Nursing Investigation Results -

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

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
MEADOWVIEW REHABILITATION AND NURSING CENTER
Inspection Results For:

There are  180 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 two complaints completed on November 10, 2021, it was determined that Meadowview Nursing and Rehabilitation Center 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 as they relate to the health portion of the survey process.








 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 observation and staff interview, it was determined that the facility failed to maintain a safe and clean environment for two of five nursing units (D wing and B wing).

Findings include:

Observations conducted of the D wing residents' rooms on November 8, 2021, from 9:20 a.m. through 10:20 a.m. in the company of licensed nurse Employee E8, revealed the following:
-The bottom piece of the door adjacent to room 2 was hanging out.
-At the entrance of day room, opposite to the D-Unit Nurses' station, the base board was punctured.
-The Fire Exit Door, near the Day Room, the tiles were peeled off, and the wall above the base board punctured;
-In room 3, the emergency push button in the bathroom was hanging out from wall;
-In room 4, the metal back portion of the toilet was rusted and damaged;
-In room 5, the bulb indicator located at the top of the entrance door, kept as the extension of the emergency push bottom of the bath room was non functioning and at the entrance, the base board's top portion was damaged.
-In room 11, the bulb indicator located at the top of the entrance door, kept as the extension of the emergency push tool of the bath room, was non functioning.
-In room 13, the base board was damaged;
-In room 14, the emergency push button in the bath room, was hanging out from the wall;
-In room 15, the base board was damaged;
-In room 16, the sink of bath room was clogged, and the caulking around the base of toilet was damaged;
-In room 20, the bath room floor's wooden tiles were lifting up off the floor, and the toilet was leaking at its base.

Observations conducted of the B wing resident rooms and resident care areas on November 7, 2021, at 11:30 a.m. with licensed nursing staff, Employee E24, revealed the following:

-In room B7A, the bed control was broken with the bed inclined at a 30 degree angle, the foot board was broken. Interview with Resident R26, at the time of the observation, revealed that it was broken approximately a week ago.
It was also observed that the dresser drawer was broken in room B7A

-In room B8B, the bottom dresser drawer was sitting against the wall.

-In room B10 the air mattress cord was placed in an unsafe condition through the middle of the room between both beds.

In B unit dinning room heating unit cover in the dining room was off which exposed sharp edges.

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

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

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






 Plan of Correction - To be completed: 12/24/2021

This Provider submits the following plan of correction in good faith and to comply with Federal regulations. This plan is not an admission of wrong doing nor does it reflect agreement with the facts and conclusions stated in the statement of deficiencies.
1.The following environmental issues below that occurred on D wing resident area have been resolved by maintenance. -The bottom piece of the door adjacent to room 2 was hanging out and has been repaired. -The entrance of the day room, opposite to the D -Unit Nurses station base board was punctured and has been repaired. - The fire exit Door near the day room tiles were peeled off and the wall above the base board was punctured and have been repaired. - In room 3, the emergency push button in the bathroom was hanging out from the wall and has been repaired. - In room 4, the metal back portion of the toilet was rusted and damaged, the toilet has been replaced. - In room 5, the bulb indicator located at the top of the entrance door, kept as the extension of the emergency push bottom of the bath room was non functioning and at the entrance, the base board's top portion was damaged and has been replaced. -. In room 11, the bulb indicator located at the top of the entrance door, kept as the extension of the emergency push tool of the bath room was nonfunctioning, was fixed. -. In room 13, the baseboard was damaged and has been repaired. -In room 14, the emergency push button in the bathroom was hanging out from the wall and has been repaired. -In room 15, the base board was damaged and has been repaired. -In room 16, the sink of bathroom was clogged, and the caulking around the base of the toilet was damaged and has been repaired. -In room 20, the bathroom floor's wooden tiles were lifting up off the floor, and the toilet was leaking at its base and has been repaired.
The following environmental issues below that occurred on B wing have been resolved -In room B7A, the bed control was broken with the bed inclined at 30-degree angle, foot board was broken and has now been repaired. -The dresser drawer was broken and has been repaired. -In room B8B, the bottom dresser drawer was sitting against the wall and has been removed and new drawer has been replaced. -In room B10, the air mattress cord was placed in an unsafe condition through the middle of the room between both beds and has been moved. -In B unit dining room heating unit cover was off which exposed sharp edges has been fixed.
2.Environmental round will be done by the Maintenance Director/Designee in resident care areas to identify any items in need of repair. Rounds will be done with a new audit template to confirm all areas were properly looked at.
3.Staff will be educated by the Educator/Designee on the importance of identifying problem environmental areas and logging them into to Tels for service. All directors were giving access to Tels to document repairs needed in a timely matter.
4.Random environmental audits will be done by NHA/Designee weekly x 4 weeks. Results will be reviewed at monthly QAPI meeting to determine if further action is needed.


483.10(a)(1)(2)(b)(1)(2) REQUIREMENT Resident Rights/Exercise of Rights: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(a) Resident Rights.
The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility, including those specified in this section.

§483.10(a)(1) A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the resident.

§483.10(a)(2) The facility must provide equal access to quality care regardless of diagnosis, severity of condition, or payment source. A facility must establish and maintain identical policies and practices regarding transfer, discharge, and the provision of services under the State plan for all residents regardless of payment source.

§483.10(b) Exercise of Rights.
The resident has the right to exercise his or her rights as a resident of the facility and as a citizen or resident of the United States.

§483.10(b)(1) The facility must ensure that the resident can exercise his or her rights without interference, coercion, discrimination, or reprisal from the facility.

§483.10(b)(2) The resident has the right to be free of interference, coercion, discrimination, and reprisal from the facility in exercising his or her rights and to be supported by the facility in the exercise of his or her rights as required under this subpart.
Observations:

Based on observations and interviews with residents and staff, it was determined that the facility failed to ensure that dignity was maintained for one of 46 residents reviewed (Resident R85).

Findings include:

Interview on November 7, 2021, at 9:50 a.m. with Resident R85 stated that "staff don't treat me right."

Observation on November 8, 2021, at 9:22 a.m. revealed Resident R85 walked into the dining room, approached Employee E14, nurse aide, and asked her if she could leave the unit. Employee E14 raised her voice and in a harsh, abrupt tone responded to the resident that she was not allowed to leave the unit, that another staff person already told her that she wasn't allowed to leave and that she needed to stop asking.

Continued observation revealed that Resident R85 was upset after the response provided by nurse aide, Employee E14. Resident R85 stated, "I wasn't treated right, there's a lot of meanness here."

Interview on November 8, 2021, at 10:40 a.m. the Nursing Home Administrator confirmed that Employee E14's response toward Resident R85 was not appropriate.

28 Pa Code 201.29(j) Resident rights






 Plan of Correction - To be completed: 12/24/2021

This Provider submits the following plan of correction in good faith and to comply with Federal regulations. This plan is not an admission of wrong doing nor does it reflect agreement with the facts and conclusions stated in the statement of deficiencies.
1.Employee E14 was re-educated on the appropriate manner to respond to a resident without raising her voice to ensure that dignity would be maintained. Emotional support was provided to Resident R85. Resident R85 felt comfortable.
2.Director of Nursing/Designee will randomly audit staff interaction with residents via direct observation and will interview random residents to ensure appropriate demeanor and dignity is felt.
3.Nursing Staff will be educated by Staff Educator/Designee regarding Resident Rights.
4.Random observation Audits of staff interactions with residents, will be conducted weekly x 4. Findings of the audits will be reviewed at monthly QAPI meetings to determine if further action is needed.

483.12(c)(2)-(4) REQUIREMENT Investigate/Prevent/Correct Alleged Violation:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
§483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must:

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

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

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

Based on review of clinical records, facility documentation, and interviews with staff, it was determined that the facility failed to complete a thorough investigation related to elopement for two of 37 records reviewed
(Resident R13 and Resident R185).

Findings include:

Review of Resident R185's clinical record revealed diagnoses of nondramatic subdural hemorrhage (a type of bleeding that often occurs outside the brain as a result of a severe head injury); traumatic subdural hemorrhage with loss of consciousness; atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow); fracture of other specified skull and facial bones; acute respiratory failure; diffuse traumatic brain injury; muscle weakness; lack of coordination; and difficulty in walking.

Review of Resident R185's Minimum Data Set ( an assessment of resident care needs) dated July 5, 2021 revealed a BIMS (Brief Interview for Mental Status) score of nine, indicating that the resident had a moderate cognitive impairment.

Review of Resident R185's care plan date initiated July 8, 2021 and revised July 17, 2021 revealed the following focus area: "I have problems with my memory. I may ask for someone to help me and wander aimlessly. Please remind me not to go on elevator or leave the unit unless supervised by staff/family. No wanderguard need right now but maybe in the future. Also, if I do get off the unit unsupervised, please make sure the staff and family are aware."

Review of "Investigation Report" dated September 17, 2021, revealed, "Resident R185 was able to get out the exit door on his unit due to a large supply delivery that was brought to the facility by Fed EX. A Nurse Practitioner from the building was leaving the premises and reported to staff via telephone that she saw an elderly gentleman walking in the parking lot. She stopped to ask him if he was okay and he said yes and he told her his name. The facility initiated Code White immediately. Staff searched the building and outside in the parking lot. Resident R185 was located at a business next to our parking lot."

Further review of the Investigation Report revealed a statement from the Director of Nursing and a statement from the Nursing Home Administrator. The investigation did not include a timeline of the Elopement or any interviews from nursing staff indicating the last time Resident R185 was seen on the nursing unit. The investigation did not include interviews with additional staff members, including the nurse practitioner who first noticed Resident R185 in the parking lot or with Maintenance and Housekeeping staff who were transporting supplies into the building.

Interview on November 8, 2021 at 2:00 p.m. with the Director of Nursing, revealed, "As soon as Code White was called, I ran out to the parking lot to find the resident. I ran across the field to the business located next to our facility. Another staff member arrived by car and we were able to return this Resident to our facility. We determined that Resident R185 was sitting near the door while a large delivery was being brought into our facility. Our Maintenance and Housekeeping staff were transporting the delivery to Central Supply. The door must have been open and he walked out of the facility."

Findings were confirmed by the Director of Nursing on November 9, 2021 at approximately 11:00 a.m.

Review of a quarterly Minimum Data set for Resident R13 dated August 2, 2021 revealed that the resident had a BIMS score of 9 which indicated that the cognitive status for daily decision making was moderately impaired.

Review of facility investigation dated September 18, 2021 revealed that at 9:50 p.m. staff heard the door alarm sounding and the nurse was notified by the other resident that Resident R13 ambulated through the fire exit door in the B unit. Facility initiated elopement protocol. The resident was located outside the facility and brought back to the facility by the facility staff.

Further review of the facility investigation revealed that the facility staff did not have a timeline of the elopement events including the time resident exited the building, the time resident was located outside of the facility and the time resident was redirected back to the facility. The investigation also did not include the location where the resident was located.

Continued review of the facility investigation revealed no documented evidence that the staff interviewed or obtained a statement from the resident who reported the resident exiting the fire door.

Interview with the Director of Nursing, on November 10, 2021 at 10:00 a.m. stated that three Nursing Assistants worked on that unit on 3-11 shift on September 18, 2021 and the facility obtained statements from two Nursing Assistants and did not obtain a statement or interview the third nursing assistant who worked on that unit. Employee E2 also stated the resident was located across the street at a bank parking lot.


28 Pa Code 201.14 (a) Responsibility of Licensee
28 Pa Code 201.18 (b)(1) (3) Management
28 PA Code 201.18 (e)(1) Management








 Plan of Correction - To be completed: 12/24/2021

This Provider submits the following plan of correction in good faith and to comply with Federal regulations. This plan is not an admission of wrong doing nor does it reflect agreement with the facts and conclusions stated in the statement of deficiencies.
1.Resident R185 was brought back to the facility and was assessed. Resident had no injuries. The resident was put on Q15 minutes checks till exit seeking behavior was resolved.
Resident R13 was safely redirected to the building and was assessed with no injuries.
2.Facility changed the process for deliveries and also added an alarm annunciator for the stairwell exit doors.
3.Staff will be educated by the Educator/designee on the policy and procedures for a through and complete investigation which includes a timeline of events and statement from all staff involved.
4.Elopement drills will be conducted with a complete investigation on each shift Monthly X1. Then Quarterly. Elopement drills will be reviewed at monthly QAPI to ensure a complete investigation was done and to determine if further action is needed

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

Based on observation, review of clinical records and interviews with staff, it was determined that the facility failed to develop a comprehensive person-centered care plans for two of 37 residents reviewed (Resident R4 and R318).

Findings include:

Review of Resident R4's clinical record revealed that the resident was admitted to the facility on October 27, 2019, with the diagnoses of epilepsy (a disorder in which nerve cell activity in the brain is disturbed, causing seizures), other Seizures (a burst of uncontrolled electrical activity between brain cells (also called neurons or nerve cells) that causes temporary abnormalities in behaviors, sensations or states of awareness, or in muscle tone or movements including stiffness, twitching or limpness), dementia (a loss of cognitive functioning - thinking, remembering, and reasoning - to such an extent that it interferes with a person's daily life and activities), and presence of cardiac pacemaker (a medical device that generates electrical impulses delivered by electrodes to cause the heart muscle chambers to contract and therefore pump blood; by doing so this device replaces and/or regulates the function of the electrical conduction system of the heart).

Review of R4's nursing notes dated July 13, 2021, revealed that hospice services were initiated. Further review of Resident R4's clinical record revealed a Social Services' note dated October 27, 2021, which confirmed that the resident was currently receiving hospice services."

Review of Resident R4's clinical record revealed that no plan of care developed for the resident receiving hospice care and service.

Interview conducted with Licensed nursing staff, Employee E25 confirmed that there was no care plan developed for hospice care.


Review of Resident R318's clinical record revealed that the resident was admitted to the facility on October 22, 2021 with the diagnosis of Diabetes Mellitus (a chronic condition that affects the way the body processes blood sugar) with Hyperglycemia (high blood sugar levels).

Review of Resident R318's October 2021 physician orders include an order for Humalog Solution 100 units/ml (Insulin Lispro), Inject as per sliding scale: if 0-120 =0; 121-150 =1 unit; 151-180=2 units; 181-210=3 units; 211-240=4 units; 241-270=5 units; 271-300=6 units; 301-350=8 units; 351-400=10 units; 401-999=12 units and call MD., subcutaneously before meals and at bedtime related to Type II Diabetes Mellitus with Hyperglycemia. LantusSoloStar 100 unit/ml solution pen-injector. Inject 40 units subcutaneously at bedtime for type I Diabetes Mellitus.

Review of Resident R318's current plan of care did not include any goals and interventions related to diagnoses of Diabetes Mellitus.

Findings were confirmed by the Director of Nursing on November 9, 2021 at approximately 1:00 p.m.



28 Pa Code 211.11(d) Resident care plan.

28 Pa Code 211.5 (f) Clinical records

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: 12/24/2021

This Provider submits the following plan of correction in good faith and to comply with Federal regulations. This plan is not an admission of wrong doing nor does it reflect agreement with the facts and conclusions stated in the statement of deficiencies.
1.Resident R4 care plan was updated to include hospice care and services. Resident R318 has discharged safety.
2.Current Hospice residents and Diabetic residents care plans were reviewed to assure it reflects appropriate goals and interventions.
3.License nursing staff will be educated by Educator/Designee on the policy and procedure of developing a comprehensive person- centered care plan.
4.Director of Nursing/designee will perform random audits of Comprehensive care plan of diabetic and hospice residents weekly X4. Findings will be discussed and reviewed at the monthly QAPI meeting to determine if further action is needed.


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


Based on clinical record review, review of facility policy and staff and resident interview, it was determined that the faciltiy failed to ensure that physician's orders were obtained for hospice services for one resident (Resident R4) and clarify and implement physician orders related to diabetic medications and monitoring of blood sugars levels for one resident (Resident R318) of 46 records reviewed.


Findings include:

Review of Facility Policy, Guidelines for Diabetes Mellitus, revised February 2019, revealed: "It is the policy of this facility to: 1. Assist the resident to establish a balance between diet, exercise and medication; 2. Restore carbohydrate utilization, correct electrolyte imbalance and prevent ketoacidosis; 3. Quickly restore normal cerebral function and prevent hyperglycemia, 4. Recognize, treat or prevent complications commonly associated with diabetes; and 5. Individualize resident teaching according to assessed resident and care giver needs." Glucose Monitoring Guidelines: 1. Blood sugar level and frequency measured, when ordered. Facility protocol in place for physician notification with specific parameters of notification. Documentation Guidelines: Blood glucose checks documented on MAR as ordered. Medication Administration documented on MAR.

Review of R4's nursing notes dated July 13, 2021, revealed that hospice services were initiated. Further review of Resident R4's clinical record revealed a Social Services' note dated October 27, 2021, which indicated, "resident currently receiving hospice services." Further review of Resident R4's October 2021 physican's orders revealed that there was no physician's order available for hospice service.

Interview conducted with licensed nursing staff Employee E25 on November 9, 2021 at 1:24 p.m. confirmed that there was no physician order obtained for hospice services.

Review of Resident R318's clinical record revealed that the resident was admitted to the facility on October 22, 2021 with the diagnoses of Diabetes Mellitus Type I (a chronic condition in which the pancreas produces little or no insulin) with Hyperglycemia (high blood sugar), Type II Diabetes Mellitus (long term condition where the body does not use insulin properly) with other skin complications.

Review of Resident R318 November 2021 physician orders include Humalog Solution 100units/ml (Insulin Lispro), Inject as per sliding scale: if 0-120 =0; 121-150 =1 unit; 151-180=2 units; 181-210=3 units; 211-240=4 units; 241-270=5 units; 271-300=6 units; 301-350=8 units; 351-400=10 units; 401-999=12 units and call MD (physician) subcutaneously before meals and at bedtime related to Type I Diabetes Mellitus with Hyperglycemia. LantusSoloStar 100 unit/ml solution pen-injector. Inject 40 units subcutaneously at bedtime for Type II Diabetes Mellitus.

Continued review of Resident R318's clinical record revealed eight blood sugar readings above 400, including: 11/4/2021 at 8:45 p.m. Blood sugar 431; 11/3/2021 at 9:19 p.m. Blood Sugar 420; 11/2/2021 at 9:21 p.m. 420; and 11/2/21 at 9:15 a.m. blood sugar 457; 11/1/2021 at 12:56 p.m. blood sugar 467; 10/30/2021 at 11:58 a.m. Blood sugar 418 and on 10/30/21 at 9:00 a.m. blood sugar 411; and 10/27/21 at 8:30 p.m. blood sugar 435.

Review of Resident 318's clinical record did not include notification of physician with blood sugar levels above 400.

Interview on November 9, 2021 at 9:30 a.m. with licensed nursing staff, Employee E6, confirmed that the physician was not notified with blood sugar levels above 400.

Review of Resident R318's Minimum Data Set ( assessment of resident care needs) dated October 22, 2022 indicated a BIMS (Brief Interview for Mental Status) Score of 15, indicating resident was cognitively intact.

Interview on November 8, 2021 at approximately 5:00 p.m. with Resident R318 revealed, "I did not get my blood sugar checked before dinner. They are supposed to check my levels before dinner and give me insulin."

An interview on November 8, 2021 at 5:05 p.m. with Employee E27, a licensed nurse, confirmed that a nurse had not shown up for second shift at 3:00 p.m on Unit D and that Resident R318 had not received insulin.

Review of Resident 318's November 2021 physician's orders revealed an order for blood sugar levels to be checked at 4:30 p.m. (before dinner) and administer insulin per sliding scale (before dinner).

Review of Resident R318's November 2021 Medication Administration Record revealed that on November 8, 2021 the resident's blood sugar was not tested at 9:00 p.m. and no insulin was administered per sliding scale as ordered by physician.

An interview on November 8, 2021 at 5:15 p.m. with the Director of Nursing, revealed that an agency nurse did not show for the second shift and did not provide notice of the absence.



28 Pa. Code 211.5(f) Clinical records

























 Plan of Correction - To be completed: 12/24/2021

This Provider submits the following plan of correction in good faith and to comply with Federal regulations. This plan is not an admission of wrong doing nor does it reflect agreement with the facts and conclusions stated in the statement of deficiencies.
1.Resident R4 physician hospice order has been obtained. Resident R318 was discharged safely.
2.Residents who were identified as receiving hospice services will be reviewed to assure that a hospice order was obtained. Residents who were diagnosed with Type II diabetes will have their chart reviewed to assure that orders are in place related to diabetic medication and blood glucose monitoring with proper notification of abnormal values having been documented.
3.Licensed professional nurses will be educated by the Educator/Designee on assuring hospice orders and diabetic monitor are followed up on.
4.Director of Nursing/Designee will perform random audits in regards to hospice orders and diabetic monitoring weekly X4. Results will be presented at monthly QAPI meeting for review to determine if further action is needed

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

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

Based on observations, review of facility policies, review of facility documentation, clinical record review and interviews with staff revealed that the facility failed to ensure resident safety for three of 46 residents reviewed related to smoking (Residents R132, R184 and R192).

Findings include:

Review of facility policy, "Smoking" dated October 2017, revealed that, "All residents will be supervised by a staff member."

Review of Resident R132's care plan, dated September 15, 2021, revealed that the resident was a smoker and required supervision with smoking. Review of Resident R132's Smoking Assessment, dated November 4, 2021, revealed that the resident required a staff person to light the cigarette and remain in attendance while the cigarette was burning.

Review of Resident R184's care plan, dated July 28, 2021, revealed that the resident was a smoker and that the resident was to supervised, during scheduled smoking breaks. Review of Resident R184's Smoking Assessment, dated October 21, 2021, revealed that the resident required a staff person to light the cigarette and remain in attendance while the cigarette was burning.

Review of Resident R192's care plan, dated November 7, 2021, revealed that the resident was a smoker and required supervision with smoking. Review of Resident R192's Smoking Assessment, dated November 4, 2021, revealed that the resident required a staff person to light the cigarette and remain in attendance while the cigarette was burning.

Observation on November 7, 2021, at 10:00 a.m. revealed Employee E14, nurse aide, assisted Residents R132, R184 and R192 outside on the C-Wing unit patio to smoke. Employee E14 then came back inside and walked off down the hall, leaving the three residents outside, unattended. All three residents were observed smoking lit cigarettes.

Interview, at the time of the observation, Employee E14 stated that the residents were "Ok by themselves, they'll knock when they're ready to come in."

Continued observation revealed that Residents R132, R184 and R192 remained outside smoking cigarettes unattended until 10:05 a.m., when Employee E13, licensed nurse, went outside and assisted the residents with the rest of their smoke break.

Interview on November 7, 2021, at 10:56 a.m. licensed nursing staff, Employee E12, unit manager, confirmed that a staff person was expected to remain with residents at all times while they are smoking.

28 Pa. Code 201.14 (a) Responsibility of Licensee

28 Pa. Code 201.18 (b)(1)(3) Management

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

28 Pa. Code 209.3(c) Smoking










 Plan of Correction - To be completed: 12/24/2021

This Provider submits the following plan of correction in good faith and to comply with Federal regulations. This plan is not an admission of wrong doing nor does it reflect agreement with the facts and conclusions stated in the statement of deficiencies.
1.Residents R132, R184, and R192 had the remaining of their smoke break supervised by a licensed nursing staff outside the patio on C-wing.
2.A Staff member will be present during smoke breaks to supervise the residents.
3.Staff will be educated by the educator/designee on the smoking policy.
4.Director of Nursing/designee will complete random smoke break audits weekly x 4 to assure policy is being followed. Findings will be reviewed at monthly QAPI meeting to determine if further action is needed.

483.20(f)(5), 483.70(i)(1)-(5) REQUIREMENT Resident Records - Identifiable Information:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
§483.20(f)(5) Resident-identifiable information.
(i) A facility may not release information that is resident-identifiable to the public.
(ii) The facility may release information that is resident-identifiable to an agent only in accordance with a contract under which the agent agrees not to use or disclose the information except to the extent the facility itself is permitted to do so.

§483.70(i) Medical records.
§483.70(i)(1) In accordance with accepted professional standards and practices, the facility must maintain medical records on each resident that are-
(i) Complete;
(ii) Accurately documented;
(iii) Readily accessible; and
(iv) Systematically organized

§483.70(i)(2) The facility must keep confidential all information contained in the resident's records,
regardless of the form or storage method of the records, except when release is-
(i) To the individual, or their resident representative where permitted by applicable law;
(ii) Required by Law;
(iii) For treatment, payment, or health care operations, as permitted by and in compliance with 45 CFR 164.506;
(iv) For public health activities, reporting of abuse, neglect, or domestic violence, health oversight activities, judicial and administrative proceedings, law enforcement purposes, organ donation purposes, research purposes, or to coroners, medical examiners, funeral directors, and to avert a serious threat to health or safety as permitted by and in compliance with 45 CFR 164.512.

§483.70(i)(3) The facility must safeguard medical record information against loss, destruction, or unauthorized use.

§483.70(i)(4) Medical records must be retained for-
(i) The period of time required by State law; or
(ii) Five years from the date of discharge when there is no requirement in State law; or
(iii) For a minor, 3 years after a resident reaches legal age under State law.

§483.70(i)(5) The medical record must contain-
(i) Sufficient information to identify the resident;
(ii) A record of the resident's assessments;
(iii) The comprehensive plan of care and services provided;
(iv) The results of any preadmission screening and resident review evaluations and determinations conducted by the State;
(v) Physician's, nurse's, and other licensed professional's progress notes; and
(vi) Laboratory, radiology and other diagnostic services reports as required under §483.50.
Observations:

Based on review of clinical records, observations, and resident and staff interviews, it was determined that the facility failed to maintain clinical records that were complete and accurate for one of 37 residents reviewed (R176).

Findings include:


Review of Resident R176's clinical records with an admission date July 29, 2017, revealed diagnoses including Schizoaffective Disorder, Bipolar Type, (a mental illness that can affect an individual's thoughts, mood and behavior), Alcohol-Induced Persisting Dementia (excessive drinking over many years may lead to alcoholic dementia which affects memory, learning, and other cognitive functions), and polyneuropathy (disease that affects the nerves in the skin, muscles, and organs. When nerves are damaged, it cannot send regular signals back to the brain).

Further review of Resident R176's physician order dated September 3, 2021, revealed the code status (a code status refers to the level of medical interventions a patient wishes to have started if a person's heart or breathing stops) as, " DNR/DNI/DNH". (DNR stands for Do Not Resuscitate, which is a legal order, indicating that a person does not want to receive cardiopulmonary resuscitation (CPR), an emergency procedure that combines chest compressions often with artificial ventilation if that person's heart stops beating); DNI stands for Do Not Intubate, which is a legal order that tells a healthcare team that a patient does not want to be intubated- no breathing tube will be placed within the patient- in the event of a life-threatening situation; and DNH means Do Not Hospitalize, having a DNH order does not mean the patient won't receive treatment; it simply means she/he will not be sent to a hospital for treatment).

Review of Resident R176's paper clincial record revealed a POLST (Pennsylvania Orders for Life-Sustaining Treatment, which is a medical order that specifies the types of medical treatment that a patient wishes to receive towards the end of life), dated September 13, 2019, which read "CPR". Review of Code status sheet kept at the Nursing Unit, indicated, for Resident R176, the code status as Full code. (Full Code is defined as full support which includes cardiopulmonary resuscitation (CPR), if the patient has no heartbeat and is not breathing.) At the time of finding, it was confirmed with licensed nursing staff, Employee E8, at 12:46 p.m. that Resident R176 code status were different.

An interview with the Director of Nursing on November 10, 2021, at 12:46 p.m., revealed the expectation that all code status information would be updated and should match both in electronic record, hard binders, and charts.

The facility failed to maintain clinical records that were complete and accurately documented for two residents reviewed.

28 Pa. Code 201.14(a) Management

28 Pa. Code 201.18(b)(3)(e)(1) Management

28 Pa Code 201.29(j) Resident rights

28 Pa. Code: 211.5(f) Clinical records















 Plan of Correction - To be completed: 12/24/2021

This Provider submits the following plan of correction in good faith and to comply with Federal regulations. This plan is not an admission of wrong doing nor does it reflect agreement with the facts and conclusions stated in the statement of deficiencies.
1.Resident R176 code status was update to reflect current status in electronic record, hard binders, and chart.
2.A facility audit by social service director/designee will be completed to assure POLST and code status match.
3.Licensed staff, social service department and medical records will be educated on POLST and Code status protocol.
4.The Social service director/designee will perform random audits weeklyX4. The results of the audit will be discussed and reviewed at the monthly QAPI meeting to determine further action is needed

483.80(a)(1)(2)(4)(e)(f) REQUIREMENT Infection Prevention & Control:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
§483.80 Infection Control
The facility must establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections.

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

§483.80(a)(1) A system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon the facility assessment conducted according to §483.70(e) and following accepted national standards;

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

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

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

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

Based on observations, review of professional literature, review of facility policies and interviews with staff, it was determined that the facility failed to maintain an effective infection control program related to wearing the appropriate personal protective equipment for one of five nursing units reviewed (C-Wing nursing unit).

Findings include:

Review of the Pennsylvania Department of Health's 2021-PAHAN-599 "Update: Response to an Outbreak and Residents with Exposure to COVID-19 for Long-term Care Facilities" dated September 24, 2021, revealed that upon identification of one or more cases of COVID-19, the facility should carefully consider options to conduct an outbreak response, including: use of contact tracing, use of a unit-based approach or use of a facility-wide approach to identify exposed residents and staff. Continued review revealed that to implement Zone-based guidance in the facility, refer to PAHAN-570.

Review of the Pennsylvania Department of Health's 2021-PAHAN-570 "Update: Response to an Outbreak and Residents with Exposure to COVID-19 for Long-term Care Facilities" dated May 10, 2021, revealed that residents pending test results but are within 14 days of known or possible exposure to COVID-19 are cohorted in a Yellow Zone (Quarantine). Continued review revealed that full PPE (personal protective equipment) must be used to care for residents in quarantine zones.

Review of facility policy, "PPE Usage in Yellow Zone" undated, revealed that "Yellow Zone = COVID-19 Exposed; Precaution: Contact and Droplet." Continued review revealed, "Required PPE Usage At ALL times: N95 Respirator, Goggles/Face Shield." Further review revealed, "Required PPE Usage During ALL patient care: N95 Respirator, Goggles/Face Shield, Gloves, Gown."

Review of facility documentation, dated November 6, 2021, revealed that the facility received test results from their laboratory provider for COVID-19 testing on November 6, 2021, at 9:21 a.m. which indicated that a staff member tested positive for the COVID-19 virus. The Nursing Home Administrator (NHA) informed the Director of Nursing (DON) and the Infection Preventionist on November 6, 2021, at 7:16 p.m. of the positive test result.

Interview on November 7, 2021, at 9:30 a.m. Employee E18, Nursing Supervisor, revealed that the C-Wing nursing unit was a Yellow Zone and the entire unit was in quarantine related to a staff member who recently tested positive for COVID-19.

Observations during initial tour of the C-Wing nursing unit on November 7, 2021, between 9:34 a.m. through 10:56 a.m. revealed the following:

A sign was posted on the main door entering the unit which indicated, "Yellow Zone."

Observation on November 7, 2021, at 9:35 a.m. Employee E11, licensed nurse, was observed going in and out of resident rooms administering medications. Employee E11 wore a surgical mask and did not have on an N95 mask, goggles/face shield or gown while providing resident care. Interview at the time of the observation, Employee E11 stated that the unit went "Yellow" yesterday, that no isolation gowns were available on the unit and that she was "waiting for the supervisor to bring some eye shields."

Employee E13, licensed nurse, was also observed going in and out of resident rooms administering medications. Employee E13 wore only a surgical mask, she did not have on an N95 mask, goggles/face shield or gown while providing resident care.

Interview on November 7, 2021, at 10:15 a.m. Employee E16, nurse aide, confirmed that the C-Wing nursing unit was a Yellow Zone Quarantine unit. Continued interview revealed that the employee was only wearing a surgical mask because other PPE (N95 masks, face shields, gowns) were not available on the unit.

Observation on November 7, 2021, at 10:30 a.m. revealed Employee E17, nurse aide, provide a.m. care to Resident R179 in his room. Employee E17 wore a surgical mask, face shield and gloves while providing care. Interview at the time of the observation, Employee E17 revealed that N95 masks and isolation gowns were not available on the unit and that staff were waiting for PPE to be brought to the unit.

Observation on November 7, 2021, at 11:56 a.m. revealed that carts with PPE, including isolation gowns, gloves, face shields and N95 masks were set up on the unit.

Continued observation on November 7, 2021, at 12:29 p.m. revealed Employee E13 entered resident room 317-A and obtained a fingerstick blood sugar reading. Employee E13 wore a surgical mask and gloves while providing care, and did not have on an N95, face shield or gown.

Observation of the luncheon meal on the C-Wing Unit on November 7, 2021, at 1:01 p.m. revealed Employees E13, E17, E14 and E12, unit manager, distributing trays to residents in their rooms as well as in the dining room. Employees E13 and E14 wore only N95 masks, Employees E17 and E12 wore N95 masks and face shields. None of the employees wore gowns or gloves while distributing and setting up the meal trays.

Continued observation on the C-Wing nursing unit on November 8, 2021, at 9:52 a.m. revealed licensed nurses, Employees E19 and E11, going in and out of resident rooms administering medications. Employees E19 and E11 wore N95 masks and face shields, however, neither employee wore a gown while providing resident care.

Interview of November 8, 2021, at 11:40 a.m., with Infection Preventionist, Employee E20, revealed that the C-Wing nursing unit was converted to a Yellow Zone Quarantine unit after an unvaccinated staff member who worked on that unit tested positive for COVID-19. Employee E20 confirmed that she became aware of the positive test result on November 6, 2021, and that the nursing supervisor on duty was informed and instructed to convert the unit to a Yellow Zone. Employee E20 was unable to explain why PPE was not promptly put on the unit on November 6, 2021. Employee E20 stated that when working in Yellow Zones, staff are required to wear full PPE, including N95 masks, eye protection, isolation gowns and gloves for all resident care activities which include medication pass, personal care and meal tray distribution.

Interview on November 9, 2021, at 9:15 a.m. the NHA stated that the facility chose to implement zone based guidance and quarantine the entire C-Wing unit after exposure to the staff member who tested positive for COVID-19 who had worked on that unit, because that worker had contact with many residents and because the residents on that unit are very mobile and difficult to contain to their rooms.

28 Pa Code 201.14(a) Responsibility of licensee

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






 Plan of Correction - To be completed: 12/24/2021

This Provider submits the following plan of correction in good faith and to comply with Federal regulations. This plan is not an admission of wrong doing nor does it reflect agreement with the facts and conclusions stated in the statement of deficiencies.
1. A Yellow Zone was immediately established on C wing. Employee E11, E12, E13, E14, E16, E17, and E19 were immediately educated on the importance of wearing appropriate PPE in the Yellow Zone. PPE items was made available to the unit and extras remain in central supplies.
2.All residents on C-Wing were swabbed for Covid-19, Zone base guidance and quarantine was immediately initiated for the entire C-wing due to an employee testing covid-19 positive whom have worked on the unit.
3.Infection preventionist/Designee will re-educate staff regarding "Covid-19 Response to Outbreak and residents with Exposure to Covid-19."
4.Infection control rounds on yellow zones will be conducted daily throughout an outbreak/exposure by the Infection preventionist/designee to assure that proper PPE is being utilized, hand hygiene is being perform in between contacts, with meals and care and supplies are available. Finding will be reviewed and discussed at the monthly QAPI meeting to determine further action is needed.

483.80 (h)(1)-(6) REQUIREMENT COVID-19 Testing-Residents & Staff:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
§483.80 (h) COVID-19 Testing. The LTC facility must test residents and facility staff, including
individuals providing services under arrangement and volunteers, for COVID-19. At a minimum,
for all residents and facility staff, including individuals providing services under arrangement
and volunteers, the LTC facility must:

§483.80 (h)((1) Conduct testing based on parameters set forth by the Secretary, including but not
limited to:
(i) Testing frequency;
(ii) The identification of any individual specified in this paragraph diagnosed with
COVID-19 in the facility;
(iii) The identification of any individual specified in this paragraph with symptoms
consistent with COVID-19 or with known or suspected exposure to COVID-19;
(iv) The criteria for conducting testing of asymptomatic individuals specified in this
paragraph, such as the positivity rate of COVID-19 in a county;
(v) The response time for test results; and
(vi) Other factors specified by the Secretary that help identify and prevent the
transmission of COVID-19.

§483.80 (h)((2) Conduct testing in a manner that is consistent with current standards of practice for
conducting COVID-19 tests;

§483.80 (h)((3) For each instance of testing:
(i) Document that testing was completed and the results of each staff test; and
(ii) Document in the resident records that testing was offered, completed (as appropriate
to the resident’s testing status), and the results of each test.

§483.80 (h)((4) Upon the identification of an individual specified in this paragraph with symptoms
consistent with COVID-19, or who tests positive for COVID-19, take actions to prevent the
transmission of COVID-19.

§483.80 (h)((5) Have procedures for addressing residents and staff, including individuals providing
services under arrangement and volunteers, who refuse testing or are unable to be tested.

§483.80 (h)((6) When necessary, such as in emergencies due to testing supply shortages, contact state
and local health departments to assist in testing efforts, such as obtaining testing supplies or
processing test results.
Observations:

Based on Centers for Medicare & Medicaid Services (CMS) guidance, review of facility documentation, review of facility policy and staff interviews, it was determined that the facility failed to follow the COVID-19 testing guidelines for staff based on the county level of community transmission of COVID-19 for two of three unvaccinated employees reviewed (Employees E22 and Employee E23 ).

Findings include:

Review of facility policy "Facility COVID-19 Employee/Resident Testing", dated October 1, 2021, revealed that Routine testing of unvaccinated staff should be conducted twice a week when level of community transmission is high(Red).

Review of CMS memo QSO-20-38-NH, revised on September 10, 2021, revealed that COVID-19 staff testing is based on the facility's county level of community transmission rate instead of the county positivity rate. Further review of the memo revealed that when the level of COVID-19 community transmission is high (red) or substantial (orange), unvaccinated staff are to be tested for COVID-19, at a minimum, twice a week. When the level of COVID-19 community transmission is moderate (yellow), unvaccinated staff are to be tested once a week and when the level of COVID-19 community transmission is low (blue), testing is not recommended.

Review of facility document for county community transmission log revealed that the county community transmission rate 4.97 (Red) on October 28, 2021 and 5.01 (Red) on November 8, 2021.

Review of facility documentation revealed the facility was using the county positivity rate to determine testing frequency. During an interview with the Infection control Nurse, Employee E20, on November 8, 2021, at 1:00 p.m. she stated that unvaccinated staff should be tested twice a week based on the county positivity rate.

Review of facility employee's COVID-19 vaccination status revealed that Employees E22, Nursing Assistant, and Employee E23, Dietary staff, were not vaccinated against COVID-19. Review of facility's testing logs revealed testing of facility employees occurred on November 2, 2021.

Further review of the facility's testing logs revealed that Employees E22 and Employee E23 was not tested for COVID-19 on November 2, 2021. The testing log also revealed that Employees E22 and Employee E23 employees were not tested twice a week on the week of October 31, 2021 to November 6, 2021.

During an interview with the Infection control nurse, Employee E20 on November 8, 2021, at 1:00 p.m. the infection control nurse confirmed that the facility was conducting testing based on the county positivity rate and that unvaccinated staff, Employees E22 and Employee E23 were not being tested based on the guidance in the QSO memo.

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

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






 Plan of Correction - To be completed: 12/24/2021

This Provider submits the following plan of correction in good faith and to comply with Federal regulations. This plan is not an admission of wrong doing nor does it reflect agreement with the facts and conclusions stated in the statement of deficiencies.
1.Employees E22 and E23 were Tested for Covid-19. Results were negative.
2.All unvaccinated staff are being monitored and tested based on the county transmission rate.
3.Infection Preventionist/designee will provide education to staff regarding routine covid -19 testing requirements for unvaccinated staff.
4.Infection preventionist/designee will perform weekly audits to assure that routine testing is being perform per county transmission rate. Audit findings will be reviewed and discussed at monthly QAPI meeting to determine if further action is needed.

35 P. S. § 448.809b LICENSURE Photo Id Reg:State only Deficiency.
(1) The photo identification tag shall include a recent photograph of the employee, the employee's FIRST name, the employee's title and the name of the health care facility or employment agency.

(2) The title of the employee shall be as large as possible in block type and shall occupy a one-half inch tall strip as close as practicable to the bottom edge of the badge.

(3) Titles shall be as follows:
(i) A Medical Doctor shall have the title " Physician. "
(ii) A Doctor of Osteopathy shall have the title " Physician. "
(iii) A Registered Nurse shall have the title " Registered Nurse. "
(iv) A Licensed Practical Nurse shall have the title " Licensed Practical Nurse. "
(v) Abbreviated titles may be used when the title indicates licensure or certification by a Commonwealth agency.

(4)A notation, marker or indicator included on an identification badge that differentiates employees with the same first name is considered acceptable in lieu of displaying an employee's last name.


Observations:

Based on observations, review of facility polices and interviews with staff, it was determined that the facility failed to ensure that staff members wore appropriate photo identification (ID) badges as required.

Findings include:

Review of facility policy, "Name Badges" dated June 2018, revealed that, "All personnel are required to wear identification name tags or badges during their work shift. An identification name tag or badge must be clearly visible and contain a picture of the employee, the employee's first name initial, last name and job title."

Observation on November 7, 2021, at 10:00 a.m. revealed Employee E14, nurse aide, was not wearing any form of identification badge. Interview at the time of the observation, Employee E14 confirmed that she was not wearing an ID badge.

Observation on November 7, 2021, at 10:15 a.m. revealed Employee E16, nurse aide, was not wearing any form of identification badge. Interview at the time of the observation, Employee E16 stated that she's worked at the facility for so long that her ID badge wore out.

Observation on November 7, 2021, at 10:30 a.m. revealed Employee E17, nurse aide, was not wearing any form of identification badge. Interview at the time of the observation, Employee E17 stated that she's worked at the facility for so long that her ID badge wore out and that she needed to get a new one.

Observation on November 7, 2021, at 10:43 a.m. revealed Employee E15, nurse aide, was not wearing any form of identification badge. Interview at the time of the observation, Employee E15 confirmed that she was not wearing an ID badge.

The facility failed to ensure that staff members wore appropriate photo ID badges as required.




 Plan of Correction - To be completed: 12/24/2021

This Provider submits the following plan of correction in good faith and to comply with Federal regulations. This plan is not an admission of wrong doing nor does it reflect agreement with the facts and conclusions stated in the statement of deficiencies.
1.Employee E14, E15, E16, and E17 were given an appropriate ID badge as required for working in the facility.
2.Staff currently working in the facility were given appropriate Photo identification ID badges for work and informed that badges are required during their work shift.
3.Director of Human Resources/designee will educate and be responsible to assure that staff have appropriate ID badges for work.
4.Random audits on the units will be performed by HR/Designee to assure staff are wearing the correct badges. Observation will be documented and presented at the monthly QAPI meeting for review and to determine if further action is needed.


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