Nursing Investigation Results -

Pennsylvania Department of Health
GREENERY CENTER FOR REHAB AND NURSING
Patient Care Inspection Results

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
GREENERY CENTER FOR REHAB AND NURSING
Inspection Results For:

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GREENERY CENTER FOR REHAB AND NURSING - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:
Based on a Medicare/Medicaid Recertification, State Licensure, Civil Rights Compliance and an Abbreviated Survey in response to a complaint, completed on September 27, 2019, it was determined that Greenery Center for Rehabilitation and Nursing, was not in compliance with the requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care Facilities and the 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.


 Plan of Correction:


483.25(d)(1)(2) REQUIREMENT Free of Accident Hazards/Supervision/Devices:This is the most serious deficiency although it is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one which places the resident in immediate jeopardy as it has caused (or is likely to cause) serious injury, harm, impairment, or death to a resident receiving care in the facility. Immediate corrective action is necessary when this deficiency is identified.
483.25(d) Accidents.
The facility must ensure that -
483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and

483.25(d)(2)Each resident receives adequate supervision and assistance devices to prevent accidents.
Observations:
Based on review of facility policies, clinical records and facility documents, and resident and staff interviews, it was determined that the facility failed to make certain that each resident's environment remained free of accident hazards regarding the facility's failure to accurately assess four of 14 residents who smoke (Resident R26, R31, R71 and R288) and failed to secure smoking materials for one of 4 residents (Resident R288) who ignited a trash can on two separate occasions, which placed the residents at a high risk for injury resulting in an Immediate Jeopardy situation.

Findings included:

Review of the facility policy "Resident Smoking" dated 6/28/19, indicated that residents will be permitted to smoke in designated areas on the outside of the facility, located in the enclosed courtyard, outside the main dining room. At no time will smoking be permitted inside the facility. Residents will be evaluated to determine whether they can safely smoke independently. If a resident is not able to smoke safely independently, they must have supervision of family or staff at set smoking times. Residents that cannot smoke independently must have their smoking items kept secured at the nurses' station. No resident is permitted to supervise another resident or give another resident smoking items.

Review of the facility admission packet provided to all residents on admission indicated in the Smoking Policy section, that all residents are prohibited from keeping any smoking material in their rooms or on their person.

Review of the facility policy "Resident Incident/Injury Investigation Protocol" dated 6/28/19, indicated that should a resident be involved in an incident/accident, an investigation will be started by the nurse on the shift. The shift supervisor will notify the physician and document in the clinical record shall include new interventions and following up with MD and notifying responsible party.

Review of the clinical record indicated that Resident R288 was admitted to the facility on 8/21/19, with diagnoses that included fracture of the lumbar spine, heart disease, Chronic Obstructive Pulmonary Disease-COPD (term used to describe progressive lung disease) and hyponatremia (low sodium).

Review of the Clinical Record for Resident R288 revealed the following progress notes:

-dated 9/9/19, at 5:30 a.m. Licensed Practical Nurse (LPN) documented, "Resident coughing, refused cough medication, out to courtyard to smoke."

-dated 9/18/19, at 2:19 a.m. LPN documented, "strong smell of smoke in the hall, when investigated found coming from this room, resident sitting on bedside, at first denied smoking in room, but after inquiring several times resident admitted that he did wake up and light a cigarette but realized where he was and immediately threw it in trash and dumped soda pop on it, bag removed from room with cigarette in it, resident refused to give lighter or smoking material to this nurse, supervisor notified, resident up and out to courtyard at this time."

-dated 9/20/19, at 12:30 a.m. LPN documented, "Strong odor of smoke detected in the hall, when investigated found partially smoked cigarette on the bedside table and smoldering tissues in the trash can beside bed, resident began snoring very loudly when nurse called name, refusing to acknowledge that this nurse and CNA are in room, trash liner taken from room as well as used cigarette, doused liner with water, called supervisor to room, resident continues to ignore staff when speaking to him, explained to resident that at this time he will need to obtain cigarettes from supervisor due to unsafe to have with him and that the two open packs on the table were being taken and put in the supervisors office, resident again not acknowledging that staff in room and snoring louder."

-dated 9/20/19, 4:06 a.m. LPN documented, "Resident in the hall yelling, Resident said police were called because staff took his smoking materials. Resident was reeducated on the incident of the trash liner being lit on fire. Resident was told for safety reasons that smoking materials were in supervisor's office."

-dated 9/20/19, 4:38 a.m. LPN documented, "Per supervisor smoking material returned to resident."

-dated 9/20/19, LPN documented, "Resident angry about floor nurse taking cigarettes. These were returned to him. Resident counseled about smoking in his room but was not listening. Was screaming that he/she did not have to talk."

During an observation on 9/24/19, at 2:08 p.m. Resident R288 was at the West Unit nurses' station with a lighter and cigarettes.

During observations on 9/24/19, at 2:09 p.m. and on 9/25/19, at 7:55 a.m. Resident R288 was seen walking through out the facility, unsupervised with a lighter and cigarettes.

During an observation on 9/24/19, at 2:18 p.m. the Assistant Director of Nursing Employee E1 confirmed that Resident R288 was in the courtyard with his smoking materials unsupervised.

Review of the clinical record did not include an assessment to determine Resident R288's ability to smoke safely.

Review of the Admission Nursing Data Collection Tool dated 8/21/19, revealed that Resident R288 was not oriented to facility's smoking policy.

Review of Resident R288's September 2019, recapitulation orders did not include a physician order to smoke.

Review of Resident R288's plan of care dated 9/20/19, indicated that Resident R288 was a smoker and was not safe to independently store smoking supplies, indicated that staff will explain/show where designated smoking areas are located, perform smoking assessment according to facility policy, and post smoking schedule for resident to refer to facility smoking times.

During an interview on 9/25/19, at 9:48 a.m. the Director of Nursing confirmed that the facility failed to provide Resident R288 with orientation of the facility's smoking policy, failed to assess Resident R288 for safe smoking behaviors or take action after smoking incidents occurred to secure Resident R288's smoking materials, and failed to investigate and develop a plan for safe smoking practice, which created the potential for harm of all residents placing the facility in an Immediate Jeopardy situation.

Review of the clinical record indicated that Resident R26 was admitted to the facility on 6/24/19, with diagnoses that included Anoxic (depletion of oxygen) brain damage, muscle weakness, dysphagia (difficulty swallowing), depression, pneumonia, unspecified convulsions, and high blood pressure.

Review of Resident R26's Acute Care Discharge Summary-Social History, indicated that resident smokes cigarettes. Discharge plan indicated that resident required maximum assistance for mobility and will need physical assistance for mobility.

Review of Resident R26's September 2019 Recapitulation orders did not include a physician's order to smoke.

Review of Resident R26's Admission Nursing Data Collection Tool dated 6/24/19, indicated that the facility did not orient resident to facility's smoking policy and the facility failed to identify Resident R26 as a smoker.

Review of Resident R26's "Smoking Risk Observation" dated 8/27/19, indicated that Resident R26 will be a supervised smoker due to inability to hold cigarettes. Staff will assist.

Review of Resident R26's care plan dated 8/27/19, indicated that resident is at risk for injury, is to be a supervised smoker, unable to handle cigarettes independently, indicated that staff will explain/show where designated smoking areas are located, perform smoking assessment according to facility policy, and post smoking schedule for resident to refer to facility smoking times.

During an interview on 9/25/19, at 9:48 a.m. Director of Nursing confirmed that the facility failed to identify Resident R26 as a smoker, assess resident for safe smoking behaviors on admission, provide an orientation of the facility smoking policy,and develop a resident-centered plan of care from admission on 6/24/19, until 8/27/19.

Review of the clinical record indicated that Resident R31 was readmitted to the facility on 4/20/16, with diagnoses that included muscle weakness, schizophrenia, spinal stenosis, and abnormal posture. The Quarterly MDS (Minimum Data Set-Assessment of residents current physical and mental needs) dated 7/4/19, indicated the diagnoses remained current.

Review of Resident R31's history of assessments completed since admission, indicated that the first smoking assessment was not completed until 8/9/19, to determine her ability to smoke safely.

Review of the current plan of care dated 8/16/19, indicated Resident R31 now required a smoking apron (fire resistant garment) while smoking.

During an interview on 9/24/19, at 9:25 a.m. Resident R31 indicated that she had dropped a cigarette and was not wearing an apron.

Review of the clinical record indicated that Resident R71 was admitted to the facility on 8/3/19, with diagnoses that included diabetes, femur (bone in upper leg) fracture, pressure ulcers, high blood pressure, muscle weakness, depression, and tobacco use.

Review of Resident R71's September 2019, recapitulation orders did not include a physician's order to smoke.

Review of the "Resident Smoking Policy" signed by Resident R71 on 8/3/19, indicated that all residents that wish to smoke they will be evaluated to determine if resident can safely smoke independently.

Review of Resident R71's "Smoking Risk Observation" dated 8/4/19, was incomplete. Information related to resident mobility, capability to follow facility safe smoking policy and clinical judgement-resident capable of supervised smoking was not completed.

Review of Resident R71's progress note dated 9/11/19, at 2:29 p.m. indicated that "resident was out in the courtyard smoking."

Review of Resident R71's progress notes dated 9/24/19, at 12:15 p.m. stated, "Resident was brought back into the facility from smoking when he was noticed to go unresponsive by a peer."

Review of Resident R71's care plan dated 8/3/19, indicated that resident is at risk for injury related to smoking. Resident R71's care plan related to smoking entailed resident will smoke in designated areas without occurrence of injury over next 90 days and the staff will explain/show designated smoking area as needed, perform smoking assessment according to facility policy, and post smoking schedule for resident to refer to facility smoking times.

During an interview on 9/25/19, at 9:48 a.m. the DON confirmed that all residents that wish to smoke are to be observed by staff for safe smoking practices, DON confirmed that Resident R71 was not observed or assessed for safety during smoking, which created the potential for an accident and/or injury.

On 9/25/19, 2:30 p.m. the Nursing Home Administer and the Director of Nursing were informed of Immediate Jeopardy at the facility and a request for a written Corrective Action Plan. The Corrective Action Plan was accepted on 9/25/19, at 6:26 p.m. and included the following:

1. After the issue was identified resident lighter and cigarettes were removed from possession and now receives from the nurse and returns when complete. Resident R288 had a smoking assessment completed and care plan was updated.

2. Current residents that smoke in the facility were assessed/reassessed for smoking safety by Assistant Director of Nursing (ADON).

3. Care plans were reviewed and revised. Point of Care in Matrix (computer charting system) to notify staff of smoking status and interventions.

4. The facility implemented a new smoking policy that all newly admitted residents will be supervised smoking only at designated smoking times, designated smoking areas, and may not have their smoking materials on their person.

5. Previously identified independent smoking residents will be able to maintain their smoking materials unless when re-assessed according to policy that they are no longer assessed to be able to smoke safely independently or they violate policy.

6. Current residents who smoke will be re-educated by Licensed Nursing Home Administrator on the new policy on 9/25/19.

7. Shift Supervisor is doing 15-minute checks on the designated smoking area's the courtyard and the ambulance entrance.

8. Current staff, included contracted staff, educated on the new policy/protocol beginning on 9/25/19, by the ADON. Staff not available will be educated on their return and newly hired staff will be educated during orientation.

9. Resident smoking assessments will be completed upon admission, quarterly, significant change, annually, and as needed. The shift supervisor or nursing staff member will supervise residents identified as needing assistance.

10. The Medical Director and QAPI Committee has been notified of the alleged Immediate Jeopardy and plan of action and the newly implemented smoking policy.

11. Residents' responsible parties/guardian will be informed of the newly implemented policy by mail. Newly admitted residents/responsible parties will be notified on admission.

During observations of the smoking areas (courtyard and ambulance entrance) on 9/27/19, at 6:45 a.m., 7:00 a.m., 7:10 a.m., 8:00 a.m., 8:15 a.m., 8:18 a.m., 9:00 a.m., 9:30 a.m., 9:50 a.m., and 9:55 a.m. Residents R31, R81, R83, and R294 were observed in the courtyard wearing smoking aprons and being supervised by facility staff. There were no observations of Resident R7, who smoked at the ambulance entrance, because the resident had not yet awakened.

During interviews on 9/27/19, at 7:15 a.m. and 8:20 a.m. Registered Nurse (RN) Employee E7, RN Employee E8, Nurse Aide (NA) Employee E9, and NA Employee E10 confirmed being educated on the facility smoking policy and were knowledgeable about the new procedure.

A review of the documentation received from the facility on 9/27/19, revealed that re-education on the smoking policy was provided to all facility staff, families and residents, and audits were conducted of the smoking areas as per the facility's action plan.

The Immediate Jeopardy was lifted on 9/27/19, at 12:45 p.m. when the action plan implementation was verified.

28 Pa. Code 201.14(a) Responsibility of licensee.
Previously cited 8/11/17.

28 Pa. Code 201.18(b)(1)(3) Management.
Previously cited 8/11/17.

28 Pa. Code 201.18(e)(1) Management.
Previously cited 10/15/18, 8/11/17.

28 Pa. Code 207.2(a) Administrator's responsibility.
Previously cited 8/11/17.

28 Pa Code 211.5(f) Clinical records.
Previously cited 8/11/17.

28 Pa. Code 211.10(a) Resident care policies.
Previously cited 8/11/17.

28 Pa. Code 211.10(b) Resident care policies.

28 Pa. Code 211.10(c)(d) Resident care policies.
Previously cited 6/25/19, 8/11/17.

28 Pa. Code 211.11(d) Resident care plan.

28 Pa. Code 211.12(d)(1)(5) Nursing services.
Previously cited 6/25/19, 8/11/17.

28 Pa. Code 211.12(d)(3) Nursing services.
Previously cited 8/11/17.


 Plan of Correction - To be completed: 11/15/2019

A directed inservice approved by DOH DKM consultants) reviewing F689 accidents and F684 Quality of care will be conducted for all staff on October 23,2019 at 7:30am and 3:30pm by an approved provider. A video recording will be made to be utilized for those who are unable to attend one of the live presentations. All current residents have been informed of the new smoking policy. All new admissions will only smoke during supervised smoking times. All smoking residents will have a smoking assessment completed upon admission or upon discovery that a resident has started smoking. We will continue to advise all new admissions of the necessity of supervised smoking times. Upon admission all smoking materials will be locked in the supervisor office. All new admission who smoke will be reviewed at morning meeting. DON/designee will review smoking resident's medical record and plan of care for proper documentation regarding the smoking policy acknowledgement and ensure that smoking materials are secured. Results of the chart audit will be presented to the QAPI committee, the QAPI committee will determine the need for continued monitoring.
483.25 REQUIREMENT Quality of Care: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 Quality of care
Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices.
Observations:
Based on review of facility policies, clinical records and facility specific documents, observation, and staff interviews, it was determined that the facility failed to evaluate and provide appropriate positioning device(s) to one of two residents in a persistent vegetative state which resulted in actual harm (a burn on the arm) to the resident (Resident R65) .

Findings include:

The facility policy "Resident Rights - Pennsylvania Law" dated 6/10/18, and last reviewed by the facility on 7/11/19, indicated that the policies of the facility set forth the rights of the resident which included being treated with consideration, respect, and full recognition of dignity and individuality in care for the necessary personal and social needs.

The facility policy "Screening, Rehabilitation" policy dated 6/10/18, and last reviewed by the facility on 7/11/19, indicated that a resident was referred for a rehabilitation screening for seating and positioning concerns.

The face sheet indicated that Resident R65 was admitted to the facility on 10/2/01, with diagnoses that included a motor vehicle accident that resulted in a traumatic brain injury, massive loss of blood, and a tracheostomy (surgically created opening in the throat to aide in breathing), and that since the head injury the resident has been non-verbal and in a persistent vegetative state (disorder of consciousness in which resident in state of partial arousal rather than true awareness of their surroundings).

Review of the Quarterly Minimum Data Set (MDS-periodic assessment of care needs) dated 9/29/18, included the same diagnoses and that Resident R65 had severe cognitive impairment, was totally dependent on at least two staff persons for transfers and bed mobility, and that the resident had impairment of both upper and lower extremities.

Review of nursing progress notes from 11/28/18 through 12/16/18, revealed multiple occasions that Resident R65 had purposeless movement (movement of body or extremities without voluntary purpose) of arms and fidgeted with sheets and gown.

Review of the annual MDS dated 12/16/18, indicated that Resident R65 continued to have severe cognitive impairment, was totally dependent on at least two staff persons for transfers and bed mobility, and that the resident had impairment of both upper and lower extremities.

Review of the care plan dated 12/16/18, indicated that Resident R65 was dependent on facility staff for all positioning needs and that the resident had no safety awareness.

Review of the nursing progress notes from 12/17/18, to 1/17/19, revealed several occasions that Resident R65 remained in a vegetative state and continued to have movements of his arms, such as digging hand into the mattress, grabbing, and pinching.

Review of ongoing physician orders originally dated 1/24/18, and last reviewed/dated by the physician on 1/3/19, indicated that Resident R65 was to be transferred out of bed to a geri-chair (large reclining chair with casters) three times a week (Monday, Wednesday, Friday) during the daylight shift.

Review of the clinical record indicated that Resident R65 was not evaluated by nursing or the rehabilitation department for positioning needs after the resident exhibited purposeless movements of his upper extremities from 11/28/18 through 1/17/19.

Review of a nursing progress note dated 1/18/19, revealed that "Resident (R65) was placed in geri-chair and sat outside of window....at 11:30 a.m. At 12:15 p.m. resident needed to be repositioned due to arm resting over geri-chair...Assessed left arm resting on baseboard heater.... Silvadene applied after measurement of 1x2 cm (one by two centimeter) blister observed, surrounding tissue is red."

Review of a physician order dated 1/18/19, instructed the nursing staff to cleanse Resident R65's "left forearm burn with normal saline solution, dry, apply Silvadene (cream used to prevent burns from getting infected) to cover the affected area, cover with ABD (large) pad and kling (gauze wrap). Change daily and as needed."

Review of the facility incident investigation dated 1/18/19, indicated that Resident R65 sustained a burn when the resident's left arm was found resting on the heater, staff educated on safety and positioning, and a referral was made to therapy for positioning to prevent hand from sliding off the geri-chair.

Review of a nursing progress note dated 1/21/19, at 1:32 p.m. indicated that RN Employee E1 further assessed Resident R65's left arm wound and that "blister remains 1x1 cm (one by one centimeter), open skin measures 5x4x0.1 cm (five by four by 0.1 centimeter) wound bed pink."

During an observation of Resident R65 on 9/24/19, at 1:05 p.m. there was a reddish colored scar on the resident's left forearm measuring 10 cm in length and 5.8 cm in width.

During an interview on 9/24/19, at 1:15 p.m. Licensed Practical Nurse confirmed that Resident R65 had sporadic movements of upper and lower extremities and that prior to the burn on 1/18/19, there were no specific instructions for safety positioning the resident's extremities when the resident was seated in the geri-chair.

During an interview on 9/25/19, at 2:40 p.m. the Nursing Home Administrator and the Director of Nursing confirmed that the facility failed to evaluate and provide appropriate positioning device(s) to Resident R65 which resulted in actual harm (a burn on the arm) to the resident.

42 CFR 483.25 Quality of Care.
Previously cited 6/25/19, 8/11/17.

28 Pa. Code 201.18(b)(1)(3) Management.
Previously cited 8/11/17.

28 Pa. Code 211.10(c)(d) Resident care policies.
Previously cited 6/25/19, 8/11/17.

28 Pa. Code 211.12(d)(1)(5) Nursing services.
Previously cited 6/25/19, 8/11/17.

28 Pa. Code 211.12(d)(3) Nursing services.
Previously cited 8/11/17.


 Plan of Correction - To be completed: 11/15/2019

A directed inservice approved by DOH (DKM Consulting) reviewing F684 Quality of Care and F689 Accidents , will be conducted for all staff on October 23, 2019 at 7:30am and 3:00pm by an approved provider. A video recording will be made to be utilized for those who are unable to attend one of the live presentations. Going forward, all residents in house will be observed for the need of positioning devices by the DON/designee. Devices will be ordered and obtained for those identified as needing positioning devices. All new admissions will be screened by therapy department for positioning devices. DON/designee will verify that proper positioning devices are being utilized weekly times 1 month then bi-weekly times one month, Results of monitoring will be reported to the QAPI committee, QAPI committee will determine the need for continued monitoring.
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 review of facility policy, observations and staff interview it was determined that the facility failed to properly label, date and store food products and maintain equipment in proper operating and sanitary condition in the Main Kitchen.

Finding include:

Review of facility policy "Food Storage" dated 6/28/19, indicated that food will be stored in an area that is clean, dry and free from contaminants, food will be stored on shelves and off the floor, will be stored a minimum of six inches off the floor. Food items will be stored in covered containers or wrap carefully carefully and secured. All refrigerator units will be kept clean and in good working condition.

During an observation of the Main Kitchen on 9/23/19 from 7:41 a. m. through 8:14 a.m. the following was observed:

Walk in cooler contained:
-milk crates stored directly on the floor.
-container of unidentified unlabeled, cooked food.
-block of butter open on shelf.
-On a shelve below the cooler piping was a bucket collection water that was dripping from the piping. A box of food below the bucket was damp and discolored.

Walk in freezer contained:
-four boxes stored directly on the floor.
-several pie crust boxes that were broken opened and crushed.

Milk cooler contained:
-several broken single serve creamers and debris on the bottom.

Scoops were stored in the bulk flour and food thickener containers, laying on top of the powders.

During an interview on 9/23/19, at 8:15 a.m. Certified Dietary Manager Employee E15 confirmed that the facility failed to label, date and store food products in a sanitary manner, maintain equipment in proper operating condition and a clean sanitary manner which created the potential for cross contamination.

28 Pa Code: 211.6(c)Dietary services

28 Pa Code: 211.6(d) Dietary services

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


 Plan of Correction - To be completed: 11/15/2019

No residents were affected due to the findings in the kitchen. The facility immediately discarded unlabeled and undated food, and removed the scoops from bulk containers. Food items below the dripping pipe was discarded. Milk cooler was cleaned. All boxes and containers were raised off the floor. Going forward the facility will properly label, date, and store food products and maintain equipment in proper operating and sanitary conditions in the main kitchen. Dietary staff will be inserviced on proper food storage and labeling by the dietary supervisor. The morning and evening cooks will check the cooler, freezer, bulk storage containers and milk coolers at the end of their shift to ensure sanitary conditions in the kitchen. We will contact a refrigerator company to assess the dripping pipe in the cooler and follow recommendations.
Result will be reported to the QAPI committee, QAPI committee will determine the need for continual monitoring.
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 interviews, it was determined that the facility failed to maintain a safe and homelike environment on two of four nursing units (North/Juniper and South/Spruce nursing units).

Findings include:

During observations on the North/Juniper nursing unit on 9/23/19, from 7:20 a.m. to 8:45 a.m. and on 9/24/19, from 9:30 a.m. to 9:50 a.m. and at 2:30 p.m. the following was observed:

-There were black streak marks across the doors of resident rooms 101, 102, 103, 104, 105, 106, 107, 108, 109, 110, 111, 112 and 121.
-The paint on the door frames of resident rooms 101, 102, 103, 104, 105, 106, 107, 108, 109, 110, 11, 112 were chipped and/or marked with black streaks.
-The inner edge of the wooden door to resident room 105 was chipped/splintered.
-The piece of vinyl that was on the lower part of the doors to resident rooms 102 and 105 was pulling away from the door.

During observations of the North/Juniper nursing unit shower room on 9/23/19, at 7:20 a.m. and at 12:25 p.m. and on 9/24/19, at 2:30 p.m. the following was observed:
-There were two buckets from bedside commodes that were sitting atop the seat of the toilet. There was a dried, brown substance on the outer part of one of the bucket and inside the other bucket.
-There were nine two inch x two inch (2x2 inch) ceramic floor tiles missing of the floor of shower stall #1 and there were three pieces of 2x2 inch ceramic floor tiles not affixed to the floor.
-There was a piece of 4x4 inch tile missing from the left side of shower stall #2.
-There was yellow "caution" tape wrapped around the faucets in shower stall #3.
-There was a piece of ceramic tile missing from the outer corner of the wall on the left side of the toilet room.
-The was a section of the wall in the cross over area (hallway between the North and South nursing units) that was protruding out.

During interviews on 9/24/19, at 2:30 p.m. and on 9/26/19, at 8:20 a.m. the Nursing Home Administrator and Maintenance Director Employee E 5 confirmed that the facility failed to maintain a safe and homelike environment for the residents who reside on the North/Juniper nursing unit.

During an observation of the South/Spruce shower room on 9/23/19, at 7:00 a.m. the following was observed:
- The second shower stall had three used razors sitting on shelf and two wound bandages on the wall, there was white grime along the floor and wall areas.
-A large bottle of bath wash was sitting in stall three with no resident name.
-A can of shaving cream was on the sink with no resident name.
-A soiled mechanical lift was stored in the room
-A soiled shower chair was stored in the room.

During a second observation on 9/26/19, at 9:00 a.m. of the South/Spruce shower room the following was observed:
-A pile of soiled linens and towels were on the floor behind the door.
-A wound dressing was stuck to the wall in the second stall.

During an interview on 9/26/19, at 9:05 a.m. Nurse Aide Employee E6 confirmed the South/Spruce shower room was in need of cleaning.

28 Pa. Code 207.2(a) Administrator's responsibility.
Previously cited 8/11/17.


 Plan of Correction - To be completed: 11/15/2019

Maintenance will be educated on the importance of maintaining an homelike environment by the NHA.
An audit of doors on the 100 unit hallway will be done by the maintenance department. Maintenance
will repair and repaint affected resident doors and door frames. Going forward maintenance will check doors weekly and repair and repaint door frames as needed. Maintenance will log doors that are repaired or repainted weekly. The missing ceramic tiles will be repaired by the maintenance department. The bedside commode buckets, and shower chair have been cleaned, and caution tape was removed. The protruding section of wall in the cross area will be repaired by maintenance. On the South/Spruce unit the unmarked personal items have been discarded, lift has been cleaned, and is stored in the shower room when showers are not being given so as to not block emergency egress,linen removed, and bandages discarded. Nursing staff will be inserviced by DON/designee on the importance of labeling personal items and maintaining cleanliness of shower room. The charge nurse will monitor the cleanliness of the shower room daily for one month then twice a week for month. Both maintenance and Nursing will report findings of their monitoring to the QAPI committee. QAPI committee will determine the need for continued monitoring.
483.24(a)(2) REQUIREMENT ADL Care Provided for Dependent Residents: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.
483.24(a)(2) A resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene;
Observations:
Based on resident interviews, clinical record reviews and staff interviews, it was determined that the facility failed to provide Activities of Daily Living (ADL) assistance with showers for 12 of 22 residents (Residents R7, R31, R37, R54, R65, R45, R48, R53, R500, R501, R504 and R506).

Findings include:

During a resident group interview on 9/24/19, 2:00 p.m. Residents R500, R501, and R504 revealed that is difficult to get showers. R501 revealed if you need help to shower you have to wait until there is enough staff to help, Resident R500 and R504, agreed and stated that sometimes you may miss the shower day. Resident R506 revealed that if you are a resident who is dependent for help it can be hard to get assistance.

During an interview on 9/23/19, at 11:46 a.m. Resident R7 stated that he is not getting help bathing regularly.

Review of Resident R7's ADL- shower documentation indicated that from 6/26/19, through 9/26/19, Resident R7 has not had any showers.

During an interview on 9/26/19, at 10:49 a.m. Resident R31 stated that until Tuesday (9/24/19), she had not had a shower and her hair washed for two weeks.

Review of Resident R31's ADL- shower documentation indicated that from 6/25/19, through 9/26/19, Resident R31 had two showers.

Review of Resident R37's ADL-shower documentation indicated that from 6/25/19, through 9/26/19, Resident R37 had four showers.

Review of Resident R54's ADL-shower documentation indicated that from 6/26/19, through 9/26/19, Resident R54 had one shower.

Review of Resident R65's ADL-shower documentation indicated that from 6/29/19, through 9/26/19, Resident R65 had two showers.

Review of Resident R45's ADL-shower documentation indicated that from 6/26/19, through 9/26/19, Resident R45 had one shower.

Review of Resident R48's ADL-shower documentation indicated that from 6/26/19, through 9/26/19, Resident R48 has not received any showers.

Review of Resident R53's ADL-shower doucmentation indicated that Resident R53 did not receive any showers.

During an interview on 9/26/19, at 11:45 a.m. the Director of Nursing confirmed that documentation did not indicate that showers had been being given, that the facility failed to provide ADL care for dependent residents.

28 Pa. Code: 211.10(c)(d) Resident care policies.
Previously cited 6/25/19 and 8/11/17

28 Pa. Code: 211.10(a)Resident care policies.
Previously cited 8/11/17

28 Pa. Code: 211.12(d)(1)(5) Nursing services.
Previously cited 6/25/19 and 8/11/17

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


 Plan of Correction - To be completed: 11/15/2019

Nothing can be done regarding the previously missed showers. ADON will educate nursing staff on showers. Going forward, the 7-3 and 3-11 CNAs are given s list of showers to be given Monday through Saturday. The charge nurse on those shifts must collect the sheets and verify that the showers were given. The charge nurse will document when a shower is not given and the reason why the shower was not given. Missed showers will given per residents preference (next shift or next day). The charge nurse will monitor the showers daily for 1 month, then 2 times a week for month. Results of the monitoring will be reported to the QAPI committee, the QAPI will determine the need for continued monitoring.
483.10(f)(1)-(3)(8) REQUIREMENT Self-Determination: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(f) Self-determination.
The resident has the right to and the facility must promote and facilitate resident self-determination through support of resident choice, including but not limited to the rights specified in paragraphs (f)(1) through (11) of this section.

483.10(f)(1) The resident has a right to choose activities, schedules (including sleeping and waking times), health care and providers of health care services consistent with his or her interests, assessments, and plan of care and other applicable provisions of this part.

483.10(f)(2) The resident has a right to make choices about aspects of his or her life in the facility that are significant to the resident.

483.10(f)(3) The resident has a right to interact with members of the community and participate in community activities both inside and outside the facility.

483.10(f)(8) The resident has a right to participate in other activities, including social, religious, and community activities that do not interfere with the rights of other residents in the facility.
Observations:
Based on resident and staff interviews, clinical record and facility documentation reviews it was determined that the facility failed to promote resident self-determination and choice for when to get out of bed/receive assistance for two of 27 residents (Resident R7 and Resident R31).

Findings include:

The clinical record indicated Resident R7 was admitted to the facility on 3/12/19, with diagnosis of COPD, chronic pain syndrome, and adjustment disorder with anxiety. These diagnosis continued on the MDS (minimum data set - a brief periodic assessment of resident needs) dated 6/15/19, and included Resident R7 to have a BIMS (Brief Individual Mental Screen - a screen to show if residents are alert to date, time and place) of "15" that indicated alert and oriented.

Review of the facility "Grievance Log" for April 2019, revealed a grievance submitted on 4/15/19, for a call bell not being answered timely and Resident R7 not receiving assistance in a timely manner.

During an interview on 4/23/19, at 11:36 a.m. Resident R7 stated that it can be hard to get help getting out of the bed. Resident R7 stated that often staff are busy and can't assist until later than preferred.

Review of the clinical record "progress notes" dated 9/24/19, at 2:16 p.m. Resident R7 wanted to get out of bed and was "re-directed" due to facility having "other residents" needs to meet as well.

During an interview on 9/27/19, at 1:01 p.m. the Director of Nursing confirmed that the facility failed to promote Resident R7 self-determination/choices.

Review of the clinical record indicated that Resident R31 was re-admitted to the facility on 12/22/17, with diagnoses that included cellulitis of Right leg, spinal stenosis, schizophrenia, COPD, and polyneuropathy.

During an interview on 9/26/19, at 10:49 a.m. Resident R31 stated that staff make her get up and go to bed at specific times because they do not have enough help and she requires two and the lift. Resident R31 stated that she is only able to have two cigarettes a day because of the time they get her up. She stated that there have been times when she would not get out of bed until 2:00 p.m. because staff were so busy.

During an interview on 9/26/19, at 11:15 a.m. the Director of Nursing (DON) confirmed that the facility failed to promote self determination and choices.

28 Pa. Code 201.29(j) Resident rights.
Previously cited 8/11/17.


 Plan of Correction - To be completed: 11/15/2019

Both R7 and R31 will be schedule for a care planning conference. They will asked their preference for time to get out of bed. Nursing staff will be educated on resident choices and will be instructed to get residents out of bed as soon as practicable. An audit will be conducted with other residents to determine OOB preference. Staff will try to meet resident's choice whenever possible. (Consideration must be given to emergency situations and residents who may have out of facility MD appts., dialysis appts. ETC...)
Staff will also be educated on answering call lights within a timely manner. Nursing supervisor will check with R7 and 4 residents from each unit twice a week for 1 month, then weekly for 1 month, and document resident's response regarding call lights and timeliness (less than 10 minutes) of staff. Results will be reported to the QAPI committee, the QAPI committee will determine the need for continued monitoring.
483.80(a)(1)(2)(4)(e)(f) REQUIREMENT Infection Prevention & Control:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.80 Infection Control
The facility must establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections.

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

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

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

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

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

483.80(f) Annual review.
The facility will conduct an annual review of its IPCP and update their program, as necessary.
Observations:
Based on review of facility policies, observation and staff interviews, it was determined that the facility failed to provide a sanitary environment to prevent possible cross contamination during a dressing change for one of one residents (Resident R83).

Findings include:

The facility policy "Aseptic Dressing Change" last reviewed 6/26/19, indicated the procedure includes the following- any area used to set up aseptic field must be cleaned with disinfectant before and after each treatment. The policy indicated to perform hand washing and glove change after each step of the dressing change. Place all supplies that will be needed during the treatment on your clean field. If scissors are used during the treatment, wipe with alcohol or cleanse with soap and water prior to placing on the field. Position resident and place towel, water proof pads, or chux underneath area to be treated. Apply gloves and remove soiled dressing- do not place scissors on clean field after using. Cleanse reusable supplies and store per facility policy.

The facility policy "Hand Hygiene/Hand Washing" last reviewed 6/26/19, indicated that hands are to be washed before and after removal of gloves. Wash hands after contact with an object or source where there is a concentration of microorganisms such as mucous membranes, non-intact skin, body fluids or wounds.

During observation of a dressing change on 9/26/19, at 11:27 a.m. Licensed Practical Nurse (LPN) Employee E2 prepared Resident R83 for a dressing change on the buttocks area. LPN Employee E2 placed clear bag on top of Resident R83's bed on top of the sheets and blankets. LPN Employee E2 failed to place a clean field under wound to protect residents bedding from contamination from the wound.

LPN Employee E2 with both gloved hands removed supplies from clean field, cleansed wound and went back to the clean field for other supplies with the same gloved hands.

LPN Employee E2 packed the wound and when complete LPN Employee E2 removed scissors from their scrub pocket, cutting extra packing material then placing scissors on the clean field. LPN Employee E2 then took other supplies from the clean field and place them on Resident R83's bed near buttocks wound, removed a marking pen from their pocket with the same gloved hands, labeled the dressing and placed the marker on the clean field and applied the new dressing. Removed gloves and took extra supplies from the bed and placed them on the clean field. LPN Employee E2 failed to perform hand washing.

LPN Employee E2 prepared Resident R83 for a dressing change of the left heel. LPN Employee E2 applied gloves, removed old dressing, LPN Employee E2 cleaned wound, removed supplies from clean field, placing supplies on the bed. Obtained packing gauze from clean field, packed resident left foot wound, when the packing was complete LPN Employee E2 used scissors from bed to cut the extra packing, placed scissors in pocket, returning the packing bottle to the clean field. LPN Employee E2 completed the dressing, removed gloves, gathered other supplies from the clean field placing them in the wound cart in the hall, then took trash bag to garbage in the hallway. LPN Employee E2 returned to wound cart and verbalized that treatment was complete for Resident R83 failed to return to Resident R83's room to sanitize table and failed to perform hand washing.

During an interview on 9/26/19, 11:51 a.m. LPN Employee E2 confirmed that proper infection control procedures were not maintained during the dressing change and created the potential for cross contamination.

28 Pa. Code: 201.14(a) Responsibility of licensee.
Previously cited 8/11/17

28 Pa. Code: 201.18(e)(1) Management.
Previously cited 10/15/18

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

28 Pa. Code: 201.20(c) Staff development.

28 Pa. Code: 211.10(d) Resident care policies.
Previously cited 8/11/17

28 Pa. Code: 211.12(d)(1)(2)(3)(5) Nursing services.
Previously cited 8/11/17


 Plan of Correction - To be completed: 11/15/2019

R#83 does not have any dressings or dressing orders. The ADON will inservice all licensed personnel on proper dressing changes to include hand washing to avoid cross contamination. The ADON will randomly monitor 3 different nurses performing dressing changes weekly for 1 month. Then 6 nurses a month for 1 month. Results of monitoring will be presented to the QAPI committee, the QAPI committee will determine the need for continual monitoring.
483.70(e)(1)-(3) REQUIREMENT Facility Assessment:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.70(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 review of the Facility Assessment, the facility failed to evaluate its resident population and identify the resources needed to provide the necessary care and services the residents required. The facility failed to assess the knowledge, skills , abilities, behaviors, and other characteristics needed to ensure the staff were able to perform work roles, to meet each residents, needs. The facility failed to identify harm situations and to implement potential changes. This failure resulted in actual harm to one residents (Resident R65) and placed the residents in an Immediate Jeopardy situation.

Findings include:

Review of the Facility Assessment tool dated 8/20/19, revealed the facility would determine what resources are necessary to care for the residents. The Facility Assessment further specifies the assessment tool aids to identify resident support/care needs.

Based on the findings of an annual Recertification and State Licensure survey, and an Abbreviated survey in response to a complaint, completed on 9/27/19, which identified areas of regulatory non-compliance including harm level deficiency, and Immediate Jeopardy, it was determined that the Nursing Home Administrator and the Director of Nursing failed to identify actual harm situations and constituted an Immediate Jeopardy situation.

Refer to F684 and F689.

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

28 Pa. Code 201.18(b)(1)Management.
Previously cited 8/11/17


 Plan of Correction - To be completed: 11/15/2019

NHA has reviewed and revised the facility assessment to include the new smoking policy. The resident involved in the smoking situation has had a smoking assessment completed and all his smoking materials locked in supervisors office. The resident has been placed on supervised smoking. The new smoking policy is presented to current smokers and all new admission who smoke. Going forward, all new admissions will be supervised smokers during designated times. Staff is assigned to each of the smoking times and supervise residents who are unable to smoke independently. All new admissions who smoke will have their medical record reviewed in morning meeting to ensure that a smoking assessment was completed. The facility assessment will be reviewed annually and up dated as needed. The facility assessment will be updated to include resident positioning. All residents will be assessed for positioning devices by DON/designee. New admissions will be screened by therapy for positioning devices. DON/designee will verify that positioning devices are being utilized weekly times one month then bi-weekly times one month. Monitoring will be reported to QAPI committee. QAPI committee will determine the need for continued monitoring. Annual updates of the facility assessment will be reviewed at the QAPI committee meeting.
483.70 REQUIREMENT Administration:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.70 Administration.
A facility must be administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident.
Observations:
Based on review of job descriptions, facility polices and clinical records, and staff interviews it was determined the the Nursing Home Administrator (NHA) and the Director of Nursing (DON) did not effectively manage the facility to make certain that the residents were protected from poor positioning/supervision resulting in a burn and failed to assess and implement safe storage of a lighter.

Findings include:

The job description for the NHA specified the primary purpose of the job position is to manage the Facility in accordance with current applicable federal, state, and local standards, guidelines and regulations that govern long term facilities.

The job description for the DON specified the purpose of the job position was to plan, organize, develop and direct the overall operation of the Nursing Service Department in accordance with current federal, state, and local standards, guidelines, and regulations that govern the facility.

Based on the findings in this report that identified that the facility failed to make certain residents were protected from poor positioning/supervision resulting in a burn and failed to assess and implement safe storage of a lighter. The NHA and DON failed to fulfill their essential job duties to ensure the the federal and state guidelines and regulations were followed, thereby placing the residents in harm with actual injury and an Immediate Jeopardy situation.

Refer to F689 and F684.

28 Pa. Code 201.14(a)Responsibility of licensee.
Previously cited 8/11/17.

28 Pa. Code 201.18(b)(1)(3)(e)(1)Management.
Previously cited 8/11/17.


 Plan of Correction - To be completed: 11/15/2019

The regional clinical Nurse Consultant will inservice the NHA and DON on their job descriptions and responsibility of managing the facility with current applicable federal, state, and local standards, guidelines and regulations. Quarterly QAPI minutes will be sent to the regional clinical nurse for review, Quarterly times 2 quarters, then randomly at his request. NHA/DON will continue to notify Governing Body of reportable incidents according to quick response criteria. Inservicing and monitoring will be reported to the QAPI committee. QAPI committee will determine the need for continued monitoring.
483.45(g)(h)(1)(2) REQUIREMENT Label/Store Drugs and Biologicals:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.45(g) Labeling of Drugs and Biologicals
Drugs and biologicals used in the facility must be labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable.

483.45(h) Storage of Drugs and Biologicals

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

483.45(h)(2) The facility must provide separately locked, permanently affixed compartments for storage of controlled drugs listed in Schedule II of the Comprehensive Drug Abuse Prevention and Control Act of 1976 and other drugs subject to abuse, except when the facility uses single unit package drug distribution systems in which the quantity stored is minimal and a missing dose can be readily detected.
Observations:
Based on facility policy review, observations and staff interviews, it was determined that the facility failed to maintain a secure environment for medication storage on one of three nursing units (West nursing unit).

Findings include:

The facility policy "Medication Use: Medication storage" dated 7/11/19, indicated that the facility store medications in a manner in accordance with Department of Health guidelines.

During an observation on 9/24/19, at 1:48 p.m. on the West Nursing Unit, Licensed Practical Nurse (LPN) Employee E2 handed keys to the West Unit Medication Room to Nurse Aide Employee E14 who enter the medication room unattended to access supplies.

During an interview on 9/24/19, at 1:50 p.m. LPN Employee E2 confirmed that the facility failed to maintain a secure environment for medication storage by giving access to unlicensed staff.

28 Pa. Code: 211.9(b) Pharmacy services.


 Plan of Correction - To be completed: 11/15/2019

The refrigerator containing ensure has been moved to an unsecured area. Licensed and CNA staff will be inserviced by DON/designee on the importance of medication room keys being held by a licensed nurse at all times. The DON/designee will randomly observe the medication room for non-licensed personnel and report findings to QAPI committee, QAPI committee will determine the need for continued monitoring.
483.20(b)(1)(2)(i)(iii) REQUIREMENT Comprehensive Assessments & Timing:Least serious deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency has the potential for causing no more than a minor negative impact on the resident.
483.20 Resident Assessment
The facility must conduct initially and periodically a comprehensive, accurate, standardized reproducible assessment of each resident's functional capacity.

483.20(b) Comprehensive Assessments
483.20(b)(1) Resident Assessment Instrument. A facility must make a comprehensive assessment of a resident's needs, strengths, goals, life history and preferences, using the resident assessment instrument (RAI) specified by CMS. The assessment must include at least the following:
(i) Identification and demographic information
(ii) Customary routine.
(iii) Cognitive patterns.
(iv) Communication.
(v) Vision.
(vi) Mood and behavior patterns.
(vii) Psychological well-being.
(viii) Physical functioning and structural problems.
(ix) Continence.
(x) Disease diagnosis and health conditions.
(xi) Dental and nutritional status.
(xii) Skin Conditions.
(xiii) Activity pursuit.
(xiv) Medications.
(xv) Special treatments and procedures.
(xvi) Discharge planning.
(xvii) Documentation of summary information regarding the additional assessment performed on the care areas triggered by the completion of the Minimum Data Set (MDS).
(xviii) Documentation of participation in assessment. The assessment process must include direct observation and communication with the resident, as well as communication with licensed and nonlicensed direct care staff members on all shifts.

483.20(b)(2) When required. Subject to the timeframes prescribed in 413.343(b) of this chapter, a facility must conduct a comprehensive assessment of a resident in accordance with the timeframes specified in paragraphs (b)(2)(i) through (iii) of this section. The timeframes prescribed in 413.343(b) of this chapter do not apply to CAHs.
(i) Within 14 calendar days after admission, excluding readmissions in which there is no significant change in the resident's physical or mental condition. (For purposes of this section, "readmission" means a return to the facility following a temporary absence for hospitalization or therapeutic leave.)
(iii)Not less than once every 12 months.
Observations:

Based on review of the Resident Assessment Instrument User's Manual and clinical records, and staff interview, it was determined that the facility failed to make certain that comprehensive admission Minimum Data Set assessments were completed in the required time frame for one of 29 residents (Resident R145).

Findings include:

The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which provides instructions and guidelines for completing required Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2017, indicated that an admission MDS assessment was to be completed no later than 14 days following admission.

The Face Sheet indicated that Resident R145 was admitted to the facility on 8/25/19, with diagnoses that included Parkinson's disease (a disease of the nervous system) and dementia.

The Admission Minimum Data Set (MDS-periodic assessment of care needs) for Resident R145 was dated as completed on 9/26/19, 32 days after admission.

During an interview on 9/27/19, at 10:05 a.m. Licensed Practical Nurse Assessment Coordinator confirmed that the facility failed to make certain that the comprehensive admission MDS assessment for Resident R145 was completed in the required time frame.

42 CFR 483.20(b)(1)(2)(i)(iii) Comprehensive Assessments & Timing.

28 Pa. Code: 211.5(f) Clinical records.
Previously cited 8/11/17.


 Plan of Correction - To be completed: 11/15/2019

I hereby acknowledge the CMS 2567-A, issued to GREENERY CENTER FOR REHAB AND NURSING for the survey ending 09/27/2019, AND attest that all deficiencies listed on the form will be corrected in a timely manner.
211.9(g) LICENSURE Pharmacy services.:State only Deficiency.
(g) If over-the-counter drugs are maintained in the facility, they shall bear the original label and shall have the name of the resident on the label of the container. The charge nurse may record a resident's name on the nonprescription label. The use of nonprescription drugs shall be limited by quantity and category according to the needs of the resident. Facility policies shall indicate the procedure for handling and billing of nonprescription drugs.
Observations:
Based on facility policy review, observations and staff interviews, it was determined that the facility failed to consistently label bottles of over-the-counter medications with the names of the residents for whom the medications were ordered on two of three nursing units (West/Evergreen and North/Juniper nursing units).

Findings include:

The facility policy "Medication Dispensing: OTC Stock List" dated 7/11/19, indicated that the facility maintained a bulk supply of over the counter (OTC) medications that were stored in accordance with applicable law and State operations and that a list was maintained of residents using OTC medications.

During an observation of the West/Evergreen unit medication cart on 9/24/19, at 11:20 a.m. there were opened bottles of OTC medications without names of residents on them. The bottles included Senna tablets, Senna plus tablets, Loperamide tablets (anti-diarrheal), Calcium +Vitamin D, Acetaminophen tablets, Aspirin tablets, Aleve tablets, Multiple vitamin tablets, Vitamin B12 tablets, Calcium carbonate (TUMS) tablets, Melatonin capsules, Ranitidine (antacid) tablets, Colace (stool softener) tablets, Folic acid tablets, Bisacodyl (laxative) tablets, multiple vitamins plus iron tablets, Ferrous sulfate tablets, Vitamin B-complex tablets, Vitamin B1 (Thiamin) tablets and Vitamin C tablets.

During an interview on 9/24/19, at 11:30 a.m. Licensed Practical Nurse (LPN) Employee E2 confirmed that the facility failed to consistently label bottles of OTC medications with the names of the residents for whom the medications were ordered on the West/Evergreen nursing unit.

During an observation of the North/Juniper unit Team One medication cart on 9/24/19, at 12:45 p.m. there were opened bottles of OTC medications without names of residents on them. The bottles included Ranitidine tablets, Omeprazole (antacid) tablets and Senna plus tablets.

During an interview on 9/24/19, at 12:50 p.m. LPN Employee E3 confirmed that the facility failed to consistently label bottles of OTC medications with the names of the residents for whom the medication were ordered on the North/Juniper nursing unit.


 Plan of Correction - To be completed: 11/15/2019

All opened over the counter medication bottles will be labeled with resident names. The DON/designee will inservice the licensed staff on proper labeling of opened over the counter medications. Whenever a new bottle is opened, the license staff will be educated on writing resident names who are ordered the medication on the medication bottle. The 11-7 supervisor will monitor the over the counter stock medication bottles on all units weekly times 1 month, then bi-weekly times 1 month. Results of the monitoring will be reported to the QAPI committee, the QAPI committee will determine the need for continued monitoring.
211.12(i) LICENSURE Nursing services.:State only Deficiency.
(i) A minimum number of general nursing care hours shall be provided for each 24-hour period. 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 2.7 hours of direct resident care for each resident.
Observations:
Based on review of nursing time schedules and staff interview, it was determined that the facility failed to provide the minimum number of general nursing hours for each resident in a 24-hour period on three of 28 days reviewed (8/10/19, 8/11/19, and 8/17/19).

Findings include:

A review of time schedules for the periods of 12/30/18, through 1/5/19, 8/419, through 8/17/19, and 9/18/19, through 9/24/19, indicated that the facility failed to maintain 2.7 hours of general nursing care for each resident, in a 24-hour period as required on the following dates:

8/10/19 - 2.65 hours
8/11/19 - 2.68 hours
8/17/19 - 2.55 hours

During an interview on 9/27/19, at 10:00 a.m. the Director of Nursing confirmed that the facility failed to provide the required general nursing hours on the above noted dates.


 Plan of Correction - To be completed: 11/15/2019

Nothing can be done to rectify past Nursing Care Hours. The facility will schedule a minimum of 2.7 Nursing Care Hours per day. The scheduler will notify the DON/designee of projected daily Nursing Care Hours. The hours will be reviewed at morning meeting (M-F). Adjustments will be made to hours as needed to ensure 2.7 hours are scheduled. RN Supervisors and scheduler will be educated on minimum Nursing care hours of 2.7 and steps to be taken to replace call-offs or no shows by the DON/ADON. The DON/ADON will continue to monitor Nursing Care Hours on a daily basis (M-F) and report findings to QAPI committee.

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