Nursing Investigation Results -

Pennsylvania Department of Health
PLEASANT VALLEY MANOR, INC./ MONROE COUNTY HOME
Patient Care Inspection Results

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PLEASANT VALLEY MANOR, INC./ MONROE COUNTY HOME
Inspection Results For:

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PLEASANT VALLEY MANOR, INC./ MONROE COUNTY HOME - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on a Medicare/Medicaid Recertification, State Licensure and Civil Rights Compliance Survey completed on November 19, 2021, it was determined that Pleasant Valley Manor 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 Regulations.



 Plan of Correction:


483.10(i)(1)-(7) REQUIREMENT Safe/Clean/Comfortable/Homelike Environment:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
483.10(i) Safe Environment.
The resident has a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

The facility must provide-
483.10(i)(1) A safe, clean, comfortable, and homelike environment, allowing the resident to use his or her personal belongings to the extent possible.
(i) This includes ensuring that the resident can receive care and services safely and that the physical layout of the facility maximizes resident independence and does not pose a safety risk.
(ii) The facility shall exercise reasonable care for the protection of the resident's property from loss or theft.

483.10(i)(2) Housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior;

483.10(i)(3) Clean bed and bath linens that are in good condition;

483.10(i)(4) Private closet space in each resident room, as specified in 483.90 (e)(2)(iv);

483.10(i)(5) Adequate and comfortable lighting levels in all areas;

483.10(i)(6) Comfortable and safe temperature levels. Facilities initially certified after October 1, 1990 must maintain a temperature range of 71 to 81F; and

483.10(i)(7) For the maintenance of comfortable sound levels.
Observations:

Based on observation and staff interview, it was determined that the facility failed to maintain a clean and orderly environment in resident areas (Resident 51).

Findings include:

An observation November 18, 2021 at 9:30 AM in resident room A-107 A, revealed Resident 51 was seated in a wheelchair in her room. The wheelchair cushion was dirty with a white, pasty substance as well as dirt, food debris and dried liquid stains. The floor in resident room A-107 was dirty with a large dried liquid stain on the floor and food and dirt debris.

An observation November 18, 2021 at approximately 9 AM in resident room B-103, revealed the heating unit grate was on the ground. Inside the heating unit a thick layer of accumulate lint and dirt was observed. The fall mats were observed to be soiled with dirt and liquid stains.

An observation November 17, 2021, at approximately 10:15 AM in the B unit resident pantry area, the floor was soiled with dirt and liquid stains. Inside the refrigerator, spilled liquid substances and food debris were observed on the shelves of the unit and the shelving on the door.

There were multiple unbagged styrofoam cups on the floor between the refrigerator and the ice machine unit.

During an interview November 18, 2021 at approximately 11 AM the Director of Nursing confirmed the above noted environmental issues and the facility's expectation that the environment be maintained in a clean and orderly manner.


28 Pa Code 207.2(a) Administrators responsibility






 Plan of Correction - To be completed: 01/14/2022

Preparation and submission of this
Plan of Correction does not
constitute admission for purposes of
general liability, professional
malpractice or any other court
proceedings.

0584 Level E-Safe/Clean/Comfortable/Homelike Environment:
1. Contain elements detailing how the facility will correct the deficiency as it relates to the individual;
Chair of resident in room A107A cleaned and the floor in A107A cleaned at time of survey. Heating Unit in B103 cleaned and repaired at time of survey. Fall Mats in B103 cleaned at time of Survey. Floor in the B-Unit Pantry Area and refrigerator in the Pantry cleaned at the time of survey.


2. Indicate how the facility will act to protect residents in similar situations;
Housekeeping staff will be educated on the importance of looking over all elements of a room to assess the need for cleaning/repair by 1/14/2021.
All rooms (floors, floor mats, and chairs) will be inspected for cleanliness and cleaned as deemed necessary by 1/14/2021.
All refrigerators will be inspected for cleanliness and cleaned as deemed necessary by 1/14/2021
Nursing staff will be educated on the need to clean off resident chairs after meals by 1/14/2021.
Person responsible for refrigerator/freezer cleaning will be indicated in the Food Storage Policy by 1/14/2021

3. Include the measures the facility will take or the systems it will alter to ensure that the problem does not recur;
Random Audits of Resident rooms, Resident Chairs, Pantries and pantry refrigerators will be done weekly x 4 weeks and then monthly to monitor compliance with maintaining in a clean and orderly manner by 1/14/2021.

4. Indicate how it plans to monitor its performance to make sure that solutions are sustained
Audits will be reviewed at QAPI to assess need for revision, increased education, and/or continuation by 1/14/2021.

483.75(g)(2)(ii) REQUIREMENT QAPI/QAA Improvement Activities:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
483.75(g) Quality assessment and assurance.

483.75(g)(2) The quality assessment and assurance committee must:
(ii) Develop and implement appropriate plans of action to correct identified quality deficiencies;
Observations:


Based on a review of clinical records, fall logs, the facility QA plan and the outcome of the activities of the facility's quality assurance committee it was determined that the facility failed to develop and implement a quality assurance plan, which was able to identify deviations in performance resulting in an actual or potential undesirable outcome, or an opportunity for improvement in the areas of falls and pain management.

Findings include:

As a result of an evaluation of the facility quality assurance program and in response to quality deficiencies noted at the time of the survey, which included a review of facility documentation regarding falls and pain management, the facility failed to ensure a quality assurance monitoring component to ensure that solutions were initiated and sustained.

The facility's quality assurance paln, last reviewed April 2021 indicated that the purpose of the plan is to provide excellent quality resident care and services. The facility maintains Performance Improvement Program (QAPI) which systemically monitors, analyses and improves resident outcomes.

The QAPI plan addresses three main areas:

1. Critical care-by monitoring existing Quality measures results, internal monitors for falls, medication errors, pressure ulcers, incident reports, infection reports and other resident care triggers.

2. Quality of Life--By monitoring existing data available through resident/family satisfaction surveys, resident/family concerns brought up at resident council meetings, concerns from care conferences and through daily staff rounds.

3. Resident choice--Assessing individualized goals for care at care conferences, through the formal survey process, and through rounds, and informal resident discussions.

At the time of the survey ending November 19, 2021, a review of fall logs revealed that multiple resident falls had occurred from May 2021 through November 2021 as well as resident pain assessments,were not identified by the QAPI team as identified quality issues and acted upon to improve resident outcomes.

A review of facility incident (fall) logs, there were the following number of resident falls in the noted month:

May 2021--20 falls during the month
June 2021--12
July 2021--13
August 2021--8
September 2021--16
October 2021--22
November 1 through 17, 2021--12

There was no documented evidence at the time of the survey that the facility's QA committee had identified resident falls as an area to be in need of further investigation and correction or improvement.

A review of a facility policy for Pain Management reviewed August 2021 revealed, Pain evaluation plans of care should be reviewed and discussed quarterly/annually and with significant change of status at care plan conference. The pain assessment form will also be completed on admission, readmission quarterly and as needed. The pain assessment interview is completed with each Minimum Data Assessment.

A review of the clinical records of Residents 46 and Resident 88 conducted during the survey ending November 19, 2021, revealed that the facility had failed to develop and implement effective individualized multimodal pain management programs. The facility staff administered excessive doses of opioid pain medications, which were prescribed on an as needed basis, to both residents, which was not identified and acted upon by the pharmacist and physician. There was no evidence of non-pharmacological measures attempted to alleviate pain prior to administration of pain medicaiton. The facility failed to implement its pain management policy for timing and frequency of pain assessments. Nursing staff failed to consistently administer pain medications according to the established pain scale.

There was no documented evidence at the time of the survey that the facility's QA committee had identified resident pain management as an area to be in need of further investigation and correction or improvement.

During an interview November 18, 2021 at approximately 1 PM, Employee 7 (RN education-QAPI nurse) stated that she was aware of the increase in resident falls during August 2021, September 2021 and October 2021. She stated that the QAPI committee were going to meet in the next few weeks and falls would be discussed. She stated that she was unaware that pain assessments were not being completed on residents as per the facility policy. She further confirmed the facility's quality assurance plan was ineffective in identifying the above noted concerns for study and improvement of processes with the intent to improve services or outcomes, and prevent or decrease the likelihood of problems, by identifying opportunities for improvement,


Refer F 697

28 Pa. Code 201.18(e)(1)(2) Management

28 Pa. Code 211.12(c) Nursing services









 Plan of Correction - To be completed: 01/14/2022

Preparation and submission of this
Plan of Correction does not
constitute admission for purposes of
general liability, professional
malpractice or any other court
proceedings.

0867 Level E-QAPI/QAA Improvement
1. Contain elements detailing how the facility will correct the deficiency as it relates to the individual;
Performance Improvement plans will be developed for both falls and pain management. Residents 46 and 88 will be reviewed with the physician and the plan of care updated as needed by 1/14/2022.

2. Indicate how the facility will act to protect residents in similar situations;
Facility will utilize tools such as incident logs, Casper report, and resident assessments to identify areas needing improvement by1/14/2022.

3. Include the measures the facility will take or the systems it will alter to ensure that the problem does not recur;
Interdisciplinary Care Plan Team will meet monthly and discuss recent logs, reports, and assessments to identify needs and create Performance Improvement Plans by 1/14/2022

4. Indicate how it plans to monitor its performance to make sure that solutions are sustained
Performance Improvement Plans will have defined desired outcomes and will be monitored through audits and progress toward the outcome to assure the plan is working- plans will be revised as needed by 1/14/2022

483.70(o)(1)-(4) REQUIREMENT Hospice Services: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.
483.70(o) Hospice services.
483.70(o)(1) A long-term care (LTC) facility may do either of the following:
(i) Arrange for the provision of hospice services through an agreement with one or more Medicare-certified hospices.
(ii) Not arrange for the provision of hospice services at the facility through an agreement with a Medicare-certified hospice and assist the resident in transferring to a facility that will arrange for the provision of hospice services when a resident requests a transfer.

483.70(o)(2) If hospice care is furnished in an LTC facility through an agreement as specified in paragraph (o)(1)(i) of this section with a hospice, the LTC facility must meet the following requirements:
(i) Ensure that the hospice services meet professional standards and principles that apply to individuals providing services in the facility, and to the timeliness of the services.
(ii) Have a written agreement with the hospice that is signed by an authorized representative of the hospice and an authorized representative of the LTC facility before hospice care is furnished to any resident. The written agreement must set out at least the following:
(A) The services the hospice will provide.
(B) The hospice's responsibilities for determining the appropriate hospice plan of care as specified in 418.112 (d) of this chapter.
(C) The services the LTC facility will continue to provide based on each resident's plan of care.
(D) A communication process, including how the communication will be documented between the LTC facility and the hospice provider, to ensure that the needs of the resident are addressed and met 24 hours per day.
(E) A provision that the LTC facility immediately notifies the hospice about the following:
(1) A significant change in the resident's physical, mental, social, or emotional status.
(2) Clinical complications that suggest a need to alter the plan of care.
(3) A need to transfer the resident from the facility for any condition.
(4) The resident's death.
(F) A provision stating that the hospice assumes responsibility for determining the appropriate course of hospice care, including the determination to change the level of services provided.
(G) An agreement that it is the LTC facility's responsibility to furnish 24-hour room and board care, meet the resident's personal care and nursing needs in coordination with the hospice representative, and ensure that the level of care provided is appropriately based on the individual resident's needs.
(H) A delineation of the hospice's responsibilities, including but not limited to, providing medical direction and management of the patient; nursing; counseling (including spiritual, dietary, and bereavement); social work; providing medical supplies, durable medical equipment, and drugs necessary for the palliation of pain and symptoms associated with the terminal illness and related conditions; and all other hospice services that are necessary for the care of the resident's terminal illness and related conditions.
(I) A provision that when the LTC facility personnel are responsible for the administration of prescribed therapies, including those therapies determined appropriate by the hospice and delineated in the hospice plan of care, the LTC facility personnel may administer the therapies where permitted by State law and as specified by the LTC facility.
(J) A provision stating that the LTC facility must report all alleged violations involving mistreatment, neglect, or verbal, mental, sexual, and physical abuse, including injuries of unknown source, and misappropriation of patient property by hospice personnel, to the hospice administrator immediately when the LTC facility becomes aware of the alleged violation.
(K) A delineation of the responsibilities of the hospice and the LTC facility to provide bereavement services to LTC facility staff.

483.70(o)(3) Each LTC facility arranging for the provision of hospice care under a written agreement must designate a member of the facility's interdisciplinary team who is responsible for working with hospice representatives to coordinate care to the resident provided by the LTC facility staff and hospice staff. The interdisciplinary team member must have a clinical background, function within their State scope of practice act, and have the ability to assess the resident or have access to someone that has the skills and capabilities to assess the resident.
The designated interdisciplinary team member is responsible for the following:
(i) Collaborating with hospice representatives and coordinating LTC facility staff participation in the hospice care planning process for those residents receiving these services.
(ii) Communicating with hospice representatives and other healthcare providers participating in the provision of care for the terminal illness, related conditions, and other conditions, to ensure quality of care for the patient and family.
(iii) Ensuring that the LTC facility communicates with the hospice medical director, the patient's attending physician, and other practitioners participating in the provision of care to the patient as needed to coordinate the hospice care with the medical care provided by other physicians.
(iv) Obtaining the following information from the hospice:
(A) The most recent hospice plan of care specific to each patient.
(B) Hospice election form.
(C) Physician certification and recertification of the terminal illness specific to each patient.
(D) Names and contact information for hospice personnel involved in hospice care of each patient.
(E) Instructions on how to access the hospice's 24-hour on-call system.
(F) Hospice medication information specific to each patient.
(G) Hospice physician and attending physician (if any) orders specific to each patient.
(v) Ensuring that the LTC facility staff provides orientation in the policies and procedures of the facility, including patient rights, appropriate forms, and record keeping requirements, to hospice staff furnishing care to LTC residents.

483.70(o)(4) Each LTC facility providing hospice care under a written agreement must ensure that each resident's written plan of care includes both the most recent hospice plan of care and a description of the services furnished by the LTC facility to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, as required at 483.24.
Observations:

Based on clinical record review and staff interview, it was determined that for four out of four residents receiving Hospice services (Residents 11, 14, 9 and 13) the facility failed to ensure coordination of necessary services between the facility and the hospice agency.

Findings include:

A review of the clinical record of Resident 11 revealed that the resident was admitted to the facility on August 27, 2021, and was receiving Hospice services related to a diagnosis of end stage dementia following a physician order for a Hospice evaluation dated May 27, 2021.

A review of the resident's current plan of care revealed that a Hospice care plan was initiated on May 27, 2021, however was not integrated into the resident's plan of care developed by the facility's interdisciplinary team.

A review of the clinical record of Resident 14 revealed that the resident was admitted to the facility on May 20, 2021, and was receiving Hospice services related to a diagnosis of end stage dementia following a physician order for a Hospice evaluation dated November 10, 2021.

A review of the resident's current plan of care revealed that no Hospice care plan was initiated as of the date of the survey ending November 19, 2021.

A review of the clinical record for Resident 9 revealed that she was admitted to the facility on February 4, 2020. Resident 9 was admitted to Hospice services on May 13, 2021, with diagnosis of End Stage Liver Cirrhosis.

Review of the resident's comprehensive care plan revealed the facility failed to integrate Hospice services into the resident's comprehensive plan of care.

A review of the clinical record for Resident 13 revealed that she was admitted to the facility on April 25, 2018. Resident 13 was admitted to Hospice services on August 19, 2021, with diagnosis of End Stage Cerebral Atherosclerosis.

Review of the resident's comprehensive care plan revealed the facility failed to integrate Hospice services into the resident's comprehensive plan of care.

During an Interview with the Director of Nursing on November 18, 2021, at 12:21 PM, she was unable to provide evidence of coordination and communication related to the services provided by the facility and the Hospice providers.


28 Pa. Code 211.11 (a)(b)(c)(d) Resident care plan

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





















 Plan of Correction - To be completed: 01/14/2022

Preparation and submission of this
Plan of Correction does not
constitute admission for purposes of
general liability, professional
malpractice or any other court
proceedings.


0849 Level E-Hospice Services
1. Contain elements detailing how the facility will correct the deficiency as it relates to the individual;
Plans of care for residents 11, 14, 9, and 13 were reviewed and hospice integrated into the plan.

2. Indicate how the facility will act to protect residents in similar situations;
All future residents placed on hospice will have a plan of care integrating hospice into the comprehensive care plan by 1/14/2022

3. Include the measures the facility will take or the systems it will alter to ensure that the problem does not recur;
Hospice policy updated to include a resident care plan meeting within 72 hours of admit to hospice to integrate care by 1/14/2022.
Random Audits of the comprehensive care plan of those residents on hospice will be done weekly x 4 weeks and then monthly to monitor compliance with by 1/14/2022.

4. Indicate how it plans to monitor its performance to make sure that solutions are sustained
Audits will be reviewed at QAPI to assess need for revision, increased education, and/or continuation by 1/14/2022


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

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

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

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

Findings include:

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

During tour of the facility conducted on November 17, 2021, at 10:15 AM, observation of the the resident pantry areas on Units A and B revealed that the facility failed to store food in a sanitary manner in the refrigerators/freezers.

Inside of the Unit A resident refrigerator there was an outdated resident vanilla shake that was defrosted on November 6, 2021, and expired on November 15, 202. There were two open gallons of milk and one opened gallon of orange juice without open dates. There were two opened 8-ounce bottles of Ensure (supplement) that did not include an open date on the containers. Two 4-ounce bowls of facility portioned vanilla pudding lacking labels or dates

Observation of inside the Unit A resident freezer revealed an opened, partially eaten lemon flavored Italian ice container that was not labeled.

Observation inside of the Unit B resident refrigerator revealed two open gallons of milk lacking dates when opened. A 4-ounce facility portioned puree yogurt was also undated.

Observation of the Unit A resident freezer had a 4-ounce vanilla frozen nutritional treat that was expired on October 30, 2021. A chicken pot pie, dated to be used by or frozen by October 10, 2021, and was not labeled with a facility discard date.

Interview with the director of nursing (DON) on November 17, 2021, at 1:00 PM, confirmed that resident food should be stored and maintained in a sanitary manner to deter the potential of food-borne illness.


28 Pa. Code 211.6 (f) Dietary services.

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








 Plan of Correction - To be completed: 01/14/2022

Preparation and submission of this
Plan of Correction does not
constitute admission for purposes of
general liability, professional
malpractice or any other court
proceedings.

0812 Level E-Procure, Store/Prepare/Serve-Sanitary:
1. Contain elements detailing how the facility will correct the deficiency as it relates to the individual;
Food currently in in the refrigerator/freezer will be thrown out or dated as needed by 1/14/2022

2. Indicate how the facility will act to protect residents in similar situations;
Staff will be educated on the policy for storing and dating food in the refrigerator/freezer by 1/14/2022

3. Include the measures the facility will take or the systems it will alter to ensure that the problem does not recur;
Refrigerator/freezers will be audited for adherence to the guidelines for proper food storage weekly x4 and then monthly by 1/14/2022

4. Indicate how it plans to monitor its performance to make sure that solutions are sustained
Audits will be reviewed at QAPI to assess need for revision, increased education, and/or continuation by 1/14/2022.

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

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

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

Based on review of select facility policy and resident and staff interviews, it was determined that the facility failed to routinely offer evening snacks as desired by five of five residents attending a group meeting (Residents 77, 5, 1, 84 and 67).

Findings include:

Review of the facility's Snack Policy, last reviewed by the facility October 2021, indicated that all residents will be offered an evening snack beginning at 7:45 PM. Dietary will deliver the snack carts to each nursing unit and snacks are served at designated time throughout the nursing unit to each resident.

During a group interview with five alert and oriented residents on November 17, 2021, at 10:00 AM, all five residents (Residents 77, 5, 1, 84 and 67) in attendance stated that snacks are not routinely offered to them in the evenings as they would like. The residents stated that it depends on which staff members are on duty whether they are offered and provided bedtime snacks .

Observations were made on November 17, 2021, at 11:15 AM of the food pantry's at each nursing unit, which revealed no snacks were available for residents and a very limited amount of juices available.

During an interview with the Director of Nursing Home Administrator on November 18, 2021, at 10:25 AM, she was unable to explain why the residents' were not routinely provided with an evening snack.


28 Pa. Code 211.2 (a)(c)(d)(3)(5) Nursing Services

28 Pa. Code 201.29(i) Resident rights







 Plan of Correction - To be completed: 01/14/2022

Preparation and submission of this
Plan of Correction does not
constitute admission for purposes of
general liability, professional
malpractice or any other court
proceedings.

0809 Level E-Frequency of meals/Snacks at HS:
1. Contain elements detailing how the facility will correct the deficiency as it relates to the individual;
Residents 77, 5,1,84, and 67 to be offered an HS snack daily by 1/14/2022

2. Indicate how the facility will act to protect residents in similar situations;
Staff to be educated on the snack process and all residents to be offered an HS snack daily by 1/14/2022
Snacks will be available in the pantry by 1/14/2022

3. Include the measures the facility will take or the systems it will alter to ensure that the problem does not recur;
Random Audits of snack pass will be done weekly x 4 weeks and then monthly to monitor compliance with HS snacks by 1/14/2022.

4. Indicate how it plans to monitor its performance to make sure that solutions are sustained
Audits will be reviewed at QAPI to assess need for revision, increased education, and/or continuation by 1/14/2022.

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

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

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

483.45(c)(5) The facility must develop and maintain policies and procedures for the monthly drug regimen review that include, but are not limited to, time frames for the different steps in the process and steps the pharmacist must take when he or she identifies an irregularity that requires urgent action to protect the resident.
Observations:

Based on clinical record review and staff interview it was determined that the pharmacist failed to identify drug irregularities in the drug regimens of two residents out of 20 sampled (Residents 46 and 88).

Findings include:

A review of the clinical record review revealed that Resident 46 had a diagnosis of Parkinsons disease (a progressive, neurological disorder) and rotator cuff tear ( tear in the tissues connecting muscle to bone (tendons) around the shoulder joint and opioid dependence.

The resident had current physician's orders, initially dated February 11, 2021, for oxycodone/acetaminophen 5 mg/325 mg (combination medication is used to help relieve moderate to severe pain. It contains a opioid [narcotic] pain reliever [oxycodone] and a non-opioid pain reliever [acetaminophen] 1 tab every 6 hours, as needed, for severe pain.

A review of Resident 51's Medication Administration Records dated from July 2021 through November 2021 revealed that the resident received the opioid pain medication daily as follows:

May 2021 93 doses of the prn opioid pain medication administered to the resident
June 2021 134 doses
July 2021, 176 doses
August 2021, 133 doses
September 2021 89 doses
October 201 90 doses
November 1 through November 17, 2021, 56 doses

There was no evidence in the clinical record that the pharmacist identified the resident's excessive daily use of the opioid pain medication prescribed on an as needed basis.

A review of Resident 88's clinical record revealed admission to the facility on October 28, 2020 with diagnoses to include peripheral vascular disease, necrotizing fasciitis (a serious bacterial infection that destroys tissue under the skin), and heart disease.

The resident had current physician's orders, initially dated March 1, 2021 for Oxycodone \ 5mg (1/2 tablet) orally every 4 hours as needed for pain- severe, Acetaminophen ES (extra strength) 500 mg give 2 tablets every 6 hours, as needed, for pain, and Acetaminophen 325 mg give 2 tablets every 4 hours as needed for mild pain.

Review of Resident 88's medication administration record (MAR) dated September 2021 revealed that the resident received 62 doses of Oxycodone during the month.

Review of Resident 88's MAR dated October 2021 revealed that the resident received 79 doses of Oxycodone during the month.

Review of Resident 88's MAR dated November 2021 revealed that as of November 16, 2021, the resident received 38 doses of Oxycodone during the month.

There was no evidence in the clinical record that the pharmacist identified the resident's excessive daily use of the opioid pain medication prescribed on an as needed basis.

During an interview November 19, 2021 9 am, the Director of Nursing confirmed that the pharmacist had not conducted monthly pharmacy reviews during the above noted dates and failed to identify Resident 46's and 88's ongoing daily excessive usage of the opioid (drugs that act on the nervous system to relieve pain. Continued use and abuse can lead to physical dependence and withdrawal symptoms) medications prescribed on an as needed basis.

refer F697


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

28 Pa. Code 211.2(a) Physician services
















 Plan of Correction - To be completed: 01/14/2022

Preparation and submission of this
Plan of Correction does not
constitute admission for purposes of
general liability, professional
malpractice or any other court
proceedings.

0756 Level E-Drug Regimen Review:
1. Contain elements detailing how the facility will correct the deficiency as it relates to the individual;
MD will be notified of resident PRN pain medication utilization by 1/14/2022.

2. Indicate how the facility will act to protect residents in similar situations;
Report of PRN pain medication utilized by all residents obtained and will be reviewed with the physician by 1/14/2022.
Pharmacist will be contacted and asked to review pain medications during monthly review of all residents by 1/14/2022.

3. Include the measures the facility will take or the systems it will alter to ensure that the problem does not recur;
Random Audits of Use of PRN pain medication will be done weekly x 4 weeks and then monthly to monitor compliance with communication of increased use by 1/14/2022.

4. Indicate how it plans to monitor its performance to make sure that solutions are sustained
Audits will be reviewed at QAPI to assess need for revision, increased education, and/or continuation by 1/14/2022.

483.25(l) REQUIREMENT Dialysis:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
483.25(l) Dialysis.
The facility must ensure that residents who require dialysis receive such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences.
Observations:

Based on review of clinical records, observations, and staff interviews it was determined that the facility failed to ensure the ready availability of necessary emergency supplies for two residents out of two sampled receiving hemodialysis (Resident 74 and Resident 37).

Findings include:

According to the National Kidney Foundation patients receiving hemodialysis should keep emergency care supplies on hand.

A review of the clinical record revealed that Resident 74 was admitted to the facility on May 27, 2020, with diagnoses to include end stage renal disease with dependence on kidney dialysis (process of removing waste products and excess fluid from the body when the kidneys are not able to adequately filter the blood), diabetes and peripheral vascular disease. The resident had a right arm AV Fistula (surgically created connection between an artery and vein in the arm of patients who need to undergo hemodialysis) for dialysis access on Tuesdays, Thursdays, and Saturdays.

A review of the resident's physician's orders for the month of November 2021 revealed that the resident was to attend dialysis on Tuesdays, Thursdays and Saturdays. An emergency hemodialysis kit was to be available in the resident's room and was to be attached to the chair when the resident went to dialysis.

A review of the resident's current plan of care revealed that staff were not to draw blood or take blood pressure in the arm with the graft (AV fistula). The resident' plan of care failed to identify, which arm was not to be used for blood draws or blood pressures.

An observation of Resident 74's room and wheelchair on November 17, 2021, at 10:30 AM revealed that there were no emergency supplies readily available in the event of an emergency with the resident's AV fistula dialysis access sites.

A review of the clinical record revealed that Resident 37 was admitted to the facility on August 18, 2021 with diagnoses to include end stage renal disease with dependence on kidney dialysis (process of removing waste products and excess fluid from the body when the kidneys are not able to adequately filter the blood), diabetes and peripheral vascular disease and went for treatments on Mondays, Wednesdays, and Fridays.

A review of the resident's physician's orders for the month of November 2021 identified that the resident was to attend dialysis on Mondays, Wednesdays, and Fridays. There were no orders for emergency hemodialysis supplies indicated in Resident 37's clinical record until after surveyor inquiry that was made on November 16, 2021.

Further review of Resident 37's physician's orders revealed a diet order dated November 8, 2021, at 5:22 PM, for a renal without a fluid restriction diet (limits amounts of certain minerals that can be harmful to dialysis patients).

Review of Resident 37's current comprehensive person-centered plan of care revealed that staff were not to draw blood or take blood pressure in the arm with the graft. The care plan failed to identify the location of the dialysis access site and failed to identify which arm was not to be used for blood draws. Also, the resident's plan of care failed to include details regarding emergency supplies.

The resident's care plan for nutrition dated August 25, 2021, indicated that the resident required a 1500 cc fluid restriction per day. However, the approaches were to serve diet as ordered, regular renal diet, no fluid restriction and offer 4 oz nutrition supplement four times per day.

An observation of Resident 37's room and wheelchair on November 17, 2021, at 11:15 AM, revealed that there were no emergency supplies readily available in the event of an emergency with the resident's dialysis access sites.

During an interview with the facility's registered dietitian (RD) on November 18, 2021, at 1:25 PM, confirmed that Resident 37's nutrition care plan was not timely revised to accurately reflect the resident's dietary needs.

Interview with Director of Nursing, (DON) and Assistant Director of Nursing (ADON) on November 18, 2021 at approximately 2:30 p.m. confirmed that there were no emergency supplies readily available at the resident's bedside and neither the resident's care plan nor current physician orders identified the location of Resident 74's AV fistula and Resident 37's dialysis access site.


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







 Plan of Correction - To be completed: 01/14/2022

Preparation and submission of this
Plan of Correction does not
constitute admission for purposes of
general liability, professional
malpractice or any other court
proceedings.

0698 Level E-Dialysis:
1. Contain elements detailing how the facility will correct the deficiency as it relates to the individual;
Care plan updated and emergency supplies provided for residents 74 and 37.

2. Indicate how the facility will act to protect residents in similar situations;
There are no further residents with ordered hemodialysis.

3. Include the measures the facility will take or the systems it will alter to ensure that the problem does not recur;
Random Audits of availability of supplies and updated care plans will be done weekly x 4 weeks and then monthly to monitor compliance with having supplies on hand by 1/14/2022.

4. Indicate how it plans to monitor its performance to make sure that solutions are sustained
Audits will be reviewed at QAPI to assess need for revision, increased education, and/or continuation by 1/14/2022

483.25(k) REQUIREMENT Pain Management:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
483.25(k) Pain Management.
The facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences.
Observations:

Based on a review of clinical records and select facility policy and staff interview, it was determined that the facility failed to develop and implement individualized pain management programs, consistent with professional standards of practice, to meet the pain management needs of two residents out of 21 reviewed (Residents 46 and 88).

Findings include:

A review of a facility policy entitled "Pain Management", last revised August 2021, revealed that it is the policy of the facility to evaluate and manage pain for all residents. Pain evaluations will be completed upon admission, readmission, and every shift if indicated and with new onset of pain. The nursing staff will evaluate and document pain findings every shift on the electronic medication administration record. The licensed nurse is responsible for implementing pain management orders. The RN supervisor/unit manager or designee is responsible for assessing the overall pain management plan and implementing changes to the pain management plan of care. Pain evaluation plans of care should be reviewed and discussed quarterly/annually and with significant change of status at care plan conference. The pain assessment form will also be completed on admission, readmission quarterly and as needed. The pain assessment interview is completed with each Minimum Data Assessment.

According to the US Department of Health and Human Services, Interagency Task Force, Executive Summary Final Report for Pain Management Best Practices the development of an effective pain treatment plan after proper evaluation to establish a diagnosis with measurable outcomes that focus on improvements including quality of life (QOL), improved functionality, and Activities of Daily Living (ADLs). Achieving excellence in acute and chronic pain care depends on the following:

An emphasis on an individualized patient-centered approach for diagnosis and treatment of pain is essential to establishing a therapeutic alliance between patient and clinician.
Acute pain can be caused by a variety of different conditions such as trauma, burn, musculoskeletal injury, neural injury, as well as pain due to surgery/procedures in the perioperative period. A multi-modal approach that includes medications, nerve blocks, physical therapy and other modalities should be considered for acute pain conditions.
A multidisciplinary approach for chronic pain across various disciplines, utilizing one or more treatment modalities, is encouraged when clinically indicated to improve outcomes. These include the following five broad treatment categories

-Medications: Various classes of medications, including non-opioids and opioids, should be considered for use. The choice of medication should be based on the pain diagnosis, the mechanisms of pain, and related co-morbidities following a thorough history, physical exam, other relevant diagnostic procedures and a risk-benefit assessment that demonstrates the benefits of a medication outweighs the risks. The goal is to limit adverse outcomes while ensuring that patients have access to medication-based treatment that can enable a better quality of life and function. Ensuring safe medication storage and appropriate disposal of excess medications is important to ensure best clinical outcomes and to protect the public health.

o Restorative Therapies including those implemented by physical therapists and occupational therapists (e.g., physiotherapy, therapeutic exercise, and other movement modalities) are valuable components of multidisciplinary, multimodal acute and chronic pain care.
o Interventional Approaches including image-guided and minimally invasive procedures are available as diagnostic and therapeutic treatment modalities for acute, acute on chronic, and chronic pain when clinically indicated. A list of various types of procedures including trigger point injections, radiofrequency ablation, cryoneuroablation, neuro-modulation and other procedures are reviewed.
o Behavioral Health Approaches for psychological, cognitive, emotional, behavioral, and social aspects of pain can have a significant impact on treatment outcomes. Patients with pain and behavioral health comorbidities face challenges that can exacerbate painful conditions as well as function, QOL, and ADLs.
o Complementary and Integrative Health, including treatment modalities such as acupuncture, massage, movement therapies (e.g., yoga, tai chi), spirituality, among others, should be considered when clinically indicated.
Effective multidisciplinary management of the potentially complex aspects of acute and chronic pain should be based

A review of the clinical record revealed that Resident 46 was admitted to the facility on July 1, 2021, with diagnoses to include, Parkinson's disease (a progressive, neurological disorder) and rotator cuff tear (tear in the tissues connecting muscle to bone (tendons) around the shoulder joint and opioid dependence. The resident had current physician's orders, initially dated February 11, 2021, for oxycodone/acetaminophen 5 mg/325 mg (combination medication is used to help relieve moderate to severe pain. It contains an opioid [narcotic] pain reliever [oxycodone] and a non-opioid pain reliever [acetaminophen] 1 tab every 6 hours, as needed for severe pain.

A quarterly Minimum Data Set assessment (MDS) dated September 23, 2021, revealed that Resident 46 was cognitively intact, required minimal staff assistance with activities of daily living, had constant pain, noted at a level of 8 (on a scale of 1 to 10, 1 least, 10 greatest) and was utilizing pain medication.

Resident 46's care plan for pain, initially dated November 3, 2016, indicated that staff were to monitor the resident's pain or discomfort and medicate as appropriate.

The last comprehensive pain assessment of the resident was dated October 8, 2020. There was no evidence of any additional comprehensive pain assessments conducted as of the survey ending date of November 19, 2021. The pain assessments were not conducted according to facility policy, which indicated that pain evaluation plans of care should be reviewed and discussed quarterly/annually and with significant change of status at care plan conference. The pain assessment form will also be completed on admission, readmission quarterly and as needed. The pain assessment interview is completed with each Minimum Data Assessment.

The resident had current physician's orders, initially dated February 11, 2021, for oxycodone/acetaminophen 5 mg/325 mg (combination medication is used to help relieve moderate to severe pain. It contains a opioid [narcotic] pain reliever [oxycodone] and a non-opioid pain reliever [acetaminophen] 1 tab every 6 hours, as needed, for severe pain.

A review of Resident 46's Medication Administration Records dated from July 2021 through November 2021 revealed that the resident received the prn opioid pain medication daily as follows:

May 2021, 93 doses
June 2021 134 doses
July 2021, 176 doses
August 2021, 133 doses
September 2021 89 doses
October 201 90 doses
November 1 through November 17, 2021, 56 doses

Resident 46's care plan for pain, initially dated November 3, 2016, indicated that staff were to monitor the resident's pain or discomfort and medicate as appropriate.

The resident had a physician orders dated November 16, 2021, for a Lidocaine Patch 5 % (a topical non-narcotic pain medication applied to the skin), apply to affected area topically one time a day for pain to affected area, remove after 12 hours, every day and Bengay Greaseless Cream 10-15 % (Menthol-Methyl Salicylate, a non-narcotic pain medication applied to the skin) apply to affected arm topically every day and evening shift for pain.

A review of physician consultations for pain management completed February 23, 2021, March 11, 2021, April 6, 2021, May 18, 2021, June 24, 2021, August 26, 2021 and November 16, 2021 revealed that the consulting physician had evaluated the resident for his pain condition and performed intramuscular injections during the visits on 4 of the 7 office visits. The consultant, however, failed to identify the resident's excessive use of the prn opioid pain medication daily.

A review of monthly attending Physician's progress noted dated January 2021 through October 2021 revealed no reference to Resident 46's ongoing pain or his excessive use of prn opioid pain medications.

There was no documented evidence of the development and implementation of an effective individualized pain management program for Resident 46.

A review of Resident 88's clinical record revealed admission to the facility on October 28, 2020 with diagnoses to include peripheral vascular disease, necrotizing fasciitis (a serious bacterial infection that destroys tissue under the skin), and heart disease. The resident had current physician's orders, initially dated March 1, 2021 for Oxycodone \ 5mg (1/2 tablet) orally every 4 hours as needed for pain- severe, Acetaminophen ES (extra strength) 500 mg give 2 tablets every 6 hours, as needed, for pain, and Acetaminophen 325 mg give 2 tablets every 4 hours as needed for mild pain.

Review of Resident 88's medication administration record (MAR) dated September 2021, revealed that the resident received Oxycodone 21 times for a pain level of 7, seven times for a pain level of 6, five times for a pain level of 5, four times for a pain level of 4, two times for a pain level of 3, three times for a pain level of 2, five times for a pain level of 0, and twice documentation stated N/A (not applicable) for a level of pain.

Review of Resident 88's MAR dated October 2021 revealed that the resident received Oxycodone 37 times for a pain level of 7, seven times for a pain level of 6, twenty times for a pain level of 5, four times for a pain level of 4, and four times for a pain level of 3.

Review of Resident 88's MAR dated November 2021 revealed that as of November 16, 2021, the resident received Oxycodone 13 times for a pain level of 7, six times for a pain level of 6, seven times for a pain level of 5, four times for a pain level of 4, twice for a pain level of 3, and twice for a pain level of 0.

Nursing documentation in Resident 88's clinical record revealed no evidence that non-pharmacological interventions were attempted and proved ineffective prior to the administration of the prn opioid pain medication.

Interview with the Assistant Director of Nursing (ADON) on November 18, 2021, at approximately 2:15 p.m. revealed that the facility identifies pain levels as 1-3 as mild pain, 4-7 as moderate pain, and 8-10 as severe pain when administering prn (as needed) pain medication. The ADON further confirmed that there was no evidence that the nursing staff were administering prn pain medication according to the facility's pain scale.

Further review of Resident 88's clinical record revealed that the last noted comprehensive pain assessment was dated October 28, 2020. There was no evidence of any additional comprehensive pain assessments as of the survey ending date of November 19, 2021.

During an interview November 19, 2021 at approximately 11 AM the Director of Nursing confirmed that the facility's pain management program policy was not being followed.


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

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

28 Pa. Code 211.10(a)(c)(d) Resident care policy





 Plan of Correction - To be completed: 01/14/2022

Preparation and submission of this
Plan of Correction does not
constitute admission for purposes of
general liability, professional
malpractice or any other court
proceedings.

0697 Level E-Pain Management:
1. Contain elements detailing how the facility will correct the deficiency as it relates to the individual;
Ordered pain medications for residents 46 and 88 were updated to include accurate directions for scale indicated for med use. Pain Assessment will completed for each resident and pain care plan updated to include nonpharmacological interventions noted as effective by 1/14/2022.

2. Indicate how the facility will act to protect residents in similar situations;
Pain assessment will be done for all residents in house and care plans updated as indicated by 1/14/2022

3. Include the measures the facility will take or the systems it will alter to ensure that the problem does not recur;
Policy for Pain Management updated with pain scale, staff educated. Pain scale reminders placed on medication carts by 1/14/2022. Ordered pain medications updated with an indicated scale for use by 1/14/2021. Orders will be updated to ask for NPI attempted by 1/14/2022
Random Audits of pain assessments and PRN pain medication use will be done weekly x 4 weeks and then monthly to monitor compliance with.

4. Indicate how it plans to monitor its performance to make sure that solutions are sustained
Audits will be reviewed at QAPI to assess need for revision, increased education, and/or continuation by 1/14/2022

483.25 REQUIREMENT Quality of Care:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
483.25 Quality of care
Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices.
Observations:

Based on observation, clinical and hospital records, and select facility policy and staff interview it was determined that the facility failed to provide resident care in accordance with the resident's plan of care and professional standards of practice for two residents out of 21 sampled (Resident 15 and 82)


Findings include:

Clinical record review for Resident 15 revealed admission to the facility on December 23, 2020 with diagnoses to include congestive heart failure, acute and chronic respiratory failure and type II diabetes.

A review of a quarterly Minimum Data Set assessment (MDS)A Minimum Data Set assessment (MDS-a federally mandated standardized assessment process conducted at specific intervals to plan resident care) dated August 27, 2021 revealed Resident 15 was cognitively intact and required maximum assistance for activities of daily living.

A physician order dated March 1, 2021, was noted for Lantus Solostar insulin pen injector 100 u/ml, give 15 units subcutaneously (SQ) twice a day, give at 12 PM and 9 PM. The times for administration were adjusted on September 8, 2021, to at lunch and at bedtime, instead of 12 PM and 9 PM.

Nursing documentation dated October 12, 2021, at 7:26 PM and 7:44 PM revealed that the resident was transferred and subsequently admitted to the hospital on October 12, 2021, for respiratory distress.

Nursing documentation dated October 26, 2021 at 5:15 PM revealed that the resident returned to the facility, but, was subsequently sent back to the hospital at 5:37 PM on October 26, 2021, due to a decline in the resident's respiratory status during the resident's transport from the hospital back to the facility. A copy of current medication administration record, treatment administration record, and care plan were attached to transfer form and sent with the ambulance attendants and the hospital staff were made aware of the resident's transfer back to the hospital.

Hospital documentation, including a discharge summary dated November 1, 2021, revealed a hospital stay from October 27, 2021, through November 1, 2021. The discharge instructions indicated that Resident 15 had a diagnosis of insulin dependant type 2 diabetes and to "continue Lantus (insulin)." The hospital discharge instructions included a list of medications, but did not include the insulin.

A review of nursing documentation dated November 1, 2021 at 4:39 PM revealed that the resident was readmitted to the facility following hospitalization. It was noted that the resident's medications were reviewed with the nurse practioner and sent to attending Physician for review. Nursing noted "all meds reviewed and confirmed."

A review of readmission physicians orders dated November 1, 2021, revealed that the physician orders failed to include Lantus insulin, which the resident had been receiving prior to hospitalization and while hospitalized.

The resident received no insulin for diabetes management from November 1, 2021, until surveyor inquiry on November 17, 2021.

A review of fingerstick blood glucose monitoring from November 1, 2021 through November 17, 2021 revealed blood glucose values from 139 mg/dl through 290 mg/dl (normal blood sugar levels 70 mg/dl to 110 mg/dl).

During an interview November 17, 2021, at approximately 11 AM, Employee 6 (RN) that upon readmission to the facility on November 1, 2021, she transcribed medication orders noted from the hospital and did not question Resident 15's absence of long standing Lantus orders. She confirmed that as of the date of this survey, Resident 15 had not received any insulin. She also confirmed that many of Resident 15's blood glucose fingerstick levels were elevated and the attending physician was not notified for any potential interventions for management of the resident's diabetes.

An interview, November 18, 2021 at approximately 1 PM, the Director of Nursing confirmed that no interventions were preformed for elevated blood sugars. She further confirmed that professional nursing staff did not ensure that Resident 15's medications were reconciled with the resident's person-centered plan upon readmission to the facility.

Review of facility policy entitled "Medication Administration" last reviewed August 2018, revealed that all medications will be administered by the same nurse who pours them.

Observation of the B-wing nursing unit on November 16, 2021, at 12:45 p.m. revealed 2 nurses performing medication administration.

Employee 2, licensed practical nurse (LPN), was observed preparing medications. Employee 2 then handed the prepared medication to Employee 1, LPN for administration to the resident. Employee 1, LPN, was then observed entering Resident 82's room and administering the medication prepared by Employee 2 to Resident 82.

Interview with Employee 1 at approximately 12:50 p.m. revealed that she was a newly hired nurse and was on orientation. Employee 1 further stated that she did not know what she had administered to Resident 82.

Interview with the Director of Nursing and Assistant Director of Nursing on November 19, 2021, at approximately 11 a.m. confirmed that Employee 1 and Employee 2 failed to administer medications securely and safely according to facility policy and professional standards of practice.


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




 Plan of Correction - To be completed: 01/14/2022

Preparation and submission of this
Plan of Correction does not
constitute admission for purposes of
general liability, professional
malpractice or any other court
proceedings.


0684 Level E-Quality of Care:
1. Contain elements detailing how the facility will correct the deficiency as it relates to the individual;
MD notified of Resident 15's recent blood sugars and new order obtained for Metformin.
Resident 82 assessed- no evidence of ill effects from a medication prepared by one nurse and then administered by a second nurse.

2. Indicate how the facility will act to protect residents in similar situations;
Blood glucose policy updated to include parameters for when to notify the physician if there is not a specific parameter noted in an order to check blood glucose. Education will be completed by 1/14/2022
Report of all residents with a diagnosis of Diabetes or hypoglycemia run and resident orders reviewed for appropriate interventions. Will be updated by 1/14/2022
Nursing to be educated to proper procedure of med pass when mentoring another nurse. Procedure will be reviewed prior to nurse-orientee starting on the floor with a mentor by 1/14/2022
When a resident is readmitted, the admitting nurse will run a copy of the medication administration record utilized at the time of discharge to the hospital and compare it with the admission orders. Any discrepancies will be communicated with the physician for review. Medication Orders policy updated to reflect this procedure and nursing will be educated on the change.

3. Include the measures the facility will take or the systems it will alter to ensure that the problem does not recur;
Random Audits of readmission orders will be done weekly x 4 weeks and then monthly to monitor compliance with addressing all previous orders with the MD by 1/14/2022
Random audits of med pass during orientation of a new hire will be done weekly x 4 weeks and then monthly to monitor compliance by 1/14/2022

4. Indicate how it plans to monitor its performance to make sure that solutions are sustained
Audits will be reviewed at QAPI to assess need for revision, increased education, and/or continuation by 1/14/2022


483.10(e)(1), 483.12(a)(2) REQUIREMENT Right to be Free from Physical Restraints:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.10(e) Respect and Dignity.
The resident has a right to be treated with respect and dignity, including:

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

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

483.12(a) The facility must-

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

Based on review of clinical records, select facility policy and investigative reports, observations, and staff interview, it was determined that the facility failed to timely conduct a systematic evaluation for the medical need of restraint use, conduct periodic re-evaluations to continue to justify the use of restraints revise a care plan to accurately reflect resident's need for restraint use for one resident out of one resident sampled physically restrained (Resident 3).

Findings included:

A review of the facility's "Restraint Usage/ Physical Restraint" policy last revised by the facility March 2020 revealed that the residents have the right to be free from any physical restraint imposed for the purposes of discipline and convenience, and not required to treat the resident's medical symptoms. Physical restraints include but are not limited to chairs with tray that cannot be easily removed by the resident.

The procedure included, a restraint assessment will be completed within 72 hours of admission by the Interdisciplinary are team for appropriateness of the device and continued need for the restraint a Physicians order obtained, risk benefits explained to the resident/or representative and consent obtained. The Physicians order is to indicate the specific reason, type, release, ease, removal time, for the use of the restraint. Physically restrained resident, who are unable to reposition themselves are to be repositioned every 2 hours, restraints are to be released every 2 hours for 15 minutes to allow for toileting and/or repositioning as indicated. The need for continued restraint use will be re-evaluated at least monthly by the Interdisciplinary care plan team and every effort will be made to lessen the restraint. All restraint usage will be addressed in the resident's care plan.

A review of Resident 3's clinical record revealed that the resident had diagnoses, which included late on-set Alzheimer's disease, anxiety, and dementia without behavioral disturbances.

A review of Resident 3's Significant Change MDS Assessment (Minimum Data Set - a federally mandated standardized assessment process completed periodically to plan resident care) dated November 9, 2021, revealed that the resident had severe cognitive impairment and required extensive assistance of two plus persons for her transfers, bed mobility, and dressing.

Physician orders dated May 5, 2021, at 12:14 PM, were noted for the resident to be OOB (out of bed) to her wheelchair with a gel cushion and a soft tray for bilateral upper extremity (BUE) support at all times.

A physician order dated May 20, 2021, at 1:37 PM, was noted for supervision of proper restraint use of the soft tray to wheelchair at all times when OOB, release every 2 hours for 15 minutes, and encourage toileting and repositioning at this time.

Review of the facility assessment entitled "Restrain-Physical" dated May 12, 2021, revealed that the Resident 3 had balance problems when seated slumping over, sliding down, and falling by leaning forward. It was noted that the resident had increased dementia symptoms and was unable to prevent herself from leaning/falling and had fallen forward and out of her chair.
Resident 3 fell forward out of her chair on April 4, 2021, that resulted in a right clavicle fracture. The family requested that resident remain in a wheelchair so that she would be able to propel around. The family did not want the facility to use the Broda chair because she was not able to propel herself in it. The Interdisciplinary Team determined to apply the restraint in attempt to eliminate/decrease falls from her chair.

The restraint was first applied on May 5, 2021, which was 7 days prior to completion of the restraint assessment.

The facility failed to timely assess Resident 3's use of the physician ordered restraint (soft tray to wheelchair) as indicated in the facility's "Restraint Usage/ Physical Restraint" policy.

Review of Resident 3's comprehensive person-centered care plan, initiated on November 15, 2021, indicated that the resident used a physical restraint (soft tray to her wheelchair) with a noted intervention to release restraint every 2-hours for 15 minutes.

Further review of facility provided documentation revealed that there was no documented evidence that staff were releasing and repositioning the resident when restrained in wheelchair and/or the frequency. There was no evidence of monthly restraint evaluations for the continued necessity and appropriateness of the restraint in Resident 3's care.

Interview with the Director of Nursing (DON) and Assistant Director of Nursing (ADON) on November 18, at 1:15 PM, confirmed that the facility failed to timely assess Resident 3 for the resident's need for a physical restraint for treatment of the resident's medical symptoms, failed to timely revise her care plan to accurately reflect care and services required to ensure the resident's safety with use of restraints. The DON and ADON confirmed that monthly reviews for restraint use did justify the continued use of restraints for treatment of the resident's medical symptoms. Additionally, the DON and ADON confirmed that the facility failed to obtain current physician's order to restrain the resident and that there was no evidence that the restraint was released at regular intervals throughout the day according to state regulatory requirements.




28 Pa. Code 201.29 (a) Resident rights

28 Pa. Code 211.10 (a) Resident care policies

28 Pa. Code 211.8 (c) Use of restraints

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





 Plan of Correction - To be completed: 01/14/2022

Preparation and submission of this
Plan of Correction does not
constitute admission for purposes of
general liability, professional
malpractice or any other court
proceedings.

0604 Level D-Right to be free from physical restraint:
1. Contain elements detailing how the facility will correct the deficiency as it relates to the individual;
The current form used for monthly evaluation of resident 3's restraint use will be revised to more accurately reflect the resident's need for restraint use by 1/14/2021. The current method of documenting restraint release will be revised to more accurately document the times the restraint was released.


2. Indicate how the facility will act to protect residents in similar situations;
A checklist will be created and utilized if the need to use another restraint arises- to include proper MD order(containing: reason/type/release, and removal time), evaluation of need within 72 hours, resident/family education of risks and benefits, consent obtained, updated care plan, and initiation of monthly re-evaluation. Checklist will be created by 1/14/2021.


3. Include the measures the facility will take or the systems it will alter to ensure that the problem does not recur;
Random Audits of restraint assessments will be done monthly to monitor compliance with the current Restraint Usage/Physical Restraint policy by 1/14/2021.


4. Indicate how it plans to monitor its performance to make sure that solutions are sustained
Audits will be reviewed at QAPI to assess need for revision, increased education, and/or continuation by 1/14/2021.

483.12(b)(1)-(3) 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,
Observations:

Based on review of the facility's abuse policy, clinical records, and concern forms and staff interview it was determined that the facility failed to implement their established procedures for identifying resident abuse and the subsequent reporting and investigation following an allegation of resident abuse of one resident out of 21 reviewed (Resident 34) and investigation of injuries of unknown origin for one resident (Resident 45) out of 21 sampled to rule out abuse, neglect or mistreatment.

Findings include:

Review of facility's policy entitled "Resident Abuse & Neglect Prevention Program" last reviewed by the facility August 2021, indicated each resident has the right to be free from verbal, physical and mental abuse, corporate punishment. Management and staff are jointly and individually responsible to ensure each resident shall be free from abuse. Every complaint or allegation of resident abuse or neglect shall be promptly reported to the immediate supervisor of the area and the Administrator and/or designee. The facility makes reasonable effort to create and maintain a proactive approach to identify occurances which may constitute abuse by providing ongoing education to report resident concerns, complaints or grievances immediately to the charge nurse, director of nursing, social worker and/or administrator. Any employee identified as the alleged perpetrator will be placed on immediate automatic suspension pending the outcome of the investigation. An incident report will be completed to include statements from residents and staff, and a review of circumstances surrounding the incident.

A review of a concern form lodged with the facility, dated September 2, 2021, revealed that Resident 34 expressed concerns of being fearful of Employee 5 (nurse aide) because the employee often yells at the resident and has threatened not to help the resident if she should sustain a fall.

Interview with the Activity Director (AD), on November 17, 2021, at 12:42 PM, stated that she completed the concern form, but had not immediately reported the resident's concerns to responsible facility. The AD stated that she reported the resident's concern to the Social Worker on September 3, 2021, but acknowledged that she should have reported the allegation on September 2, 2021, when received according to the facility's abuse prohibition policy and procedures.

During an interview with the Director of Nursing (DON) and Assistant Director of Nursing (ADON) on November 17, 2021, at 1:45 PM, it was confirmed that the facility was not made aware of the allegation timely. It was also confirmed during this interview that the failed to implement their abuse policy for timely reporting and failed to complete a thorough investigation to rule out the potential for abuse.

Further review of the facility abuse policy, injuries of unknown origin sections, last reviewed by the facility September 2021, indicated that when a resident sustains an injury and the origin of the injury has not been ascertained or is suspicious in nature, the facility will make every effort to determine if any aspect of the provision of resident care or resident/staff behavior has contributed to or has been a potential factor in the development of the injury. An incident report will be completed. All potential witnesses providing care for the residents during the twenty four hour period prior to discovery of the injury should be interviewed and written statements obtained when possible.

A review of incident report, dated June 19, 2021, at 6:30 PM indicated that while staff was providing PM care to the Resident 45, the resident complained about pain in her leg. The staff lifted the bed sheet and found blood on the sheet and reported it to the nurse. A "C" shaped laceration was noted to the resident's right lower leg measuring a 2 cm by 1.5 cm by 0.5 cm. The resident was transferred to the emergency room and returned with four sutures to the area.

According to the DON (Director of Nursing) the facility sent a maintenance work order to determine if there was something on, or in, the resident's bed to cause the laceration. The order concluded, there was nothing in the bed that could have caused the laceration.

The DON confirmed on November 18, 2021, at 9:45 AM, that the laceration was considered an injury of unknown origin. However, there were no statements provided by staff in the previous 24 hours to rule out the potential for abuse, neglect or mistreatment. The DON acknowledged that the facility's abuse policy was not implemented in an attempt to rule out the potential for abuse, neglect or mistreatment as the cause of the resident's injury of unknown origin.



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

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

28 Pa. Code 201.14(a)(c)(e) Responsibility of Licensee











 Plan of Correction - To be completed: 01/14/2022

Preparation and submission of this
Plan of Correction does not
constitute admission for purposes of
general liability, professional
malpractice or any other court
proceedings.

0607 Level D-Develop/Implement Abuse/Neglect Policies:
1. Contain elements detailing how the facility will correct the deficiency as it relates to the individual;
Resident 34 and 45 will be assessed by at least 2 members of the ICDT to assure no verbalization or evidence of abuse is noted at this time by 1/14/2022.
Investigation was completed of the complaint made by resident 34 that she is afraid of her 7-3 aid. On re-interview she was found to not be fearful but did express that she did not like the aid's personality she was not cheerful. The aid was reassigned and resident 34 has had no further complaints. Residents on the same unit with a BIMS of 12 or greater were interviewed and none expressed dissatisfaction or fear with employee 5's care.
Injury to resident 45 occurred after the start of the shift. Both NA and LPN were interviewed- had no idea as to its origin. Resident was not transferred in or out of bed, bed was assessed for sharp objects- none noted. Noted at 7PM, no other residents in area. Area was on lower shin, statement from NA is that she moves a lot in bed. Area probable to be self-inflicted from her toenail. Podiatry reviewed. No distress noted in resident. No evidence of abuse.

2. Indicate how the facility will act to protect residents in similar situations;
Will re-educate staff on the need for immediate reporting of every complaint or allegation of abuse by 1/14/2022.
Nurse Managers will be re-educated on the process of investigation and how to rule out abuse if they have an injury with unknown origin by 1/14/2022

3. Include the measures the facility will take or the systems it will alter to ensure that the problem does not recur
Investigation worksheet will be added to track staff assigned to the resident in the past 24 hours and timely return of a statement from them by 1/14/2022. Incidents will be audited weekly x 4 and then monthly to assess timeliness of investigation and appropriate intervention by 1/14/2022.

4. Indicate how it plans to monitor its performance to make sure that solutions are sustained
Audit will be reviewed at QAPI to assess need for revision, increased education, and/or continuation by 1/14/2022.


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

Based on a review of clinical records and the Resident Assessment Instrument and staff interviews, it was determined that the facility failed to ensure the Minimum Data Set Assessments (MDS - a federally mandated standardized assessment conducted at specific intervals to plan resident care) accurately reflected the status of one resident out of 4 sampled residents who smoke (Resident 73).

Findings include:

A review of Resident 73's annual MDS assessment dated October 28, 2021, Section J 1300 current tobacco use, indicated that the resident was not a tobacco user during the fourteen day look back period.

Review of Resident 73's clinical record revealed a smoking assessment form, dated June 1, 2021, which indicated the resident was a smoker.

Interview with the Employee 3 (RNAC-Registered Nurse Assessment Coordinator) on November 18, 2021 at 12:44 PM confirmed the smoking section MDS assessment was inaccurate and should have reflected that Resident 73 was a smoker at the time of the annual assessment.


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

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






 Plan of Correction - To be completed: 01/14/2022

Preparation and submission of this
Plan of Correction does not
constitute admission for purposes of
general liability, professional
malpractice or any other court
proceedings.

0641 Level D-Accuracy of Assessments:
1. Contain elements detailing how the facility will correct the deficiency as it relates to the individual;
MDS for resident 73 will be corrected by 1/14/2021

2. Indicate how the facility will act to protect residents in similar situations;
MDS of all residents who use tobacco will be audited for accuracy by 1/14/2021

3. Include the measures the facility will take or the systems it will alter to ensure that the problem does not recur;
Random Audits of MDS Section J 1300 will be done weekly x 4 weeks and then monthly to monitor accuracy of entries by 1/14/2021

4. Indicate how it plans to monitor its performance to make sure that solutions are sustained
Audits will be reviewed at QAPI to assess need for revision, increased education, and/or continuation by 1/14/2021

483.21(b)(2)(i)-(iii) REQUIREMENT Care Plan Timing and Revision:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.21(b) Comprehensive Care Plans
483.21(b)(2) A comprehensive care plan must be-
(i) Developed within 7 days after completion of the comprehensive assessment.
(ii) Prepared by an interdisciplinary team, that includes but is not limited to--
(A) The attending physician.
(B) A registered nurse with responsibility for the resident.
(C) A nurse aide with responsibility for the resident.
(D) A member of food and nutrition services staff.
(E) To the extent practicable, the participation of the resident and the resident's representative(s). An explanation must be included in a resident's medical record if the participation of the resident and their resident representative is determined not practicable for the development of the resident's care plan.
(F) Other appropriate staff or professionals in disciplines as determined by the resident's needs or as requested by the resident.
(iii)Reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments.
Observations:

Based on clinical record reviews and staff interviews it was determined that the facility failed to review and revise the care plan to meet the current individualized needs of one of 21 residents reviewed (Resident 88).

Findings include:

Review of Resident 88's clinical record revealed that the resident was admitted to the facility on October 28, 2020, with diagnoses that included tracheostomy (an opening surgically created in the trachea/windpipe to relieve an obstruction to breathing), gastrostomy (creation of an opening into the stomach from the abdominal wall for nutritional support), and diabetes.

Review of Resident 88's comprehensive care plan that was initiated on November 9, 2020, and was revised on April 7, 2020, revealed a focus area of ADL self-care performance deficit related to weakness, pain, not being able to see small print. The resident's goal was to maintain current level of function through the review date, last revised August 31, 2021. Included interventions were to elevate head of bed at all times during feeding and 30 minutes after feeding due to aspiration precautions related to tube feeding.

Further review of Resident 88's current care plan revealed a focus area of pain related to gout, neuropathy, necrotizing fasciitis, throat pain has trach with goal that resident will not have an interruption in normal activities due to pain through the review date, last revised on August 31, 2021.

There was no evidence during the survey ending November 19, 2021 that Resident 88 still had a tracheostomy or gastrostomy tube.

Interview with the Director of Nursing (DON) and Assistant Director of Nursing (ADON) on November 18, 2021, at 2:30 p.m. confirmed that the facility failed to revise Resident 88's person-centered comprehensive care plan to accurately reflect the resident's current plan of care. The DON and ADON further confirmed that the resident no longer had a tracheostomy or gastrostomy tube and the resident's plan of care had not been updated.



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

28 Pa. Code 211.11(d)(e) Resident Care Plan.







 Plan of Correction - To be completed: 01/14/2022

Preparation and submission of this
Plan of Correction does not
constitute admission for purposes of
general liability, professional
malpractice or any other court
proceedings.

0657 Level D-Care Plan Timing and Revision:
1. Contain elements detailing how the facility will correct the deficiency as it relates to the individual;
Care plan of resident 88 reviewed and updated.

2. Indicate how the facility will act to protect residents in similar situations;
Resident Care Plan Conference Policy will be updated and all members of the IDCT will be re-educated on the process of Care Conferences by 1/14/2022

3. Include the measures the facility will take or the systems it will alter to ensure that the problem does not recur;
Random Audits of resident care plans will be done weekly x 4 weeks and then monthly to monitor compliance with updating the care plan timely by 1/14/2022

4. Indicate how it plans to monitor its performance to make sure that solutions are sustained
Audits will be reviewed at QAPI to assess need for revision, increased education, and/or continuation by 1/14/2022

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 review of clinical records and select facility policies and staff interviews, it was determined that the facility failed to timely monitor nutritional parameters and oral intake to timely identify and address a resident's declining nutritional and hydration status for one resident out of 21 residents sampled (Resident 16).

Findings include:

Review of the facility policy entitled "Weight Monitoring" with a revision date of September 2019, indicated that monthly weights were to be obtained by the tenth day of each month and if there was a change of 5 pounds or more the nurse aide must notify the licensed nurse. If a fluctuation of 5 pounds or greater is noted the resident must again be weighed immediately to verify accuracy. The Unit Managers or designees will notify the Clinical Dietary Department/dietitian of the 5-pound fluctuation in weight within 24-hours. The Clinical Dietary Department will evaluate weight change and recommend interventions.

Review of Resident 16's clinical record revealed that the resident was most admitted to the facility on December 28, 2016, with diagnoses of hypertensive heart disease with heart failure.

A review of a quarterly MDS (Minimum Data Set) assessment (a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated August 30, 2021, indicated that Resident 16 had severe cognitive impairment.

Resident 16's current care plan indicated that the resident had nutritional problems with a goal to consume at least 75% of meals daily. Interventions planned were to monitor intake and record each meal and to monitor, record, and report significant weight loss of 5# or greater and 5% or greater change in 1 month, 7.5% or greater change in 3 months, and 10% or greater change in 6 months.

Review of Resident 16's "Weight Record" revealed that on October 21, 2021, first weight for the month of October 2021, the resident weighed 142.6 pounds. On November 12, 2021, the resident weighed 131.4 pounds, which was a significant weight loss of 11.2 pounds or 7.8% in 3 weeks and significant loss of 10.4% in 6 months.

There was no documented evidence that a re-weight was performed to verify the significant weight loss as indicated in the facility's "Weight Monitoring Policy."

Review of "Nutritional Intake Record" for October 2021 revealed that staff failed to record Resident 16's meal intakes for 7 meals during the month. Resident 16's intakes varied throughout the month, 20 meals out of 91 meals served she consumed 25-50% and 11 meals out of the 91 meals served that she consumed 0%.

Further review of "Nutrition Intake Record" for November 2021, reviewed thru November 17, 2021, revealed that staff failed to record Resident 16's meal intakes for 4 meals during the month of November 2021 to date. Resident's 16' intakes varied throughout the month, during which at 9 meals out of 51 the resident consumed 25-50% and 17 meals out of 51 meals served she consumed 0% of her meals, with consecutive 0% meals consumed.

Labs results that were obtained on November 12, 2021, at 9:50 PM, revealed that Resident 16's sodium value was elevated at 153 mmol/L (normal range at 136-145 mmol/L) and chloride value was elevated at 117 mmol/L (normal range at 100-108 mmol/L).

Review of "Physician's Orders" dated November 13, 2021, at 11:47 AM, revealed an order to encourage patient to increase her fluid intake due to increased sodium/hypernatremia [elevated sodium values reflect dehydration (lack of water)] and initiated intravenous fluids [IV fluids are specially formulated liquids that are injected into a vein to prevent or treat dehydration] of 5% dextrose solution and water (D5W) at 60 milliliters per hour for 24-hours to treat abnormal labs with hypernatremia.

Review of the "Nutrition/Dietary Progress" completed by the Registered Dietitian (RD) on November 15, 2021, revealed that a re-weight was requested due to a change from 142.6 pounds, labs were pending for November 16, 2021, and Lasix (a diuretic) 40 milligrams daily was in place.

During interview with the director of nursing (DON) on November 17, 2021, at 10:30 AM, the DON stated that a re-weight would be expected to be obtained if not immediately, within 24-hours after a significant weight change was identified. The DON reported that nursing would then notify the physician, notify the resident's responsible party (if cognitively impaired), and notify the registered dietitian. Also, the DON reported that nursing staff were expected to record all meals served for all resident to ensure accurate monitoring and assessment of their nutritional status.

Interview with the facility's Registered Dietitian on November 18, 2021, at 1:15 PM, revealed that the expectation for a re-weight to be completed was immediately or within 24 hours. She made multiple requests to nursing to obtain a re-weight to verify the significant weight loss. However, no re-weight was completed as of November 18, 2021 (during on-site survey). The RD stated that nursing staff does not always record the meal and fluid intakes, which affects the accuracy of nutritional assessment and development of appropriate interventions to deter weight loss and adequate hydration status and fluid balance.

Further interview with the DON and assistant director of nursing (ADON) on November 18, 2021, at 2:00 PM, confirmed that the facility failed to timely obtain weights, failed consistently and accurately record Resident 16's meal intakes, and identify declined food/fluid patterns help to deter significant weight loss and fluid imbalance.



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

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






 Plan of Correction - To be completed: 01/14/2022

Preparation and submission of this
Plan of Correction does not
constitute admission for purposes of
general liability, professional
malpractice or any other court
proceedings.

0692 Level D-Nutrition/Hydration Status Maintenance:
1. Contain elements detailing how the facility will correct the deficiency as it relates to the individual
Reweight obtained for resident 16 by 11/20/2021confirming weight loss. Resident placed for review by the Nutritionally at Risk Team, placed on Speech Therapy to work on diet texture, nutritional supplement offered four times a day, prosource twice a day, and Remeron-an appetite stimulant daily. Resident placed on weekly weights x 4 weeks, MD and representative notified.

2. Indicate how the facility will act to protect residents in similar situations
All weights will be audited to assure that they have been completed as ordered and any missing weights/reweights will be completed and physician, representative, dietician notified as necessary by 1/14/2022.
Staff will be educated on the importance of entering food and fluid intakes by 1/14/2022.

3. Include the measures the facility will take or the systems it will alter to ensure that the problem does not recur
Random Audits of weights, meal intakes, and fluid intakes will be done at least weekly x 4 weeks and then monthly to monitor compliance with weight monitoring by 1/14/2022

4. Indicate how it plans to monitor its performance to make sure that solutions are sustained
Audits will be reviewed at QAPI to assess need for revision, increased education, and/or continuation by 1/14/2022

483.25(g)(4)(5) REQUIREMENT Tube Feeding Mgmt/Restore Eating Skills: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)(4)-(5) Enteral Nutrition
(Includes naso-gastric and gastrostomy tubes, both percutaneous endoscopic gastrostomy and percutaneous endoscopic jejunostomy, and enteral fluids). Based on a resident's comprehensive assessment, the facility must ensure that a resident-

483.25(g)(4) A resident who has been able to eat enough alone or with assistance is not fed by enteral methods unless the resident's clinical condition demonstrates that enteral feeding was clinically indicated and consented to by the resident; and

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

Based on observations, clinical record review, and staff interview it was determined that the facility failed to implement physician's orders and provide appropriate care and services to one resident receiving an enteral feeding out of one resident sampled receiving an enteral tube feeding (Resident 80).

Findings include:

Reviewed of Resident 80's clinical record revealed that the resident was readmitted to the facility on November 11, 2021, with diagnoses to have included hemiplegia following cerebral infarction affecting the right side (stroke), dysphagia (difficulty swallowing), aspiration pneumonia, severe protein-calorie malnutrition, dementia, and dehydration.

Clinical record review revealed that Resident 80 had a PEG tube (Percutaneous endoscopic gastrostomy (PEG) is an endoscopic medical procedure in which a tube [PEG tube] is passed into a patient's stomach through the abdominal wall, most commonly to provide a means of feeding when oral intake is not adequate [for example, because of dysphagia] for enteral feeding [enteral nutrition generally refers to any method of feeding that uses the gastrointestinal [GI] tract to deliver part or all of a person's caloric requirements].

A physician order initially dated September 27, 2021, at 4:31 PM, directed staff to monitor the resident's fluid intake and output.

A physician order initially dated October 27, 2021, at 6:04 PM, indicated that Resident 80 was NPO (nothing by mouth) related to aspiration and dysphagia and required a tube feeding to provide adequate nutrition, hydration, and medications and to maintain intake and output and encourage fluids every shift.

A physician order initially dated October 28, 2021, at 8:56 PM, were noted for the resident to receive the tube feeding formula of Jevity 1.5 Cal (liquid feeding administered via feeding tube) at 53 ccs per hour continuous for 24-hours daily with 150 ccs of water every 6 hours with med passes, and to flush with 5-15 cc's between each med (via Peg Tube), and to document the amounts of fluids given at every shift.

Resident 80's care plan initiated October 28, 2021, identified the resident's potential for fluid imbalance related to diuretic (medication used to rid the body of excess fluids) use, hospitalizations, and aspiration pneumonia. Planned interventions were to monitor and document intakes and outputs and to provide tube feeding and water flushes as approved and ordered by the physician based on current status to evaluate nutrient needs.

A review of the facility's "Fluid Intake/Output Monitoring" forms dated October 31, 2021 indicated that the resident was given a total of 200 ccs and 360 ccs on November 1, 2021. On November 1, 2021, the resident's 3-day average of fluid intake was 183 ccs. On November 10, 2021, the resident received a total of 300 ccs; 60 ccs on November 11, 2021, and 0 ccs on November 12, 2021. On November 12, 2021, the resident's 3-day average fluid intake was 120 ccs.

Review view of the Medication Administration Records for October 2021 and November 2021, through survey end date of November 19, 2021, revealed that the facility was not accurately monitoring tube feeding volume, water flushes administered, and physician ordered I & O (oral intakes and outputs) amounts. On November 6, 2021 and November 7, 2021 there was no documented fluids given on day shifts and there were no documented flushes given between medications.

The facility was unable to provide documented evidence to demonstrate staff was adhering to physician's orders and monitoring accurate I & O's.

Review of Resident 80's Kardex [a summary of a resident's care for staff to perform tasks as noted on resident care plans] revealed that there was no documented evidence that the resident was NPO (nothing by mouth).

Review of Resident 80's care tasks revealed the task to provide water at the resident's bedside and to provide a HS snack (bedtime snack) revealed that on October 28, 2021, November 1, 2021, November 4, 2021, November 6, 2021, November 10, 2021, November 13, 2021, November 14, 2021, and November 16, 2021 water was provided at the bedside despite the resident order to be NPO due to aspiration.

During an interview with the Assistant Director of Nursing (ADON) on November 17, 2021, at 1:33 PM, the ADON stated that several agency nursing staff were working in the facility and may not have realized that Resident 80 was not able have fluids/foods orally and as result the ADON was unable to confirm that the physician order for the resident to remain NPO was consistently followed.

Interview with the Director of Nursing (DON) on November 18, 2021, at 10:45 AM, confirmed that the facility failed to consistently and accurately record and monitor Resident 80's I & O as ordered by the physician and confirmed that the resident's Kardex used by direct care staff failed to reflect the resident's comprehensive person-centered plan of care by failing to include/note that the resident was NPO to ensure staff members were aware that the resident was NPO.



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



 Plan of Correction - To be completed: 01/14/2022

Preparation and submission of this
Plan of Correction does not
constitute admission for purposes of
general liability, professional
malpractice or any other court
proceedings.

0693 Level D-Tube Feeding Management/Restore Eating Skills:
1. Contain elements detailing how the facility will correct the deficiency as it relates to the individual;
Resident 80's kardex was updated to reflect her NPO status and the task to provide water at the bedside and an HS snack were removed. Tube feeding/flush orders will be revised to assure accurate administration and documentation of amounts given by 1/14/2022

2. Indicate how the facility will act to protect residents in similar situations;
A report of all resident's with an NPO order will be run and Kardex's updated as necessary by 1/14/2022.
Tube feeding/flush orders will be revised for all residents to assure accurate administration and documentation of amounts given. Staff will be educated on the proper procedure by 1/14/2022

3. Include the measures the facility will take or the systems it will alter to ensure that the problem does not recur;
Random audits will be done of meal and fluid intakes for completion and accuracy weekly x 4 weeks and then monthly by 1/14/2022

4. Indicate how it plans to monitor its performance to make sure that solutions are sustained
Audits will be reviewed at QAPI to assess need for revision, increased education, and/or continuation by 1/14/2022

207.4 LICENSURE Ice containers and storage.:State only Deficiency.
Ice storage containers shall be kept clean, and ice shall be handled in a sanitary manner to prevent contamination.
Observations:


Based on observation and staff interview, it was determined that the facility failed to handle ice in a sanitary manner.

Findings include:

During an observation on November 18, 2021 at 9 AM, an employee was observed to open the ice chest, remove a scoop full of ice and filled a resident's drinking cup with ice. The employee then returned the ice scoop into the ice chest containing the ice, closed the lid and continued to pass ice to residents in this same manner. Observation revealed a closed container on the cart shelf for placement/storage of the ice scoop.

During an interview November 18, 2021 at approximately 1 PM, the Director of Nursing confirmed that the ice scoop should be placed in the container provided on the cart and not placed within the ice in the chest.



 Plan of Correction - To be completed: 01/14/2022

Preparation and submission of this
Plan of Correction does not
constitute admission for purposes of
general liability, professional
malpractice or any other court
proceedings.

P1510 Ice Containers and Storage
1. Contain elements detailing how the facility will correct the deficiency as it relates to the individual;
Ice chest and scoop cleaned. Scoop stored in appropriate container.

2. Indicate how the facility will act to protect residents in similar situations;
Staff will be re-educated on the proper procedure for ice pass by 1/14/2022.

3. Include the measures the facility will take or the systems it will alter to ensure that the problem does not recur;
Random Audits of ice pass will be done weekly x 4 weeks and then monthly to monitor compliance with proper sanitation by 1/14/2022.

4. Indicate how it plans to monitor its performance to make sure that solutions are sustained
Audits will be reviewed at QAPI to assess need for revision, increased education, and/or continuation by 1/14/2022.


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