Pennsylvania Department of Health
REFORMED PRESBYTERIAN HOME
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

REFORMED PRESBYTERIAN HOME
Inspection Results For:

There are 107 surveys for this facility. Please select a date to view the survey results.

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REFORMED PRESBYTERIAN HOME - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:

Based on a Medicare/Medicaid Recertification, State Licensure, and a Civil Rights Compliance Survey completed on August 14, 2024, it was determined that Reformed Presbyterian Home was not in compliance with the following requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care Facilities and the 28 Pa. Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.

Plan of Correction:

483.10(g)(14)(i)-(iv)(15) REQUIREMENT Notify of Changes (Injury/Decline/Room, etc.):

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

§483.10(g)(14) Notification of Changes.
(i) A facility must immediately inform the resident; consult with the resident's physician; and notify, consistent with his or her authority, the resident representative(s) when there is-
(A) An accident involving the resident which results in injury and has the potential for requiring physician intervention;
(B) A significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications);
(C) A need to alter treatment significantly (that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment); or
(D) A decision to transfer or discharge the resident from the facility as specified in §483.15(c)(1)(ii).
(ii) When making notification under paragraph (g)(14)(i) of this section, the facility must ensure that all pertinent information specified in §483.15(c)(2) is available and provided upon request to the physician.
(iii) The facility must also promptly notify the resident and the resident representative, if any, when there is-
(A) A change in room or roommate assignment as specified in §483.10(e)(6); or
(B) A change in resident rights under Federal or State law or regulations as specified in paragraph (e)(10) of this section.
(iv) The facility must record and periodically update the address (mailing and email) and phone number of the resident
representative(s).

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

Observations:

Based on review of clinical records and staff interview, it was determined that the facility failed to document notification of changes in one of three residents reviewed (Resident R36).

Findings include:

Review the clinical record revealed that Resident R36 was admitted to the facility on 6/9/23, and readmitted on 12/11/23.

Review of the Minimum Data Set (MDS- periodic assessment of care needs) dated 7/11/24, , included diagnosis of Diabetes Mellitus (condition that happens when your blood sugar is too high), and hypertension (condition where your pressure in your blood vessels is consistently elevated).

Review of Resident R36's clinical record indicated "check fingerstick glucose before dinner on Monday, Wednesday, and Friday please report if glucose >200".

Review of Resident R36's clinical record MAR (medication administration record for July 2024 and May 2024 showed the following dates with above >200 glucose:
July 8th and 17th.
May 1st, 17th, and 24th.

Additional review of the clinical records failed to show any report or notification of the higher than 200 glucose for Resident R36.

During an interview on 8/14/24 at 1:56 p.m. Registered Nurse Unit Manger Employee E6 confirmed that no report/notification was completed for Resident R36 glucose being higher than 200.

28 Pa. Code 201.14(a)Responsibility of licensee.
28 Pa. Code 201.18(b)(1)(3)Management.
28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.

Plan of Correction - To be completed: 09/27/2024

1) Nurses involved in R36 will be re-educated by Director of Nursing. Signatures on file with NHA

2) All nurses re-educated to policy and procedure for hypoglycemia/hyperglycemia. Education to be completed by Director of Nursing. Signatures on file with NHA

3) Policy and procedure reviewed related to monitoring glucose and response.

4) Director of Nursing will complete weekly audits of diabetic checks to review for compliance with communication/notification. Audits to continue until more than 6 weeks consec. 100% compliance. Audit results on file with NHA.

5) QAPI will track and trend audit results.

483.10(i)(1)-(7) REQUIREMENT Safe/Clean/Comfortable/Homelike Environment:

§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 81°F; and

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

Observations:

Based on review of facility policy, observations and staff interviews it was determined that the facility failed to provide a clean, safe, comfortable, and homelike environment for one of five resident rooms (Resident R55).

Findings include:

Review of the facility policy "Resident Rights", last reviewed 7/22/24, indicated a resident has the right to a safe, clean comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

During an observation on 8/12/24 at 10:00 a.m. The wall area behind residents R55's headboard was noted to have pieces of drywall missing, large gouges, and denting.

During an interview on 8/12/24, at 10:03 a.m. Licensed Practical Nurse Employee E3 confirmed the observation and stated that the facility has started to put protective sheets behind the headboards.

28 Pa Code: 201.18 (e)(1)(2) Management
28 Pa Code: 201.29 (a)(c)(d) Resident Rights

Plan of Correction - To be completed: 09/27/2024

1) R55 wall will be repaired. Work order to be provided to NHA upon completion.

2) All resident rooms will be inspected and prioritized for continue work to repair walls.

3) Re-education to Facility Management Director regarding preventative maintenance and ongoing maintenance of the resident environment.

4) Monthly environmental audits will be conducted by Facility Service Director and Assistant Administrator. Results to be reported to NHA and QAPI Team.

483.21(b)(1)(3) REQUIREMENT Develop/Implement Comprehensive Care Plan:

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

Observations:

Based on review of facility policies, clinical records, and staff interviews, it was determined that the facility failed to develop and implement comprehensive care plans to meet care needs for two of four residents (Resident R9 and R15).

Findings include:

A review of facility policy "Care Management" reviewed 7/22/24, indicated the care plan will be developed consistent with each resident's rights and to meet the residents medical, nursing, and mental and psychosocial needs identified in the comprehensive assessment.

Review of Resident R9's MDS (Minimum Data Set, periodic assessment of resident care needs) dated 7/25/24, indicates reentry to facility on 7/12/24, with the diagnosis of diagnoses of anemia (low iron in the blood) hypertension (high blood pressure) and Diabetes (high sugar in the blood)

Review of physician orders 7/23/24, Indicates FreeStyle Libre 3 reader device (continuous glucose system receiver) check residents blood sugar before meals and at bedtime.

Review of Resident R9's July 2024, medication administration record (MAR) indicates in use.

Review of Resident R9's care plan did not include interventions for the FreeStyle Libre 3 reader device.

During an interview on 8/14/24, Registered Nurse Employee (RN) Employee E5 confirmed the facility failed to develop a care plan to meet the resident R9's medical, nursing, and psychosocial needs.

Review of Resident R15's MDS dated 5/8/24, indicated reentry date of 4/9/24, with the diagnosis of hypertension (high blood pressure) end stage renal disease (last stage of kidney failure) and diabetes (high sugar in the blood)

Review of physician orders dated 6/5/24, indicate FreeStyle Libre 3 reader device before meals and at bedtime.

Review of Resident R15's June MAR indicates in use.

Review of Resident R15's care plan did not include interventions for the FreeStyle Libre 3 reader device.

During an interview on 8/14/24, at 1:15 pm RN Employee E5 confirmed the facility failed to develop a care plan to meet the resident R15's medical, nursing, mental and psychosocial needs.

28 Pa. Code 211.10(c)(d) Resident Care Policies
28 Pa. Code 211.12(d)(1)(2)(5) Nursing Services
28 Pa. Code: 201.29(i) Resident Rights
28 Pa. Code: 211.11 (a,c)(d) Resident care plan.

Plan of Correction - To be completed: 09/27/2024

1) R9 Care Plan was updated at discovery to include the use of FreeStyle Libre with the diabetic CarePlan.

2)R15 care plan updated and on file with EHR.

3) IDT (RNAC, Social Services, Charge Nurses and DON) will be re-educated to care plan needs for Free Style Libre system and Care Plan Management Policy and Procedure.

4) 15% of resident care plans will be reviewed monthly to ensure accuracy with care plan. Audits to be completed monthly until 95% compliance for 3 months consecutive.

5) Results of Auditing to tracked/trended with QAPI Committee

483.25(b)(1)(i)(ii) REQUIREMENT Treatment/Svcs to Prevent/Heal Pressure Ulcer:

§483.25(b) Skin Integrity
§483.25(b)(1) Pressure ulcers.
Based on the comprehensive assessment of a resident, the facility must ensure that-
(i) A resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable; and
(ii) A resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing.

Observations:

Based on review of facility policy, resident clinical records, and staff interviews, it was determined that the facility failed to accurately monitor and provide comprehensive assessments of a pressure area for one of three resident (Resident R17).

Findings include:

The facility "Wound management program" dated 3/25/24, indicated that the facility is committed to providing a comprehensive wound management program to minimize the development of pressure injuries. A visual skin assessment is completed by the nurse. Results are documented in the skin observation tool. When the nurse observes a wound, he or she will assess the wound and document the findings. The following may be documented such as skin issues, type, length, width, depth, and wound stage.

Review of Resident R17's admission record indicated she was admitted on 11/7/21, and readmitted on 7/11/23.

Review of Resident R17's MDS assessment (Minimum Data Set assessment: MDS -a periodic assessment of resident care needs) dated 4/26/24, indicated that she had diagnoses that included vascular dementia (a condition characterized by memory loss and progressive or persistent loss of intellectual functioning), hyperlipidemia (elevated lipid levels within the blood), obesity, compression fracture of the lumbar vertebrae, cellulitis (bacterial infection of the skin causing redness, aches, and swelling), and bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs). The record indicated the diagnoses were still current upon review.

Review of Resident R17's physician ordered dated 1/17/22, indicated to complete skin assessments weekly every Monday. Write a note or complete a skin sheet.

Review of Resident R17's care plan dated 5/2/24, indicated Resident R17 is at risk for signs of skin integrity impairment/pressure injury due to incontinence. Notify doctor as needed if wound worsened or does not respond to current treatment.

Review of Resident R17's physician ordered dated 8/13/24, indicated to cleanse Stage two wound. Hospice nurse to complete on Tuesdays and Thursdays. Facility nurse to complete on Saturdays and as needed.

Review of Resident R17's wound assessment, skin observation documents, and nurse progress notes did not include a wound assessment with measurements for the week of 7/4/24.

Review of Resident R17's wound assessment dated 7/9/24, indicated that Resident R17's pressure area was a Stage three wound measuring 4.00cm x 3.00 cm x 0.30cm. The assessment indicated the area to the coccyx began on 5/26/24.

Review of Resident R17's skin observation tool dated 7/17/24, indicated that Resident R17 had a Stage two wound to the coccyx area. The assessment tool did not include measurements of the area.

During an interview on 8/14/24, at 8:44 a.m. Registered Nurse (RN) Employee E2 stated: "Resident R17 still has a wound. All information and assessments should be in the miscellaneous section on the computer."

During an interview on 8/14/24, at 8:55 a.m. the Registered Nurse Assessment Coordinator (RNAC)/Infection Control Preventionist Employee E5 stated: "the wound team comes once a week. A wound nurse saw Resident R17 upon admission."

During an interview on 8/14/24, at 9:51 a.m. the Registered Nurse Assessment Coordinator (RNAC)/Infection Control Preventionist Employee E5 confirmed that the facility failed to accurately monitor and provide comprehensive assessments of a pressure area for Resident R17 as required.

28. Pa Code 201.18(b)(1)(e)(1) Management.
28 Pa. Code: 211.10(d) Resident care policies.
28. Pa. Code 211.12(d)(1)(5) Nursing services.

Plan of Correction - To be completed: 09/27/2024

1) R17 wound was assessed at the time of discovery by the facility staff. Review of all residents in the facility indicate weekly wound tracking

2) Wound team will assess and document/measure resident wounds weekly as outlined in the facility policy and procedure.

3) Weekly Monitor of residents with wounds will be conducted to ensure proper documentation. Tracking on file with NHA.

4) Wound team participants to be re-educated to measure/assess all resident wounds. Re-education to be provided by NHA and proof of education on file with NHA.

5) Audit results to QAPI team for monitoring.

483.25(i) REQUIREMENT Respiratory/Tracheostomy Care and Suctioning:

§ 483.25(i) Respiratory care, including tracheostomy care and tracheal suctioning.
The facility must ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals and preferences, and 483.65 of this subpart.

Observations:

Based on facility policy review, observations, and staff interviews, it was determined that the facility failed to maintain sanitary conditions of respiratory equipment for one of three residents(Resident R49).

Findings include:

A review of the facility policy "Respiratory Equipment" last reviewed on 7/22/24, indicates to prevent the administration of oxygen or medication through contaminated equipment. Nebulizer sets will be changed weekly or as needed. After treatments units will be rinsed with hot tap water and allowed to dry. Set will be stored in clean plastic bags between treatments. Nebulizer sets will be marked with Resident's name, the date and initials when changed.

A review of the admission record indicated Resident R49 was admitted to the facility on 7/6/23.

A review of R49's Minimum Data Set (MDS-periodic assessment of care needs) dated 7/6/24, included diagnoses of anemia (low iron in the blood), chronic obstructive pulmonary disease (COPD-makes it hard to breathe), and chronic kidney disease (gradual loss of kidney function).

A review of Resident R49's physician orders dated 7/19/23, indicate DuoNeb Solution 0.5-2.5 MG/3ML (Ipratropium-Albuterol) 1 dose inhale orally every 6 hours as needed for wheezing.

During an observation on 8/12/24 at 9:42 a.m. resident R49 was in her bed, a nebulizer was noted to be sitting on top of dresser not bagged and failed to be labeled with resident ' s name and date.

During an interview 8/12/24 at 10:21 a.m. Registered Nurse (RN) Employee E2 E confirmed that Resident R49's nebulizer was not bagged and failed to be labeled with resident ' s name and date.

28 Pa. Code: 211.10(c)(d) Resident care policies.
28 Pa. Code: 211.12(d)(1)(2)(3)(5) Nursing services.

Plan of Correction - To be completed: 09/27/2024

1) Equipment was replaced per policy for R49 at the time of discovery.

2) Weekly environmental audits of oxygen/nebulizer equipment will be audited weekly by Nursing Administration. Audits to be on file with NHA. Audits to continue weekly until 100% accuracy X 4 weeks consec.

3) Policy and Procedure to be reviewed.

4) All nurses to be educated to the policy and procedure. Education to be provided by DON. Proof of educations (signatures) on file with NHA.

5) QAPI to be notified of audits and compliance.

483.25(l) REQUIREMENT Dialysis:

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

Observations:

Based on review of resident clinical records, facility policy and staff interview, it was determined the facility failed to provide consistent and complete communication with the dialysis (treatment that helps body remove extra fluid and waste products) center for one of one resident receiving hemodialysis (Resident R15).

Findings include:

A review of the facility policy "Dialysis Services" dated 7/22/24, indicated to ensure that residents who require dialysis receives such service, consist with professional standards of practice, the comprehensive person-centered care plan and the resident's goals and preferences. Communication between the dialysis staff and nursing staff provide continuity of care will be ongoing via dialysis assessment binder.

A review of Resident R15's MDS dated 5/8/24, indicated reentry date of 4/9/24, with the diagnosis of hypertension (high blood pressure) end stage renal disease (last stage of kidney failure) and diabetes (high sugar in the blood)

A review of Resident R15's physician orders last revised on 8/3/24, indicate dialysis Tuesdays, Thursdays, and Saturdays.

A review of Resident R15's nursing progress notes indicated attendance to dialysis sessions.

A review of Resident R15's dialysis communication binder indicated dialysis sheets completed on 7/20/24, 7/25/24, 7/30/24, 8/8/24, and 8/10/24 were incomplete, the section for the dialysis unit is blank. No dialysis sheets were found for the following days 7/23/24, 7/27/24, and 8/6/24.

During an interview on 8/12/24, at 10:29 a.m. Licensed Practical Nurse (LPN) Employee E3 indicated a dialysis assessment binder is a binder that holds a dialysis communication form. The form is to be completed by facility and sent with the resident to the dialysis center, the dialysis center is to complete their portion of the form and return in binder to facility. LPN Employee E3 confirmed the dialysis communication forms were incomplete as the dialysis center had not completed their portion and some days were missing.

28 Pa. Code: Clinical records.
28 Pa. Code: Management.
28 Pa. Code: Resident care policies.
28 Pa. Code: Nursing services.

Plan of Correction - To be completed: 09/27/2024

1) No form for 7/30/24 as resident OTH. Unable to correct forms from the past for resident.

2) DON will provide education to Dialysis Center to request communication via the Dialysis Communication Book sent with the resident. DON will provide summary of education.

3) Resident will be educated to request Dialysis center to complete communication form at appointments.

4) Nurses will be re-educated to policy and procedure and to monitor dialysis communication compliance.

5) No other residents to audit at this time - as no other resident receiving dialysis.

6) DON will audit communication book weekly to audit for compliance with communication. Results to be provided to NHA. Audits to continue until 100% compliance X 3 months consec.

7) Results on file with QAPI Committee

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 §483.71.

§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 manufacturer's instructions, clinical record review, and staff interview it was determined that the facility failed to ensure that nursing staff have the specific competencies and skill sets necessary to provide care for a resident with a Free Style Libre 3 system (a new way for people with diabetes to check their sugar levels, without a finger stick test, using a sensor that can read changes in the liquid just underneath the skin) for two of two residents (Resident R9 and R15)

Findings include:

Review of the "FreeStyle Libre 3 continuous glucose monitoring system" updated 5/2023, indicated the following:
. What to know before using the system.
. Who should not use the system.
. What you should know about wearing a sensor.
. How to store the sensor kit.
. How to store the unit.
. When not to use the system.
. What to know about the system.
. What to know before applying the sensor.
. When is sensor glucose different from blood glucose.
. What to know about x rays.
. When to remove the sensor.
. What to know about the reader.
. What to know about charging your reader.
. Interfering substances.

Review of Resident R9's MDS (Minimum Data Set, periodic assessment of resident care needs) dated 7/25/24, indicates reentry to facility on 7/12/24, with the diagnosis of diagnoses of anemia (low iron in the blood) hypertension (high blood pressure) and Diabetes (high sugar in the blood)

Review of Resident R9's physician orders dated 7/23/24, Indicates FreeStyle Libre 3 reader device (continuous glucose system receiver) check residents blood sugar before meals and at bedtime.

Review of Resident R9's July 2024, medication administration record (MAR) indicates in use.

Review of Resident R15's MDS dated 5/8/24, indicated reentry date of 4/9/24, with the diagnosis of hypertension (high blood pressure) end stage renal disease (last stage of kidney failure) and diabetes (high sugar in the blood)

Review of Resident R15's physician orders dated 6/5/24, indicate FreeStyle Libre 3 reader device before meals and at bedtime.

Review of Resident R15's June MAR indicates in use.

During an interview on 8/14/24, at 11:05 a.m. Registered Nurse (RN) Employee E E2 stated " I know absolutely nothing about the system, a packet comes with the machine, I did educate myself, I have read the instructions, I received no facility in-servicing concerning the system".

During an interview on 8/14/24, at 11:33 a.m. Licensed Practical Nurse LPN E3 stated "I received no in-service here, I am familiar with the system as I have used them before in different facilities".

During an interview 8/14/24, at 11:53 a.m. RN Unit Manager Employee E6 stated "no staff in -servicing has been completed concerning the use of the FreeStyle Libre system, we missed the in-service piece, and confirmed the facility failed to ensure that nursing staff have the specific competencies and skill sets necessary to provide care for a resident with a Free Style Libre 3 system.

28 Pa. Code 201.14(a) Responsibility of licensee
28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Plan of Correction - To be completed: 09/27/2024

1) E6, E3, E2 will be educated to the use of the Libre system. Education to be provided by Director of Nursing. Signatures of education on file with NHA.

2) All nurses will be educated by DON to the use of the Libre System - proof of education (signatures) on file with NHA.

3) Policy and Procedure to be reviewed and updated as appropriate. To be approved by the QAPI Committee

4) QAPI Committee to monitor needs for education/training related to new equipment/tools. Review quarterly by QAPI team. This will be ongoing.

5) Observations of nurses completing the Libre System will be conducted. Results of observations on file with NHA. Observations completed by DON or Pharmacy. 5 Medication observations will continue monthly until 100% compliance demonstrated.

483.35(d)(7) REQUIREMENT Nurse Aide Peform Review-12 hr/yr In-Service:

§483.35(d)(7) Regular in-service education.
The facility must complete a performance review of every nurse aide at least once every 12 months, and must provide regular in-service education based on the outcome of these reviews. In-service training must comply with the requirements of §483.95(g).

Observations:

Based on review of facility policy, personnel records and staff interview it was determined that the facility failed to complete annual performance evaluations for two of five nurse aide personnel records (Nurse aide Employee E8 and Nurse aide Employee E9).

Findings include:

The facility "Certified nursing assistant" position description last reviewed 7/22/24, indicated that the performance expectations are that the incumbent must be able to demonstrate the knowledge and skills necessary to provide care. Each employee is to be evaluated based on the standards set forth in the position description.

Review of Nurse aide (NA) Employee E8's personnel record indicated she was hired to the facility on 2/4/19. The record indicated that the position description and the employee handbook were both signed on 2/4/19.

Review of Nurse aide (NA) Employee E8's performance evaluation for the evaluation period of 3/14/23 to 1/26/24, did not indicate a review with the employee and was observed without a review date.

Review of Nurse aide (NA) Employee E9's personnel record indicated she was hired to the facility on 1/13/20. The record indicated that the position description and the employee handbook were both signed on 1/13/20.

Review of Nurse aide (NA) Employee E9's performance evaluation for the evaluation period of 7/12/23 to 7/24/24 did not indicate a review with the employee and was observed without a review date.

During an interview on 8/13/24, at 12:48 p.m. the Director of human resources Employee E10 confirmed that the facility failed to complete annual performance evaluations for Nurse aide (NA) Employee E8 and Nurse aide (NA) Employee E9 as required.

28 Pa Code: 201.20 (a)(b)(c)(d) Staff development.

Plan of Correction - To be completed: 09/27/2024

1) E8 performance evaluation will be completed and reviewed with Employee. Completed evaluation on file with NHA.

2) E9 performance evaluation which was completed prior to the outlined date was reviewed with the employee upon return to work. Evaluation on file with NHA.

3) DON re-educated to performance evaluation, annual completion. Education provided by NHA. Signature of education on file with NHA.

4. HR will audit performance evaluation monthly to monitor for compliance with timely and complete performance evaluation. Audit results on file with NHA. Audits will continue until 4 months of 100% compliance

5) QAPI will receive audit results and track results.

483.40(b)(1) REQUIREMENT Treatment/Srvcs Mental/Psychoscial Concerns:

§483.40(b) Based on the comprehensive assessment of a resident, the facility must ensure that-
§483.40(b)(1)
A resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder, receives appropriate treatment and services to correct the assessed problem or to attain the highest practicable mental and psychosocial well-being;

Observations:

Based on review of clinical records, and staff interview it was determined that the facility failed to make certain residents receive appropriate treatment and services for highest practicable mental and psychosocial services for one of three residents (Resident R28).

Findings include:

Review of facility policy dated 7/11/24, "Behavioral Health Services, Trauma Informed Care" indicated: It is the goal of the facility to provide necessary behavioral health care and services to attain or maintain the highest practicable physical, mental and psychosocial well-being.

Review of Resident R28's indicated was originally admitted on 8/24/23, and readmitted on 6/11/24.

Review of the MDS (minimum data set - a periodic assessment of resident needs) dated 4/30/24, with the following diagnosis adjustment disorder with depression (mental condition triggered by a serious event).

Review of Resident R28's clinical record indicated the following:

7/4/24: nurses notes : alerted by Resident R28's roommate that resident demonstrating behaviors such as coming into roommates space being exposed.
7/14/24: nurses note: Resident R37 Reported to nurse that Resident R28 exposed himself.

Review of the clinical record for Resident R28 failed to include documentation/referral for psych services between 7/4/24 and 7/14/24.

During an interview on 8/14/24, at 10:38 a.m. Social service Employee E11 confirmed that the facility had an allegation of Resident R28 acting out sexually on 7/4/24 and again on 7/14/24. Social Service Employee 11 confirmed that psych services were not provided between the first incident on 7/4/24 and 7/14/24, and the facility failed to help Resident R28 receive appropriate treatment and services for highest practicable mental and psychosocial services.

28 Pa. Code 201.18(b)(1)Management.
28 Pa. Code 211.12(d)(3)(5)Nursing services.

Plan of Correction - To be completed: 09/27/2024

1) Incident noted on 7/4/24 was unsubstantiated for R28. R28 was referred to psy services when incident on 7/14/28 occurred. Note on file of R28 file.

2) Nursing Administration will continue to monitor for incidents/accidents daily in clinical meeting and address as needed. Daily review on file with NHA.

3) Nursing Administration will continue with monitor behaviors at monthly Resident Medication Behavior Management Meeting. Signatures of attendance on file- Notes in appropriate resident EHR. This occurs monthly.

4) QAPI committee will receive incident/accident tracking quarterly.

5) All staff will be educated to reporting behaviors and interventions in response. Education to be completed by DON or NHA. Signature on file with NHA.

483.45(g)(h)(1)(2) REQUIREMENT Label/Store Drugs and Biologicals:

§483.45(g) Labeling of Drugs and Biologicals
Drugs and biologicals used in the facility must be labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable.

§483.45(h) Storage of Drugs and Biologicals

§483.45(h)(1) In accordance with State and Federal laws, the facility must store all drugs and biologicals in locked compartments under proper temperature controls, and permit only authorized personnel to have access to the keys.

§483.45(h)(2) The facility must provide separately locked, permanently affixed compartments for storage of controlled drugs listed in Schedule II of the Comprehensive Drug Abuse Prevention and Control Act of 1976 and other drugs subject to abuse, except when the facility uses single unit package drug distribution systems in which the quantity stored is minimal and a missing dose can be readily detected.

Observations:

Based on review of facility policies, observations, and staff interviews it was determined that the facility failed to properly store medical supplies and biologicals in one of one medication rooms (third floor medication room) and one of three medication carts (yellow medication cart), properly secure medications in one of three medication carts (green hall medication cart) and failed to date open medications.

Findings include:

Review of the facility policy "Medication Distribution System" dated 7/22/24, indicate medications and biologicals are stored safely, securely, and properly. Orally administered medications are kept separate from medication administered by other routes. The facility's medication room is used to ensure an effective medication distribution by availability of a "medication only refrigerator" limiting access to only authorized personnel, kept clean, well-lit, and free of clutter.

During an observation on 8/12/24, at 12:25 p.m. Licensed Practical Nurse (LPN) Employee E3 was completing a medication pass for Resident R261. LPN Employee E3 administered medications for Resident R261, after using the artificial tears eye drops, LPN Employee E3 placed the eye drops back in box and placed on top of the medication cart and returned to the room to inquire about medication and any further needs. The medication cart was placed across the hall from Resident R261 's room and the medication was left unattended.

During an interview on 8/12/24, at 12:40 p.m. LPN Employee E3 confirmed the medication for Resident R261 (Artificial Tears eye drops) was left unattended and not properly secured on top of the medication cart accessible to anyone passing by in the hallway.

During a review of Resident R15's MDS dated 5/8/24, indicated reentry date of 4/9/24, with the diagnosis of hypertension (high blood pressure) end stage renal disease (last stage of kidney failure) and diabetes (high sugar in the blood)

During a review of physician orders dated 8/5/24, indicate Stiolto Respimat inhalation aerosol 2.5-2.5 mcg/act two puffs inhaled on time a day.

During an observation on 8/12/24, 10:00 a.m. a Stiolto inhaler was placed on Resident R15's bedside table. Resident R15 stated "they left it here".

During an interview 08/12/24, 10:03 a.m. with LPN Employee E3 confirmed Resident R15's Stiolto inhaler was in the room, should not have been left, removed it and stated, "I was looking for that."

During an observation on 8/12/24 at 9:25 a.m. a opened bottle of saline solution was noted on Resident R52's night stand.

During an interview on 8/12/24 at 10:19 a.m. Registered Nurse Employee E2 confirmed the saline solution should not have been on resident R52's night stand and removed it.

During an observation 8/13/24, 8:52 a.m. the yellow hall medication cart top drawer contained an unlabeled open tube of diclofenac sodium (topical medication for joint pain).

During an interview 8/13/24, at 8:52 a.m. LPN Employee E4 confirmed the unlabeled open tube of diclofenac sodium in the top drawer of the medication cart did not belong in the medication cart and removed it.

Observation on 8/13/24, at 8:53 a.m. the third-floor medication room refrigerator contained one vial of tuberculin solution noted to be opened and without a date. The freezer contained a container of chocolate ice cream. The chair in the medication room had a large leopard print tote bag on it. The medication room shelf contained:
. One black thermos
. One grey travel cup
. One green travel cup
. One opened can of Celsius sparkling drink, with a cup on top of it.

During an interview on 8/13/24, at 8:55 a.m. LPN Employee E4 confirmed the tuberculin solution did not have a date opened, ice cream was in the freezer, and employee personal items were stored in the medication room.

28 Pa. Code: 211.9(a)(1)(k) Pharmacy services.
28 Pa. Code: 211.10(c) Resident care policies.
28 Pa. Code 211.12(d)(1)(5) Nursing services.

Plan of Correction - To be completed: 09/27/2024

1) Employee E3 to be re-educated by Director of Nursing to medication storage policy and procedure. Signature sheet on file with NHA.

2) All nurses will be re-educated to medication storage policy and procedure. Education provided by DON. Signatures on file with NHA.

3) Audits of Medication Storage Room and Medication pass to be completed by pharmacy on monthly basis. Results on file with NHA and QAPI Committee.

4) Weekly environmental rounds to be completed by NSG Administration to audit medication room, resident bedside and medication charts to ensure compliance with medication storage. Audits to be completed until 95% compliance for 3 months consecutive. Audits on file with NHA.

5) Audits to be provided to QAPI Committee

6) Items removed for R15 and R52 room at the time of the inspection.

7) Employee removed diclofenac sodium at the time of inspection and stored properly.

8) The medication room was cleaned, items removed and medication items dated following discovery.

9) Whole house audits of resident rooms, Medication Rooms including storage (fridge, etc) and audit of medications for dates to be completed by DOH. Audit results on file with NHA.

483.80(a)(1)(2)(4)(e)(f) REQUIREMENT Infection Prevention & Control:

§483.80 Infection Control
The facility must establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections.

§483.80(a) Infection prevention and control program.
The facility must establish an infection prevention and control program (IPCP) that must include, at a minimum, the following elements:

§483.80(a)(1) A system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon the facility assessment conducted according to §483.71 and following accepted national standards;

§483.80(a)(2) Written standards, policies, and procedures for the program, which must include, but are not limited to:
(i) A system of surveillance designed to identify possible communicable diseases or
infections before they can spread to other persons in the facility;
(ii) When and to whom possible incidents of communicable disease or infections should be reported;
(iii) Standard and transmission-based precautions to be followed to prevent spread of infections;
(iv)When and how isolation should be used for a resident; including but not limited to:
(A) The type and duration of the isolation, depending upon the infectious agent or organism involved, and
(B) A requirement that the isolation should be the least restrictive possible for the resident under the circumstances.
(v) The circumstances under which the facility must prohibit employees with a communicable disease or infected skin lesions from direct contact with residents or their food, if direct contact will transmit the disease; and
(vi)The hand hygiene procedures to be followed by staff involved in direct resident contact.

§483.80(a)(4) A system for recording incidents identified under the facility's IPCP and the corrective actions taken by the facility.

§483.80(e) Linens.
Personnel must handle, store, process, and transport linens so as to prevent the spread of infection.

§483.80(f) Annual review.
The facility will conduct an annual review of its IPCP and update their program, as necessary.

Observations:

Based on review of facility policy, observations, and staff interviews, it was determined that the facility failed to implement infection control practices to prevent cross contamination during a dressing change for one of three residents (Resident R17) and failed to implement infection control practices during administration of eye drops on one of three residents. (Resident R261)

Findings include:

A review of the facility policy "Dressing Change, Clean Technique", last reviewed 7/22/24 indicates to prevent contamination of wounds such as pressure ulcers procedure includes but not limit to:
. Remove the soiled dressing, place in trash bags.
. Remove your gloves, wash your hands, and apply new gloves.
. Clean the wound with normal saline solution or prescribed cleanser.
. Use a dry 4x4 to pat the tissue surrounding the wound dry.
. Remove your gloves, wash your hands, and apply new gloves.

Review of the facility policy "Medication Administration and Charting Guidelines", last reviewed 7/22/24, indicate ophthalmic (eye) drops administration procedure:
. Wash hands, apply clean gloves.

A review of the facility procedure "Hand Hygiene" last reviewed 7/22/24 indicates to prevent the transmission of infectious disease, therefore, all personnel working in the facility are required to wash their hands before and after resident contact, before and after performing any procedure, after sneezing or blowing their nose, after using the bathroom, before handling food, and when hands become visibly soiled.

Review of the admission record indicated Resident R17 was admitted to the facility on 7/11/23.

Review of R17's Minimum Data Set (MDS-periodic assessment of care needs) dated 4/26/24, included diagnoses of anemia (the blood doesn't have enough healthy red blood cells), hypertension (high blood pressure), and hyperlipidemia (high fats in the blood)

Review of Resident 17's physician order dated 7/13/24 indicates cleanse coccyx with wound cleanser, blot dry, cover with Opti-foam dressing daily.

Observation of Resident R17's dressing change on 8/13/24 at 12:56 p.m. Registered Nurse (RN) Employee E7 failed to complete hand hygiene. After cleansing wound, RN Employee E7 continued the pat the wound dry and apply the opti-foam dressing.

During an interview on 8/13/24, at 1:37 p.m. RN Employee E7 confirmed she failed to implement infection control practices to prevent cross contamination during a dressing change for Resident R17 by not completing hand hygiene after cleansing and patting the wound dry.

During an observation on 8/12/24, at 12:25 p.m. Licensed Practical Nurse (LPN) Employee E3 was completing a medication pass. LPN Employee E3 took Resident R261's Artificial tears (for dry eyes) into room with oral medications, after administering oral medications LPN Employee E3 proceeded to instill the eye drops without utilizing gloves.

During an interview on 8/12/24, at 12:40 p.m. LPN Employee E3 confirmed the failure to implement infection control practices during administration of eye drops.

28 Pa. code: 201.14 (a) Responsibility of licensee.
28 Pa. Code: 201.18 (b) (1) (e) (1) Management.
28 Pa. Code: 211.10 (d) Resident care policies.
28 Pa. Code: 211.12 (d) (1) (2) (5) Nursing services.

Plan of Correction - To be completed: 09/27/2024

1) Nurse involved in dressing change will be re-educated to policy and procedure. Including a competency observation to be completed by Director of Nursing. Signature and observation on file with NHA.

2) All nurses will receive re-education on Policy and Procedure for dressing change. Signatures on file with NHA. Education provided by DON or Wound Care Consultant.

3) Observations of dressing change to be completed 5 times each month until 100% compliance for 3 consecutive months. Audits on file with NHA.

4) E3 will be re-educated to policy and procedure for eye drop administration. Education to be provided by DON. Signature of education on file with NHA.

5) All nurses will be re-educated to policy and procedure for eye drop administration by DON and signatures on file with NHA.

6) 3-5 Medication Administration Observations to be completed monthly by DON/Charge Nurse or Pharmacy. Audit results on file with NHA. To continue until 100% compliance X 3 months.

7) Audit results reported to QAPI for quarterly review.

§ 201.14(a) LICENSURE Responsibility of licensee.:

(a) The licensee is responsible for meeting the minimum standards for the operation of a facility as set forth by the Department and by other Federal, State and local agencies responsible for the health and welfare of residents. This includes complying with all applicable Federal and State laws, and rules, regulations and orders issued by the Department and other Federal, State or local agencies.

Observations:

Based on state regulations, staff interview, and review of the facility's Infection Control Committee Meeting attendance records, it was determined that the facility failed to ensure all of the required nine multidisciplinary members were present at the Infection Control meetings (a community member).

Findings include:

Review of Act 52 (The Act of March 20, 2002, P.L. 154, No. 13), known as the Medical Care Availability and Reduction of Error (MCARE) Act, Chapter 4, Section 403(1) Infection Control plan states, "A health care facility... shall develop and implement an internal infection control plan that shall include... a multidisciplinary committee including representatives from each of the following if applicable to that specific health care facility." A review of the applicable members at infection control meetings includes medical staff, administration, laboratory personnel, nursing staff, pharmacy staff, physical plan personnel, patient safety officer, a community member, and a member of the infection control team.

Review of the facility's Infection Control (IC) Committee Meeting attendance log forms dated January 23,2024 and July 30,2024, failed to reveal that a community member was in attendance.

During an interview on 8/13/24, the Infection Preventionist Employee E5 stated " I do not know anything about the meetings or community member.

During an interview on 8/14/24, at 9:40 am Assistant Nursing Home Administrator Employee E1 confirmed that there was not a community member for the Infection Control meetings held on January 23, 2024, and July 30, 2024.

Plan of Correction - To be completed: 09/27/2024

1) Infection Control Committee Policy and Procedure will be reviewed.

2) Infection Control Committee Meeting is scheduled for July 29, 2024, and will have community Member present for the meeting.

3) QAPI committee will monitor participation of required committee members to ensure 100% compliance.

§ 211.12(f.1)(2) LICENSURE Nursing services. :

(2) Effective July 1, 2023, a minimum of 1 nurse aide per 12 residents during the day, 1 nurse aide per 12 residents during the evening, and 1 nurse aide per 20 residents overnight.

Observations:

Based on review of 3 week nursing schedule, and staff interview it was determined that the facility failed to provide a minimum of one nurse aide per 12 residents during the daylight shift for two out of 21 days (7/6/24 and 7/7/24) and failed to provide one nurse aide for one evening shift (7/2/24) and failed to provide one nurse aide for three night shift (7/1/24, 7/5/24, and 7/27/24).

Findings include:

Review of a 3 week nurse schedule documents (7/1/24 to 7/7/24 and 7/22/24 to 7/28/24).
- The facility did not have sufficient staff nurse aides for the daylight shift on 7/6/24 ( 4 nurse aides for 55 residents).
- The facility did not have sufficient staff nurse aides for the daylight shift on 7/7/24 ( 4 nurse aides for 55 residents).
- The facility did not have sufficient staff nurse aides for evening shift on 7/2/24 ( 4 nurse aides for 55 residents).
- The facility did not have sufficient staff nurse aides for night shift on 7/1/24, 7/5/24, and 7/27/24 ( 3 nurse aides for 55 residents, 2 nurse aides for 55 residents, and 2 nurse aids for 56 residents).

During an interview on 8/14/24, at 2:26 p.m. the assistant Nursing Home Administrator confirmed that the facility failed to provide a minimum of one nurse aide per 12 residents during a daylight shift and failed to provide one nurse aide per 12 residents during the evening shift and one nurse per 20 residents during the night shift.

Plan of Correction - To be completed: 09/27/2024

1) The nursing scheduled will continue to be planned to meet staffing regulations stated.

2) Daily staffing sheets will be audited in advance to adjust for last minute changes.

3) Re-education to the staffing policy and procedure. (DON, Staffing Coordinator, Charge Nurses) provided by NHA. Signatures on file with NHA.

4) Daily tracking to be completed to monitor for compliance with stated staffing regulations.

5) Audits to be reported to QAPI Committee.

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