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

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

MEADOWVIEW REHABILITATION AND NURSING CENTER
Inspection Results For:

There are 222 surveys for this facility. Please select a date to view the survey results.

Surveys don't appear on this website until at least 41 days have elapsed since the exit date of the survey.


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

Initial comments:
Based on a Medicare/Medicaid Recertification survey, State Licensure survey, Civil Rights Compliance survey and an Abbreviated survey in response to one complaint completed June 10, 2024, it was determined that Meadowview Rehabilitation and Nursing Center was not in compliance with the following requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care and the 28 Pa. Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations as they relate to the Health portion of the survey.

Plan of Correction:

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

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

�483.10(i) Safe Environment.
The resident has a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

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

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

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

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

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

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

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

Observations:

Based on observations, and resident and staff interviews, it was determined that the facility failed to maintain a safe, clean, homelike environment on three of five nursing units(A, B, E Nursing Units) E unit shower room.

Findings include:

Facility Policy titled Bathroom Cleaning" unknown date, indicated "under option 5 "clean and sanitize toilet (including raised toiled seats) using infectable cleaner."

Facility Policy titled "Resident's Room Cleaning" unknown date, indicated "to provide a detailed description of the steps that are to be completed daily in the cleaning of a resident room. Daily cleaning will ensure optimum levels of cleanliness and sanitation, prohibit the spread of infections and bacteria, and maintain the outward appearance of the facility.

Observation of facility B nurisng unit on June 5, 2024, 10:22 a.m. revealed the following observations,
In room B 101 there was CPAP (a respiratory equipment) tubing on the floor.

In room B 106 there was dried brown substance on the floor, it appeared like dried tube feeding which was hanging right above. Interview with Employee E28, Housekeeper stated the substance was dried tube feeding at it was there from 6/4/24. She stated it was hard for her to remove when she cleaned the area on 6/4/24. Interview with Housekeeping Director, Employee E25, stated the substance could be removed using chemical and he would remove it right away.

Observation of room B 118 revealed there was strong odor appeared like urine inside the room and at the doorway next to the room. Observation made inside the room revealed that there were no sheets on the bed. There was linen, tissue, and food particles on the floor.

Observation of room B 113 revealed that there were two oxygen concentrators inside the room one undated and one dated March 2024 next to the window side, food particles, paper towel on the floor, dirty cloths on the chair and open hamper with lid on the chair.

On June 5, 2024, at 10:45 an interview was held with Resident R202 who reported that her toilet had yellow brown stains inside the toilet, and it has not been cleaned up since her admission. The shower room "is like a storage with briefs and other equipment, briefs are stored in moist environment".

On June 5, 2024, at approximately 10:59 a.m. observation was taken place with license unit manager, Employee E3 confirmed the following observations in shower room on the E unit indicated 3 shower stalls. The shower stalls and shower room were used as storage and only one stall was available for shower use .The second stall was packed with 2 resident's trays, unknown random resident's clothing was stacked up, extra wheelchair rests on the floor, and 3 compartments laundry bins, the third stall had a Hoyer lift with wheelchair rest observed on the grown and extra shower chairs. Next to the sink there was approximately 20 boxes of different size briefs stacked up on the floor exposed to shower steam. Then it had shelf with additional brief that were open and unprotected from the showers steam. The shower sink had two shower chairs which was blocking the entrance to the sink. Sink also had extra hygiene body washes stored on the top of the sink.

On June 5, 2024, at 12:07 interview with Resident R524 revealed that she did not have a chair in her room to sit. Also, there was a need of a crab bar inside her bathroom on the wall when she transitions from wheelchair to the toilet that she would have stability and safety.

On June 5, 2024, at 12:16 p.m. interview with Resident R 212 revealed that his toilet was stained with yellow, orange and brown drains, the bathroom sealing had cracks, and bathroom light was flickering.

On June 5, 2024, at 12:34 p.m. a regional maintenance director, Employee E6 with Housekeeping Director, Employee E25 confirmed the stained toiles and reported the stains are from a water what does not have a softer and used a rock cleaning supply to brush and removed the toilet stain. The following rooms were identified to have the same issue of yellow, orange and brown stains in the toilet: room 519. 520, 513, 511, 510, 504.

28 Pa. Code: 201.29(j)(k) Resident rights.

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

Plan of Correction - To be completed: 07/26/2024

F584 Safe/clean/comfortable/homelike environment
This Provider submits the following plan of correction is good faith and to comply with Federal regulations. This plan is not admission of wrongdoing nor does it reflect agreement with the facts and conclusions stated in the statement of deficiencies
The CPAP tubing in B101 was replaced
The dried brown substance on the floor in B 106 was cleaned.
Housekeeping cleaned room B118 removing food particles and paper towel on the floor. The mattress on the bed was also sanitized
Room B113 the oxygen concentrators were dated appropriately. The floor in B113 was cleaned removing the food particles and paper towels. The dirty cloths were removed and the open hamper with lid on the chair was removed.
R202's toilet has been cleaned.
The briefs and other equipment were all removed from the shower room
R524 was provided with a chair and grab bars inside her bathroom.
R212's toilet was cleaned, the bathroom ceiling was repaired and the bathroom light was repaired.
Room 519, 520, 513, 511, 510, 504 toilets were cleaned

An audit was done by the housekeeping supervisor to ensure resident rooms/toilets were clean and any repairs that were needed in the room was completed.
An audit of shower rooms was done by the housekeeping supervisor to ensure nothing is being stored in the shower rooms on each unit.

Housekeeping staff were educated by the housekeeping director on proper cleaning of resident rooms as well as cleaning the toilets in the resident rooms.

The housekeeping director/designee will do random audits of 5 resident rooms per unit and shower rooms on each unit to ensure cleanliness of the room.
Audits will be done weekly x 4 weeks then monthly x 2 months. Results of these audits will be submitted to quality assurance committee to determine if further action is needed.

483.80(a)(3) REQUIREMENT Antibiotic Stewardship Program:

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

�483.80(a)(3) An antibiotic stewardship program that includes antibiotic use protocols and a system to monitor antibiotic use.

Observations:

Based on a review of facility documentation, facility policies and staff interviews, it was determined that the facility failed to maintain an effective antibiotic stewardship program that includes a system that includes antibiotic use protocols and a system to effectively monitor antibiotic usage for three of four months of antibiotic stewardship program data reviewed. (January 2024, February 2024, March 2024 and April 2024).

Findings Include:

Review of facility policy "Antibiotic Stewardship-Surveillance" dated February 8, 2024, revealed the " Antibiotic usage and outcome data will be collected and documented using a facility: approved antibiotic surveillance tracking form. The data will be used to guide decisions for improvement of individual resident antibiotic prescribing practices and facility-wide antibiotic stewardship. The facility's antibiotic stewardship program will promote the appropriate use of antibiotics and includes a system of monitoring to improve resident outcomes and reduce antibiotic resistance. This development should include leadership support and accountability via the participation of the medical director, consulting pharmacist, nursing and administrative leadership, and individual with designated responsibility for the infection control program (i.., infection preventionist).
1.As part of he facility Antibiotic Stewardship Program, all clinical infections treated with antibiotics will undergo review by the Infection Preventionist (IP), or designee.
2.The IP, or designee, will review all antibiotic starts within 48 hours to determine if continued therapy is justified, justified with needed intervention, or not justified. Utilizing facility line listings and "Antibiotic Dashboard" maintained by the chosen EHR.
a.Therapy is NOT justified if: 1) The organism is not susceptible to antibiotic chosen; (2) The organism is susceptible to narrower spectrum antibiotic; (3) Therapy was ordered for prolonged surgical prophylaxis; or (4) Therapy was started awaiting culture, but no organism was isolated after 72 hours .
b.Interventions that may resolve unjustified therapy: (1) Dosage change; (2) Switch from IV to PO route; (3) Duration change; (4) Additional antibiotic added; (5) Obtain cultures; and (6) Check levels.
c.If therapy remains NOT justified, proceed with: (1) Alternative antibiotic regimen; or (2) Discontinue therapy.
3.At the conclusion of the review, the provider will be notified of the review findings and recommendations. His or her response will be documented as follows: a. Agrees to make change; b: Needs to discuss with team before making change; or c. Will not make change because: 1. He or she does not agree with recommendations; and or 2. Team does not agree with recommendation.

Review of facility documentation from the month of January 2024 to April 2024 revealed that the facility used antibiotics to treat infection for 73 residents. Further review of facility documentation revealed that a review of antibiotic usage for appropriateness or if the usage criteria were met was not completed for the antibiotics prescribed according to facility antibiotic stewardship program.

Interview with the Infection Control Nurse, Employee E33, June 7, 2024, at 12:24 p.m. confirmed that a review of antibiotic usage for appropriateness or if the usage criteria were met was not completed for the antibiotics prescribed according to facility antibiotic stewardship program.

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: 07/26/2024

F881 Antibiotic Stewardship
This Provider submits the following plan of correction is good faith and to comply with Federal regulations. This plan is not admission of wrongdoing nor does it reflect agreement with the facts and conclusions stated in the statement of deficiencies
pThe facility cannot go back retroactively to correct the issue.

The regional infection preventionist educated the facility infection preventionist on the antibiotic stewardship surveillance policy
The infection preventionist educated the medical staff on the Mcgeer critera as it relates to antibiotic usage.
The Infection Preventionist educated licensed staff on the Mcgeer criteria as it relates to antibitotic usage

The Infection Preventionist will audit antibiotic usage for appropriateness, or if the usage criteria was met. Documentation of this will appear on the monthly line listing.
Audits will be done weekly x 4 weeks

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 �483.70(e) and following accepted national standards;

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

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

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

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

Observations:

Based upon observations, interviews and review of clinical records and facility policy, determined the facility failed to establish and maintain an infection prevention and control program to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of Multidrug-resistant organism (MDRO) transmission for three residents with indwelling medical devices and hand hygiene for one resident during medication administration (Resident R21, R87 and R129) of 35 residents records reviewed.

Findings include:

Review of the facility 's policy "Transmission Based Precautions" revised in April 2024, states Transmission Based Precautions (TBP) will be initiated when there is a reason to believe a resident has a communicable infectious disease, which may include using Enhanced-Barrier Precautions (EBP). EBP are designed to reduce the transmission of multidrug-resistant organisms (MDRO) in facilities by using targeted gown and glove during high contact resident care activities to reduce transmission of infections. The policy further states, "EBP are indicated for residents with any wounds and/or indwelling medical device (including feeding tubes and foley catheters), even if the resident is not known to be infected or colonized with a MDRO."

Resident R129 was admitted on March 6, 2024 diagnosed with a gastrostomy (a surgical opening into the stomach used for nutrition). Review of the residents care plan dated April 17, 2023, indicated the resident required the gastrostomy due to dysphagia (inability to swallow). On June 6, 2024 at 11:35 a.m. it was observed and confirmed with the Unit Manager, Employee E7 that the facility was not utilizing Enhanced Barrier Precautions with the resident.

Observations on June 5, 2024, at 10:48 a.m. and on June 6, 2024, at 12:57 p.m. revealed that Resident R21 was resting in bed. Resident R21 was observed to have a gastrostomy tube and had tube feeding equipment and supplies at her bedside. Further observation revealed no evidence of any enhanced barrier precautions available or implemented for the resident.

Review of Resident R21's care plan, dated initiated February 21, 2017, revealed that the resident was risk for alteration in nutrition/hydration related to her need for artificial nutrition through a feeding tube.

Review of physician orders for Resident R21 revealed an order dated February 28, 2024, for a gastrostomy tube (a surgical opening and placement of a tube though a person's abdominal wall into their stomach). Continued review revealed another order, dated March 20, 2024, for Diabetasource AC (artificial nutrition) 40 ml (milliliters) per hour for 20 hours or until 800 ml infused.

Further review of Resident R21's clinical record revealed that no documentation was available for review at the time of the survey to indicate if enhanced barrier precautions were implemented for the resident.

Review of the facility policy titled "Medication Administration and Disposition" last revised September 6, 2023, indicated that the Staff shall follow established facility infection control procedures (e.g., hand hygiene, gloves, Isolation precautions, etc.) for the administration of medications prior to and after medication administration.

Observation of medication pass on June 6, 2024, at 08:05a.m. revealed Employee E22 administering medication on the nursing unit A back hall. Employee E 22 was observed preparing the resident medication, entering the resident room, and passed the medication to the resident. Employee E22 exited the room and began to prepare medication for another resident. Employee E 22 did not practice hand hygiene by sanitizing or washing her hands between residents.

Observation of medication pass on June 6, 2024, at 08:50 a.m. revealed Employee E 25 preparing to administer medication on the nursing unit A front hall. Employee E 25 was observed preparing medication. The employee entered the room and passed the medication to the resident. Employee E 25 exited the room and began to prepare medication for another resident. Employee E25 then entered another resident's room, confirmed the resident, passed the medication then exited the room. Employee E 25 was then instructed by unit manager Employee E 21 to sanitize her hands. Interview with Employee E 25 at the time of observation confirmed she did not sanitize her hands, to practice proper infection control.

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

28 Pa Code 201.14(a) Responsibility of licensee

Plan of Correction - To be completed: 07/26/2024

F880 Infection control
This Provider submits the following plan of correction is good faith and to comply with Federal regulations. This plan is not admission of wrongdoing nor does it reflect agreement with the facts and conclusions stated in the statement of deficiencies

R21, R87 and R129 Enhanced barrier precautions were initiated.
E22 and E 25 were educated on hand hygiene during medication administration

The Infection Preventionist conducted an audit of residents that meet criteria per policy for enhanced barrier precautions to ensure proper precautions were implemented per policy

Licensed staff were educated by the Infection Preventionist on Enhanced Barrier Precautions

Licensed staff were educated by the facility educator on hand hygiene during medication administration.

The Infection Preventionist will audit residents requiring enhanced barrier precautions to ensure proper precautions were implemented according to the policy.
Audits will be done weekly x 4 weeks then monthly x 2 months. Results of these audits will be submitted to the quality assurance committee to determine if further action is needed.

483.12 REQUIREMENT Free from Misappropriation/Exploitation:

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

Plan of Correction - To be completed: 07/26/2024

F602 Free from misappropriation/exploitation
This Provider submits the following plan of correction is good faith and to comply with Federal regulations. This plan is not admission of wrongdoing nor does it reflect agreement with the facts and conclusions stated in the statement of deficiencies

R205's Medication was replaced.

The facility immediately initiated a plan of correction 1/1/24 related to the narcotic diversion .

The DON/designee conducted an audit of narcotic books on 1/1/24 to ensure shift counts and narcotic log documentation was complete and accurate. Audits continue to be done weekly

Licensed staff were educated by the facility educator on 1/1/24 on proper use of narcotic books including signing out narcotics, entering narcotics into the book and transferring narcotics to a new page and destroying narcotics. Licensed staff will be re-educated by the facility educator on the abuse policy relating to misappropriation of medication as well as the Narcotic Management policy.

The DON/designee will continue to audit Narcotic books to ensure documentation is complete and accurate weekly. Results of these audits will be submitted to the Quality assurance committee to determine if further action is needed

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

�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, and interviews with staff, it was determined that the facility failed to conduct a complete and thorough investigation of an alleged violation for one of 35 residents reviewed. (Resident R81).

Findings include:

Review of the facility policy titled, " .... Reporting and Investigation" dated, September 2023, revealed, " ..... The Administrator, Director of Nursing, and Risk Manager, if applicable are responsible for Investigation and reporting. Upon receiving an incident or suspected incident of resident abuse, Neglect, misappropriation of resident property, or injury of an unknown source, the Administrator/DON/designee will conduct an investigation to include but not limited to the Following: Complete paperwork for investigation of abuse, neglect, misappropriation;
Interview the person(s) reporting the incident;
Interview any witnesses to the incident;
Interview the resident, if able;
Interview the resident ' s attending physician and review of the resident ' s record;
Interview staff members (on all shifts) having contact with the resident during the period of The alleged incident;"

Review of facility investigation dated November 22, 2023 from Register Nurse (RN) Employee E26 stated a nursing aide stated Resident R81 was in his room in bed and then she observed the resident rushing into the dining room because it was mealtime. When resident went into the dining room, he was observed by staff taking food from another resident's tray which was not his diet. Staff instructed resident to stop and slow down. Staff stated that the resident just kept shoving food in his mouth and when the staff attempted to approach him, he got up and slipped on the food that he dropped on the floor. The resident fell into the table he was sitting at and hit his head falling to the floor. Nursing staff was in dining room and responded and observed him turning cyanotic. RN who was present did an abdominal thrust causing resident to vomit the rest of food he had in his mouth. Staff stated resident vomited again and RN called 911. The resident was assessed with a laceration to his head. When 911 arrived, the resident was back to his baseline. The resident was transferred to the hospital diagnosed with aspiration pneumonia,

Further review of the investigation revealed a witness statement by Employee E26 indicating she was the assigned charge nurse and during dinner stated the resident stood up with a mouth full of food and slipped and started choking. The nurse stated the resident needed to be revived and sustained a laceration to his eye. Witness statement from Licensed Practical Nurse (LPN) who was sitting at the nurses' station observed Resident R81 in the dining room "Stuffing his mouth with food." The LPN statement stated that when the resident stood up and fell to the floor, "This nurse assisted with CPR."

Continue review of the investigation revealed the facility did not obtain further statements or conduct interviews with other staff present during dinner when the incident occurred.

Interview with the Nursing Home Administrator(NHA) on June 10, 2024. at approximately 10:00 a.m. could not provide any additional documents at that time related to the facility's investigation. In addition, the Nursing Home Administrator indicated most were from agency nursing and no longer work at the facility.

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

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

483.20(k)(1)-(3) REQUIREMENT PASARR Screening for MD & ID:

�483.20(k) Preadmission Screening for individuals with a mental disorder and individuals with intellectual disability.

�483.20(k)(1) A nursing facility must not admit, on or after January 1, 1989, any new residents with:
(i) Mental disorder as defined in paragraph (k)(3)(i) of this section, unless the State mental health authority has determined, based on an independent physical and mental evaluation performed by a person or entity other than the State mental health authority, prior to admission,
(A) That, because of the physical and mental condition of the individual, the individual requires the level of services provided by a nursing facility; and
(B) If the individual requires such level of services, whether the individual requires specialized services; or
(ii) Intellectual disability, as defined in paragraph (k)(3)(ii) of this section, unless the State intellectual disability or developmental disability authority has determined prior to admission-
(A) That, because of the physical and mental condition of the individual, the individual requires the level of services provided by a nursing facility; and
(B) If the individual requires such level of services, whether the individual requires specialized services for intellectual disability.

�483.20(k)(2) Exceptions. For purposes of this section-
(i)The preadmission screening program under paragraph(k)(1) of this section need not provide for determinations in the case of the readmission to a nursing facility of an individual who, after being admitted to the nursing facility, was transferred for care in a hospital.
(ii) The State may choose not to apply the preadmission screening program under paragraph (k)(1) of this section to the admission to a nursing facility of an individual-
(A) Who is admitted to the facility directly from a hospital after receiving acute inpatient care at the hospital,
(B) Who requires nursing facility services for the condition for which the individual received care in the hospital, and
(C) Whose attending physician has certified, before admission to the facility that the individual is likely to require less than 30 days of nursing facility services.

�483.20(k)(3) Definition. For purposes of this section-
(i) An individual is considered to have a mental disorder if the individual has a serious mental disorder defined in 483.102(b)(1).
(ii) An individual is considered to have an intellectual disability if the individual has an intellectual disability as defined in �483.102(b)(3) or is a person with a related condition as described in 435.1010 of this chapter.

Observations:

Based on clinical record reviews, review of facility policies and staff interviews, it was determined that the PASRR (Preadmission Screening and Resident Review) was not appropriately completed according to the resident assessment for two of three residents reviewed related to PASRR assessments (Residents R25 and R208).

Findings include:

The PASRR (Preadmission Screening Resident Review) was created in 1987 through language in the Omnibus Budget Reconciliation Act (OBRA) and it has three goals: to identify individuals with mental illness and/or intellectual disability, to ensure they are placed appropriately, whether in the community or in a nursing facility, and to ensure they receive the services they require for their mental illness or intellectual disability.

The PASRR Level 1 must be completed on all persons who are considering admission to a Medicaid certified nursing facility. A Level II PASRR evaluation must be completed if the Level 1 PASRR determined that the person is a targeted person with mental illness or an intellectual disability. The Level II PASRR would determine if placement or continued stay in the requested or current nursing facility is appropriate.

Review of facility policy, "Social Service Assessment" dated revised February 6, 2024, revealed, "Social Services is responsible for the Level 1 screening process ... The PASRR Level 1 form is completed by the nursing facility, the hospital or the Area Agency on Aging office no later than the day of admission ... Nursing facilities are responsible to make sure the form is filled out correctly at the time of admission."

Review of Resident R25's Admission MDS (Minimum Data Set - a mandatory periodic resident assessment tool), dated September 6, 2023, revealed that the resident was admitted to the facility on August 31, 2023, and had diagnoses including bipolar disorder (also known as manic depression, is a mental illness that brings severe high and low moods and changes in sleep, energy, thinking, and behavior) and psychotic disorder (mental illness associated with loss of contact with reality).

Review of Resident R25's PASRR Level 1 assessment, dated August 31, 2023, revealed that the resident did not have any serious mental illnesses listed on the assessment. Continued review revealed that the assessment was signed as completed by staff from the nursing facility.

Review of Resident R208's Admission MDS, dated March 7, 2024, revealed that the resident was admitted to the facility on February 29, 2024, and had diagnoses including schizophrenia (mental illness associated with loss of reality contact, delusions and hallucinations).

Review of Resident R208's PASRR Level 1 assessment, dated February 29, 2024, revealed that the resident did not have any serious mental illnesses listed on the assessment. Continued review revealed that the assessment was signed as completed by staff from the nursing facility.

Interview on June 7, 2024, at 11:32 a.m. Employee E10, Director of Social Work, confirmed that the PASRR Level 1 assessments for Residents R25 and R208 were not completed accurately and that the assessments should have included that the residents had diagnoses of serious mental illnesses.

28 Pa. Code 201.8(b)(1) Management

28 Pa. Code 201.8(e)(1) Management

28 Pa. Code 211.10(a) Resident care policies

Plan of Correction - To be completed: 07/26/2024

F645 PASRR Screening for MD & ID
This Provider submits the following plan of correction is good faith and to comply with Federal regulations. This plan is not admission of wrongdoing nor does it reflect agreement with the facts and conclusions stated in the statement of deficiencies
R25 PASRR was updated with appropriate diagnosis
R208 PASRR was updated with appropriate diagnosis

The Service Director/designee conducted an audit of current residents to ensure that the PASRR assessment was appropriately completed/

The NHA/designee educated the social department on completing PASRR's accurately.

The Social service director/designee will audit new admissions to ensure that the PASRR is completed accurately.
Audits will be done weekly x 4 weeks, then monthly x 2 months. Results of these audits will be submitted to the quality assurance committee to determine if further action in needed

483.21(a)(1)-(3) REQUIREMENT Baseline Care Plan:

�483.21 Comprehensive Person-Centered Care Planning
�483.21(a) Baseline Care Plans
�483.21(a)(1) The facility must develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. The baseline care plan must-
(i) Be developed within 48 hours of a resident's admission.
(ii) Include the minimum healthcare information necessary to properly care for a resident including, but not limited to-
(A) Initial goals based on admission orders.
(B) Physician orders.
(C) Dietary orders.
(D) Therapy services.
(E) Social services.
(F) PASARR recommendation, if applicable.

�483.21(a)(2) The facility may develop a comprehensive care plan in place of the baseline care plan if the comprehensive care plan-
(i) Is developed within 48 hours of the resident's admission.
(ii) Meets the requirements set forth in paragraph (b) of this section (excepting paragraph (b)(2)(i) of this section).

�483.21(a)(3) The facility must provide the resident and their representative with a summary of the baseline care plan that includes but is not limited to:
(i) The initial goals of the resident.
(ii) A summary of the resident's medications and dietary instructions.
(iii) Any services and treatments to be administered by the facility and personnel acting on behalf of the facility.
(iv) Any updated information based on the details of the comprehensive care plan, as necessary.

Observations:

Based on the review of facility policy, review of clinical records and interview with staff, it was determined that the facility did not develop a baseline care plan for a newly admitted residents with history of drug abuse for one of 35 residents reviewed. (Resident R527)

Findings Include:

Review of clinical record for Resident R527 revealed that the resident was admitted to the facility on March 4, 2024, with diagnosis including opioid abuse, psychoactive substance abuse and schizophrenia (A disorder that affects a person's ability to think, feel, and behave clearly).

Review of a physician progress note for Resident R527 dated March 5, 2024 revealed that the resident had history of opioid( heroin) abuse.

A review of baseline care plan for Resident R 527 dated March 4, 2024, revealed that there was evidence that the facility developed a care plan with intervention for drug abuse and behavioral concerns.

Continued review of baseline care plan under social service section revealed that the mental health needs, social service needs, behavioral concerns and social service goals were not completed.

Interview with Employee E29, Assistant Director of Nursing, on June 10, 2024, confirmed that the there was no baseline care plan developed and interventions implemented for Resident R527 for drug abuse concerns.

28 Pa. Code 211.11(a)(d) Resident care plans

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

Plan of Correction - To be completed: 07/26/2024

F655 Baseline Care Plan
This Provider submits the following plan of correction is good faith and to comply with Federal regulations. This plan is not admission of wrongdoing nor does it reflect agreement with the facts and conclusions stated in the statement of deficiencies
R527 was discharged from the facility

The DON/designee conducted an audit of last 2 weeks of admissions to ensure that if a resident has a drug abuse history it is included on the baseline care plan.

Licensed staff were educated by the staff educator on Care Plan Policy.

The DON/designee will audit new admissions to ensure baseline care plans are developed with interventions for residents with drug abuse concerns.
Audits will be done weekly x 4 weeks, then monthly x 2 months. Results of these audits will be submitted to the quality assurance committee to determine if further action is needed.

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 facility policy, clinical record review, and staff interview, it was determined that the facility failed to ensure a comprehensive resident care plan was developed and implemented related to adaptive equipment required for swallowing liquids properly (Resident R40) and failed to implement care and services identified on a comprehensive care plan regarding unwanted behaviors and mealtime (Resident R81) for two of 35 residents reviewed.

Findings include:

Review of facility policy titled "Care Planning Process and Care Conference" last revised July 2023, indicated that the care plan is a working tool that provides a profile of the needs of the individual resident/patient; the resident/patient care plan will be available for use by staff caring for the resident. The interdisciplinary team will meet within 21 days of admission, readmission, when a change of condition occurs and annually to develop the comprehensive, resident centered plan of care for each resident. Once the initial MDS is completed, the Clinical Reimbursement Specialist will initiate any care plan triggered by a CAA. Each care plan need/problem must have a goal and interventions to address the need of the resident/patient. Realistic target dates should be established to meet goals.

Review of resident R 40's clinical record revealed that resident R40 had diagnosis's of Type 2 diabetes (long term medical condition which the body does not use insulin properly, resulting in unusual blood sugar levels), obesity, Barrett's esophagus with dysplasia,(a change in the lining of the esophagus, the cells are muted into precancerous state and indicate disease), panic disorder (a type of anxiety disorder), cardiomegaly(enlarged heart), depression (mood disorder that causes persistent feeling of sadness), chronic kidney disease(gradual loss of kidney function) and schizoaffective disorder(mental health condition characterized by symptoms of hallucinations or delusions), perforation of intestine ,major depressive disorder, gastro esophageal reflux disease (condition in which the stomach acid move up into the esophagus), bi polar disease(mood disorder that caused intense mood swings).

Review of resident Minimum Data Set (MDS A periodic assessment of resident care needs) dated May 27,2024, indicated Brief interview for mental status (BIMS) indicated Resident R 40 had a score of 13 (measured 1-15, 15 being cognitively intact) .

Further review of resident R 40 clinical record speech therapy plan of care notes dated May 13, 2024, revealed that resident R 40 has had increased signs and symptoms of aspiration while using a straw. The speech therapist employee E 17 recommendation no straws for this resident.

Review of resident R 40's clinical record physician orders, revealed an order dated May 13, 2024, declaring no straws with thin liquids for this resident.

Interview with speech therapist Employee E 17, on June 10, 2024, at 09:25 a.m. revealed that she had assessed resident R 40 and determined that resident R 40 was at risk for aspiration and recommended no straws for thin liquids.

Resident care plan revealed no documented evidence of a person-centered comprehensive care plan was developed related to the care and management of residents R 40 swallowing difficulties.

Observation of resident R 40 June 5, 2024, at 10:06 a.m., revealed the resident coughing while drinking orange juice from a straw. Further observation during this this time noticed was a clear sign above the resident bed stating "NO STRAWS". The above observation was confirmed but unit manager E 21.

Interview with speech therapist Employee E 17 at time of the above observation confirmed that resident R 40 was not allowed to have a straw. Employee took the straw from resident R 40 and stated that it was unknown where or how he received the straw.

Review of Resident R81 clinical record revealed the resident was admitted in April 2017 diagnosed with anxiety, depression and schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly), psychosis severe cognitive impairment and poor safety awareness.

Review of Resident R81 physician orders dated November 24, 2024 revealed the resident was ordered a pureed texture diet requiring 1:1 for all meals secondary to poor safety, staff to cue for small bites at a slow pace and aspiration precautions.

Review of Resident R81 clinical record revealed the resident was care planed for his agitation, mood and behaviors that included wandering on the unit, running down the halls, not following direction, stealing other resident's food, and ambulating and transferring without assistance. Interventions iniated on June 12, 2023, involved reassuring and redirecting the resident instructing resident not to steal other resident's food that are not consistent with the resident's diet of puree foods, Staff will provide 1:1 supervision during mealtime, Staff will remove resident from common area during meal times to ensure that resident does not steal other resident's food.

Review of clinical nursing note dated November 22, 2023, from Registered Nurse Employee E26 revealed Resident R81 "Rushed into the dining room started eating food from other resident's tray, His tray was then placed in front of him and he started spooning the food in his mouth non-stop without swallowing. One of the staff, noticed how fast he was eating kept telling him to slow down and swallow, but the resident did not comply. The resident stood up and slipped on the food he had spilled and banged his face on another resident's table and started choking." The same note indicated the resident became cyanotic and the nurse Employee E26 and Licensed Practical Nurse Employee E27 were able to revive him. The resident was assessed with a laceration on the top on of the right eyelid, 911 was called and the resident was transferred to the hospital diagnosed with aspiration pneumonia.

Interview with the Nursing Home Administrator on June 10, 2024. at approximately 10:00 a.m. could not recollect the details of the incident and Employee E26 no longer worked at the facility to interview. The NHA stated the care plan's interventions were for mealtime and during the incident Employee E26 was in the dining room to feed the resident but before that could occur the resident was showing behaviors enabling the nurse to properly feed him.

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

Plan of Correction - To be completed: 07/26/2024

F656 Comprehensive Care plan
This Provider submits the following plan of correction is good faith and to comply with Federal regulations. This plan is not admission of wrongdoing nor does it reflect agreement with the facts and conclusions stated in the statement of deficiencies
R40 care plan as it relates to adaptive equipment for swallowing liquids with no straw to be used is currently being implemented
R81 Care plan regarding behaviors during meals has been implemented

The DON/designee conducted an audit of residents requiring adaptive equipment for swallowing liquids as well as residents with behaviors during meals to ensure care plans are implemented as directed.

Nursing staff were educated by the educator on the Care planning Process and implementation of appropriate interventions.

The DON/designee will audit residents requiring adaptive equipment for swallowing liquids as well as residents with behaviors during meals to ensure care plans are being followed
Audits will be done weekly x 4 weeks then monthly x 2 months. Results of these audits will be submitted to the quality assurance committee to determine if further action is needed.

483.21(b)(3)(i) REQUIREMENT Services Provided Meet Professional Standards:

�483.21(b)(3) Comprehensive Care Plans
The services provided or arranged by the facility, as outlined by the comprehensive care plan, must-
(i) Meet professional standards of quality.

Observations:

Based on clinical review, staff interviews and medication manufacture's medication insert, it was determined the facility failed to ensure care and services were provided in accordance with professional standards of practice for one of 35 residents reviewed (resident R 96) regarding proper medication order.

Findingsinclude:

The Pennsylvania Code, Title 49, Chapter 21 physician assistant and certified registered nurse practitioners. Profession, and vocational standards, Standards, subpart A Chapter 18 The State Board of Medical Practitioners other than medical doctors, indicates that a CRNP(certified nurse practitioner) with prescriptive authority approval may, when acting in collaboration with a physician as set forth in a prescriptive authority collaborative agreement and within the CRNP's specialty, prescribe and dispense drugs and give written or oral orders for drugs and other medical therapeutic or corrective measures. These orders may include: orders for drugs, total parenteral nutrition and lipids, in accordance with 21.284 and 21.285 (relating to prescribing and dispensing parameters; and prescriptive authority collaborative agreements).

Based on clinical record review, and staff interview, it was determined that the facility failed to ensure that a non-physician practitioner, maintained professional standards of quality care for one resident receiving an antidiabetic medication. (Resident R 96)

Review of resident R96 clinical record revealed that this resident was admitted to the facility on December 15, 2023 with diagnosis of bipolar disorder(a mental disorder that causes unusual shifts in a person's mood), right knee osteoarthritis(also known as degenerative joint disease, loss of cartilage), cognitive communication deficit/9attention, concentration and communication difficulty) ,peripheral vascular disease (disease that occurs in the leg veins causing blood to pool in the legs),left leg above knee amputation ,hypertension(high blood pressure),anxiety(disorder of persistent worrying), major depression(mood disorder that causes a persistent feeling of sadness),

Review of Resident R 96's progress notes/physician notes dated May 15, 2024, revealed that "patient seen by requests for concerns of weight. Resident blood sugar 260. Morning labs blood sugar 350. Accu check 250. Patient would like medication to help with weight loss. A1c is 6.4 Ozempic ordered low dose 2 mg every Thursday, counseled patient about seeing endocrinology". Written by non-physician practitioner, Employee E 18.

Further review of Resident R 96 progress note/ physician note signed by non-physician practitioner Employee E 18 on May 16, 2024, revealed "patient seen today by request of rn for medication clarification on Ozempic : ordered Ozempic 2 mg every Thursday on 5/15 due to patient hgb a1c 6.4 and having a hard time loosing weight, RN wants clarification on how to administer dose for Ozempic, medication education given to unit manager and RN, patient is on 2mg which is low dose, injection pen comes in low concentration warranting for injections to meet the total dose of 2mg weekly. Called pharmacy to see if there is a higher concentration pen available".

Continued review of resident R96's progress notes indicate that on May 16, 2024, resident R96 received first dose of Ozempic 2 mg at 3:15 pm. Resident expressed pain during administration of medication.

Further Review of Resident R96 clinical record revealed a physician note signed by Employee E 18 on May 17, 2024, revealed that the "patient seen today for follow up of first dose of Ozempic given, during eval patient offers complaints of nausea. LOWERED DOSE TO 0.25 , Zofran ordered".

Review of The Manufacture, Novo Nordisk, of Ozempic, (semaglutide )Novo Nordic medication insert for the drug Ozempic revealed that the current dosage are injections 0.5, 1mg and 2mg an adjunct to diet and exercise to improve glycemic control in adults with type 2 diabetes.
Continued review of the manufacture instruction revealed the Dosage and administration is to administer once weekly at any time of day with or without meals. Start at 0.25 mg once weekly. After four weeks increase dose to 0.5 mg once weekly.
If additional glycemic control is needed, increase the dosage to 1 mg once weekly after at least four weeks on the 0.5 mg dose.
If additional glycemic control is needed, increase the dosage to 2 mg once weekly only after at least four weeks on the 1 mg dose.

In the event of an overdose. Appropriate supportive treatment should be initiated according to the patients' clinical signs and symptoms. Consider calling poison Help Line or a medical toxicologist for additional overdosage management recommendations. A prolonged period of observation and treatment may be necessary, taking into account the long half-life (a drugs half-life estimates the time it takes an initial concentration of the medication to be reduced by half in the body) of Ozempic of approximately of one week.

Interview with Employee E 18 on June 7, 2024, at 11:21a.m., confirmed that she mistakenly ordered the wrong dose for the resident.

28 Pa. Code 201.18(a)(1) Management
28 Pa. Code211.2(d)(10) Medical director

Plan of Correction - To be completed: 07/26/2024

F658 Services meet professional standards
This Provider submits the following plan of correction is good faith and to comply with Federal regulations. This plan is not admission of wrongdoing nor does it reflect agreement with the facts and conclusions stated in the statement of deficiencies
R 96 was discharged from the facility

The DON/designee conduct an audit of residents receiving Ozempic to ensure appropriate dosage is being administered.

E18 no longer works at this facility.
Nurse practitioners provide service to the facility were educated by the medical director/designee on the proper dosage of ozempic

The DON/designee will audit residents receiving Ozempic to ensure appropriate dosage is being administered. Audits will be done weekly x 4 weeks, then monthly x 2 months. Results of these audits will be submitted to the quality assurance committee to determine if further action is needed.

483.25 REQUIREMENT Quality of Care:

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

Plan of Correction - To be completed: 07/26/2024

F684 Quality of Care
This Provider submits the following plan of correction is good faith and to comply with Federal regulations. This plan is not admission of wrongdoing nor does it reflect agreement with the facts and conclusions stated in the statement of deficiencies
R6 physician was made aware of the elevated blood sugars
R42 physician was made aware of the medication that was held related to a blood sugar of 167
R40 straw was removed from his water cup

The DON/designee conducted an audit of diabetic residents to ensure elevated blood sugars are reported to the MD and blood sugar parameters are being followed as ordered.
The DON/designee conducted an audit of residents requiring adaptive equipment for swallowing liquids to ensure orders are being followed.

Licensed staff were educated by the facility educator on the Diabetes Mellitus Policy and following physician orders.

The DON/designee will audit diabetic residents blood sugars to ensure elevated levels are reported to the MD and blood sugar parameters are being followed.
The DON/designee will audit residents requiring adaptive equipment for swallowing liquids to ensure orders are being followed.
Audits will be done weekly x 4 weeks then monthly x 2 months. Results of these audits will be submitted to the quality assurance committee to determine if further action is needed.

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 clinical record reviews, observations, and staff interviews, it was determined that the facility failed to implement treatment and services to prevent pressure ulcers for two of 35 sampled residents reviewed. (Resident R59 and Resident R177)

Findings include:

Review of facility policy "Risk assessment and prevention" dated October 6, 2023, revealed that "The facility will strive to ensure that a resident entering the facility without pressure ulcers/pressure injuries does not develop pressure ulcer/injuries. Unless the clinical condition demonstrates unavoidable skin breakdown. Prevention of pressure ulcer/injuries requires early identification of at-risk residents and the implementation of preventions strategies.

Manage pressure.
-Use support surface on bed and or wheelchair.
-Use turning and positioning plan if indicated
-Off load heel pressure"

Clinical record review revealed that Resident R59 had diagnoses that included cognitive communication deficit and severe protein calorie malnutrition.

The Minimum Data Set assessment (Assessment of resident care needs) dated March 28, 2024, indicated that the resident required moderate assistance from the staff on staff for transferring in and out of bed and bed mobility. The resident was at risk for developing pressure ulcer (injuries to the skin and underlying tissue, primarily caused by prolonged pressure on the skin).

Review of physician orders for Resident R59 dated April 22, 2024, revealed an order to off load left heel at all times.

Review of care plan for Resident R59 dated September 22, 2023, revealed an intervention to not leave bony areas or in one position for longer periods of time.

Observation of Resident R59 on June 5, 2024, from 10:40 a.m. through 12:00 p.m. revealed that the resident was lying flat in bed. It was observed that Resident R59's left heels were placed against the foot board of the bed. There was a pillow next to the resident which did not off load the heels. Interview with Resident R59 at the time of the observation stated he had pain to the left heel. He stated he had a wound at the left heel and it was improving.

Interview with Employee E20, Nurse Aide, on June 5, 2024, from 11:40 a.m. confirmed the above observation.

Observation of Resident R59 on June 7, 2024, at 2:00 p.m. with Assistant Director of Nursing, Employee E29 revealed that Resident R59's left heels were placed against the foot board of the bed there was a pillow underneath resident's foot, but it was not positioned in a way to off load the heels. Employee E29 stated Resident R59's foot was not off loaded as ordered.

Review of clinical record revealed that Resident R177 had diagnoses that included cognitive communication deficit and severe protein calorie malnutrition and pressure ulcer of left heel.

Review of physician orders for Resident R177 dated January 31, 2024, revealed an order to off load heels at all times.

Observation of Resident R177 on June 5, 2024, at 0:45 a.m. revealed that the resident was lying flat in the bed. It was observed that Resident R177's heels were placed on the bed without any offloading measures. It was also observed that one heel boot was placed on the nightstand and the other heel boot was outside the room on the linen cart. This observation was also confirmed by Employee E30, Licensed Practical Nurse.

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

483.25(c)(1)-(3) REQUIREMENT Increase/Prevent Decrease in ROM/Mobility:

�483.25(c) Mobility.
�483.25(c)(1) The facility must ensure that a resident who enters the facility without limited range of motion does not experience reduction in range of motion unless the resident's clinical condition demonstrates that a reduction in range of motion is unavoidable; and

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

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

Observations:

Based on the observations, review of clinical records, facility policies, and interview with staff, it was determined that the facility failed to ensure that a resident with limited range of motion, received appropriate services to prevent further decline in range of motion and maintain appropriate positioning for one of 35 resident s reviewed. (Resident R70).

Finding Include:

Review of facility policy "ADL Care, Contractures, Preventative Care and Treatment and Restorative ROM Program", dated March 12, 2024, revealed that "A plan of care will be developed based on the resident's individual ADL ROM/impaired joint mobility Needs. -There must be a clearly defined problem statement that identifies the restorative need; -The restorative nursing program is not the problem statement, it is an intervention; -There must be a measurable goal related to the problem; measurable objectives describe what The resident is expected to achieve, such as ROM goals/measurements to be achieved within a Specific timeframe; - There must be individualized Interventions; care plan interventions must include the provision of Necessary equipment and/or services necessary; and =Resident/resident representative should be included in the development of the care plan, if able.

The Nursing Assistant will communicate to the Unit Manager/Charge Nurse of the need for an Evaluation as changes in ROM/joint immobility occur. These changes could be: i. A resident's strength has improved such that they may be able to participate more during ROM/joint immobility programs; ii. resident's strength has declined such that they may need more assistance while Performing ROM/joint immobility programs; iii. There is a question about the safest means of care related to a specific ROM/joint immobility Program.

As changes in resident condition occur the changes are communicated to the care giving staff with the updated information and the resident's care plan is revised as necessary"

Observation of Resident R70 on June 5, 2024, at 10:53 a.m. revealed that the resident was seated in Geri-chair (a large, padded chair that is designed to help seniors with limited mobility). It was observed that residents head was tilted to right side, appeared to be contracted to the right side. Residents head was not supported, and the resident was not using any positioning devices.

Observation of Resident R70 on June 6, 2024, at 1:26 p.m. revealed that the resident was being fed by a nurse aide in the dining room. Resident's head was tilted to the right side, head was unsupported. The aide was feeding the resident in same position.

Review of care plan for Resident R70 dated October 23, 2023, revealed that the resident was on restorative nursing program related to the prevention of functional decline through daily activities. Resident had ADL self-care deficit related to decline in overall function, decreased activity tolerance.

Continued review of resident R70's care plan revealed no care plan intervention or services for head/neck positioning.

Interview with Employee E31, Rehab director, on June 10, 2024, at 10:57 a.m. stated the resident have contracture to the neck. Employee E31 confirmed that there was no intervention or services for head/neck positioning or prevent further decline in functional range of motion.

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

28 Pa. Code: 201.18 (b)(2) Management

28 Pa. Code: 211.10 (d) Resident care policies

Plan of Correction - To be completed: 07/26/2024

F688 Increase Prevent Decrease ROM/mobility
This Provider submits the following plan of correction is good faith and to comply with Federal regulations. This plan is not admission of wrongdoing nor does it reflect agreement with the facts and conclusions stated in the statement of deficiencies

R70 was re-assessed by therapy for appropriate positioning device

The Director of Rehab/designee conducted an audit of residents with limited range of motion to ensure residents that require a positioning device have an appropriate device in place.

Nursing staff were educated by the facility educator on the policy for contractures and reporting any new residents identified with limited range of motion to the therapy department.

The Director of Rehab/designee will audit any new residents identified by nursing with limited range of motion to ensure appropriate devices are in place.
Audits will be done weekly x 4 weeks, then monthly x 2 months. Results of these audits will be submitted to the quality assurance committee to determine if further action is needed.

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

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

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

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

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

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

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

Observations:

Based on the review of facility records, observations, and interviews with staff, it was determined that the facility failed to ensure accurate accounting of controlled drugs for one of three medication storage rooms reviewed (B unit medication room).

Finding Include

Observation of facility B unit medication room with Employee E32, Licensed Practical Nurse, on June 6, 2024, at 9:17 a.m., revealed a bottle of lorazepam liquid medication in the refrigerator. The bottle contained 14 ml of medications left in the bottle. Employee E32 confirmed the amount of medication left in the bottle.

Review of narcotic count sheet for the lorazepam medication revealed that the amount should have been left should have been 4.5 ml. Employee E32 stated noticed the discrepancy 2 days ago and the amount was almost 10 ml extra that what was accounted for.

Interview with Director of Nursing on June 6, 2024, at 12:17 p.m., confirmed that there was discrepancy with Lorazepam liquid on B nursing unit.

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

Plan of Correction - To be completed: 07/26/2024

755 Pharmacy srvcs/procedures

The lorazepam liquid medication was reconciled by 2 licensed staff members.

The DON/designee conducted an audit of lorazepam liquid in the facility to ensure accurate accounting of this controlled drug

Licensed staff were educated on reporting drug discrepancies of controlled drugs to the DON/Unit manager

The DON/designee will audit lorazepam liquid to ensure accurate accounting of this controlled drug weekly x 4 weeks, then monthly x 2 months. Results of these audits will be submitted to the quality assurance committee to determine if further action is needed.

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

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

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

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

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

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

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

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

Observations:

Based on the review of clinical records, interviews with resident and staff, it was determined that the facility failed to ensure that residents drug regimen was free of unnecessary drugs related to the use of antipsychotic medication without adequate monitoring for one of five resident reviewed for drug regimen. (Resident R207.)

Findings Include:

Review of physician order for Resident R207 dated April 3, 2024, revealed an order for Quetiapine Fumarate 25 mg, half tablet by mouth at bedtime for schizophrenia.

Review of pharmacy review of Resident R207 dated May 19, 2024, revealed that "Please watch for ataxia and falls secondary to Seroquel. Seroquel may cause extra pyramidal symptoms (ide effects of some medications, such as antipsychotic drugs, that can affect movement.), tardive dyskinesia (a chronic, drug-induced movement disorder that causes involuntary, repetitive body movements.), akathisia (a neuropsychiatric movement disorder that makes it difficult to sit still and causes an uncontrollable urge to move.), hypoglycemia, hyperprolactinemia and hyperlipidemia.
Review of Resident R207's current care plan for June 2024 revealed an intervention to monitor that the medication was effective and treating the symptoms and that the resident was tolerating it without any side effects or adverse reactions. Report abnormal findings to RN and physician.

Review of clinical record for Resident R207 revealed no evidence that the facility monitored Resident R207 consistently for the adverse effects for the antipsychotic medication as recommended by the pharmacy consultant.

Interview with Employee E29, Assistant Director of Nursing, on June 10, 2024, at 12:20 p.m. confirmed that Resident R207 was not monitored for the adverse effects for the antipsychotic medication as recommended by the pharmacy consultant. Employee E29 stated resident should have an order to monitor the side effects/adverse effects for antipsychotic medication.

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

Plan of Correction - To be completed: 07/26/2024

F757 Drug regimen free from unnecessary drugs
This Provider submits the following plan of correction is good faith and to comply with Federal regulations. This plan is not admission of wrongdoing nor does it reflect agreement with the facts and conclusions stated in the statement of deficiencies
R207 side effect monitoring was added to this residents orders

An Audit was conducted by the DON/designee of antipsychotic medications to ensure side effect monitoring is in place.

Licensed staff were educated on side effect monitoring of antipsychotic medications.

The DON/designee will audit residents receiving antipsychotic medications to ensure side effect monitoring is in place.
Audits will be done weekly x 4 weeks, then monthly x 2 months. Results of these audits will be submitted to the Quality assurance committee to determine if further action is needed.

483.60(d)(4)(5) REQUIREMENT Resident Allergies, Preferences, Substitutes:

�483.60(d) Food and drink
Each resident receives and the facility provides-

�483.60(d)(4) Food that accommodates resident allergies, intolerances, and preferences;

�483.60(d)(5) Appealing options of similar nutritive value to residents who choose not to eat food that is initially served or who request a different meal choice;

Observations:

Based on observations and staff interviews it was determined that the facility failed to provide accurate meal trays for one of two residents and failed to provide food products based on the resident's food preference for three of 35 residents (Resident R88, 107, R212).

Review of facility policy "Resident Preferences", last revised January 2024, indicates " Residents' individual choices including religious, cultural, and ethnic needs and preferences are obtained. Residents are served meals that offer choices and comply with food preferences.

On June 5, 2024, at 12:13 p.m. Resident R212 reported that food preferences are not being honored. His/her ticket is preference for double portions protein, and he/she is not getting them during meals times.

On June 5, 2024, at 12:25 p.m. Resident's R212 lunch arrived, and lunch ticket indicated "double meat sandwich to meals tray". Lunch tray was missing sandwich. Licensed Dietician, Employee E5 confirmed that resident's preference did not reflet the lunch tray.

On June 6, 2024, at 10:21 a.m. Resident Council Meeting was held with 11 alert and oriented (R108, R125, R475, R139, R116, R60, R75, R194, R217, R193, R168) residents who reported that their meal tickets would be missing items on the meal tray and when French fries are being served or potatoe tots, the facility would run out and not everyone would get those items when they are scheduled to be served.

On June 6, 2024, at 1:26 p.m. Resident R88's lunch was observed, and resident's lunch ticket had preference for canned fruit and it was not on the lunch tray. Resident R107's ticket preference had extra source gravy and there was no gravy available on the tray. Nursing Aid, Employee E9 confirmed the observations.

Pa Code: 211.6(a) Dietary services

Plan of Correction - To be completed: 07/26/2024

F806 Allergies preferences
This Provider submits the following plan of correction is good faith and to comply with Federal regulations. This plan is not admission of wrongdoing nor does it reflect agreement with the facts and conclusions stated in the statement of deficiencies
R88 is now receiving canned fruit on the tray
R107 is receiving extra sauce and gravy
R212 is receiving double portions R139, R116, R60, R75, R194, R217, R193, R168 to discuss
The plan of correction on meal tray accuracy and to assure adequate amount of food items that the residents would prefer.

The Dietary director educated dietary staff on honoring resident preferences and meal tray accuracy.

The Dietary director/designee will do random audits of 5 meal trays per meal to ensure that the residents tray matches the residents meal ticket for their preferences. Audits will be done weekly x 4 weeks then monthly x 2 months . results of these audits will be submitted to the Quality assurance committee to determine if further action is needed.

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