Nursing Investigation Results -

Pennsylvania Department of Health
MEADOWS NURSING AND REHABILITATION CENTER
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

MEADOWS NURSING AND REHABILITATION CENTER
Inspection Results For:
There are 74 surveys for this facility. Please select a date to view the survey results.

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MEADOWS NURSING AND REHABILITATION CENTER - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:

Based on a Medicare/Medicaid Recertification, State Licensure, Civil Rights Compliance and Abbreviated Complaint Survey completed on November 5, 2021, it was determined that Meadows Nursing and Rehabilitation Center was not in compliance with the following requirements of 42 CFR Part 483 Subpart B Requirements for Long Term Care and the 28 PA Code, Commonwealth of Pennsylvania Long Term Licensure Regulations.

Plan of Correction:

483.10(f)(5)(i)-(iv)(6)(7) REQUIREMENT Resident/Family Group and Response:

This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.

§483.10(f)(5) The resident has a right to organize and participate in resident groups in the facility.
(i) The facility must provide a resident or family group, if one exists, with private space; and take reasonable steps, with the approval of the group, to make residents and family members aware of upcoming meetings in a timely manner.
(ii) Staff, visitors, or other guests may attend resident group or family group meetings only at the respective group's invitation.
(iii) The facility must provide a designated staff person who is approved by the resident or family group and the facility and who is responsible for providing assistance and responding to written requests that result from group meetings.
(iv) The facility must consider the views of a resident or family group and act promptly upon the grievances and recommendations of such groups concerning issues of resident care and life in the facility.
(A) The facility must be able to demonstrate their response and rationale for such response.
(B) This should not be construed to mean that the facility must implement as recommended every request of the resident or family group.

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

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

Plan of Correction - To be completed: 01/04/2022

1. All occupied resident rooms have a clock in their room.
2. Current Resident complaints/grievances expressed during Resident Council shall be promptly addressed through the Grievance Concern Process and documented in the Resident Council Minutes. Residents shall be informed of the corrective action taken to address their concerns within five business days, per facility policy.
The Resident Council minutes shall identify the specific concerns expressed by the resident and that the resident concerns have been resolved or if they remain an issue.
3. Health Care Personnel will receive education on the Facility Grievance Process.
4. NHA/designee will audit Resident Council minutes to ensure issues/grievances are addressed and supporting documentation exists to ascertain resident awareness and/or satisfaction with actions taken by the facility to resolve or respond to the concern raised by resident. Results of audit will be presented at Quality Assurance meeting for recommendation and review.
5.Corrective Action Date January 4, 2022

483.55(b)(1)-(5) REQUIREMENT Routine/Emergency Dental Srvcs in NFs:

§483.55 Dental Services
The facility must assist residents in obtaining routine and 24-hour emergency dental care.

§483.55(b) Nursing Facilities.
The facility-

§483.55(b)(1) Must provide or obtain from an outside resource, in accordance with §483.70(g) of this part, the following dental services to meet the needs of each resident:
(i) Routine dental services (to the extent covered under the State plan); and
(ii) Emergency dental services;

§483.55(b)(2) Must, if necessary or if requested, assist the resident-
(i) In making appointments; and
(ii) By arranging for transportation to and from the dental services locations;

§483.55(b)(3) Must promptly, within 3 days, refer residents with lost or damaged dentures for dental services. If a referral does not occur within 3 days, the facility must provide documentation of what they did to ensure the resident could still eat and drink adequately while awaiting dental services and the extenuating circumstances that led to the delay;

§483.55(b)(4) Must have a policy identifying those circumstances when the loss or damage of dentures is the facility's responsibility and may not charge a resident for the loss or damage of dentures determined in accordance with facility policy to be the facility's responsibility; and

§483.55(b)(5) Must assist residents who are eligible and wish to participate to apply for reimbursement of dental services as an incurred medical expense under the State plan.

Observations:

Based on review of clinical records and staff interview, it was determined that the facility failed to offer routine annual dental services for three Medicaid payor sources out of 18 residents sampled. (Resident 36, 56, and 70).

Findings include:

Review of Resident 36's clinical record indicated that the resident was admitted to the facility on March 5, 2012, and that the resident's payor source was Medicaid. The resident was seen by the dentist on October 7, 2020. Dental notes indicated that the resident had plaque and calculus buildup and would benefit from a 6 month cleaning. There was no indication Resident 36 was seen by the dentist since October 7, 2020, and no indication the resident received a 6 month cleaning.

Review of Resident 56's clinical record indicated that the resident was admitted to the facility on November 10, 2017, and that the resident's payor source was Medicaid. There was no documented evidence that the resident had been offered dental services in the past year.

Review of Resident 70's clinical record indicated that the resident was admitted to the facility on April 10, 2017, and that the resident's payor source was Medicaid. The resident was seen by the dentist on October 7, 2020. Dental notes indicated that the resident had plaque and calculus buildup and would benefit from a 6 month cleaning. There was no indication that Resident 70 was seen by the dentist since October 7, 2020, and no indication the resident received a 6 month cleaning.

Interview with the Director of Nursing on November 5, 2021 at 10:30 a.m. confirmed that the facility had no documented evidence that Resident's 36, 56 and 70 were offered routine dental services in the past year.

28 Pa. Code 211.15(a) Dental services

Plan of Correction - To be completed: 01/04/2022

1. Resident 36 had an annual exam on 11/18/2021; Resident 70 is deceased and Resident 56's resident representative does not wish for resident to have an annual exam or dental services.

2. Facility has sent a mass mailing to resident and/or their representative inquiring if they would like to receive dental care from the on-site dentist (HealthDrive) or wish to make alternate arrangements. The UDA Eye and Dental Assessment has been revised to include was dental exam offered.

3. Resident and/or Resident Representative shall be offered annual dental services during eye and dental assessment with annual or significant change in status MDS. Results of audit shall be presented at QA for comment and review.

4.Corrective Action Date January 4, 2022

483.45(a)(b)(1)-(3) REQUIREMENT Pharmacy Srvcs/Procedures/Pharmacist/Records:

§483.45 Pharmacy Services
The facility must provide routine and emergency drugs and biologicals to its residents, or obtain them under an agreement described in §483.70(g). The facility may permit unlicensed personnel to administer drugs if State law permits, but only under the general supervision of a licensed nurse.

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

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

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

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

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

Observations:

Based on clinical record review and staff interview, it was determined that the facility failed to implement procedures to promote accurate narcotic medication records for one resident (Resident 79) and failed to ensure physician-ordered medications were available in a timely manner for one resident out of 18 sampled. (Resident CR1).

Findings include:

A review of the clinical record revealed that Resident 79 was admitted to the facility on July 2, 2021, with diagnoses of pain and dementia. The resident expired in the facility on August 29, 2021.

The resident had physicians orders dated August 27, 2021, for Morphine Sulfate Solution (a pain medication) 5 milligrams (mg) sublingually four times a day for dyspnea/pain and for Ativan (an anti-anxiety medication) 0.5 mg sublingually every 4 hours for end stage agitation.

Review of the Medication Administration Record (MAR) for August 2021 indicated that Morphine Sulfate Solution and the Ativan were administered August 27, 2021, August 28, 2021, and August 29, 2021. At the time of the survey ending November 5, 2021, there was no documented evidence of a Controlled Drug Records for the resident's Morphine Sulfate Solution and Ativan and no evidence of the quantity remaining at the time of the resident's discharge and its disposal.

Interview with the Director of Nursing on November 5, 2021, at 12:30 p.m. confirmed that there was no documented evidence of the quantity and disposition of any remaining Morphine Sulfate Solution and Ativan upon the resident's discharge.

Resident CR1 was admitted to the facility on October 27, 2021, with numerous diagnoses including end stage kidney disease with dependence on dialysis, hypertension, heart failure, and benign neoplasm of cerebral meninges (a tumor that grows from the protective membranes that cover the brain and spinal cord).

Among the resident's physician ordered medications upon admission, were Apixaban 2.5 mg give one tablet daily for atrial fibrillation, Calcium-Vitamin D3 tablet 250-125 mg give one tablet two times a day (day and time dependent on dialysis days), Famotidine 10mg give one tablet by mouth two times a day for GERD (gastroesophageal reflux disease), Lactobacillus Acid-Pectin Capsule give one capsule two times a day for supplement, Levetiracetam 500 mg one tablet two times a day for meningioma of brain with seizures (day and time dependent on dialysis days), Levothyroxine Sodium 100 mcg one tablet at bedtime for hypothyroidism, Prednisone 10mg give 5 tablets in the afternoon until 10/28/21, Prednisone 20mg one tablet in the afternoon for hypopituitarism, Prednisone 10mg give 4 tablets in the afternoon until 10/29/21 for hypopituitarism, Prednisone 10mg give 3 tablets in the afternoon until 10/30/21 for hypopituitarism, Renvela 800 mg two tablets with meals chronic kidney disease with hemodialysis (day and time dependent on dialysis days), and Testosterone Gel 10 mg/act (2%) apply 4 pumps transdermally one time a day for panhypopituitarism.

A review of the resident's medication administration records for October 2021, revealed that Prednisone 10 mg five tablets, Testosterone gel, Apixaban, Calcium-Vit D3, Famotidine, Lactobacillus, Levetiracetam, and Renvela were not administered as ordered in the morning of October 28, 2021. The October 2021 medication administration record revealed that Famotidine, Lactobacillus evening doses and Renvela afternoon dose were not administered on October 28, 2021.

Further review of the resident's clinical record revealed that Employee 5, licensed practical nurse (LPN), documented on October 28, 2021, that the resident's medications had not been received from pharmacy.

When interviewed on November 4, 2021, at 11:05 a.m., the Nursing Home Administrator and Director of Nursing were unaware that the facility was having any issues with obtaining m
medications from the pharmacy timely.

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

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

Plan of Correction - To be completed: 01/04/2022

1. Resident CR1's controlled record was unable to be located.
2. RN Staff Development Nurse/Designee will educate nursing personnel on Controlled substances Policy.
3. Pharmacy delivery occurs twice a day with cut-off order times. Facility has access to an Omnicell (emergency back-up dispense machine) on premise, as well as the ability to utilize a back-up pharmacy to obtain medications. Licensed Nursing personnel will be re-educated on use of Omnicell, pharmacy ordering and delivery protocols, and if medication can not be obtained the physician will be notified.
4. Current resident with a physician order for a controlled drug will be audited for an accurate controlled drug record to include disposition and quantity of remaining controlled drug.
5. Current resident records will be audited for discontinuation of controlled drugs with accuracy for disposition and quantity.
6. New resident admissions EMAR shall be reviewed to ensure medications have been received by Pharmacy and administered as per physician's order. Results of audit will be presented to QA for comment and review.
7. Corrective Action Date January 4, 2022

483.25 REQUIREMENT Quality of Care:

§ 483.25 Quality of care
Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices.

Observations:

Based on review of clinical records and select facility policy, and staff interview it was determined that the facility failed to provide nursing services consistent with professional standards of quality by failing to ensure that licensed nurses accurately administered prescribed medications to one of 18 sampled residents (Resident 278).

Findings included:

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

A review of the clinical record of Resident 278 revealed readmission to the facility on October 4, 2021, with diagnoses, which included orthostatic hypotension (a form of low blood pressure that happens when standing up from sitting or lying down), congestive heart failure, and hypertension and had moderate cognitive impairment.

A physician order dated October 6, 2021, was noted for Losartan Potassium 100mg one tablet orally one time a day for diagnosis of hypertension. Hold the medication for systolic blood pressure (top number on blood pressure reading) less than 100 and/or diastolic blood pressure (bottom number on blood pressure reading) less than 60.

A review of Resident 278's medication administration record dated October 2021, revealed that on October 6 through October 12, 2021, the medication was administered without documented evidence that the resident's blood pressure was obtained prior to administration.

Further review of the medication administration record revealed that from October 13, 2021, through October 31, 2021, the medication was administered on 8 occasions, despite Resident 278's blood pressure being below the prescribed parameters.

A review of Resident 278's medication administration record dated November 2021, revealed that the medication was administered on 2 occasions, despite the resident's blood pressure being below the prescribed parameters.

Interview with the Nursing Home Administrator on November 4, 2021, at approximately 11:30 a.m. confirmed that there was no evidence that Resident 278's blood pressure medication was administered by the licensed nurses as prescribed.

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

28 Pa. Code 211.5 (f)(g)(h) Clinical Records

Plan of Correction - To be completed: 01/04/2022

1. Resident 278 is receiving blood pressure medication as prescribed by a licensed nurse. Medication is administered with documented evidence that the resident's blood pressure was obtained prior to administration.
2. Current residents with blood pressure parameters are receiving medications as prescribed with appropriate documentation that resident blood pressure is being obtained prior to administration.
3. Staff Development Nurse/Designee will provide reeducation to licensed nurses regarding following Physician orders for BP medication with parameters. ADON/Designee will audit residents on blood pressure medications with parameters to ensure medications are administered according to physician order. Results of audits will be reported to QA committee for review and recommendations.
4. Corrective Action Date January 4, 2021

483.12(a)(3)(4) REQUIREMENT Not Employ/Engage Staff w/ Adverse Actions:

This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.

§483.12(a) The facility must-

§483.12(a)(3) Not employ or otherwise engage individuals who-
(i) Have been found guilty of abuse, neglect, exploitation, misappropriation of property, or mistreatment by a court of law;
(ii) Have had a finding entered into the State nurse aide registry concerning abuse, neglect, exploitation, mistreatment of residents or misappropriation of their property; or
(iii) Have a disciplinary action in effect against his or her professional license by a state licensure body as a result of a finding of abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property.

§483.12(a)(4) Report to the State nurse aide registry or licensing authorities any knowledge it has of actions by a court of law against an employee, which would indicate unfitness for service as a nurse aide or other facility staff.

Observations:

Based on review of employee personnel files and select facility policy and staff interviews, it was determined the facility failed to screen one of five employees sampled to ensure that they were eligible for employment in a long-term care nursing facility. (Employee 1)

Findings include:

In accordance with Act 13 Elder Abuse Mandatory Reporting and Act 169 Criminal Background Checks, nursing facilities are required to obtain a criminal background check on all newly hired employees. Facilities are required to obtain the Pennsylvania State Police background check within 30 days of hire on all prospective employees. If the prospective employee does not have continuous residency in Pennsylvania for two years prior to employment, then the facility is required to obtain a Federal Bureau of Investigation (FBI) check within 90 days.

A review of the facility policy entitled "Investigation of Allegations of Abuse, Neglect or the Misappropriation of Resident Property" last reviewed August 2021 indicated that prospective employees will verify Pennsylvania residency by completing the Pre-employment Criminal History Information Form. This will be completed prior to the date of hire. Further review revealed that the last 2 places of employment will be contacted for a positive reference prior to date of hire. One employment and one personal reference check will be checked at minimum. Prospective employees will complete a "Request for Criminal Record Check" form. The facility conducts a criminal background check on-line via the PATCH system prior to commencement of work. A positive report will be obtained within 30 days from date of hire.

A review of the personnel file of Employee 1, licensed practical nurse (LPN), hired by the facility on July 30, 2021, revealed that a Pennsylvania State Police Background Check and reference checks were not completed prior to Employee 1 upon employment.

Interview with Employee 2, Human Resources Manager, on November 5, 2021 at approximately 11:03 AM revealed that Employee 1 had initially been employed at the facility as a nurse aide from November 2017 to May 2021. Employee 1 then resigned from her nurse aide position and took a job as an LPN in another facility until July 2021. Employee 2 further stated that the background check and reference checks that were completed on Employee 1 upon hire in November 2017 were the same background check and references used for her re-hire in July 2021.

Additional Interview with Employee 2, the Human Resources Manager on November 5, 2021 at 11:41 a.m. confirmed that a Pennsylvania State Police background check and reference checks were not completed on Employee 1 upon re-hire and according to policy, each should have been completed.

28 Pa. Code 201.14(a) Responsibility of Licensee

28 Pa Code 201.18 (e)(1) Management

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

28 Pa. Code 201.19 Personnel policies and procedures

Plan of Correction - To be completed: 01/04/2022

1. A Pennsylvania State Police Background Check and reference checks have been completed for Employee 1
2. Employees hired since November 1, 2021 have been reviewed and Background Checks and References have been completed.
3. New Hires and Re-Hires are screened to ensure eligibility for employment in a long-term care nursing facility. PA State Police Background Checks and Reference Checks have been completed according to facility policy and Act 13 and Act 169.
4. NHA/Designee will audit new hires/re-hires file for appropriate background checks and reference checks completed prior to date of hire. Results of audit will be presented at Quality Assurance meeting for recommendation and review.
5. Corrective Action Date January 4, 2022

483.20(g) REQUIREMENT Accuracy of Assessments:

§483.20(g) Accuracy of Assessments.
The assessment must accurately reflect the resident's status.

Observations:

Based on a review of clinical records and the Resident Assessment Instrument (RAI) and staff interviews, it was determined that the facility failed to ensure that the Minimum Data Set Assessments (MDS - a federally mandated standardized assessment conducted at specific intervals to plan resident care) accurately reflected the status of two residents out of 18 sampled (Resident 78 and 50).

Findings include:

A review of Resident 78's discharge MDS Assessment dated August 8, 2021, revealed Section A2100 was coded as "03" indicating that the resident was discharged to an acute care hospital.

However, a review of Resident 78's clinical record revealed that the resident was discharged home with home health services.

Interview with the Nursing Home Administrator on November 4, 2021, at approximately 11:30 AM confirmed that the resident's MDS Assessment dated August 8, 2021, was inaccurate, with respect to completion of Section A2100 related to discharge status.

A review of Resident 50's quarterly MDS Assessment dated September 20, 2021, revealed that Section N0350 Insulin (Record the number of days that insulin injections were received during the last seven days) noted that the resident received zero injections in the last 7 days.

However, review of Resident 50's September 2021 Medication Administration Record revealed that insulin was administered per physician order on September 14, 15, 16, and 20, 2021 for a total of four days during the assessment look back period.

Interview with the director of nursing on November 4, 2021, at approximately 9:00 AM confirmed that Resident 50's quarterly MDS assessment was inaccurate with respect to completion of Section N0350 Insulin.

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

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

Plan of Correction - To be completed: 01/04/2022

1. Resident 78's discharge MDS Assessment has been revised to accurately reflect the discharge status.
2. Resident 50's quarterly MDS Assessment has been revised to reflect the number of days that Insulin injections were received in Section N0350
3. Section A2100 related to Discharge Status and Section N0305 related to Insulin Injections are documented accurately.
4. RNAC/Designee will audit Section A2100 on Discharged Residents and Section N0305 for residents receiving Insulin for accuracy. Results of audits will be brought to QA Committee for review and recommendations
5. Corrective Action Date January 4, 2022

483.24 REQUIREMENT Quality of Life:

§ 483.24 Quality of life
Quality of life is a fundamental principle that applies to all care and services provided to facility residents. Each resident must receive and the facility must provide the
necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, consistent with the resident's comprehensive assessment and plan of care.

Observations:

Based on observation and staff interview it was determined that the facility failed to provide care in an environment, which promotes each resident's quality of life by failing to respond timely to one resident's request for assistance as observed on one of two nursing units for one of 18 residents sampled (Resident 12).

Findings include:

Observation on the Clover Second Floor Nursing Unit on November 3, 2021 at 12:50 PM revealed that Resident 12's bathroom call light was on indicating that Resident 12 needed staff assistance.

Further observation at this time revealed that there were no nursing staff present at this time on the Clover hall of the Second Floor Nursing Unit. Due to current construction at the nursing station, the double doors of each of the three halls (Clover, Bluebell, and Dogwood) on the Second Floor Nursing Unit are kept closed to decrease noise and dust.

At 1:10 PM Employee 3 (LPN) was observed to enter onto the Clover hall. Interview with employee 3 at this time revealed that she had just returned from break. Employee 3 confirmed that due to the double doors of the Clover Hall being kept closed, and the nurses station being reconstructed, at least one nurse or aide were to be present on each hall of the unit at all times.

At this time, 20 minutes after Resident 12 activated the call bell light requesting staff assistance in the bathroom, Employee 3 entered Resident 12's bathroom to provide assistance to the resident.

Interview with the director of nursing on November 5, 2021, at approximately 9:00 AM confirmed that Resident 12's call bell was to be timely answered to promote the resident's highest physical, mental, and psychosocial well-being and ensure the resident's quality of life and safety.

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

28 Pa. Code 201.29 (j) Resident Rights

Plan of Correction - To be completed: 01/04/2022

1. Resident 12 needs are being met in a timely manner.
2. Facility staff will be reeducated on the Facility Call Bell protocol and importance of responding and addressing residents needs in a timely manner and on facility call bell protocol.
3. Call bell audits will be conducted randomly on all shifts. Results of audits will be reported to QA committee for review and recommendations.
4. Corrective Action Date January 4, 2022

483.25(d)(1)(2) REQUIREMENT Free of Accident Hazards/Supervision/Devices:

§483.25(d) Accidents.
The facility must ensure that -
§483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and

§483.25(d)(2)Each resident receives adequate supervision and assistance devices to prevent accidents.

Observations:

Based on a review of clinical records and select facility reports and staff interview, it was determined that the facility failed to provide sufficient staff supervision and assistance during a transfer to prevent an injury, a skin tear (a wound caused by shear, friction, and/or blunt force resulting in separation of skin layers), for one of four residents reviewed (Resident 4).

Findings include:

A review of the clinical record revealed Resident 4 was admitted to the facility on June 18, 2021 and had diagnoses, which included rhabdomyolysis (a life-threatening condition caused by muscle breakdown and muscle death).

Resident 4's admission Minimum Data Set assessment (MDS - a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated June 22, 2021, revealed that the resident had a BIMS score of 9 (Brief Interview for Mental Status- a tool to assess cognitive status; a score of 8-12 indicates moderately cognitively impaired), required extensive two person physical assistance for bed mobility (which includes how resident moves to and from lying position and turning side to side), transfers (includes how resident moves between surfaces), and toileting and had a history of falls.

Review of an initial care plan dated June 18, 2021, indicated that Resident 4 had an ADL (activities of daily living deficit related to impaired balance and weakness. Interventions planned to improve the resident's current function in ADLs were that the resident transfer with the assist of two staff.

A health status note dated July 1, 2021, at 11:17 PM noted that the resident was being transferred outside the plan of care by Employee 4 (temporary nurse aide) off the commode. While being transferred, the resident's leg came in contact with the metal paper toilet paper holder. The resident sustained a skin tear shaped like a 'V' to the outer lower extremity. A moderate amount of bleeding was noted. The area was cleansed and covered with Tegaderm Absorbent (a wound dressing). The physician was notified.

Review of a facility incident report dated July 1, 2021, at 9:52 PM indicated that Employee 4 relayed that she was toileting Resident 4 on her own, without the assistance of another staff member, and the resident's calf (right) scraped off the toilet paper roll holder. The resident's right outer calf skin tear measured 4.5 cm (length) by 3.5 cm (width) by 0.5 cm (depth).

Interview with the director of nursing on November 4, 2021, at approximately 2:00 PM failed to provide evidence that the intervention to safely transfer Resident 4 with the assistance of two staff as care planned to prevent injury to the extent possible was implemented at the time of the incident.

483.25 (d)(2) Free of Accident Hazards/Supervision/Devices
Previously cited 1/14/21

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

Plan of Correction - To be completed: 01/04/2022

1. Resident 4 is being transferred according to Physician Order and being provided appropriate staff assistance to prevent accident and injury
2. RN Staff Educator/Designee shall provide reeducation to nursing personnel on the importance of reviewing resident Kardex prior to transferring resident.
3. Charge nurse/designee will audit level of assistance being provided to residents by staff to ensure that it is completed according to physician order and plan of care. Results of audits will be reported to QA Committee for review and recommendations.
4. Corrective Action Date January 4, 2022

483.25(l) REQUIREMENT Dialysis:

§483.25(l) Dialysis.
The facility must ensure that residents who require dialysis receive such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences.

Observations:

Based on review of clinical records and staff interviews it was determined that the facility failed to assure the development and implementation of person-centered care plan for one resident receiving dialysis services out of one resident sampled receiving dialysis.

Findings include:

A review of Resident 228 was admitted to the facility on October 21, 2021. The clinical record revealed that the resident was receiving dialysis due to End Stage Renal disease.

Review of Resident 228's comprehensive plan of care, initiated October 21, 2021, revealed that the facility failed to develop and implement a plan of care to address the residents individual needs, for care and services, related to hemodialysis

Interview with the Director of Nursing on November 4, 2021, at 11:45 AM confirmed the facility failed to initiate Resident 228's plan of care for hemodialysis, to include any emergency care of the resident's dialysis access site.

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

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

Plan of Correction - To be completed: 01/04/2022

1. Resident 228's care plan has been updated to reflect plan of care for hemodialysis and emergency care for resident's dialysis access site.
2. Current residents on dialysis have a careplan addressing needs related to hemodialysis, which includes emergency care of the resident's dialysis access site.
3. RN Staff Educator/Designee will educate Licensed nursing staff on initiating care plans as per the requirements for comprehensive care plans, which states, "For newly admitted residents, the comprehensive care plan must be completed within seven days of the completion of the comprehensive assessment and no more than 21 days after admission.". Interdisciplinary team will update care plans at morning meeting for resident's on dialysis.
4. DON / designee will audit dialysis care plans for accuracy. Results of audits will be presented to QA Committee for review and recommendations.
5. Corrective Action Date January 4, 2022

483.45(d)(1)-(6) REQUIREMENT Drug Regimen is Free from Unnecessary Drugs:

§483.45(d) Unnecessary Drugs-General.
Each resident's drug regimen must be free from unnecessary drugs. An unnecessary drug is any drug when used-

§483.45(d)(1) In excessive dose (including duplicate drug therapy); or

§483.45(d)(2) For excessive duration; or

§483.45(d)(3) Without adequate monitoring; or

§483.45(d)(4) Without adequate indications for its use; or

§483.45(d)(5) In the presence of adverse consequences which indicate the dose should be reduced or discontinued; or

§483.45(d)(6) Any combinations of the reasons stated in paragraphs (d)(1) through (5) of this section.

Observations:

Based on clinical record review and staff interview, it was determined that the facility failed to clinical justify the use of duplicate drug therapy for GERD for one of 18 residents reviewed (Resident 63).

Findings include:

A review of the clinical record revealed that Resident 63 was admitted to the facility on August 9, 2021, with diagnoses to include Gastro-Esophageal Reflux Disease (GERD).

Resident 63 had physicians orders from admission August 9, 2021, for Famotidine (a histamine-2 blocker that works by decreasing the amount of acid the stomach produces) 40 milligrams (mg) by mouth at bedtime (9:00 p.m.) and Omeprazole (a proton pump inhibitor that decreases the amount of acid produced in the stomach) 20 mg by mouth one time a day at 6:00 a.m.

A review of a Medication Administration Record (MAR) from admission August 9, 2021, to October 31, 2021, revealed that Resident 63 received both the Omeprazole at 6:00 a.m. and the Famotidine at bedtime (9:00 p.m.) from August 9, 2021, to October 31, 2021. There was no physician documentation of the clinical necessity of duplicate drug therapy for GERD.

There was no the pharmacist recognized the duplicate drug therapy for treatment of GERD.

Interview with the Director of Nursing on November 5, 2021, at 12:30 p.m. confirmed that the pharmacist failed to identify the duplicate drug therapy for GERD in the absence of physician documentation of the clinical necessity for both drugs in treating the resident's GERD>

28 Pa. Code 211.2(a) Physician services

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

Plan of Correction - To be completed: 01/04/2022

1. Resident 63's regime for treatment of GERD was reviewed by both Pharmacists and Physician. Order was clarified for treatment of GERD.
2. Pharmacist has been directed to review physician documentation for clinical necessity of duplicate drug therapy for treatment of GERD.
3.Pharmacist shall audit resident medical records to identify duplicate drug therapy for GERD and make appropriate recommendations. Results of audit will be presented to QA for comment and review.
4. Corrective Action Date January 4, 2022

§ 201.22(c) LICENSURE Prevention, control and surveillance of TB.:

Observations:

Based on a review of personnel records of newly hired staff and select facility policy it was determined that the facility failed to obtain a baseline TB (tuberculosis) status on one of five staff members reviewed (Employee 1)

Findings include:

Review of the facility policy entitled "Tuberculosis Screening for Employees" dated March 2019, indicated new employees who have been made a conditional offer of employment shall be screened for presence of infection with M. tuberculosis using the Mantoux PPD skin test. Individuals with a documented history of a negative 2 step TST/PPD performed within the last 12 months need to receive only one intradermal injection of PPD tuberculin. Individuals with no documented history of a TST/PPD skin test within the last 12 months will undergo the two-step procedure. If the 2nd test remains negative, no further action in necessary. A negative chest x-ray, T-spot serological test completed in the last 12 months will be accepted. Employees with a negative skin test history will have an annual health assessment completed and depending on the test results, will be followed as above. The two-step procedure need not be used. The frequency of repeat skin testing will depend on the facility's annual TB risk assessment.

According to regulatory and CDC (centers for disease control) guidelines, two step PPD testing consists of injecting a 0.1 mL of liquid containing 5 TU (tuberculin units) PPD (purified protein derivative) into the top layers of skin of the forearm. The skin tests should be read 48-72 hours after the injection. Two step testing is the recommended method for initial testing. After the first test is read and negative the second step will be given within 1 to 3 weeks. To obtain a baseline the second step PPD should not be given any later than 21 days.

Employee 1, licensed practical nurse, was hired by the facility on July 30, 2021. A review of the employee's prior vaccinations and testing indicated that Employee 1 last received a two-step PPD in 2017. There was no evidence of additional testing for tuberculosis until December 2020 when Employee 1 received a one-step PPD.

There was no evidence that Employee 1 was screened for tuberculosis prior to being hired on July 30, 2021.

Interview with Employee 2, Human Resource Manager on November 5, 2021, at approximately 11:15 a.m. revealed that Employee 1 had initially been employed at the facility as a nurse aide from November 2017 to May 2021. Employee 1 then resigned from her nurse aide position and took a job as an LPN in another facility until July 2021. Employee 2 further stated that the initial tuberculosis screening that was completed on Employee 1 upon hire in November 2017 was the same screening used for her re-hire in July 2021.

Interview with Employee 2, on November 5, 2021 at 12:00 PM confirmed that the facility failed to obtain a baseline TB status on this employee upon hire.

Plan of Correction - To be completed: 01/04/2022

1. A baseline TB Status has been completed for Employee 1
2. Employee 2 has been re-educated that facility shall obtain a baseline TB Status on new hires and rehires as per protocol
3. Current new hires/re-hires have been audited to ensure a baseline TB status has been obtained and documented.
4. Corrective Action Date January 4, 2022

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