Pennsylvania Department of Health
QUADRANGLE, THE
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

There are 63 surveys for this facility. Please select a date to view the survey results.

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QUADRANGLE, THE - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:

Based on a Medicare Recertification Survey, Civil Rights Compliance Survey, State Licensure Survey, completed on May 22, 2024, it was determined that The Quadrangle, was not in compliance with the requirements of 42 CFR part 483, Subpart B, Requirements for Long Term Care Facilities and the 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations related to the health portion of the survey process.

Plan of Correction:

483.60(i)(1)(2) REQUIREMENT Food Procurement,Store/Prepare/Serve-Sanitary:

This is a less serious (but not lowest level) deficiency 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 observations, interviews with staff, and a review of facility policies and documentation, it was determined that the facility did not ensure that food was stored, prepared, distributed, and served in accordance with professional standards for food service safety.

Findings include:

Review of facility policy titled, "Food Storage, Preparation and Service" revised April 11, 2022, revealed that cutting boards are color coded and used according to food type." The red cutting board is to be utilized for raw meat and processed (not raw) items are to be handled on a white cutting board. Further review revealed that "all food items are labeled, dated and rotated to maintain a system of First In First Out (FIFO).

An initial tour of the Food Service Department was conducted on May 20, 2024, at 10:14 a.m. with the Food Service Director (FSD), Employee E5, and the Dietary Manager (DM), Employee E6.

Observations revealed the following:

Employee E11, the Cook, was observed cutting vegetables on the white cutting board. Further observation revealed Employee E11 proceeded to handle raw ground beef on the same white cutting board, soon after finishing cutting the vegetables.

Employee E12, Dietary Aid, was scooping raw crab cakes on the sheet tray without wearing disposable gloves.

Observations in the pantry and the main refrigerator revealed that opened food items (including cheeses, cut pineapple, pineapple, and pulled raw meat) contained a single date.

Interview with the FSD during the tour confirmed that items in the pantry and refrigerator contained only one date and acknowledged that all items should have a "use by date." Further electronic communication with the FSD, on May 22, 2024, at 4:03 p.m. confirmed that "all items should receive a date upon delivery ... If the product is open, it should be wrapped, labeled, and dated after use and fixed with an open date and an expiration date and placed in proper FIFO rotation ... All prepared food should be wrapped, labeled, and dated with an expiration date of 72 hours after preparation."

28 PA Code: 201.14(a) Responsibility of licensee.

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

Plan of Correction - To be completed: 06/28/2024

1.With respect to the specific resident/situation cited:

Employee 11 and 12 were re-educated by Food Service Director at the time of the inspection. Identified food items were immediately discarded.

2.With respect to how the facility will identify residents/situations for the identified concerns:

Food Service Director audited all kitchen storage areas for proper labelling, wrapping, and dating of food; no issues were identified.
Certified Dietary Manager or designee will observe food preparation and inspect all food storage areas for proper labeling and dating three times weekly for one month and weekly for two additional months.
3.With respect to what systemic measures have been put into place to address the stated concern:

Food Service Director completed staff in-services for Food Safety requirements including proper storage, preparation and storage, hand hygiene, appropriate usage of disposable gloves and avoiding cross contamination on 5/27/2024.
4.With respect to how the plan of correction will be monitored:

The QAPI committee will review audits for three months. At the conclusion of the three months, the QAPI committee will re-evaluate and initiate any necessary action or extend the review period if needed. The Administrator is responsible for ensuring implementation and ongoing compliance with the components of the Plan of Correction and addressing variances that may occur.

5. Area cited in F 812 will be corrected by 6/28/2024.

483.60(i)(4) REQUIREMENT Dispose Garbage and Refuse Properly:

§483.60(i)(4)- Dispose of garbage and refuse properly.

Observations:

Based on observations and interviews with staff, it was determined that the facility failed to ensure that garbage was dispose of properly.

Findings include:

Observation in the receiving area revealed five dumpsters with the lid open revealing contents; dirty plastics were observed around the dumpsters. The ground all around the loading dock was littered with hundreds of cigarette butts.

Interview with Food Service Director at 9:45 a.m. on May 14, 2024, 10:40 a.m. confirmed the above findings.

Plan of Correction - To be completed: 06/28/2024

1.With respect to the specific resident/situation cited:

The dumpster lids were closed and the area surrounding the dumpsters was cleaned of debris at the time of the inspection.

2.With respect to how the facility will identify residents/situations for the identified concerns:

On 5/20/2024 all refuse areas were inspected for proper disposal and containment of garbage and refuse; no issues were identified.

3.With respect to what systemic measures have been put into place to address the stated concern:

The Resident Service Director or designee will complete an inspection of the dumpster area twice daily for 30 days after which daily inspection will be ongoing.

4.With respect to how the plan of correction will be monitored:

The QAPI committee will review audits of the refuse area inspections for three months. At the conclusion of the three months, the QAPI committee will re-evaluate and initiate any necessary action or extend the review period if needed.

5. Area cited in F 814 will be corrected by 6/28/2024.

483.12(c)(2)-(4) REQUIREMENT Investigate/Prevent/Correct Alleged Violation:

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(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must:

§483.12(c)(2) Have evidence that all alleged violations are thoroughly investigated.

§483.12(c)(3) Prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress.

§483.12(c)(4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken.

Observations:

Based on review of clinical records, facility policies and procedures, interviews with staff, it was determined that the facility failed to conduct a complete and thorough investigation of one alleged violation of unknown source of injury for one of 16 residents reviewed. (Resident R165).

Findings include:

Review of the facility policy titled, "Abuse, Neglect & Exploitation - Prevention, Reporting and Investigation" dated, May 4, 2016, revealed, "The SNA/designee manages and directs the investigation of all abuse, neglect and/or exploitation."

Review of facility investigation dated August 21, 2023, revealed that while providing care, a nurse aide transferred Resident R165, and her head hit the guard rail. This resulted in a hematoma on the right side of her forehead. Resident was sent to the hospital for further assessment.

Further review of the investigation revealed a statement by Employee E13, nurse aide revealed that she provided care to resident including transfer with the help of other staff. She also provided care to resident in bed. Employee E13 indicated that there was no incident happened during her care or the resident did not complain of any pain or incident. Employee E13 indicated that the incident did not happen on her shift.

Further review of the investigation revealed a hospital record dated August 21, 2023, which indicated that the resident stated she sustained the injury during a transfer by nurse aide.

Continued review of the investigation revealed that facility did not obtain statements or conducted interviews with other staff who provided care to the resident prior to the injury.

Interview with the Administrator on May 22, 2024, at 11:30 a.m. stated resident alleged that the injury was sustained during a transfer from previous shift. She stated the injury was reported by the employees of 7am-3pm shift.
Administrator confirmed that the facility investigation was focused on Nurse aide, Employee E13 who allegedly transferred the resident. However, it was determined that there was no transfer occurred during the care. Administrator also confirmed that there was no other staff interviewed or obtained statements from staff who provided care to Resident R165.

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

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

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

Plan of Correction - To be completed: 06/28/2024

1.With respect to the specific resident/situation cited:

Resident R165 was discharged from the facility on 8/31/2023.

2.With respect to how the facility will identify residents/situations for the identified concerns:

Nursing team assessed current residents for injuries of unknown origin. No such injuries were observed. Incident reports from previous 90 days will be audited by 6/28/2024 for injuries of unknown origin. Any identified injuries of unknown origin will be thoroughly investigated and reported to the Department of Health, concurrently.

3.With respect to what systemic measures have been put into place to address the stated concern:

Nursing, curse aides, and interdisciplinary team in-serviced by administrator on training on reporting abuse.
Regional Director of Resident Care provided Administrator training on proper reporting of abuse/neglect and thorough investigation protocol.
According to the training, any bruising of unknown origin will be investigated through interviews and statements of anyone who has provided care for them 72 hours prior to identification of bruise. Family will also be involved in the investigation process.
Incident reports will be reviewed daily by administrator and License Social Workers or designee, for appropriate reporting and investigation.
Bruising of unknown origin will be reported to the Department of Health as potential neglect.
4.With respect to how the plan of correction will be monitored:

Quality Assurance/Performance Improvement committee (QAPI) will review all Incident reports for three months to ensure that all incidents of alleged abuse/neglect are properly reported and investigated. At the conclusion of the three months, the QAPI committee will re-evaluate and initiate any necessary action or extend the review period. The Administrator is responsible for ensuring implementation and ongoing compliance with the components of the Plan of Correction and addressing resolving variances that may occur.
5.Areas cited in F 610 will be corrected by 6/28/2024.

483.15(c)(3)-(6)(8) REQUIREMENT Notice Requirements Before Transfer/Discharge:

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

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

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

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

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

Observations:

Based on the review of clinical records and interview with staff, it was determined that the facility failed to notify the resident and the resident's representative(s) of the transfer to the hospital and the reasons for the transfer to the hospital in a timely manner, in writing and in a language and manner they understoodfor one of 16 residents reviewed. (Resident R52)

Findings Include:

Review of nursing note for Resident R52, dated May 8, 2024, revealed that the resident was febrile (having or showing symptoms of a fever), and was discharged to the hospital.

Further review revealed a nursing note for Resident R52, dated April 26, 2024, revealed that the resident was discharged to the hospital for systemic anemia.

Another nursing note for Resident R52, dated March 11, 2024, revealed that the resident was admitted to the hospital with acute kidney injury.

Review of clinical record revealed no evidence that Resident R52's representative was notified of the transfer to the hospital and the reasons for the transfer in writing, and in a language and manner they understood.

Interview with the Nursing Home Administrator, Director of Nursing, and Social Worker, Employee E3, on May 22, 2024, at 11:49 a.m. confirmed that the Resident R52's representative was not notified of the hospital transfers and the reasons for the transfers in writing, and in a language and manner they understood. Further interview confirmed that there was no system in place in regard to notifying the residents representatives, in writing, including the reasons, prior to resident transfer or discharge.

28 Pa. Code 201.14(a) Responsibility of license

28 Pa. Code 201.29(a) Resident rights

Plan of Correction - To be completed: 06/13/2024

1.With respect to the specific resident/situation cited:

R52 is currently in the hospital, and family has been notified, via writing, of A. reason for transfer to hospital, B. including a statement of resident's right to appeal, and C. Name, address, and telephone number of the Office of the State Long-Term Care Ombudsman.

2.With respect to how the facility will identify residents/situations for the identified concerns:

Licensed Social Workers will complete an audit of discharged and transferred residents for the previous 30 days. Audit will be reviewed by Administrator. For any identified concerns, written communication of the reason for the discharge/transfer and a statement of the right to appeal to include the name, address and telephone number of the Office of the State Long-Term Care Ombudsman will be sent to the resident and/or resident representative. A copy of the notice will be sent to the State Long-Term Care Ombudsman.

3.With respect to what systemic measures have been put into place to address the stated concern:

Licensed Social Workers have been in-serviced on Notice Requirements of Transfer/Discharge on 6/11/2024 by Administrator. Licensed Social Workers will submit to the Administrator a monthly random sample list of resident transfer/discharges to include copy of written transfer/discharge notice.

4.With respect to how the plan of correction will be monitored:

Over the next 3 months, the findings from the administrator's random sample audit will be reviewed at the Quality Assurrance Performance Improvement (QAPI) meetings. At the conclusion of the three months, the QAPI committee will re-evaluate and initiate any necessary action or extend the review period if needed. The Administrator is responsible for ensuring implementation and ongoing compliance with the components of the Plan of Correction and addressing resolving variances that may occur.
5.Areas cited in F 623 will be corrected by 6/28/2024.

483.15(d)(1)(2) REQUIREMENT Notice of Bed Hold Policy Before/Upon Trnsfr:

§483.15(d) Notice of bed-hold policy and return-

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

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

Observations:

Based on clinical record review and staff interview, it was determined that the facility failed to ensure that the resident and resident representative receive written notice of the facility bed-hold policy at the time of a facility-initiated transfer to a hospital for one of 16 residents reviewed. (Resident R52)

Findings include:

Review of nursing note for Resident R52, dated May 8, 2024, revealed that the resident was febrile (having or showing symptoms of a fever), and was discharged to the hospital.

Further review revealed a nursing note for Resident R52, dated April 26, 2024, revealed that the resident was discharged to the hospital for systemic anemia.

Another nursing note for Resident R52, dated March 11, 2024, revealed that the resident was admitted to the hospital with acute kidney injury.

Further review of Resident R52's clinical record revealed that there was no documented evidence that the resident and his representative were provided with a written notice of the facility bed-hold policy at the time of Resident R52's facility-initiated transfer to the hospital.

Interview with the Nursing Home Administrator, Employee E1; Director of Nursing, Employee E2; and Social Worker, Employee E3, on May 22, 2024, at 11:49 a.m. confirmed that the Resident R52 and his representative were not provided with the bed hold policy, that included information explaining the duration of the bed-hold, bed hold reserve payment and permitting return to a bed at the facility. Further interview confirmed that there was no system in place to ensure that the resident and resident representative receive written notice of the facility bed-hold policy at the time of a facility-initiated transfer to a hospital.

28 Pa Code 201.14(a) Responsibility of licensee

28 PA Code 201.29(f) Resident rights

Plan of Correction - To be completed: 06/28/2024

1.With respect to the specific resident/situation cited:

R52 is currently at the hospital, and family has been notified, via writing, of bed-hold policy, including information explaining the duration of the bed-hold, bed-hold reserve payment and permitting return to a bed at the facility.
2.With respect to how the facility will identify residents/situations for the identified concerns:

Licensed Social Workers completed an audit on 6/14/2024 of all residents currently transferred to hospital or on therapeutic leave.

Those identified through the audit have been notified, via writing, of bed-hold policy, including: information explaining the duration of the bed-hold, bed-hold reserve payment and permitting return to a bed at the facility.

3.With respect to what systemic measures have been put into place to address the stated concern:

Licensed Social Workers and nursing team will be in-serviced by 6/28/2024 on bed-hold policy to be offered to residents/families who have had facility-initiated transfers to hospital or to residents on therapeutic leave to include information explaining the duration of the bed-hold, bed-hold reserve payment and permitting return to a bed at the facility. Licensed Social Workers or designee will audit hospital transfers to ensure that bed-holds were offered, per policy. This information will be reviewed with the QAPI Committee.
4.With respect to how the plan of correction will be monitored:

The Quality Assurance/Performance Improvement QAPI committee will review weekly audit findings for thirty days, and monthly audit for two months. At the conclusion of the three months, the QAPI committee will re-evaluate and initiate any necessary action to extend the review period if needed.

5. Area cited in F 625 will be corrected by 6/28/2024.

483.25(g)(1)-(3) REQUIREMENT Nutrition/Hydration Status Maintenance:

§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 facility policy, review of clinical records, and staff interview, it was determined that the facility failed to monitor and modify interventions consistent with the resident's needs to maintain acceptable parameters of nutritional status for two of three residents reviewed for nutritional status (Resident R44 and R55).

Findings Include:

Review of facility policy titled, "Nutritional Intervention Pathways for Weight Loss" undated, revealed that oral supplements must be obtained from the physician and documented.

Review of facility policy titled, "Fortified Foods" revised June 7, 2016, revealed that fortified foods "will meet the increased nutritional needs of residents who are underweight, have significant weight loss, pressure ulcers or poor intake." Once the physician approves the fortified food, a diet order written as "Fortified food" will appear in the resident's medical records. "Recipes, amount to be served and frequency must be kept on file." Further review revealed that acceptance of the Fortified foods should be assessed regularly.

Review of Resident R44's comprehensive Minimum Data Set (MDS - federally mandated resident assessment and care screening) dated February 21, 2024, revealed the resident was admitted to the facility on May 27, 2022, with diagnoses including fracture and muscle weakness.

Review of Resident R44's weight history revealed resident experienced continual weight loss. Weights were discontinued per resident preference, with the last weight registered 83.6 pounds on March 26, 2024.

Review of nutrition notes for Resident R44, dated April 4, 2024, and April 11, 2024, revealed that the resident had mixed intakes. The Dietitian, Employee E4 made a recommendation for "Boost Breeze 240cc in the morning. Nursing to provide and record percent intake."

Review of Physician order dated, April 11, 2024, revealed an order for "Boost Breeze clear 240cc in the morning. Nursing provide and record consumption."

Review of Resident R44's clinical record failed to reveal documented supplement intakes for nutrition monitoring.

Interview with the Registered Dietitian, Employee E4, on May 22, 2024, at 2:21 p.m. confirmed that there is no documentation of Resident R44's supplement percent intakes for nutrition monitoring.

Review of Resident R55's comprehensive Minimum Data Set (MDS - federally mandated resident assessment and care screening) dated April 21, 2024, revealed the resident was most recently admitted to the facility on April 17, 2024, with diagnoses including partial intestinal obstruction, prediabetes, muscle weakness, and obstructive pulmonary disease.

Review of nutrition notes for Resident R55 revealed that the resident has a history of Crohn's disease (chronic inflammation of the digestive trat that leads to abdominal pain, weight loss) and malnutrition. Further review revealed that the resident was eating approximately 50% of his meals.

Review of physician orders for Resident R55 revealed an order dated, April 18, 2024, "fortified food program: fortified pudding at lunch." Further review failed to indicate the amount, per facility policy, Fortified Foods.

Review of Resident R55's clinical records failed to reveal documented evidence of the Fortified Pudding consumption for resident.

Interview with the Registered Dietitian, Employee E4, on May 22, 2024, at 2:21 p.m. confirmed that there is no documentation of the fortified pudding consumption to evaluate Resident R55's acceptance of the Fortified Food and overall nutrition intervention.

28 Pa. Code 211.10 (c) Resident care policies

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

Plan of Correction - To be completed: 06/28/2024

1.With respect to the specific resident/situation cited:
R44 order for Boost Breeze was discontinued. Resident is a long-term comfort care.
R55 is discharged from the facility.

2.With respect to how the facility will identify residents/situations for the identified concerns:
A Director of Nursing or designee will ensure that orders are entered properly with instructions for percent consumption. Audit will be completed by 6/28/2024.

3.With respect to what systemic measures have been put into place to address the stated concern:

Administration or designee is providing training to nursing staff on properly entering orders for nutritional supplement and fortified foods, to ensure that the proper percentage of consumption is prompted and recorded.

Administration or designee is also providing CNAs training on proper documentation and recording of fortified foods consumption.

4.With respect to how the plan of correction will be monitored:

The Quality Assurance/Performance Improvement committee will review audit findings for thirty days, and monthly audit for two additional months. Audit will include proper entry of orders for fortified foods and nutritional supplement, and the proper completion of percentage of consumption. At the conclusion of the three months, the QAPI committee will re-evaluate and initiate any necessary action for extend the review period.

5. Area cited in F 692 will be corrected by 6/28/2024.

483.35(a)(3)(4)(c) REQUIREMENT Competent Nursing Staff:

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

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

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

§483.35(c) Proficiency of nurse aides.
The facility must ensure that nurse aides are able to demonstrate competency in skills and techniques necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care.

Observations:

Based on the review of clinical records, facility documentation, observations, interview with staff, it was determined that the facility failed to ensure that nursing staff possessed the appropriate competencies and skill sets related to the care of residents with intravenous line and medication administration for two of two employee records reviewed. (Employee E14 and E15).

Findings Include:

Review of facility reported incident dated December 14, 2024, revealed that Resident R164 was involved in a medication error. Nurse accidentally administered Sertraline (Antidepressant) 100 milligrams (mg) tablet and Lisinopril (Blood Pressure medication) 10 mg. Resident's family requested evaluation from nurse practitioner in-house. They were not available and therefore resident was sent to the hospital for further evaluation.

Review of clinical record revealed that the medication was administered by Licensed nurse, Employee E15.

A request for medication administration competency prior to the medication error was requested to the Director of Nursing n May 21, 2024.

Facility did not provide evidence that Employee E15 had the competency of medication administration.

Review of physician order for Resident R38 on March 1, 2024, revealed a physician order for normal saline 0.9 % 2 liters intravenously for one time a day, first liter at 80 ml/hour and the second bag at 60 ml /hr.

Review of facility documentation revealed that on March 3, 2024, revealed that the nurse administered 8 normal saline flushes (one flush of 10 ml) a total of 80 ml within minutes. This medication was administered by Licensed nurse, Employee E14.

Interview with Director of Nursing on May 21, 2024, stated nurse should have administered intravenous fluid bag via intravenous set at a rate set by the physician.

A request for intravenous medication administration competency for Licensed nurse, Employee E14 was requested to the Director of Nursing on May 21, 2024.

Facility did not provide evidence that Licensed nurse, Employee E15 had the competency of intravenous medication administration.

28 Pa Code 211.10 (c) Resident care policies

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

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

Plan of Correction - To be completed: 06/28/2024

1.With respect to the specific resident/situation cited:

Attending physician was notified of medication errors for residents 164 and 38. Resident 164 was discharged from the facility. Resident 38 suffered no adverse outcome.
E14 and E15 are no longer employed at the facility.

2.With respect to how the facility will identify residents/situations for the identified concerns:

Director of Nursing or designee will audit all education files to identify nurses without IV training. Administrator will schedule IV training to be provided by contract pharmacy.

3.With respect to what systemic measures have been put into place to address the stated concern:

Education on Medication Administration will be completed with the nursing staff by the Director of Nursing Services by 6/28/2024 . Director of Nursing will conduct medication administration observation, including IV management, of three nurses per week for the first month and then biweekly for two months.

4.With respect to how the plan of correction will be monitored:

Over the next three months, the findings from the medication administration observations will be reviewed by the QAPI committee. At the conclusion of the three month period, the QAPI committee will re-evaluate and initiate At the conclusion of the three months, the QAPI committee will re-evaluate and initiate any necessary action or extend the review period if needed. The Administrator is responsible for ensuring implementation and ongoing compliance with the components of the Plan of Correction and addressing resolving variances that may occur.

5. Areas cited in F 726 will be corrected by 6/28/2024.

483.45(f)(2) REQUIREMENT Residents are Free of Significant Med Errors:

The facility must ensure that its-
§483.45(f)(2) Residents are free of any significant medication errors.

Observations:

Based on review of the clinical records, review of facility policies and interviews with staff, it was determined that the facility failed to ensure that a resident was free of significant medication error for two of five residents reviewed for medication administration (Resident R164 and Resident R167).

Findings include:

Review of facility reported incident dated December 14, 2024, revealed that Resident R164 was involved in a medication error. Nurse accidentally administered sertraline (Antidepressant) 100 mg tablet and lisinopril (Blood Pressure medication) 10 milligrams (mg). Resident's family requested evaluation from nurse practitioner in-house. They were not available and therefore resident was sent to the hospital for further evaluation.

Review of physician orders for Resident R164 on December 14, 2023, revealed that there was no physician orders for sertraline and lisinopril.

Interview with Director of Nursing on May 21, 2024, stated nurse did not follow appropriate practice of medication administration. The nurse who administered medication to Resident R64 was unable to provide a reason for administering wrong medication to Resident R164.

Review of physician order for Resident R167 on January 3, 2024, revealed a physician order for Carvedilol 6.25 mg tablet twice daily. Hold for systolic blood pressure less than 95 or heart rate less than 55.

Review of facility documentation revealed that on January 3, 2024, Resident R167 was given with blood pressure of 93/57. Further review of the documentation revealed that the medication was administered by Employee E14, Licensed Practical Nurse.

Review of physician order for Resident R38 on March 1, 2024, revealed a physician order for normal saline 0.9 % 2 liters intravenously for one time a day, first liter at 80 ml/hour and the second bag at 60 ml /hr.

Review of facility documentation revealed that on March 3, 2024, revealed that the nurse administered 8 normal saline flushes (one flush of 10 ml) a total of 80 ml within minutes. This medication was also administered by Employee E14.

Interview with Director of Nursing (DON) on May 21, 2024, at 11:00 a.m. DON stated Employee E14 made two significant medication error. DON stated the nurse should have administered intravenous fluid bag via intravenous set at a rate set by the physician.

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

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

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

Plan of Correction - To be completed: 06/28/2024

1.With respect to the specific resident/situation cited:

R164 has discharged from the facility. The attending physician for resident 38 was notified and no new orders were received. Resident suffered no adverse outcome.

2.With respect to how the facility will identify residents/situations for the identified concerns:

The Director of Nursing will conduct a medication administration record review of medication administered over the previous 30 days. Any issues identified will include reporting to the Medical Director and staff re-education.

3.With respect to what systemic measures have been put into place to address the stated concern:

Director of Nursing or designee will conduct medication administration observations of three nurses each week for one month and then biweekly for two more months to assess proper administration of medications.

4.With respect to how the plan of correction will be monitored:

The QAPI committee will review medication administration assessment for residents for three months to ensure that medications are being administered, per physician orders. At the conclusion of the three months, the QAPI committee will re-evaluate and initiate any necessary action or extend the review period if needed. The Administrator is responsible for ensuring implementation and ongoing compliance with the components of the Plan of Correction and addressing variances that may occur.

5. Area cited in F 760 will be corrected by 6/28/2024.

483.75(g)(1)(i)-(iii)(2)(i); 483.80(c) REQUIREMENT QAA Committee:

§483.75(g) Quality assessment and assurance.
§483.75(g) Quality assessment and assurance.
§483.75(g)(1) A facility must maintain a quality assessment and assurance committee consisting at a minimum of:
(i) The director of nursing services;
(ii) The Medical Director or his/her designee;
(iii) At least three other members of the facility's staff, at least one of who must be the administrator, owner, a board member or other individual in a leadership role; and
(iv) The infection preventionist.

§483.75(g)(2) The quality assessment and assurance committee reports to the facility's governing body, or designated person(s) functioning as a governing body regarding its activities, including implementation of the QAPI program required under paragraphs (a) through (e) of this section. The committee must:
(i) Meet at least quarterly and as needed to coordinate and evaluate activities under the QAPI program, such as identifying issues with respect to which quality assessment and assurance activities, including performance improvement projects required under the QAPI program, are necessary.

§483.80(c) Infection preventionist participation on quality assessment and assurance committee.
The individual designated as the IP, or at least one of the individuals if there is more than one IP, must be a member of the facility's quality assessment and assurance committee and report to the committee on the IPCP on a regular basis.

Observations:

Based on review of facility documents and staff interviews, it was determined that the facility failed to ensure that the Medical Director or designee was in attendance at monthly Quality Assurance Process Improvement (QAPI) Committee meetings for three of three months reviewed. (January 2024 through April 2024)

Findings include:

A review of QAPI Committee meeting sign-in sheets for the period of January 2024 through April 2024, revealed no documented evidence that the Medical Director or other physician was in attendance, virtually or in-person, at the QA meetings held from January 2024 through April 2024.

Interview with the administrator on May 22, 2024, at 12:00 PM confirmed that the facility documentation did not show evidence that the medical director was in attendance, virtually or in-person, at the QA meetings held from January 2024 through April 2024.

28 Pa. Code 211.2(d)(5)(6)(7)(8)(10) Medical director

28 Pa. Code 201.18 (e)(2)(3)(4) Management.

Plan of Correction - To be completed: 06/28/2024

1.With respect to the specific resident/situation cited:

The Quality Assurance/Performance Improvement meeting minutes for April 2024 were shared and discussed with Medical Director. Signatures were not obtained, as the medical director was not in attendance at the time of the meeting.

2.With respect to how the facility will identify residents/situations for the identified concerns:

The Medical Director was provided with the time and dates of the next three months of QAPI meetings. The Administrator provided re-education to the Medical Director of the requirement to attend a meeting on a quarterly basis. He confirmed receipt of the time and date of the June meeting and acknowledged that he will be in attendance.

3.With respect to what systemic measures have been put into place to address the stated concern:

Training was provided to administrator by Regional Director of Resident Care regarding QAPI requirements to maintain compliance with F 868. QAPI calendar invites were shared with QAPI team, including Medical Director Dr. Cahill, through the next three months.
4.With respect to how the plan of correction will be monitored:

The Quality Assurance/Performance Improvement committee will review QAPI meeting attendance sheets over the next three months to verify Medical Director attendance of a minimum of one meeting quarterly. At the conclusion of the three-month period, the QAPI committee will re-evaluate and initiate any necessary action or extend the review period if needed.

5. Area cited in F 868 will be corrected by 6/28/2024.

§ 211.12(f.1)(4) LICENSURE Nursing services. :

(4) Effective July 1, 2023, a minimum of 1 LPN per 25 residents during the day, 1 LPN per 30 residents during the evening, and 1 LPN per 40 residents overnight.

Observations:
Based on review of punch reports and staff interviews, it was determined that the facility failed to provide a minimum of one LPN (Licensed Practical Nurse) per 40 residents during the overnight shift on five of 21 days reviewed (March 10, 2024; March 13, 2024; December 25, 2023; December 27, 2023; and December 30, 2023).

Findings include:

Review of facility census data indicated that on March 10, 2024, the facility census was 61, which required 1.53 LPNs during the overnight shift. Review of facility punch reports revealed 1.01 LPNs provided care on the overnight shift on March 10, 2024.

Review of facility census data indicated that on March 13, 2024, the facility census was 57, which required 1.43 LPNs during the overnight shift. Review of facility punch reports revealed 1.10 LPNs provided care on the overnight shift on March 13, 2024.

Review of Facility census data indicated that on December 25, 2023, the facility census was 55, which required 1.38 LPNs during the overnight shift. Review of the facility punch reports revealed 1.38 LPNs provided care on the overnight shift on December 25, 2023.

Review of facility census data indicated that on December 27, 2023, the facility census was 55, which required 1.38 LPNs during the overnight shift. Review of facility punch reports revealed 1.38 LPNs provided care on the overnight shift on December 27, 2023.

Review of facility census data indicated that on December 30, 2023, the facility census was 55, which required 1.38 LPNs during the overnight shift. Review of the facility punch reports revealed 0.95 LPNs provided care on the overnight shift on December 30, 2023.

Documented electronic communications with the facility Administrator, on May 22, 2024, at 3:27 p.m. acknowledged the above-mentioned findings. Further documentation, including working schedules, punch reports, and assignment sheets were requested by surveyor on May 22, 2024, at 3:27 p.m.

Documented electronic communications with the facility Administrator, on Thursday, May 23, 2024, at 10:48 a.m. confirmed that the staffing grid, punch reports, working schedules, and assignment sheets for the dates mentioned above were requested by 1:00 p.m. on Thursday, May 24, 2024.

Further documented electronic communications with the facility administrator, conducted on Thursday, May 23, 2024, at 1:04 p.m. confirmed that the staffing ratios were not met on the above dates.

The facility failed to timely provide working schedules for the requested dates in March 2024 and December 2023 for verification of facility input.

Plan of Correction - To be completed: 06/28/2024

1.With respect to the specific resident/situation cited:
The regulation has been reviewed and recruitment is working towards meeting regulatory compliance.
2. With respect to how the facility will identify residents/situations for the identified concerns:
6/10/2024 Human Resources and recruiters reconciled the current positions with the job posting to ensure that the correct shifts will be filled to meeting staffing requirement. In addition, the scheduler was instructed to encourage current staff to pick up open positions.
Director of nursing and Administrator will review the candidates daily.
3.With respect to what systemic measures have been put into place to address the stated concern.
On 6/11/2024, administrator provided training to the Scheduling Coordinator to staff at the levels of the Licensed Practical Nurse staffing ratio. Once the hires have been on-boarded, they will beadded to the schedule to meet regulatory requirements.
4.With respect to how the plan of correction will be monitored.
Skilled Nursing administrator/designee monitors staffing ratio daily, and will address needs. In addition, Skilled Nursing Administrator will report the schedule and staffing ratio summaries to the monthly QAPI Committee for 3 months, the Committee will reevaluate and initiate necessary action or extend the review period.
The Administrator is responsible for confirming implementation and compliance of this POC and addressing and resolving variances that may occur.

§ 211.12(f.1)(5) LICENSURE Nursing services. :

(5) Effective July 1, 2023, a minimum of 1 RN per 250 residents during all shifts.

Observations:
Based on review of nursing time schedules, punch reports and staff interviews, it was determined that the facility administrative staff failed to provide a minimum of one RN (Registered Nurse) shifts on 3 of 21 days (March 15, 2024; March 16, 2024; and December 26, 2023).

Findings include:

Review of facility census data indicated that on March 15, 2024, the facility census was 55, which required 1.00 RNs during the overnight shift. Review of punch reports revealed 0.00 RN provided care on the overnight shift on March 15, 2024. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on March 16, 2024, the facility census was 58, which required 1.00 RNs during the overnight shift. Review of punch reports revealed 0.00 RN provided care on the overnight shift on March 16, 2024. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on December 26, 2024, the facility census was 55, which required 1.00 RNs during the overnight shift. Review of punch reports revealed 0.96 RN provided care on the overnight shift on December 26, 2024. No additional excess higher-level staff were available to compensate this deficiency.

Documented electronic communications with the facility Administrator, on May 22, 2024, at 3:27 p.m. acknowledged the above-mentioned findings. Further documentation, including working schedules, punch reports, and assignment sheets were requested by surveyor on May 22, 2024, at 3:27 p.m.

Documented electronic communications with the facility Administrator, on Thursday, May 23, 2024, at 10:48 a.m. confirmed that the staffing grid, punch reports, working schedules, and assignment sheets for the dates mentioned above were requested by 1:00 p.m. on Thursday, May 24, 2024.

Further documented electronic communications with the facility administrator, conducted on Thursday, May 23, 2024, at 1:04 p.m. confirmed that the staffing ratios were not met on the above dates.

The facility failed to timely provide working schedules for the requested dates in March 2024 and December 2023 for further verification of facility input.

Plan of Correction - To be completed: 06/28/2024

1.With respect to the specific resident/situation cited:
The regulation has been reviewed and recruitment is working towards meeting regulatory compliance.
2. With respect to how the facility will identify residents/situations for the identified concerns:
6/10/2024 Human Resources and recruiters reconciled the current positions with the job posting to ensure that the correct shifts will be filled to meeting staffing requirement. In addition, the scheduler was instructed to encourage current staff to pick up open positions.
Director of nursing and Administrator will review the candidates daily.

3.With respect to what systemic measures have been put into place to address the stated concern.
On 6/11/2024, the Administrator provided training to the Scheduling Coordinator to staff at the levels RN staffing ratio. Once the hires have been on-boarded, they will be added to theschedule to meet regulatory requirements.
4.With respect to how the plan of correction will be monitored.
Skilled Nursing administrator/designee monitors staffing ratio daily, and will address needs. In addition, Skilled Nursing Administrator will report the schedule and staffing ratio summaries to the monthly QAPI Committee for 3 months, the Committee will reevaluate and initiate necessary action or extend the review period.
The Administrator is responsible for confirming implementation and compliance of this POC and addressing and resolving variances that may occur.

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