at 9:54 a.m. Dietician, Employee E8 stated Resident R11 " has PICA (an eating disorder where a person compulsively eats things that aren't food and don't have any nutritional value or purpose), we have to be really careful, he will drink anything, eat anything." Dietician, Employee E8 indicated Resident R11 "came from poor home environment" and his "brother was feeding him alcohol and popsicle sticks." It was indicated the facility was aware.

During an interview on 4/3/24, at 9:59 a.m. Registered Nurse, Employee E3 indicated she has worked at the facility for 30 years. It was indicated the facility is aware of Resident R11's history of ingesting foreign objects and substances.

During an interview on 4/3/24, at 10:24 a.m. the Director of Nursing confirmed the facility failed to develop and implement person-centered care plan that include and support the behavioral health care needs for one of three residents (Resident R11).

Review of Resident R33's admission record indicated Resident R 33 was admitted on 12/28/22.

Review of Resident R33's MDS assessment dated 3/13/24, indicated diagnoses that included schizophrenia (a mental disorder characterized by delusions, hallucinations, disorganized speech and behavior), bipolar disorder, and dementia (a group of symptoms that affects memory, thinking and interferes with daily life).

Review of Resident R33's clinical record revealed a progress note from psychiatric services provided in-house by the facility dated 1/24/24, that stated resident has "Passive suicidal ideation (thinking about suicide). Thinking often about death in general, denies plan or intent".

Review of Resident R33"s clinical record revealed a progress note from psychiatric services provided in-house by the facility dated 2/1/24, that stated "Met with patient today to discuss his decision on which practitioner he would liked to continue with. Patient decided to go with the psychiatrist he has been with for years at Behavioral Health Center. Facility made aware. Will discharge from services".

Review of Resident R33's clinical record revealed a progress note dated 3/31/24, that stated that Resident R33 "took his weighted fork (a eating utensils that has extra weight to help minimize tremors while eating) and made a stabbing motion towards his throat this morning while charge nurse was passing his meds. Spoke with resident. Resident stated 'I wasn't going to do anything. I don't know why I do it'. Asked resident for the silverware in his room. He had two butter knives, 1 fork, 1 spoon, 1 weighted spoon and 1 weighted fork. All silverware removed from his room. Resident placed on 15 minute checks. MD aware".

During an interview on 4/3/24, at 11:02 a.m. Social Worker Employee E6 stated that Resident R33 had been going to an outside facility for Behavioral Health services two times per week, but had not gone in several weeks because "The wheelchair van is broken".

During an interview on 4/4/24, at 12:28 p.m. Medical Supply/Resident Appointment/Transportation Employee E7 stated that Resident R33 had been going to group therapy twice per week on Tuesdays and Thursdays at the Behavioral Health Center, and was also seeing a psychiatrist and a social worker at the Behavioral Health Center but hasn't seen anyone since 2/15/24 as he had a contract that only allowed a set number of visits and that he had utilized all of his allowed visits. Medical Supply/Resident Appointment/Transportation Employee E7 also stated that the van was broken but only for residents who required transportation in a wheelchair as something was wrong with the lift mechanism that loaded residents into the van while in a wheelchair, but since Resident R33 is able to walk he could ride in the front of the van. Medical Supply/Resident Appointment/Transportation Employee E7 stated that Resident R33 "was just in here asking if he could restart therapy".

During an interview on 4/4/24, at 1:00 p.m. Resident R33 stated he had not received any psychiatric services since the incident when he threatened to stab himself in the throat, but added "I still need it though". Resident R33 also stated that he did not want to see the provider of psychiatric services that came into the facility and wanted to see his established providers at the Behavioral Health Center.

During an interview on 4/5/24, at 2:14 p.m. Registered Nurse (RN) Supervisor Employee E1 stated that Resident R33 had a contract for a set amount of visits at the Behavioral Health Center and was no longer receiving them as the contract was exhausted.

During a phone interview on 4/5/24, at 10:49 a.m. Behavior Health Center Licensed Social Worker (LSW) stated that Resident R33 no longer receives services at the Behavior Health Center as the facility's "van is broken". When Behavior Health Center LSW was asked if Resident R33 had a contract for a set amount of visits, she replied "We don't offer contracts. I'm not sure what they (the facility) are talking about". Behavior Health Center LSW stated that resident is still able to get all of his behavioral health services at the Behavioral Health Center, and that they even offer telehealth visits if the resident could not come into the Center in person, however she knows that Resident R33 prefers to come into the Center in person. "He likes to get out". Behavior Health Center LSW stated that the facility had told her that Resident R33 could receive psychiatric services at the facility, and that he probably could not continue services at the Behavioral Health Center as it may be a duplication of services. When Behavior Health Center LSW was asked of Resident R33 would still have a need for therapy she replied "Oh yeah. He also has dementia and confusion and needs therapy".

During an interview on 4/5/24, at 10:56 a.m. Nursing Home Administrator was asked about the discontinuation of Resident R33 Behavioral Health Center visits, and NHA stated that the wheelchair van is "out of inspection", as it was due 4/1/24. Informed NHA that his last appointment at the Behavioral Health Center was 2/15/24.

During an interview on 4/5/24, at 11:35 p.m. Licensed Practical Nurse (LPN) Employee E10 stated that Resident R33 had been going out of the facility for psychiatric services but was told that "He wasn't allowed any more services", and that he had been offered psychiatric services in the facility by an outside contract company that who comes into the facility every other week, but that Resident R33 had refused this service and wanted to go to the Behavioral Health Center. LPN Employee E10 also stated that Resident R33 has made comments about "jumping off a bridge".

During an interview on 4/5/24, at 11:37 a.m. Nurse Aide (NA) Employee E11 stated that Resident R33 likes going to his appointments as "He likes to go out in the sunlight".

During an interview on 4/5/24, at 12:55 p.m. Van Driver Employee E9 stated that there was a recall with the wheelchair van regarding the lift control that moves wheelchairs into the van and that they are still waiting for a part, and that the inspection for the van was due 4/1/24. Van Driver Employee E9 stated that since there haven't been trips for him to take residents to, that he has been filling in as a receptionist. Van Driver Employee E9 stated that facility now has to contract out to other transportation services if a resident requires a wheelchair van. Van Driver Employee E9 stated that Resident R33 often comes up to him and asks him when he can take him back to the Behavioral Health Center. Van Driver Employee E9 stated that he explained to Resident R33 that he is not the one that makes appointments, but that he just drives residents where and when they need to go as scheduled. When Van Driver Employee E9 was asked if the wheelchair van could be used if someone did not need a wheelchair, he replied "Yes", and that Resident R33 "can ride up front because he only needs a walker. He (Resident R33) hasn't been to his appointments for over a month and I don't know why".

During an interview on 4/5/24, at 1:59 a.m. Nursing Home Administrator confirmed that that the facility failed to provide Resident R33 with necessary behavioral healthcare services to maintain the highest practicable mental and psychosocial well-being, the discontinuation of behavioral health services preceded an attempt of suicide for one resident (Resident R33), and failed to offer psychiatric services for one resident (Resident R33) after a threat of suicide.


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

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

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


 Plan of Correction - To be completed: 04/29/2024

R 11 is stable and room is inspected q shift to assure it is maintained in a safe manor in accordance with Residents behavioral plan of care.
R33 is stable and he had a virtual Psyche appointment on 4/15 and a face to face appointment scheduled with Mercy behavioral health on 5/3/24.
One time audit by DON/Designee to assure all behavioral health appointments and Residents behavioral plans of care are up to date and accurate.
DON/Designee will educate nursing staff on behavior care plans and behavior health services.
Weekly audit x 4 on 5 residents by DON/designee for assurance that all behavioral health appointments and Residents plans of care are up to date and accurate.
DON/ designee will submit report of compliance to QAPI on compliance with maintaining behavioral health appointments and plans of care x one month. Van is repaired, registered and fully insured. 2 other transportation companies are used if/when the van needs repaired.

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

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

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

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

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

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

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

Based on a review of facility policy, clinical records and staff interviews, it was determined that the facility failed to limit as needed antipsychotic drugs to 14 days for one of five residents (Resident R11).

Findings include:

Review of the facility "Antipsychotic Drugs" policy last reviewed 1/1/24, indicated evidence that supports justification of why a drug is being used outside the Guidelines, must be documented in the clinical record.

Review of Resident R11's clinical record indicated the resident was admitted to the facility on 4/13/22, with diagnoses that included bipolar disorder (a serious mental illness characterized by extreme mood swings), anxiety, and developmental disorders of scholastics skills (significant disability of learning that cannot be solely accounted for by mental retardation, visual acuity, or inadequate schooling).

A Minimum Data Set Assessment (MDS, a form completed at specific intervals to determine care needs) dated 2/3/24, indicated the diagnoses were current.

Review of Resident R11's care plan dated 3/4/23, indicated the resident uses antianxiety medications. It was indicated to give antianxiety medications as ordered by physician and monitor for effectiveness.

Review of Resident R11's physician order dated 9/11/23, through 10/11/23, indicated to administer 25 mg of hydroxyzine (medication used to treat anxiety) , one tablet by mouth every 12 hours as needed, twice a day for anxiety for 30 days.

Review of Resident R11's physician order dated 8/11/23, through 9/11/23, indicated to administer 25 mg of hydroxyzine, one tablet by mouth every 12 hours as needed, twice a day for anxiety for 30 days.

During an interview on 4/4/24, at 10:12 a.m. Registered Nurse, Supervisor Employee E1 confirmed the facility failed to limit as needed antipsychotic drugs to 14 days as required for one of five residents (Resident R11).

28 Pa Code 211.12 (d)(1)(2)(3)(5) Nursing services


 Plan of Correction - To be completed: 04/29/2024

R11's psychoactive medication use has been reviewed with his physician and modified accordingly.
One time audit by DON/Designee of Residents with PRN Psychotropic medication for any inappropriate medication use. Nursing staff was educated on the 14 day limit for PRN psych meds audits were initiated.

DON/Designee will educate Licensed nursing staff on appropriate use of psychoactive medication.
Weekly audit of 5 Residents x 4 by DON/Designee to identify any residents that have inappropriate psychotropic medication use.
DON/Designee will submit report of compliance to QAPI on compliance with psychotropic medication use x one month.

483.45(f)(2) REQUIREMENT Residents are Free of Significant Med Errors: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.
The facility must ensure that its-
483.45(f)(2) Residents are free of any significant medication errors.
Observations:

Based on review of facility policy and clinical record, observation and staff interviews it was determined that the facility failed to make certain that residents are free from significant medication errors for one of three residents (Resident R45).

Findings include:

Review of the facility's "Medication Error" policy dated, 1/1/24, indicated medications errors are documented and reported to the attending physician, Director of Nursing, Pharmacy Coordinator, and the facility Quality Assurance/Improvement Committee. Medication errors are any and all errors made in the administration and/or documentation of medications.

Review of Resident R45's Minimum Data Set (MDS-periodic review of care needs) dated 3/6/24, indicated the resident was admitted on 7/17/21, with diagnoses of opiod and alcohol abuse, chronic viral Hepatitis C and major depressive disorder.

Review of Resident R45's physician order dated 2/22/24, instructed the nurse to give Suboxone Sublingual Film 4-1 MG, 1 film sublingually every 12 hours for psychoactive substance abuse.

Review of Resident R45 nurse progress notes dated 3/20/24 indicated Nurse Aide (NA) in room doing care heard resident frantically searching for something in a panic state. NA asked what she is looking for and resident stated, "I can't find my Suboxone. NA came and informed med nurse of what just happened and med nurse went into room to do a search and found 3 Suboxone films in room that resident was hoarding.

Review of Resident R45's March 2024 and April 2024 Medication Administration Record (MAR) indicated that the Suboxone was given as ordered.

During an interview on 4/4/24, at 12:15 p.m. the Assistant Director of Nursing Employee E21 confirmed that the facility failed to make certain that residents are free from significant medication errors for one of three residents (Resident R45).

28 Pa Code: 211.9 (a) Pharmacy services.
28 Pa code: 211.12 (d)(1)(5) Nursing services.


 Plan of Correction - To be completed: 04/29/2024

R45 is stable and sustained no ill effects from suboxone discrepancy.
One time audit by DON/Designee of Residents with scheduled medication/narcotic to assure they are receiving the medication as per order
DON/Designee will educate licensed nurses on narcotic recording and management as well as medication administration and 5 rights of med pass and to remain with resident until medication has been taken. R45's care plan has been updated on the fact that resident has tendency to hoard medications. thereof and significant medication errors.
Weekly audit of 5 Residents x 4 by DON/Designee to review Residents with scheduled medication/narcotics to assure they are receiving the medication as per order.
DON/Designee will submit report of compliance to QAPI on compliance with scheduled medication/narcotic use x one month.

483.50(a)(1)(i) REQUIREMENT Laboratory 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.
483.50(a) Laboratory Services.
483.50(a)(1) The facility must provide or obtain laboratory services to meet the needs of its residents. The facility is responsible for the quality and timeliness of the services.
(i) If the facility provides its own laboratory services, the services must meet the applicable requirements for laboratories specified in part 493 of this chapter.
Observations:

Based on clinical record review and staff interview it was determined the facility failed to obtain laboratory services as ordered for one of two residents reviewed (Resident R55).

Findings Include:

Review of the facility "Transcribing Physician Orders" policy dated 1/1/24, indicated physician orders will be transcribed when they are received. It was indicated ordered lab work will be documented in the facility's lab tracking tool, a lab form will be completed listing the ordered test, and diagnostic studies will be called to the appropriate diagnostic service for scheduling and noted in the nursing progress notes.

Review of Resident R55's "Follow-Up" summary dated 3/25/23, completed by Nurse Practitioner (NP) Employee E23 indicated the resident was seen for follow up for pneumonia. It was indicated the resident's Blood Urea Nitrogen (a common blood test that reveals important information about how well your kidneys are working) and Creatine (a waste product in your blood that comes from muscle wear and tear, blood levels are checked to assess kidney function.) levels were slightly elevated. NP, Employee E23 ordered to "repeat labs on 4/1/24."

Review of Resident R
55's physician orders revealed an order dated 4/1/24, indicated to "repeat CBC, BMP one time only for 5 days get blood work done on net lab draw day."

Review of the Resident R55's clinical record failed to reveal the resident's labs were obtained on 4/1/23, as ordered.

Interview with the Director of Nursing on 4/3/24, at 1:23 p.m. confirmed the facility failed to obtain laboratory services as ordered for one of two residents (Resident R55).

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


 Plan of Correction - To be completed: 04/29/2024

R55 is stable. CBC and CMP was obtained on 4/6/24.
One time audit by DON/Designee of all Residents with current Laboratory orders have been obtained.
DON/Designee will educate licensed nurses on appropriate laboratory policy and procedure.
Weekly audit of 5 Residents x 4 by DON/Designee to assure current Laboratory orders have been obtained.
DON/Designee will submit report of compliance to QAPI Laboratory services x one month

483.50(a)(2)(i)(ii) REQUIREMENT Lab Srvcs Physician Order/Notify of Results: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.
483.50(a)(2) The facility must-
(i) Provide or obtain laboratory services only when ordered by a physician; physician assistant; nurse practitioner or clinical nurse specialist in accordance with State law, including scope of practice laws.
(ii) Promptly notify the ordering physician, physician assistant, nurse practitioner, or clinical nurse specialist of laboratory results that fall outside of clinical reference ranges in accordance with facility policies and procedures for notification of a practitioner or per the ordering physician's orders.
Observations:

Based on review of clinical records, and staff interview it was determined that the facility failed to ensure that a resident's physician was notified about abnormal laboratory test results for one of two residents (Resident R60).

Findings include:

Review of facility policy "Notification of Changes" dated 7/24/23, indicated the facility will immediately inform the resident; consult with the resident ' s physician; and if known, notify the resident's legal representative or an interested family member when there is:

- An accident involving the resident which results in injury and has the potential for requiring physician intervention.

- A significant change in the resident's physical, mental, or psychosocial status

- A need to alter treatment significantly.

Review of the clinical record indicated Resident R60 was admitted to the facility on 11/27/23.

Review of Resident R60's MDS (Minimum Data Set, periodic assessment of resident care needs) dated 1/10/24, indicated diagnoses of heart failure (a progressive heart disease that affects pumping action of the heart muscles), hypertension (high blood pressure in the arteries) and, anemia (too little iron in the body causing fatigue).

Review of Resident R60's physician orders revealed an order written on 3/22/24, that indicated CBC (complete blood count) blood laboratory test to be completed on 3/27/24.

Review of Resident R60's clinical record reveal resident had CBC blood work obtained per physician's order on 3/27/24.

Review of Resident R60's clinical record reveal that the facility obtained residents lab results. Resident's hemoglobin (a protein found in red blood cells that carries oxygen from the lungs to all other organs in the body) was 7.3, which is low and abnormal.

Review of Resident R60's clinical record indicated that the facility failed to call the physician to review the abnormal results and/or obtain new orders.

During an interview on 4/3/24, at 10:09 a.m. the Director of Nursing (DON) confirmed that the facility failed to ensure that a resident's physician was notified about abnormal laboratory test results for one of two residents (Resident R60).

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


 Plan of Correction - To be completed: 04/29/2024

R60 is stable and on 4/7 MD was notified of laboratory results. This is reflected in R60's medical record.
One time audit by DON/Designee of all Residents with current Laboratory results have been reported to the MD.
DON/Designee will educate nursing staff on policy for laboratory results and MD notification and follow up.
Weekly audit of 5 Residents x 4 by DON/Designee to assure current Laboratory results have been reported to the MD.
DON/Designee will submit report of compliance to QAPI Laboratory results follow up x one month

483.60(g) REQUIREMENT Assistive Devices - Eating Equipment/Utensils: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(g) Assistive devices
The facility must provide special eating equipment and utensils for residents who need them and appropriate assistance to ensure that the resident can use the assistive devices when consuming meals and snacks.
Observations:

Based on facility policy, observations, and staff interviews it was determined that the facility failed to provide adaptive feeding devices for one of three residents (Resident R55).

Findings include:

Review of the facility policy "Flow of Care" dated 1/1/224, indicated care will be provided to residents, as needed 24-hours a day to attain and maintain the highest level of functioning.

Review of the clinical record indicated Resident R55 was admitted to the facility on 3/25/21, with diagnoses of anxiety, depression, and adult failure to thrive (happens when an older adult has a loss of appetite, eats and drinks less than usual, loses weight, and is less active than normal). Review of the Minimum Data Set (MDS, periodic assessment of resident care needs) dated 2/21/24, indicated the diagnoses were current.

Review of Resident R55's physician order dated 2/19/24, indicated to provide red foam built up utensils for all meals.

Review of Resident R55's care plan dated 2/20/24, indicated the resident is to use red foam built up utensils for all meals.

Review of Resident R55's Kardex (documentation system that enables nurses to write, organize, and easily reference key patient information that shapes their nursing care plan) dated 4/4/24, indicated the resident is to use red foam built up utensils for all meals.

During an observation on 4/2/24, at 11:46 a.m. Resident R55 did not have built-up utensils as ordered with lunch.

During an interview on 4/2/24, at 11:49 a.m., Registered Nurse, Employee E3 confirmed the facility failed to provide adaptive feeding devices for one of three residents (Resident R55).

28 Pa Code: 211.6(a) Dietary service.


 Plan of Correction - To be completed: 04/29/2024

R55 is stable and has assistive devices on tray as per physician orders.
One time audit by DON/Designee of all Residents with assistive devices to assure they are being utilized according to Residents plan of care.
DON/Designee will educate nursing staff as well as dietary staff on assistive device policy and use of.
Weekly audit of 5 Residents x 4 by DON/Designee of assistive devices to assure they are being utilized according to Residents plan of care
DON/Designee will submit report of compliance to QAPI on compliance with assistive devices x one month

483.20(f)(5), 483.70(i)(1)-(5) REQUIREMENT Resident Records - Identifiable Information: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(f)(5) Resident-identifiable information.
(i) A facility may not release information that is resident-identifiable to the public.
(ii) The facility may release information that is resident-identifiable to an agent only in accordance with a contract under which the agent agrees not to use or disclose the information except to the extent the facility itself is permitted to do so.

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

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

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

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

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

Based on the review of facility job descriptions, clinical records, and staff interviews, it was determined that the facility failed to maintain and complete accurate documentation for one of six residents (Resident R25).

Findings include:

Review of Title 42 Code of Federal Regulations (CFR) Medical records. In accordance with accepted professional standards and practice, the facility must maintain medical records that are complete, accurately documented, readily accessible, and systematically organized.

Review of the facility document "Staff Nurse RN (Registered Nurse) Job Description" indicated that facility RN must:
Chart nurse's notes in an informative, relevant, concise, and descriptive manner that reflects the care provided to the resident, as well as the resident's response to care.
Develop a nursing care plan, individualizing the care, revises the plan as necessary.
Routinely assesses the total needs of the residents and adjust care plans as needed.
Reviews care plan daily to ensure that appropriate care is being provided.
Interact/communicate with residents, staff, and visitors in a courteous manner.
Acts as a positive representative of the facility.
Ensure that all residents are treated fairly, and with kindness, dignity, and respect.
Must possess the ability to deal tactfully with personnel, resident, family members, visitors, government
agencies/personnel, and the general public.
Must be able to relate information concerning a resident's condition.

Review of the facility document LPN (Licensed Practical Nurse) Job Description" indicated that the facility LPN must:
Ensure that nurse's notes are charted in an informative and descriptive manner that reflects the care provided to the resident, as well as the resident's response to the care.
Maintain established nursing objectives and standards.
Administer professional services such as catheterization as required.
Ensure that resident care plans are reviewed for appropriate resident goals, problems, approaches, and revisions based on nursing needs.
Must possess the ability to deal tactfully with personnel, residents, family members, visitors, government agencies or personnel, and the general public.
Must be knowledgeable of nursing and medical procedures, as well as laws, regulations, and guidelines that pertain to nursing care facilities.

Review of the clinical record indicated Resident R25 was admitted to the facility on 10/28/22.

Review of Resident R25's Minimum Data Set (MDS) (assessment of a resident's abilities and care needs) dated 2/5/24, indicated diagnoses of Post Traumatic Stress Disorder (PTSD- a disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event), benign prostatic hyperplasia (an enlarged prostate gland that may contribute to difficulty urinating), and high blood pressure.

Review of the nursing progress notes for Resident R25 dated 5/7/23, stated the following: "After treatment to penis was completed by this nurse and during dressing change to right lower leg, resident stated that he was talking to a female from the VA (Veterans Affairs) and was telling her about a staff member in this facility that he trusts to take care of his penis dressing. He stated that this nurse took good care of his dressings and that he got a hard on with this nurse was rubbing his penis up and down while cleaning it. He stated that it felt good his pecker got as hard as a rock."

Review of the above note did not reveal that any of the language was in quotation marks to suggest that Resident R25 had verbalized these words.

Review of the clinical record revealed a care plan for Resident R25 dated 5/7/23 that stated the following: "He got a hard on with this nurse rubbing his penis up and down, it felt so good his penis got as hard as a rock."

Review of the above note did not reveal that any of the language was in quotation marks to suggest that Resident R25 had verbalized these words.

During an interview on 4/4/24, at 9:15 a.m. RN Supervisor Employee E1 confirmed that the facility failed to chart accurately and appropriately for one of six residents reviewed (Resident R25)


28 Pa. Code: 211.5(f)(g)(h) Clinical records.


 Plan of Correction - To be completed: 04/29/2024

R 25 has been is stable and has been discharged to a Veterans facility.
One time audit by DON/Designee of all nurses notes on 4/16/24 for assurance of identification of any documentation that does not meet Standards of professional practice.

DON/Designee has educated licensed nursing staff on proper documentation with Standards of professional practice as well as following HIPPA guidelines.

DON/Designee will complete a weekly audit x 4 weeks to identify any documentation that does not meet Standards of professional practice.

DON/ designee will submit report of compliance to QAPI on compliance with Standards of professional practice x one month.
483.70(o)(1)-(4) REQUIREMENT Hospice 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.
483.70(o) Hospice services.
483.70(o)(1) A long-term care (LTC) facility may do either of the following:
(i) Arrange for the provision of hospice services through an agreement with one or more Medicare-certified hospices.
(ii) Not arrange for the provision of hospice services at the facility through an agreement with a Medicare-certified hospice and assist the resident in transferring to a facility that will arrange for the provision of hospice services when a resident requests a transfer.

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

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

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

Based on review of facility policy, resident record and staff interview it was determined that the facility failed to establish a written agreement with a Medicare-certified hospice provider prior to the start of hospice services for one of two sampled resident records (Resident R59).

Findings include:

The facility "Hospice care" last reviewed 1/1/24, indicated that all hospice services are provided under contractual arrangement. Complete details outlining the responsibilities of the facility and the hospice agency are contained in this agreement. A copy of this agreement is on file in the business office.

Review of Resident R59's admission record indicated he was admitted on 10/27/20.

Review of Resident R59's MDS assessment (Minimum Data Set assessment: MDS -a periodic assessment of resident care needs) dated 1/11/24, with diagnoses that included lewy body dementia (a progressive form of dementia associated with protein deposits to the nervous system impacting memory, mood, and movement), anxiety disorder (a medical condition creating a sense of acute fear, restlessness, and worry), and hypertension (a condition impacting blood circulation through the heart related to poor pressure).

Review of Resident R59's care plan dated 10/31/23, indicated he was receiving hospice services.

Review of Resident R59's physician orders dated 10/30/23, indicated to admit to hospice.

Review of Resident R59's physician note dated 3/12/24, indicated that the he is continuing hospice services.

Review of Medicare-certified hospice contracts through October 2023 to March 2024 did not include a hospice contract between the facility and Resident R59's hospice provider.

During an interview on 4/3/24, at 12:28 p.m. the Nursing Home Administrator (NHA) confirmed that the facility failed to establish a written agreement with a Medicare-certified hospice provider prior to the start of hospice services for Resident R59 as required.

28 Pa Code: 211.5(f)(h) Clinical records

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


 Plan of Correction - To be completed: 04/29/2024

The facility will provide written agreement with a Medicare-certified hospice provider prior to the start of hospice services.

A Hospice contract was immediately presented and signed by the NHA for resident R59
The Administrator or Designee was reeducated by the regional LNHA/designee on the facilities policy and procedures by the Regional Director of operations on "Hospice care" for residents transitioning to Hospice and maintaining dated and signed documentation.
The Administrator or Designee will complete an audit of Hospice residents weekly for four weeks then weekly for three months to validate hospice contracts are signed and dated properly.
The results of these audits will be forwarded to the monthly Quality Assurance and Performance Improvement Committee for review and frequency of audits.

483.80(a)(1)(2)(4)(e)(f) REQUIREMENT Infection Prevention & Control: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.
483.80 Infection Control
The facility must establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections.

483.80(a) Infection prevention and control program.
The facility must establish an infection prevention and control program (IPCP) that must include, at a minimum, the following elements:

483.80(a)(1) A system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon the facility assessment conducted according to 483.70(e) and following accepted national standards;

483.80(a)(2) Written standards, policies, and procedures for the program, which must include, but are not limited to:
(i) A system of surveillance designed to identify possible communicable diseases or
infections before they can spread to other persons in the facility;
(ii) When and to whom possible incidents of communicable disease or infections should be reported;
(iii) Standard and transmission-based precautions to be followed to prevent spread of infections;
(iv)When and how isolation should be used for a resident; including but not limited to:
(A) The type and duration of the isolation, depending upon the infectious agent or organism involved, and
(B) A requirement that the isolation should be the least restrictive possible for the resident under the circumstances.
(v) The circumstances under which the facility must prohibit employees with a communicable disease or infected skin lesions from direct contact with residents or their food, if direct contact will transmit the disease; and
(vi)The hand hygiene procedures to be followed by staff involved in direct resident contact.

483.80(a)(4) A system for recording incidents identified under the facility's IPCP and the corrective actions taken by the facility.

483.80(e) Linens.
Personnel must handle, store, process, and transport linens so as to prevent the spread of infection.

483.80(f) Annual review.
The facility will conduct an annual review of its IPCP and update their program, as necessary.
Observations:

Based on review of facility policy, clinical record review and staff interview, it was determined that the facility failed to implement procedures to prevent the development and transmission of communicable diseases and infections for three of 11 residents. (Resident R55, R60, and R63)

Findings include:

A review of the facility 'COVID-19 Testing Schedule" policy dated 1/1/24, indicated that residents, regardless of vaccination status, with signs or symptoms must be tested.

A review of the facility policies "Isolation Procedure: Resident placement in transmission-based precautions" dated 1/1/24, indicated transmission-based precautions (airborne, contact, droplet) will be implemented when indicated by suspicion or presence of infectious disease.

Review of Resident R55's progress note dated 3/14/24, indicated the resident complained of a non-productive cough. Lung sounds with rhonchi (an abnormal breathing sound caused when air passes through accumulated fluids or secretions in lungs) and wheezes. The resident complained of chest discomfort on inspiration.

Review of Resident R55's clinical record failed to reveal he was tested for COVID-19.

Review of the clinical record revealed that Resident R60 was admitted to the facility on 11/27/23.

Review of Resident R60's MDS (Minimum Data Set, periodic assessment of resident care needs) dated 1/10/24, indicated diagnoses of heart failure (a progressive heart disease that affects pumping action of the heart muscles), hypertension (high blood pressure in the arteries) and, anemia (too little iron in the body causing fatigue).

Review of Resident R60's clinical records reveal a urine culture result was obtained by the facility from a hospital visit on 2-14-24.

Review of Resident R60's clinical records reveal that the urine culture was positive for ESBL (extended-spectrum beta-lactamases, a multi drug resistive organism), indicating that resident was infectious and should have been placed in contact isolation precautions.

Review of Resident R60's clinical record reveal that the facility failed to initiate contact precautions to prevent the spread of disease to other residents and staff.

Review of Resident R60's physician orders dated February through April 2024, did not include an order for contact precautions for ESBL.

Review of Resident R63's progress note dated 3/13/24, indicated the resident was coughing, pale, and had upper airway congestion. It was indicated there was period where the resident became slightly lethargic and confused.

Review of Resident R63's clinical record failed to reveal she was tested for COVID-19.

Review of the facility's undated "COVID OUTBREAK" testing log, failed to indicate Resident R55 and Resident R63 were tested for COVID-19.

During an interview on 4/1/24, at 10:41 a.m. Infection Preventionist, Employee E21 stated the facility implements the COVID protocol as soon as possible whenever someone is exposed or displays symptoms, such as shortness of breath, wheezing in chest, or any respiratory symptoms. It was indicated there is a standing order for a rapid COVID test for all residents and once completed it is documented in the resident's electronic record and a progress note entered of result the.

During an interview on 4/2/24, at 2:08 p.m. the Assistant Director of Nursing/Infection Preventionist, Employee E21, confirmed that Resident R60 was not placed in contact isolation.

During an interview on 4/3/24, at 10:09 the Director of Nursing (DON) confirmed that the facility failed to implement procedures to prevent the development and transmission of communicable diseases and infections for one of two residents. (Resident R60).

During an interview on 4/3/24, at 1:01 p.m. the Director of Nursing confirmed the facility tests for COVID-19 based on symptoms. The DON confirmed the facility failed to test for COVID for two of 11 residents (Resident R55 and R63).

28 Pa. Code 207.2(a) Administrator's Responsibility.

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

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


 Plan of Correction - To be completed: 04/29/2024

R60 is stable and has been placed in isolation for ESBL.
R63 is stable and has recovered from diagnosed pneumonia. R63 has been tested for Covid with negative results.
R55 was tested and was determined to have pneumonia test therefore no Covid test was performed. R55 is stable and has recovered from diagnosed pneumonia.
One time audit by DON/Designee of all Residents with any infectious signs and symptoms have been followed up according to facilities infection control policies. This audit will also include appropriate placement of any residents requiring isolation.
Weekly audit of 5 Residents x 4 by DON/Designee of Resident with infectious signs and symptoms have been followed up according to facility infection control policies. This audit will include appropriate placement of any residents requiring isolation
DON/Designee will educate licensed nursing staff on infection control policies and procedures with a review of facility covid policy.
DON/Designee will submit report of compliance to QAPI on Infection Prevention and Control follow up x one month

35 P. S. 448.809b LICENSURE Photo Id Reg:State only Deficiency.
Law amended July 11, 2022 Act 79 2022 HB 2604

(1) The photo identification tag shall include a recent
photograph of the employee, the employee's first name, the
employee's title and the name of [the health care facility or
employment agency.] any of the following:
(i) The health care facility.
(ii) The health system.
(iii) The employment agency.
(iv) The fictitious name of an entity under
subparagraph (i), (ii) or (iii) which is registered with
the Department of State under 54 Pa.C.S. Ch. 3 (relating
to fictitious names) or a successor statute.

(2) The title of the employee shall be as large as possible
in block type and shall occupy a one-half inch tall strip as
close as practicable to the bottom edge of the badge.


(3) Titles shall be as follows:
(i) A Medical Doctor shall have the title "Physician."
(ii) A Doctor of Osteopathy shall have the title
"Physician."
(iii) A Registered Nurse shall have the title
"Registered Nurse."
(iv) A Licensed Practical Nurse shall have the title
"Licensed Practical Nurse."
(v) All other titles shall be determined by the
department. Abbreviated titles may be used when the title
indicates licensure or certification by a Commonwealth
agency.

(4)A notation, marker or indicator included on an identification badge that differentiates employees with the same first name is considered acceptable in lieu of displaying an employee's last name.


Observations:

Based on review of facility documents, observations, and staff interviews, it was determined that the facility failed to make certain that staff members displayed identification badges to include a name, title, and a photo as required for seven of seven employees (Employee E11, E 15, E16, E17, E18, E19, and E20).

Finding include:

Review of the facility's "Employee Handbook", dated 1/1/17, indicated that all employees must wear a name badge at all times so that residents can identify employees.

Review of the Photo Identification Tag Regulation indicates that staff must wear a photo identification tag that shall include a recent photograph of the employee, the employee's first name, the employee's title and the name of the health care facility or employment agency.

During an interview on 4/1/24, at 10:01 a.m. Resident R40 stated that many staff members do not wear name tags.

During an observation on 4/4/24, at 10:30 a.m. Nurse Aide (NA) Employee E15 and NA Employee E16 were displaying their name and title hand written on a piece of masking tape that was adhered to their shirts.

During an interview on 4/4/24, at 10:30 a.m. NA Employee E15 and E16 confirmed that they did not display proper identification badges.

During an observation and interview on 4/4/24, at 12:26 p.m. NA Employee E17 displayed her name written on a piece of masking tape that was adhered to her shirt, and confirmed that she did not display proper identification badge.

During an observation and interview on 4/5/24, at 10:01 a.m. NA employee 18 did not have any identification badge, and confirmed that she did not display an identification badge.

During an observation and interview on 4/5/24, at 10:03 a.m. NA Employee E19 did not have an identification badge, and confirmed that he did not display an identification badge

During an observation on 4/5/24, at 10:04 a.m. Physical Therapy Assistant Employee E20 did not have an identification badge, and confirmed that he did not display an identification badge

During an interview on 4/5/24, at 10:17 a.m. the Assistant Director of Nursing Employee E21 confirmed that the facility failed to make certain that Employee E11, E15, E16, E17, E18, E19 and E20 properly wore photo identification tags with the require information displayed as required.


 Plan of Correction - To be completed: 04/29/2024

1. A badge maker was requested to be purchased immediately for the facility. A whole house audit of both agency and in-house staff was performed to determine who needed a properly documented name badge.
2. The Human Recourses Director was re-educated by the NHA/designee on the facility policy on name badges.
3. The HR Director/designee will audit new hire staff to determine if proper name badges were offered and provided weekly for 4 weeks, biweekly for 2 months then monthly for 1 month.
4. Outcomes will be reported to the Quality Assurance Performance Improvement Committee for review and recommendations.


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