Nursing Investigation Results -

Pennsylvania Department of Health
MEYERSDALE HEALTHCARE AND REHABILITATION CENTER
Patient Care Inspection Results

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
MEYERSDALE HEALTHCARE AND REHABILITATION CENTER
Inspection Results For:

There are  61 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.
MEYERSDALE HEALTHCARE AND REHABILITATION CENTER - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on a Medicare/Medicaid Recertification survey, State Licensure survey, Civil Rights Compliance survey, and a complaint survey completed on December 20, 2019, it was determined that Meyersdale Healthcare and Rehabilitation Center was not in compliance with the following requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care Facilities and the 28 Pa. Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.












 Plan of Correction:


483.10(f)(1)-(3)(8) REQUIREMENT Self-Determination:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
483.10(f) 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 review of policies and clinical records, as well as resident and staff interviews, it was determined that the facility failed to honor the resident's right to make choices about activities and aspects of the their lives that were important to them for one of 36 residents reviewed (Resident 53).

Findings include:

The facility's policy regarding smoking, dated October 24, 2019, indicated that the facility would establish and maintain safe resident smoking practices. Residents were to be evaluated prior to or upon admission to determine their smoking status, and an active smoker would be evaluated to determine if he/she was able to smoke independently or required the supervision of staff.

A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 53, dated November 26, 2019, indicated that the resident was understood, could understand, was moderately cognitively impaired, required assistance with multiple daily care tasks, and required supervision for locomotion on unit and off the unit, toileting, eating, and personal hygiene. A comprehensive admission MDS assessment dated June 7, 2019, indicated that it was very important for the resident to participate in his favorite activities.

A nursing note, dated September 11, 2019, at 5:58 p.m. revealed that Resident 53 came to the nursing station with his pipe in his mouth and he had a lighter and tobacco in his hand. The resident gave his smoking supplies to the nurse, was educated about the smoking policy, and the physician was notified. A nursing note dated September 12, 2019, at 1:35 p.m. revealed that the physician would not give the resident an order to smoke.

During a meeting with a group of residents on December 18, 2019, at 1:30 p.m., Resident 53 stated that he wanted to smoke his pipe, but his pipe and tobacco were taken away from him.

Interview with Registered Nurse 5 on December 19 , 2019, at 3:25 p.m. revealed that Resident 53 used to smoke but does not anymore.

Interview with Director of Nursing on December 19, 2019, at 4:30 p.m. revealed that Resident 53 was originally admitted to the facility in March 2019 and received an order from the physician to smoke at that time. The resident was then discharged home, and upon readmission, the physician would not give the resident an order to smoke. The Director of Nursing indicated that if the resident would receive an order from the physician to smoke, then a smoking assessment would be completed.

Interview with the Nursing Home Administrator on December 20, 2019, at 2:28 p.m. revealed that Resident 53 should be permitted to smoke, as it was his choice to do so, and she could not find any documented evidence regarding why the resident could not smoke.

42 CFR 483.10(f)(1)-(3)(8) Self-Determination.
Previously cited 12/13/18.

28 Pa. Code 201.29(j) Resident rights.
Previously cited 12/13/18.


 Plan of Correction - To be completed: 02/12/2020

A Smoking Safety Assessment was completed for resident 53. Resident was deemed safe to smoke with staff supervision and has been provided smoking privileges.

The facility has one additional resident that has smoking privileges. No other residents in the facility have requested smoking privileges.

Upon admission to the facility and upon request, residents will be evaluated for safe smoking.

Director of Nursing/Designee will review new admissions and/or any resident requesting to smoke for 3 months. Results of the above audit will be forwarded to the Quality Assurance Improvement Committee for review and recommendation.
483.75(g)(2)(ii) REQUIREMENT QAPI/QAA Improvement Activities: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)(2) The quality assessment and assurance committee must:
(ii) Develop and implement appropriate plans of action to correct identified quality deficiencies;
Observations:


Based on review of the facility's plans of correction for previous surveys and the results of the current survey, it was determined that the facility's Quality Assurance Performance Improvement (QAPI) committee failed to correct quality deficiencies and ensure that plans to improve the delivery of care and services effectively addressed recurring deficiencies.

Findings include:

The facility's deficiencies and plans of correction for a State Survey and Certification (Department of Health) survey ending December 13, 2018, revealed that the facility developed plans of correction that included quality assurance systems to ensure that the facility maintained compliance with cited nursing home regulations. The results of the current survey, ending December 20, 2019, identified repeated deficiencies related to a failure to ensure that resident could make choices, that information pertaining to contacting all pertinent resident advocacy agencies was accessible to residents, developing and implementing a comprehensive individualized care plan, following professional standards of practice, providing assisted care to dependent residents, providing quality care, and issues with urinary catheters and oxygen therapy.

The facility's plan of correction for a deficiency regarding ensuring that resident's could make choices, cited during the survey ending December 13, 2018, revealed that the facility would complete audits and report the results of the audits to the QAPI committee for review. The results of the current survey, cited under F561, revealed that the facility's QAPI committee failed to maintain compliance with the regulation regarding ensuring that resident's could make choices about their activities and important aspects of their lives.

The facility's plan of correction for a deficiency regarding ensuring that information about contacting all pertinent resident advocacy agencies was accessible to residents, cited during the survey ending December 13, 2018, revealed that the facility would complete audits and report the results of the audits to the QAPI committee for review. The results of the current survey, cited under F575, revealed that the facility's QAPI committee failed to maintain compliance with the regulation regarding ensuring that information pertaining to contacting all pertinent resident advocacy agencies was accessible to residents.

The facility's plan of correction for a deficiency regarding developing and implementing a comprehensive individualized care plan for each resident, cited during the survey ending December 13, 2018, revealed that the facility would complete audits and report the results of the audits to the QAPI committee for review. The results of the current survey, cited under F656, revealed that the facility's QAPI committee failed to maintain compliance with the regulation regarding developing and implementing a comprehensive individualized care plan for each resident.

The facility's plan of correction for a deficiency regarding failure to clarify questionable physician's orders and to ensure that a registered nurse assessed residents after a change in condition, cited during the survey ending December 13, 2018, revealed that the facility would complete audits and report the results of the audits to the QAPI committee for review. The results of the current survey, cited under F658, revealed that the facility's QAPI committee was ineffective in maintaining compliance with the regulation regarding following professional standards of practice.

The facility's plan of correction for a deficiency regarding providing care to dependent residents, cited during the surveys ending December 13, 2018, revealed that the facility would complete audits and report the results of the audits to the QAPI committee for review. The results of the current survey, cited under F677, revealed that the facility's QAPI committee was ineffective in maintaining compliance with the regulation regarding providing care to dependent residents.

The facility's plan of correction for a deficiency regarding providing quality care, cited during the survey ending December 13, 2018, revealed that the facility would complete audits and report the results of the audits to the QAPI committee for review. The results of the current survey, cited under F684, revealed that the facility's QAPI committee was ineffective in maintaining compliance with the regulation regarding providing quality care.

The facility's plan of correction for a deficiency regarding failures to provide proper incontinent and catheter care and/or toileting, cited during the survey ending December 13, 2018, revealed that the facility would complete audits and the results would be reviewed as part of quality assurance. The results of the current survey, cited under F690, revealed that the facility's QAPI committee was ineffective in maintaining compliance with the regulation regarding incontinent/catheter care and/or toileting.

The facility's plan of correction for a deficiency regarding a failure to provide oxygen therapy as ordered by the physician, cited during the survey ending December 13, 2018, revealed that the facility would complete audits and the results would be reviewed as part of quality assurance. The results of the current survey, cited under F695, revealed that the facility's QAPI committee was ineffective in maintaining compliance with the regulation regarding providing oxygen therapy as ordered by the physician.

Refer to F561, F575, F656, F658, F677, F684, F690, F695.

42 CFR 483.75(g)(2)(ii) QAPI/QAA Improvement Activities.
Previously cited 12/13/18.

28 Pa. Code 201.14(a) Responsibility of licensee.
Previously cited 12/13/18.

28 Pa. Code 201.18(e)(1) Management.
Previously cited 12/13/18.




 Plan of Correction - To be completed: 02/12/2020

All members of the Quality Assurance committee met to discuss repeat deficiencies from surveys enduing on December 13, 2018, (F656, F658, F651, F575, F677, F684, F690, and F695). This meeting was held to modify the facility's Quality Assurance and Performance Improvement plan (QAPI).

The committee will root cause by data analysis the root caused of repeat deficiencies. The team will analysis the system process break to ensure it is corrected to deter repeat deficiencies.


An action plan was generated with findings of those audits to be discussed weekly at the Interdisciplinary meeting. The facility has determined that all residents have the potential to be affected.

An in-service education program was conducted by the Administrator on various shifts regarding the elements and goals of the facility's Quality Assurance and Performance Improvement program. All staff were educated.

The Human Resource Director will submit a new hire list from all departments to the Administrator monthly to verify the new hires have been educated on the facility's Quality Assurance and Performance Improvement program. The Quality Assurance Committee will meet monthly to discuss action plan related to repeat deficiencies, in addition to those items on the Quality Assurance and Performance Improvement plan agenda. Status of action plan related to repeat deficiencies will discussed with the Resident Council monthly.
This plan of correction will be monitored at the monthly Quality Assurance Committee meeting until such time consistent substantial compliance with the regulations and the facility's Quality Assurance and Performance Improvement plan has been met.

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

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

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

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

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

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


Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that clinical records were complete and accurately documented for four of 36 residents reviewed (Residents 12, 13, 49, 269).

Findings include:

The facility's policy regarding documentation, dated October 24, 2019, revealed that all services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional, or psychosocial condition, were to be documented in the resident's medical record. The medical record was to facilitate communication between the interdisciplinary team regarding the resident's condition and response to care.

A quarterly Minimum Data Set (MDS) assessment (a federally-mandated assessment of a resident's abilities and care needs) for Resident 12, dated November 30, 2019, indicated that the resident was alert and oriented, and had diagnoses that included diabetes. Physician's orders, dated February 15, 2017, included orders for staff to check the resident's blood sugar four times a day, and insulin was to be administered depending on the results of the blood sugar tests.

Resident 12's blood sugar test results for June 2019 revealed that staff documented that the 9:00 p.m. blood sugar on June 24, 2019, was 1,390 milligrams per deciliter (mg/dL). However, there were no corresponding nursing notes that addressed the extremely high blood sugar result and no indication that the resident's physician was notified.

Interview with the Director of Nursing on December 19, 2019, at 4:05 p.m. confirmed that there was no other documentation that supported the June 24, 2019, at 9:00 p.m. blood sugar of 1,390 mg/dL, including the administration of insulin, a registered nurse assessment, and physician notification. The Director of Nursing indicated that the blood sugar entry of 1,390 had to be an error.


A diagnosis record for Resident 13, dated December 1, 2019, revealed that the resident had diagnoses that included dementia with dysphagia (difficulty swallowing) and required a Percutaneous endoscopic gastrostomy (PEG) tube (a tube surgically inserted into the stomach to provide feeding). Physician's orders for Resident 13, dated January 21, 2019, included an order for the resident to receive Jevity 1.5 at 60 mililiters (ml) an hour for 20 hours per day to provide a total of 1300 ml/day, and an order, dated July 18, 2019, for the resident to receive PEG tube flush of 200 ml water every four hours.

Resident 13's current care plan, revised October 1, 2019, revealed that the resident was to be provided enteral feeding and flushes per the physician orders and to check tube placement and residuals per guideline or physician orders.

Resident 13's clinical record for January 1 through December 18, 2019, revealed that there was no documented evidence that gastric residuals were checked every six to eight hours per the facility's policy, and the total volume of feeding formula and flushes received by the resident each day was not calculated and recorded.

Interview with Licensed Practical Nurse 1 on December 17, 2019, at 10:27 a.m. revealed that he was not aware of any way to calculate the total amount of fluid Resident 13 actually received each shift, and he was not sure if the feeding tube pump was able to give an accurate amount of fluids that the resident received.

Interview with the Dietician on December 19, 2019, at 3:06 p.m. revealed that she was not aware that nursing staff were not keeping an accurate account of Resident 13's intake. She indicated that she used the amount of fluids the resident was ordered to receive and not the actual amount the resident received when determining intake; therefore, she did not have an accurate account of the fluids the resident received.


A diagnosis record for Resident 49, dated December 1, 2019, and nursing note dated November 19, 2019, at 6:23 p.m., revealed that the resident had diagnoses that included a brain injury with dysphagia and required a PEG tube. Physician's orders, dated December 12, 2019, included an order for the resident to receive Glucerna 1.2 at 80 ml an hour, to be connected at 8:00 p.m. and disconnected at 6:00 a.m. A nutrtition note, dated December 12, 2019, revealed that the tube feeding would provide 960 calories, 48 grams of protein, and 1364 cubic centimeters (cc's) of free fluid per day.

Resident 49's clinical record for December 12-18, 2019, revealed no documented evidence that the amount of tube feeding formula received during the time the feeding was connected was recorded.

Interview with the Nursing Home Administrator on December 20, 2019, at 2:32 p.m. confirmed that there was no documented evidence that the amount of tube feeding formula that Resident 49 received was recorded in the resident's clinical record.


An admission nursing note for Resident 269, dated December 16, 2019, indicated that the resident was oriented to person and place, his skin color was normal, his nail beds were normal in appearance with brisk capillary refill, his lips and mucus membranes were pink in color, his lung sounds were diminished throughout all fields, and oxygen was ordered as needed.

Observations of Resident 269 on December 17, 2019, at 11:22 a.m. revealed that the resident was in a wheelchair in his room, and his nail beds were dark purple and his hands were cool. The surveyor asked Licensed Practical Nurse 1 to check the resident, and the nurse obtained oxygen saturation levels (the percentage of oxygen in the blood) of 73 percent and 65 percent (normal is 90-100 percent). Licensed Practical Nurse 1 placed the resident on oxygen at a flow rate of 2 liters per minute via nasal cannula (tubes placed in the nostrils). A recheck of Resident 269's oxygen saturation on December 17, 2019, at 11:42 a.m. revealed that the resident's readings were still low at 45 percent. Licensed Practical Nurse 1 stated that it was because the resident's hands were cold and that he would try to warm his hands to get a better reading. The pulse oximeter (machine that reads the oxygen level) was reading a correct pulse as confirmed by a manual pulse. The surveyor asked Licensed Practical Nurse 1 what he would do in this case, and he responded that he would put the resident on oxygen and recheck him. The nurse indicated that the resident was not having any issues. The surveyor asked the nurse if he would do anything else, and he responded, "Not at this time, no."

As of December 18, 2019, at 9:52 a.m. there was no documentation in Resident 269's clinical record regarding the hypoxic (low oxygen) episode on December 17, 2019.

An interview with Licensed Practical Nurse 1 on December 18, 2019, at 10:51 a.m. confirmed that he did not document that Resident 269 had a hypoxic episode on December 17, 2019, and he did not notify the registered nurse and/or the physician about the change in the resident's condition.

An interview with the Director of Nursing on December 18, 2019, at 11:00 a.m. confirmed that there was no documented evidence that Licensed Practical Nurse 1 or a registered nurse documented Resident 269's hypoxic episode on December 17, 2019.

28 Pa. Code 211.5(f) Clinical Records.
Previously cited 12/13/18.




 Plan of Correction - To be completed: 02/12/2020

R12 blood sugar results have been recorded and the physician was notified when the results have been outside the normal limits of the sliding scale coverage. The results of those blood sugars are also shared with the resident at the time of testing.

R13 clinical record now reflects that gastric residuals are checked every six to eight hours per the facility's policy and the total volume of the feeding formula and flushes received are calculated and recorded on the Medication Administration Record.

R49 clinical record now reflects the amount of tube feeding formula that would be provided to the resident. This amount will be recorded on the Medication Administration Record.

The dietician has been made aware of the changes to ensure accuracy of consumption.

R269 Registered Nurse assessment following the hypoxic episode was recorded in the clinical chart. The physician for R269 was also notified of the hypoxic episode.

The listing of all residents who receive tube feeding formula was audited to ensure consumption is measured and recorded in the clinical chart. Results will be reported to the Quality Assurance committee quarterly. The Administrator will be responsible for any follow up recommendations by the Quality Assurance committee.

The director of nursing/designee will educate the licensed staff that all residents who receive tube feeding formula must have the consumption recorded on the clinical chart to ensure resident records reflect identifiable information. This education will be provided to new and agency licensed staff. A weekly audit will be conducted by the Assistant Director of Nursing or Designee to ensure those residents have their consumption recorded on the clinical record for four weeks.

Results will be reported to the Quality Assurance committee quarterly. The Administrator will be responsible for any follow up recommendations by the Quality Assurance committee.

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


Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that physician's orders for medications were followed, resulting in a significant medication errors for two of 36 residents reviewed (Residents 12, 46).

Findings include:

The facility's policy regarding medication administration, dated October 24, 2019, revealed that medications must be administered in accordance with physician's orders, including any required time frames. Before giving the medication, the nurse administering the medications must check the label "THREE (3) times" to verify the right resident, right medication, right dosage, right time, and right method (route) of administration.

A quarterly Minimum Data Set (MDS) assessment (a federally-mandated assessment of a resident's abilities and care needs) for Resident 12, dated November 30, 2019, indicated that the resident was alert and oriented, and had diagnoses that included high blood pressure and diabetes (disease that interferes with blood sugar control). Physician's orders dated May 7, 2019, included and order for the resident to receive half of a 0.5 milligram tablet of clonazepam (a controlled mediation used to treat anxiety) (0.25 mg) three times a day.

A nursing note for Resident 12, dated September 20, 2019, revealed that it was discovered that the resident received 0.5 mg of clonazepam, instead of 0.25 mg, for three consecutive doses on September 19 at 9:00 p.m., and September 20 at 9:00 a.m. and 2:00 p.m., and when the resident was informed about the error she stated that she felt tired. Resident 12's clonazepam controlled substance record (a form that accounts for each dose of a controlled medication) for September 19 and 20, 2019, and a medication error report dated September 20, 2019, confirmed that staff administered 0.5 mg doses of clonazepam to the resident, instead of 0.25 mg, for three consecutive doses on September 19 and 20, 2019.

Interview with the Director of Nursing on December 18, 2019, at 3:00 p.m. confirmed that a medication error occurred and Resident 12 received double the dose of clonazepam three times on September 19, and 20, 2019.

Physician's orders for Resident 12, dated October 1, 2019, included an order for the resident to receive 25 mg of Toprol XL (a medication to treat high blood pressure) twice daily, and to hold the medication if the resident's pulse was less than 60, if the systolic (top number) blood pressure was less than 100 millimeters of mercury (mmHg), or if the diastolic (bottom number) blood pressure was less than 60 mmHg.

Resident 12's Medication Administration Records (MAR's) for October and November 2019 revealed no documented evidence that nurses obtained a blood pressure reading prior to administering the 5:00 p.m. dose of Toprol XL daily from October 1 through November 15, 2019.

Interview with the Director of Nursing on December 19, 2019, at 4:10 p.m. confirmed that nurses administering medications should have obtained and documented a blood pressure prior to administering the 5:00 p.m. doses of Toprol XL to Resident 12, but there was no documented evidence that a blood pressure was obtained on the above dates.


Physician's orders for Resident 46, dated August 31, 2018, included orders for the resident to receive 180 mg of diltiazem CD (treats high blood pressure) daily, and to hold the medication if the resident's systolic blood pressure was less than 100 mmHg and the pulse was less than 60 beats per minute. The resident's care plan, dated November 19, 2019, indicated that medications were to be administered according to physician's orders.

Resident 46's MAR's for October, November and December 2019 revealed no documented evidence that nurses obtained a blood pressure prior to administering diltiazem to the resident daily from October 4-8, 10-23, and 25-31, 2019; November 1-30, 2019; and December 1-18, 2019.

Interview with the Director of Nursing on December 19, 2019, at 12:01 p.m. confirmed that nurses should have obtained a blood pressure before administering diltiazem to Resident 46 on the above dates, but there was no documented evidence that they did.

28 Pa. Code 211.12(d)(5) Nursing services.
Previously cited 12/13/18.




 Plan of Correction - To be completed: 02/12/2020

Medication error report completed for resident 12. Blood pressures are being obtained prior to administration of medication for residents 12 and 46. Staff education was completed. Resident 12 and 46 are receiving medications as ordered by the physician.

Reviewed residents receiving blood pressure medications for the inclusion of parameters and blood pressures as ordered by the physician.

Supplementary documentation for the inclusion of blood pressure and pulse readings was not entered into the medication order. Director of Nursing/Designee will educate Registered Nurses on how to enter orders to include necessary vital sign documentation. Director of Nursing/Designee will educate licensed nurses on the rights of medication administration and their responsibility for following physician orders. These educations will provided for new and agency licensed staff.

Director of Nursing/Designee will observe med passes on 5 residents weekly for 3 months. Results of above monitoring will be forwarded to the Quality Assurance Improvement Committee for review and recommendation.
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 reviews and staff interviews, it was determined that the facility failed to provide pain management as ordered by the physician for two of 36 residents reviewed (Residents 31, 46).

Findings include:

Physician's orders for Resident 31, dated December 26, 2018, and December 6, 2019, included an order for the resident to receive one 5/325 milligram (mg) tablet of hydrocodone-acetaminophen (a narcotic pain medication) by mouth every six hours as needed for pain ratings of 4 to 6 (on a scale of 1 to 10, where 10 is the worst pain). The resident's care plan, dated April 11, 2019, indicated that medications for pain were to be administered according to physician's orders.

Resident 31's Medication Administration Records (MAR's) for November 2019 revealed that staff administered hydrocodone-acetaminophen for pain ratings that were greater than 6 on November 3 at 12:26 p.m. and November 6 at 3:25 p.m.


Physician's orders for Resident 46, dated December 26, 2018, included an order for the resident to receive one 5/325 mg tablet of hydrocodone-acetaminophen by mouth every six hours as needed for pain ratings of 4 to 6. The resident's care plan, dated November 19, 2019, indicated that medications for pain were to be administered according to the physician's orders

Resident 46's MAR's for October, November, and December 2019 revealed that staff administered hydrocodone-acetaminophen for pain ratings that were greater than 6 on October 16 at 10:07 a.m., October 30 at 2:35 p.m., November 2 at 12:28 p.m., November 7 at 11:34 a.m., November 27 at 12:20 p.m., December 6 at 10:12 a.m., December 12 at 3:52 p.m., and December 16 at 11:54 p.m.

Interview with the Director of Nursing on December 1, 2019, at 11:59 a.m. confirmed that Resident 31 and 46's MAR's showed that staff administered pain medication outside of the parameters that were ordered by the physician.

28 Pa. Code 211.12(d)(5) Nursing services.
Previously cited 12/13/18.






 Plan of Correction - To be completed: 02/12/2020

Resident 31 and resident 46 are receiving pain management as ordered by their physician.

Residents on pain management will be reviewed to ensure the physician orders are being followed.

Physicians orders include and pain ratings and pain scale parameters. The Director of Nursing will educate Licensed nurses, new staff, and any agency staff on the pain management policy, rights of medication administration, and their responsibility to administer medications per physicians orders.

Director of Nursing/Designee will audit that pain medications are administered according to physician orders for 5 residents 3 times a week for 4 weeks and then weekly for 2 months.
483.25(i) REQUIREMENT Respiratory/Tracheostomy Care and Suctioning: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(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 policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that oxygen therapy was provided as ordered by the physician for two of 36 residents reviewed (Residents 47, 269), and failed to ensure that oxygen concentrators were clean for four of 36 residents reviewed (Residents 24, 26, 57, 269).

Findings include:

The facility's policy regarding oxygen therapy, dated October 24, 2019, indicated that a physician's order was required for the provision of oxygen therapy, and that the flow rate should be set as prescribed (by the physician).

A diagnosis record for Resident 47, dated October 18, 2019, revealed that the resident had diagnoses that included chronic obstructive pulmonary disease (COPD - a progressive lung disease that makes it difficult to breath). Physician's orders, dated October 20, 2019, included an order for the resident to receive continuous oxygen at a flow rate of 2 liters per minute via nasal canula (tubes that deliver oxygen into the nostrils).

Observations on December 17, 2019, at 10:34 a.m. revealed that Resident 47 was in his room with a nasal cannula in place and connected to an oxygen concentrator; however, the oxygen concentrator was turned off.

Interview with Licensed Practical Nurse 1 on December 17, 2019, at 10:35 a.m. revealed that the building was having power problems and he believed that was why Resident 47's oxygen was off. Resident 47's oxygen saturation level (the percentage of oxygen in the blood) was 90 percent on room air. Licensed Practical Nurse 1 stated that the resident's oxygen saturation level should be greater than 92 percent and he turned on the oxygen concentrator.


An admission nursing note for Resient 269, dated December 16, 2019, at 5:06 p.m. indicated that the resident was oriented to person and place, had decreased lung sounds throughout all fields, and was on oxygen as needed. A diagnoses list, dated December 16, 2019, included diagnoses of heart failure and high blood pressure, and physician's orders dated December 18, 2019, included orders for the resident to receive continuous oxygen at a flow rate of 2 liters per minute.

Observations of Resident 269 on December 19, 2019, at 1:10 p.m. revealed that the resident in his wheelchair in the hallway near the nursing station with his nasal cannula in his lap and his portable oxygen tank was empty. Licensed Practical Nurse 1 applied the resident's nasal cannula and then replaced his portable oxygen tank with a full tank.
An interview with Licensed Practical Nurse 1 at that time revealed that the tank should have been monitored and changed prior to it being emptied.

An interview with the Director of Nursing on December 19, 2019, at 1:19 p.m. revealed that all staff are responsible to check portable oxygen tanks and change them and Resident 269's portable tank should not have been empty.


A quarterly Minimum Data Set (MDS) assessment (a federally-mandated assessment of a resident's abilities and care needs) for Resident 24, dated November 1, 2019, indicated that the resident was alert and oriented, had diagnoses that included high blood pressure, diabetes and chronic obstructive lung disease (COPD - lung condition that makes it hard to breathe), and was short of breath with exertion, at rest and lying flat, and was on oxygen. Physician's orders, dated October 18, 2019, included orders for the resident to use continuous oxygen at a flow rate of 2 liters per minute via nasal cannula (tubes that deliver oxygen into the nostrils). Physician's orders, dated July 25, 2019, included an order for oxygen concentrator filter cleaning every Friday during the night shift and as needed. The resident's Treatment Administration Record (TAR) indicated that the oxygen concentrator was cleaned as ordered on Friday, December 13, 2019.

However, observations on December 17, 2019, at 2:45 p.m. and December 20, 2019, at 10:57 a.m. revealed that Resident 24's oxygen concentrator filter was heavily soiled with dust particles.


A comprehensive admission MDS assessment for Resident 26, dated November 4, 2019, indicated that the resident was alert and oriented, had diagnoses that included heart failure, high blood pressure and pneumonia, and was on oxygen. Physician orders dated October 28, 2019, included orders for the resident to receive continuous oxygen at a flow rate of 2 liters per minute via nasal cannula. Physician's orders, dated October 28, 2019, included an order for the oxygen concentrator filter to be cleaned every Friday during the night shift and as needed. The resident's TAR indicated that the oxygen concentrator was cleaned as ordered on Friday, December 13, 2019.

However, observations on December 17, 2019, at 3:07 p.m. and December 18, 2019, at 10:45 a.m. revealed that Resident 26's oxygen concentrator filter was heavily soiled with dust particles.


An annual MDS assessment for Resident 57, dated October 28, 2019, indicated that the resident was able to understand and be understood, and had diagnoses that included heart disease, high blood pressure and stroke. Physician's orders, dated December 10, 2019, included orders for the resident to receive continuous oxygen at a flow rate of 2 liters per minute via nasal cannula. Physician's orders dated July 15, 2019, included an order for oxygen concentrator filter cleaning every Friday during the night shift and as needed. The resident's TAR indicated that the oxygen concentrator was cleaned as ordered on Friday, December 13, 2019.

However, observations on December 17, 2019, at 10:15 a.m. and December 18, 2019, at 10:52 a.m. revealed that Resident 57's oxygen concentrator filter was heavily soiled with dust particles.


An admission nursing note dated December 16, 2019, at 5:06 p.m. indicated that Resident 269 was oriented to person and place, had decreased lung sounds throughout all fields, and was on oxygen as needed. A diagnosis list dated December 16, 2019, included diagnoses of heart failure and high blood pressure, and physician's orders dated December 18, 2019, included orders for the resident to receive continuous oxygen at 2 liters per minute continuously. Physician's orders dated December 16, 2019, included an order for oxygen concentrator filter cleaning every Friday during the night shift and as needed, and the resident's TAR indicated that the oxygen concentrator was cleaned as ordered on Friday, December 13, 2019.

However, observations on December 17, 2019, at 1:17 p.m.; December 18, 2019, at 10:56 a.m.; and December 19, 2019, at 1:00 p.m. revealed that Resident 269's oxygen concentrator filter was heavily soiled with dust particles.

Interview with the Director of Nursing on December 20, 2019, at 2:09 p.m. confirmed that the above oxygen concentrator filters were heavily soiled and should have been cleaned weekly.

42 CFR 483.25(i) Respiratory/Tracheostomy Care and Suctioning.
Previously cited 12/13/18.

28 Pa. Code 211.12(d)(3) Nursing services.
Previously cited 12/13/18.

28 Pa. Code 211.12(d)(5) Nursing services.
Previously cited 12/13/18.




 Plan of Correction - To be completed: 02/12/2020

Oxygen concentrator for resident 47 has been replaced. Resident 269 no longer resides at the facility. Oxygen concentrator filters were cleaned for residents 24, 26, 57, and 269. Resident 269 was provided a full portable oxygen tank.

Facility Oxygen concentrator filters have been cleaned.

Exsisting Staff, new staff, and agency staff will be trained on how to properly clean oxygen concentrator filters. The policy for cleaning oxygen filters will be added to the nursing orientation checklist. The policy has been checked against manufacturer's guidelines to ensure the facility is following the recommended protocol. Filters will be cleaned weekly and as needed. Facility will utilize a guideline for use of portable oxygen tanks which will be maintained at the nurses stations for staff reference. Director of Nursing/Designee will educate nursing staff on the concentrator cleaning schedule and use of oxygen guidelines for Portable oxygen tanks. The education will also include staff responsibility to check and clean oxygen concentrator filters as needed.

Director of Nursing/Designee will audit 5 residents receiving oxygen three times a week for one month, and then weekly for 2 months. Results of the above monitoring will be forwarded to the Quality Assurance Improvement Committee for review and recommendations.
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 review of policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that a tube feeding was administered and documented in accordance with physician's orders for one of 36 residents reviewed (Resident 22).

Findings include:

The facility's policy regarding enteral feeding (providing a nutritional formula via a tube inserted into the stomach), dated October 24, 2019, indicated that staff were to document on the formula label their initials, date and time the formula was hung/administered, and to initial that the label was checked against the physician's order. The policy also included that staff were to check gastric residual volume (the amount left in the stomach) every six to eight hours after target feeding volume and rate have been established.

A diagnosis record for Resident 22, dated December 1, 2019, revealed that the resident had diagnoses that included stroke with dysphagia (difficulty swallowing) and required a percutaneous endoscopic gastrostomy (PEG) tube (a tube surgically inserted into the stomach). Physician's orders dated June 6, 2018, included orders for the resident to receive Glucerna 1.2 (a tube feeding formula) at 90 milliliters (ml) an hour for 16 hours per day, to provide a total of 1440 ml/day. The tube feeding was to be shut off from 11:00 a.m. to 7:00 p.m. An order dated June 30, 2018, revealed that staff were to flush the resident's PEG tube with 200 ml of water every four hours, and an order dated June 30, 2018, was to change the feeding tube administration set (the bags and tubes used to administer feeding formula) every 24 hours.

Resident 22's current care plan, most recently revised on November 1, 2019, revealed that she was to receive enteral feeding and flushes according to the physician's orders and to check tube placement and residuals according to guidelines or physician's orders.

Resident 22's clinical record for January 1 through December 18, 2019, revealed that there was no documented evidence that gastric residuals were checked every six to eight hours in accordance with the facility's policy.

Observations of Resident 22's feeding tube administration set on December 17, 2019, at 9:42 a.m. revealed that the feeding tube bag was empty and was dated December 14, 2019; the flush bag was empty; and the feeding tube was not connected to the resident and was not infusing in accordance with the the physician's orders (the tube feeding was not to be shut off until 11:00 a.m.).

Interview with Licensed Practical Nurse 2 on December 17, 2019, at 10:17 a.m. revealed that she hung and turned on Resident 22's feeding during the evening shift the night before, but she did not look at the date/time on the bag and she should have. She hung the tube feeding bag on December 14, 2019, and she labeled and dated it at that time; however, she was not sure why it was not changed since then.

Interview with Licensed Practical Nurse 1 on December 17, 2019, at 10:27 a.m. revealed that he turned Resident 22's pump off before he went to lunch, but he did not remember what time he turned it off. He stated that he did not know how much feeding formula Resident 22 received, or how much she still needed for her 16-hour period. He indicated that he was not aware that the feeding tube pump was able to record the amount of feeding and flush that the resident received, and he was not aware of how to collect that data. He stated that he did not look at the date on the feeding tube bag because staff on the night shift were supposed to do that.

Interview with the Director of Nursing on December 17, 2019 at 10:30 a.m. revealed that Resident 22's feeding formula should have been infusing at 10:22 a.m. in accordance with the physician's order, and she did not know why it was turned off.

Interview with the Dietician on December 19, 2019, at 3:06 p.m. revealed that she was not aware that nursing staff were not keeping an accurate record of Resident 22's tube feeding and flush intake, and that she used the amount of fluids the resident was ordered to determine her intake, not the actual amount she received.

28 Pa. Code 211.12(d)(5) Nursing services.
Previously cited 12/13/18.


 Plan of Correction - To be completed: 02/12/2020

Resident 22 was reevaluated by the dietitian and is receiving their enteral feed per physician order.

Residents receiving enteral feedings will be evaluated by the dietitian and adjustments to physician orders will occur if recommended.

Documentation of Gastric residual and enteral feeding volume infused will be included on the medical record. Director of Nursing/Designee will educate licensed nurses, new staff hired and agency staff on the enteral feeding policy, checking gastric residual, documentation of enteral feeding infused, and changing of enteral feeding administration set.

Director of Nursing/Designee will audit enteral feeding management and proper documentation. This audit will be completed on 3 residents three times a week for 4 weeks, then monthly for two months. Results of the above monitoring will be forwarded to the Quality Assurance Improvement Committee for review and recommendations.


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 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(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 clinical record reviews, observations and staff interviews, it was determined that the facility failed to ensure that the resident's dignity was maintained for one of 36 residents reviewed (Resident 51).

Findings include:

A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 51, dated November 22, 2019, revealed that the resident was severely cognitively impaired, was understood and could understand, required extensive assistance from staff for multiple daily care tasks, required supervision and set-up for eating, and had medical diagnoses that included Alzheimer's disease (a brain disease that causes a slow decline in memory, thinking and reasoning skills) and dementia (symptoms affecting memory, thinking and social abilities severely enough to interfere with daily life).

Observations in the second floor dining room on December 18, 2019, at 3:20 p.m. revealed that Resident 51 was sitting in a wheelchair at a table while Housekeeper 7 cleaned the floor. Resident 51 said to Housekeeper 7, "Hey nurse, get me a drink." Housekeeper 7 responded, "I am not your nurse. I am a housekeeper. Go find your nurse." Resident 51 self-propelled his wheelchair into the hallway, grabbed Resident 53's wheelchair, and threatened Resident 53 with a raised voice. Two staff separated the residents by having Resident 51 hold Licensed Practical Nurse 8's hand, and directing Resident 53 to his room. Resident 51 continued to hold onto Licensed Practical Nurse 8's hand and would not let go. Licensed Practical Nurse 8 offered the resident a snack, which the resident refused. Licensed Practical Nurse 8 offered to take him to his room and Resident 51 refused. Licensed Practical Nurse 8 offered Resident 51 a drink, and the resident accepted and let go of the nurse's hand. Resident 51 then drank some juice in the hallway without further incident.

Interview with Housekeeper 7 on December 19, 2019, at 10:08 a.m. confirmed that she should have told the nurse about Resident 51's request for a drink, because she could not get him a drink herself.

Interview with the Nursing Home Administator on December 19, 2019, at 1:37 p.m. confirmed that Housekeeper 7 should have notified a nurse about Resident 51's need for assistance.

28 Pa. Code 201.29(j) Resident rights.
Previously cited 12/13/18.





 Plan of Correction - To be completed: 02/12/2020

Upon notification to the Nursing Home Administrator resident 51 was provided a beverage. Nursing Home Administrator provided education the housekeeper 7 regarding resident rights.

Resident rights are posted in the facility. Resident rights/dignity is reviewed at monthly resident council and Pennsylvania Empowered Expert Residents program group meetings. Director of Nursing/Designee will complete a whole house education on resident rights/dignity and staff responsibility to communicate a residents needs to the nurse if assistance is needed.

Facility will review new hire orientation, for the inclusion of staffs understanding of what actions to take if they are unable to fulfill a residents request. This information will also be included in the agency orientation process.

Then Director of Nursing/Designee will complete random observations of staff care and staff interactions with residents. This audit will be completed on 5 residents, 3 times a week for 4 weeks and then once weekly for 2 months. Results will be reviewed by the facility Quality Improvement Committee for recommendations as necessary.
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 policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that staff used proper infection control practices during wound care for two of 36 residents reviewed (Residents 12, 270), and failed to ensure that proper infection control practices were followed while preparing medications.

Findings include:

The facility's policy regarding the application of wound dressings, dated October 24, 2019, indicated that clean gauze was to be used for each cleansing stroke.

A quarterly Minimum Data Set (MDS) assessment (a federally-mandated assessment of a resident's abilities and care needs) for Resident 12, dated November 30, 2019, indicated that the resident was alert and oriented and had diagnoses that included diabetes and peripheral vascular disease (impaired circulation to the extremities). The resident's care plan, dated November 25, 2019, indicated that she had a chronic non-pressure ulcer/wound of the left lower extremity.

Observations of Resident 12's wound care on December 17, 2019, at 2:48 p.m. revealed that there were two distinct and separate open areas on her left shin. Licensed Practical Nurse 8 cleansed the top wound with a piece of moistened gauze, then using the same piece of moistened gauze, cleansed the second open area located below the first. After cleansing both open areas, the nurse dispensed a small amount of Iodosorb ointment (an ointment that promotes healing by absorbing excess wound drainage) onto a cotton-tipped applicator, dabbed the ointment onto the base of the upper wound, then dispensed more Iodosorb onto the same cotton-tipped applicator and applied it to the base of the second wound. Licensed Practical Nurse 8 then applied cream to the skin surrounding both wounds and covered the open areas with an absorbent padded dressing.

Interview with the Director of Nursing on December 18, 2019, at 2:52 p.m. revealed that Licensed Practical Nurse 8 should not have used the same gauze to clean both wounds, and should have used two different cotton-tipped applicators to apply the Iodosorb to each wound base. She also confirmed that each wound should have been treated with separate supplies.

Interview with Licensed Practical Nurse 8 on December 18, 2019, at 3:02 p.m. confirmed that he used the same piece of moistened gauze and the same cotton-tipped applicator to treat both of Resident 12's open wounds, and he should have used different pieces of gauze and different cotton-tipped applicators for each wound.


The facility's infection control policy, dated October 24, 2019, indicated that the facility was to maintain a safe, sanitary, and comfortable environment for personnel, residents, visitors, and the general public.

A nursing note for Resident 270, dated December 18, 2019, at 2:51 p.m. indicated that the resident went to the wound clinic.

Observations of Resident 270's room on December 19, 2019, at 3:00 p.m. revealed that there was tubing attached to the right side (the side that faced the entry door), and the tubing was filled with a large amount of yellow/brown liquid with large particles of sediment that were draining into a collection bag. Interview with Resident 270's roommate at that time revealed that Resident 270 went to the wound clinic the day before and was then admitted to the hospital. Interview with the Nursing Home Administrator on December 19, 2019, at 3:30 p.m. confirmed that Resident 270 was admitted to the hospital on December 18, 2019.

Interview with the Director of Nursing on December 20, 2019, at 2:09 p.m. revealed that the tubing on Resident 270's bed was used to drain the resident's ileostomy (a surgical procedure in which a piece of the small intestine is diverted to an artificial opening in the abdominal wall to drain bowel contents) and that the tubing and collection bag should have been removed from the room and discarded when the resident was admitted to the hospital.


The facility's handwashing/hand hygiene policy, dated October 24, 2019, revealed that an alcohol-based hand rub or soap and water were to be used after removing gloves, and hand hygiene was to be completed before applying non-sterile gloves.

Observations during medication administration on December 19, 2019, from 9:21 a.m. to 9:56 a.m. revealed that Licensed Practical Nurse 1 removed a pair of non-sterile gloves, did not perform hand hygiene, then prepared medications for a resident, and did not perform hand hygiene before putting on a new pair of non-sterile gloves.

Interview with Licensed Practical Nurse 1 on December 19, 2019, at 10:05 a.m. revealed that he forgot to use alcohol-based hand rub or wash his hands after removing and before applying gloves. Interview with the Infection Control Nurse on December 20, 2019, at 10:58 a.m. confirmed that staff are to wash their hands or use sanitizing hand gel after removing gloves or before putting on new gloves, according to basic infection control standards.

28 Pa. Code 211.12(d)(1) Nursing services.
Previously cited 12/13/18.

28 Pa. Code 211.12(d)(5) Nursing services.
Previously cited 12/13/18.








 Plan of Correction - To be completed: 02/12/2020

R12 did not suffer any adverse reactions due to the wound treatment received by Licensed Practical Nurse 8. Licensed Practical Nurse #8 was immediately provided infection control education and education on the proper wound care procedure.


In the room of Resident #270 the collection bag filled with a large amount of yellow/liquid with large particles of sediment that was attached to the right side of the bed was immediately removed and the room was deep cleaned. The licensed staff, new staff, and agency staff were educated to remove any collection drainage bags that are not accompanying residents outside the facility.

Licensed Practical Nurse #1 was provided education on hand hygiene procedure during medication administration.

Residents with collection drainage bags were reviewed to ensure that collection bags are discarded at the time of departure from the facility. Proper wound care procedure will be reviewed with all licensed staff, new hires, and agency.

All licensed nursing staff and agency staff will be re-educated on the facility's infection control policy that the facility is to maintain a safe, sanitary, and comfortable environment for personnel, residents, visitors, and the general public.

The Director of Nursing/Designee will audit licensed staff for proper hand hygiene during medication administration twice weekly for four weeks then monthly for two months.

The Director of Nursing/Designee will audit wound care on two residents weekly for four weeks then monthly for two months.
The Director of Nursing/Designee will conduct an audit of residents with collection bags upon departure of the facility to ensure proper disposal weekly for four weeks then monthly for two months.
Results of the above monitoring will be forwarded to the Quality Assurance Improvement Committee for review and recommendation.

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 clinical record reviews, observations and staff interviews, it was determined that the facility failed to provide appropriate care to prevent urinary tract infections for one of 36 residents reviewed (Resident 64) who had an indwelling urinary catheter.

Findings include:

A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 64, dated December 3, 2019, revealed that the resident required extensive assistance from staff for transfers, required supervision with locomotion off the unit, used a wheelchair, and had an indwelling urinary catheter (a tube placed and held in the bladder to drain urine). A nursing note dated November 20, 2019, at 1:20 p.m. revealed that the resident had a urinary tract infection and was treated with an antibiotic.

Observations of Resident 64 on December 20, 2019, at 8:58 a.m. revealed that the resident was in a wheelchair and was self-propelling out of the dining room with her catheter tubing dragging on the floor. The Director of Nursing then began to push the resident down the hallway to the shower room with the tubing dragging on the floor.

Interview with Director of Nursing at that time confirmed that Resident 64's catheter tubing was on the floor and should not have been.

42 CFR 483.25(e)(1)-(3) Bowel/Bladder Incontinence, Catheter, UTI.
Previously cited 12/13/18.

28 Pa. Code 211.12(d)(5) Nursing services.
Previously cited 12/13/18.




 Plan of Correction - To be completed: 02/12/2020

Catheter tubing was adjusted for resident 64.

Residents with Foley catheters were reviewed to ensure that the tubing was at a level below the bladder and free from touching with the floor.

Director of Nursing/Designee will educate nursing staff, agency personnel and any new staff hired on how to properly hang catheter tubing to promote proper drainage but remain free of contact with the floor.

Director of Nursing/Designee will audit residents with catheters to ensure catheter tubing remains from of contact with the floor. This audit will be completed on 2 residents 3 times a week, and then monthly for 2 months. Results of the above monitoring will be forwarded to the Quality Assurance/Improvement Committee for review and recommendation.

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 review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to follow physician's orders for medication and for obtaining vital signs prior to administering medication for one of 36 residents reviewed (Resident 12), and failed to follow physician's orders and facility policy regarding hypoglycemia for one of 36 residents reviewed (Resident 58).

Findings include:

The facility's policy regarding administering medications, dated October 24, 2019, revealed that medications were to be administered in accordance with physician's orders, including any required time frames. The nurse administering the medications was to check the label "THREE (3) times" to verify the right resident, right medication, right dosage, right time, and right method (route) of administration before giving the medication.

A quarterly Minimum Data Set (MDS) assessment (a federally-mandated assessment of a resident's abilities and care needs) for Resident 12, dated November 30, 2019, indicated that the resident was alert and oriented, had diagnoses that included high blood pressure and diabetes, experienced constant pain that inhibited her sleep patterns and ability to perform daily activities, and received both routine and "as needed" pain medication.

Physician's orders for Resident 12, dated September 11, 2019, included an order for the resident to receive 300 milligrams (mg) of Neurontin (a medication used to treat nerve pain) every eight hours to treat diabetic nerve pain. However, the resident's Medication Administration Record (MAR) for September 2019 revealed that the 2:00 p.m. dose of Neurontin was not administered on September 21 and 27, 2019.

Physician's orders for Resident 12, dated September 13, 2019, included an order for a 4 percent Lidocaine patch (a pain patch) to be applied topically to the right neck/shoulder area (on in the a.m./off in the p.m.). The resident's MAR's for October, November and December 2019 revealed that the 4 percent Lidocaine patch was not applied on October 7, 12 and 17; November 5 and 6; and December 11 and 12, 2019. Nursing notes dated October 7, 12 and 17; November 5 and 6; and December 11 and 12, 2019, revealed that the 4 percent Lidocaine patch was not available and was not applied because it did not did not arrive from the pharmacy.

Interview with the Director of Nursing on December 19, 2019, at 4:10 p.m. confirmed that Resident 12 did not receive a 4 percent Lidocaine patch on the above dates and should have.

Physician's orders for Resident 12, dated June 9, 2017, included an order for the resident to receive 120 mg of Cardizem (used to treat high blood pressure) daily, with instructions to hold the medication if the resident's pulse was less than 45 (beats per minute) or if the systolic blood pressure (top number) was less than 100 millimeters of mercury (mmHg).

Resident 12's MAR's for November 2019 revealed that on November 16, 2019, staff administered the 9:00 a.m. dose of Cardizem; however, the resident's blood pressure reading was documented as 95/55 mmHg.

Interview with the Director of Nursing on December 19, 2019, at 4:05 p.m. confirmed that staff should not have administered the dose of Cardizem on November 16, 2019, because the resident's systolic blood pressure was less than 100.


The facility's policy regarding diabetes care, dated October 24, 2019, included that a resident who was symptomatic with hypoglycemia (low blood sugar) should immediately receive oral glucose paste to the buccal mucosa (cheek area), intramuscular glucagon (an injection into the muscle for low blood sugar), or IV (intravenous - directly into a vein) 50 percent glucose (sugar) according to the facility's protocol, and staff were to notify the physician for further orders.

A quarterly Minimum Data Set (MDS) assessment (a federally-mandated assessment of a resident's abilities and care needs) for Resident 58, dated November 27, 2019, indicated that the resident was alert and oriented; had diagnoses that included high blood pressure, heart failure and diabetes (disease that interferes with blood sugar control); and received insulin (medication to lower blood sugar levels) daily.

Physician orders for Resident 58 dated October 13, 2019, indicated that if the resident's blood sugar was less than 70 milligrams per deciliter (mg/dL), to give 17 grams of carbohydrates, 1/2 cup of juice, 1 cup of milk, or 3-5 glucose tablets and recheck the blood sugar level in 15 minutes. If the blood sugar was still less than 70 mg/dL, repeat the above and recheck the level in 15 minutes.

A nursing note for Resident 58, dated December 13, 2019, at 7:07 a.m. indicated that the resident fell at 5:15 a.m., was disoriented and confused, complained of not feeling well, and a check of the blood sugar level showed that it was 42 (mg/dL). The resident was given orange juice and glucogel, the blood sugar was rechecked with a reading of 56 (mg/dL), the resident continued to be confused, and the next blood sugar was 76 mg/dL.

There was no documented evidence that the hypoglycemic protocol and/or physician's orders were followed for Resident 58, and there was no evidence that the exact treatment provided was documented on the MAR and/or in the nursing notes.

Interview with the Director of Nursing on December 20, 2019, at 1:12 p.m. confirmed that the facility's hypoglycemic policy and Resident 58's physician's orders were not followed to treat his hypoglycemic episode.

42 CFR 483.25 Quality of Care.
Previously cited 12/13/18.

28 Pa. Code 211.12(d)(3) Nursing services.
Previously cited 12/13/18.

28 Pa. Code 211.12(d)(5) Nursing services
Previously cited 12/13/18.




 Plan of Correction - To be completed: 02/12/2020

Medication administrations for resident 12 were reviewed. Facility confirmed that Neurontin and Lidocaine patches were present on the med cart for resident 12. Physician was notified by the RN at the time of administration of the blood pressure outside of parameters for resident 12. Hypoglycemia orders were reviewed for resident 58. Medical Director was educated on the facility policy for Hypoglyemia. The order was revised to reflect facility Hypoglycemia protocol.

Medication Administrations will be monitored routinely as part of morning meeting for completeness and missed medication administrations. Any medications noted to be unavailable from pharmacy will be provided by a back up pharmacy. Vital signs will be monitored as part of morning meeting for any triggering vital signs that fall outside of parameters. An audit of all diabetic residents' orders will be completed to ensure they reflect the facility policy/protocol for hypoglycemia.

Director of Nursing/Designee will educate Licensed staff, new staff, and agency staff on their responsibility to notify administrative staff the need of acquiring a medication from the back up pharmacy. Director of Nursing/Designee will educate Licensed staff on the facility Hypoglycemia protocol and new orders. Director of Nursing/Designee will educate Licensed staff on notifying physician and properly documenting any blood pressures that fall outside of parameters.

Director of Nursing/Designee will complete audits of medication administrations for any missed administrations and any vital sign values outside of parameters, on 5 residents three times a week for 4 weeks and then monthly for 2 months. Director of Nursing/Designee will complete audits on resident blood sugars for the hypoglycemia protocol, on 3 diabetic residents three times a week for 4 weeks and then monthly for 2 months. Results of the above monitoring will be forwarded to the Quality Assurance Improvement Committee for review and recommendations.
483.24(a)(2) REQUIREMENT ADL Care Provided for Dependent Residents:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.24(a)(2) A resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene;
Observations:


Based on review of clinical records and grievance reports, as well as staff interviews, it was determined that the facility failed to remove a bed pan in a timely manner for one of 36 residents reviewed (Resident 7).

Findings include:

An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 7, dated September 23, 2019, revealed that the resident was cognitively impaired, was frequently incontinent of bowel and urine, and required extensive assistance with toileting.

A grievance report, dated September 23, 2019, revealed that Resident 7 stated that she felt as though she had something under her, and the occupational therapist found a bed pan that was filled with feces and urine, and had overflowed onto the bed. The resident had a red area on the coccyx (tailbone), an area behind the left knee, and a red area on the fold at the hip of her right leg. The facility's investigation, dated September 27, 2019, revealed that there were no staff found who had placed the bed pan under the resident.

Interview with the Director of Nursing on December 20, 2019, at 3:40 p.m. confirmed that staff failed to remove the bed pan from under Resident 7 in a timely manner.

42 CFR 483.24(a)(2) ADL Care Provided for Dependent Residents.
Previously cited 12/13/18.

28 Pa. Code 211.12(d)(5) Nursing services.
Previously cited 12/13/18.




 Plan of Correction - To be completed: 02/12/2020

Resident 7 no longer resides at the facility.

Director of Nursing/Designee will educate Nursing Staff on their responsibility to ensure residents who are unable to carry out their activities of daily living receive the necessary services to maintain good hygiene, and staffs responsibility to follow up with completion of care needs.

Director of Nursing/Designee will complete observational audits of Dependent residents Activities of Daily Living (ADL) care. These audits will be completed on 5 residents, 3 times a week for 4 weeks, then weekly for 2 months.
483.21(b)(3)(i) REQUIREMENT Services Provided Meet Professional Standards:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.21(b)(3) Comprehensive Care Plans
The services provided or arranged by the facility, as outlined by the comprehensive care plan, must-
(i) Meet professional standards of quality.
Observations:


Based on review of the Pennsylvania Nurse Practice Act, facility policies and residents' clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that a professional (registered) nurse completed an assessment of a resident following a change in condition for one of 36 residents reviewed (Resident 269).

Findings include:

The Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, 21.11 (a)(1)(2)(4) indicated that the registered nurse was to collect complete and ongoing data to determine nursing care needs, analyze the health status of individuals and compare the data with the norm when determining nursing care needs, and carry out nursing care actions that promote, maintain and restore the well-being of individuals.

The facility's policy regarding acute changes in condition, dated October 24, 2019, indicated that the nurse was to gather and document baseline information and assess the resident who was identified as having an acute change in condition.

Observations of Resident 269 on December 17, 2019, at 11:22 a.m. revealed that resident was in a wheelchair in his room, and his nailbeds were dark purple and his hands were cool. The surveyor asked Licensed Practical Nurse 1 to check the resident, and the nurse obtained oxygen saturation levels (the percentage of oxygen in the blood) of 73 percent and 65 percent (normal is 90-100 percent). Licensed Practical Nurse 1 placed the resident on oxygen at a flow rate of 2 liters per minute via nasal cannula (tubes placed in the nostrils). A recheck of Resident 269's oxygen saturation on December 17, 2019, at 11:42 a.m. revealed that the resident's readings were still low at 45 percent. Licensed Practical Nurse 1 stated that it was because the resident's hands were cold and that he would try to warm his hands to get a better reading. The pulse oximeter (machine that reads the oxygen level) was reading a correct pulse as confirmed by a manual pulse. The surveyor asked Licensed Practical Nurse 1 what he would do in this case, and he responded that he would put the resident on oxygen and recheck him. The nurse indicated that the resident was not having any issues. The surveyor asked the nurse if he would you do anything else, and he responded, "Not at this time, no."

As of December 18, 2019, at 9:52 a.m. there was no documented evidence that a registered nurse completed an assessment of Resident 269's change in condition on December 17, 2019.

An interview with Licensed Practical Nurse 1 on December 18, 2019, at 10:51 a.m. revealed that he did not document Resident 269's low oxygen (hypoxic) episode on December 17, 2019, and he did not notify the registered nurse about the change in the resident's condition.

An interview with the Director of Nursing on December 18, 2019, at 11:00 a.m. confirmed that there was no documented evidence that Licensed Practical Nurse 1 or a registered nurse documented Resident 269's hypoxic episode on December 17, 2019, and the licensed practical nurse should have notified the registered nurse, who should have assessed the resident.

42 CFR 483.21(b)(3)(i) Services Provided Meet Professional Standards.
Previously cited 12/13/18.

28 Pa. Code 211.12(d)(1) Nursing services.
Previously cited 12/13/18.

28 Pa. Code 211.12(d)(5) Nursing services.
Previously cited 12/13/18.







 Plan of Correction - To be completed: 02/12/2020

An Registered Nurse assessment was completed on resident 269.

Residents were reviewed for a 5 day look back for changes in conditions and the completion of a Registered Nurse assessment.

Facility Licensed Practical Nurses will notify the facility Registered Nurse of identified changes in condition. The Registered Nurse will complete an assessment on residents with changes in condition and document assessment findings in the medical record. The interdisciplinary team will review clinical alerts to identify any residents needing an RN assessment for a change in condition. Director of Nursing/Designee will educate Licensed Nurses on the identification of changes in condition and the requirement for a Registered Nurse assessment. The registered Nurses will be educated on their responsibility to complete an assessment for changes in condition and the completion of appropriate notifications. These educations will be provided to new and agency licensed staff.

Director of Nursing/Designee will audit as part of morning meeting that Registered Nurse assessments were completed and documented in the medical record on noted changes in condition. This audit will be completed on 5 residents, 3 times a week for 4 weeks and then once a week for 2 months. Results of the above monitoring will be forwarded to the Quality Assurance Improvement Committee for review and recommendations.
483.21(b)(2)(i)-(iii) REQUIREMENT Care Plan Timing and Revision:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.21(b) Comprehensive Care Plans
483.21(b)(2) A comprehensive care plan must be-
(i) Developed within 7 days after completion of the comprehensive assessment.
(ii) Prepared by an interdisciplinary team, that includes but is not limited to--
(A) The attending physician.
(B) A registered nurse with responsibility for the resident.
(C) A nurse aide with responsibility for the resident.
(D) A member of food and nutrition services staff.
(E) To the extent practicable, the participation of the resident and the resident's representative(s). An explanation must be included in a resident's medical record if the participation of the resident and their resident representative is determined not practicable for the development of the resident's care plan.
(F) Other appropriate staff or professionals in disciplines as determined by the resident's needs or as requested by the resident.
(iii)Reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments.
Observations:


Based on clinical record reviews, observations and staff interviews, it was determined that the facility failed to review and revise care plans to reflect current care needs for one of 36 residents reviewed (Resident 63).

Findings include:

A quarterly Minimum Data Set (MDS) assessment for Resident 63, dated December 2, 2019, revealed that the resident was cognitively impaired, required assistance with eating, and received a mechanically altered diet. Resident 63's care plan, initially dated December 21, 2018, revealed that she was at a nutritional risk due to non-compliance with the current pureed consistency diet, and an intervention was for the resident, family, and power of attorney (POA - a person legally authorized to make decisions for another) to be educated on importance of strict adherence to the resident's need for pureed food. The resident's care plan, revised on April 5, 2019, indicated the resident, family, and POA were to comply with the current diet regimen.

Physician's orders for Resident 63, dated September 19, 2019, included an order for the resident to receive a mechanical soft diet with chopped texture and no rice.

Observations during the lunch meal on December 17, 2019, at 12:35 p.m. revealed that Resident 63 was being assisted by a family member to eat a mechanical soft consistency meal.

There was no documented evidence that Resident 63's care plan was revised to reflect that she was to receive a mechanical soft consistency diet versus a pureed consistency diet.

Interview with the Dietitian on December 19, 2019, at 3:25 p.m. confirmed that Resident 63 previously received a pureed diet, and her care plan should have been updated to reflect the current diet order.

42 CFR 483.21(b)(2)(i)-(iii) Care Plan Timing and Revision.
Previously cited 12/13/18.

28 Pa. Code 211.11(d) Resident care plan.
Previously cited 12/13/18.

28 Pa. Code 211.12(d)(5) Nursing services.
Previously cited 12/13/18.




 Plan of Correction - To be completed: 02/12/2020

Resident 63's care plan was reviewed and updated to reflect current diet order. The facility conducted an audit of all care plans to ensure the residents accurate diet is reflected on the care plan.


The plans of care for residents will be assessed for individualization and will be updated accordingly. The licensed staff were instructed that they must update the care plan when any diet change occurs. As part of the daily clinical review, any changes will be reviewed to ensure appropriate care plan revision. Care plan reviews will occur quarterly with quarterly reviews. Licensed staff will be educated on the need to update the care plan as changes occur. This education will also be provided to new facility and agency licensed staff.

Dietician/Designee will randomly audit 3 care plans weekly for 2 weeks a weeks and monthly for 2 months to assure all residents diets are care planned accurately. Care plans are reviewed and updated with clinical changes. The results of the audit will reviewed at the monthly Quality Assurance meeting for recommendations as necessary.

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


Based on clinical record reviews and staff interviews, it was determined that the facility failed to ensure that resident-centered care plans were developed to meet each resident's care needs for one of 36 residents reviewed (Resident 64).

Findings include:

A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 64, dated December 3, 2019, revealed that the resident was cognitively intact, received anti-anxiety medication daily, and had diagnoses that included anxiety (a feeling of worry, nervousness, or unease).

Physician's orders for Resident 64, dated September 27, 2019, included an order for the resident to receive one 0.5 milligram (mg) tablet of Ativan (medication used to treat anxiety) every eight hours.

There was no documented evidence that a care plan was developed to address Resident 64's care needs related to anxiety.

Interview with the Director of Nursing on December 19, 2019, at 2:42 p.m. confirmed that a care plan to address anxiety for Resident 64 should have been developed.

42 CFR 483.21(b)(1) Develop/Implement Comprehensive Care Plan.
Previously cited 12/13/18.

28 Pa. Code 211.11(d) Resident care plan.
Previously cited 12/13/18.

28 Pa. Code 211.12(d)(5) Nursing services.
Previously cited 12/13/18.




 Plan of Correction - To be completed: 02/12/2020

The plan of care for resident 64 has been updated to include specific care needs related to the diagnosis of anxiety.

Current residents were reviewed. Residents who were identified with a diagnosis of anxiety had care plans reviewed and revised if needed.

The Registered Nurse Assessment Coordinator will be educated by clinical support services on F 656 and the need to development and implement a resident centered care plan. The interdisciplinary team reviews resident changes as part of the daily clinical review. Care plans will be reviewed and revised to reflect changes with this review. Care plans will be reviewed quarterly with care conferences.

Director of Nursing/Designee will audit resident care plans to ensure residents centered care plans are in place and meet the resident care needs. This audit will be completed on 5 residents weekly for 1 month, and then 5 residents monthly for 2 months.
483.10(g)(14)(i)-(iv)(15) REQUIREMENT Notify of Changes (Injury/Decline/Room, etc.):This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.10(g)(14) Notification of Changes.
(i) A facility must immediately inform the resident; consult with the resident's physician; and notify, consistent with his or her authority, the resident representative(s) when there is-
(A) An accident involving the resident which results in injury and has the potential for requiring physician intervention;
(B) A significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications);
(C) A need to alter treatment significantly (that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment); or
(D) A decision to transfer or discharge the resident from the facility as specified in 483.15(c)(1)(ii).
(ii) When making notification under paragraph (g)(14)(i) of this section, the facility must ensure that all pertinent information specified in 483.15(c)(2) is available and provided upon request to the physician.
(iii) The facility must also promptly notify the resident and the resident representative, if any, when there is-
(A) A change in room or roommate assignment as specified in 483.10(e)(6); or
(B) A change in resident rights under Federal or State law or regulations as specified in paragraph (e)(10) of this section.
(iv) The facility must record and periodically update the address (mailing and email) and phone number of the resident
representative(s).

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


Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that the resident's attending physician was notified about significant changes in condition for one of 36 residents reviewed (Resident 269).

Findings include:

The facility's policy regarding charting and documentation, dated October 24, 2019, indicated that a resident's changes in condition should be documented and that the physician should be notified.

An admission nursing note dated December 16, 2019, indicated that the resident was oriented to person and place, his skin color was normal, his nail beds were normal in appearance with brisk capillary refill, his lips and mucus membranes were pink in color, his lung sounds were diminished throughout all fields, and oxygen was ordered as needed.

Observations of Resident 269 on December 17, 2019, at 11:22 a.m. revealed that the resident was in a wheelchair in his room, and his nail beds were dark purple and his hands were cool. The surveyor asked Licensed Practical Nurse 1 to check the resident, and the nurse obtained oxygen saturation levels (the percentage of oxygen in the blood) of 73 percent and 65 percent (normal is 90-100 percent). Licensed Practical Nurse 1 placed the resident on oxygen at a flow rate of 2 liters per minute via nasal cannula (tubes placed in the nostrils). A recheck of Resident 269's oxygen saturation on December 17, 2019, at 11:42 a.m. revealed that the resident's readings were still low at 45 percent. Licensed Practical Nurse 1 stated that it was because the resident's hands were cold and that he would try to warm his hands to get a better reading. The pulse oximeter (machine that reads the oxygen level) was reading a correct pulse as confirmed by a manual pulse. The surveyor asked Licensed Practical Nurse 1 what he would do in this case, and he responded that he would put the resident on oxygen and recheck him. The nurse indicated that the resident was not having any issues. The surveyor asked the nurse if he would do anything else, and he responded, "Not at this time, no."

As of December 18, 2019, at 9:52 a.m. there was no documented evidence that the physician was notified about Resident 269's change in condition on December 17, 2019.

An interview with Licensed Practical Nurse 1 on December 18, 2019, at 10:51 a.m. revealed that he did not notify the physician about Resident 269's low oxygen (hypoxic) episode on December 17, 2019.

An interview with the Director of Nursing on December 18, 2019, at 11:00 a.m. confirmed that there was no documented evidence that the physician was notified about the change in Resident 269's condition on December 17, 2019.

42 CFR 483.10(g)(14)(i)-(iv)(15) Notify of Changes (Injury/Decline/Room, Etc.)
Previously cited 12/13/18.

28 Pa. Code 211.12(d)(3)(5) Nursing services.
Previously cited 12/13/18.





 Plan of Correction - To be completed: 02/12/2020

Resident 269 was assessed by the Registered Nurse. The physician was notified of the application of oxygen and assessment findings.

A baseline audit was completed for a 5 day look back to ensure residents with a change in condition had appropriate notifications. As part of morning meeting a clinical review will take place to identify the need of any physician notification.

Facility Licensed Practical Nurses will notify the facility Registered Nurse of identified changes in condition. The Registered Nurse, based on assessment findings, will make notifications to the attending physician. Director of Nursing/Designee will complete education on significant changes in condition that require notification to the physician and the responsibility of notifying the physician of resident changes in condition. This education will be provided as part of licensed staff orientation for new employees, and agency staff.

Director of Nursing/Designee will audit as part of morning meeting that physician was completed for residents having a change in condition. This audit will be completed on 5 residents, 3 times a week for 4 weeks and then once a week for 2 months. Results of above monitoring will be forwarded to the Quality Assurance/Improvement Committee for review and recommendation.




483.10(g)(5)(i)(ii) REQUIREMENT Required Postings:Least serious deficiency but affects more than a limited number of residents, staff, or occurrences. This deficiency has the potential for causing no more than a minor negative impact on the resident but is not found to be throughout this facility.
483.10(g)(5) The facility must post, in a form and manner accessible and understandable to residents, resident representatives:
(i) A list of names, addresses (mailing and email), and telephone numbers of all pertinent State agencies and advocacy groups, such as the State Survey Agency, the State licensure office, adult protective services where state law provides for jurisdiction in long-term care facilities, the Office of the State Long-Term Care Ombudsman program, the protection and advocacy network, home and community based service programs, and the Medicaid Fraud Control Unit; and
(ii) A statement that the resident may file a complaint with the State Survey Agency concerning any suspected violation of state or federal nursing facility regulation, including but not limited to resident abuse, neglect, exploitation, misappropriation of resident property in the facility, and non-compliance with the advanced directives requirements (42 CFR part 489 subpart I) and requests for information regarding returning to the community.
Observations:


Based on observations and staff interviews, it was determined that the facility failed to ensure that information regarding how to contact all pertinent resident advocacy agencies was accessible to residents.

Findings include:

Observations on December 18, 2019, at 7:50 a.m. and December 19, 2019, at 9:10 a.m. revealed that information regarding how to contact the State Survey Agency (Department of Health) was not accessible to residents and was posted at the top of the bulletin board on the third floor.

Observations on December 19, 2019, at 5:32 p.m. revealed that information regarding how to contact the State Survey Agency (Department of Health) was not accessible to residents and was posted at the top of the bulletin board on the second floor.

Interview with the Director of Nursing on December 20, 2019, at 1:35 p.m. confirmed that the posted information about contacting the Department of Health was not accessible to all residents.

42 CFR 483.10(g)(5)(i)(ii) Required Postings.
Previously cited 12/13/18.

28 Pa. Code 201.29(i) Resident rights.
Previously cited 12/13/18.





 Plan of Correction - To be completed: 02/12/2020

The information regarding how to contact State Survey Agency (Department of Health) was moved immediately to an accessible level for residents.

The facility will conduct baseline audit that pertinent resident advocacy agencies are posted on each floor at an accessible level for residents.

The Nursing Home Administrator/Designee will educate facility Department heads that resident advocacy postings must be posted at an accessible level for residents on each floor.

The Nursing Home Administrator/Designee will audit that postings are maintained at accessible levels on each floor. This audit will be conducted weekly for 3 months. Results of the above monitoring will be forwarded to the Quality Assurance/Improvement Committee for review and recommendation.
483.10(g)(17)(18)(i)-(v) REQUIREMENT Medicaid/Medicare Coverage/Liability Notice:Least serious deficiency but affects more than a limited number of residents, staff, or occurrences. This deficiency has the potential for causing no more than a minor negative impact on the resident but is 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 clinical record reviews and staff interviews, it was determined that the facility failed to provide an Advance Beneficiary Notice of Non-Coverage (ABN) in a timely manner to two of three residents reviewed (Residents 56, 63) who remained in the facility after their Medicare coverage ended.

Findings include:

A Skilled Nursing Facility (SNF) Beneficiary Protection Notification Review form completed by the facility revealed that Medicare coverage for Resident 56 started on November 5, 2019, and the resident's last covered day was November 21, 2019. The form indicated that the facility initiated discontinuation from Medicare Part A coverage and that the resident's benefit days were not exhausted. There was no documented evidence that Resident 56 was provided with an ABN notice at least 48 hours prior to the end of Medicare coverage.

A SNF Beneficiary Protection Notification Review form completed by the facility revealed that Medicare coverage for Resident 63 started on August 26, 2019, and the resident's last covered day was September 8, 2019. The form indicated that the facility initiated discontinuation from Medicare Part A coverage and that the resident's benefit days were not exhausted. There was no documented evidence that Resident 63 was provided with an ABN notice at least 48 hours prior to the end of Medicare coverage.

Interview with the Nursing Home Administrator on December 20, 2019, at 1:24 p.m. confirmed that Residents 56 and 63 were not provided with a timely ABN notice as required.

28 Pa. Code 201.18(e)(1) Management.
Previously cited 12/13/18.


 Plan of Correction - To be completed: 02/12/2020

Medicare Beneficiary Protection Notification Review Form has been provided for resident 56 and resident 63.

Residents who experience a change in his/her Medicare coverage are at risk for being affected by the sited practice.

The Social Service Director has received education by the Nursing Home Administrator on the regulatory Guidelines regarding timely presentation of the Medicare Beneficiary Protection Notification Review Form. A checklist has been originated and being maintained by the Social Services Director.

The Nursing Home Administrator/Designee will audit the checklist along with resident conversation to ensure the forms were received. This audit will occur weekly for 4 weeks then monthly for 2 months. Results of the above monitoring will be forwarded to the Quality Assurance Improvement Committee for review and recommendation.
483.75(g)(1)(i)-(iii)(2)(i) REQUIREMENT QAA Committee:Least serious deficiency but affects more than a limited number of residents, staff, or occurrences. This deficiency has the potential for causing no more than a minor negative impact on the resident but is not found to be throughout this facility.
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;

483.75(g)(2) The quality assessment and assurance committee must:
(i) Meet at least quarterly and as needed to identifying issues with respect to which quality assessment and assurance activities are necessary.
Observations:


Based on review of attendance records for the facility's Quality Assurance Committee, as well as staff interviews, it was determined that the facility failed to ensure that all required members of the Quality Assurance Committee attended quarterly meetings.

Findings include:

Review of the attendance records for the facility's Quality Assurance Committee meetings revealed that the Medical Director did not attend any meetings that were held during the third and fourth quarters of 2019.

Interview with the Nursing Home Administrator on December 19, 2019, at 9:00 a.m. confirmed that neither the Medical Director nor a designee attended meetings of the Quality Assurance Committee that were held during the third and fourth quarters of 2019.




 Plan of Correction - To be completed: 02/12/2020

The facility Medical Director has been educated by the Director of Nursing his responsibility to participate and attend the Quality Assurance and Improvement Committee.

Director of Nursing provided Medical Director Quality Assurance and Improvement Meeting schedule.

The Nursing Home Administrator will be audit the signature sheet and validate the attendance of the Medical Director during the Quality Assurance and Improvement meetings.

This audit will be completed to ensure attendance occurs on a quarterly basis.
201.14(a) LICENSURE Responsibility of licensee.:State only Deficiency.
(a) The licensee is responsible for meeting the minimum standards for the operation of a facility as set forth by the Department and by other State and local agencies responsible for the health and welfare of residents.
Observations:


Based on review of Pennsylvania laws and Infection Control Committee meeting minutes, as well as staff interviews, it was determined that the facility failed to ensure that the medical director attended meetings of the Multi-disciplinary Infection Control Committee.

Findings include:

The Act 52 Infection Control Plan, dated March 20, 2002, revealed that a health care facility should develop and implement an internal infection control plan that should be established for the purpose of improving the health and safety of residents and health care workers, and should include a multidisciplinary committee including a representative from each of the following, if applicable to the specific health care facility. Applicable members included medical staff that would include the chief medical officer or nursing home medical director; the nursing home administrator; laboratory personnel; nursing staff that would include the director of nursing or a nursing supervisor; pharmacy staff; physical plant personnel; a patient safety officer; and a community member that may not be an agent, employee or contractor of the facility.

The Infection Control Committee attendance records, dated January 17, April 12, May, June 20, July 18, August 15, September 19, October 17, and November 21, 2019, revealed that the medical director was not in attendance at the meetings.

Interview on December 20, 2019, at 10:53 a.m. with the facility's Registered Nurse Assessment Coordinator (RNAC), who was the previous Infection Control Nurse, confirmed that there was no documented evidence that the medical director was in attendance at the above Infection Control Committee meetings.





 Plan of Correction - To be completed: 02/12/2020

Facility Medical Director has been educated by the Director of Nursing on his responsibility as Medical Director to attend the Multidisciplinary Infection Control Committee meetings.

Medical Director has been provided the Multidisciplinary Infection Control Committee meeting calendar for 2020, by the Director of Nursing.

The Nursing Home Administration will audit Multidisciplinary Infection Control Committee meeting signature sheet to validate Medical Director attendance.
201.22(e) LICENSURE Prevention, control and surveillance of TB.:State only Deficiency.
(e) The 2-step intradermal tuberculin skin test shall be the method used for initial testing of residents and employes. If the first test is positive, the person tested shall be considered to be infected. If the first test is negative, a second test should be administered in 1--3 weeks. If the second test is positive, the person tested shall be considered to be previously infected. If the second test result is negative, the person is to be classified as uninfected.
Observations:


Based on review of policies and employee records, as well as staff interviews, it was determined that the facility failed to ensure that a two-step tuberculin skin test was completed for four of five newly hired employees reviewed (Employees 3, 4, 5, 6).

Findings include:

The personnel file for Employee 3 revealed that she was hired on October 28, 2019. There was no documented evidence that Employee 3 had a previous two-step tuberculin test or completed a two-step tuberculin skin test upon hire.

The personnel file for Employee 4 revealed that he was hired on September 9, 2019. There was no documented evidence that Employee 4 had a previous two-step tuberculin test or completed a two-step tuberculin skin test upon hire.

The personnel file for Employee 5 revealed that she was hired on September 4, 2019. There was no documented evidence that Employee 5 had a previous two-step tuberculin test or completed a two-step tuberculin skin test upon hire.

The personnel file for Employee 6 revealed that she was hired on October 3, 2019. There was no documented evidence that Employee 6 had a previous two-step tuberculin test or completed a two-step tuberculin skin test upon hire.

Interviews with the Nursing Home Administrator and the Director of Nursing on December 19, 2019, at 11:30 a.m. confirmed that they had no documented evidence that the above new employees had prior two-step tuberculosis tests or that they completed two-step tuberculosis tests prior to being hired.




 Plan of Correction - To be completed: 02/12/2020

Director of Clinical Services educated the Nursing Home Administrator, the Director of Nursing, and the Infection Control Committee on the require to perform a two step intradermal Tuberculin skin test for initial testing of residents and employees. The information on dates initial and second step given and the results when read be recorded and presented to the Quality Assurance meeting.


Human Resources will ensure completion of Two Step Tuberculin Skin Test of all new hires. Registered Nurse Assessment Coordinator will ensure completion of Two Step Tuberculin Skin Test is completed on all new residents. Director of Nursing/Designee will review audit findings through Infection control meetings and Quality Assurance meetings.
205.26(e) LICENSURE Laundry.:State only Deficiency.
(e) Equipment shall be made available and accessible for residents desiring to do their personal laundry.
Observations:


Based on observations and staff interviews, it was determined that the facility failed to ensure that laundry equipment was available and accessible for residents desiring to do their own laundry.

Findings include:

Daily observations of the facility revealed there was no laundry equipment for the residents to utilize for personal laundry if they would wish to do so.

Interview with Housekeeper/Laundry Employee 9 on December 19, 2019, at 10:15 p.m. revealed that residents were not permitted to do their own laundry.

Interview with Occupational Therapy Assistant 10 on December 19, 2019, at 1:24 p.m. revealed that the therapy room did not have laundry equipment.

Interview with the Nursing Home Administrator on December 19, 2019, at 1:34 p.m. confirmed that there was no laundry equipment in the building for the residents to use should they wish to do their own laundry.





 Plan of Correction - To be completed: 02/12/2020

The facility has purchased laundry equipment for the residents to use should they wish to do their own laundry. The laundry equipment area was also marked with a sign so residents can recognize this area is designated for their personal use. The Activity Director has also reiterated this new area in Resident Council meeting.The availability of the personal laundry machines will be provided to the residents in the new admission packet.

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