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

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GREENWOOD CENTER FOR REHABILITATION AND NURSING
Inspection Results For:

There are  105 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.
GREENWOOD CENTER FOR REHABILITATION AND NURSING - 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 two Complaint Investigations completed on March 29, 2024, it was determined that Greenwood Center For Rehabilitation And Nursing 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 Care Licensure Regulation as they relate to the Health portion of the survey process.


 Plan of Correction:


483.60(i)(1)(2) REQUIREMENT Food Procurement,Store/Prepare/Serve-Sanitary:This is a less serious (but not lowest level) deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents.  This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.60(i) Food safety requirements.
The facility must -

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

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

Based on observation and staff interview, it was determined the facility failed to store food to prevent the potential spread of food borne illness and maintain food service/storage equipment in a sanitary manner in the facility's main kitchen and one of three dining areas nursing units (100/300 dining room).

Findings include:

An observation of the facility's main kitchen on March 26, 2024, at 9:58 AM revealed the following:

A large white bin next to the ice machine contained a white powdery substance. The bin was labeled as flour and dated September 7, 2023, with a use by date of March 7, 2024.

An additional white bin next to the flour also contained a white powdery substance and was not labeled or dated. Employee 7, dietary manager, indicated it was "thickener" in the bin.

An air vent on the front of the industrial ice machine was covered in dust on the exterior and interior of the vent.

The lower shelf of a preparation table holding a food processor was dusty and contained dried particles on the shelf.

A shelf extending from the wall over the above preparation table was observed with several plastic containers of spices on it. Debris from the various spice containers was observed all over the shelf. One container of rotisserie chicken seasoning was labeled with an open date of March 2, 2023, and expiration date of March 2, 2024.

The walk-in cooler had several wire storage racks with food stored on them. Liners on the bottom shelf were soiled with dried liquid spots and dirt and debris. One lower shelf contained a cardboard box with packages of ground beef in the box. Pooled red liquid was observed in the bottom of the box. The shelf beside the box contained dried brown liquid spots.

A clear plastic container labeled as corn meal was observed in the dry storage area with a use by date of January 4, 2024.

A three-tier cart with food supplies on it was observed in the main production area where staff were observed cooking items on the stove top. The lower shelves of the cart contained dried food, debris, and dust.

The lower shelf of the steam table area was dusty and contained crumbs and dried food.

A metal storage rack located outside the dish room area across from the steam tables had visible dust hanging from the frame of the shelf throughout the rack.

Flooring throughout the kitchen under shelving units and equipment had a black buildup that was not visible in the main paths of the kitchen area.

A vent unit in the hood of the dish machine was covered in thick dust buildup.

The white wall behind the area of the dish machine where staff were observed placing dirty dishes into the machine was covered in a black buildup, which extended to the metal backsplash area.

Observation of the walk-in freezer revealed several plastic storage bins labeled with various food items. Employee 7 indicated the items were leftovers saved for future use. Review of four of the containers revealed labels reading "chicken noodle soup 3/14/24-4/14/24," "broccoli cheese soup 3/18/24 - 4/18/24," "beef tips 3/21/24-4/21/24," and "smoked sausage 3/24/24-4/25/25." Concurrently upon review of the kitchen cool down log utilized for saving cooked products for future use, with Employee 7, there was no evidence that the products noted were cooled down in a manner to prevent the potential of food borne illness by assuring the food was cooled to 70 degrees Fahrenheit within two hours, and to 41 degrees Fahrenheit within 6 hours.

Observation of the 100/300 hall dining room area revealed a refrigerator stored with items for resident use. The refrigerator had dried liquid spills in the door, lower shelf, and back wall of the refrigerator.

The above findings were reviewed with the Nursing Home Administrator and Director of nursing on March 28, 2024, at 2:30 PM.

483.60 (i)(2) Food storage safe and sanitary
Previously cited 4/14/23

28 Pa. Code 201.14(a) Responsibility of licensee


 Plan of Correction - To be completed: 04/30/2024

1.The expired flour in the bin which was located next to the ice machine was discarded. The bin containing thickener was appropriately labeled as such. The air vent on the front of the ice machine was removed and cleaned by the maintenance department. The shelving on the preparation table was cleaned. Shelving above the preparation table was cleaned of debris. Spices were checked for expiration dates and were discarded if expired. The wire storage racks in the walk-in cooler were cleaned. The three-tier food carts were cleaned of any dried food, debris and dust. The shelving on the steam table was cleared of any dried food, crumbs and dust. The metal storage rack outside of the dish room was cleaned of any dust. Kitchen flooring was cleaned of any build up. The vent unit in the hood of the dish machine was cleaned of any dust. The wall behind the dish machine was cleaned of black build up. The four containers of leftover food in the walk-in freezer were discarded. The 100/300 hall dining room refrigerator and back wall of refrigerator was cleaned of spills. The container of expired corn meal observed in the dry storage area was discarded.

2.Dietary Manager and/or Designee will inspect the remainder of kitchen to ensure appropriate cleaning, storage and maintenance of supplies and equipment.

3.Administrator and/or Designee will reeducate the dietary staff on Federal Regulation F812.

4.The dietary Manager and/or Designee will monitor the kitchen for expired items, appropriate labeling of bins, cleaning of ice machine vents, cleaning of shelves, food carts are free of dried food, crumbs or dust, kitchen floor is free of build up, dish machine hood vent is free of dust, wall behind dish machine is free of build up and left over food is discarded as per policy. Audits to occur 1x a week for 4 weeks 2x a month x 2 months then monthly x 3 months. The findings of these quality monitoring's to be reported to the Quality Assurance/Performance Improvement Committee monthly and/or until substantial compliance is met. Quality Monitoring schedule modified based on findings.

5.Date of completion will be April 30, 2024.

483.15(d)(1)(2) REQUIREMENT Notice of Bed Hold Policy Before/Upon Trnsfr: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.
483.15(d) Notice of bed-hold policy and return-

483.15(d)(1) Notice before transfer. Before a nursing facility transfers a resident to a hospital or the resident goes on therapeutic leave, the nursing facility must provide written information to the resident or resident representative that specifies-
(i) The duration of the state bed-hold policy, if any, during which the resident is permitted to return and resume residence in the nursing facility;
(ii) The reserve bed payment policy in the state plan, under 447.40 of this chapter, if any;
(iii) The nursing facility's policies regarding bed-hold periods, which must be consistent with paragraph (e)(1) of this section, permitting a resident to return; and
(iv) The information specified in paragraph (e)(1) of this section.

483.15(d)(2) Bed-hold notice upon transfer. At the time of transfer of a resident for hospitalization or therapeutic leave, a nursing facility must provide to the resident and the resident representative written notice which specifies the duration of the bed-hold policy described in paragraph (d)(1) of this section.
Observations:

Based on clinical record review and staff interview, it was determined that the facility failed to ensure that the resident or resident representative received written notice of the facility bed hold policy at the time of transfer for three of six residents reviewed for hospitalizations (Residents 41, 75, and 221).

Findings include:

Clinical record review revealed that Resident 41 was transferred to the hospital on November 8, 2023, after they had a change in condition. There was no documentation available that the facility provided written notice regarding a bed hold to the resident and/or the resident's responsible party upon transfer out to the hospital.

Clinical record review revealed that Resident 221 was transferred to the hospital on March 1, 2024, after they had a change in condition. There was no documentation available that the facility provided written notice regarding a bed hold to the resident and/or the resident's responsible party upon transfer out to the hospital.

The surveyor reviewed the above information for during an interview with the Director of Nursing on March 28, 2024, at 12:39 PM and March 29, 2024, at 11:19 AM.

Clinical record review for Resident 75 revealed that she was transferred to the hospital on December 33, 2023, due to a fall. There was no documentation available that the facility provided written notice regarding a bed hold to the resident and/or Resident 75's responsible party upon transfer out of the facility.

Interview with the Director of Nursing on March 29, 2024, at 11:35 AM confirmed that the facility did not provide a written bed hold notice to Resident 75 or his responsible party.

28 Pa. Code 201.14(a) Responsibility of licensee

28 Pa. Code 201.29(f) Resident rights


 Plan of Correction - To be completed: 04/30/2024

1.The facility gave written notice of the facility bed hold policy to the RP of resident 41 and 75. The facility cannot retroactively correct the lack of notification to resident 221 as she is no longer at the facility.

2.The Director of Nursing/Designee will complete an audit of the residents who have transferred out of the facility in the past 7 days for written documentation of notification to the resident and/or responsible party for proper bed hold notice.

3.The Director of Nursing/Designee will reeducate staff on the appropriate provision of notification of the bed hold policy upon a resident's transfer.

4.The DON and/or Designee will audit the records of those residents who have been transferred from the facility to ensure proper bed hold policy notification to the resident and/or responsible party has occurred. Audits to occur 1x a week x 4 weeks, 2x a month x 2 months, then monthly x 3 months. The findings of these quality monitoring's to be reported to the Quality Assurance/Performance Improvement Committee monthly and/or until substantial compliance is met. Quality Monitoring schedule modified based on findings.

5.Date of completion will be April 30, 2024.


483.95(g)(1)-(4) REQUIREMENT Required In-Service Training for Nurse Aides: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.
483.95(g) Required in-service training for nurse aides.
In-service training must-

483.95(g)(1) Be sufficient to ensure the continuing competence of nurse aides, but must be no less than 12 hours per year.

483.95(g)(2) Include dementia management training and resident abuse prevention training.

483.95(g)(3) Address areas of weakness as determined in nurse aides' performance reviews and facility assessment at 483.70(e) and may address the special needs of residents as determined by the facility staff.

483.95(g)(4) For nurse aides providing services to individuals with cognitive impairments, also address the care of the cognitively impaired.
Observations:

Based on review of facility staff education records and staff interview, it was determined that the facility failed to ensure that all nurse aide staff completed a minimum of 12 hours of in-service education training each year for three of three nurse aides reviewed (Employees 1, 2, and 3).

Findings include:

During an interview with the Nursing Home Administrator and the Director of Nursing on April 12, 2023, at 2:00 PM the surveyor requested evidence of annual in-service education for the three nurse aide staff as follows:

Employee 8, nurse aide, hired March 14, 2022.
Employee 9, nurse aide, hired December 7, 2021.
Employee 10, nurse aide, hired January 31, 2022.

Interview with the Director of Nursing on March 29, 2024, at 11:00 AM confirmed that the facility had no evidence of any in-service education for Employees 8, 9, or 10, that included dementia training, abuse prevention training, and any areas of weakness or resident special care needs in the past year.

483.95 (g)(g 1-4) Training requirements
Previously cited 4/14/23

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

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

28 Pa. Code 211.12(c) Nursing services


 Plan of Correction - To be completed: 04/30/2024

1.Employees 8, 9 and 10 have been provided the annual education to include Dementia training, abuse prevention training, care of the cognitively impaired, person centered care. A performance review was conducted for employees 8, 9 and 10 to address areas of weakness.

2.Annual in-service education will be provided to nurse aide staff. DON/Designee will monitor attendance records of the in-service education to ensure completion by nurse aide staff members.

3.To ensure completion rate of staff participation, nurse aide staff members will be unable to work until their annual education is completed.

4.The Director of Nursing/Designee will audit nurse aide staff files to ensure the nurse aide has completed a minimum of 12 hour in-service education training each year. Audits to be completed as per the nurse aide hire date. The findings of these quality monitoring's to be reported to the Quality Assurance/Performance Improvement Committee monthly and/or until substantial compliance is met. Quality Monitoring schedule modified based on findings.

5.Date of completion will be April 30, 2024.


483.80(a)(1)(2)(4)(e)(f) REQUIREMENT Infection Prevention & Control: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.
483.80 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 select policies and staff interview, it was determined that the facility failed to implement an effective Water Management Program for the prevention and control of water-borne contaminants, such as Legionella (a bacteria that may cause Legionnaires' Disease, a serious type of pneumonia).

Findings include:

The CDCs (Centers for Disease Control and Prevention) current Water Management Program Toolkit, Practical Guide to Implementing Industry Standards, indicated that many buildings need a water management program to reduce the risk for Legionella (bacteria that can grow and spread in water systems and can cause a serious type of pneumonia (lung infection) known as Legionnaires' disease) growing and spreading within their water system and devices. Developing and maintaining a water management program is a multi-step process that requires continuous review. Steps to building an effective Legionella water management program include:

A description of the building's water system using flow diagrams and a written description to include details like connections to the municipal water supply, how water is distributed, and location of water heaters/boilers.
Identification of potentially hazardous conditions such as areas where water temperature could promote Legionella growth or where water flow might be low.
Control measures (such as heating, adding disinfectant, or cleaning) that include where and how to monitor them. Control limits are the maximum value, minimum value, or range of values that are acceptable for the control measure.
Determine what corrective actions or contingency responses to take when control measures are outside the control limits established.

Review of documents provided by Employee 3 (Director of Maintenance) on March 29, 2024, at 12:45 PM related to the facility's water management program revealed that the information provided was a source water assessment summary for the Municipal Authority of the Borough of Lewistown, Mifflin County for the month of November 2003.
She also provided a document entitled, "Pennsylvania Department of Environmental Protection Division of Drinking Water Management Maximum Contaminant Levels and Maximum Residual Disinfectant Levels that was dated April 2006.

Concurrent interview of Employee 3 revealed that she did not have a flow diagram of the facilities water system. She also indicated that this was her first year back and that the information from the previous maintenance director could not be located.

On March 29, 2024, at 1:07 PM Employee 3 provided a document entitled, "Legionella Water Management Plan Greenwood Village," dated February 30, 2024. The policy was missing page 2, and the facility did not provide the missing page when the surveyor inquired about it.

Concurrent interview with Employee 3 revealed that the facility sends their water out to be tested as the borough does not test for legionella. She stated that it was due by the end of April this year. Employee 3 indicated the results for last year's test were not available. She also indicated that she could not provide evidence that the facility identified areas of potentially hazardous conditions such as areas where water temperature could promote Legionella growth or where water flow might be low, control measures that include where and how to monitor them, control limits that are acceptable for the control measures, or corrective actions or contingency responses to take when control measures are outside the control limits.

The surveyor reviewed the above concerns regarding the facility's water management program during a meeting with the Nursing Home Administrator on March 29, 2024, at 1:45 PM.

The facility failed to develop and maintain a water management program to reduce the risk for Legionella growing and spreading within their water system and devices.

28 Pa. Code 201.14(a) Responsibility of licensee

28 Pa. Code 201.18(b)(1) Managment

28 Pa. Code 211.10(d) Resident care policy


 Plan of Correction - To be completed: 04/30/2024

1.No individual residents were affected by the deficiency.

2.The Legionella samples were collected and sent to the testing vendor with appropriate paperwork to process the samples.

3.The Environmental Director will educate the maintenance department on collecting and mailing Legionella samples with the appropriate paperwork to the testing vendor. The Environmental Director/Designee will follow through with following up with the vendor to ensure the appropriate paperwork was received and the samples are processed timely. The Environmental Director/Designee will educate nursing staff that all resident equipment/machines utilizing water must continue to be filled with distilled water.

4.The Environmental Director/Designee will audit the Legionella paperwork to ensure the necessary paperwork is sent to process samples for results. Audits to occur based on testing schedule. The findings of these quality monitoring's to be reported to the Quality Assurance/Performance Improvement Committee monthly and/or until substantial compliance is met. Quality Monitoring schedule modified based on findings.

5.Completion will be April 30, 2024.


483.40(b)(3) REQUIREMENT Treatment/Service for Dementia: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.
483.40(b)(3) A resident who displays or is diagnosed with dementia, receives the appropriate treatment and services to attain or maintain his or her highest practicable physical, mental, and psychosocial well-being.
Observations:

Based on clinical record review and staff interview, it was determined that the facility failed to develop and implement individualized person-centered care plans to address dementia and cognitive loss displayed by four of four residents reviewed (Residents 17, 43, 44, 94).

Findings include:

Clinical record review for Resident 17 revealed the facility admitted her on July 19, 2022, with diagnoses including dementia (loss of memory, language, problem-solving, and other thinking abilities that interfere with daily life). A review of Resident 17's most recent annual Minimum Data Set Assessment (MDS, a form completed at specific intervals to determine care needs) dated June 9, 2023, indicated that the facility assessed Resident 17 as having a diagnosis of dementia. The facility determined that a care plan for dementia and cognitive loss would be developed.

A review of Resident 17's care plan revealed that there was no indication that the facility had developed and implemented a person-centered care plan to address the resident's dementia and cognitive loss.

Clinical record review for Resident 43 revealed the facility admitted him on July 11, 2020, with diagnoses including dementia. A review of Resident 43's Minimum Data Set Assessment dated July 17, 2023, indicated that the facility assessed Resident 43 as having a diagnosis of dementia. The facility determined that a care plan for dementia and cognitive loss would be developed.

A review of Resident 43's care plan revealed that there was no indication that the facility had developed and implemented a person-centered care plan to address the resident's dementia and cognitive loss.

Clinical record review for Resident 44 revealed the facility admitted him on June 9, 2022, with diagnoses including dementia. A review of Resident 44's most recent annual Minimum Data Set Assessment dated May 2, 2023, indicated that the facility assessed Resident 44 as having a diagnosis of dementia. The facility determined that a care plan for dementia and cognitive loss would be developed.

A review of Resident 44's care plan revealed that there was no indication that the facility had developed and implemented a person-centered care plan to address the resident's dementia and cognitive loss.

Clinical record review for Resident 94 revealed the facility admitted her on June 22, 2023, with diagnoses including dementia. A review of Resident 94's admission Minimum Data Set Assessment dated June 25, 2023, indicated that the facility assessed Resident 94 as having a diagnosis of dementia. The facility determined that a care plan for dementia and cognitive loss would be developed.

A review of Resident 94's care plan revealed that there was no indication that the facility had developed and implemented a person-centered care plan to address the resident's dementia and cognitive loss.

The findings were reviewed with the Nursing Home Administrator and Director of Nursing during a meeting on March 28, 2024, at 2:25 PM. Further interview with the Director of Nursing confirmed the facility had no further documentation that the facility developed and implemented an individualized person-centered care plan to address Residents 17, 43, 44, and 94's dementia and cognitive loss.

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


 Plan of Correction - To be completed: 04/30/2024

1.Resident 17, 43, 44 and 94's care plan has been updated to address Dementia and cognitive loss.

2.The Director of Nursing/Designee will audit the care plan of those residents in the facility with Dementia and cognitive loss to ensure plan of care has been developed to address the focus.

3.The Director of Nursing/Designee will educate the nursing staff, Assessment Coordinator and the Social Service office on implementing care plans to address Dementia and cognitive loss.

4.The Director of Nursing/Designee will audit the care plans of new residents being admitted to ensure a plan of care has been developed to address Dementia and cognitive loss, if present. Audits to occur 1x a week for 4 weeks 2x a month x 2 months then monthly x 3 months. The findings of these quality monitoring's to be reported to the Quality Assurance/Performance Improvement Committee monthly and/or until substantial compliance is met. Quality Monitoring schedule modified based on findings.

5.Date of completion will be April 30, 2024.

483.24(a)(2) REQUIREMENT ADL Care Provided for Dependent Residents:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
483.24(a)(2) A resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene;
Observations:

Based on clinical record review, observation, and staff and resident interview, it was determined that the facility failed to provide bathing assistance for residents dependent on staff assistance for five of six residents sampled for activities of daily living (Residents 52, 60, 64 and 96), and the facility failed to provide a resident with transfer assistance out of bed for a resident dependent on staff assistance, for one of six residents sampled. (Resident 92).

Findings include:

Clinical record review for Resident 60 revealed that he is to have a bed bath on Fridays dayshift due to wound dressings.

Review of Resident 60's care plan for self-care deficit revealed that he required one assist with his activities of daily living. He also had a care plan intervention that indicated he was to receive a bed bath related to dressings on both of his lower legs.

Review of Resident 60's task documentation (computerized documentation of care that is done for the resident) revealed that he did not have his complete bed bath on Friday March 1, 8, 15, or 22, 2024.

Interview with the Director of Nursing on March 29, 2024, at 10:29 AM confirmed the above noted finding related to Resident 60's bathing.

Clinical record review for Resident 96 revealed that the facility completed an admission MDS (Minimum Data Set, an assessment tool completed at specific intervals to determine resident care needs) on December 26, 2023, which indicated that she was not cognitively intact and that she needed partial to moderate assistance on staff to shower. Staff interviewed family who indicated that it was very important to choose between a tub bath, shower, bed bath, or sponge bath.

Review of Resident 96's January, February, and March 2024, care plan documentation revealed that staff was to provide a bath on Mondays during day shift. Task documentation revealed that there was no documentation that staff provided a bath or shower to her.

Observation of Resident 96 on March 27, 2023, at 11:08 AM revealed that she was in the activity room. Her hair was stringy and unkempt.

Clinical record review for Resident 92 revealed that the facility completed a quarterly MDS on February 2, 2024, which indicated that she was cognitively intact, was diagnosed with multiple sclerosis, and that she was dependent on a staff member to complete transfers from the bed to chair.

Interview with Resident 92 on March 26, 2024, at 12:45 PM revealed that she transfers via a Hoyer lift (a device to lift a person) out of bed and would like to be out of bed by 10:00 AM daily, but frequently has to wait until second shift staff arrive to get out of bed. She indicated that it was after 2:00 PM yesterday (March 25, 2024) until staff were able to get her up.

Observation of and interview with Resident 92 on March 27, 2024, at 11:41 AM revealed that she was still in bed. She indicated that she would like to get up into her chair but would "probably be evening shift until they (staff) get her up."

Interview with the Nursing Home Administrator and the Director of Nursing on March 27, 2024, at 1:45 PM and with the Director of Nursing on March 29, 2024, at 11:17 AM acknowledged that staff were not getting residents up timely, and that staff were not providing showers or baths to residents.

In an interview with Resident 64 on March 26, 2024, at 1:21 PM, the resident stated she had been doing things for herself at the facility. Resident 64 stated, "If they think I am getting 24-hour care here, I am not." Resident 64 continued stating she "has washed up in the bathroom" and has not had an actual shower in five weeks, and she likes showers. Resident 64 stated she was aware everyone had their night to get one but was not sure what happened. The resident stated she has been given a basin in her room and has just washed up in her bathroom.

Clinical record review for Resident 64 revealed a 5-day MDS dated January 25, 2024, that revealed facility staff assessed the resident as requiring partial/moderate assistance with shower/bathing.

Further clinical record review for Resident 64 revealed the resident had a scheduled task to receive a shower/bath every Wednesday evening shift since January 22, 2024.

A review of Resident 64's bathing records report obtained March 28, 2024, for the last 30 days, revealed "no data found." There was no evidence to indicate Resident 64 had received a shower, been offered a shower, or refused a shower in the last 30 days.

An observation of Resident 52 on March 26, 2024, at 1:35 PM revealed the resident was in bed. Resident 52's hair appeared greasy with extensive dandruff and flaking and peeling skin throughout his hair. Resident 52 indicated he believed he was to be showered twice a week, and then thought it may have changed to Tuesdays, but did not recall his last shower. Resident 52 indicated he had seen a dermatologist prior and was supposed to use a special shampoo.

A review of Resident 52's physician orders revealed the resident was ordered Nizoral External Shampoo 2% (a medicated shampoo to treat dandruff) to be applied to the scalp topically every evening shift Mondays, Wednesdays, and Fridays for dandruff. A review of Resident 52's treatment record for March 2024, revealed Resident 52 had only received the shampoo March 20, 2024, and was documented as refused all other times.

A review of the manufacturer instructions for use of the Nizoral shampoo indicated it was to be applied to wet hair and scalp, lathered, left on for 3-5 minutes and rinse thoroughly.

Clinical record review for Resident 52's quarterly MDS dated February 10, 2024, revealed facility staff assessed the resident as requiring substantial/maximum assistance to shower/bathe.

A review of Resident 52's bathing schedule and preference per the resident's task list in the resident's electronic record revealed the resident had two shower tasks listed, one to receive shower/baths every Wednesday and Saturday day shift, and another to receive a shower/bath every Wednesday evening shift.

A review of Resident 52's bathing records from February 28 to March 27, 2024, did not reveal any evidence the resident received a bath or shower. All entries in the time frame noted were marked as "not applicable."
Review of additional bathing information for Resident 52 provided by the facility indicated the resident was documented as receiving a shower on February 7, 2024, and refused a shower on February 24, 2024.

In an interview with the Director of Nursing on March 29, 2024, at 11:00 AM the Director of Nursing confirmed there was no evidence to indicate Resident 64 was offered or refused a shower as indicated above, or that Resident 52 received or was offered a shower from February 28 to March 27, 2024, and was unsure how the resident was to receive the medicated shampoo when it was not correlated with the days the resident was to receive a shower to complete washing the resident's hair.

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


 Plan of Correction - To be completed: 04/30/2024

1.Resident 52 received a shower on 4/2/24 and his hair was washed with Nizoral Shampoo per MD order. Resident 60 received a shower on 3/29. Resident 64 received a shower on 4/4 and resident 96 received a shower on 4/1/24. The plan of care of resident 92 has been updated to reflect her request to be out of bed by 10am.

2.Residents who are dependent on staff assistance for ADL completion will be reviewed to ensure that a shower or bath and hair washing has occurred according to the resident's plan of care. The shower schedule for all hallways has been reviewed to ensure that shower days are clarified in the shower binder, Kardex, and in the resident's orders. Each resident now has a shower order that requires the LPN to sign off that the shower was given. The shower report will be pulled each morning for the prior day's showers and will be reviewed by the Nursing Management Team to ensure the scheduled showers were given and, if not given, determine the reason and offer shower on next shift. Resident 92's task list for the Kardex has been updated to reflect her preference to be out of bed by 10am. An order has also been placed into the chart so that an LPN can ensure the task is completed. Therapy will also assist on prn basis to assist the staff to get resident out of bed if additional assistance is needed. Current facility residents or, responsible parties where applicable, who require assistance with ADLs and transfers will be interviewed for their preference related to getting out of bed. Preferences will be updated on the CNA task sheet.

3.Nursing staff will be reeducated to utilize the Task Section of the residents Kardex to offer bathing/showering/hair washing. The task section of the Kardex will be updated with resident specific information to include shower days and resident specific wake time preferences.

4.The Director of Nursing/Designee will audit bathing/showering documentation of those residents who are dependent on staff assistance to ensure the residents are being provided their shower/bath based on their preference. The Director of Nursing/Designee will audit, through record review and direct resident interaction, those residents who are care dependent and have specific wake time preferences to ensure requests/preferences are being met. Audits to occur 1x a week for 4 weeks 2x a month x 2 months then monthly x 3 months. The findings of these quality monitoring's to be reported to the Quality Assurance/Performance Improvement Committee monthly and/or until substantial compliance is met. Quality Monitoring schedule modified based on findings.

5.Date of completion will be April 30, 2024.


483.12(b)(1)-(5)(ii)(iii) REQUIREMENT Develop/Implement Abuse/Neglect Policies: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(b) The facility must develop and implement written policies and procedures that:

483.12(b)(1) Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property,

483.12(b)(2) Establish policies and procedures to investigate any such allegations, and

483.12(b)(3) Include training as required at paragraph 483.95,

483.12(b)(4) Establish coordination with the QAPI program required under 483.75.

483.12(b)(5) Ensure reporting of crimes occurring in federally-funded long-term care facilities in accordance with section 1150B of the Act. The policies and procedures must include but are not limited to the following elements.

483.12(b)(5)(ii) Posting a conspicuous notice of employee rights, as defined at section 1150B(d)(3) of the Act.

483.12(b)(5)(iii) Prohibiting and preventing retaliation, as defined at section 1150B(d)(1) and (2) of the Act.
Observations:

Based on review of select facility policies and procedures, review of employee personnel records, observation, and staff interview, it was determined that the facility failed to investigate a resident's injuries of unknown origin for one of 25 residents sampled (Resident 75) and failed to implement its abuse prohibition policy pertaining to screening for one of five newly hired employees reviewed (Employee 1).

Findings include:

Review of the facility policy entitled "Abuse Prevention Program," last reviewed January 4, 2024, revealed all reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment, and/or injuries of unknown source (abuse) will be thoroughly investigated by facility management.

The current facility policy entitled "Abuse, Neglect, Exploitation, and Misappropriation" last reviewed without changes on January 4, 2024, revealed that the facility will not tolerate abuse, neglect, exploitation of its residents or the misappropriation of resident property and will undertake background checks on all employees. Prior to hiring a new employee, the facility will conduct a criminal background check in accordance with Pennsylvania law and facility policy.

Observation of Resident 75 on March 27, 2024, at 10:25 AM revealed a large purple bruise on Resident 75's left upper arm, a smaller bruise on her right upper arm, and a bruise to the top of Resident 75's right hand.

An interview with the Nursing Home Administrator and Director of Nursing on March 29, 2024, at 10:41 AM revealed the facility had no evidence that they investigated Resident 75's bruises to rule out abuse.

Review of Employee 1's, activity assistant, personnel record revealed that the facility hired her on December 20, 2023. Employee 1's personnel record did not reveal evidence that the facility completed a background check prior to hire and/or access to residents.

This surveyor reviewed this information during an interview with the Director of Nursing on March 29, 2024, at 12:45 PM.

483.12(b)(1) Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property.
Previously cited 4/14/23.

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

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


 Plan of Correction - To be completed: 04/30/2024

1.Injury of unknown origin for resident 75 was investigated and was found to be unsubstantiated with no evidence of abuse or neglect. The investigation was completed per Abuse Investigation and Reporting Policy. Employee 1 was removed from the schedule immediately. Her prior background check was located and approved prior to her start date.

2.Director of Nursing/ Designee will review injuries of unknown origin for the last 30 days to ensure an investigation is complete to rule out abuse or neglect. Background checks will be performed for employees hired on after January 1, 2024. HR Director/Designee will audit current new hires files to ensure background checks were completed prior to start date.

3.The DON/NHA were educated on the components of this regulation with an emphasis on ensuring that Injuries of Unknown Origin are investigated and reported as required. The HR Director has been educated regarding the need to obtain background checks as part of the pre-hire process.

4.The DON/Designee will audit the facility's risk management reporting to ensure that any Injuries of Unknown Origin have been investigated and reported as required. The NHA will conduct random audits 3 employees files to ensure that background checks have been obtained as required. Audits to occur 1x a week x4 weeks, 2x a month x2 months, then monthly x3 months. The findings of these quality monitoring's to be reported to the Quality Assurance/Performance Improvement Committee until monthly and/or until substantial compliance is met. Quality Monitoring schedule modified based on findings.

5.Date of completion will be April 30, 2024.

483.80(d)(1)(2) REQUIREMENT Influenza and Pneumococcal Immunizations: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(d) Influenza and pneumococcal immunizations
483.80(d)(1) Influenza. The facility must develop policies and procedures to ensure that-
(i) Before offering the influenza immunization, each resident or the resident's representative receives education regarding the benefits and potential side effects of the immunization;
(ii) Each resident is offered an influenza immunization October 1 through March 31 annually, unless the immunization is medically contraindicated or the resident has already been immunized during this time period;
(iii) The resident or the resident's representative has the opportunity to refuse immunization; and
(iv)The resident's medical record includes documentation that indicates, at a minimum, the following:
(A) That the resident or resident's representative was provided education regarding the benefits and potential side effects of influenza immunization; and
(B) That the resident either received the influenza immunization or did not receive the influenza immunization due to medical contraindications or refusal.

483.80(d)(2) Pneumococcal disease. The facility must develop policies and procedures to ensure that-
(i) Before offering the pneumococcal immunization, each resident or the resident's representative receives education regarding the benefits and potential side effects of the immunization;
(ii) Each resident is offered a pneumococcal immunization, unless the immunization is medically contraindicated or the resident has already been immunized;
(iii) The resident or the resident's representative has the opportunity to refuse immunization; and
(iv)The resident's medical record includes documentation that indicates, at a minimum, the following:
(A) That the resident or resident's representative was provided education regarding the benefits and potential side effects of pneumococcal immunization; and
(B) That the resident either received the pneumococcal immunization or did not receive the pneumococcal immunization due to medical contraindication or refusal.
Observations:

Based on clinical record review and staff interview, it was determined that the facility failed to ensure a resident received or was offered pneumococcal conjugate vaccines for one of five residents reviewed for immunization concerns (Resident 4).

Findings include:

Clinical record review for Resident 4 revealed that the facility admitted her on October 6, 2022.

Further clinical record review revealed that the facility documented on admission that Resident 4 previously had a pneumovax 23 (a vaccine administered to prevent pneumonia) on March 1, 2007. There was no evidence in Resident 4's clinical record that indicated she was offered pneumococcal conjugate vaccines (vaccines that prevent against bacteria that cause pneumonia)

Review of the document published April 1, 2022, by the Center for Disease Control and Prevention, entitled "Pneumococcal Vaccine Timing for Adults," Resident 4 should have been offered a pneumococcal conjugate vaccine.

Interview with Employee 2, Registered Nurse, Infection Preventionist, on March 29, 2024, at 12:30 PM confirmed the above noted findings for Resident 4.

The facility failed to follow-up with the pneumococcal vaccinations for Resident 4 and ensure the resident received the appropriate vaccinations as recommended.

28 Pa. Code 201.14(a) Responsibility of licensee

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

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



 Plan of Correction - To be completed: 04/30/2024

1.Resident 4 was educated on and offered the pneumococcal conjugate vaccine.

2.The pneumococcal vaccination status of the remaining residents in the facility were audited to determine what other residents need to be educated and offered the pneumococcal conjugate vaccine.

3.The Director of Nursing/Designee reviewed the Pneumococcal Vaccine policy with the Medical Director Group and the facility's Infection Preventionist. The DON/Designee educated the Infection Preventionist on proper monitoring of the vaccination status of residents.

4.The Director of Nursing/Designee will audit the vaccination record of new residents being admitted to the facility to determine the necessity of the Pneumococcal Vaccination and to ensure the resident is offered the Pneumococcal Vaccination once they have been educated. Audits to occur 1x a week for 4 weeks 2x a month x 2 months then monthly x 3 months. The findings of these quality monitoring's to be reported to the Quality Assurance/Performance Improvement Committee monthly and/or until substantial compliance is met. Quality Monitoring schedule modified based on findings.

5.Date of completion will be April 30, 2024.


483.80(a)(3) REQUIREMENT Antibiotic Stewardship Program: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(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)(3) An antibiotic stewardship program that includes antibiotic use protocols and a system to monitor antibiotic use.
Observations:

Based on clinical record review and staff and responsible party interview, it was determined that the facility failed to monitor antibiotic use for one of one resident reviewed for a urinary tract infection (Resident 74).

Findings include:

In an interview with a responsible party for Resident 74 on March 26, 2024, at 1:01 PM, the responsible party indicated the resident had been sick and had to go to the hospital as she had a urinary tract infection.

Clinical record review for Resident 74 revealed the resident was sent to the emergency room from the facility on February 13, 2024, for abdominal pain, and not eating.

Review of Resident 74's emergency room visit summary dated February 13, 2024, revealed the resident received multiple studies and lab work at the emergency room, which included a urinalysis with culture and sensitivity and results were pending. The resident was returned to the facility with a diagnosis of hypernatremia (an elevated sodium level), headache, and loss of appetite. Resident 74 received intravenous fluids at the emergency room and was returned to the facility with a change in an antipsychotic medication to be reviewed by psychiatry, but no other medication changes or additions. There was no diagnosis of a urinary tract infection listed on the report.

A nursing note dated February 14, 2024, at 1:40 PM noted the resident was sent to the hospital last evening with a diagnosis of a urinary tract infection and the nurse practitioner was made aware and ordered extra fluids for 48 hours and directed nursing to wait for the culture and sensitivity results of the resident's urine to arrive.

A late entry nurse practitioner note dated February 19, 2024, for February 16, 2024, at 2:03 PM noted Resident 74's emergency room visit, and that the resident was stable, and to continue medications and treatment regimen as ordered with no new orders. There was no mention of the urine culture and sensitivity or indication an antibiotic was needed.

A review of the final culture and sensitivity report faxed and printed with a date of February 16, 2024, from Resident 74's urinalysis obtained at the emergency room on February 13, 2024, indicated a final result of "no significant growth."

A review of physician's orders for Resident 74 revealed the resident was ordered Macrobid (an antibiotic) 100 milligrams, by mouth two times a day for seven days for a urinary tract infection on February 18, 2024.

A late entry physician's note entered on March 15, 2024, for February 18, 2024, at 8:39 PM noted the resident had no issues or concerns since the last visit, and laboratory and imaging studies were reviewed and discussed with nursing with the resident's current medications reviewed, which did not include Macrobid or any antibiotic. The note indicated no changes or acute distress. There was no documentation to indicate the resident had a urinary tract infection or required the use of an antibiotic.

A nursing note dated February 19, 2024, at 1:40 AM noted the resident was started on Macrobid for a urinary tract infection, and the resident is confused but had no current complaints of urinary discomfort or burning. Clinical record review for Resident 74 revealed a diagnosis of dementia since December 13, 2022.

There was no physician documentation or evidence provided by the facility during the onsite visit to indicate why Resident 74 was ordered the Macrobid for a urinary tract infection on February 18, 2024, and the urine obtained during the emergency room visit on February 13, 2024, was cultured, and resulted in no growth.

In an interview with the Director of Nursing on March 29, 2024, at 11:00 AM it was confirmed there was no information as to why Resident 74 was ordered the antibiotic as indicated above.

28 Pa. Code 211.10(d) Resident care policies

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


 Plan of Correction - To be completed: 04/30/2024

1.The facility cannot correct deficiency F0881 for this particular resident as she is no longer receiving antibiotic therapy.

2.The Director of Nursing/Designee will audit the records of current residents on antibiotic therapy to determine necessity of the Antibiotic in correlation with a proper diagnosis.

3.The Director of Nursing/Designee will review the Antibiotic Stewardship policy with the facility's Infection Preventionist and Medical Director.

4.The Director of Nursing/Designee will audit new antibiotic orders daily to ensure the necessity of the Antibiotic in correlation with a proper diagnosis. Audits to occur 1x a week for 4 weeks 2x a month x 2 months then monthly x 3 months. The findings of these quality monitoring's to be reported to the Quality Assurance/Performance Improvement Committee monthly and/or until substantial compliance is met. Quality Monitoring schedule modified based on findings.

5.Date of completion will be April 30, 2024.

483.35(a)(3)(4)(c) REQUIREMENT Competent Nursing Staff: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.
483.35 Nursing Services
The facility must have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment required at 483.70(e).

483.35(a)(3) The facility must ensure that licensed nurses have the specific competencies and skill sets necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care.

483.35(a)(4) Providing care includes but is not limited to assessing, evaluating, planning and implementing resident care plans and responding to resident's needs.

483.35(c) Proficiency of nurse aides.
The facility must ensure that nurse aides are able to demonstrate competency in skills and techniques necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care.
Observations:
Based on review of facility documentation and staff interviews, it was determined that the facility failed to ensure that nursing staff possessed the appropriate competencies and skill sets related to the care and assessment of residents with enteral tube feeding, catheter care, medication administration, and dressing changes for two of six employee competencies reviewed (Employees 11 and 12).

Findings include:

A review of the facility documentation revealed that the facility had a total of 124 residents receiving medications, 10 residents with indwelling catheters (insertion of a tube into the bladder to remove urine), six residents with pressure ulcers, and two residents with enteral tube feedings (device that allows liquid food to enter your stomach or intestine through a tube).

A request for nursing staff competencies for enteral tube feeding, catheter care, medication administration, and dressing changes revealed the facility was unable to provide any for Employees 11 and 12 (licensed practical nurses).

The findings were reviewed with the Nursing Home Administrator and Director of Nursing on March 28, 2024, at 2:55 PM. Further interview with the Director of Nursing on March 29, 2024, at 10:58 AM confirmed the facility could provide no documentation that ensured Employees 11 and 12 have specific competencies and skill sets to care for the residents' needs listed above.

28 Pa Code 201.20(a) Staff development


 Plan of Correction - To be completed: 04/30/2024

1.Staff competencies were completed with employees 11 and 12.

2.The Director of Nursing/Designee will identify employee files of current nursing staff who need completion of nursing competencies and will provide the nursing competency training.

3.The Director of Nursing/Designee will educate all licensed nursing staff on the importance of completion of nursing competencies/skills set.

4.The Director of Nursing/Designee will audit employee files of nursing staff members to ensure completion of nursing competencies. Audits to occur 1x a week for 4 weeks 2x a month x 2 months then monthly x 3 months. The findings of these quality monitoring's to be reported to the Quality Assurance/Performance Improvement Committee monthly and/or until substantial compliance is met. Quality Monitoring schedule modified based on findings.

5.Date of completion will be April 30, 2024.


483.25(n)(1)-(4) REQUIREMENT Bedrails: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(n) Bed Rails.
The facility must attempt to use appropriate alternatives prior to installing a side or bed rail. If a bed or side rail is used, the facility must ensure correct installation, use, and maintenance of bed rails, including but not limited to the following elements.

483.25(n)(1) Assess the resident for risk of entrapment from bed rails prior to installation.

483.25(n)(2) Review the risks and benefits of bed rails with the resident or resident representative and obtain informed consent prior to installation.

483.25(n)(3) Ensure that the bed's dimensions are appropriate for the resident's size and weight.

483.25(n)(4) Follow the manufacturers' recommendations and specifications for installing and maintaining bed rails.
Observations:

Based on observation, clinical record review, and staff and family interview, it was determined that the facility failed to assess for the risk of side rail entrapment, for three of five residents reviewed for side rails (Residents 74, 104, and 105).

Findings include:

Clinical record review for Resident 105 revealed that she was admitted on January 18, 2024, with an assessment that indicated she did not need to utilize side rails. On January 30, 2024, a physician ordered Resident 105 to utilize bilateral (both sides) side rails to (her) bed for positioning. There was no documentation after the January 30, 2024, order that indicated the bilateral side rails were assessed to ensure the side rails were appropriate and the resident's ability to utilize them.

Observation of Resident 105 on March 26, 2023, at 12:03 PM revealed that she was dressed and sitting in a chair. There were bilateral side rails observed on the bed.

The surveyor reviewed the above information during an interview with the Director of Nursing on March 29, 2024, at 11:19 AM.

An observation of Resident 104 on March 26, 2024, at 12:47 PM revealed the resident was in bed. Enabler bars were observed on each side of the bed. A family member who was present indicated the resident does not use the bars to move in bed as she has no muscle ability to do so.

Clinical record review for Resident 104 revealed a state only MDS (minimum data set assessment, an assessment completed at periodic intervals of time to assess resident care needs) dated March 1, 2024, in which facility staff assessed the resident as having a BIMS (brief interview of mental status) score of one, indicating severe cognitive impairment, and that the resident required extensive assistance of two plus persons for bed mobility.

Further review revealed a siderail consent form dated July 28, 2023, one day after Resident 104 was admitted to the facility signed by Resident 104's responsible party, although a box indicating whether the responsible party did or did not consent to the rails was not checked.

A side rail assessment form for Resident 104 completed on July 28, 2023, again one day after admission, revealed the resident was non-ambulatory, no history of falls, and "no" to the question of, "Does the resident want the side rail raised.

A side rail assessment dated November 2, 2023, for Resident 104 indicated the resident was currently using the side rail for support or positioning, and the resident uses the side rail as an enabler to promote independence. There was no evidence to indicate Resident 104 had the physical ability to utilize an enabler bar.

There was no evidence facility staff assessed the enabler bars that were present on Resident 104's bed for the risk of entrapment.

An observation of Resident 74 on March 27, 2024, at 10:42 AM revealed enabler bars on both sides of the resident's bed.

Clinical record review for Resident 74 revealed a significant change MDS dated February 29, 2024, in which facility staff assessed the resident as having a BIMS score of zero, indicating severe cognitive impairment, impairment on both sides of her upper body for range of motion, and dependent on staff for bed mobility. The review also identified the resident had a diagnosis of dementia since December 13, 2022.

The last side rail assessment for Resident 74 completed by facility staff was dated July 21, 2023. The side rail assessment indicated that if a "yes" answer was indicated for any of the entrapment risk questions and the facility was still intending to prescribe bedrails, a clear reasoning must be documented. The first entrapment risk question listed as "Does the resident have dementia, confusion, learning disability, agitation, unable to comprehend or distressed?" was listed with an answer of "no," despite the resident having a dementia diagnosis. The assessment also indicated a "yes" answer to the question, "Does the resident refuse the use of bed rails?" but also then noted "dementia" in the box as an alternative method.

A quarterly MDS dated July 13, 2023, near the time the last side rail assessment was completed and indicated staff assessed the resident as a BIMS of one, and extensive assistance of two plus person physical assist for bed mobility.
There was no evidence to indicate Resident 74 could utilize the bilateral enabler bars observed on her bed or that any staff indicated the resident had the ability to utilize the enabler bars.

In an interview with the Director of Nursing on March 29, 2024, at 11:00 AM the finding for Residents 104 and 74 were reviewed. The Director of Nursing indicated the side rail assessments appeared to be completed on admission and the enabler bars were just left on the resident's beds.

483.25 (n) (1) (3) (4) Bed rails
Previously cited 4/14/23

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


 Plan of Correction - To be completed: 04/30/2024

1.Side Rail Entrapment Zone Assessments were completed on resident 74 and 105. An Enabler Bar Assessment was completed for residents 74 and 105 to determine appropriateness of the enabler bars. The enabler bars for resident 104 have been removed per the family request.

2.The Director of Nursing/Designee completed a facility wide audit to determine which residents currently have enabler bars. The therapy department will complete enabler bar assessments to determine which residents are appropriate for the use of enabler bars. Consents for enabler bars will be audited to ensure completion of all areas of the consent, including signature of resident or responsible party.

3.The Director of Nursing/Designee will educate therapy and nursing staff on the importance of completing Enable Bar Assessments accurately when assessing for the appropriateness of them.

4.The Director of Nursing/Designee will audit the records of those residents who have enabler bars to assess the risk of side rail entrapment. Audits will be completed to ensure enabler bar assessments are completed, consents are signed by the resident or Responsible Party and entrapment zone assessments are completed. Audits to occur 1x a week for 4 weeks 2x a month x 2 months then monthly x 3 months. The findings of these quality monitoring's to be reported to the Quality Assurance/Performance Improvement Committee monthly and/or until substantial compliance is met. Quality Monitoring schedule modified based on findings.

5.Date of completion will be April 30, 2024.

483.25(m) REQUIREMENT Trauma Informed 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(m) Trauma-informed care
The facility must ensure that residents who are trauma survivors receive culturally competent, trauma-informed care in accordance with professional standards of practice and accounting for residents' experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization of the resident.
Observations:

Based on clinical record review and resident and staff interview, it was determined that the facility failed to identify triggers related to a resident's diagnosis of Post-Traumatic Stress Disorder, to provide culturally, competent, trauma-informed care and eliminate or mitigate re-traumatization for one of one resident reviewed (Resident 50).

Findings include:

Clinical record review for Resident 50 revealed a quarterly Minimum Data Set (MDS, an assessment completed by the facility at intervals to determine care needs of the resident) assessment dated March 5, 2024, that indicated she had an active diagnosis of PTSD (Post Traumatic Stress Syndrome, a mental and behavioral disorder that develops from experiencing a traumatic event).

Interview with Resident 50 on March 27, 2024, at 10:35 AM revealed that she has PTSD from being raped by her mom's brother and by her father, after her mother died. She also indicated that she was beaten in a past relationship.

A psychiatric note dated January 31, 2024, revealed that Resident 50 indicated she mourns the death of her son who died a day and a half after he was born. She indicated that she never got to hold him. She also mourns the loss of multiple pregnancies that ended in miscarriage and cycles through the grieving process when the anniversary date of these events occurs.

Clinical record review of Resident 50's current care plan revealed a care plan problem that indicated she is at risk for adverse effects related to the use of antipsychotic (used to treat psychosis) medications for a diagnosis of anxiety (intense, excessive and persistent worry and fear about everyday situations) bipolar (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs), schizophrenia (a serious mental illness that affects how a person thinks, feels and behaves), and PTSD. The care plan did not identify Resident 50's triggers that may retraumatize her related to her diagnosis of PTSD.

Interview with the Director of Nursing on March 29, 2024, at 11:00 AM confirmed the above noted findings related to Resident 50's diagnosis of PTSD.

The facility failed to identify care plan triggers that may retraumatize Resident 50 related to her diagnosis of PTSD.

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


 Plan of Correction - To be completed: 04/30/2024

1.Resident 50's care plan has been updated to include specific triggers for her PTSD and interventions have been added to her plan of care.

2.Director of Nursing/Designee will identify any other residents who have a PTSD diagnosis to ensure their care plan included specific triggers.

3.The Director of Nursing/Designee will educate the nursing staff, Social Service Office and the Assessment Coordinator on updating the resident's care plan to include specific triggers of those resident's affected by PTSD.

4.The Social Worker/Designee will audit the care plan of new resident's admitting to the facility to identify if a PTSD diagnosis is present to ensure the plan of care includes the resident's triggers. Audits to occur 1x a week for 4 weeks 2x a month x 2 months then monthly x 3 months. The findings of these quality monitoring's to be reported to the Quality Assurance/Performance Improvement Committee monthly and/or until substantial compliance is met. Quality Monitoring schedule modified based on findings.

5.Date of completion will be April 30, 2024.


483.25(l) REQUIREMENT Dialysis: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(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 clinical record review, observations, and staff and resident interview, it was determined that the facility failed to ensure the availability of necessary emergency supplies for two out of three residents reviewed receiving hemodialysis (Residents 70 and 90).

Findings include:

Clinical record review for Resident 70 revealed the resident had an AV fistula (a connection that's made between an artery and a vein for dialysis access) in his left wrist for dialysis treatment.

A physician's order for Resident 70 dated March 22, 2024, indicated the resident was to receive hemodialysis (a machine that performs a basic function of the kidney by cleansing the blood of impurities) every Tuesday, Thursday, and Saturday at a dialysis center. An additional physician's order dated March 22, 2024, indicated the resident was to have and emergency dialysis kit at bedside to contain two sterile 4x4's, hemostats (a tool used to control bleeding), and tape, and to replace the kit if needed.

An observation and interview with Resident 70 on March 26, 2024, at 2:50 PM the resident stated he receives dialysis treatment every Tuesday, Thursday, and Saturday. Observation of the resident's room did not reveal any emergency kit visible in the room.

Clinical record review for Resident 90 revealed the resident is ordered to receive hemodialysis on Tuesdays, Thursdays, and Saturdays, at a dialysis center as indicated in the resident's physician order dated March 21, 2024.

A review of Resident 90's plan of care revealed the resident has an AV fistula in his left upper extremity and an emergency dialysis kit is to be kept as his bedside as added on March 22, 2024.

An observation of Resident 90's room on March 26, 2024, at 1:48 AM did not reveal any visible emergency kit in the resident's room.

A follow up observation of Resident 70's and Resident 90's room on March 27, 2024, at 10:55 AM with employee 6, licensed practical nurse, revealed no emergency kit in Resident 70 or Resident 90's room. Employee 6 indicated both residents had recently moved rooms and the emergency kits must not have moved with the residents.

In an interview with the Nursing Home Administrator and Director of Nursing on March 27, 2024, at 2:20 PM the above findings regarding Resident 70 and Resident 90 were reviewed.

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


 Plan of Correction - To be completed: 04/30/2024

1.An Emergency Dialysis Kit was placed at the bedside of resident 90. Resident 70 no longer resides at the facility.

2.Director of Nursing/Designee has audited the rooms of other residents in the facility receiving dialysis to ensure Dialysis Emergency Kits are at bedside.

3.Director of Nursing/Designee will educate licensed staff on the importance of maintaining placement of a Dialysis Emergency Kit at the bedside of residents who receive Dialysis.

4.Director of Nursing/Designee will audit the rooms of those residents who receive Dialysis treatment to ensure emergency kits are at bedside as ordered. Audits to occur 1x a week for 4 weeks 2x a month x 2 months then monthly x 3 months. The findings of these quality monitoring's to be reported to the Quality Assurance/Performance Improvement Committee monthly and/or until substantial compliance is met. Quality Monitoring schedule modified based on findings.

5.Date of completion will be April 30, 2024.

483.25(k) REQUIREMENT Pain Management: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(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 review and staff interview, it was determined that the facility failed to provide the highest practicable care regarding physician ordered pain medications for one of four residents reviewed (Resident 91).

Findings include:

Review of Physiopedia's and Wikipedia's definition of the numeric pain rating scale (parameters) from zero to 10 indicated that no pain was identified as zero, mild pain was identified as one to three, moderate pain was identified as four to six, and severe pain was identified as seven to 10.

Clinical record review for Resident 91 revealed physician's orders for the following pain medications:

Ordered on April 20, 2023, Acetaminophen (Tylenol, for mild pain) 325 milligrams (mg) 2 tablets by mouth (PO) every 6 hours as needed (PRN) for pain 1-4.

Ordered on August 8, 2023, and discontinued on July 15, 2024, Tramadol (for moderate to severe pain) 50 mg PO every 4 hours PRN for pain.

Ordered on January 15, 2024, Tramadol (for moderate to severe pain) 50 mg PO every 4 hours PRN for pain 6-10.

Review of Resident 91's August, September, October, November, and December 2023 and January, February, and March 2024 MAR (medication administration record, a form to document medication administration) revealed the following:

Staff administered the following PRN pain medications:

Acetaminophen 325 mg 2 tablets PO every 6 hours PRN for pain 1-4

August 1, 2023, at 7:56 PM for a pain level of 5.
August 2, 2023, at 8:15 PM for a pain level of 5.
August 6, 2023, at 7:50 PM for a pain level of 5.
August 11, 2023, at 8:26 PM for a pain level of 5.
August 19, 2023, at 7:42 PM for a pain level of 5.
August 20, 2023, at 4:18 AM for a pain level of 7.

September 8, 2023, at 2:19 PM for a pain level of 5.
September 13, 2023, at 3:26 PM for a pain level of 8.

October 18, 2023, at 4:32 PM for a pain level of 5.
October 31, 2023, at 12:54 PM for a pain level of 5.

November 13, 2023, at 7:41 PM for a pain level of 8.
November 27, 2023, at 8:30 PM for a pain level of 7.
November 28, 2023, at 8:01 PM for a pain level of 5.
November 29, 2023, at 6:58 PM for a pain level of 5.

December 3, 2023, at 8:10 PM for a pain level of 7.
December 13, 2023, at 10:09 PM for a pain level of 7.
December 15, 2023, at 8:26 PM for a pain level of 7.
December 17, 2023, at 8:18 PM for a pain level of 6.
December 27, 2023, at 9:02 PM for a pain level of 5.

January 13, 2024, at 7:39 PM for a pain level of 7.

February 3, 2024, at 8:02 PM for a pain level of 5.
February 28, 2024, at 12:53 PM for a pain level of 5.

March 4, 2024, at 8:04 PM for a pain level of 6.
March 10, 2024, at 7:52 PM for a pain level of 6
March 19, 2024, at 12:50 PM for a pain level of 5.
March 23, 2024, at 7:45 PM for a pain level of 6.
March 24, 2024, at 1:58 PM for a pain level of 6.


Tramadol 50 mg PO every 4 hours PRN for pain 6-10

February 5, 2024, at 7:34 PM for a pain level of 5.

The surveyor reviewed Resident 91's pain information and not following the parameters during an interview with Employee 5, registered nurse, assistant director of nursing, on March 29, 2024, at 10:11 AM.

483.25(k) Pain Management
Previously cited 4/14/23

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


 Plan of Correction - To be completed: 04/30/2024

1.Resident 91's pain medications have been reviewed by the physician and orders received as appropriate.

2.Director of Nursing/Designee will audit orders for current residents receiving PRN pain medications to ensure the pain scale parameters are in place. The resident's eMAR will be audited to ensure the licensed staff are following the pain parameter scale as ordered by the physician.

3.Director of Nursing/Designee will educate licensed nursing staff on the Pain Policy and following pain scale parameters.

4.Director of Nursing/Designee will audit the eMAR records of residents receiving prn pain medication to ensure licensed staff are following the pain parameter scale as ordered. Audits to occur 1x a week for 4 weeks 2x a month x 2 months then monthly x 3 months. The findings of these quality monitoring's to be reported to the Quality Assurance/Performance Improvement Committee monthly and/or until substantial compliance is met. Quality Monitoring schedule modified based on findings.

5.Date of completion will be April 30, 2024.


483.25(i) REQUIREMENT Respiratory/Tracheostomy Care and Suctioning:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.25(i) Respiratory care, including tracheostomy care and tracheal suctioning.
The facility must ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals and preferences, and 483.65 of this subpart.
Observations:

Based on observation, clinical record review, and staff interview, it was determined that the facility failed to provide appropriate respiratory care and services for one of three residents reviewed (Resident 75).

Findings include:

Observation of Resident 75 on March 27, 2024, at 9:39 AM revealed Resident 75 was in her room with oxygen on and running at 3 liters per minute.

Observation of Resident 75 on March 27, 2024, at 10:28 AM revealed she was in the dining room without oxygen. Further observation revealed Resident 75's oxygen was running in her room at 3 liters per minute, with the nasal cannula tubing lying across Resident 75's bed.

Review of Resident 75's clinical record revealed there was no physician's order for Resident 75 to receive oxygen.

An interview with Employee 5 (assistant director of nursing) confirmed the above findings for Resident 75. Employee 5 indicated she was unsure when staff began administering Resident 75's oxygen but noted documentation in Resident 75's clinical record that Resident 75 utilized oxygen starting on March 22, 2024. Nursing staff obtained an order for Resident 75's oxygen after the surveyor's questions on March 27, 2024.

The above findings regarding Resident 75 were reviewed with the Nursing Home Administrator and Director of Nursing on March 27, 2024, at 2:00 PM.

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


 Plan of Correction - To be completed: 04/30/2024

1.The Director of Nursing/Designee clarified Resident 75's physician orders for the need for supplemental oxygen and the plan of care was updated appropriately.

2.The Director of Nursing/Designee will audit the current residents receiving oxygen therapy to ensure that physician orders are being administered and meeting resident needs.

3.The Director of Nursing/Designee will review the oxygen therapy policy and educate licensed nursing staff on the importance of obtaining and following physician orders to meet the resident's oxygen needs.

4.The Director of Nursing/Designee will audit the records of residents receiving oxygen therapy to ensure physician orders are in place to mee the need of the resident. Audits to occur 1x a week for 4 weeks 2x a month x 2 months then monthly x 3 months. The findings of these quality monitoring's to be reported to the Quality Assurance/Performance Improvement Committee monthly and/or until substantial compliance is met. Quality Monitoring schedule modified based on findings.

5.Date of completion will be April 30, 2024.

483.25(g)(1)-(3) REQUIREMENT Nutrition/Hydration Status Maintenance:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.25(g) Assisted nutrition and hydration.
(Includes naso-gastric and gastrostomy tubes, both percutaneous endoscopic gastrostomy and percutaneous endoscopic jejunostomy, and enteral fluids). Based on a resident's comprehensive assessment, the facility must ensure that a resident-

483.25(g)(1) Maintains acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that this is not possible or resident preferences indicate otherwise;

483.25(g)(2) Is offered sufficient fluid intake to maintain proper hydration and health;

483.25(g)(3) Is offered a therapeutic diet when there is a nutritional problem and the health care provider orders a therapeutic diet.
Observations:

Based on clinical record review and staff interview, it was determined that the facility failed to implement interventions to promote acceptable parameters of nutrition for one of six residents reviewed (Resident 42).

Findings include:

Clinical record review revealed the facility admitted Resident 42 on January 23, 2024. Further review of Resident 42's clinical record revealed the following weight assessments:

January 23, 2024, 145 pounds
January 29, 2024, 127.8 pounds (a 17.2 pound, an 11.8 percent severe weight loss)
January 30, 2024, 127.8 pounds
February 2, 2024, 127.0 pounds
February 7, 2024, 124.2 pounds
February 13, 2024, 122.6 pounds

Further review of Resident 42's clinical record revealed a nutrition progress note dated January 30, 2024, which noted "resident showing a weight loss, request a re-weight.

A nutrition progress note dated January 31, 2024, revealed Resident 42 was noted to have a 16.8-pound weight loss over seven days. The registered dietician recommended fortified foods for added calories for weight stabilization. An addendum was added to the note indicating Resident 42 has an allergy to lactose and recommends double protein portions at meals for Resident 42, instead of fortified foods.

A nutrition progress note dated February 14, 2024, noted Resident 42 continues with slow weight loss.

Review of Resident 42's clinical record revealed no evidence that the facility implemented the registered dietician's recommendation of double protein portions at meals.

An interview with Employee 5 (assistant director of nursing) on March 29, 2024, at 10:37 AM confirmed the above findings for Resident 42 and stated the facility had no further documentation addressing Resident 42's severe weight loss.

28 Pa. Code 211.10(d) Resident care policies

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



 Plan of Correction - To be completed: 04/30/2024

1.Resident 42's plan of care was updated on 3/28/2024 to reflect the Registered Dietician's recommendation for double protein portions with meals to meet the resident's nutritional needs.

2.Other residents in the facility were reviewed by the Registered Dietician to ensure dietary supplements are being administered as ordered and interventions are in place to ensure acceptable parameters of nutrition for residents who have had a significant weight loss.

3.The Director of Nursing/Designee will educate licensed nurses on the proper implementation of the Registered Dietician's recommendations for supplements and/or other interventions to address weight loss.

4.The Registered Dietician/Designee will audit resident charts to ensure recommendations for supplements are in place as ordered in order to meet acceptable parameters of nutrition. Audits to occur 1x a week for 4 weeks 2x a month x 2 months then monthly x 3 months. The findings of these quality monitoring's to be reported to the Quality Assurance/Performance Improvement Committee monthly and/or until substantial compliance is met. Quality Monitoring schedule modified based on findings.

5. Date of completion will be April 30, 2024.


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 review and staff interview, it was determined that the facility failed to assess and implement individualized interventions to promote bowel and bladder continence for one of two residents reviewed for incontinence (Resident 115).

Findings include:

On March 29, 2024, at 12:35 PM The Director of Nursing (DON) indicated that the facility did not have a policy on evaluating resident bowel and bladder incontinence.

Clinical record review for Resident 115 revealed a care plan that was initiated on March 4, 2024, that indicated she was incontinent of bowel and bladder.

Further clinical record review for Resident 115 revealed a bowel and bladder program screener dated March 9, 2024, that indicated she was always continent of bladder and never incontinent of bowel.

Care plans initiated March 4, 2024, indicated that Resident 115 is incontinent of bowel and incontinent of bladder.

Review of Resident 115's task documentation (computerized documentation of the care provided) revealed that Resident 115 was documented as being incontinent of bowel 15 times and bladder 15 times from March 3 to 27, 2024.

Review of Resident 115's most recent MDS (Minimum Data Assessment, an assessment performed by the facility at intervals to document care needs) dated March 3, 2024, revealed that Resident 115 was occasionally incontinent of bowel and frequently incontinent of bladder. The MDS also indicated that Resident 115 had a BIMS (Brief interview for mental status, an assessment used to monitor cognition) score of 15 indicating she was cognitively intact.

Interview with the Director of Nursing on March 29, 2024, at 12:35 PM confirmed the above noted inconsistencies related to Resident 115's bowel and bladder continence. She confirmed that there was no evidence that the facility further assessed Resident 115 to implement interventions to promote bowel and bladder continence.

The facility failed to appropriately assess and implement individualized interventions to promote bowel and bladder continence for Resident 115.

28 Pa. Code 21.12(d)(1)(5) Nursing services


 Plan of Correction - To be completed: 04/30/2024

1.The Director of Nursing/Designee assessed and developed an individualized incontinence program for resident 115.

2.The Director of Nursing/Designee will audit current residents who are identified by the bowel and bladder incontinence assessment to ensure that an individualized incontinence program is present.

3.The Director of Nursing/Designee will review and educate staff on the Bowel and Bladder Incontinence policy.

4.The Director of Nursing/Designee will audit residents identified with bowel or bladder incontinence to ensure that an individualized bowel and bladder incontinence program is developed. Audits to occur 1x a week for 4 weeks 2x a month x 2 months then monthly x 3 months. The findings of these quality monitoring's to be reported to the Quality Assurance/Performance Improvement Committee monthly and/or until substantial compliance is met. Quality Monitoring schedule modified based on findings.

5.Date of completion will be April 30, 2024.


483.25(d)(1)(2) REQUIREMENT Free of Accident Hazards/Supervision/Devices:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.25(d) Accidents.
The facility must ensure that -
483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and

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

Based on observation, review of select facility policies, facility documents, clinical record review, and staff and resident interview, it was determined that the facility failed to implement appropriate interventions to prevent falls for one of five residents reviewed for falls (Resident 52).

Findings include:

In an interview an observation of Resident 52 on March 26, 2024, at 1:33 PM the resident was observed in bed with several steri strips (strips used to heal wounds by pulling two sides of a wound together) on his left hand. Resident 52 stated he fell out of bed a couple days ago.

Clinical record review for Resident 52 revealed a nursing note dated March 20, 2024, at 4:11 PM, which noted when the resident was being changed, the resident rolled out of bed, landed on his knees, then rolled onto his right side, and hit his head on the wheel of the bed. It was also noted the resident's knees were red and excoriated, and a hematoma was present on the left side of his head.

A nursing note dated March 21, 2024, at 1:14 AM for Resident 52 noted the resident's hand was assessed status post fall, and a 5 cm (centimeter) by 4.3-centimeter skin tear was noted to the back of the resident's left hand, and the resident stated he got it from the fall. It was noted the area was cleansed and steri strips were applied to all edges.

A review of facility documentation of the incident dated March 20, 2024, at 5:42 PM indicated a nurse aide was providing care of the resident while in bed and the resident rolled out of the bed away from the nurse aide. An attached staff statement noted the staff member was providing incontinence care to the resident and the call bell came out of the wall, so the staff member turned to plug it back in and when she turned back toward the resident he was on the floor. The staff member noted the resident was getting his brief changed at the time of the incident.

A review of a quarterly MDS (minimum data set, an assessment completed at periodic intervals of time to assess resident care needs) completed on February 10, 2024, revealed facility staff assessed the resident as being dependent on staff to roll left and right, dependent on staff for hygiene, and the resident had impaired range of motion on both upper extremities. Further review of a state only MDS assessment of the same date, facility staff assessed the resident as requiring extensive assistance of two plus person physical assistance for bed mobility.

Further clinical record review for Resident 52 revealed a physician's order listed under behaviors dated February 14, 2023, indicating the resident is to have two people in the room at all times with care.

Review of documentation did not indicate whether Resident 52 was demonstrating any behaviors at the time of the incident, but it was evident that care was being provided at the time of the incident when a nurse aide turned away to attend to a different task. There was no evidence to indicate another staff member was present as ordered for two for care as a behavioral intervention. Resident 52 did roll out of bed while receiving care and sustained minor injuries.

The above information was reviewed with the Director of Nursing on March 29, 2024, at 11:00 AM.

483.25(d)(1)(2) Free of Accident Hazards
Previously cited 4/14/23

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

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


 Plan of Correction - To be completed: 04/30/2024

1.Resident 52's physician's orders and care plan have been reviewed and updated in accordance with the resident's needs.

2.Director of Nursing/Designee will review incident reports relating to falls since 3/1/2024 to ensure all care plan interventions are in place and are appropriate.

3.Director of Nursing/Designee will reeducate licensed nursing staff regarding ensure incident report interventions are in place and are appropriate.

4.Director of Nursing/Designee will monitor fall incident reports upon completion to ensure care plan interventions are in place and appropriate. Audits to occur 1x a week for 4 weeks 2x a month x 2 months then monthly x 3 months. The findings of these quality monitoring's to be reported to the Quality Assurance/Performance Improvement Committee monthly and/or until substantial compliance is met. Quality Monitoring schedule modified based on findings.

5.Date of completion will be April 30, 2024.




483.25(c)(1)-(3) REQUIREMENT Increase/Prevent Decrease in ROM/Mobility:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.25(c) Mobility.
483.25(c)(1) The facility must ensure that a resident who enters the facility without limited range of motion does not experience reduction in range of motion unless the resident's clinical condition demonstrates that a reduction in range of motion is unavoidable; and

483.25(c)(2) A resident with limited range of motion receives appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion.

483.25(c)(3) A resident with limited mobility receives appropriate services, equipment, and assistance to maintain or improve mobility with the maximum practicable independence unless a reduction in mobility is demonstrably unavoidable.
Observations:

Based on clinical record review and staff interview, it was determined that the facility failed to provide services to maintain a resident's range of motion for one of 5 residents reviewed (Resident 44).

Findings include:

Clinical record review revealed a quarterly MDS (Minimum Data Set, an assessment completed at specific intervals to determine resident care needs) dated August 2, 2023, noting staff assessed Resident 44 as having no upper or lower extremity impairments.

Review of physical therapy documentation revealed Resident 44 was discharged from physical therapy on August 4, 2023. A review of Resident 44's physical therapy discharge summary revealed his prognosis to maintain his current level of function would be good with consistent staff follow-through. The physical therapy discharge summary noted the facility does not offer restorative nursing programs.

Further review of Resident 44's clinical record revealed his next quarterly MDS assessment dated November 2, 2023, nursing staff assessed Resident 44 as having a limited range of motion to his bilateral lower extremities. Nursing staff again assessed Resident 44 as having a limited range of motion to his bilateral lower extremities on his most recent annual MDS assessment dated March 22, 2024.

The facility failed to ensure Resident 44 received appropriate treatment and services to maintain his range of motion (ROM, movement of the body to maintain a resident's ability) or prevent further decrease in his range of motion.

An interview with Employee 4 (director of rehabilitation) confirmed he was not made aware of Resident 44's decline in range of motion. He also confirmed that the facility does not have a restorative nursing program to maintain residents' level of function when discharged from therapy services.

The findings for Resident 44 were reviewed with the Nursing Home Administrator and Director of Nursing during a meeting on March 28, 2024, at 2:15 PM

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


 Plan of Correction - To be completed: 04/30/2024

1.Resident 44 has been screened by therapy to determine his current level of function. Therapy will recommend an appropriate course of treatment for staff follow through specific to resident 44. Therapy will provide education to staff regarding the course of treatment and appropriate follow through to prevent further decrease in range of motion.

2.The Director of Therapy/Designee will complete audits on residents who have been discharged from therapy for the past 30 days who require functional maintenance needs to ensure an appropriate course of treatment has been established to prevent further decrease in range of motion.

3.The Director of Therapy/Designee will reeducate all licensed and direct care staff on the follow through of the course of treatment set forth by the therapy department to prevent further decline/decrease in range of motion of the residents.

4.The Director of Therapy/Designee will conduct audits of those residents who have been discharged from therapy to ensure there are services in place to maintain the resident's range of motion. Audits to occur 1x a week for 4 weeks 2x a month x 2 months then monthly x 3 months. The findings of these quality monitoring's to be reported to the Quality Assurance/Performance Improvement Committee monthly and/or until substantial compliance is met. Quality Monitoring schedule modified based on findings.

5.The date of completion will be April 30, 2024.

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 review and family and staff interview, it was determined that the facility failed to promote resident and/or responsible party involvement with care plan development for one of one resident reviewed (Resident 101).

Findings include:

Clinical record review for Resident 101 revealed that the facility conducted care plan meetings for her on August 4, 2023, September 6, 2023, and November 20, 2023.

During a telephone interview with Resident 101's responsible party on March 26, 2024, at 1:51 PM she revealed that she only attended one care plan meeting and that she did not get invited to other ones. She indicated that she had to invite herself to the one she did attend by requesting a meeting.

The Director of Nursing (DON) was made aware of the concern related to Resident 101's care plan meetings on March 27, 2024, at 2:00 PM.

The Director of Nursing provided the surveyor with evidence that Resident 101's responsible party attended a meeting on March 18, 2024. The DON also confirmed at this time that this was a meeting that was requested by Resident 101's responsible party.

Interview with the DON at 11:02 AM March 29, 2024, revealed that there was no evidence that Resident 101's responsible party was invited to attend her care plan meetings that were held on August 4, 2023, September 6, 2023, and November 20, 2023.

The facility failed to promote resident and/or responsible party involvement with care plan development for Resident 101.

483.21(b)(2)(E) Care Plan Timing and Revision
Previously cited 4/14/23

28 Pa. Code 211.10(a) Resident care policies


 Plan of Correction - To be completed: 04/30/2024

1.Resident 101's family was invited and attended the care plan conference on 3/18/2024.

2.The Director of Nursing/Social Worker will audit the care plan conferences for the past 30 days to ensure the responsible party of the resident was invited to attend.

3.The Administrator or Director of Nursing will educate the Social Services office on the Care Planning process to ensure that responsible parties of the residents are given notification to the care plan conference.

4.The Director of Nursing/Social Services office will audit 5 care plan notifications to ensure the resident and responsible party were notified of the care plan meeting to promote involvement. Audits to occur 1x a week for 4 weeks 2x a month x 2 months then monthly x 3 months. The findings of these quality monitoring's to be reported to the Quality Assurance/Performance Improvement Committee monthly and/or until substantial compliance is met. Quality Monitoring schedule modified based on findings.

5.Date of completion will be April 30, 2024.

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

Based on clinical record review and resident and staff interview, it was determined that the facility failed to develop and implement a comprehensive person-centered care plan to maintain the highest practicable care for one of one resident reviewed (Residents 50).

Findings Include:

Clinical record review for Resident 50 revealed a psychiatry note dated January 31, 2024, that indicated she wanted to die so she can be with her babies. The note indicated that she did not have a plan and that she stated she would never harm herself.

Further review of the psychiatry note revealed that Resident 50 indicated that she mourns her son's death. She stated he died one- and one-half days after he was born, and she never got to hold him. She also reported that she mourns the loss of multiple pregnancies that ended in miscarriage and cycles through the grieving process when the anniversary date of these events occurs. The note also indicated that she hears her deceased mother's voice and seeing her deceased mother from time to time.

The note also indicated that a safety plan was developed, and the resident agrees to tell nursing staff should she begin to have feelings of suicidal ideation. The resident does not appear to be of immediate threat but recommends monitoring resident closely for any changes in condition or worsening of symptoms of depression.

Review of Resident 50's current care plan revealed no evidence of a plan of care to address Resident 50's concerns related to wanting to die related to miscarriages and the death of her infant son and hearing her deceased mother's voice.

Interview with the Director of Nursing on March 29, 2024, at 10:34 AM confirmed the above noted findings related to Resident 50's care plan.

The facility failed to implement a person center care plan to maintain the highest practicable care for Resident 50.

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




 Plan of Correction - To be completed: 04/30/2024

1.Resident 50's plan of care was updated to address her concerns of wanting to die related to her miscarriages and death of her infant son and hearing her deceased mother's voice.

2.The Director of Nursing/Designee will audit the care plan of the residents receiving psychiatric services to ensure that a comprehensive person-centered care plan has been developed.

3.Nursing staff, Registered Nurse Assessment Coordinator and Social Services will be educated regarding developing person centered/individualized care plans.

4.The Director of Nursing/Designee will audit the care plans of five residents receiving psychiatric services to ensure the care plan developed is person centered and individualized. Audits to occur 1x a week for 4 weeks 2x a month x 2 months then monthly x 3 months. The findings of these quality monitoring's to be reported to the Quality Assurance/Performance Improvement Committee monthly and/or until substantial compliance is met. Quality Monitoring schedule modified based on findings.

5.Date of completion will be April 30, 2024.


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

Based on clinical record review and staff interview, it was determined that the facility failed to ensure complete and accurate Minimum Data Set (MDS) assessments for one of 25 residents reviewed (Resident 110).

Findings include:

Review of Resident 110's clinical record revealed the facility admitted her on January 12, 2024. A review of Resident 110's admission Minimum Data Set Assessment (MDS, a form completed at specific intervals to determine care needs) dated January 18, 2024, noted staff assessed Resident 110 as utilizing a limb restraint less than daily.

Observation of Resident 110 on March 26, 2024, at 11:04 AM, and March 27, 2024, at 9:42 AM revealed no evidence of a limb restraint.

Review of Resident 110's physician orders did not include evidence of Resident 110 utilizing a restraint.

An interview with the Director of Nursing on March 28, 2024, at 10:52 AM confirmed the MDS was incorrect, and Resident 110 never utilized a restraint.


28 Pa. Code 211.5(f) Clinical records

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


 Plan of Correction - To be completed: 04/30/2024

1.MDS modification has been submitted for the cited assessment for resident 110.

2.The RNAC/Designee will audit Section P (physical restraints) of MDS assessments submitted in the past three months to ensure accuracy of clinical assessments.

3.Assessment Coordinators were reeducated regarding accurate completion of Section P of the MDS to ensure accuracy of the clinical assessments.

4.The RNAC/Designee will audit ten MDS assessments to ensure accuracy of the clinical assessment for section P. Audits to occur 1x a week for 4 weeks 2x a month x 2 months then monthly x 3 months. The findings of these quality monitoring's to be reported to the Quality Assurance/Performance Improvement Committee monthly and/or until substantial compliance is met. Quality Monitoring schedule modified based on findings.

5.Date of completion will be April 30, 2024.



483.15(c)(3)-(6)(8) REQUIREMENT Notice Requirements Before Transfer/Discharge: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.
483.15(c)(3) Notice before transfer.
Before a facility transfers or discharges a resident, the facility must-
(i) Notify the resident and the resident's representative(s) of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand. The facility must send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman.
(ii) Record the reasons for the transfer or discharge in the resident's medical record in accordance with paragraph (c)(2) of this section; and
(iii) Include in the notice the items described in paragraph (c)(5) of this section.

483.15(c)(4) Timing of the notice.
(i) Except as specified in paragraphs (c)(4)(ii) and (c)(8) of this section, the notice of transfer or discharge required under this section must be made by the facility at least 30 days before the resident is transferred or discharged.
(ii) Notice must be made as soon as practicable before transfer or discharge when-
(A) The safety of individuals in the facility would be endangered under paragraph (c)(1)(i)(C) of this section;
(B) The health of individuals in the facility would be endangered, under paragraph (c)(1)(i)(D) of this section;
(C) The resident's health improves sufficiently to allow a more immediate transfer or discharge, under paragraph (c)(1)(i)(B) of this section;
(D) An immediate transfer or discharge is required by the resident's urgent medical needs, under paragraph (c)(1)(i)(A) of this section; or
(E) A resident has not resided in the facility for 30 days.

483.15(c)(5) Contents of the notice. The written notice specified in paragraph (c)(3) of this section must include the following:
(i) The reason for transfer or discharge;
(ii) The effective date of transfer or discharge;
(iii) The location to which the resident is transferred or discharged;
(iv) A statement of the resident's appeal rights, including the name, address (mailing and email), and telephone number of the entity which receives such requests; and information on how to obtain an appeal form and assistance in completing the form and submitting the appeal hearing request;
(v) The name, address (mailing and email) and telephone number of the Office of the State Long-Term Care Ombudsman;
(vi) For nursing facility residents with intellectual and developmental disabilities or related disabilities, the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with developmental disabilities established under Part C of the Developmental Disabilities Assistance and Bill of Rights Act of 2000 (Pub. L. 106-402, codified at 42 U.S.C. 15001 et seq.); and
(vii) For nursing facility residents with a mental disorder or related disabilities, the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with a mental disorder established under the Protection and Advocacy for Mentally Ill Individuals Act.

483.15(c)(6) Changes to the notice.
If the information in the notice changes prior to effecting the transfer or discharge, the facility must update the recipients of the notice as soon as practicable once the updated information becomes available.

483.15(c)(8) Notice in advance of facility closure
In the case of facility closure, the individual who is the administrator of the facility must provide written notification prior to the impending closure to the State Survey Agency, the Office of the State Long-Term Care Ombudsman, residents of the facility, and the resident representatives, as well as the plan for the transfer and adequate relocation of the residents, as required at 483.70(l).
Observations:

Based on clinical record review and staff interview, it was determined that the facility failed to notify a resident and/or their responsible party in writing of a transfer to the hospital for four of six residents reviewed (Residents 41, 60, 75, and 221).

Findings include:

Clinical record review for Resident 41 revealed that they were transferred to the hospital on November 8, 2023, after a change in their condition. There was no documentation that the facility provided written notification to the resident or the resident's responsible party regarding the transfer that included the required contents: the reason for the transfer, the effective date of the transfer, the location to which the resident was transferred, contact and address information for the Office of the State Long-Term Care Ombudsman, and information for the agency responsible for the protection and advocacy of individuals with developmental disabilities.

Clinical record review for Resident 221 revealed that they were transferred to the hospital on March 1, 2024, after there was a change in their condition. There was no documentation that the facility provided written notification to the resident, or their responsible party as required regarding the transfer that included the required contents.

The surveyor reviewed the above information for Residents 41 and 221 during an interview with the Director of Nursing on March 28, 2024, at 12:39 PM and March 29, 2024, at 11:19 AM.

Clinical record review for Resident 75 revealed the resident was transferred and admitted to the hospital on December 30, 2023, returning to the facility on January 2, 2024. There was no evidence to indicate that Resident 75's responsible party was provided written notification to include the above-required contents. Further review of facility documentation revealed there was no documented evidence that the facility notified the Office of the State Long-Term Care Ombudsman of Resident 75's transfer to the hospital.

The Director of Nursing confirmed the above-noted findings regarding Resident 75's transfer notices during a meeting on March 29, 2024, at 11:35 AM.

Clinical record review for Resident 60 revealed that the resident was transferred to the hospital and admitted on October 28, 2023, returning to the facility on November 1, 2023. There was no evidence to indicate that Resident 60's responsible part was provided with written notification to include the above-required contents. Further review of facility documentation revealed that there was no evidence that the facility notified the Office of the State Long-Term Care Ombudsman of Resident 60's transfer to the hospital.

The Director of Nursing confirmed the above-noted findings regarding Resident 60's transfer notices during a meeting on March 29, 2024, at 12:20 PM.

28 Pa. Code 201.14 (a) Responsibility of license

28 Pa. Code 201.29(a) Resident rights


 Plan of Correction - To be completed: 04/30/2024

1.The facility cannot retroactively correct the lack of notification to the resident and/or responsible party for resident 41, 75, and 221. Resident 60's clinical record has been updated to reflect that notification of the transfer to the hospital was made to the resident's RP. Notification of transfer for resident 41, 60, 75 and 221 has been made to the Office of the State Long-Term Care Ombudsman.

2.The DON/Designee will complete an audit of the any other resident's record who have been transferred out to the hospital in the last 90 days to ensure the appropriate transfer notification to the resident and/or responsible party and the Office of the State Long-Term Care Ombudsman has occurred.

3.Director of Nursing/Designee will reeducate nursing staff on the appropriate provision of resident/responsible party notification upon transfer.

4.The DON/Designee will audit the records of those residents who have been transferred out of the facility to ensure proper notification has been made to the resident, responsible party and the Office of the State Long-Term Care Ombudsman. Audits to occur 1x a week x 4 weeks, 2x a month x 2 months, then monthly x 3 months. The findings of these quality monitoring's to be reported to the Quality Assurance/Performance Improvement Committee monthly and/or until substantial compliance is met. Quality Monitoring schedule modified based on findings.

5.Date of completion will be April 30, 2024.


201.18(b)(2) LICENSURE Management.:State only Deficiency.
(2) Protection of personal and property rights of the residents, while in the facility, and upon discharge or after death, including the return of any personal property remaining at the facility within 30 days after discharge or death.
Observations:

Based on clinical record review and staff interview, it was determined that the facility failed to maintain a complete and accurate record of residents' personal possessions upon discharge for two of three residents reviewed (Residents 119 and 221).

Findings include:

Closed clinical record review for Resident 221 revealed that the facility discharged them on March 1, 2024. There was no documentation indicating that the facility completed a resident belonging sheet (a form used to identify resident belongings) or acknowledged that all resident belongings were returned at the time of discharge.

The surveyor reviewed the above information for Resident 221 during an interview with the Director of Nursing on March 29, 2024, at 11:19 AM.

Closed clinical record review for Resident 119 revealed he was discharged from the facility on January 5, 2025. A review of Resident 119's personal belongings inventory form revealed that it was not signed by the resident/responsible party upon discharge from the facility. Further review of Resident 119's closed clinical record revealed no documentation to indicate the disposition of his personal belongings.

The surveyor reviewed the above information for Resident 119 during an interview with Employee 5 (assistant director of nursing) on March 29, 2024, at 10:14 AM.


 Plan of Correction - To be completed: 04/30/2024

1.The deficiency cannot be corrected as it pertains to resident 119 and 221 as they are no longer at the facility.

2.The RN who discharges a resident will be responsible for ensuring that the resident or responsible party has accounted for the personal belongings by signing the Inventory of Personal Effects form at time of discharge.

3.The Director of Nursing/Designee will educate nursing staff on the Personal Property policy.

4.The Health Information Management professional will audit the closed records of those residents who have been discharged from the facility to ensure completion of Personal Inventory forms. Audits to occur 1x a week for 4 weeks 2x a month x 2 months then monthly x 3 months. The findings of these quality monitoring's to be reported to the Quality Assurance/Performance Improvement Committee monthly and/or until substantial compliance is met. Quality Monitoring schedule modified based on findings.

5.Date of completion will be April 30, 2024.

211.9(j.1) (1) - (5) LICENSURE Pharmacy services.:State only Deficiency.
(j.1) The facility shall have written policies and procedures for the disposition of medications that address all of the following:
(1) Timely and safe identification and removal of medications for disposition.
(2) Identification of storage methods for medications awaiting final disposition.
(3) Control and accountability of medications awaiting final disposition consistent with standards of practice.
(4) Documentation of actual disposition of medications to include the name of the individual disposing of the medication, the name of the resident, the name of the medication, the strength of the medication, the prescription number if applicable, the quantity of medication and the date of disposition.
(5) A method of disposition to prevent diversion or accidental exposure consistent with applicable Federal and State requirements, local ordinances and standards of practice.

Observations:

Based on closed clinical record review and staff interview, it was determined that the facility failed to document the accounting and disposition of medications in the clinical record upon discharge for of three of three residents reviewed (Residents 119, 120, and 221).

Findings include:

Closed clinical record review for Resident 120 revealed the resident expired at the facility, and the facility discharged the resident on January 22, 2024.

There was no documented evidence in Resident 120's closed clinical record of the disposition of the following medications:
Dexamethasone (treats inflammation) 2 mg (milligrams)
Fentanyl Transdermal Patch (treats pain) 12 mcg (micrograms)
Buspirone HLC (treats anxiety) 10 mg
Haloperidol Lactate concentrate (treats mood disorders) 2 mg/ml (milligrams/milliliter)
Haloperidol tablet (treats mood disorders) 1 mg
Hydromorphone HCL oral liquid (treats severe pain) 1 mg/ml
Hydromorphone HCO tablet (treats severe pain) 2 mg
Furosemide (treats fluid retention) 20 mg
Metoprolol Tartrate (treats high blood pressure) 25 mg
Buspirone (treats anxiety) 10 mg
Lorazepam (treats anxiety) 0.5 mg

There was no documented evidence to determine if the medications were destroyed or returned to the pharmacy.

Interview with the Director of Nursing on March 29, 2024, at 11:00 AM confirmed that the facility was unable to provide documented evidence of appropriate disposition of Resident 120's medications upon discharge.

Closed clinical record review for Resident 221 revealed that on March 1, 2024, the facility transferred her to the hospital. Review of a discharge summary dated March 1, 2024, revealed that Resident 221 was discharged from the facility.

Review of Resident 221's March 2024 MAR (medication administration record, a form to document medication administration) and current physician's orders revealed that she was ordered the following medications:

Coumadin (a blood thinner)
Ergocalciferol (Vitamin D, a supplement)
Incruse ellipta (a medication used for chronic obstructive pulmonary disease)
Renal vitamins (a supplement)
Advair (a medication used for asthma)
Docusate sodium (a medication used for constipation)
Doxycycline (an antibiotic used for pneumonia)
Auryxia (a medication used for high phosphate levels)
Tylenol (a medication used for mild pain and fever)

There was no documentation indicating that the facility accounted for all of Resident 221's medications at the time of discharge.

The surveyor reviewed the above information for Resident 221 during an interview with the Director of Nursing on March 29, 2024, at 11:19 AM.

Closed clinical record review for Resident 119 revealed that on January 5, 2024, Resident 119 left the facility against medical advice.

Review of Resident 119's January 2024 MAR and physician's orders revealed that he was ordered the following medications:

Carvedilol (medication used to treat high blood pressure)
Finasteride (medication used to treat urinary retention)
Fluticasone and Salmeterol Oral Inhalation (medication used to treat chronic obstructive pulmonary disease)
Furosemide (medication used to treat fluid retention, and swelling)
Incruse Ellipta Inhaler (medication used to treat chronic obstructive pulmonary disease)
Omeprazole (medication used to treat heartburn)
Rosuvastatin (medication used to treat high cholesterol)
Tamsulosin (medication used to treat urinary retention)
Xarelto (blood thinner, medication to treat blood clots)

There was no documentation indicating that the facility accounted for the disposition of Resident 119's medications at the time of discharge.

Interview with the Director of Nursing on March 29, 2024, at 10:14 AM confirmed that the facility was unable to provide documented evidence of the disposition of Resident 119's medications upon discharge.


 Plan of Correction - To be completed: 04/30/2024

1.The deficiency cannot be corrected for residents 119,120 and 221as they are no longer at the facility.

2.The DON/Designee contacted Specialty Rx pharmacy regarding documentation of medications that were returned for resident 120.

3.The Director of Nursing/Designee will educate RN's and LPN's on the correct disposition of medications at time of discharge.

4.The Director of Nursing/Designee will complete audits on the closed charts of those residents who have been discharged to ensure a disposition of medications has been completed. Audits to occur 1x a week for 4 weeks 2x a month x 2 months then monthly x 3 months. The findings of these quality monitoring's to be reported to the Quality Assurance/Performance Improvement Committee monthly and/or until substantial compliance is met. Quality Monitoring schedule modified based on findings.

5.Date of completion will be April 30, 2024.


211.12(f.1)(2) LICENSURE Nursing services. :State only Deficiency.
(2) Effective July 1, 2023, a minimum of 1 nurse aide per 12 residents during the day, 1 nurse aide per 12 residents during the evening, and 1 nurse aide per 20 residents overnight.

Observations:

Based on a review of nursing staffing hours and staff interview, it was determined that the facility failed to ensure a minimum of one nurse aide per 12 residents during the day shift for 4 of the 21 days reviewed, and one nurse aide per 12 residents during the evening shift for 7 of the 21 days reviewed.

Findings include:

Review of nursing staff care hours provided by the facility revealed the following nurse aides (NA) scheduled for the resident census:

Day shift:

March 15, 2024, 10 nurse aides for a census of 125, requires 10.42 nurse aides.
March 17, 2024, 10 nurse aides for a census of 124, requires 10.33 nurse aides.
March 20, 2024, 9 nurse aides for a census of 125, requires 10.42 nurse aides.
March 24, 2024, 10 nurse aides for a census of 125, requires 10.42 nurse aides.

Evening shift:

November 2, 2024, 9 nurse aides for a census of 113, requires 9.42 nurse aides.
March 15, 2024, 8 nurse aides for a census of 125, requires 10.42 nurse aides.
March 16, 2024, 9 nurse aides for a census of 125, requires 10.42 nurse aides.
March 18, 2024, 9 nurse aides for a census of 125, requires 10.42 nurse aides.
March 23, 2024, 10 nurse aides for a census of 125, requires 10.42 nurse aides.
March 24, 2024, 8 nurse aides for a census of 125, requires 10.42 nurse aides.
March 26, 2024, 9 nurse aides for a census of 124, requires 10.33 nurse aides.

Interview with the Director of Nursing on March 28, 2024, at 2:30 PM confirmed the above findings.


 Plan of Correction - To be completed: 04/30/2024

1.The facility cannot retroactively correct the identified days the facility did not ensure the correct staffing ratio.

2.There was the potential for any resident to be affected.

3.The facility continues to recruit and hire Certified Nursing Assistants. The facility will continue to implement emergency staffing strategies that include the use of nursing management providing direct resident care. The DON/Designee will monitor the staffing schedule, including ratios, daily with the scheduling department.

4.The Director of Nursing/Designee will monitor the staffing ratios and PPD daily to ensure the correct staffing ratio requirements have been met. Audits to occur 1x a week for 4 weeks 2x a month x 2 months then monthly x 3 months. The findings of these quality monitoring's to be reported to the Quality Assurance/Performance Improvement Committee monthly and/or until substantial compliance is met. Quality Monitoring schedule modified based on findings.

5.Date of completion will be April 30, 2024.



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