Pennsylvania Department of Health
AVENTURA AT TERRACE VIEW
Patient Care Inspection Results

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AVENTURA AT TERRACE VIEW
Inspection Results For:

There are  178 surveys for this facility. Please select a date to view the survey results.

Surveys don't appear on this website until at least 41 days have elapsed since the exit date of the survey.
AVENTURA AT TERRACE VIEW - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on a Medicare/Medicaid Recertification, State Licensure, Abbreviated Complaint Survey and Civil Rights Compliance Survey completed on February 9, 2024, it was determined that Aventura at Terrace View was not in compliance with the following requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care Facilities and the 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.




 Plan of Correction:


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

Based on a review of clinical records and incident reports, observations and staff interview it was determined that the facility failed to timely identify and act upon changes in skin integrity, promptly assess and treat pressure sores and consistently implement interventions to prevent pressure sore development resulting in two facility acquired pressure sores, a Stage 3 sacral wound and unstageable pressure sores on the resident's foot, for one resident out of five sampled (Resident 23).

Findings included:

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

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

Review of Resident 23's clinical record revealed that the resident was admitted to the facility on December 19, 2019, with diagnoses of unspecified dementia (a group of symptoms that affects memory, thinking and interferes with daily life), and kidney disease.

Review of Resident 23's Annual Minimum Data Set Assessment (MDS- a federally mandated standardized assessment process conducted periodically to plan resident care) dated October 5, 2023, revealed that the resident had a moderate cognitive impairment, required moderate assistance for rolling in bed, was totally dependent for toileting, bathing, dressing, and transfers, was at-risk for developing pressure ulcers and injuries, and was always incontinent of bowel and bladder.

Review of Resident 23's care plan, revised October 5, 2023, revealed that the resident had the potential for skin breakdown due to decreased mobility and incontinence. Planned interventions were the application of a barrier cream every shift, and as needed, for incontinency, dietary supplements as per MD order, encourage the resident to reposition side to side in bed (the resident's MDS 10/5/23 indicated that the resident required moderate staff assistance with rolling in bed), observe skin condition daily during care and report skin issues/reddened/open areas to MD/nurse, pressure reducing device to bed and chair, provide incontinence care as needed, and skin checks to be completed with showers.

The resident's care plan included no additional measures to prevent pressure sores, such as pressure relief for the resident's heels or a scheduled time interval for repositioning the resident since the resident required moderate assistance from staff for rolling bed and was dependent on staff for transfers.

Review of physician orders revealed no physician ordered turning/repositioning schedule or physician ordered an off-loading intervention device to prevent heel wounds in a resident identified at-risk for pressure ulcers.

Review of a facility incident report dated January 3, 2024, at 3:30 AM revealed that a nurse aide noted an open area on Resident 23's sacrum while providing care. Employee 7 (RN) measured the open area as 3 cm x 5 cm on the sacrum. Employee 1 indicted that the area was cleansed with saline and covered with a non-adhering dressing. The resident's responsible party and physician were notified. No further description of the appearance of the open area was noted on the incident report.

There was no corresponding documentation in the resident's clinical record regarding the resident's sacral pressure sore.

Review of Employee 8 (nurse aide) witness statement dated January 3, 2024, (no time indicated) revealed that Employee 2, a nurse aide, "was providing care on resident when I saw the skin tear on butt."

Review of Employee 9's (LPN licensed practical nurse) witness statement dated January 3, 2024, (no time indicated) revealed Employee 2 called her into the resident's room, reporting that Resident 23 had an open area on her sacrum. Employee 9 observed a 3 cm x 5 cm open area on the resident's sacrum with scant amount of blood noted. The RN supervisor ws notified.

Review of Employee 10, LPN, witness statement dated January 3, 2024, (no time indicated) reported that she "was told by nurse that Employee 2 found an open wound area on Resident 23's sacrum. Area was known but not charted on."

Review of Employee 11, a nurse aide's witness statement dated January 3, 2024, (no time indicated) reported "aide on 11-7 shift noticed area on Resident 23's bottom. It has been a known area but never officially documented."

During an interview with the Director of Nursing (DON) on February 8, 2024, at approximately 2:30 PM, the DON stated that she was unaware that two of the nursing staff's witness statements reported that staff were aware of the presence of an open area on the resident's sacrum prior completion of incident report on January 3, 2024. The DON confirmed it is the facility's policy to report and document any skin changes in the resident's medical record and it is the expectation that staff will report and document on any skin changes in the medical record. The DON was unable to provide any documented evidence that the facility's follow up efforts to ascertain why nursing staff failed to timely document the identification and assessment of the resident's pressure sore in the clinical record and obtain orders for treatment.

Review of the "wound evaluation & management summary" dated January 5, 2024, at 1:29 PM, revealed that the consultant wound care physician staged the resident's sacrum as a stage 3 pressure wound full thickness (Stage 3 - a serious wound caused by pressure in which the wound has worn through all skin layers, exposing the fat. At this stage, there may be undermining and/or tunneling that makes the wound much larger than it may seem on the surface) measuring 3 cm in length by 2 cm in width by 0.2 cm in depth. It was reported that the duration of the wound was greater than 10 days old. Recommendations included: cleanse with saline at time of dressing change, off-load wound, reposition per facility policy and low air loss mattress.

Facility turning and repositioning tracking forms dated from April 2023, through December 31, 2023, revealed no documented evidence that staff turned and repositioned Resident 23 at least every two hours as noted on the resident task form. The turn and reposition task indicated that the frequency of the task was completed "every shift."

Review of a facility provided documentation titled "Point of Care Audit Report" for Resident 23's turn and reposition schedule dated for April 2023 through December 2023, revealed that staff failed to turn/reposition the resident timely and consistently every 2 hours as noted on the resident's task form. Facility documentation revealed that staff turned/repositioned Resident 23 one to three times per day. The turn/reposition documentation and times the resident was turned/repositioned for December 22, 2023, through December 31, 2023, were as follows:

December 22, 2023 - 5:45 AM, 9:45 PM
December 23, 2023 - 5:45 AM, 1:45 PM, 9:45 PM
December 24, 2023 - 5:45 AM, 9:45 PM
December 25, 2023 - 9:45 PM
December 26, 2023 - 5:45 AM, 9:45 PM
December 27, 2023 - 5:45 AM, 9:45 PM
December 28, 2023 - 5:45 AM
December 29, 2023 - 5:45 AM, 9:45 PM
December 30, 2023 - 5:45 AM, 1:45 PM
December 31, 2023 - 5:45 AM, 9:45 PM

The facility failed to demonstrate timely and consistent turning and repositioning of the resident to prevent the development of a State 3 pressure sore.

Review of Resident 23's "NSG- SKIN-Pressure Ulcer Record (Briggs)- V2 dated January 4, 2024, at 11:17 AM, revealed a new wound evaluation for the resident's right heel. The report indicated that the wound was a facility acquired Stage 1 wound, measuring 3 cm in length x 2 cm in width.

Observation of Resident 23's wound treatment in the presence of Employee 12, RN, and consultant wound care physician on February 9, 2024, at 9:48 AM, revealed a stage 4 sacral pressure ulcer measuring 11 cm in length x 9 cm in width x .5 cm in depth with moderate serous drainage. The consultant wound care physician indicated that the wound's deteriorating condition was exacerbated by Resident 23's generalized decline and compromised nutritional status.

Further observation of the resident's pressure sores on February 9, 2024, revealed an unstageable deep tissue injury of the right medial heel measuring 2 cm in length x 3 cm in width, an unstageable deep tissue injury of the right distal medial 1st toe bunion measuring 0.2 cm in length x 0.2 cm in width, an unstageable deep tissue injury of the right medial midfoot measuring 2 cm in length x 1 cm in width, and an unstageable deep tissue injury of the right ankle measuring 1 cm in length x 2 cm in width.

The facility failed to provide documented evidence that the facility developed, implemented and provided preventative measures to prevent the development of pressure ulcers and deep tissue injuries on the resident's feet.

Interview with the Nursing Home Administrator (NHA) on February 9, 2024, at 8:30 AM confirmed that the facility was unable to documented evidence that preventative measures were timely and consistently implemented to prevent the development of a stage 3 pressure injury of the sacrum and a deep tissue injury of the right foot for Resident 23.



28 Pa. Code 211.5 (f) Medical records

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

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






 Plan of Correction - To be completed: 04/09/2024

Resident # 23 no longer resides at the facility.

All at risk residents for potential skin breakdown, will be observed for any alterations by RN or LPN. All residents at risk for potential skin breakdown will have charts reviewed and corrected by RN or LPN for appropriate intervention in place to prevent and or treat pressure sore via care plan, Kardex, orders and tasks.

Education will be provided by the DON or designee to registered and licensed nurses regarding assessing for risk of skin breakdown, assessment of skin integrity, and pressure ulcer prevention and treatment. Education will be provided to direct care staff on the CNA's role in preventing pressure ulcers and the CNA's role in healing pressure ulcers.

The DON or designee will conduct weekly audits of residents to ensure all residents are assessed by Braden scale on admission and quarterly, all residents identified as high risk have the appropriate interventions in the plan of care to prevent pressure ulcers and all residents with pressure ulcers have a focused wound assessment completed weekly and the interventions on the plan of care are appropriate, as follows: all new admissions and 5 residents weekly for 4 weeks, all new admissions and 3 residents weekly for 4 weeks, then all new admissions an 1 resident weekly for 4 weeks. any trends identified will be reported at the QAPI meeting and if necessary corrections will be modified to address trends as necessary.
483.25(d)(1)(2) REQUIREMENT Free of Accident Hazards/Supervision/Devices:This is a more serious deficiency but is isolated to the fewest number of residents, staff, or occurrences. This deficiency results in a negative outcome that has negatively affected 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 observations, review of clinical records and select facility incident reports and resident and staff interviews it was determined that the facility failed to provide necessary staff assistance and supervision with activities of daily living and plan for the use of necessary individualized safety measures to prevent injury, a second-degree burn, to one resident out of 30 sampled (Resident 63).

Findings include:

Clinical record review revealed that Resident 63 was admitted to the facility on September 27, 2016, with diagnoses to include chronic kidney disease, hypertension, muscle weakness, and lack of coordination, and history of right radial neck fracture (are a common type of elbow fracture that typically occurs after a fall on an outstretched arm).

A review of Resident 63's current plan of care, initiated September 28, 2016, and revised November 11, 2021, revealed that the resident had decreased ADL (activity of daily living) self-care performance. The care plan noted that the resident ambulated independently in his room. Interventions to include, staff to set up and assist the resident with ADLs.

A review of a quarterly MDS (Minimum Data Set - a federally mandated standardized assessment process conducted periodically to plan resident care) dated January 15, 2024, revealed that the resident was cognitively intact with a BIMS score of 15 (Brief Interview for Mental Status section of the MDS which assesses cognition, a tool to assess the resident's attention, orientation, and ability to register and recall new information) and required assistance for activities of daily living.

A review of a nurses note dated February 3, 2024 at 9:00 AM revealed that Resident 63 approached the nurse and asked for something for a burn. The nurse asked where his burn was and he raised his shirt to show, the nurse an oval shaped burn to his lower mid abdomen. The resident stated he spilled hot tea on himself yesterday (February 2, 2024). The entry indicated "I asked him why he didn't tell anyone yesterday when it happened, he replied it wasn't bothering him then but he would like a cream to put on it today. RN Supervisor made aware and arrived on unit to assess resident."

An incident report completed by Employee 1 (LPN) on February 3, 2024, at 10:00 AM, revealed that the Resident 63 sustained a first-degree burn (a mild burn injury of the outermost layer that make up the skin (epidermis). First-degree burns affect only the epidermis, or outer layer of skin. The burn site is red, painful, dry, and with no blisters. Mild sunburn is an example. Long-term tissue damage is rare and usually consists of an increase or decrease in the skin color) to the mid-center abdomen that measured 4.0 cm in length by 1.5 cm in width by 0.01 cm in depth and base color was red, no drainage, no odor, with intact skin and closed tissue. The attending physician was notified with new orders noted to cleanse the area with mild soap/water or normal saline (NSS), apply a thin layer of Silvadene (fights bacteria and yeast on the skin. Silvadene (for the skin) is used to treat or prevent serious infection on areas of skin with second- or third-degree burn) to wound bed, cover, with dressing twice daily and as needed for soilage.

The incident report concluded that the resident made staff aware that he spilled a cup of tea on himself Friday evening (February 2, 2024) and did not think much of it. Resident 63 was educated not to use the microwave and to request assistance when needing food or drink to be heated. The facility removed the microwave from the pantries on the resident units to prevent recurrence.

During an interview on February 6, 2024, at approximately 8:26 pm Resident 63 stated that it was his usual morning routine to go into the resident pantry room and make himself a cup of tea. He stated that yesterday (February 2, 2024) he used a 16-fluid ounce Styrofoam cup filled with water and placed the cup into the microwave for one-minute, then placed his tea bag in the cup and heated for another minute and walked back to his room. He stated that he sat down on his bed and spilled the hot tea on himself, causing a burn on his stomach. The resident stated that there was no lid on the cup when he walked back to his room with the tea. He stated that the pantry is across the hall from his room and the room is always locked. He stated that staff gave him the code to the keypad on the door and he goes in the room when he wants. Resident 63 stated that he makes a cup of tea for himself every morning in the pantry and brings the tea back to his room. The resident stated that the preparation of the hot tea was his daily routine, of which staff were aware. He stated that facility staff never instructed him on the microwave use. He confirmed that he does not have a plastic cup to use for his tea, and uses a styrofoam cup.

There was no evidence at the time of the survey ending February 9, 2024, any heating instructions had been or were presently posted in the resident pantries for guidance on safe heating practices, length of time to reheat items, etc.

Observation of the resident pantry on Resident 63's unit on February 9, 2024, at approximately 7 PM revealed that there were no lids for the styrofoam cups present and the microwave oven had been removed from the pantry. There was no thermometer noted in the pantry at the time of the observation.

Observation of Resident 63's burn to his abdomen with Employee 5, agency LPN, on February 6, 2024, at 8:30 p.m., revealed that the area on his abdomen (burn) measured 6.5 cm x 1.5 cm x 0.1 cm with a large amount of white exudate (a liquid produced by the body in response to tissue injury) covering the wound bed with pink surrounding skin and a moderate amount of yellow drainage present on the dressing. The injury appeared to be a second-degree burn, which involved the epidermis and part of the dermis layer of skin.

During an interview on February 6, 2024, at 8:45 p.m., the DON (with the Director of Nursing) confirmed that staff did not provide adequate supervision or assistance to the resident in preparing his tea, which resulted in a second degree burn. The DON also verified that she did not observe Resident 63's burn and was not aware of the status of the resident's injury.

The facility was unable to provide evidence that the facility had assisted or supervised Resident 63 with preparing and serving himself the hot tea, and provided any necessary adaptive equipment that may assist the resident with drinking and handling the hot beverage that he preferred on a daily basis. The facility failed to incorporate the resident's preference for daily hot tea into the resident's care plan and plan to provide staff assistance or supervision to the resident to prevent injury, a second degree burn.


Refer F684


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
























 Plan of Correction - To be completed: 04/09/2024

Upon notification of the alleged deficient practice, resident # 63 was assessed by an RN for injury and appropriate interventions and the physician was notified and new orders put in place. The Kardex, care plan updated to reflect interventions.

All 144 resident residing in the facility at the time of the survey were reviewed and determined to be at risk for being affected by the alleged deficient practice. all like residents requiring assistance with food/meals assessed for and reviewed for clinically appropriate interventions and assistance with food/meals by licensed & registered staff.
All pantries observed to be locked and in working order by maintenance director.

Education provided to all staff regarding providing assistance for food/meals, safety/supervision utilizing thermometer, microwave safety and utilizing adaptive equipment by RD or CDM/ designee.
observation of pantry doors will be done by DON/designee 4x weekly x 4 weeks.

Observe 4 like residents 4 x week to ensure proper ADL assistance with meals/snack by DON or designee.

Any trends identified will be reported during the monthly QAPI meeting. This plan of correction may be modified to address those trend as necessary.
483.60(i)(1)(2) REQUIREMENT Food Procurement,Store/Prepare/Serve-Sanitary:This is a less serious (but not lowest level) deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents.  This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.60(i) Food safety requirements.
The facility must -

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

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

Based on observation and staff interview, it was determined that the facility failed to maintain acceptable practices for the storage and service of food to prevent the potential for contamination and microbial growth in food, which increased the risk of food-borne illness.

Findings include:

Food safety and inspection standards for safe food handling indicate that everything that comes in contact with food must be kept clean and food that is mishandled can lead to foodborne illness. Safe steps in food handling, cooking, and storage are essential in preventing foodborne illness. You cannot always see, smell, or taste harmful bacteria that may cause illness according to the USDA (The United States Department of Agriculture, also known as the Agriculture Department, is the U.S. federal executive department responsible for developing and executing federal laws related to food).

The initial tour of the kitchen was conducted with the evening dietary supervisor on February 6, 2024, at 6:14 p.m., revealed the following unsanitary practices with the potential to introduce contaminants into food and increase the potential for food-borne illness, was identified:

Observation outside of the walk-in freezer, two metal racks with 18 trays of thawed 4-fl. ounce juice cups of orange juice and cranberry juice and felt room temperature to touch. The supervisor reported that "staff pull the juice cups out of the freezer to thaw the day prior to serving due to the juice cups not fully defrosting for breakfast tray line, then the staff put the thawed juice on ice for the breakfast tray line service." Temperatures were obtained of a 4-fl. ounce orange juice cup that was 59.4 degrees F and the 4-fl. ounce cranberry juice was 50.5 degrees F. The supervisor was not sure how long the trays were outside the freezer and confirmed the above temperatures were outside acceptable range. A review of the juice cup manufacture's safe storage and handling revealed that once thawed, 4-ounce juice cups should be kept refrigerated at or below 40F.

Observation of the bottom of the wall, housing the reach-in wall oven revealed that the wall was crumbling and the molding was pulling away from the wall and leaving a large gap.

Several rodent traps were observed located throughout the cook's area, dish room area, and around the perimeter of the kitchen. Observations of the cook's area revealed that underneath equipment, opposite side of the 3-compartment sink, that there were mouse traps with multiple black colored speckles, which appeared to be rodent droppings, scattered about the area. The supervisor stated at the time of the observation, that the facility's pest control company has been treating the kitchen area due to rodent activity.

Underneath two inoperable steam kettles, in the cook's area, there was a large open degraded drain and several floor tiles that were damaged, leaving gaps between the surfaces.

The ceiling tiles above the cook's hanging pot/pan and utensil rack was observed visibly soiled with food/liquid splatter.

Observation inside the cart storage/storage area revealed uncovered styrofoam containers and boxes of utensils, staff's travel mugs stored on the shelves, and a pack of mouse repellant on an overbed table located next to a coffee maker.

Observation in the dry storage room behind the can rack revealed a piece of paneling covering a mesh wall of sheet rock that was pulled away from the wall.

During the initial tour of the emergency food and water storage area located on the second floor of the facility, in the presence of the evening dietary supervisor, on February 6, 2024, at 6:43 p.m., revealed that there were approximately 28 cases of twelve 16-ounce bottles of water that had been expired since April 4, 2022, and September 2023, three cases of 22 oz lemon lime sports drink that had been expired since June 12, 2022, and cases of # 10 cans of mixed vegetables for the emergency menu that expired December 2023.

An interview with the Nursing Home Administrator (NHA) on February 8, 2024, at 2:25 p.m. confirmed that the kitchen and all food storage areas should kept in a sanitary manner and all foods and beverages should be stored in a safe and sanitary manner. Additionally, confirmed that the facility's on hand emergency water supply and some of the emergency food supply were outdated and that the facility should maintain an emergency food and water supply in a safe and sanitary manner.


28 Pa. Code 201.18 (e) (2.1) Management

28 Pa. Code 211.6 (f) Dietary Services



 Plan of Correction - To be completed: 04/09/2024

The wall identified repaired.

The Black unidentified material was cleaned up.

The identified drain tiles were repaired.
The ceiling tiles above cook's rack were cleaned.
The dietary department along with the maintenance department will develop a monthly preventative maintenance schedule to include the items identified at time of survey.

Monthly identified items for preventative maintenance in the dietary department will be reviewed at the monthly QAPI meeting.

Pest control management will increase to once a week with a meeting with the NHA/or designee regarding the effectiveness for the pest control management as well as identifying measure to take to prevent pest.

The identified storage area with personal belongings were cleared out and properly stored in employee lockers.


CDM educated employee on the of infection control practices as it relate to personal belongings in the kitchen.

The CDM will revise the current sanitation schedule to include the items identified during the survey. CDM will educated dietary staff on the revised schedule. The shift supervisor will audit each day a particular area(s) for proper and complete sanitation. the CDM will meet 3 x week to discuss results of the sanitation audits, theses audit will be reported at the QAPI meetings by the CDM/designee.

Dry storage area identified wall repaired at the time of survey.
the identified expired food items were discarded and replace at the time of survey.

The soft drinks and canned vegetables identified were discarded and replace at the time of survey.

The CDM will review the emergency food plan up date as necessary and ensure compliance is met on the guideline for facility census.

A new process identifying emergency food supply and expiration dates will be developed and implemented by CDM & RD.

CDM/ RD will educate all dietary staff on identifying expiration dates and proper temperatures of food including beverages in include thawing of foods and beverages.

Audits will be done once a month by CDM/designee on all emergency food supply to ensure compliance is met with expiration dates.

The results of the audits will be discussed/reported at the monthly QAPI meetings.
483.90(i)(4) REQUIREMENT Maintains Effective Pest Control Program: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.
483.90(i)(4) Maintain an effective pest control program so that the facility is free of pests and rodents.
Observations:

Based on observation, a review of facility pest service records and staff interview, it was determined that the facility failed to maintain an effective pest control program.

Findings include:

A review of the facility's contracted pest management company service inspection report dated January 30, 2024, at 10:10 a.m., revealed that maintenance staff reported mice activity in resident rooms 216, 226, 253, 256, and 268.

Further review of the pest management company service inspection report dated February 5, 2024, at 9:56 a.m., revealed that resident rooms were treated for mice (C267, 268, 253, 216, and B265) and the nurses' stations and common areas for occasional invaders. Additionally, the kitchen areas, storage areas, dish room, and dining room were treated for pests and mice.

During the initial tour of the facility's dietary department on February 6, 2024, at 6:43 p.m., several rodent traps located throughout the cook's area, dish room area, and around the perimeter of the kitchen.

Observations of the cook's area revealed that underneath equipment (opposite side of the 3-compartment sink, that there were mouse traps and plastic bags of peppermint used as natural pest control deterrents, along with multiple black colored speckles, which appeared to be rodent droppings, scattered about the area.

The on-duty dietary supervisor confirmed that the facility's pest control company has been treating the kitchen area due to observed rodent activity.

Further observations on February 6, 2024, at 7:30 pm., revealed that the doors leading outside to the resident smoking area, which was located next to a dining room and dietary department, were propped open creating a potential entry for rodents and pests. Throughout the days of the survey ending February 9, 2024, the doors to the resident smoking area were observed to be propped open with a rock and a brown door stop.

Interview with the Nursing Home Administrator (NHA) on February 9, at 2:00 p.m., confirmed that the facility failed to identify potential modes of rodent, insects and pests entry and failed to perform environmental maintenance to deter rodent and invader entry and maintain an effective pest control program.

Refer F812

28 Pa. Code 201.18 (e)(2.1) Management



 Plan of Correction - To be completed: 04/09/2024

Residents were educated about propping open door near the smoking area, the new monitoring policy will eliminate the need to prop open doors, in addition another door was identified to use for resident to go an smoke.

Social services will educate residents who smoke, about the alternate doors to use when smoking.

Facility will post signage regarding propping door open to prevent unwanted rodents in the building.

During daily ambassador rounds staff will check the doors near the kitchen work area to identify is they are being held open by un authorized devices.

A revised pest management program was instated, to now provide weekly service for pest control, and a meeting at the end with the NHA/designee, for identification of potential breaches and solutions to correct it.

A report of potential breaches and solutions, as well as any sightings of pest in the facility, will be reviewed and reported by the Director of maintenance at the QAPI meeting.

Ambassadors will report during morning report about compliance regarding the doors to the smoking area.

483.70(e)(1)-(3) REQUIREMENT Facility Assessment: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.
483.70(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 staff interviews and a review of documentation provided by the facility, it was determined that the facility failed to timely review and update its facility wide assessment in order to identify the specific personnel resources presently available, which are necessary to care for its current resident population.

Findings include:

At the time of the survey ending February 9, 2024, the facility had reviewed its facility assessment on June 3, 2023, to determine the specific and unique needs of its resident population and the available and accessible resources to meet these needs on a daily basis and during emergent situations.

The facility provided a facility assessment tool to the survey team on February 9, 2024. There was no documentation on the form that identified and addressed the needs of the locked D1 unit, Dementia/Memory care unit or the C1 male behavior unit. The form did not include any focus on the care and needs of the 71 residents with documented diagnosis of Dementia/Alzheimers disease, 53 residents residing on the locked dementia unit and 5 of the 10 residents residing on the male C1 unit (behavioral unit).

A review of the results of surveys completed by the state survey agency on March 23, 2023, September 21, 2023 and November 15, 2023, revealed that the facility had failed to provide adequate services for residents with dementia, behaviors and/or meet their psychosocial needs. During this current survey ending February 9, 2024, the facility was also cited for failing to provide services to meet the mental health needs of a resident with a diagnosed mental disorder.

There was no evidence that the facility updated its facility-wide assessment in a timely manner to address available resources for making staffing and operating budget decisions while managing the resident census to ensure that the facility had the necessary staff resources to care for its resident population in a manner that met minimum licensure and certification standards.

The facility assessment presented to the survey team during the survey ending February 9, 2024, did not include updated comprehensive data with respect to its current resident population and updated resources necessary to competently and safely care for the residents in the facility.

Refer F600, F742

28 Pa. Code 201.14(a) Responsibility of licensee

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













 Plan of Correction - To be completed: 04/09/2024

The facility can not retroactively correct the alleged deficient practice.

A new assessment with facility management and corporate leadership will be developed and updated to identify the necessary resources for the operations and needs of the residents.

Education of tag 838 will be conducted by the Regional Director of operations/designee to all leadership of the facility.

a quarterly review of the assessment plan will be conducted by the NHA/designee to ensure needs are being
identified and updated as necessary.

Results of the quarterly review will be discussed/reported by the NHA at the QAPI meetings.
483.10(a)(1)(2)(b)(1)(2) REQUIREMENT Resident Rights/Exercise of Rights: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(a) Resident Rights.
The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility, including those specified in this section.

483.10(a)(1) A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the resident.

483.10(a)(2) The facility must provide equal access to quality care regardless of diagnosis, severity of condition, or payment source. A facility must establish and maintain identical policies and practices regarding transfer, discharge, and the provision of services under the State plan for all residents regardless of payment source.

483.10(b) Exercise of Rights.
The resident has the right to exercise his or her rights as a resident of the facility and as a citizen or resident of the United States.

483.10(b)(1) The facility must ensure that the resident can exercise his or her rights without interference, coercion, discrimination, or reprisal from the facility.

483.10(b)(2) The resident has the right to be free of interference, coercion, discrimination, and reprisal from the facility in exercising his or her rights and to be supported by the facility in the exercise of his or her rights as required under this subpart.
Observations:

Based on a review of grievances lodged with the facility, clinical records and select reports, observations and staff and resident interviews, it was determined that the facility failed to provide care in a manner that respects and enhances each resident's quality of life as evidenced by the removal of devices to heat/reheat food from the resident pantries and preventing resident access to the pantries as desired and reported by seven of nine residents interviewed (Residents 36, 63, 56, 6, 67, 49, and 111) and failing to respond timely to residents' requests for assistance as reported by three residents (Residents 48, 75, and 81)


Findings include:

According to the Title 28 Pa. Code Kitchen. (b) A service pantry shall be provided for each nursing unit. The pantry shall contain a refrigerator, device for heating food, sink, counter and cabinets. For existing facilities, a
service pantry shall be provided for a nursing unit unless the kitchen is sufficiently close for practical needs and has been approved by the Department.

A review of a Resident/Family Complaint/Grievance Investigation Form completed by Resident 36 dated February 4, 2024, and reported to Employee 6, social services, revealed a complaint that the Nursing Home Administrator (NHA) removed the microwaves from the resident unit pantry/kitchenette rooms and that he would not put them back in the areas due to a resident getting burned (Resident 63). In addition to Resident 36, residents 63, 56, 6, 67, 49, and 111 signed the grievance form because they were upset that their units did not have a microwave to reheat their food/beverages as they preferred.

A review of Resident 56's clinical record revealed that she was admitted to the facility on July 15, 2019, with diagnoses that included generalized osteoarthritis, hypothyroidism, and history of transient ischemic attacks and cerebral attacks without residual [occurs when a person suddenly experiences muscle weakness, difficulty walking, and coordination problems (all of which are symptoms of stroke) and may be having a TIA (sometimes called a mini stroke) is a medical emergency and has the same symptoms and causes as a stroke]. Resident 56 was cognitively intact with a BIMS of 15.

An interview with Resident 56 on February 6, 2024, at 7:02 p.m., revealed that she was frustrated and angry that the microwave was removed from their pantry/kitchenette area. She stated, "my roommate and I like to have our food reheated later in the evening, now we can't have the items we normally like to eat because there isn't a microwave available on the unit."

A review of Resident 49's clinical record revealed that she was admitted to the facility on July 22, 2019, with diagnoses that included depression, osteoarthritis, and gastroesophageal reflux [(GERD) is a chronic digestive disease where the liquid content of the stomach refluxes into the esophagus, the tube connecting the mouth and stomach]. Resident 49 was cognitively intact with a BIMS of 13.

An interview with Resident 49 on February 6, 2024, at 7:15 p.m., revealed that she liked to reheat food after dinner to eat before she goes to bed and that she was very upset that the unit microwave had been removed from the unit. She indicated that other residents were upset with the facility's actions and that she and other residents voices their concerns to Employee 6 via a grievance form.

A tour of the facility on February 6, 2024, at 7:25 p.m. revealed that there were no microwaves present in the resident pantry/kitchenette areas on all units B2, C1, C2, and D.

During a resident group interview on February 7, 2024, at 10:30 AM, with nine alert and oriented residents in attendance Residents 36, 48, 56, 63, 67, 75, 81, 111 and 112, indicated that the facility recently removed the resident microwaves from the pantries on their units.

Residents 36, 63, and 111 reported that they were upset, angry, and frustrated that the facility had recently removed all the microwaves from their unit pantry/kitchenettes.

Resident 63 explained that he was upset and felt guilty because he spilled hot tea on himself, and following the incident, the facility removed all the microwaves from the resident pantries. He stated that he was frustrated that the resident pantries' locks were changed and that residents no longer had access to them.

During the resident group interview Resident 36 indicated that she was angry and upset about the microwave being removed from the resident pantries and that the resident pantries' locks were changed, and residents no longer had access. She also reported that she filed a grievance a few days ago with other residents, but the facility had not yet responded to her concerns.

Resident 111 indicated that she was upset that facility staff removed the microwaves from the resident pantries and that the locks were changed on the pantries preventing resident access to the pantries.

The facility removed devices for reheating foods/beverages from the resident pantries and established a policy that negatively affected the residents' quality of life and failed to respect the residents' rights and preferences.

An interview with the Nursing Home Administrator (NHA) on February 8, 2024, at 2:15 p.m., confirmed that microwaves were removed from the resident pantry/kitchenette areas due to Resident 63 sustaining a burn after preparing his own cup of hot tea and thought that it was reasonable for staff to use the microwave located in the facility's kitchen/dining room to reheat items for the residents.

During a group interview on February 7, 2024, at 10:30 AM, three alert and oriented residents in attendance (Residents 48, 75, and 81) stated that they experience long waits for nursing staff to respond to their requests for assistance via the nurse call bell system.

During the group interview on February 7, 2024, at 10:30 AM, Resident 48 stated that she has recently waited over 2 hours for nursing staff to provide needed assistance after ringing her call bell for help from nursing staff. Resident 48 explained that the wait time for staff to respond to her call bell is usually about an hour. She stated that she becomes frustrated and upset when nursing staff pass by her room and tell her that they can't assist her because that staff member is not assigned to her care. Resident 48 further stated that she believes the wait times are long because the facility is low on nursing staffing.

During the group interview on February 7, 2024, at 10:30 AM, Resident 81 stated that he waits about 25 minutes on average for nursing staff to respond to he rings his call bell for assistance from nursing staff.

During the group interview on February 7, 2024, at 10:30 AM, Resident 75 indicated that he waits at least 20 minutes for nursing staff to respond to his call bell when he rings for assistance. The resident stated that there are not enough nurse aides working to help the residents that need care.

The facility failed to timely respond to residents' requests for assistance, which was negatively impacting their quality of life in the facility.


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

28 Pa. Code 201.29 (a) Resident Rights.

28 Pa. Code 205.25 (b) Kitchen

28 Pa. Code 211.12 (c)(d)(4)(5) Nursing services













 Plan of Correction - To be completed: 04/09/2024

Correction resident # 36 grievance was submitted to social services on 2/7/24 not 2/4/24.

prior to gradience submitted residents were not aware microwaves were placed back in pantries on 2/07/24, after the safety needs of the resident were assessed.

A new policy and procedure was developed and implemented on providing documentation of temperatures and proper use of safe kitchen wares are available.

All direct care staff were educated by CDM and RD on the process of reheating foods for residents.

As part of daily announcements activities will remind residents to ask staff for assistance for items in the pantries.

As part of daily ambassador rounds pantry stock and and functional kitchen wares will now be identified.

Daily rounds will be discussed at each morning meeting to identify any non compliance trends and correct them as needed.

Resident #81 & 75 were interviewed social services and stated no issues of needs being met.

the facility always staff nurse aides to the required resident to staff ratio.

a review of the last two resident council meeting minutes acknowledge that needs are being met.

Designees will be appointed to continue to preform physical call bell audits, by means of actually ringing /setting them off, on different units at different times, and discussed with staff at the time of audit.

Social Service will interview 4 resident a week for 4 weeks, to identify if call bells and needs are being met.

The results of the audit will be discussed/reported at the QAPI monthly meeting.





483.90(i)(5) REQUIREMENT Smoking Policies: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.
483.90(i)(5) Establish policies, in accordance with applicable Federal, State, and local laws and regulations, regarding smoking, smoking areas, and smoking safety that also take into account nonsmoking residents.
Observations:

Based on a review of clinical records and select facility policy, observation, resident, and staff interview, it was determined that the facility failed to implement procedures for safe smoking and the safety of smoking areas as evidenced by two out of the two residents sampled who smoke (Residents 81 and 112).

Findings include:

Review of the facility policy titled "Smoking Policy - Residents", dated October 20, 2023 indicated that the facility shall establish and maintain safe resident smoking practices. Policy implementation includes "Residents may not have or keep any smoking articles, including cigarettes, tobacco, etc., except when they are under direct supervision."

A clinical record review revealed that Resident 81 was admitted to the facility on August 18, 2023, with diagnoses to include hemiparesis following a cerebral infarction (a weakness or inability to move after disruption of blood flow to the brain). A review of a quarterly Minimum Data Set assessment (MDS - a federally mandated standardized assessment process conducted periodically to plan resident care) dated January 12, 2024, revealed that Resident 81 was cognitively intact with a BIMS score of 15 (Brief Interview for Mental Status- a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 13-15 indicates cognition is intact).

A form titled Smoking Safety Screen dated November 30, 2023, indicated that Resident 81 had been assessed with the ability to safely smoke unsupervised. The assessment indicated that Resident 81 needs the facility to store his lighter and cigarettes.

A clinical record review revealed that Resident 112 was admitted to the facility on September 9, 2022 with diagnoses to include end stage renal disease (final stage of kidney decline where the kidneys are no longer able to function to meet the body's needs).A review of a quarterly MDS dated January 26, 2024 revealed that Resident 112 was cognitively intact with a BIMS score of 15.

A form titled Smoking Safety Screen dated December 7, 2023, indicated that Resident 112 has no safety concerns and is able to smoke without supervision. However, the question, "Does resident need facility to store lighter and cigarettes" was not answered.

An observation on February 6, 2024 at 7:15 PM in resident room B268 revealed that Resident 112 had smoking materials in his room including a cigarette lighter and cigarettes. At the time of the observation Resident 112 stated that he keeps the smoking items locked in the top drawer of his bedside cabinet. A drawer was observed with a locking mechanism in the resident's bedside cabinet.

An observation on February 6, 2024, at 7:30 PM revealed Resident 81 and 112 smoking cigarettes outside the facility, near the exit next to the first floor dining area. At the time of the observation, Resident 81 and 112 explained that they can smoke "at any time" and both stated that they keep their cigarettes and lighters in their rooms. Both residents stated that they have keys to lock and secure their smoking supplies in their rooms. The residents also stated that they are able to enter and exit their individual units and exit the facility, and re-enter the building, by entering a key code.

Observation of the doorways used to exit the building to access the smoking area, revealed two sets of doors. Resident 81 stated that he "needs to use a rock or doorstop" to keep the first set of doors propped open when outside smoking because there is no way to open the first set of doors when outside the facility. The residents were observed to use a brown rubber doorstop to prop the first door open. The second doors had a key punch system to gain access to the facility.

During an interview on February 9, at approximately 10:00 AM, the Director of Nursing (DON) and Nursing Home Administrator (NHA) confirmed that the residents were propping the door open when smoking because if the door closed, then the residents would be locked outside with no means to regain entrance to the building. The NHA and DON were not able to provide evidence that staff monitored the residents' storage of smoking materials to assure resident safety. NHA and DON were unable to demonstrate the implementation of protocols to assure staff awareness of the whereabouts of the residents that go outside to smoke at will and prop open doors to prevent them from being locked outside.

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

28 Pa. Code 209.3 (a) Smoking




 Plan of Correction - To be completed: 04/09/2024

The identified smoking material identified during the survey was secured from resident #112.

All resident identified having smoking privileges' were re-educated by social service that smoking materials is not prohibited in resident rooms and that is needs to be secured, as well as acceptable areas of smoking on the facility grounds.

Smoking assessments on the identified residents will be done by social service and nursing and updated as necessary, care plans will be updated if warranted.

A new procedure will be developed and implemented regarding the monitoring of residents, which will include assigning a staff member to monitor residents during posted smoking times, for the 3 residents who have been grandfathered in smoking privileges.

In addition a new procedure will be developed, using a log book on each unit to monitor and account for when residents are off the unit, to identify locations, in the event of an emergency.

The DON/designee will educate all direct care staff on the smoking procedures. as well as residents unit log book

A weekly audit will be done by social services on the monitoring of residents and compliance with smoking materials.

The results of this audit will be discussed/reported at the QAPI meeting and if necessary plan of correction may be modified should trends change.
483.75(g)(1)(i)-(iii)(2)(i); 483.80(c) REQUIREMENT QAA Committee: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.
483.75(g) Quality assessment and assurance.
483.75(g) Quality assessment and assurance.
483.75(g)(1) A facility must maintain a quality assessment and assurance committee consisting at a minimum of:
(i) The director of nursing services;
(ii) The Medical Director or his/her designee;
(iii) At least three other members of the facility's staff, at least one of who must be the administrator, owner, a board member or other individual in a leadership role; and
(iv) The infection preventionist.

483.75(g)(2) The quality assessment and assurance committee reports to the facility's governing body, or designated person(s) functioning as a governing body regarding its activities, including implementation of the QAPI program required under paragraphs (a) through (e) of this section. The committee must:
(i) Meet at least quarterly and as needed to coordinate and evaluate activities under the QAPI program, such as identifying issues with respect to which quality assessment and assurance activities, including performance improvement projects required under the QAPI program, are necessary.

483.80(c) Infection preventionist participation on quality assessment and assurance committee.
The individual designated as the IP, or at least one of the individuals if there is more than one IP, must be a member of the facility's quality assessment and assurance committee and report to the committee on the IPCP on a regular basis.
Observations:

Based on a review of facility documents of QA meeting attendance and staff interviews, it was determined that the facility failed to ensure that the Medical Director or designee attended quarterly Quality Assurance Process Improvement (QAPI) Committee meetings for two of four quarters (July 2023 through January 2024)

Findings include:

A review of QAPI Committee meeting sign-in sheets for the period of January 2023 through January 2024, revealed that the Medical Director or other physician was not in attendance, virtually or in-person, at the QA meetings held from July 2023 through January 2024 missing 3 monthly/quarterly meetings (July 2023, August 2023, December 2023, and January 2024).

An interview with the Nursing Home Administrator (NHA) on February 9, 2024, at 12:00 p.m., confirmed that a physician failed to attend the facility's QAPI meetings on a quarterly basis.



28 Pa. Code 211.2 (d)(3)(4)(5)(6) Medical Director

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




 Plan of Correction - To be completed: 04/09/2024

Medical Director will review minutes/notes from missed identified QAPI meetings and sign off.

The medical Director will be educated by Regional Nurse regarding Tag 868 and the role of the medical director plays in it.

The medical Director will be given a yearly schedule for meetings so that plans of attendance or a delegate in his place is necessary can attend.

Audits of QAPI attendance will be reviewed regional nurse and discussed with NHA to identify non compliance for attendance and alert attendees who potentially may be out of compliance.

The results of QAPI attendance will be discussed at each meeting.
483.60(f)(1)-(3) REQUIREMENT Frequency of Meals/Snacks at Bedtime:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
483.60(f) Frequency of Meals
483.60(f)(1) Each resident must receive and the facility must provide at least three meals daily, at regular times comparable to normal mealtimes in the community or in accordance with resident needs, preferences, requests, and plan of care.

483.60(f)(2)There must be no more than 14 hours between a substantial evening meal and breakfast the following day, except when a nourishing snack is served at bedtime, up to 16 hours may elapse between a substantial evening meal and breakfast the following day if a resident group agrees to this meal span.

483.60(f)(3) Suitable, nourishing alternative meals and snacks must be provided to residents who want to eat at non-traditional times or outside of scheduled meal service times, consistent with the resident plan of care.
Observations:

Based on observation and staff and resident interviews, the facility failed to ensure bedtime snacks are provided to residents when the time between the evening meal and breakfast is greater than 14 hours, including nine out of the nine residents during a resident group interview (Residents 36, 48, 56, 63, 67, 75, 81, 111, and 112).

Findings include:

A review of the facility form titled "mealtime schedule for food cart delivery" revealed that the scheduled length of time between residents' dinner and residents' breakfast is 15 hours.

An observation on February 6, 2024, at 7:00 PM in Nursing Unit B2 Resident Pantry revealed the pantry was stocked with a loaf of bread, pudding cups, jello cups, various juices, ice pops, ice cream, and peanut butter and jelly sandwiches.

During a group interview on February 7, 2024, at 10:30 AM, all nine alert and oriented residents in attendance (Residents 36, 48, 56, 63, 67, 75, 81, 111, and 112) stated that they are not provided evening snacks when requested.

During the group interview on February 7, 2024, at 10:30 AM, Resident 63 explained that snacks are provided at dinner for the residents. He stated that residents are denied snacks after dinner time. Resident 63 explained that nursing staff told him that there are no snacks available after dinner.

During the group interview on February 7, 2024, at 10:30 AM, Residents 36, 48, 56, 63, 67, 75, 81, 111, and 112 confirmed that facility nursing staff has informed the residents that no snacks are available after dinner.

During an interview on February 9, 2024, at approximately 1:30 PM, the Nursing Home Administrator (NHA) and Director of Nursing (DON) confirmed that residents should be offered a bedtime snack and evening snacks provided when requested by residents. The NHA and DON were unable to explain why residents stated that staff were not providing snacks after the evening meal.


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





 Plan of Correction - To be completed: 04/09/2024

The current process of snack delivery was approved by resident at resident council and resident food committee.

resident rooms will now have a list of items available in the pantry. during morning announcements resident will be reminded to ask for assistance in procuring items from the pantry when desired.

A designated dietary employee will now be assigned every evening to pass out snacks on each floor and document residents acceptance or refusal. In addition, announcements will be made prior to passing out of snacks on the floors to alert residents.

CDM/designee will audit 4 residents a day for 4 days a week for 4 weeks regarding the receiving of night time snacks.

Audit results of resident evening snack programs will be discussed and reported at the QAPI meeting as well as resident council and food committee.



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

483.45(h) Storage of Drugs and Biologicals

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

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

Based on review of manufacturer's directions for use and select facility policy, and staff interview, it was determined that the facility failed to ensure adherence to medication expiration/beyond use by dates for multidose medication on one of six medication carts (C1 and C2 Low side carts), timely disposition of discontinued medications, and failed to secure one of four medication rooms to prevent unauthorized access (C2 unit)


Findings include:

Observation of the medication cart for unit C1 on February 6, 2024, at 6:22 PM in the presence of Employee 2, licensed practical nurse (LPN) revealed one Aspart Flex insulin pen and one Lantus insulin multidose vial were not dated when opened. Employee 2 confirmed that the medication was to be dated when first opened for use.

Observation of the medication cart for unit C2 Low side on February 6, 2024, at 6:40 PM in the presence of Employee 3, LPN, revealed that two multidose vials of Novolog insulin, one multidose vial of Lispro insulin, and one Basaglar insulin pen were not dated when opened. Employee 3 confirmed that the medication was to be dated when opened and put into use.

Observation of the medication storage room on unit C2 on February 6, 2024, at 7 PM in the presence of Employee 3, LPN revealed that the medication room was unlocked. Observation in the medication room revealed "overflow" medications (extra resident medications that won't fit in the medication cart) on open shelves. Further observation of the medication room revealed two bottles of medication Cefadroxil suspension (antibiotic) labeled "Refrigerate" on the shelf. According to the label, the course of the antibiotic therapy was completed on December 28, 2023, and remained in the medication storage room. Employee 3 confirmed that the medication was not disposed of in a timely manner.

Repeat observation of medication cart for unit C1 on February 9, 2024, at 8:42 AM in the presence of Employee 4, LPN, revealed an unopened multidose vial of Lantus insulin labeled to "Refrigerate" and an unopened multidose vial of Novolog insulin also labeled "Refrigerate" which were not refrigerated. The medication labels revealed that the multidose vials of insulin were received from pharmacy on February 7, 2024, and Employee 4 confirmed that the medications should be stored in refrigerator until ready to be used.

According to manufacturer instructions, unopened vials of insulin are to be stored in the refrigerator. After opening, store in the refrigerator or at room temperature. Throw away any part not used after 28 days.

Interview with the Director of Nursing on February 9, 2024, at 1:33 PM confirmed that the discontinued medications should have been removed from the medication room and medications in use should have been dated when first opened. The Director of Nursing further confirmed that medication rooms were to be locked when not in use by staff.



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

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



 Plan of Correction - To be completed: 04/09/2024

Upon notification of the alleged deficient practice, all medications that wee not correctly stored or unable to be determine expiration date wee discarded per manufacture's recommendations.

All 144 residents residing in the facility at the time of the survey were identified as at risk for being affected by this alleged deficient practice.

The DON provided education to licensed and registered nurses on proper medication storage, labeling and disposal as well as proper securement of medications.

The DON or designee will monitor each medication room and each medication cart for proper storage of medications, proper labeling of open date and proper disposal as follows: each med room, and med cart, will be checked once a week for 4 weeks, THEN monthly thereafter for 8 weeks.

Any trends identified will be reported during the monthly QAPI meeting. This plan of correction may be modified to address thoes trends as necessary.
483.45(c)(3)(e)(1)-(5) REQUIREMENT Free from Unnec Psychotropic Meds/PRN Use:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
483.45(e) Psychotropic Drugs.
483.45(c)(3) A psychotropic drug is any drug that affects brain activities associated with mental processes and behavior. These drugs include, but are not limited to, drugs in the following categories:
(i) Anti-psychotic;
(ii) Anti-depressant;
(iii) Anti-anxiety; and
(iv) Hypnotic

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

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

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

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

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

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

Based on clinical record review and staff interviews, it was determined that the facility failed to attempt gradual dose reductions of psychoactive medications for two residents reviewed (Residents 105 and 107) and failed to demonstrate the clinical necessity for initiation of an antipsychotic drug and monitor for potential adverse side effects for one resident (Resident 198) out of five reviewed.

Findings included:

A review of Resident 105's clinical record revealed that the resident was admitted to the facility on October 5, 2022, with diagnoses that included SCHIZOPHRENIA.

The resident's current physician's orders, initially dated October 6, 2023, included Abilify (an antipsychotic medication) 2.5 mg daily for dementia with psychotic behaviors, December 10, 2022, Zyprexa 7.5 mg every day for behaviors, January 26, 2023, Divalproex Sodium (a mood stabilizer) 125 mg daily for dementia and October 8, 2022, Cymbalta delayed release (an antidepressant) 20 mg daily used to treat depression.

There was no physician documentation of a resident specific information which detailed why a dose reduction attempt of these psychoactive drugs was clinically contraindicated and of the resident's continued need for these medications and their current dosage.

A review of Resident 107 clinical record revealed that the resident was admitted to the facility on March 16, 2022, with diagnoses that included cerebral infarction [or stroke, is a brain lesion in which a cluster of brain cells die when they don't get enough blood], traumatic subdural hemorrhage [also known as a subdural hematoma, occurs when there is bleeding between the brain and the skull], and major depressive disorder.

A physician orders dated May 3, 2022, 6:51 p.m., was noted for Seroquel (an antipsychotic medication used to treat certain mental/mood disorders, such as schizophrenia, bipolar disorder, sudden episodes of mania or depression associated with bipolar disorder) 25 mg give 25 mg by mouth two times a day related to diagnosis of unspecified major depressive disorder. Physician orders were also noted, dated January 30, 2023, at 3:15 p.m., for trazodone HCL (antidepressant) Oral Tablet 100 mg, give one tablet by mouth at bedtime related to diagnosis of recurrent major depressive disorder, dated April 7, 2023, at 9:00 a.m., for valproic acid (Depakote, for bipolar disorder, epilepsy, and migraine and belongs to a group of antiepileptic drugs) oral capsule 250 mg, give two capsules by mouth two times a day related to diagnosis of major depressive disorder, an order dated June 28, 2023, at 12:47 p.m., for bupropion HCL (Wellbutrin, an antidepressant) oral tablet, give 100 mg by mouth two times a day for diagnosis of depression and an order dated October 13, 2023, at 9:00 a.m., for Aripiprazole (Abilify, an atypical antipsychotic primarily used in the treatment of schizophrenia, obsessive compulsive disorder (OCD), and bipolar disorder; other uses include as an add-on treatment in major depressive disorder) oral tablet 5 mg, give one tablet by mouth one time a day related to major recurrent depressive disorder, schizoaffective disorder, bipolar type.

There was no physician documentation of the clinical justification for the continued use of each of the psychoactive drugs and the resident specific information which detailed why dose reduction attempts were clinically contraindicated and of the resident's continued need for these medications and their current dosage.


During an interview with the Director of Nursing on February 9, 20124, at 11 a.m. she confirmed that no attempts at gradually reducing the doses of the above psychoactive medications had been made and the physician documentation failed to include resident specific details in support of the GDR declinations.


Clinical record review revealed that Resident 198 was admitted to the facility on December 28, 2023, with diagnoses of dementia, alcohol abuse with unspecified alcohol induced disorder, anxiety and Wernicke's encephalopathy (Wernicke-Korsakoff syndrome is an unusual type of memory disorder due to a lack of thiamin (vitamin B1) requiring immediate treatment).

A review of an admission Minimum Data Set assessment (MDS, is part of the U.S. federally mandated process for clinical assessment of all residents in Medicare or Medicaid certified nursing homes) dated January 4, 2024, revealed Resident A1 was moderately cognitively impaired with a BIMS score of 8 ( BIMS a test administered to all residents in skilled nursing facilities to assess patient cognitive patterns, behavior, and mood, a score of 8-12 suggests moderate cognitive impairment) and required staff assistance with activities of daily living.


A review of the resident's care plan revealed that Resident 198 has potential to exhibit physical
and verbal aggression toward others. May seek unwanted sexual contact with other female residents (kissing), initiated January 2, 2024

Nursing documentation from the time of the resident's admission December 28, 2023, through the time of the survey ending February 9, 2024, revealed that Resident 198 displayed confrontational, threatening, disruptive, aggressive, sexually inappropriate directed towards other residents and staff and intrusive wandering behaviors, mostly entering the rooms of female residents. The resident was receiving both Ativan .5 mg TID for anxiety and Depakote 125 mg, 3 tablets, TID for dementia.

A review of a nurses note dated February 7, 2024, at 11:30 AM revealed that "Called to the C1 unit by nursing staff. 198) became aggressive with NA (nurse aide) on the one-to-one watch, hitting the male nurse aide in the back when he attempted to prevent the resident from going after another female resident passing by him in the hallway. Resident was redirected and additional LPN and NAs intervened. NA denies needing medical interventions/treatment at this time. Resident 168 was addressed and educated on not being aggressive with staff or other residents. Ambulance called for transport to the hospital for psychiatric evaluation and treatment due to increased aggression towards staff and other residents."

A nurses note dated February 7, 2024 at 12:18 PM revealed that Resident 198 left facility to hospital via ambulance. He returned to the facility the dame day.

On February 7, 2024 Resident 198 was moved from the facility's locked dementia/memory care unit room D 114-1 to the recently created, all male behavioral unit, room C1-164-1.

A nurses note dated February 8, 2024 at 09:45 AM revealed "Pt left unit with his 1:1 observation staff member with him. While off the unit, resident attempted to head towards the exit, NA (nurse aide) redirected resident away from the exit. Resident became agitated and started to swing at NA (nurse aide). Attempted to redirect the resident back into the unit without success. Pt's responsible party (RP) in the building and witnessing the resident's behavior. The resident's sister attempted to redirect the resident unsuccessfully. RP gave consent to send resident to the hospital for evaluation and psychiatric consult for potential medication changes. The resident was transferred to the hospital."

A nurses note dated February 8, 2024 at 5 P.M. revealed that the "Resident arrived to unit on stretcher via EMS. Resident was very drowsy upon arrival."

A review of readmission physicians orders dated February 8, 2024 revealed a new order for Haloperidol ( an antipsychotic medication) Oral Tablet 1 MG, Give 1 mg by mouth two times a day related to dementia.

At the time of the survey ending February 9, 2024, there was no documented evidence of the clinical necessity or clinically supporting diagnosis for use of this antipsychotic medication prescribed for dementia or the plan to monitor the resident for extrapyramidal side effects, or adverse side effects, including lethargy and drowsiness.


28 Pa. Code 211.8 (c.1)(e)(f) Use of restraints

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

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

28 Pa. Code 211.5 (f) Medical records

28 Pa. Code 211.2 (d)(8) Medical director














 Plan of Correction - To be completed: 04/09/2024

Resident #198 no longer resides at the facility.
residents #107 & #105 pharmacy recommendations were reviewed with a response by the physician.

Residents receiving psychoactive drugs will be reviewed to ensure there is physician documentation for the clinical justification for the continued use of that drug as well as GRD as appropriate with physician documentation to detail why GDR was contraindicated, as appropriate.

DON, will provide re-education to registered and licensed nurses on the requirements for physician documentation of clinical justification for the continued use of a psychoactive drug as well as physician documentation to detail why those who use GDR is contraindicated.

The DON or designee will conduct audits of resident records for residents receiving psychoactive drugs to ensure there is physician documentation for clinical justification for continued use as well as appropriate physician documentation to detail why for those who GDR is contraindicated as follows: 5 residents weekly for 4 week, THEN 3 resident weekly for 4 weeks, THEN 1 resident weekly for 4 weeks. any tends will be reviewed by the QAPI committee, this plan may be modified to address trends as necessary.


483.45(c)(1)(2)(4)(5) REQUIREMENT Drug Regimen Review, Report Irregular, Act On:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
483.45(c) Drug Regimen Review.
483.45(c)(1) The drug regimen of each resident must be reviewed at least once a month by a licensed pharmacist.

483.45(c)(2) This review must include a review of the resident's medical chart.

483.45(c)(4) The pharmacist must report any irregularities to the attending physician and the facility's medical director and director of nursing, and these reports must be acted upon.
(i) Irregularities include, but are not limited to, any drug that meets the criteria set forth in paragraph (d) of this section for an unnecessary drug.
(ii) Any irregularities noted by the pharmacist during this review must be documented on a separate, written report that is sent to the attending physician and the facility's medical director and director of nursing and lists, at a minimum, the resident's name, the relevant drug, and the irregularity the pharmacist identified.
(iii) The attending physician must document in the resident's medical record that the identified irregularity has been reviewed and what, if any, action has been taken to address it. If there is to be no change in the medication, the attending physician should document his or her rationale in the resident's medical record.

483.45(c)(5) The facility must develop and maintain policies and procedures for the monthly drug regimen review that include, but are not limited to, time frames for the different steps in the process and steps the pharmacist must take when he or she identifies an irregularity that requires urgent action to protect the resident.
Observations:
Based on clinical record review and staff interview it was determined that the physician failed to act upon drug irregularities identified in the drug regimens of two of five residents sampled (Resident 105 and 107).

Findings included:


A review of Resident 105's clinical record revealed that the resident was admitted to the facility on October 5, 2022, with diagnoses that included SCHIZOPHRENIA.

The resident's current physician's orders, initially dated October 6, 2023, included Abilify (an antipsychotic medication) 2.5 mg daily for dementia with psychotic behaviors, December 10, 2022, Zyprexa 7.5 mg every day for behaviors, January 26, 2023, Divalproex Sodium (a mood stabilizer) 125 mg daily for dementia and October 8, 2022, Cymbalta delayed release (an antidepressant) 20 mg daily used to treat depression.

A pharmacist recommendation to the physician dated August 21, 2023, requested that the physician consider evaluating the effectiveness of the medications Cymbalta, Depakote,and Zyprexa and to consider an attempted dose reduction or trial discontinuation. The pharmacist note requested that the physician check an appropriate box to best fit a response. The physician's response was to check a box that indicated that "a benefit/risk analysis of the effectiveness of the medication warrants its continuation at the present dose and time. The medication helps to improve the quality of the resident's life, so the benefits outweigh the risks." There was no physician's response noted on the form, when reviewed during the survey ending February 9, 2024.

There was no physician documentation of a resident specific information which detailed why a dose reduction attempt was clinically contraindicated and of the resident's continued need for the medication and its current dosage.

A review of Resident 107 clinical record revealed that the resident was admitted to the facility on March 16, 2022, with diagnoses that included cerebral infarction [or stroke, is a brain lesion in which a cluster of brain cells die when they don't get enough blood], traumatic subdural hemorrhage [also known as a subdural hematoma, occurs when there is bleeding between the brain and the skull], and major depressive disorder.

A physician orders dated May 3, 2022, 6:51 p.m., was noted for Seroquel (an antipsychotic medication used to treat certain mental/mood disorders, such as schizophrenia, bipolar disorder, sudden episodes of mania or depression associated with bipolar disorder) 25 mg give 25 mg by mouth two times a day related to diagnosis of unspecified major depressive disorder. Physician orders were also noted, dated January 30, 2023, at 3:15 p.m., for trazodone HCL (antidepressant) Oral Tablet 100 mg, give one tablet by mouth at bedtime related to diagnosis of recurrent major depressive disorder, dated April 7, 2023, at 9:00 a.m., for Valproic acid (Depakote, for bipolar disorder, epilepsy, and migraine and belongs to a group of antiepileptic drugs) oral capsule 250 mg, give two capsules by mouth two times a day related to diagnosis of major depressive disorder, an order dated June 28, 2023, at 12:47 p.m., for bupropion HCL (Wellbutrin, an antidepressant) oral tablet, give 100 mg by mouth two times a day for diagnosis of depression and an order dated October 13, 2023, at 9:00 a.m., for Aripiprazole (Abilify, an atypical antipsychotic primarily used in the treatment of schizophrenia, obsessive compulsive disorder (OCD), and bipolar disorder; other uses include as an add-on treatment in major depressive disorder) oral tablet 5 mg, give one tablet by mouth one time a day related to major recurrent depressive disorder, schizoaffective disorder, bipolar type.

A review of a consultant pharmacist's recommendation to prescriber dated December 26, 2023, at 6:34 p.m., for psychotropic management, identified that the Resident 107 continued to receive Abilify 5 mg, Seroquel 25 mg twice daily and 100 mg at bedtime, Trazadone 100 mg at bedtime, Bupropion 100 mg twice daily, and Valproic Acid 500 mg twice daily and recommended that the resident's attending physician to consider an attempted dose reduction or trial discontinuation as you deem appropriate. If this cannot be accomplished, please document the risk vs. benefits of continued therapy with current regimen.
At the time of the survey ending February 9, 2024, that Resident 107's attending physician failed to respond/address the pharmacist's recommendation.

The facility failed to provide evidence that the attending physician responded/addressed the drug irregularities and provided individualized clinical justification for the continued use of the psychoactive drugs.


Refer F758


28 Pa. Code 211.5 (f) Medical records

28 Pa. Code 211.2 (d)(8)(9) Medical director

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




 Plan of Correction - To be completed: 04/09/2024

Residents # 107 & # 105 pharmacy recommendations were reviewed with response by physician documented.

All 144 resident residing in the facility at the time of survey were identified as at risk for being affected by the alleged deficient practice.

The DON, nursing management, physician and CRNP were educated by Regional Nurse on importance of responding to pharmacy consultant recommendations and addressing drug irregularities and providing clinical justification for continued use of psychoactive medication.

The DON or designee will monitor pharmacy consultant report recommendations to ensure they have been addressed by the physicians follows: 4 residents per week for 4 weeks, THEN 1 resident per week for 8 weeks.

Any trends identified will be reported during the monthly QAPI meetings. This plan of correction may be modified to address those trends as necessary.
483.35(d)(4)-(6) REQUIREMENT Nurse Aide Registry Verification, Retraining: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.
483.35(d)(4) Registry verification.
Before allowing an individual to serve as a nurse aide, a facility must receive registry verification that the individual has met competency evaluation requirements unless-
(i) The individual is a full-time employee in a training and competency evaluation program approved by the State; or
(ii)The individual can prove that he or she has recently successfully completed a training and competency evaluation program or competency evaluation program approved by the State and has not yet been included in the registry. Facilities must follow up to ensure that such an individual actually becomes registered.

483.35(d)(5) Multi-State registry verification.
Before allowing an individual to serve as a nurse aide, a facility must seek information from every State registry established under sections 1819(e)(2)(A) or 1919(e)(2)(A) of the Act that the facility believes will include information on the individual.

483.35(d)(6) Required retraining.
If, since an individual's most recent completion of a training and competency evaluation program, there has been a continuous period of 24 consecutive months during none of which the individual provided nursing or nursing-related services for monetary compensation, the individual must complete a new training and competency evaluation program or a new competency evaluation program.
Observations:

Based on a review of employee personnel files and staff interviews, it was determined that the facility failed to ensure current registry verification of two nurse aides out of five employee files reviewed (Employees 15 and 16)


Findings include:

A review of facility-provided nurse aide registration for active employees on February 9, 2024, at 10:30 AM revealed a Pennsylvania Department of Health Nurse Aide Registration for Employee 15, a nurse aide, effective December 13, 2022, and expiring on November 9, 2023.

A review of facility provided nurse aide registration for active employees on February 9, 2024, at 10:30 AM revealed a Pennsylvania Department of Health Nurse Aide Registration for Employee 16, Nurse Aide (NA), effective February 19, 2022, and expiring on November 6, 2023.

During an interview on February 9, 2024, at 11:00 AM, the Director of Nursing confirmed that the nurse aide registration for Employees 15 and 16 had expired in November 2023. The facility failed to provide, upon request, documented evidence to confirm that Employees 15 and 16 did not work in the facility following the registration expiration dates. The facility did not provide documentation regarding any shifts Employee 15 and Employee 16, may have worked nurse aide registration expiration dates through the end of the survey February 9, 2024, and it could not be confirmed that these employees did not work with expired nurse aide certifications.


28 Pa. Code 211.12 (c) Nursing services

28 Pa. Code 201.19 (1)(3) Personnel records









 Plan of Correction - To be completed: 04/09/2024

Employee #15 & #16 identified at the time of the survey were able to renew their certification.

The HR director will review all nurse aide staff certification to ensure registration is current.

The HR director will develop and implement using software form our payroll company, a monthly procedure to pre identify 30 days in advance certifications due for renewal, so that staff maybe alerted.

Education on tag 729 will be done by the regional director of human resources to the facility HR director.

NHA or designee will review 6 nurse aide registration a month for 6 months.

Any trends identified will be reported at the monthly QAPI meetings.
483.25(k) REQUIREMENT Pain Management: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(k) Pain Management.
The facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences.
Observations:

Based on clinical record and select facility policy review and staff interview, it was determined that the facility failed to attempt non-pharmacological interventions to alleviate pain prior to the administration of a pain medication prescribed on an as needed basis for one resident out of two residents sampled for pain management (Resident 12).

Findings include:

Review of a facility policy entitled "Pain - Clinical Protocol" (no policy review date provided by the facility and noted last revised on August 2022) indicated that staff will use a consistent approach and a standardize pain assessment instrument appropriate to the resident's cognitive level. Using the numeric pain scale, 1-3 mild, 4-7 moderate, and 7-10 severe or resident's verbal description of stating tolerable/intolerable or severe. The physician will order appropriate non-pharmacologic and medication interventions to address the individual's pain and that staff will provide the elements of a comforting environment and appropriate physical and complementary interventions, for example local heat or ice, and repositioning. An analgesic (used to relieve pain and inflammation) regime should utilize the simplest regime and lowest risk medications before using more problematic or higher risk approaches.

A review of Resident 12's clinical record revealed that the resident was admitted to the facility on May 18, 2022, with diagnoses that included muscle weakness, rheumatoid arthritis [is a chronic inflammatory disorder that can affect more than just your joints], and a history of a femur [the bone of the thigh or upper hind limb, articulating at the hip and the knee] fracture (crack/break).

A physician's order dated May 10, 2023, at 10:22 p.m., was noted for Acetaminophen Tablet [(Tylenol) is used to treat mild to moderate pain (from headaches, menstrual periods, toothaches, backaches, osteoarthritis, or cold/flu aches and pains) and to reduce fever] 325 mg (milligrams), give two tablets by mouth every six hours as needed for pain (PRN). The physician order did not identify the level of pain (such as mild, moderate or severe or pain scale of 0-10)

An additional physician order was noted January 18, 2024, at 1:08 p.m., revealed an order for Tramadol HCL [is an opioid pain medication and a serotonin-norepinephrine reuptake inhibitor (SNRI) used to treat moderately severe pain] oral tablet 50 mg (milligrams), give one tablet by mouth every eight hours as needed for pain (PRN). The physician order did not specify the pain level or degree.

A review of Resident 12's electronic Medication Administration Record [(MAR, or eMAR for electronic versions) dated January 2024, revealed that licensed nursing staff administered PRN pain medication on the following dates:

January 2, 2024, at 6:40 a.m., Tylenol given for a reported pain level at 2.
January 7, 2024, at 4:04 a.m., Tylenol given for a reported pain level at 3.
January 19, 2024, at 8:23 a.m., Tramadol given for a reported pain level at 7.
January 19, 2024, at 8:40 p.m., Tramadol given for a reported pain level at 7.
January 20, 2024, at 8:37 a.m., Tramadol given for a reported pain level at 7.
January 21, 2024, at 9:47 p.m., Tramadol given for a reported pain level at 8.
January 22, 2024, at 10:01 p.m., Tramadol given for a reported pain level at 7.
January 24, 2024, at 11:12 p.m., Tramadol given for a reported pain level at 7.
January 29, 2024, at 2:25 p.m., Tramadol given for a reported pain level at 5.

A review of the resident's eMAR dated February 2024, through survey ending on February 9, 2024, revealed that PRN pain medications were administered on the following dates:

February 1, 2024, at 12:21 a.m., Tramadol given for a reported pain level at 6.
February 3, 2024, at 2:00 a.m., Tramadol given for a reported pain level at 6.

The facility failed to demonstrate attempts of non-pharmacological interventions prior to administering Tramadol prescribed on an as needed basis.

Interview with the Director of Nursing (DON) on February 8, 2023, at 1:33 p.m., confirmed that there was no documented evidence that licensed nursing staff to attempted non-pharmacological interventions prior to administering opioid pain medications


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




 Plan of Correction - To be completed: 04/09/2024

Resident # 12 was assessed by RN, no adverse effects were noted.

All like residents with PRN pain medication ordered will be assessed by RN/LPN for any adverse affects of administration of opioid pain medication.

The DON or designee will educate licensed, and registered staff of clinical protocol providing non-pharmacological intervention to alleviate pain prior to administration of pain administration.

The DON or designee will observe residents who receive PRN pain medication to ensure proper utilization of non-pharmacological interventions are used to alleviate pain were utilized appropriate as follows: 4 residents per week for 4 weeks, THEN 1 resident per week for 8 weeks.

Any trends identified will be reported during the monthly QAPI meeting. This plan of correction may be modified to address those trends as necessary.
483.25(g)(4)(5) REQUIREMENT Tube Feeding Mgmt/Restore Eating Skills:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
483.25(g)(4)-(5) Enteral Nutrition
(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)(4) A resident who has been able to eat enough alone or with assistance is not fed by enteral methods unless the resident's clinical condition demonstrates that enteral feeding was clinically indicated and consented to by the resident; and

483.25(g)(5) A resident who is fed by enteral means receives the appropriate treatment and services to restore, if possible, oral eating skills and to prevent complications of enteral feeding including but not limited to aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, and nasal-pharyngeal ulcers.
Observations:

Based on observations, review of clinical records and staff interview it was determined that the facility failed to provide enteral nutrition as prescribed for one of three sampled residents (Resident 93).

Findings include:

A review of the clinical record revealed that Resident 93 was admitted to the facility on March 31, 2023, with diagnoses of cerebrovascular disease (stroke) and dysphagia (swallowing problems occurring in the throat or esophagus).

According to the clinical record Resident 93 required a PEG tube [Percutaneous endoscopic gastrostomy (PEG) is an endoscopic medical procedure in which a tube (PEG tube) is passed into the patient's stomach through the abdominal wall, most commonly to provide a means of feeding when oral intake is not adequate [for example, because of dysphagia] for enteral feeding [enteral nutrition generally refers to any method of feeding that uses the gastrointestinal (GI) tract to deliver part or all of a person's caloric requirements].

Review of Resident 93's plan of care, initiated on May 5, 2023, revealed the resident's need for a PEG tube enteral feeding due to history of weight loss with planned interventions to administer the tube feeding formula (Jevity 1.5 65 ml/hr x 18 hr), flush 120 ml (milliliters) every 6 hours. The care plan failed to including maintenance care, to include cleansing and care of the peg tube site or identify the type and size of the PEG tube the resident required.

Resident 93 had a physician order dated December 1, 2023, order for the enteral feeding Jevity 1.5 (enteral feeding formula) at 65 ml per hour x 18 hours, on at 4 PM, off at 10 AM. The physician order did not specify the type and size of the PEG tube the resident required.

An observation of the resident's tube feeding and pump on February 7, 2024, at approximately 9:45 AM , revealed that the resident was lying in bed receiving enteral feedings to the resident delivered via a feeding pump. The label on the bottle was dated February 6, 2024, and timed as being administered at 4 PM (the time the Jevity 1.5 enteral feeding was hung to begin delivery to the resident).

Observation on February 7, 2024, at approximately 10:25 AM revealed that the resident's enteral tube feeding delivery was stopped as per physician order. The bottle contained approximately 850 ml of formula remaining, which indicated that only 650 ml enteral feeding formula had been administered since 4 PM on February 6, 2024. After 18 hours of infusion, the enteral feeding bottle should have been decreased by 1170 ml, leaving approximately 330 ml remaining. The resident had received 520 ml less enteral nutrition than prescribed.

Observation on February 8, 2024, at 10:50 AM, revealed that the enteral feeding was stopped as per physician order. The label on the bottle was dated February 6, 2024, and timed as being administered at 4 PM. The bottle appeared to be the same bottle as the day before. The bottle contained approximately 100 ml of remaining formula, indicating that the resident received approximately 750 ml of enteral feeing formula since 4 PM on February 7, 2024. The resident had received 420 ml less enteral nutrition than prescribed.

During an interview with the Director of Nursing (DON) on February 9, 2024, at approximately 8:20 AM the facility was unable to provide documented evidence as to the reason Resident 93 did not receive the 1170 ml of tube feeding as prescribed on February 7 and February 8, 2024. The DON confirmed that the enteral feeding had not been administered as ordered by the physician.



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








 Plan of Correction - To be completed: 04/09/2024

Resident # 93 was assessed by Registered dietitian, and doctor notified with no adverse affects noted.
Resident care plan and orders were reviewed and updated with appropriate interventions/orders by registered and licensed personnel.

All resident were reviewed and those with G-tube feedings were found to be a risk for being affected by the alleged deficient practice.

Education will be provided to registered and licensed nursing staff by the DON or designee, on providing eternal nutrition and following physician orders.

The DON or designee will observe residents to ensure feedings are administered as ordered and record review to ensure appropriate interventions and orders are in place as follows: 4 resident per week for 4 weeks, THEN 1 resident per week for 8 weeks.
Any trends identified will be reported during the monthly QAPI meeting. This plan of correction may be modified to address those trends as necessary.
483.10(e)(1), 483.12(a)(2) REQUIREMENT Right to be Free from Physical Restraints: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(e) Respect and Dignity.
The resident has a right to be treated with respect and dignity, including:

483.10(e)(1) The right to be free from any physical or chemical restraints imposed for purposes of discipline or convenience, and not required to treat the resident's medical symptoms, consistent with 483.12(a)(2).

483.12
The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms.

483.12(a) The facility must-

483.12(a)(2) Ensure that the resident is free from physical or chemical restraints imposed for purposes of discipline or convenience and that are not required to treat the resident's medical symptoms. When the use of restraints is indicated, the facility must use the least restrictive alternative for the least amount of time and document ongoing re-evaluation of the need for restraints.
Observations:

Based on observation, a review of select facility policy and clinical records, and staff interviews, it was determined that the facility failed to ensure ongoing evaluation of a resident's need and use of restraints, including evaluation of the least restrictive measure needed to treat the resident's medical symptom for one resident out of 30 sampled (Resident 104)


Findings include:

A review of a facility policy titled "Use of Restraints," (a policy review date was not provided by the facility), revealed that it is the facility's policy that when the use of a physical restraint is indicated, the least restrictive alternative will be used for the least amount of time necessary, and the ongoing re-evaluations for the need for restraints will be documented. The policy indicates examples of devices that are or may be considered physical restraints, including leg restraints, arm restraints, and hand mitts. Also, the policy indicates that restraints may only be used upon the written order of a physician and after obtaining consent from the resident and/or resident representative. The order shall include the following:
1.The specific reasons for the restraint (as it relates to the resident's medical symptom);
2.How the restraint will be used to benefit the resident's medical symptoms; and
3.The type of restraint and the period of time for the use of the restraint.
Furthermore, the policy indicated that a resident placed in a restraint will be observed at least every thirty (30) minutes by nursing personnel, and an account of the resident's condition shall be recorded in the resident's medical record.

A clinical record review revealed that Resident 104 was admitted to the facility on April 25, 2022, with diagnoses to include end-stage renal disease (kidneys are no longer able to function to meet the body's needs) and bipolar disorder (a mental health disorder that causes unusual shifts in a person's mood, energy, activity levels, and concentration).

A review of the quarterly Minimum Data Set Assessment (MDS - a federally mandated standardized assessment process conducted periodically to plan resident care) dated January 11, 2024, revealed Resident 104's BIMS score was 99 (Brief Interview for Mental Status- a tool to assess cognitive function; a score of 99 indicates that the resident was unable to provide or did not provide answers to complete this section).

Resident 104's care plan, initiated May 10, 2022, identified that the resident had the potential to exhibit distressed mood and behavioral symptoms, as evidenced by paranoia, tearfulness, negative statements, restlessness, calling out, pulling staff's hair, and banging head on the floor related to her diagnosis of bipolar disorder. Interventions planned included bi-lateral hand mittens as needed to reduce the risk of dialysis catheter dislodgement, and if used, must be removed every 2 hours.

Resident 104's care plan, initiated August 4, 2022, also noted that the resident was at high risk for skin tears and bruising related to fragile skin, self-abusive acts, and self-propelling locomotion. Planned interventions were the use of mitts \ to be removed every 2 hours for 10 minutes for hand assessment and the findings must be documented.

A restraint consent form signed and dated September 25, 2023, indicated that Resident 104's representative gave consent to utilize mitts \ for the resident's safety and dignity. The form indicated that the risks versus benefits of the restraint were explained to the resident's representative and that the resident representative agreed with the use of the restraint.

A physical restraint evaluation form dated October 3, 2023, revealed that the form was incomplete, lacking Section A Diagnosis, Section B Medication and Reasons, Section C Neurological Status, Section D History of Falls/Injuries, Section E Current Restraints, Section F Less Restrictive Measures, Section G Mobility Status, Section H Body Alignment Status, Section I Team Recommendations, and Section IDT individuals involved in the evaluation.

A physician order was initiated on December 28, 2023, for protective mittens on at HS (hour of sleep) and during times of increased agitation to prevent residents from pulling at the dialysis catheter (at bedtime).

Resident 104's Treatment Administration Record (TAR) for December 2023 revealed that the ordered protective mittens were used on the resident on December 28, 29, 30, and 31 at 10:00 PM. According to the TAR, the protective mittens were applied four times in December 2023.

Resident 104's TAR for January 2024 revealed that the ordered protective mittens were used on the resident each day in January 2024 at 10:00 PM. According to the TAR, the protective mittens were applied 31 times in January 2024.

Resident 104's TAR for February 2024 revealed that the ordered protective mittens were used on the resident on February 1, 2, 3, 5, 6, 7, and 8 at 10:00 PM. The February 2024 TAR was reviewed through the survey exit on February 9, 2024. According to the TAR, the protective mittens were applied seven times in February 2024.

A review of the resident's clinical record at the time of the survey ending February 9, 2024, revealed no documented evidence of ongoing monitoring and evaluation of the resident's increased need for restraint application during January 2024 and February 2024 and that the mittens were consistently removed at least every two hours if used during any waking hours.

An observation on February 9, 2024, at 12:30 PM in Resident 104 room #B216 revealed two blue mesh protective mittens present in the resident's room, with fabric bands that could be utilized to tie and secure the mittens to a person's wrist.

During an interview on February 9, 2024, at approximately 1:00 PM, the Director of Nursing was unable to provide evidence that the facility's interdisciplinary team was consistently evaluating the resident's restraint use every 30 days, or sooner if necessary, and determining the least restrictive method was used for the least amount of time.




28 Pa. Code 211.8 (c.1)(f) Use of restraints






 Plan of Correction - To be completed: 04/09/2024

Upon notification of the alleged deficient practice, the facility conducted a restraint assessment to determine the least restrictive method and resident 104 was assessed, by RN, no adverse effects noted. resident was evaluated and orders, care plans updated to include monitoring per policy by DON.

All like residents were assessed and evaluated to proper interventions and monitoring by RN and LPNs along with rehab department, to ensure and identify less restrictive devices are implemented.


The DON along with Director of rehab will educate licensed and registered nurses and rehab department, regarding restraint evaluations,, implementation & monitoring.

5 like residents with restraints will be evaluated for proper usage, monitoring, and evaluation of restraints. 4x week x 4 weeks. Any trends identified will be reported during the monthly QAPI committee meeting.

This plan maybe modified to address those trends as necessary.

483.12(a)(1) REQUIREMENT Free from Abuse and Neglect: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 Freedom from Abuse, Neglect, and Exploitation
The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms.

483.12(a) The facility must-

483.12(a)(1) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion;
Observations:

Based on a review of clinical records, select facility policy and investigative reports and staff and resident interviews it was determined that the facility failed to consistently implement sufficient measures to protect three residents (Resident 7, 83 and 137) out of 18 sampled from physical, sexual verbal abuse perpetrated by another resident (Resident 198).

Findings included:

A review of a facility policy for "Abuse" last reviewed by the facility on June 2022, revealed, It is the policy of the facility that acts of physical, verbal, psychological and financial abuse directed against residents are absolutely prohibited. Each resident has the right to be free from verbal, sexual, physical and mental abuse, corporal punishment, involuntary seclusion, mistreatment, neglect, exploitation and misappropriation of property.

Clinical record review revealed that Resident 198 was admitted to the facility on December 28, 2023, with diagnosis to include dementia, alcohol abuse with unspecified alcohol induced disorder, anxiety and Wernicke's encephalopathy (Wernicke-Korsakoff syndrome is an unusual type of memory disorder due to a lack of thiamin (vitamin B1) requiring immediate treatment. It most often happens in people with alcohol use disorder and malnutrition).

A review of an admission Minimum Data Set assessment (MDS, is part of the U.S. federally mandated process for clinical assessment of all residents in Medicare or Medicaid certified nursing homes) dated January 4, 2024, revealed Resident 198 was moderately cognitively impaired with a BIMS score of 8 ( BIMS a test administered to all residents in skilled nursing facilities to assess patient cognitive patterns, behavior, and mood, a score of 8-12 suggests moderate cognitive impairment) and required staff assistance with activities of daily living.

A review of the resident's care plan revealed that Resident 198 has potential to exhibit physical
and verbal aggression toward others. May seek unwanted sexual contact with other female residents (kissing), initiated January 02, 2024. Interventions to included:
1:1 visits for support prn.
Approach in a calm/unhurried manner.
Attempt to determine problem causing stimuli; remove stressors as identified.
Encourage appropriate behaviors with others and educate on appropriate behaviors
with others.
Encourage resident to express feelings and offer emotional support and reassurance
with effect.
If exhibiting agitation/frustration then keep distant from others until calm.
Keep distance from residents who are exhibiting agitation or behavioral changes.
- Keep distance from residents who are exhibiting agitation or behavioral changes
Maintain safe environment.
Observe for any changes in mood,
Remove resident from environment as needed.

Nursing documentation dated January 14, 2024 at 10:02 AM revealed that the nurse was informed of an incident involving Resident 198 witnessed by an agency nursing staff member. Resident 198 placed his lips against another resident in the hallway.

A review of a facility investigation report dated January 14, 2024 at 3 PM revealed that Resident 7, a severly cognitively impaired resident, was seated in her wheelchair at the nurses station. Resident 198 was next to her and Employee 18, a nurse aide, observed Resident 198 lean over and kiss Resident 7 on her lips. Staff immediately separated the resident and assessed them for injuries. Resident 198 was placed on every 15 minutes watch.

A review of a facility investigation dated January 19, 2024 at 5:30 PM revealed that Resident 198 became involved in a verbal altercation with Resident 137 in the dining room just prior to lunch. The argument escalated quickly and Resident 198 approached Resident 137 and placed is hands around her neck (Resident 137) and said " I'm going to strangle you." Additional staff intervened and separated the residents.

A review of a nurses note dated February 3, 2024 at 1:30 P.M. Resident 198 was observed kissing Resident 83. Staff members immediately removed both residents and redirected Resident 198. 1:1 supervision of Resident 198 was initiated for safety. This incident was not reported to the State Survey Agency or investigated as potential sexual abuse of Resident 83.

A nurses note dated February 7, 2024 at 12:18 PM revealed, Resident 198 left facility to hospital via ambulance. He returned to the facility the dame day.

The DON confirmed during interview on February 9, 2024 at 11 A.M, that the facility was aware of Resident 198's aggressive and sexual behaviors and failed to demonstrate that Residents 7, 83, and 137 were free from abuse perpetrated by Resident 198.

Refer F742 and F605

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

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

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


















 Plan of Correction - To be completed: 04/09/2024

Resident #198 no longer resides at the facility.
An event report was reported to the state survey agency by the DON.

Resident #7, #83 & #137 were assessed for any adverse affects from the events by medical practioner, none were noted.

Upon review the facility found that all 144 residents residing at the facility at the time of the survey had a potential to be affected by the alleged deficient practice.
All like residents with aggression or sexual behaviors were identified and reviewed for effective interventions by the LPN or RN.

The DON/designee re-educated all staff on abuse and behavior management.

5 resident 4x week and 2 week will be interviewed or observed for signs of abuse by DON/designee.
5 resident with sexual behaviors or aggression will be reviewed for effective interventions to prevent abuse 4x week x 4weeks,

NHA will review all allegations of abuse or neglect yo ensure adherence with facility abuse and neglect policy and procedure and adherence to state and federal reporting guidelines weekly for 12 weeks.

Any trends identified will be reported during the monthly QAPI meeting. This plan of correction may be modified to address those trends as necessary.
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 observations and staff interview, it was determined that the facility failed to maintain a clean and orderly environment in resident areas on three of four active resident units (B2 unit, C2 unit and D unit)

Findings included:

An observation on February 6, 2024, at 7:00 PM of resident room B267 revealed a red substance buildup along the assist rail attached to the resident's bed.

An observation of the resident's bathroom revealed an unlabeled urine collection graduate containing a small amount of a yellow urine like liquid resting on the back of the resident's toilet. Brown paper towels, a shampoo bottle, and a bed urinal were observed on the resident's bathroom floor. Black dirt, debris, and dead bugs were observed in the translucent bathroom ceiling light.

An observation on February 7, 2024, at 9:00 AM in the bathroom of resident room B223 revealed black dirt, debris, and dead bugs in the bathroom ceiling light fixture.

An observation on February 7, 2024, at 9:05 AM in resident room B219 revealed a urinary catheter drainage leg bag containing a urine-like yellow liquid hanging over the resident's bathroom hand assist bar.

An observation on February 7, 2024, at 9:15 AM in resident room B217 revealed black dirt, debris, and dead bugs in the bathroom ceiling light fixture.

An observation on February 7, 2024, at 9:23 AM in resident room B214 revealed an area of brown and tan stains under the resident's sink measuring approximately 14 inches by 12 inches.

An observation on February 7, 2024, at 9:31 AM in resident room B211 revealed that the sink in the resident's room would not drain water. Water was visible in the sink basin. Gray and tan debris was adhered to the inside of the sink along the water line.

An observation on February 7, 2024, at 9:33 AM in resident room B213 revealed that the sink in the resident's room would not drain water. Water was visible in the sink basin.

An observation on February 7, 2024, at 9:45 AM in resident room B256 revealed black dirt, debris, and dead bugs in the bathroom ceiling light fixture

An observation on February 7, 2024, at 9:50 AM in resident room B259, revealed a green tube with a gray cap was found on the floor. At the time of the observation, Employee 17, a Licensed Practical Nurse (LPN), identified the object as a multi drawing needle (a needle used for the collection of blood). Employee 17, LPN, removed the needle from the resident's room and indicated that the item should not be on the floor in the resident's room. Employee 17, LPN, explained that the cap had an unbroken paper seal. A white paper seal was observed covering the gray cap and green tube and the seal did not appear to be broken.

An observation on February 7, 2024, at 10:00 AM in resident room C224 revealed an unknown brown substance on the middle bed privacy curtain.

An observation on February 7, 2024, at 10:03 AM in resident room C226 revealed an unknown dark red substance on the middle bed privacy curtain.

An observation on February 7, 2024, at 10:10 AM in resident room C210 revealed brown stains on both privacy curtains. On the wall, to the right of the sink, there was evidence of water damage and water stains, extending horizontally approximately four feet behind and beyond the resident's dresser.

Observation of the D-unit large shower room on February 8, 2024, at 7:30 AM revealed a broken stationary shower chair. Multiple cracks were observed on the front edge of the shower chair seat and a bottom part of the seat ledge was broken, exposing sharp edges.

A dark brown substance was observed on the back of toilet seat in the large shower room.

The shower curtains were worn and frayed.

The wheels on a mobile shower chair did not function properly, when the surveyor attempted to move it out of the way. The wheels were not locked, but the chair would not move without increased pushing force.

Interview with the Director of Nursing on February 9, 2024, at approximately 8:45 AM confirmed the facility is to be maintained daily to provide a clean, functional, orderly and sanitary environment for the residents.




28 Pa. Code 201.18 (e)(2.1) Management













 Plan of Correction - To be completed: 04/09/2024

Room 267 substance on resident's assist rail was cleaned upon surveyor's notification by the housekeeper on that unit.
Resident bathroom light fixtures in identified rooms; B223, 217, 256, & 267 were taken down and cleaned.
Housekeeping director/designee will check each resident bathroom light fixture for non-compliance regarding debris in the light fixture, and preform the necessary cleaning if needed.
The housekeeping director will educate the housekeeping staff regarding identifying and complete daily objectives to include bathroom light fixtures and to correct it as soon as possible.
Housekeeping director/designee will audit 5 resident rooms daily, 5 days a week to ensure compliance is achieved for bathroom light fixtures.
Audit results form bathroom light fixtures will be reported by housekeeping director/designee at QAPI meetings.

Resident room B219 bag identified was discarded at the time of surveyor's identification.
The DON quickly educated the direct care staff, that the identified urinary catheter bags, the facility purchases, were not reusable.

The DON/designee will audit weekly, for one month residents that use disposable urinary catheter drainage bags, to ensure reuse of bags is not being practiced.

Results of the audit will be reported by the DON/designee at QAPI meetings.

Room B259 needle was identified as a blood collection needle, it was also identified that the facility does not use that type of needle, and that the resident recently has a blood draw from a contracted lab collection company.
the needle was immediately disposed of in a sharps container, staff searched the resident room for any other collection equipment that may have fallen out of the phlebotomist carry case.

The DON will implement a new process and educate all direct care staff to check, and document resident rooms after phlebotomist leaves, to ensure no equipment is left behind by mistake.

Room check audits will be reviewed by DON/designee and reported at QAPI meetings.

The identified sink in room B211 & B213 as not draining, was unclogged, by the maintenance department, day of survey.
The maintenance department checked all sinks that day for any clogged or slow draining, and made necessary maintenance if needed.

The maintenance department will check all resident sinks every other month to ensure sinks remain unclogged.

Rooms C224,C210 privacy curtains identified at the time of the survey, were taken down immediately and replaced. In addition the identified will area was addressed that same day.
The director of Housekeeping and designee at the time of survey audit each resident room to identify any non compliance regarding privacy curtains.
any privacy curtains in non-compliance were taken changed.
The Director of Housekeeping will educate all housekeeping staff to identify during daily assignments to check privacy curtains for stains and replace them immediately.

The director of Housekeeping will randomly audit five resident rooms a day , five days a week for one month to ensure compliance is met regarding clean and in good shape.
results of audits will be reported by

Director of Housekeeping at QAPI meeting.
The shower chair identified was discarded upon notification.
The identified toilet seat was cleaned by housekeeping.

The DON will educated direct care staff that toilets must be disinfected between use of residents.

The Director of Maintenance will audit facility wide of all shower chair in use and stored to identify no cracks, sharp edges are present, any identified will be discarded, and replaced with acceptable chairs.
The shower curtain identified was replaced at the time of survey.
The Director of Housekeeping /designee will audit facility wide all shower rooms for curtains that appear worn or frayed condition and replace them with acceptable ones.
The Director of housekeeping will educated his staff to identify worn and frayed shower curtains on their daily assignments and to replace them as needed.
The Director of Housekeeping/designee will audit room room curtains weekly for two months to ensure curtain are in acceptable condition.

Results of audits will be reported at QAPI meetings.
The mobile shower chair identified wheels were checked by maintenance and identified that the surveyor had one wheel locked.
The maintenance department did preform some minor preventative measures by applying some lubricant to the bearing of the wheels of the chair.

The Director of maintenance will add shower chairs to the facility's monthly preventative measures.
The director of Maintenance will audit 5 shower chairs weekly for one month for function.

Results of the audits will be reported by Director of maintenance at QAPI meetings.



483.10(g)(17)(18)(i)-(v) REQUIREMENT Medicaid/Medicare Coverage/Liability Notice: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(g)(17) The facility must--
(i) Inform each Medicaid-eligible resident, in writing, at the time of admission to the nursing facility and when the resident becomes eligible for Medicaid of-
(A) The items and services that are included in nursing facility services under the State plan and for which the resident may not be charged;
(B) Those other items and services that the facility offers and for which the resident may be charged, and the amount of charges for those services; and
(ii) Inform each Medicaid-eligible resident when changes are made to the items and services specified in 483.10(g)(17)(i)(A) and (B) of this section.

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

Based on a review of clinical records and facility documentation, and staff interview, it was determined that facility failed to provide an advance notice of the Skilled Nursing Facility Advanced Beneficiary Notice of Non-Coverage (SNF ABN) for two residents out of three reviewed (Residents 42 and 6) and failed to provide a Notice of Medicare Provider Non - Coverage (NOMNC) and for the appeal process for three out of three records reviewed (Resident 42, 6, and 398).

Findings include:

A review of the form "Instructions for Skilled Nursing Facility Advanced Beneficiary Notice of Non-Coverage (SNF ABN) CMS-10055," (information to the beneficiary so that he/she can decide whether or not to get the care that may not be paid for by Medicare and assume financial responsibility) revealed instructions that Medicare requires Skilled Nursing Facilities (SNFs) to issue the SNF ABN to Original Medicare, also called fee-for-service (FFS), beneficiaries prior to providing care that Medicare usually covers, but may not pay for in this instance because the care is a) not medically reasonable and necessary; or b) considered custodial. The SNF must give the applicable Medicare coverage guideline(s) and a brief explanation of why the beneficiary's medical needs or condition do not meet Medicare coverage guidelines. The reason must be sufficient and specific enough to enable the beneficiary to understand why Medicare may deny payment. The SNF provides the beneficiary with an estimated cost of the corresponding care that may not be covered by Medicare. There are 3 options listed on the SNF ABN and the beneficiary must check only one option; 1) I want the care listed above, 2) I want the care listed above, but don't bill Medicare, 3) I don't want the care listed above. The beneficiary or their authorized representative must sign the signature box to acknowledge that they read and understood the notice. The date should reflect the date that the SNF gave notice to the beneficiary in-person, or when appropriate, the date contact was made with the beneficiary's authorized representative by phone.

A review of the form "Instructions for the Notice of Medicare Non-Coverage (NOMNC) CMS-10123," (a notice that informs the recipient when care receive from skilled nursing facility is ending and how you can contact a Quality Improvement Organization (QIO) to appeal) revealed instructions that a Medicare provider must ensure that the notice is delivered at least two calendar days before Medicare covered services end. The provider must ensure that the beneficiary or their representative signs and dates the NOMNC to demonstrate that the beneficiary or their representative received the notice and understands the termination of services can be disputed.

Review of the list of discharged residents, provided by the facility, from a Medicare covered Part A stay with benefit days remaining in the past six months revealed no indication that Resident 42 and Resident 6 or their representatives were provided information to decide whether to receive care that may not be paid for by Medicare.

Review of the list of discharged residents, provided by the facility, from a Medicare covered Part A stay with benefit days remaining in the past six months revealed no indication that Resident 42, Resident 6, and Resident 398 or their representatives was given at least a two-day notice, informing the beneficiary that skilled nursing services will end (last covered day) in two days.

Clinical record review revealed that Resident 42 Medicare Part A skilled services started on August 10, 2023, and the last covered day of Part A services was October 25, 2023.

Clinical record review revealed that Resident 6 Medicare Part A skilled services started on November 1, 2023, and the last covered day of Part A services was December 16, 2023.

Clinical record review revealed that Resident 398 Medicare Part A skilled services started on November 22, 2023, and the last covered day of Part A services was January 2, 2024.

An interview with the Director of Nursing (DON) on February 9, at 8:45 AM confirmed that there was no documented evidence that Resident 42 and Resident 6 and/or their representative were provided the information regarding receiving care and services no longer covered by Medicare. The DON also confirmed that there was no documented evidence that Resident 42, Resident 6, and Resident 398 and/or their representative received verbal or written notice 48 hours prior to the last covered day of Medicare Part A skilled services.


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

28 Pa. Code 201.29(a) Resident rights






 Plan of Correction - To be completed: 04/09/2024

The facility can not retroactively correct the alleged deficient practice. for resident #42 & #6.
A review of all residents within the past two weeks of survey will be reviewed by the RNAC to identify if NOMNCs were issued to resident/responsible party, any identified will be sent.
A policy and procedure will be developed by administration, of informing and documenting NOMNCs and the role how each member of the multidisciplinary team will participate.
The NHA/designee will educate the individuals of the multidisciplinary team on the new process.
The NHA/designee will audit weekly the residents who have been identified that NOMNCs should be issued to, and ensure notice was sent and in the parameters of time.
The NHA/designee will report the results of the NOMNC audit at QAPI meeting.
483.10(c)(2)(3) REQUIREMENT Right to Participate in Planning Care:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.10(c)(2) The right to participate in the development and implementation of his or her person-centered plan of care, including but not limited to:
(i) The right to participate in the planning process, including the right to identify individuals or roles to be included in the planning process, the right to request meetings and the right to request revisions to the person-centered plan of care.
(ii) The right to participate in establishing the expected goals and outcomes of care, the type, amount, frequency, and duration of care, and any other factors related to the effectiveness of the plan of care.
(iii) The right to be informed, in advance, of changes to the plan of care.
(iv) The right to receive the services and/or items included in the plan of care.
(v) The right to see the care plan, including the right to sign after significant changes to the plan of care.

483.10(c)(3) The facility shall inform the resident of the right to participate in his or her treatment and shall support the resident in this right. The planning process must-
(i) Facilitate the inclusion of the resident and/or resident representative.
(ii) Include an assessment of the resident's strengths and needs.
(iii) Incorporate the resident's personal and cultural preferences in developing goals of care.
Observations:

Based on a review of clinical records and staff interviews, it was determined that the facility failed to afford a resident and their appointed representative the right to participate in the development of the resident's plan of care for one resident out of 30 sampled (Resident 100).

Findings include:

A clinical record review revealed Resident 100 was admitted to the facility on August 10, 2023, with diagnoses to include congestive heart failure (a condition in which the heart is unable to pump enough blood to meet the body's needs) and major depressive disorder (a condition affecting a person's mood that may cause persistent feelings of sadness, hopelessness, and loss of interest in things that were once pleasurable).

A review of the quarterly Minimum Data Set assessment (MDS - a federally mandated standardized assessment process conducted periodically to plan resident care) dated August 16, 2023 revealed that Resident 100 was cognitively intact with a BIMS score of 15 (Brief Interview for Mental Status- a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 13-15 indicates cognitively intact).

A review of the quarterly Minimum Data Set assessment dated November 16, 2023, revealed that Resident 100 now moderately cognitive impairment with a BIMS score of 11 (a score of 8-12 indicates moderate impairment).

A review of documentation dated May 24, 2023, revealed that Resident 100 was adjudicated incapacitated and a guardian was appointed. The document indicated that the guardian shall respect the expressed wishes and preferences of Resident 100 and encourage Resident 100 to participate to the maximum extent of her abilities in all decisions that affect her.

There was no documented evidence that Resident 100 or Resident 100's guardian were invited to attend the resident's interdisciplinary care plan meetings.

During an interview on February 7, 2024, at 10:00 AM, Resident 100 stated that she has not been invited to participate in the care planning process for development of her comprehensive person-centered care plan or to attend care plan meetings.

During an interview on February 9, 2024, at approximately 12:30 PM, the Director of Nursing was unable to provide evidence that Resident 100 or Resident 100's guardian have been provided the opportunity to attend multidisciplinary care plan meetings to participate in the development of the resident's plan of care.




28 Pa. Code 201.29 (a) Resident rights.





 Plan of Correction - To be completed: 04/09/2024

Resident #100 and responsible party will be contacted by Social service Director to schedule another care plan meeting within the next 15 calendar days of this submission.

A review will be done by the social service department of the past 60 days of care plan invitations to attend will be completed. any resident /responsible party not identified of having been invited, will be invited for an updated care plan meeting, within the 30 days of this submission. in addition any resident or responsible party not having attended the care in the past 60 days will receive the version 1.7 care plan note form.
A new process of informing and inviting residents and responsible parties to the multidisciplinary care conference will be developed and implemented by the Director of Social Services. As part of the process, resident or responsible parties that can not attend will now receive a copy mailed/emailed or hand delivered of the version 1.7 care conference note.

The Director of Social Services will educate the entire multidisciplinary team on the new process.

An audit of care conferences invitations, attendance and summary will be done by NHA/designee weekly to ensure compliance is met.

The results of the audit will be reported by NHA/designee at QAPI meetings.


483.10(c)(7) REQUIREMENT Resident Self-Admin Meds-Clinically Approp:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.10(c)(7) The right to self-administer medications if the interdisciplinary team, as defined by 483.21(b)(2)(ii), has determined that this practice is clinically appropriate.
Observations:

Based on observation, a review of clinical records and select facility policy and staff and resident interview, it was determined that the facility failed to ensure that self-administration of medications was clinically appropriate for one of 30 residents sampled (Resident 86).

Findings include:

A review of a facility policy entitled "Self-administration of Medications" last reviewed by the facility on January 24, 2024, revealed that residents have the right to self-administer medications if the interdisciplinary team (IDT) has determined that it is clinically appropriate and safe for the resident to do so. As part of the evaluation comprehensive assessment, the IDT assesses each resident's cognitive and physical abilities to determine whether self-administering medication is safe and clinically appropriate for the resident. If it is deemed safe and appropriate for a resident to self-administer medications, this is documented in the medical record and the care plan. The decision that a resident can safely self-administer medications is reassessed periodically based on changes in the resident's medical and/or decision-making status.

A review of the clinical record revealed that Resident 86 was admitted to the facility on December 26, 2023, with diagnoses which included diabetes, heart failure, and peripheral vascular disease, and was cognitively intact.

A physician order was noted December 26, 2023, for Latanoprost Ophthalmic solution 0.005% instill one drop in right eye at bedtime for dry eyes, Ofloxacin solution 0.3% instill one drop in right eye four times a day for prevention, Simbrinza Ophthalmic Suspension 1-0.2% instill one drop in right eye three times a day for irritation, and Timolol Maleate Ophthalmic solution 0.5% instill one drop in right eye every morning and at bedtime for dry eyes.

An observation conducted on February 9, 2024, at approximately 8:30 AM revealed Resident 86 had three bottles of eye drops on his overbed table, Lantoprost, Simbrinza, and Timolol.

Interview with Resident 86 at that time revealed that the resident stated that he keeps them at his bedside so that he knows he is taking them "the right way", like he was doing at home. Resident 86 declined to allow Employee 4, licensed practical nurse, to remove the prescription eye drops from his room.

Review of the resident's clinical record revealed no documented evidence that the facility had assessed Resident 86 for self-administration of medications.

During an interview with the Director of Nursing on February 9, 2024, at approximately 11:30 AM, it was confirmed that the facility had not conducted a self-medication assessment for this resident.


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






 Plan of Correction - To be completed: 04/09/2024

Resident # 86 assessed by RN for adverse effects of self-administration no adverse effects noted.

RN assessed resident #86 for self -administration of medications and clinically appropriate self-administration of medications and clinically appropriate interventions regarding self-administration.

Upon review of the facility found that all 144 residents residing in the facility at the time of survey had the potential to be affected by this alleged deficient practice.

The DON or designee will provide education to all registered and licensed nurses regarding the self-administration of medication policy.

The DON or designee will audit resident who self -administer medications as follows: 4 residents for 4 weeks, THEN 1 resident monthly for the remainder of 90 days for appropriate assessment and clinically approved interventions regarding self-administration of medication.
Any trends will be identified at the monthly QAPI meeting. This plan of correction may be modified to address those trends as necessary.
483.20(g) REQUIREMENT Accuracy of Assessments:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.20(g) Accuracy of Assessments.
The assessment must accurately reflect the resident's status.
Observations:


Based on a review of clinical records and the Resident Assessment Instrument (RAI) and staff interview, it was determined that the facility failed to ensure that the Minimum Data Set Assessments (MDS - a federally mandated standardized assessment conducted at specific intervals to plan resident care) accurately reflected the status of one resident out of 30 sampled (Residents 104).

Findings include:

According to the RAI User's Manual, Section P, "Restraints and Alarms," dated October 2023, this section is to record the frequency that the resident was restrained by any of the listed devices or an alarm was used at any time during the day or night during the 7-day look-back period.

A review of Resident 104's quarterly MDS Assessment dated January 11, 2024, Section P indicated that no restraints were used in bed or in chair out of bed during the 7-day look-back period.

A review of Resident 104's clinical record revealed a physician order initiated on December 28, 2023, for protective mittens on at HS (hour of sleep) and during times of increased agitation to prevent the resident from pulling at the dialysis catheter (at bedtime).

Resident 104's Treatment Administration Record (TAR) for January 2024 revealed that the ordered protective mittens were applied to the resident, as a restraint, each day in January 2024 at 10:00 PM. According to the TAR, the protective mittens, restraints, were applied 31 times in January 2024, including each day during the 7-day look-back period.

An interview with the Registered Nurse Assessment Coordinator on February 9, 2024, at 9:45 AM confirmed that Resident 104's MDS quarterly assessment was not accurate.





 Plan of Correction - To be completed: 04/09/2024

Upon notification of the alleged deficient practice, the MDS for resident # 104 was modified and resubmitted to accurately reflect resident assessment data.

Upon review the facility found that all 144 residents residing in the facility at the time of this survey had the potential to be affected by this alleged practice.

The DON provided re-education for the MDS nurse regarding MDS accuracy and accurate coding of MDS section P.

The DON/designee will audit MDS section P for coding accuracy as follows: new admission charts and 4 resident records weekly and 4 resident records weekly for 4 weeks, THEN l new admission records plus 1 resident weekly for 8 weeks. Any trends identified will be reported during the monthly QAPI meeting. This plan of correction may be modified to address those trends as necessary.
483.25 REQUIREMENT Quality of Care: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 Quality of care
Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices.
Observations:

Based on clinical record review and staff interviews it was determined that the facility failed to provide nursing services consistent with professional standards of practice by failing to ensure that licensed and professional nursing staff conducted a thorough assessment of resident's injury for one resident out of 30 sampled (Resident 63).


Findings include:

According to the Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, 21.11 (a)(1)(2)(4) indicates that the registered nurse was to carry out nursing care actions that promote, maintain, and restore the well-being of individuals.

The Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, 21.145 Functions of the Licensed Practical Nurse (LPN) (a) The LPN is prepared to function as a member of the health-care team by exercising sound judgement based on preparation, knowledge, skills, understandings, and past experiences in nursing situations. The LPN participates in the planning, implementation, and evaluation of nursing care in settings where nursing takes place. 21.148 Standards of nursing conduct (a) A licensed practical nurse shall: (5) Document and maintain accurate records.

According to the American Nurses Association Principles for Nursing Documentation, nurses document their work and outcomes and provide an integrated, real-time method of informing the health care team about the patient status. Timely documentation of the following types of information should be made and maintained in a patient's EHR (electronic health record) to support the ability of the health care team to ensure informed decisions and high quality care in the continuity of patient care:
Assessments
Clinical problems
Communications with other health care professionals regarding
the patient
Communication with and education of the patient, family, and the patient ' s designated support person and other third parties.

A review of Resident 63's clinical record revealed admission to the facility on November 13, 2023, included generalized muscle weakness, lack of coordination, osteoarthritis (inflammation of one or more joints and is the most common form of arthritis that affects joints in the hand, spine, knees and hips) and history of right radial neck fracture (are a common type of elbow fracture that typically occurs after a fall on an outstretched arm).

A review of Resident 63's current plan of care in effect on February 2, 2024, revealed that the resident had decreased ADL (activity of daily living) self-care performance with history of right radial neck fracture. The care plan noted that the resident ambulates independently in his room without assistive device for transfers and ambulation, with interventions for staff to set up the resident with ADLs and to provide assistance as needed.

A review of a Resident 63's quarterly- MDS (Minimum Data Set - a federally mandated standardized assessment process conducted periodically to plan resident care) dated January 15, 2024, revealed that the resident was cognitively intact with a BIMS score of 15 (Brief Interview for Mental Status section of the MDS which assesses cognition, a tool to assess the resident's attention, orientation, and ability to register and recall new information).

Nursing progress notes completed by Employee 1, a licensed practical nurse (LPN), dated February 3, 2024, at 9:00 AM, revealed that Resident 63 approached this nurse \ and asked for something for a burn. Employee 1 asked the resident where he was burned, and the resident raised his shirt to show an oval shaped burn to his lower mid abdomen. Resident 63 stated that he spilled hot tea on himself yesterday (2/2/2024) and that he didn't tell anyone because it wasn't bothering him at that time and wanted ton the area treatment applied to the area today. RN Supervisor was made aware and arrived on unit to assess resident."

An incident report completed by Employee 1 on February 3, 2024, at 10:00 AM, revealed that the Resident 63 sustained a first-degree burn (a mild burn injury of the outermost layer that make up the skin (epidermis). First-degree burns affect only the epidermis, or outer layer of skin. The burn site is red, painful, dry, and with no blisters. Mild sunburn is an example. Long-term tissue damage is rare and usually consists of an increase or decrease in the skin color) to the mid-center abdomen that measured 4.0 cm in length by 1.5 cm in width by 0.01 cm in depth and base color was red, no drainage, no odor, with intact skin and closed tissue. The attending physician was notified with new orders noted to cleanse the area with mild soap/water or normal saline (NSS), apply a thin layer of Silvadene (fights bacteria and yeast on the skin. Silvadene (for the skin) is used to treat or prevent serious infection on areas of skin with second- or third-degree burn) to wound bed, cover, with dressing twice daily and as needed for soilage. The incident report concluded that the resident made staff aware that he spilled a cup of tea on himself Friday evening (2/2/2024) and did not think much of it. Resident 63 was educated not to use the microwave and to request assistance when needing food or drink to be heated. The facility removed the microwave from the units to prevent recurrence.

A review of Resident 63's clinical record failed to reveal documented evidence that a registered nurse (RN) thoroughly assessed the resident's abdominal burn following the resident's report of his injury on February 3, 2024. The only assessment of the area was noted by an LPN, which is outside their scope of practice, and was documented on the incident report, not the resident's clinical record.

Observation of Resident 63's burn to his abdomen with Employee 5, agency LPN, on February 6, 2024, at 8:30 p.m., revealed that the burn measured 6.5 cm in length by 1.5 cm wide with white exudate (a liquid produced by the body in response to tissue injury) covering the wound bed with pink surrounding skin and a moderate amount of yellow drainage present on the dressing. The injury appeared to be a second-degree burn, which involved the epidermis and part of the dermis layer of skin, and not a first degree burn as Employee 1, LPN noted on the incident report dated February 3, 2024.

During an interview with the Director of Nursing on February 6, 2024, at 8:45 p.m., the DON confirmed that she did not observe Resident 63's burn and was not aware of the status of the resident's injury. The DON also confirmed that there was no RN assessment of the resident's burn at the time it was reported and no RN assessment of the wound documented in the resident's clinical record.



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

28 Pa. Code 211.5 (f) Medical records






 Plan of Correction - To be completed: 04/09/2024

Upon notification of the alleged deficient practice, resident # 63 was assessed by RN with documentation of assessment documented in the medical record.

All like residents with injuries have received an assessment of resident injuries and documented in the medical record, by the RN.

The DON or designee provided re-education on conducting focused nursing assessments for injuries immediately following incidents and accidents with potential or suspected injury and re-education to licensed nurses on reporting incidents and accidents to the RN for the RN to conduct an assessment for injury.

The DON or designee will review all incidents and accidents to ensure appropriate nursing assessments were conducted 5 times a week for 4 weeks, THEN 3 times a week for 4 weeks, THEN 1 ties a week for 4 weeks. Any trends identified will be reported during the QAPI meeting. This plan of correction maybe modified to address those trends as necessary.
483.25(e)(1)-(3) REQUIREMENT Bowel/Bladder Incontinence, Catheter, UTI: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(e) Incontinence.
483.25(e)(1) The facility must ensure that resident who is continent of bladder and bowel on admission receives services and assistance to maintain continence unless his or her clinical condition is or becomes such that continence is not possible to maintain.

483.25(e)(2)For a resident with urinary incontinence, based on the resident's comprehensive assessment, the facility must ensure that-
(i) A resident who enters the facility without an indwelling catheter is not catheterized unless the resident's clinical condition demonstrates that catheterization was necessary;
(ii) A resident who enters the facility with an indwelling catheter or subsequently receives one is assessed for removal of the catheter as soon as possible unless the resident's clinical condition demonstrates that catheterization is necessary; and
(iii) A resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible.

483.25(e)(3) For a resident with fecal incontinence, based on the resident's comprehensive assessment, the facility must ensure that a resident who is incontinent of bowel receives appropriate treatment and services to restore as much normal bowel function as possible.
Observations:

Based on observations, clinical record reviews, and staff interviews, it was determined that the the facility failed to ensure that residents received appropriate treatment and services to prevent potential complications related to the use of an indwelling catheter for one out of the 30 residents sampled (Resident 129).

Findings include:

Review of the clinical record revealed that Resident 129 was admitted to the facility on November 28, 2023, with diagnoses to include ventricular tachycardia (a type of abnormal heart rhythm) and obstructive and reflux uropathy (a condition in which the flow of urine is blocked).

A physician order was noted November 28, 2023, for a foley catheter, foley catheter Care every shift for urinary elimination and to change foley catheter drainage bag as needed and every month, starting on the 1st (of the month), and check position of leg strap/anchor each shift for placement.

A Minimum Data Set assessment (MDS - a federally mandated standardized assessment process conducted periodically to plan resident care) dated December 5, 2023, Section H0100 Appliances revealed that Resident 129 had an indwelling catheter.

A physician order initiated on February 1, 2023, was noted to change foley irrigation set to irrigate every dayshift.

Resident 129's care plan dated December 15, 2023, noted that the resident had an indwelling catheter related to obstruction with interventions to irrigate foley catheter as ordered by physician, foley flush and care as ordered and as needed, measure urinary output as ordered, monitor urine characteristics, cover foley with dignity bag, monitor resident for pain as per physician orders, and resident occasionally puts cath \ bag on floor, re-educate as needed.

Neither the physician order nor care plan identified the catheter size to be used.

An observation of Resident 129's, in the resident's room, B219, on February 7, 2024, at 9:05 AM revealed that the resident's urinary catheter drainage leg bag was hanging over the assist grab bar in the resident's bathroom. A yellow urine-like substance was visible in the bag.

During an interview on February 7, 2024, at 9:15 AM Employee 14, a Licensed Practical Nurse (LPN), indicated that the catheter drainage bag should not be hanging from the resident's assist bar. Employee 14, LPN, explained that the drainage bag should be cleaned, put in a plastic bag, and stored in the resident's bottom bedside dresser.

During an interview on February 9, 2024, at approximately 12:30 PM, the Director of Nursing (DON) confirmed that the facility failed to clarify Resident 129's orders and care plan for the resident's catheter use and failed to ensure the consistent care in a manner to prevent potential complications.


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








 Plan of Correction - To be completed: 04/09/2024

Resident # 129 was assessed by registered nurse for adverse effects related to the catheter care. order and care plan was updated to include catheter size.

All residents with catheters residing in the facility at the time of the survey were reviewed and determined to be at risk for being affected by the alleged deficient practice.

Education provided by the DON to licensed nurses and CNAs on catheter care policies and documentation practices to prevent potential complications related to the use of indwelling catheters.

the DON or designee will observe residents to ensure bedside drainage bag is properly stored and will conduct a record review to ensure the MD order and care plan includes catheter size as follows: 4 residents per week for 4 weeks then 1 resident per week for 8 weeks.
Any trends identified will be reported during the monthly QAPI meeting. This plan of correction may be modified to address those trends as necessary.
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 clinical records, observation, and staff interview, it was determined that the facility failed to follow physician orders for oxygen therapy for two residents out of 30 sampled (Residents 9 and 40).

Findings include:

Clinical record review revealed that Resident 9 had a current physician's order, dated January 13, 2023, for continuous oxygen therapy administration via nasal cannula (flexible plastic tubing with small prongs inserted into the nostrils to deliver supplemental oxygen) at 3.0 liters per minute.

An observation conducted on February 6, at 6:50 PM revealed that Resident 9 was lying in bed with supplemental oxygen in place via an oxygen concentrator (bedside machine that concentrates ambient air to supply an oxygen-rich gas stream) with the liter flow set at 2.0 liters per minute. The resident's oxygen tubing was not dated.

Additional observation on February 7, 2024, at 9:10 AM revealed Resident 9 was lying in bed with supplemental oxygen tubing in place via an oxygen concentrator with the liter flow set at 2.0 liters per minute. The resident's oxygen tubing was not dated.

Interview with Employee 13 (RN Supervisor) on February 7, 2024, at 9:20 AM confirmed that resident 9 was prescribed 3.0 liters of oxygen continuously, but the resident was currently receiving 2.0 liters per minute. Employee 7 confirmed Resident 9's oxygen tubing was not dated.

Clinical record review revealed that Resident 40 had a current physician's order, initially dated December 5, 2021, for continuous oxygen therapy administration via nasal cannula at 2.0 liters per minute.

An observation conducted on February 6, 2024, at 8:00 PM, and on February 7, 2024, at 1:30 PM revealed that Resident 40 was lying in bed with supplemental oxygen in place via an oxygen concentrator with the liter flow set at 3.0 liters per minute. The oxygen tubing was not dated.

Interview with Employee 4 (licensed practical nurse) on February 7, 2024, at 1:30 PM confirmed that Resident 40 was prescribed 2.0 liters per minute of oxygen continuously, but the resident was currently receiving 3.0 liters per minute.

Interview with Nursing Home Administrator on February 9, 2024, at 8:25 AM confirmed the facility failed to follow physician orders for the administration of oxygen.


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











 Plan of Correction - To be completed: 04/09/2024

Residents # 39 & # 40 were both assessed for adverse effects of the oxygen administration by registered/licensed nursing staff. Oxygen was corrected to flow per order. The tubing was changed and dated and physician was notified.

All residents were reviewed and those who receive oxygen were identified as at risk for being affected by this alleged deficient practice.
All like residents whom receive O2 were observed and assessed for any alteration in oxygen regime per order all tubing was checked for proper date, physician were notified of any issues.

Education was provided by DON/designee to all registered and licensed nurses, on proper oxygen use per order, and policy on maintain oxygen equipment.

DON or designee will observe residents who received oxygen therapy to ensure proper administration and the record will be reviewed to ensure the order includes all necessary components as follows: 5 residents per week for 4 week.

Any trends identified will be reported that the monthly QAPI meeting. This plan of correction may be modified to address those trends as necessary.
483.40(b)(1) REQUIREMENT Treatment/Srvcs Mental/Psychoscial Concerns: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(b) Based on the comprehensive assessment of a resident, the facility must ensure that-
483.40(b)(1)
A resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder, receives appropriate treatment and services to correct the assessed problem or to attain the highest practicable mental and psychosocial well-being;
Observations:


Based on clinical record reviews and staff interviews, it was determined that the facility failed to provide the necessary treatment and services for a resident displaying a mental disorder to promote the resident's highest practicable mental and psychosocial well being for one resident out of 30 sampled.


Findings included:

Clinical record review revealed that Resident 198 was admitted to the facility on December 28, 2023, with diagnoses of dementia, alcohol abuse with unspecified alcohol induced disorder, anxiety and Wernicke's encephalopathy (Wernicke-Korsakoff syndrome is an unusual type of memory disorder due to a lack of thiamin (vitamin B1) requiring immediate treatment).

A review of an admission Minimum Data Set assessment (MDS, is part of the U.S. federally mandated process for clinical assessment of all residents in Medicare or Medicaid certified nursing homes) dated January 4, 2024, revealed Resident A1 was moderately cognitively impaired with a BIMS score of 8 ( BIMS a test administered to all residents in skilled nursing facilities to assess patient cognitive patterns, behavior, and mood, a score of 8-12 suggests moderate cognitive impairment) and required staff assistance with activities of daily living.

A review of the resident's care plan revealed that Resident 198 has potential to exhibit physical
and verbal aggression toward others and that the resident may seek unwanted sexual contact with other female residents (kissing), initiated January 2, 2024

Nursing documentation from the time of the resident's admission December 28, 2023, through the time of the survey ending February 9, 2024, revealed that Resident 198 displayed confrontational, threatening, disruptive, aggressive, sexually inappropriate directed towards other residents and staff and intrusive wandering behaviors, mostly entering the rooms of female residents. The resident was receiving both Ativan .5 mg TID for anxiety and Depakote 125 mg, 3 tablets, TID for dementia during this time period.

A review of a facility investigation report dated January 19, 2024 at 5:30 P.M. revealed that Resident 198 became involved in a verbal altercation with Resident 137 in the dining room just prior to lunch. The argument escalated quickly and Resident 198 approached Resident 137 and placed is hands around her neck and said " I'm going to strangle you." Additional staff separated the residents.

A PA-C (physician assistant) note January 19, 2024, indicated that nursing reported that the resident had increasingly aggressive behaviors, both verbal and physical, towards other residents and staff on the unit. The resident was becoming increasingly aggressive toward another resident, thinking that the resident is the "man who killed my wife." Resident 198 quickly approaches that resident and threatens "I'm going to strangle the air out of you."
Resident 198 being transferred to the ER for unsolicited verbal threats against other residents and staff. Upon Resident 198's return from the emergency room, the resident's please Depakote was increased to 375 mg by mouth three times a day. The PA-C noted "Will continue to monitor patient's condition and provide supportive care."

A review of a nurses note dated February 7, 2024, at 11:30 AM revealed that "Called to the C1 unit by nursing staff. 198) became aggressive with NA (nurse aide) on the one-to-one watch, hitting the male nurse aide in the back when he attempted to prevent the resident from going after another female resident passing by him in the hallway. Resident was redirected and additional LPN and NAs intervened. NA denies needing medical interventions/treatment at this time. Resident 198 was educated on not being aggressive with staff or other residents. Ambulance called for transport to the hospital for psychiatric evaluation and treatment due to increased aggression towards staff and other residents."

A nurses note dated February 7, 2024 at 12:18 PM revealed that Resident 198 left facility to hospital via ambulance. He returned to the facility the dame day.

On February 7, 2024 Resident 198 was moved from the facility's locked dementia/memory care unit room D 114-1 to the recently created, all male behavioral unit, room C1-164-1.

A nurses note dated February 8, 2024 at 09:45 AM revealed "Pt left unit with his 1:1 observation staff member with him. While off the unit, resident attempted to head towards the exit, NA (nurse aide) redirected resident away from the exit. Resident became agitated and started to swing at NA (nurse aide). Attempted to redirect the resident back into the unit without success. Pt's responsible party (RP) in the building and witnessing the resident's behavior. The resident's sister attempted to redirect the resident unsuccessfully. RP gave consent to send resident to the hospital for evaluation and psychiatric consult for potential medication changes. The resident was transferred to the hospital."

A nurses note dated February 8, 2024 at 5 P.M. revealed that the resident returned to the faciltiy with a new order dated February 8, 2024, for Haloperidol ( an antipsychotic medication) Oral Tablet 1 MG, Give 1 mg by mouth two times a day related to dementia.

The facility failed to demonstrate the provision of necessary behavioral health services and
individualized approaches to care that addressed the assessed mental health and behavioral heath needs of this and resources available within the scope of the facility assessment and failed to show ongoing assessment as to whether the care approaches are meeting the emotional and psychosocial needs of the resident.

During an interview with the Director of Nursing on February 9, 2024, at 11:15 AM, she acknowledged that there was no documented evidence that the facility was actively addressing Resident 198's mental health needs and consistently implementing interventions to promote the resident's mental and psychosocial well-being.




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

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

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














 Plan of Correction - To be completed: 04/09/2024

Resident # 198 no longer resides at the facility.

All liked residents displaying a mental disorder will be offered service by social services department staff or designee. All like residents charts will be reviewed by social services/designee, to measure monitoring practices in place for behavior, personalized and resident specific interventions and effectiveness to ensure psychosocial needs are being met on the resident.

The DON or designee will provide education to social services and administrative nursing on the importance of offering and providing comprehensive mental health services, appropriate interventions and services. 5 like resident charts will be reviewed by Social Services/designee for necessary treatments/services to show they have been offered and in place, personalized, behavior monitoring and intervention effectiveness.
Any trends identified will be reported during the monthly QAPI meeting. This plan of correction maybe modified to address those trends as necessary.


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

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

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

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

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

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

Based on a review of clinical records and resident and staff interviews, it was determined that the facility failed to implement pharmacy procedures for accurately recording the administration of controlled drugs prescribed for one resident out of 30 sampled (Resident 48).

Findings include:

A review of the clinical record revealed that Resident 48 was admitted to the facility on November 30, 2023, with diagnosis to include pleural effusion (the accumulation of fluid in the area surrounding the lungs) and rheumatoid arthritis (a chronic autoimmune and inflammatory disease). An MDS assessment dated December 7, 2024, indicated that the resident was cognitively intact with a BIMS score of 12.

A physician order was noted January 29, 2024, at 9:00 PM, for Oxycodone HCL tablet 5 mg one 5.0 mg tablet by mouth two times a day for pain management.

During an interview on February 7, 2024, at 10:30 AM, Resident 48 stated that she had concerns about receiving her pain medication. Resident 48 stated that two weeks ago she did not receive her oxycodone (opioid) for pain. She stated that the facility nursing staff told her the pharmacy did not deliver the medication.

Resident 48's controlled drug record accounting for the resident's supply of Oxycodone 5 mg tablets revealed that 56 5 mg tablets were received by the facility on December 29, 2023. The controlled drug record indicated that staff administered the last dose to the resident on January 28, 2024, at 9:00 PM. An additional controlled drug record indicated that 28 oxycodone 5 mg tablets were received by the facility on February 1, 2024. The record indicated that staff administered a dose to the resident on February 1, 2024, at 9:00 AM.

A review of individual resident controlled substance administration records revealed no documented evidence that staff administered Oxycodone 5 mg tablets to the resident on January 29, 2024, January 30, 2024, or January 31, 2024, as ordered, which was confirmed during interview with the DON on February 8, 2024, at approximately 1:00 PM.


28 Pa. Code 211.5 (f) Clinical records

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

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








 Plan of Correction - To be completed: 04/09/2024

Resident # 48 was evaluated for pain by RN, no issues noted, physician notified of deviation of medication regimen.

All residents receiving controlled pain medication were identified as at risk for being affected by this alleged deficient practice.

Education was provided by the DON to licensed and registered nurses
on the procedures for re-ordering controlled pain medication, escalation of issues with reordering controlled pain medications and procedures for managing medications availability issues with controlled pain medication.

The DON or designee will monitor residents who receive controlled pain medication for availability issues as follows: 4 resident per week for 4 weeks, THEN 1 resident per week for 8 weeks.

Any trends identified will be reported during the monthly QAPI meeting. This plan of correction maybe modified to address those necessary trends.


483.60(d)(1)(2) REQUIREMENT Nutritive Value/Appear, Palatable/Prefer Temp:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.60(d) Food and drink
Each resident receives and the facility provides-

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

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

Based on observation, resident and staff interview, test tray results, and a review of select facility policy, it was determined that the facility failed to serve meals at safe and palatable temperatures.

The findings include:

According to the federal regulation 483.60(i)-(2) Food safety requirements - the definition of "Danger Zone", found under the Definitions section, is food temperatures above 41 degrees Fahrenheit and below 135 degrees Fahrenheit that allow rapid growth of pathogenic microorganisms that can cause foodborne illness.

Review of the current facility policy entitled "Temperatures" indicated that all hot food items must be held and served at a temperature of at least 135 degrees Fahrenheit and cold food items must be maintained at served at a temperature of 41 degrees Fahrenheit or below.

A test tray was performed on the D-unit on February 8, 2024, at 9:30 AM. Observation revealed that the first breakfast tray delivery cart arrived on the unit at 7:46 AM and nursing staff began passing the trays at at 7:50 AM. The second breakfast tray delivery cart arrived on the unit at 8:06 AM. The final tray was passed at 9:30 AM, a test tray was tested.

Acceptable temperature for hot foods should be >/= 135 degrees Fahrenheit and cold food should be
The test tray food temperatures results were as follows: omelet was at 98.6 degrees Fahrenheit, toast was at 86 degrees Fahrenheit, oatmeal was at 119 degrees Fahrenheit, and coffee was at 107.6 degrees Fahrenheit. Taste assessment of these food and beverages revealed that the foods and beverages were luke warm and not palatable at the temperatures served.

Interview with the Nursing Home Administrator on February 9, 2024, at 3:30 PM, confirmed that the above food and beverage temperatures were not served at palatable temperatures.






 Plan of Correction - To be completed: 04/09/2024

Facility can not retroactively correct alleged deficient practice.

A new process identified as all hands on deck dining will be implemented for the D Unit. This process will be announced five minutes before D wing is served.
the identified staff will be prompted to go to D wing and assist with tray service. The training will be done by CDM and RD.

Education will be done by the CDM and RD to dietary staff regarding service and temperatures.

Audits will be done by CDM/designee on D unit randomly on staggered meals times 4 days a week for 4 weeks. The audits will include test trays at the completed point of service as well as temperature monitoring.

Results of the audit will be discussed/reported by the CDM/ or RD at the QAPI meetings and if necessary address and update plan of correction to address trends.
205.25(b) LICENSURE Kitchen.:State only Deficiency.
(b) A service pantry shall be provided for each nursing unit. The pantry shall contain a refrigerator, device for heating food, sink, counter and cabinets. For existing facilities, a service pantry shall be provided for a nursing unit unless the kitchen is sufficiently close for practical needs and has been approved by the Department.
Observations:

Based on observation and interviews with staff and resident interviews it was determined that the facility failed to provide a device for heating food on four of four nursing units observed (B2, C1, C2, and D

Findings include:

A tour of the facility on February 6, 2024, at 7:25 p.m. revealed that there were no microwaves or devices for reheating foods present in the resident pantry/kitchenette areas on all units B2, C1, C2, and D.

During a Resident Council group meeting with nine cognitively intact and oriented residents on February 7, 2024, at 10:30 a.m., Residents 56, 63, 36, 6, 67, 49, and 111 stated that they were upset that the facility removed the microwaves from the pantry/kitchenette areas on their units and did not provide another method to reheat their food/beverages on their units.

Interview with the Nursing Home Administrator (NHA) on February 8, 2024, at 2:15 p.m., confirmed that microwaves were removed from the unit pantry/kitchenette areas.



 Plan of Correction - To be completed: 04/09/2024

The facility had replaced the microwaves back on the all units 2/7/2024. residents at the time of the surveyor's meeting, residents nor surveyors were not aware of the microwaves back in place.

During the the three days in between,
the facility did provide another method to heat up foods, there was a central microwave in the main dining room, if needed.

The facility needed the time to ensure the safety of the residents and create a new process for usage of microwaves in pantries.

During daily rounds by "ambassadors" microwave check has been added to the list when auditing the pantries.

The ambassadors do report at daily stand up the results of their rounds.

In addition the facility has purchase a "back up " microwave to be stored in the nursing supervisor office, in the event a microwave needs to be replaced.





211.12(i)(1) LICENSURE Nursing services.:State only Deficiency.
(1) Effective July 1, 2023, the total number of hours of general nursing care provided in each 24-hour period shall, when totaled for the entire facility, be a minimum of 2.87 hours of direct resident care for each resident.

Observations:

Based on a review of nurse staffing and resident census and staff interview, it was determined that the facility failed to consistently provide minimum general nursing care hours to each resident daily on one day out of 21 reviewed (February 2, 2024).

Findings include:

A review of the facility's weekly staffing records revealed that on the following dates the facility failed to provide minimum nurse staffing of 2.87 hours of general nursing care to each resident:

A review of the facility's calculated total nursing care hours per resident day for February 2, 2024, was at 393.05 total hours for a maximum resident census of 141 and the facility required 404.67 total hours for a maximum resident census of 141.

Further review of PPD for February 2, 2024, revealed that the facility provided 2.79 hours of direct nursing care and failed to provide the minimum of 2.87 hours of direct nursing care daily.

An interview with the Nursing Home Administrator (NHA) on February 9, 2024, at 1 PM, confirmed that the facility failed to provide the minimum of 2.87 hours of direct nursing care daily for each resident.






 Plan of Correction - To be completed: 04/09/2024

The facility can not retro corrected the alleged deficient practice.

The facility continues to staff at the state PPD requirement and the required resident to staff ratio.

The new nursing scheduler with return understanding, will be educated by Human resource director and Regional labor director, regarding tag 5630.

In addition a large 3'X3' signage will be placed in the schedulers office to act as a reference to state required ratios.

A new process where the nursing scheduler will now attend a labor meeting each morning, prior to daily stand up, with in attendance of the NHA, HR and Regional Labor Director/designee to review daily ration/ppd and review three days in advance of staffing needs.

The regional labor director/designee will review/ audit staffing ratio/ppd 5 x a week X4 weeks and then weekly x8 weeks.

The findings of the audits will be discussed /reviewed at the QAPI meetings.







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