Pennsylvania Department of Health
 ST. ANNE HOME
Patient Care Inspection Results

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ST. ANNE HOME
Inspection Results For:

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ST. ANNE HOME - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on a Medicare/Medicaid Recertification survey, State Licensure survey, and Civil Rights Compliance survey completed on July 25, 2024, it was determined that St. Anne Home was not in compliance with the following requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care Facilities and the 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.



 Plan of Correction:


483.21(b)(2)(i)-(iii) REQUIREMENT Care Plan Timing and Revision: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.
§483.21(b) Comprehensive Care Plans
§483.21(b)(2) A comprehensive care plan must be-
(i) Developed within 7 days after completion of the comprehensive assessment.
(ii) Prepared by an interdisciplinary team, that includes but is not limited to--
(A) The attending physician.
(B) A registered nurse with responsibility for the resident.
(C) A nurse aide with responsibility for the resident.
(D) A member of food and nutrition services staff.
(E) To the extent practicable, the participation of the resident and the resident's representative(s). An explanation must be included in a resident's medical record if the participation of the resident and their resident representative is determined not practicable for the development of the resident's care plan.
(F) Other appropriate staff or professionals in disciplines as determined by the resident's needs or as requested by the resident.
(iii)Reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments.
Observations:


Based on review of facility policy and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that a resident's care plan was updated/revised to reflect the resident's specific care needs for seven of 48 residents reviewed (Residents 3, 7, 26, 30, 64, 66, 73).

Findings include:

The facility policy for care plans, dated October 13, 2024, indicated that care plans are to reviewed/rewritten/revised quarterly and/or on an ongoing basis to reflect the changes in the resident and the care that the resident is receiving.

An annual Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 3, dated July 3, 2024, revealed that the resident was cognitively impaired, was clearly understood and able to understand others, required assistance with care needs, was receiving antianxiety and antipsychotic medications, and had diagnoses that included depression, anxiety, and dementia.

Physician's order for Resident 3, dated April 2, 2024, indicated that the resident was ordered five milligrams (mg) of Olanzapine (an antipsychotic medication) daily for Sundowning Dementia with Behaviors.

Physician's order for Resident 3, dated April 22, 2024, indicated that the resident was ordered 0.5 mg of Lorazepam (an antianxiety medication) three times daily for restlessness/anxiety.

Clinical record review for Resident 3 revealed that she had a care plan, dated June 22, 2022, for psychotropic medications that addressed antidepressant medications. There was no documented evidence that the care plan was revised to reflect the resident's need for antianxiety and antipsychotic medications.

Interview with the Director of Nursing on July 25, 2024, at 1:16 p.m. confirmed that Resident 3's care plan was not revised to reflect the need for antianxiety and antipsychotic medications and it should have been.

A significant change MDS assessment for Resident 7, dated May 26, 2024, revealed that the resident was cognitively impaired, was clearly understood and able to understand others, and required assistance with care needs.

Clinical record review for Resident 7 revealed that she had a care plan, dated September 10, 2019, for history of falls with a fracture and risk for falls related to her inability to ambulate related to left hemiparesis, muscle weakness, and poor balance.

An event report for Resident 7 related to a fall on July 7, 2024, revealed that failure to use her reacher was a contributing fall factor and indicated that both therapy and nursing would re-educate the resident on the importance of using the reacher. There was no documented evidence that the care plan was revised to reflect the resident's need for a reacher to aide in fall prevention. There was no documented evidence in the resident's care plan to address her failure to use to reacher and her need for re-education on the use of the reacher.

Interview with the Director of Nursing on July 25, 2024, at 5:01 p.m. confirmed that Resident 7's care plan was not revised to reflect the resident's need for a reacher to aide in fall prevention and was not revised to address her failure to use to reacher and her need for re-education on the use of the reacher.

A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 26, dated July 2, 2024, revealed that the resident was cognitively impaired, required substantial assistance with care needs, and required a mechanically altered diet.

Observations of Resident 26 at lunch on July 23, 2024, at 12:13 revealed the resident had plastic utensils.

Review of Resident 26's nutrition care plan did not indicate that the resident was to use plastic utensils.

A nurse's note, dated April 27, 2024, revealed that Resident 26 was on a feeding program and required plastic utensils for her safety.

Interview with the Director of Nursing on July 25, 2024, at 11:2 a.m. revealed that Resident 26 has been using plastic utensils for a long period of time, and the care plan should have been updated to reflect the use of plastic utensils.

A quarterly MDS assessment for Resident 30, dated April 25, 2024, revealed that the resident was cognitively impaired, was usually understood and usually understood others, required assistance with care needs, and had a feeding tube (a mechanical device surgically implanted into the stomach to provide nutrition, fluids and medications to a person who is unable to eat or drink by mouth).

Physician's orders for Resident 30, dated June 29, 2024, indicated that the resident's feeding tube was to be flushed with 250 milliliters (ml) of water every four hours.

Clinical record review for Resident 30 revealed that she had a nutrition care plan, dated June 26, 2019, that indicated the resident's feeding tube was to be flushed with 175 ml of water every four hours effective October 3, 2023. There was no documented evidence that the care plan was revised to reflect the current order for feeding tube flushes as of June 29, 2024.

Interview with the Director of Nursing on July 25, 2024, at 12:38 p.m. confirmed that Resident 30's care plan was not revised to reflect the current order for feeding tube flushes.

An annual MDS assessment for Resident 64, dated June 29, 2024, revealed that the resident was cognitively impaired, required extensive assistance from staff for daily care needs, and had diagnoses that included urinary retention (a condition that occurs when a person is unable to empty their bladder).

Physician's orders for Resident 64, dated August 1, 2023, included an order for the resident have a urinary catheter (a tube that is inserted into the bladder to drain urine) and an order to discontinue the urinary catheter on August 8, 2023.

A review of care plans for Resident 64, dated July 27, 2023, included a care plan for an indwelling catheter related to a history of urinary retention. There was no documented evidence that the care plan was revised to reflect the discontinuation of the urinary catheter on August 8, 2023.

Interview with the Director of Nursing on July 25, 2024, at 3:32 p.m. confirmed that Resident 64's care plan, dated July 27, 2023, should have been revised to reflect the discontinuation of the urinary catheter and it was not.

A quarterly Minimum Data Set (MDS) assessment for Resident 66, dated June 3, 2024, revealed that the resident was cognitively impaired, required assistance with care needs, and was receiving anticoagulant (a blood thinning medication) medication.

Physician's order for Resident 66, dated January 2, 2024, indicated that the resident was ordered 5 mg of Eliquis (anticoagulant medication) twice a day times day for atrial fibrillation (abnormal heartbeat).

A care plan for Resident 66, dated January 2, 2024, revealed that the resident was being monitored for side effects of anticoagulant medication, with an intervention for staff to be aware that Xarelto (an anticoagulant medication) drug information, including the mechanism of the medication to indirectly inhibit platelet aggregation induced by thrombin.

Interview with the Director of Nursing on July 25, 2024, at 2:45 p.m. confirmed that Resident 66's care plan was not revised to reflect the current ordered anticoagulant medication, and should have been.

A quarterly MDS assessment for Resident 73, dated May 8, 2024, indicated that the resident was cognitively impaired, required assistance from staff for her daily care needs, and had a Stage 4 pressure ulcer (pressure wound with full thickness tissue loss with exposed bone, tendon or muscle).

Physician's order for Resident 73, dated July 3, 2024, indicated that the resident's wound to her left heel was to be cleansed with normal saline (a sterile solution used for the moistening of wound dressings and wound debridement), apply santyl (a wound debridement treatment) to wound base, top with Calcium alginate (a dressing used to wounds with a high amount of drainage), and cover with a dry dressing daily.

Physician's order for Resident 73, dated July 3, 2024, indicated that the resident's wound to her coccyx was to be irrigated with Vashe (a wound cleanser that promotes healing), pat dry, fill with Vashe-soaked gauze, and cover with a dry dressing twice daily.

Clinical record review for Resident 73 revealed that she had a care plan, dated February 9, 2024, for skin impairments and pressure ulcers (localized skin and soft tissue injuries that form as a result of prolonged pressure). The care plan indicated that the left heel wound was to be cleansed with normal saline, apply polysporin (antibiotic ointment used to treat minor wounds and skin infections), cover with kerlix/kling (used to secure dressings) to secure daily. The care plan indicated that the Stage 4 pressure ulcer to the coccyx was to be irrigated with Dakin's solution (a solution used to treat and prevent tissue infections), pack wound with Dakin's solution moistened kerlix, cover with abdominal pad, and secure with minimal tape daily and as needed. There was no documented evidence that the care plans were updated to reflect current treatment orders as of July 3, 2024.

A wound note for Resident 73, dated April 26, 2024, indicated that the wound to the left calf was resolved. There were no current treatment orders for a pressure ulcer to the left lower buttocks.

Clinical record review for Resident 73 revealed that she had a care plan, dated February 10, 2024, for a Stage 2 pressure ulcer (pressure wound with superficial skin loss) to her left lower buttock and a vascular ulcer (ulcers caused by problems with blood flow in the leg veins) to her left central calf. There was no documented evidence that the care plans were updated to reflect that the wounds to the left calf and left lower buttocks were resolved.

Interview with the Corporate Compliance Officer on July 25, 2024, at 12:09 p.m. confirmed that the care plans for Resident 73 were not revised to reflect that the current treatments to the wounds on the left heel and coccyx and were not revised to reflect that the left central calf vascular ulcer and pressure ulcer to the left lower buttocks were resolved.

28 Pa. Code 201.24(e)(4) Admission Policy.

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



 Plan of Correction - To be completed: 08/30/2024

Preparation and/or execution of this plan of correction does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of federal and state law.
1. Resident 3 care plan revision completed 8/9/24 to reflect resident's need for antianxiety and antipsychotic medications. Resident 7 care plan updated on 7/7/24 for reminder sign to utilize call bell for assistance. Therapy referral sent on 8/9/24 for Resident 7 to be evaluated for reacher device with therapy not recommending utilization of reacher device. Resident 26 care plan revision completed on 8/. Resident 30 care plan revision completed on 8/12/24 to reflect current need for feeding tube flushes. Resident 64 care plan revised on 8/9/24 to reflect the discontinuation of the urinary catheter on 8/8/23. Resident 66 care plan revision completed 7/25/24 removing Xarelto from resident's anticoagulant care plan. Resident 73 care plan revision completed on 7/25/24 resolving wounds to resident's left calf and left lower buttocks and to follow physician orders for current treatment of coccyx and left heel wound.
2. The Registered Nurse Assessment Coordinator (RNAC) and Licensed Practical Nurse Assessment Coordinators (LPNAC) have completed a whole house audit to ensure resident care plans are updated with each residents current needs.
3. The Registered Nurse Assessment Coordinator (RNAC) and Licensed Practical Nurse Assessment Coordinators (LPNAC) were re-educated by the Quality Assurance Performance Improvement (QAPI) Nurse on the timing and revision of care plans as it relates to resident diagnosis's/new physician orders. RNAC and LPNAC's will run physician order summary daily to revise care plan's timely.
4. The Quality Assurance Performance Improvement (QAPI) Nurse or designee will audit the timing and revision of care plans of a sample size of five residents once a week beginning 8/12/24 for four weeks and then once a month for two months. All findings will be reported to the Quality Assurance Performance Committee. If deficient practices are identified additional corrective action will be taken.


483.45(f)(1) REQUIREMENT Free of Medication Error Rts 5 Prcnt or More:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
§483.45(f) Medication Errors.
The facility must ensure that its-

§483.45(f)(1) Medication error rates are not 5 percent or greater;
Observations:


Based on review of clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure a medication error rate of less than five percent.

Findings include:

Observations during medication administration on July 24, 2024, at 9:59 a.m. revealed that eight medication administration errors were made during 28 opportunities for error, resulting in an error rate of 28.57 percent.

Current physician's orders for Resident 12 included orders for the resident to receive 35 milliliters (ml) of Valproic acid 250 milligram (mg)/5 ml oral solution twice a day by mouth for a seizure disorder; 30 ml of Lactulose 220 grams/30 ml oral solution (a medicine used as a laxative) twice a day via gastric tube; 1 mg of Klonopin (a medicine used as a sedative) twice a day via gastric tube (tube inserted through the belly that brings nutrition or medication directly to the stomach) for profound mental retardation with agitation; 1 mg of Risperdal (a medicine used as an antipsychotic) twice a day via gastric tube for profound mental deficiency secondary to mental retardation with psychosis; 400 mg of magnesium oxide (a medicine used as a mineral supplement) four times a day via gastric tube for a supplement; 0.125 mg of Levsin (a medicine used as an antispasmodics) twice a day via gastric tube for excessive secretion; 500 mg of Carbamazepine (a medicine used as an anticonvulsant) twice a day via gastric tube; and 2.5 ml of Ferrous sulfate (220 mg/5 ml) oral solution (a medicine used as a mineral supplement) daily via gastric tube.

Observations during A hall medication pass on July 24, 2024, at 9:53 a.m. revealed that Licensed Practical Nurse 13 prepared the following medications for Resident 12 to be administered via the gastrostomy tube (feeding tube): ferrous sulfate, Valproic acid, Lactulose, Risperdal, magnesium oxide, Levsin and Carbamazepine. She did not prepare the Klonopin.

On July 24, 2024, at 10:01 a.m. Licensed Practical Nurse 13 checked the residual contents of Resident 12's gastrostomy tube via aspiration, resulting in one syringe of approximately 60 ml. Licensed Practical Nurse 13 stated that the amount of gastric residual was too much and did not administer the prepared medications. She contacted her supervisor.

Interview with Licensed Practical Nurse 13 on July 24, 2024, at 10:18 a.m. revealed that she was unable to find an order to hold the medication if the residual met a certain amount but was still going to hold them. She also explained that she was not going to prepare the scheduled Klonopin just to waste the medication.

Observations on July 24, 2024, at 10:34 a.m. revealed that Licensed Practical Nurse 13 and Registered Nurse Supervisor 14 wasted the seven prepared medications. Licensed Practical Nurse 13 said. "I know I made mistakes and I am sorry."

The July 2024 Medication Administration Record (MAR) for Resident 12 indicated that the 8:00 a.m. medications were not administered due to excess residual; however, there was no evidence in the clinical record of a physician's order to hold the medications based on a residual amount.

Interview with Registered Nurse Supervisor 14 on July 24, 2024, at 3:44 p.m. revealed that the nurse should have prepared all eight medications. She was also told that Licensed Practical Nurse 13 had two syringes full of gastric residual (120 ml) for Resident 12.

Interview with Registered Nurse Supervisor 6 on July 25, 2024, at 10:07 p.m. revealed that she received report from Registered Nurse Supervisor 14 indicating that there had been 120 ml of residual for Resident 12.

Interview with the Director of Nursing on July 24, 2024, at 5:03 p.m. confirmed that Licensed Practical Nurse 13 did not have over 100 ml of residual contents for Resident 12 and the medications should have been administered. She initiated a medication error report.

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



 Plan of Correction - To be completed: 08/30/2024

Preparation and/or execution of this plan of correction does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of federal and state law.
1. The Licensed Practical Nurse received education by Director of Nursing or designee and counsel on administering medication via a gastrostomy tube. Education included but not limited to checking residuals and contacting the Registered Nurse Supervisor before electing to hold a medication based on a residual when there was no physician order to hold. The physician was notified of missed mediation on July 24, 2024, with no additional orders received. The resident is at baseline with a medication error form completed as per facility policy.
2. The facility has 2 residents with gastrostomy tubes with no other Gastrostomy tubes or other types of tubes in the facility currently that individuals are receiving medications. The Director of nursing observed medication administration on both these residents with no additional concerns identified.
3. Professional Nursing staff were reeducated by the Director of Nursing or designee on the Policy Medication Administration via Gastrostomy tubes.
4. The Director of Nursing or designee will audit weekly for four weeks, then once a month for two months and will continue monthly unless deemed no longer necessary by the Quality Assurance Performance Committee.


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


Based on a review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to follow physician's orders for four of 48 residents reviewed (Residents 43, 58, 65, 125).

Findings include:

A Quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 43, dated April 17, 2024, revealed that the resident was cognitively impaired, required extensive assistance for daily care needs, and had diagnoses that coronary artery disease, hypertension (high blood pressure), and was on Eliquis (a medication to prevent blood clots). The resident's care plan, dated April 11, 2024, indicated that the resident was to be assessed for alterations in skin conditions and bleeding.

Physician's orders for Resident 43, dated April 11, 2024, included an order for the physician to be notified of side effects of Eliquis such as bruising, bleeding, or complications.

A nursing note for Resident 43, dated May 28, 2024, at 9:31 a.m., revealed that staff observed a new bruise to the resident's right arm.

There was no documented evidence in Resident's 43 clinical record to indicate that the physician was notified of the new bruise per physician's orders.

Interview with the Director of Nursing on July 25, 2024, at 1:54 p.m. confirmed that the physician was not notified regarding Resident 43's new bruise per physician orders and should have been.

An Annual MDS assessment for Resident 58, dated June 14, 2024, revealed that the resident was cognitively intact, required extensive assistance for daily care needs, and had diagnoses that included atrial fibrillation (a medical condition where the heart beats are out of sync), hypertension (high blood pressure), and kidney disease.

Physician's orders for Resident 58, dated March 15, 202, revealed that the resident was to receive 5 milligrams (mg) of midodrine for hypotension (low blood pressure) three times a day, and the medication was to be held if the resident's systolic blood pressure (top number) was greater than 130 millimeters of mercury (mm/Hg) or diastolic blood pressure (bottom number) was greater than 70 mm/Hg.

The medication administration record or MAR for May and June 2024 for Resident 58 revealed that the resident's blood pressure was 119/74 mm/Hg at 2:00 p.m. on May 4, 2024; 128/75 mm/Hg at 8:00 p.m. on May 5, 2024; 127/74 mm/Hg at 8:00 p.m. on May 9, 2024; 113/76 mm/Hg at 2:00 p.m. on May 10, 2024; 118/78 mm/Hg at 8:00 p.m. on May 10, 2024; 124/79 mm/Hg at 2:00 p.m. on May 11, 2024; 120/71 mm/Hg at 8:00 p.m. on May 12, 2024; 116/72 mm/Hg at 4:00 a.m. on May 15, 2024; 119/80 mm/Hg at 8:00 a.m. on May 16, 2024; 124/78 mm/Hg at 2:00 p.m. on May 16, 2024; 110/74 mm/Hg at 8:00 p.m. on May 16, 2024; 114/71 mm/Hg at 8:00 a.m. on May 19, 2024; 106/71 mm/Hg at 4:00 a.m. on May 20, 2024; 140/88 mm/Hg at 4:00 a.m. on May 24, 2024; 126/78 mm/Hg at 8:00 a.m. on May 25, 2024; 151/64 mm/Hg at 8:00 a.m. on June 1, 2024; 138/66 mm/Hg at 2:00 p.m. on June 1, 2024; 155/74 mm/Hg at 4:00 a.m. on June 3, 2024; 110/79 mm/Hg at 8:00 p.m. on June 5, 2024; 106/76 mm/Hg at 8:00 a.m. on June 6, 2024; 101/72 mm/Hg at 2:00 p.m. on June 6, 2024; 105/72 mm/Hg at 8:00 p.m. on June 7, 2024; 130/77 at 8:00 p.m. on June 11, 2024; no vital signs were taken at 2:00 p.m. and 8:00 p.m. on June 14, 2024; 128/76 mm/Hg at 8:00 p.m. on June 17, 2024; 122/81 mm/Hg at 2:00 p.m. on June 18, 2024; 118/73 mm/Hg at 8:00 p.m. on June 18, 2024; 99/77 mm/Hg at 2:00 p.m. on June 19, 2024; 110/73 mm/Hg at 4:00 a.m. on June 21, 2024; 106/84 mm/Hg at 8:00 p.m. on June 25, 2024; and 133/65 mm/Hg at 2:00 p.m. on June 30, 2024.

The resident received 5 mg of midodrine on the above dates and times; however, the medication should have been held since the blood pressures were outside of the parameters.

Interview with the Director of Nursing on July 25, 2024, at 11:54 p.m. confirmed the above medication should not have been administered and should have been held

A quarterly MDS assessment for Resident 65, dated July 25, 2024, revealed that the resident was cognitively intact, required assistance from staff for daily care needs, and had a diagnosis of hypoxia (low levels of oxygen in body tissue).

Physician's orders for Resident 65, dated August 26, 2023, included an order for a pulse oximetry (a measurement of oxygen in the blood) to be obtained every shift.

The treatment administration record or TAR for July 2024 for Resident 65 revealed that there was no documented evidence that the pulse ox was obtained on July 6, 7, 14 and 20, 2024, as ordered by the physician.

Interview with the Director of Nursing on July 24, 2024, at 12:38 p.m. confirmed that there was no documented evidence that Resident 65's pulse oximetry was obtained on the above mentioned dates.

An annual MDS assessment for Resident 125, dated July 3, 2024, revealed that the resident was cognitively intact, required assistance from staff for daily care needs, and had diagnoses that included high blood pressure and chronic kidney disease (kidneys are damaged and cannot filter blood properly).

Physician's orders for Resident 125, dated June 28, 2024, included an order for intake and output to be obtained every shift.

The TAR for July 2024 for Resident 125 revealed no documented evidence that the intake and output was obtained on July 1, 2 ,3, 5 and 6, 2024, as ordered by the physician.

Interview with the Director of Nursing on July 24, 2024, at 3:33 p.m. confirmed that there was no documented evidence that Resident 65's intake and output was obtained on the above mentioned dates.

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




 Plan of Correction - To be completed: 08/30/2024

Preparation and/or execution of this plan of correction does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of federal and state law.
. 1. R43: The physician was notified on July 25, 2024, of bruise that had been reported and documented on the St. Anne Home Incident/ Accident Form May 28th. No new orders. Resident has no current bruises or alterations in skin integrity not known by physician however remains at high risk for bruising with activities of daily due to the mediation regime.
R58: The physician was notified, and the nurse practitioner examined the resident on 08/13/2024. Based on the nurse practitioner's assessment as well as review of the vital signs, the parameters for Midodrine were changed. There are clearly defined parameters to give Midodrine if Systolic Blood pressure is 130 or lower. Diastolic is not a factor per the Nurse practitioner and was removed from the orders.
R65: The physician was notified and evaluated the daily pulse ox readings that were done with all readings in the high 90's with no respiratory distress noted. Every shift pulse ox assessment was discontinued.
R125 was discharged home on 7/27/24 in stable condition.
2. All current residents were assessed by the daylight Registered Nurse Supervisor with no additional residents found as it relates to changes in condition without physician notification as well as failure to follow physician orders.
3. The Director of Nursing and or designee reeducated nursing staff on Quality-of-Care requirements which included but were not limited to following physician orders including those medications with physician ordered parameters as well as ordered vital assessments including pulse oximetry. Also reeducated on notification of physician with changes in condition including but not limited to bruises and alterations in skin integrity. The Interdisciplinary team will utilize the Clinical Follow Up Tool for clinical morning meetings and the facility implemented an end of the day meeting for the clinical leaders titled Stand Down at which time it is verified Quality of Care standards have been met including but not limited to physician notification of changes in condition .
4. The Director of Nursing or designee will audit weekly for four weeks, then once a month for two months. All findings will be reported to the Quality Assurance Performance Committee. If deficient practices are identified additional corrective action will be taken.

483.10(c)(7) REQUIREMENT Resident Self-Admin Meds-Clinically Approp: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(c)(7) The right to self-administer medications if the interdisciplinary team, as defined by §483.21(b)(2)(ii), has determined that this practice is clinically appropriate.
Observations:


Based on review of policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to determine if residents were safe to self-administer medications for one of 48 residents reviewed (Resident 58).

Findings include:

The facility's self-administration of medications policy, dated October 13, 2023, indicated that if a resident desired to self-administer medications, they would require a physician's order. The facility's medication administration policy, dated October 13, 2023, indicated that the nurse must stay with the resident until the medication is taken.

An annual Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 58, dated June 14, 2024, indicated that the resident was cognitively intact and required extensive assistance from staff with care. Current physician's orders included an order for the resident to receive a 100 mg tablet of Colace (a medication to treat constipation) twice a day; 5 mg of Eliquis (a blood thinning medication), 1 tablet in the a.m.; 800 mg of Renvela (a medication to control phosphorus levels), 3 tablets once a day; 25 mg of Benadryl (a medication to treat allergies), 1 tablet twice a day; and 81 mg of aspirin in the a.m. The resident's record contained no documented evidence that an evaluation was completed to determine if the resident was capable of self-administering medications and no evidence of a physician's order for self-administering medications.

Observations during medication administration on July 25, 2024, at 8:25 a.m. revealed that Resident 58 was lying in bed with a medication cup containing the morning doses of the medications listed above and Licensed Practical Nurse 1 was not in the room.

Interview with Licensed Practical Nurse 1 on July 25, 2024, at 8:29 a.m. confirmed that she left the room after administering medication to Resident 58 and did not observe the resident taking his medication.

Interview with the Director of Nursing on July 25, 2024, at 1:23 p.m. confirmed that there was no assessment completed to determine if Resident 58 was safe to self-administer medications and no physician's order for self-administration. She also confirmed that Licensed Practical Nurse 1 should not have left the morning medications with Resident 58.

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




 Plan of Correction - To be completed: 08/30/2024

Preparation and/or execution of this plan of correction does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of federal and state law.
1. Resident 58 is not permitted to self-administer his medications despite his Brief Interview for Mental Status (BIMS) score of 13. He does not demonstrate the physical and visual acuity to perform such tasks safely per the Nurse Practitioner (CRNP). Resident is at baseline.
2. The Registered Nurse Supervisor reviewed all residents with no current residents appropriate for self-administration of medications. No one is currently care planned for self-administration of medications.
3. The Director of Nursing will educate the Licensed professional staff on the Medication Self Administration Policy.
4. The Director of Nursing or designee will audit weekly for four weeks, then once a month for two months. All findings will be reported to the Quality Assurance Performance Committee. If deficient practices are identified additional corrective action will be taken.


483.95(g)(1)-(4) REQUIREMENT Required In-Service Training for Nurse Aides: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.
§483.95(g) Required in-service training for nurse aides.
In-service training must-

§483.95(g)(1) Be sufficient to ensure the continuing competence of nurse aides, but must be no less than 12 hours per year.

§483.95(g)(2) Include dementia management training and resident abuse prevention training.

§483.95(g)(3) Address areas of weakness as determined in nurse aides' performance reviews and facility assessment at § 483.70(e) and may address the special needs of residents as determined by the facility staff.

§483.95(g)(4) For nurse aides providing services to individuals with cognitive impairments, also address the care of the cognitively impaired.
Observations:


Based on a review of employee education records, as well as staff interviews, it was determined that the facility failed to ensure that nurse aides completed the required annual education for two of five nurse aides reviewed (Nurse Aides 12, 18)

Findings include:

A facility policy regarding Orientation/Training/Evaluation, dated October 13, 2023, indicated that a minimum of 12 hours of in-service education will be provided to nurse aides annually based on their anniversary hire date (day and month).

Review of the employee education file for Nurse Aides 12 and 18 revealed that there was no documented evidence to indicate that a minimum of 12 hours of in-service education was completed annually based on their anniversary hire date (day and month).

Interview with the Director of Nursing on July 24, 2024, at 2:35 p.m. confirmed that there was no documented evidence to indicate that Nurse Aides 12 and 18 completed a minimum of 12 hours of in-service education based on their anniversary hire date (day and month) as required.

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

28 Pa. Code 201.19 Personnel Policies and Procedures.



 Plan of Correction - To be completed: 08/30/2024

Preparation and/or execution of this plan of correction does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of federal and state law.
1. St. Anne Home policy has been revised to reflect that Nurse Aides that are not compliant with annual education will be removed from the schedule until able to complete the required education. Nurse Aides 12 and 18 in-service education has been completed or scheduled to be compliant by 8/30/2024. Nurse Aides 12 and 18 annual education is ongoing.
2. All current Nurse Aide files were reviewed by the Infection Preventionist and have had the required annual education or are scheduled to be compliant by 8/30/2024.
3. The Infection Preventionist or designee will review employee records monthly to determine Nurse Aides that require more education within 2 months. The Infection Preventionist or designee will then notify Human Resources Director or designee to allow staff scheduling for annual education.
4. The Infection Preventionist or designee will do audits every 3 weeks for three months to ensure monthly compliance. All findings will be reported to the Quality Assurance Performance Committee. If deficient practices are identified additional action will be taken.

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 review of established infection control guidelines, facility policy, and residents' clinical records, as well as observations and staff interviews, it was determined that the facility failed to follow infection control guidelines from the Centers for Medicare/Medicaid Services (CMS) and the Centers for Disease Control (CDC) to reduce the spread of infections and prevent cross-contamination for one of 48 residents reviewed (Resident 5).

Findings include:

CDC guidance on isolation precautions and Implementation of Personal Protective Equipment (PPE) use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs), dated July 12, 2022, indicates that multidrug-resistant organism (MDRO) transmission is common in skilled nursing facilities, contributing to substantial resident morbidity and mortality and increased healthcare costs. Enhanced Barrier Precautions (EBP) are an infection control intervention designed to reduce transmission of resistant organisms that employs targeted gown and glove use during high contact resident care activities. CMS updated its infection prevention and control guidance effective April 1, 2024. The recommendations now include the use of EBP during high-contact care activities for residents with chronic wounds or indwelling medical devices, regardless of their MDRO status, in addition to residents who have an infection or colonization with a CDC-targeted or other epidemiologically important MDRO when contact precautions do not apply.

The facility's policy regarding Enhanced Barrier Precautions (EBP), dated April 30, 2024, indicated that before performing high-contact resident care activity which includes transferring, gloves and a gown must be used and properly discarded before exiting the resident room to contain pathogens.

A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 5, dated July 10, 2024, revealed that the resident was cognitively intact, required extensive assistance from staff for daily care needs, and had a history of CRE (Carbapenem Resistant Enterobacterales - a bacteria that causes infection in people and animals) in her urine. A care plan for Resident 5 regarding EBP, dated July 14, 2024, revealed that the resident had EBP in place due CRE in her urine.

Observations of Resident 5 on July 24, 2024, at 10:55 a.m. revealed that the resident had signage at the entrance to her room to indicate that infection control measures for EBP were in place related to a history of CRE in her urine. Nurse Aide 17 had placed Resident 5 in a sling in preperation to use a mechanical lift for a transfer. Nurse Aide 17 had gloves on her hands; however, she was not wearing a gown at the time of the transfer.

Interview with Nurse Aide 17 on July 24, 2024, at 10:58 a.m. revealed that she did not wear a gown when transferring Resident 5 and she should have.

Interview with the Director of Nursing on July 24, 2024, at 3:32 p.m. confirmed that Resident 5 had EBP, and staff should have been wearing a gown and gloves while transferring the resident.

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

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

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



 Plan of Correction - To be completed: 08/30/2024

Preparation and/or execution of this plan of correction does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of federal and state law.
1. Resident 5 affected by the alleged deficient practice had no negative impact on their status. Nurse Aide 17 was re-educated by the Infection Preventionist on 7/24/2024 regarding care of residents in Enhanced Barrier Precautions, including Personal Protective Equipment (gown) use while performing high-contact resident care activities, and rationale.
2. All residents in Enhanced Barrier Precautions had the potential to be affected by the same alleged practice. No other Nurse Aides were observed not wearing a gown while caring for residents in Enhanced Barrier Precautions.
3. The Infection Preventionist or designee will re-in-service nursing staff on Enhanced Barrier Precautions, Personal Protective Equipment use while performing high-contact care activities, and rationale.
4. The Infection Preventionist or designee will audit Personal Protective Equipment usage for 3 Nurse Aides caring for residents in Enhanced Barrier Precautions 3 times a week for 4 weeks, then 2 times a week for 4 weeks, then once a week for 4 weeks. All findings will be reported to the Quality Assurance Performance Committee. If deficient practices are identified additional action will be taken.

483.75(c)(d)(e)(g)(2)(i)(ii) REQUIREMENT QAPI/QAA Improvement Activities: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.
§483.75(c) Program feedback, data systems and monitoring.
A facility must establish and implement written policies and procedures for feedback, data collections systems, and monitoring, including adverse event monitoring. The policies and procedures must include, at a minimum, the following:

§483.75(c)(1) Facility maintenance of effective systems to obtain and use of feedback and input from direct care staff, other staff, residents, and resident representatives, including how such information will be used to identify problems that are high risk, high volume, or problem-prone, and opportunities for improvement.

§483.75(c)(2) Facility maintenance of effective systems to identify, collect, and use data and information from all departments, including but not limited to the facility assessment required at §483.70(e) and including how such information will be used to develop and monitor performance indicators.

§483.75(c)(3) Facility development, monitoring, and evaluation of performance indicators, including the methodology and frequency for such development, monitoring, and evaluation.

§483.75(c)(4) Facility adverse event monitoring, including the methods by which the facility will systematically identify, report, track, investigate, analyze and use data and information relating to adverse events in the facility, including how the facility will use the data to develop activities to prevent adverse events.

§483.75(d) Program systematic analysis and systemic action.

§483.75(d)(1) The facility must take actions aimed at performance improvement and, after implementing those actions, measure its success, and track performance to ensure that improvements are realized and sustained.

§483.75(d)(2) The facility will develop and implement policies addressing:
(i) How they will use a systematic approach to determine underlying causes of problems impacting larger systems;
(ii) How they will develop corrective actions that will be designed to effect change at the systems level to prevent quality of care, quality of life, or safety problems; and
(iii) How the facility will monitor the effectiveness of its performance improvement activities to ensure that improvements are sustained.

§483.75(e) Program activities.

§483.75(e)(1) The facility must set priorities for its performance improvement activities that focus on high-risk, high-volume, or problem-prone areas; consider the incidence, prevalence, and severity of problems in those areas; and affect health outcomes, resident safety, resident autonomy, resident choice, and quality of care.

§483.75(e)(2) Performance improvement activities must track medical errors and adverse resident events, analyze their causes, and implement preventive actions and mechanisms that include feedback and learning throughout the facility.

§483.75(e)(3) As part of their performance improvement activities, the facility must conduct distinct performance improvement projects. The number and frequency of improvement projects conducted by the facility must reflect the scope and complexity of the facility's services and available resources, as reflected in the facility assessment required at §483.70(e). Improvement projects must include at least annually a project that focuses on high risk or problem-prone areas identified through the data collection and analysis described in paragraphs (c) and (d) of this section.

§483.75(g) Quality assessment and assurance.

§483.75(g)(2) The quality assessment and assurance committee reports to the facility's governing body, or designated person(s) functioning as a governing body regarding its activities, including implementation of the QAPI program required under paragraphs (a) through (e) of this section. The committee must:

(ii) Develop and implement appropriate plans of action to correct identified quality deficiencies;
(iii) Regularly review and analyze data, including data collected under the QAPI program and data resulting from drug regimen reviews, and act on available data to make improvements.
Observations:


Based on review of the facility's plans of correction for previous surveys, and the results of the current survey, it was determined that the facility's Quality Assurance Performance Improvement (QAPI) committee failed to correct quality deficiencies and ensure that plans to improve the delivery of care and services effectively addressed recurring deficient practices.

Findings include:

The facility's deficiencies and plans of correction for State Survey and Certification (Department of Health) survey ending, September 14, 2023, revealed that the facility developed plans of correction that included quality assurance systems to ensure that the facility maintained compliance with cited nursing home regulations. The results of the current survey, ending July 25, 2024, identified repeated deficiencies related to unresolved grievances, the accuracy of Minimum Data Set (MDS) assessments (federally-mandated assessments of residents' abilities and care needs), initiating residents' care plans, revising residents' care plans, quality of care, accident hazards, maintaining proper nutrition and hydration status, and hospice care.

The facility's plan of correction for a deficiency regarding unresolved grievances, cited during the survey ending September 14, 2023, revealed that the facility developed a plan of correction that included completing audits and reporting the results of the audits to the QAPI committee for review. The results of the current survey, cited under F585, revealed that the facility's QAPI committee failed to maintain compliance with the regulation regarding unresolved grievances.

The facility's plan of correction for a deficiency regarding accurate MDS assessments, cited during the survey ending September 14, 2023, revealed that the facility developed a plan of correction that included completing audits and reporting the results of the audits to the QAPI committee for review. The results of the current survey, cited under F641, revealed that the facility's QAPI committee failed to maintain compliance with the regulation regarding completing accurate MDS assessments.

The facility's plan of correction for a deficiency regarding the development of resident care plans to reflect their current care needs, cited during the survey ending September 14, 2023, revealed that the facility developed a plan of correction that included completing audits and reporting the results of the audits to the QAPI committee for review. The results of the current survey, cited under F656, revealed that the facility's QAPI committee failed to maintain compliance with the regulation regarding developing residents' care plans.

The facility's plan of correction for a deficiency regarding revising residents' care plans to reflect their current care needs, cited during the survey ending September 14, 2023, revealed that the facility developed a plan of correction that included completing audits and reporting the results of the audits to the QAPI committee for review. The results of the current survey, cited under F657, revealed that the facility's QAPI committee failed to maintain compliance with the regulation regarding revising residents' care plans.

The facility's plan of correction for a deficiency regarding quality of care, cited during the survey ending September 14, 2023, revealed that the facility developed a plan of correction that included completing audits and reporting the results of the audits to the QAPI committee for review. The results of the current survey, cited under F684, revealed that the facility's QAPI committee failed to maintain compliance with the regulation regarding quality of care.

The facility's plan of correction for a deficiency regarding accident hazards, cited during the survey ending September 14, 2023, revealed that the facility developed a plan of correction that included completing audits and reporting the results of the audits to the QAPI committee for review. The results of the current survey, cited under F689, revealed that the facility's QAPI committee failed to maintain compliance with the regulation regarding accidents hazards.

The facility's plan of correction for a deficiency regarding proper nutrition and hydration, cited during the survey ending September 14, 2023, revealed that the facility developed a plan of correction that included completing audits and reporting the results of the audits to the QAPI committee for review. The results of the current survey, cited under F692, revealed that the facility's QAPI committee failed to maintain compliance with the regulation regarding maintaining proper nutrition and hydration status.

The facility's plan of correction for a deficiency regarding hospice care, cited during the survey ending September 14, 2023, revealed that the facility developed a plan of correction that included completing audits and reporting the results of the audits to the QAPI committee for review. The results of the current survey, cited under F849, revealed that the facility's QAPI committee failed to maintain compliance with the regulation regarding hospice care.

Refer to F585, F641, F656, F657, F684, F689, F692, F849.

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

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



 Plan of Correction - To be completed: 08/30/2024

Preparation and/or execution of this plan of correction does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of federal and state law.
1. Areas identified on Pennsylvania Department of Health, Division of Nursing Care Facilities survey completed on July 25, 2024, will be reviewed at the Quality Assurance Performance Improvement (QAPI) Committee scheduled for August 16, 2024.
2. The Quality Assurance Performance Improvement (QAPI) Committee will review compliance audits and make recommendations based on the audit information provided by the interdisciplinary team to ensure plan of corrections for F0554, F0578, F0582, F0583, F0585, F0600, F0602, F0623, F0641, F0656, F0657, F0684, F0689, F0690, F0692, F0693, F0698, F0730, F0744, F0759, F0761, F0791, F0804, F0849, F0880, and F0947 are being monitored and followed.
3. The Quality Assurance Performance Improvement (QAPI) Committee will review the education provided to staff regarding these deficiencies and make recommendations for improvements as necessary until compliance is achieved.
4 Quality Assurance Performance Improvement (QAPI) Committee co-chairs (Assistant Administrator and Director of Nursing) will monitor Quality Assurance and Performance Improvement meetings to ensure all necessary audits are done timely and reported on during the quarterly meetings. If deficient practices are identified, a plan of action will be implemented to take corrective action. Quality Assurance Performance Improvement (QAPI) Committee will monitor compliance with past deficiencies quarterly for a year with revelation after one year.
The Nursing Home Administrator, Quality Assurance Performance Improvement (QAPI) co-chairs or designee will randomly audit the plan of correction action plans related to for F0554, F0578, F0582, F0583, F0585, F0600, F0602, F0623, F0641, F0656, F0657, F0684, F0689, F0690, F0692, F0693, F0698, F0730, F0744, F0759, F0761, F0791, F0804, F0849, F0880, and F0947 to ensure that appropriate plans of actions are carried out. Additionally, a Quality-of-Care subcommittee chaired by the Director of Nursing will meet at least quarterly specifically tasked with reviewing past deficient practices, assigning and conducting specific audits to check for continued compliance and adding any Performance Improvement Projects (PIPs) where indicated to coincide with regular Quality Assurance Initiatives within the facility.

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

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

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

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


Based on clinical record reviews and staff interviews, it was determined that the facility failed to ensure that the designated interdisciplinary team member obtained the required information from the contracted hospice provider for two of 48 residents reviewed who were receiving hospice services (Residents 36, 45).

Findings include:

An agreement between the facility and the hospice provider (end-of-life services) indicated that the hospice provider would maintain medical records for each hospice patient. Such records will be prepared and maintained with federal and state law, rules, regulations, procedures, policies, guidelines, and generally accepted medical record practices. A record of all services provided to the patient and events regarding the patient's care will be located at the facility.

A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 36, dated June 11, 2024, indicated that the resident was cognitively impaired, required extensive assistance with daily care needs including transfers, was receiving hospice services, and had diagnosis that included Alzheimer's disease, heart failure, and Parkinson's disease (a progressive disorder that affects the nerves).

Physician's orders for Resident 36, dated March 14, 2024, revealed that the resident was to receive hospice services from the facility's contracted hospice provider. As of July 24, 2024, there was no documented evidence in the resident's clinical record, or in the hospice provider's clinical record, that the facility obtained updated nursing notes from hospice.

Interview with the Director of Nursing on July 24, 2024, at 10:36 a.m. confirmed that Resident 36 did not have updated nursing notes on the hospice chart and that there should have been.

A hospice contract, dated March 28, 2023, revealed that the company would promptly and accurately record all physician's orders and medical services, as appropriate, and will provide signed medical record entry for each service.

A quarterly Minimum Data Set (MDS) assessment for Resident 45, dated July 8, 2024, indicated that the resident was cognitively impaired, required assistance for her daily care needs, had diagnoses that included cerebral atherosclerosis, and was receiving hospice services.

The care plan for Resident 45, dated February 15, 2022, included that the resident was receiving hospice services and hospice staff were to coordinate the resident's care to facilitate the resident's and/or the family's wishes for comfort and symptom management with respect and dignity.

As of July 23, 2024, at 3:10 p.m. there was no documented evidence readily available in Resident 45's clinical record, or in the hospice provider's clinical record, that the facility had documentation of the hospice's registered nurse and nurse aide progress notes.

Interview with Director of Nursing on July 23, 2024, at 3:10 p.m. confirmed that the communication should be part of the hospice provider's clinical record on the unit but were not.

28 Pa. Code 211.12(d)(3)(5) Nursing Services.



 Plan of Correction - To be completed: 08/30/2024

Preparation and/or execution of this plan of correction does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of federal and state law.
1. Resident 36 who is currently under Vitas hospice services has updated nursing notes from the hospice provider in the clinical record as of 7/31/24. Resident 45 who is currently under Heartland hospice services has registered nurse and nurse aide progress notes from the hospice provider in the clinical record as of 8/1/24.
2. All clinical records of 9 additional residents who have elected the hospice benefit were audited by The Medical Records Licensed Practical Nurse or designee for registered nurse and nurse aide progress notes/documentation. On 8/2/24 the audit verified that all residents electing the hospice benefit had all required documentation in their clinical record.
3. The Medical Records Licensed Practical Nurse and The Quality Assurance Performance Improvement (QAPI) Nurse will re-educate Vitas hospice and Heartland hospice providers on the importance of having all required documentation including but not limited to nursing documentation and progress notes timely in residents clinical record.
4. The Medical Records Licensed Practical Nurse or designee will audit the clinical records for required nursing documentation for all residents who have elected the hospice benefit once a week beginning 8/12/24 for four weeks and then once a month for two months. All findings will be reported to the Quality Assurance Performance Committee. If deficient practices are identified additional corrective action will be taken.

483.60(d)(1)(2) REQUIREMENT Nutritive Value/Appear, Palatable/Prefer Temp: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.
§483.60(d) Food and drink
Each resident receives and the facility provides-

§483.60(d)(1) Food prepared by methods that conserve nutritive value, flavor, and appearance;

§483.60(d)(2) Food and drink that is palatable, attractive, and at a safe and appetizing temperature.
Observations:


Based on facility records and observations, as well as resident and staff interviews, it was determined that the facility failed to serve food items at palatable temperatures.

Findings include:

Facility grievance logs revealed no grievances related to food; however, resident council meeting minutes on April 29, 2024, revealed that Resident 5 had concerns with hot food. She documented that it would be nice to have the hot meal cart at all meals. The meals are hotter and taste better.

A memo from the Director of Resident and Community Engagement, dated May 2, 2024, revealed that she had spoken with the Dietary Director regarding food concerns, including temperatures of food. She stated she would have dietary check to make sure the temperatures are properly done and food is served at correct temperatures.

A memo with attached education from the Dietary Director, dated May 4, 2024, revealed that she had spoken to dietary staff to make sure temperatures are taken for each meal. She had attached a list of employees educated.

Observations of the meal trayline in the kitchen on July 24, 2024, at 12:14 p.m. revealed that the last tray for Benjamin Court was placed on the food cart at 12:17 p.m. and the test tray was put on the food cart at 12:18 p.m. The trays were delivered to Benjamin court on a metal open cart on warmed plates covered by a warmed plate cover. The cart was not enclosed or insulated. Trays arrived on the unit at 12:19 p.m. The first tray was passed at 12:20 p.m. and the last tray was passed at 12:25 p.m. A test tray tested for palatable temperature was sampled at 12:25 p.m. The temperature of the foods were as follows: French fries were 108 degrees Fahrenheit (F), hamburger was 116 degrees (F), soup was 153 degrees (F), milk was 57 degrees (F), juice was 67 degrees (F), and the water was 66 degrees Fahrenheit. The fries and hamburger were cool to taste and not palatable. The cold liquids were warm to taste and not palatable. Interview with Dietary Aide 2, who was temping the foods at the time of the test tray, stated that the food could always be heated up in the microwave if needed.

Interview with the Chef Manager on July 24, 2024, at 12:35 p.m. confirmed that the food was not served at a palatable temperature.

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

28 Pa. Code 211.6(c) Dietary Services.




 Plan of Correction - To be completed: 08/30/2024

Preparation and/or execution of this plan of correction does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of federal and state law.
1. The Food Preparation and Service Policy will be reviewed and updated as necessary by the Director of Dining Services. Both Nursing and Dinning Staff will ask the residents at each meal if the food is hot enough and palatable, if not the meal will be reheated or re-prepared or the alternative menu item will be provided.
2. The Director of Dining Services will provide re-education to all Dining Service staff on the Food Preparation and Service Policy and the requirement to have a hot holding temperature above 140 degrees. Dining Service Director and Director of Nursing or Designee will educate Dining and Nursing service staff to regularly ask the residents if their meal is hot enough and palatable and if not, the meal will be reheated or re-prepared.
3. Dining staff will take the temperature of food prior to serving the last resident meal in each dining location to ensure hot foods are served at 140 degrees or above and the holding temperature of cold foods for serving was to be 40 F or below. If holding temperatures are not at these parameter's then alternative meal or re- prepared meal will be served, and the Director of Dining Services will be notified to assist in determining root cause.
4. The Director of Dining Services or designee will monitor food temperatures after the last resident receives their meal at each dining location for each meal daily for 4 weeks then one meal daily for four weeks then randomly after that. Findings will be reported quarterly to the Quality Assurance and Performance Improvement Committee for a period of one year by the Director of Dinning Services. If deficient practices are identified additional corrective action will be taken.

483.55(b)(1)-(5) REQUIREMENT Routine/Emergency Dental Srvcs in NFs: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.
§483.55 Dental Services
The facility must assist residents in obtaining routine and 24-hour emergency dental care.

§483.55(b) Nursing Facilities.
The facility-

§483.55(b)(1) Must provide or obtain from an outside resource, in accordance with §483.70(g) of this part, the following dental services to meet the needs of each resident:
(i) Routine dental services (to the extent covered under the State plan); and
(ii) Emergency dental services;

§483.55(b)(2) Must, if necessary or if requested, assist the resident-
(i) In making appointments; and
(ii) By arranging for transportation to and from the dental services locations;

§483.55(b)(3) Must promptly, within 3 days, refer residents with lost or damaged dentures for dental services. If a referral does not occur within 3 days, the facility must provide documentation of what they did to ensure the resident could still eat and drink adequately while awaiting dental services and the extenuating circumstances that led to the delay;

§483.55(b)(4) Must have a policy identifying those circumstances when the loss or damage of dentures is the facility's responsibility and may not charge a resident for the loss or damage of dentures determined in accordance with facility policy to be the facility's responsibility; and

§483.55(b)(5) Must assist residents who are eligible and wish to participate to apply for reimbursement of dental services as an incurred medical expense under the State plan.
Observations:


Based on review of policies and clinical records, as well as resident and staff interviews, it was determined that the facility failed to provide dental services to meet the needs of each resident for one of 48 residents reviewed (Resident 8).

Findings include:

The facility's dental services policy, dated October 13, 2023, indicated that all residents are to be provided annual oral assessments by a licensed dentist/hygienist.

A dental progress note for Resident 8, dated May 25, 2023, indicated that the resident was not seen by 360 dental due to her refusal for treatment. There was no documented evidence in the resident's clinical record to indicate a follow-up appointment was attempted.

A nursing note for Resident 8, dated December 28, 2023, at 6:00 p.m., indicated that the resident was complaining of right-side facial pain. The resident was crying in pain when she asked for Tylenol. She stated the pain was from her ear to her mouth.

A nursing note for Resident 8, dated January 26, 2024, at 1:34 p.m. indicated that the resident had no pain in the past five days and had upper and lower dentures but had not been wearing them. She stated they did not fit well and caused some discomfort. There was no documented evidence in the resident's clinical record to indicate that the resident was seen by a dentist for her ill-fitting dentures.

Interview with Resident 8 on July 22, 2024, at 12:35 p.m. revealed that she had no teeth and no dentures in her mouth. She stated that she had dentures but did not have them in because her mouth hurt when she put them in. She stated that she had pain to the right side of her mouth and jaw.

Interview with the Corporate Compliance Officer on July 25, 2024, at 6:45 p.m. confirmed that Resident 8 was not seen by the dentist for complaints of ill-fitting dentures or annually and she should have been.

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

28 Pa. Code 211.15(a) Dental Services.





 Plan of Correction - To be completed: 08/30/2024

Preparation and/or execution of this plan of correction does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of federal and state law.
1. Resident 8 was scheduled to see the Dentist for a revisit on 8/6/24. The resident refused at the time of visit to both staff as well as the dental provider despite encouragement and reeducation on the importance. The resident's responsible party was notified and was requested to be at the next dentist's appointment. Resident 8 consistently refuses to wear dentures as evidenced by the nursing documentation.
2. The Registered Nurse Supervisor assessed all other residents for complaints of mouth pain including pain associated with dentures and none found at this time. No other dental care concerns identified.
3. The Director of Nursing and or designee performed education for licensed nursing staff on that the facility must provide routine dental care and, in the event, resident refuses follow up appointments must be attempted with all refusals documented as well as notification of responsible parties on this refusal.
4. The Director of Nursing or designee will audit weekly for four weeks, then once a month for two months and will continue monthly unless deemed no longer necessary by the Quality Assurance Performance Committee.

483.45(g)(h)(1)(2) REQUIREMENT Label/Store Drugs and Biologicals: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.
§483.45(g) Labeling of Drugs and Biologicals
Drugs and biologicals used in the facility must be labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable.

§483.45(h) Storage of Drugs and Biologicals

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

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


Based on review of policies, as well as observations and staff interviews, it was determined that the facility failed to ensure that medications were properly secured in the medication cart, failed to label medications with the date they were opened in one of eight medication carts reviewed (B100 Room), and failed to ensure the narcotic box was properly affixed in the refrigerator.

Findings include:

The facility's policy regarding the security of the medication cart, dated October 13, 2023, indicated that the nurse was to secure the medication cart during the medication pass to prevent unauthorized entry, and the medication cart was to be securely locked at all times when out of the nurse's view.

Observations on July 25, 2024, at 8:23 a.m. revealed that a medication cart in the hallway was unlocked and unattended by Licensed Practical Nurse 1 when she went into Resident 137's room to provide care to resident.

Interview with Licensed Practical Nurse 1 on July 25, 2024, at 8:27 a.m. confirmed that her medication cart should have been locked when unattended.

Interview with the Director of Nursing on July 25, 2024, at 11:43 a.m. confirmed that the medication cart should have been locked when unattended by Licensed Practical Nurse 1.

The facility's policy regarding medication administration, dated October 13, 2024, revealed that once opened, a multi-dose vial was to have the date it was opened recorded on the container.

An undated package insert for Lispro Insulin (used to treat diabetes) revealed that once entered/opened, the vial was to be discarded after 28 days.

Observations in the B1001 Medication cart on July 24, 2024, at 9:16 a.m. revealed that an opened vial of Lispro Insulin was not properly labeled with the date it was opened.

An interview with Registered Nurse 15 on July 24, 2024, at 9:16 a.m. confirmed that the opened vial of Lispro Insulin was not properly labeled with the date it was opened.

An interview with the Director of Nursing on May 25, 2024, at 11:43 a.m. confirmed that an opened vial of Lispro Insulin was not properly labeled with the date it was opened, and it should have been.

Observations of the medication refrigerator in the medication room on Elizabeth wing on July 24, 2024, at 8:05 a.m. revealed that there was a locked apartment-size refrigerator. Inside the refrigerator was a clear plastic box that was secured to the refrigerator for the storage of narcotic medication; however, the box was not locked, and there was one bottle of Lorazepam oral concentrate (schedule IV anxiety medication) in the unlocked box for Resident 59. Interview with Licensed Practical Nurse 16 at the time of the observation confirmed that the box containing the Lorazepam was not locked because a key broke off in it and it would not lock.

Interview with the Director of Nursing on July 24, 2024, at 8:52 a.m. confirmed that the bottle of Lorazepam was stored in an unlocked box.

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

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



 Plan of Correction - To be completed: 08/30/2024

Preparation and/or execution of this plan of correction does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of federal and state law.
. 1. Villa Elizabeth Medication Room(B100) narcotic box was repaired on 8/12/2024 by PharMerica technician. Villa Benjamin Garden medication cart has been consistently locked and secured any time the cart has been unattended with Licensed Practical Nurse 1 receiving reeducation by Director of Nursing on facility policy as well as disciplinary counsel. Identified Licensed Practical Nurse opened the insulin vial Lispro on the eve of 7/23/24 failing to date at time of opening. The date was confirmed with nurse and date placed on vial and sent with resident at time of discharge to her personal care home. The Licensed Practical Nurse who failed to date vial received counsel from the Director of Nursing.
2. Director of Nursing inspection of the eight Medication Rooms reveals no other narcotic box unsecured, and audit of all medication carts found no additional medication vials undated or unsecured medication carts.
3. Director of Nursing or designee will reeducate Licensed Nursing Staff on notification to PharMerica immediately of any ill repair of medication carts, treatment carts and medication refrigerators located in medication rooms in each Villa. While waiting for repairs all medications are moved to a secured location determined by the registered Nurse Supervisor on duty. Director of Nursing or designee will also reeducate on policies and procedures as it relates to Label/ Store Drugs and Biologicals.
4. The Director of Nursing or designee will audit weekly for four weeks, then once a month for two months and will continue monthly unless deemed no longer necessary by the Quality Assurance Performance Committee.

483.40(b)(3) REQUIREMENT Treatment/Service for Dementia: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.
§483.40(b)(3) A resident who displays or is diagnosed with dementia, receives the appropriate treatment and services to attain or maintain his or her highest practicable physical, mental, and psychosocial well-being.
Observations:


Based on clinical record reviews and staff interviews, it was determined that the facility failed to provide appropriate treatment and services for residents with dementia-related behaviors and failed to develop and implement an individual person-centered plan to address dementia-related behavioral symptoms displayed for one of 48 residents reviewed (Resident 3) who had dementia.

Findings include:

An annual Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 3, dated July 3, 2024, revealed that the resident was cognitively impaired; was clearly understood and able to understand others; required assistance with care needs; was receiving antidepressant, antianxiety and antipsychotic medications; and had diagnoses that included depression, anxiety, and dementia.

The current care plan for behavior for Resident 3, dated October 30, 2023, revealed inappropriate behaviors related to dementia that included screaming, hitting at staff, and refusing care and medications. Interventions included to monitor behaviors and attempt to identify patterns, precursors and causes of behaviors; use a consistent, calm, firm approach during periods of inappropriate behavior; attempt to determine the source of agitation by asking opened-ended questions and seek to resolve; maintain a calm environment with limited clutter/distraction; allow resident time and opportunity to express self and verbalize frustrations; and review abnormal behaviors with the interdisciplinary team.

Physician's order for Resident 3, dated February 1, 2022, included an order that the resident's behaviors were to be monitored and documented on the Medication Administration Record (MAR) every shift for monitoring as follows: 1-Combative, 2-Resistive, 3-Verbally Aggressive, 4-Socially Inappropriate, 5-Wandering and 6-Disrobing. Interventions for behaviors were to be documented on the MAR every shift as follows: 1-one to one, 2-Activities, 3-Quiet area, remove from situation, 4-Diversional Activity, 5-Food/drink, 6-Medicate, 7-re-approach and 8-Toilet.

Physician's order for Resident 3, dated March 31, 2024, included an order for 75 milligrams (mg) of Effexor extended release (an antidepressant medication), two capsules (to equal 150 mg) daily for dementia with psychosis.

Physician's order for Resident 3, dated April 2, 2024, included an order for 5 mg of Olanzapine (an antipsychotic medication) daily for Sundowning Dementia with Behaviors.

Physician's order for Resident 3, dated April 22, 2024, included an order for 0.5 mg of Lorazepam (an antianxiety medication) three times daily for restlessness/anxiety.

A nursing note for Resident 3, dated April 22, 2024, at 1:39 p.m., revealed that the resident was extremely confused and agitated that day. She went into another resident's room and was going through all of her belongings. When asked to leave she stated. "I'm taking all of this stuff. I want to put it in my room," and was especially fixated on a clock stating that it was her mother's clock. Resident 3 was in that resident's room approximately a dozen times and got physical with staff when she was asked to leave. A nurse aide asked the nurse to remove the resident as she had a pair of tweezers and told her that she would stab her with them if she got any closer. The nurse was able to talk with the resident and calm her down and was able to get the resident to give her the tweezers. She was removed from the room and brought down to the dining room with the nurse. While in the dining room, Resident 3 grabbed onto another resident's chair and started pulling it. The other resident raised her voice and asked her to stop, and Resident 3 raised her voice back. The other resident then struck Resident 3 with a closed fist to her right arm and Resident 3 struck her back with a closed fist to her left arm. Staff intervened and they were immediately separated. Resident 3 was still very agitated and insisted on going back into another resident's room to take her clock. The doctor was notified, and medication changes were made.

A nursing note for Resident 3, dated April 22, 2024, at 2:37 p.m.. revealed that the registered nurse was called to Resident 3's room at 10:00 a.m. Resident 3 had an altercation with another resident. No injuries were noted. No bumps or bruises were noted. Residents were separated by the licensed practical nurse on duty. The Medical Director examined the resident and made changes to the resident's Ativan (Lorazepam) order.

An Electronic Event Report that was submitted on April 23, 2024, related to the incident, indicated that a recent dose reduction of Ativan was thought to be a contributing factor for Resident 3's behaviors and the Medical Director changed the Ativan order so Resident 3 would receive 0.5 mg of Ativan three times daily.

Review of Resident 3's MAR for April 2024 revealed that on April 22, 2024, staff did not attempt to implement any of the interventions in place for her behaviors as per physician's orders. There was no documented evidence that an individualized behavior plan was developed with specific, person-centered, or individualized interventions included in the plan to address the resident's behaviors. There was no documented evidence that new behavioral interventions were put in place related to incident on April 22, 2024, to keep other residents safe from Resident 3, who has a history of behaviors related to dementia.

Interview with the Director of Nursing on July 25, 2024, at 4:08 p.m. confirmed that staff did not attempt to implement any of the interventions in place for behaviors as per physician's orders related to the incident with Resident 3 on April 22, 2024, there was no individualized behavior plan developed for the resident with specific, person-centered, or individualized interventions included in the plan to address her behaviors and no new behavioral interventions were put in place related to incident on April 22, 2024, to keep other residents safe from Resident 3, who has a history of behaviors related to dementia.

28 Pa. Code 201.24(e)(4) Admission Policy.

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





 Plan of Correction - To be completed: 08/30/2024

Preparation and/or execution of this plan of correction does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of federal and state law.
1. Resident 3 behavioral care plan revised by Quality Assurance Performance Improvement (QAPI) Nurse to included specific person-centered interventions to address resident's behaviors.
2. Facility audit completed by Quality Assurance Performance Improvement (QAPI) Nurse of incidents that occurred over the past 12 months to identify any additional current residents with behavioral events. Two additional residents identified and currently have a behavioral care plan in place with person-centered interventions to reduce behavioral expressions.
3. Nursing staff will be re-educated by Quality Assurance Performance Improvement (QAPI) Nurse or designee on behavioral expressions, behavioral care plans, and person-centered interventions. Behavioral incidents will be discussed with the interdisciplinary team to collaboratively identify person-centered interventions to prevent behavioral expression occurrences.
4. The Quality Assurance Performance Improvement (QAPI) Nurse or designee will audit residents for behavioral expressions once a week beginning 8/12/24 for four weeks and then once a month for two months and revise behavioral care plans with additional person-centered interventions as needed. All findings will be reported to the Quality Assurance Performance Committee. If deficient practices are identified additional corrective action will be taken.

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


Based on review of personnel files, as well as staff interviews, it was determined that the facility failed to ensure that nurse aide performance evaluations were completed at least annually for two of five nurse aides reviewed (Nurse Aides 11 and 12).

Findings include:

A list of nurse aides provided by the facility revealed that based on their months and days of hire, annual performance evaluations for Nurse Aides 11 and 12 were due between November 2023 and February 2024. As of July 24, 2024, there was no documented evidence that annual performance evaluations were completed as required for Nurse Aides 11 and 12.

Interview with the Director of Nursing on July 24, 2024, at 2:35 p.m. confirmed that she could not provide evidence that annual performance evaluations were completed as required for Nurse Aides 11 and 12.

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

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

28 Pa. Code 201.20(a)(c) Staff Development.





 Plan of Correction - To be completed: 08/30/2024

Preparation and/or execution of this plan of correction does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of federal and state law.
1.The policy has been revised to reflect that performance evaluations will be completed no later than the employee's hire date (day/month), or no later than 12 months from their last performance evaluation. All Nurse Aides will have a performance evaluation within the last 12 months by 8/30/2024. Nurse Aide's 11 and 12 performance evaluations are current.
2. All current Nurse Aides files were reviewed by the Infection Preventionist and have had or are scheduled to have performance evaluations completed by 8/30/2024.
3. The Infection Preventionist or designee will review employee records monthly to ascertain Nurse Aides that have a performance evaluation due within 2 months. The Infection Preventionist or designee will then review the schedule with Human Resources Director or designee to allow performance evaluation to be reviewed during the Nurse Aides work schedule prior to 12 months.
4. The Infection Preventionist or designee will perform audits every 3 weeks x 4 to ensure monthly compliance. All findings will be reported to the Quality Assurance Performance Committee. If deficient practices are identified additional action will be taken.


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


Based on clinical record reviews and staff interviews, it was determined that the facility failed to ensure that dialysis residents had an active physician's order to attend dialysis, failed to obtain physician's orders for the care and monitoring of dialysis sites, and failed to provide communication with dialysis facility for one of 48 residents reviewed (Resident 58).

Findings include:

The facility's policy regarding care for residents who receive dialysis (mechanical process that cleanses the blood when the kidneys are not functioning properly), dated October 13, 2023, indicated that a physician's order would be obtained for dialysis to establish the days of the week that the dialysis will be given. Observation and a communication form that has been completed by the dialysis clinic will be scanned into the resident's electronic medical record.

An annual Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 58, dated July 14, 2021, indicated that the resident was cognitively intact, required assistance from staff for daily care needs, had diagnoses that included kidney failure, and required dialysis treatments. The resident's care plan, dated March 14 2024, indicated that he required dialysis related to renal failure.

The current dialysis agreement between the facility and dialysis clinic revealed that the facility will provide care and education for emergency situations regarding the dialysis site for Resident 58.

Observations of Resident 58 on July 25, 2024, at 8:20 a.m. revealed that he had a dry gauze dressing on his left inner arm/wrist area. An interview with the resident at that time revealed that he had a fistula (surgical dialysis access site) for dialysis access, but there was no kit in the resident's room for emergency situations. Resident 58 also stated that he does not take any paperwork with him to dialysis but brings back a piece of paper to give to the registered nurse supervisor.

Interview with Licensed Practical Nurse 1 on July 25, 2024, at 8:25 a.m. revealed that she was not aware of an emergency kit for Resident 58's room and was not aware of protocol in an emergency situation for Resident 58's fistula.

There was no documented evidence in Resident 58's clinical record of a physician's order for dialysis, for the care of his fistula, and no documented evidence of continued communication between the facility and dialysis center.

Interview with the Director of Nursing on July 25, 2024, at 2:30 p.m. confirmed that there was no documented evidence of active physician's orders for Resident 58 to attend dialysis, no orders for the care and monitoring of the dialysis site, and no evidence of continued communication between the dialysis center and the facility.

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




 Plan of Correction - To be completed: 08/30/2024

Preparation and/or execution of this plan of correction does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of federal and state law.
1. Physician order was obtained on 7/25/24 for Resident 58 to continue receiving dialysis three times per week. The facility received verbal report from dialysis center regarding resident tolerating previous procedures with no change in plan of care. Physician order was obtained for care of resident 58 fistula site.
2. Facility wide audit completed by the Quality Assurance Performance Improvement (QAPI) Nurse with no other residents identified as currently receiving dialysis care.
3. The Quality Assurance Performance Improvement (QAPI) Nurse provided education to the facility's licensed nurses regarding residents requiring dialysis along with dialysis site monitoring. Registered Nurse Supervisor provided verbal education to dialysis center regarding completion of dialysis communication form and will call dialysis center upon residents return if communication sheet is not provided/completed.
4. The Quality Assurance Performance Improvement (QAPI) Nurse or designee will audit the completion of dialysis communication forms and monitoring of resident's fistula site once a week beginning 8/12/24 for four weeks and then once a month for two months. All findings will be reported to the Quality Assurance Performance Committee. If deficient practices are identified additional corrective action will be taken.

483.25(g)(4)(5) REQUIREMENT Tube Feeding Mgmt/Restore Eating Skills:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
§483.25(g)(4)-(5) Enteral Nutrition
(Includes naso-gastric and gastrostomy tubes, both percutaneous endoscopic gastrostomy and percutaneous endoscopic jejunostomy, and enteral fluids). Based on a resident's comprehensive assessment, the facility must ensure that a resident-

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

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


Based on review of facility policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that residents who were receiving tube feedings received appropriate treatment and services to prevent complications for one of 48 residents reviewed (Resident 30).

Findings include:

The facility's policy regarding Enteral Feeding, dated October 13, 2023, indicated that prior to administering enteral feedings, the peg tube should be checked for placement.

A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 30, dated April 25, 2024, revealed that the resident was cognitively impaired, was usually understood and usually understood others, required assistance with care needs, and had a feeding tube (a mechanical device surgically implanted into the stomach to provide nutrition, fluids and medications to a person who is unable to eat or drink by mouth).

The current care plan for Resident 30 indicated that the resident had a need for a feeding tube and that it should be checked for placement.

Review of the clinical record for Resident 30 revealed no documented evidence that the feeding tube was being checked for placement per the resident's care plan and per facility policy.

Interview with the Director of Nursing on July 25, 2024, at 1:16 p.m. confirmed that there was no documented evidence that Resident 30's feeding tube was being checked for placement as care planned and as per facility policy, and it should have been.

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




 Plan of Correction - To be completed: 08/30/2024

Preparation and/or execution of this plan of correction does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of federal and state law.
1.Resident 30 has a physician order to check patency and placement of the peg tube as of 7/25/24. Nursing has completed this assessment as evident by the Electronic Medication Administration Record (EMAR) with no problems identified.
2. A facility assessment completed by the Director of Nursing reveals only one other peg tube in the facility at this time with the Electronic Medication Administration Record (EMAR) reflecting that patency and placement assessments are in place with an order date as of April 2021. Assessments have been completed as per facility policy.
3. The Director of Nursing and or designee reeducated nursing staff on policies and procedures as it relates to gastrostomy tubes including the Enteral Feeding Tube Policy.
4. The Director of Nursing and or designee will audit weekly for four weeks, then once a month for two months. All findings will be reported to the Quality Assurance Performance Committee. If deficient practices are identified additional corrective action will be taken.


483.25(g)(1)-(3) REQUIREMENT Nutrition/Hydration Status Maintenance:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
§483.25(g) Assisted nutrition and hydration.
(Includes naso-gastric and gastrostomy tubes, both percutaneous endoscopic gastrostomy and percutaneous endoscopic jejunostomy, and enteral fluids). Based on a resident's comprehensive assessment, the facility must ensure that a resident-

§483.25(g)(1) Maintains acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that this is not possible or resident preferences indicate otherwise;

§483.25(g)(2) Is offered sufficient fluid intake to maintain proper hydration and health;

§483.25(g)(3) Is offered a therapeutic diet when there is a nutritional problem and the health care provider orders a therapeutic diet.
Observations:


Based on clinical record reviews and staff interviews, it was determined that the facility failed to ensure that fluid restrictions were being followed for one of 48 residents reviewed (Resident 58) and failed to ensure that a resident's weight was obtained and documented as per physician's order for a resident with a documented history of weight loss for one of 48 residents reviewed (Resident 73).

Findings include:

A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 58, dated June 14, 2024, indicated that the resident was cognitively intact, required assistance from staff for care, and had a diagnosis of kidney failure.

A care plan for Resident 58, dated March 14, 2024, revealed that the resident was to be on a 1500 cc/day fluid restriction allowing 960 cc of fluid from dietary, 240 cc of fluid for day shift, 240 cc of fluid for evening shift, and 60 cc of fluid for night shift. A review of Resident 58's medical record revealed no documented evidence that the fluid restriction was being followed.

Interview with the Director of Nursing on July 25, 2024, at 2:29 p.m. confirmed that there was no documented evidence that the fluid restriction was being followed and should have been.

A quarterly MDS assessment for Resident 73, dated May 8, 2024, revealed that the resident was cognitively impaired, required assistance from staff for her daily care needs, had a Stage 4 pressure ulcer (pressure wound with full thickness tissue loss with exposed bone, tendon or muscle), and had a significant weight loss.

A physician's order for Resident 73, dated April 2, 2024, included an order to obtain weekly weights.

A dietician note for Resident 73, dated April 23, 2024, at 11:10 a.m. revealed that the resident had a significant weight loss of 22.8 pounds (15.3 percent) in the last six months. The resident's weight on April 21, 2024 was 126.2 pounds; on March 24, 2024, the weight was 127.2 pounds; and on November 28, 2023, the weight was 149 pounds. Her body mass index was considered normal but her weight loss was not desirable (advanced age). She had an inadequate intake (an average of 35 percent) of mechanical soft meals. She was ordered supplements to help meet nutritional needs and promote weight maintenance and was taking 100 percent of all supplements, and she appeared to be maintaining weight. She was ordered snacks between meals for added calories. She has a Stage 4 pressure area to coccyx and an unstageable pressure ulcer (full-thickness pressure injuries in which the base is obscured by slough and/or eschar) to her left heel and was taking vitamins and supplements to promote wound healing. She was ordered weekly weights to monitor for changes.

A review of Resident 73's clinical record, including the Treatment Administration Record (TAR) for April and May 2024, revealed that weights were not obtained as ordered on April 14, April 28, May 12, May 19, and May 26.

An interview with the Director of Nursing on July 24, 2024, at 3:37 p.m. confirmed that there was no documented evidence that weights were obtained as ordered for Resident 73 on the dates listed above.

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



 Plan of Correction - To be completed: 08/30/2024

Preparation and/or execution of this plan of correction does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of federal and state law.
1. Resident 58 medical record was revised by the Quality Assurance Performance Improvement (QAPI) Nurse to include current fluid restrictions into the nurse aide charting system in addition to the licensed nurse administration record. Resident 73 weight is now stable. Certified Registered Nurse Practitioner (CRNP) discontinued order for weekly weights on 6/8/24. Registered Dietician quarterly assessment completed on 7/29/24 noted resident 73 weight loss has resolved with resident's body mass index (BMI) now being normal at 23.9.
2. The Registered Dietician completed an audit identifying thirty-two residents that have current orders requiring weights more frequently than once monthly. The Quality Assurance Performance Improvement (QAPI) Nurse completed an audit identifying four residents with current fluid restrictions. Nurse aide charting system updated to include current orders for residents requiring weights and/or fluid restrictions.
3. Nursing staff have been re-educated by Quality Assurance Performance Improvement (QAPI) Nurse on fluid restrictions, weight monitoring, and how to complete documentation in the electronic health record. The Registered Dietician has been added to the interdisciplinary team clinical meeting to review resident weights and fluid restrictions weekly.
4. The Registered Dietician or designee will audit documentation of fluid restrictions and the documentation of weekly weights once a week beginning 8/12/24 for four weeks and then once a month for two months. All findings will be reported to the Quality Assurance Performance Committee. If deficient practices are identified additional corrective action will be taken.

483.25(e)(1)-(3) REQUIREMENT Bowel/Bladder Incontinence, Catheter, UTI: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(e) Incontinence.
§483.25(e)(1) The facility must ensure that resident who is continent of bladder and bowel on admission receives services and assistance to maintain continence unless his or her clinical condition is or becomes such that continence is not possible to maintain.

§483.25(e)(2)For a resident with urinary incontinence, based on the resident's comprehensive assessment, the facility must ensure that-
(i) A resident who enters the facility without an indwelling catheter is not catheterized unless the resident's clinical condition demonstrates that catheterization was necessary;
(ii) A resident who enters the facility with an indwelling catheter or subsequently receives one is assessed for removal of the catheter as soon as possible unless the resident's clinical condition demonstrates that catheterization is necessary; and
(iii) A resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible.

§483.25(e)(3) For a resident with fecal incontinence, based on the resident's comprehensive assessment, the facility must ensure that a resident who is incontinent of bowel receives appropriate treatment and services to restore as much normal bowel function as possible.
Observations:


Based on review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that physician's orders for monitoring output were followed for one of 48 residents reviewed (Resident 73) who had an indwelling urinary catheter.

Findings include:

The facility's policy regarding measuring output, dated October 13, 2023, indicated that output is to be monitored for residents that receive tube feedings, have a foley catheter, edema, dehydration, vomiting, IV fluids, specific diagnoses that require intake and output, and anyone that has a physician's order.

A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 73, dated May 8, 2024, revealed that the resident was cognitively impaired, required assistance from staff for her daily care needs, and had an indwelling urinary catheter (a thin, flexible tube inserted into the bladder to drain urine from the bladder).

Physician's orders for Resident 73, dated February 9, 2024, included an order for staff to monitor intake and output every shift.

Resident 73's Treatment Administration Records (TAR's) dated April, May, June and July 2024 revealed that there was no documented evidence that the resident's indwelling catheter output was monitored on all three shifts for the entire month of April; on all three shifts for the entire month of May with the exception of May 8 and May 22 on the night shift; on all three shifts for the entire month of June; and on all three shifts for the entire month of July through and including July 23 with the exception of July 5 on the day shift, July 6 on the evening shift, and July 23 on the night shift.

Interview with the Director of Nursing on July 25, 2024, at 3:46 p.m. confirmed that there was no documented evidence that Resident 73's indwelling catheter output was monitored on the dates and shifts noted above.

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




 Plan of Correction - To be completed: 08/30/2024

Preparation and/or execution of this plan of correction does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of federal and state law.
1. Resident 73 indwelling urinary catheter output was documented under the nurse aide charting system throughout the months of April, May, June, and July 2024. Root cause analysis identified that licensed nurses erroneously coded zero on the Electronic Treatment Administration Record related to the nurse aide providing the indwelling urinary catheter care. Order entry process clarified for licensed nurse to monitor urinary catheter function and urinary catheter care every shift.
2. Facility wide audit completed with ten other residents currently requiring output monitoring for indwelling urinary catheter use. Order entry is being clarified for licensed nurse to monitor urinary catheter function and urinary catheter care every shift. Facility nurse aides will continue to document urinary output for residents with indwelling urinary catheters in the Electronic Health Record.
3. Nursing staff have been re-educated by Quality Assurance Performance Improvement (QAPI) Nurse on role responsibility as related to indwelling urinary catheters and documentation of urinary catheter output. Documentation for indwelling catheter output will be entered in one location of a resident's electronic health record.
4. The Quality Assurance Performance Improvement (QAPI) Nurse or designee will audit urinary catheter output documentation of a sample size of 5 residents once a week beginning 8/12/24 for four weeks and then once a month for two months. All findings will be reported to the Quality Assurance Performance Committee. If deficient practices are identified additional corrective action will be taken.

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 review of policy and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that the residents' environment remained as free of accident hazards as possible by transporting a resident without leg rests for one of 48 residents reviewed (Resident 26).

Findings include:

The facility's policy for transportation, dated October 13, 2023, revealed that footrests must be used when staff, family, volunteers and healthcare partners are assisting residents who are transported by wheelchair, broad chair or any other chair with attachable footrests to prevent accident/injury.

A quarterly Minimum Data Set (MDS) assessment (a federally-mandated assessment of a resident's abilities and care needs) for Resident 26, dated July 2, 2024, revealed that the resident was cognitively impaired, required maximum assistance for all of her care, and used a broda chair (a wheelchair with the ability to tilt and recline).

Observations on July 22, 2024, at 2:30 p.m. revealed that Nursing Assistant 10 pushed Resident 26 in a broda chair from her room through the hallway and into the dining room without any leg/footrests while the resident elevated her feet. The leg/footrests were not on the resident's wheelchair.

An interview with Nursing Assistant 10 on July 22, 2024, at 2:33 a.m. revealed that she was aware that leg rests were to be used when transporting Resident 26 in her wheelchair.

An interview with the Director of Nursing on July 24, 2024, at 8:52 a.m. confirmed that staff, agency staff, and hospice staff should be using leg/footrests on wheelchairs when residents are being transported in their wheelchairs.

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




 Plan of Correction - To be completed: 08/30/2024

Preparation and/or execution of this plan of correction does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of federal and state law.
1. The Therapy Department was notified after the resident was transported and a new chair with leg rests was provided. The nurse aide was educated on the need to have notified Therapy or the Registered Nurse before moving the resident in the chair without the leg rests. The Therapy Department was notified and a new chair with leg rests was provided. Occupational Therapy then had the resident on caseload working with the new broda chair with legs rests from 7/29/24 through 8/5/24. No injury to resident.
2. The Therapy department and Nursing audited all nursing units and found no additional poor fitting or broken leg rests.
3. The Director of Nursing or designee will in-service nursing staff on importance of safety during transport and the use of legs rests.
4. The Director of Nursing or designee will audit weekly for four weeks, then once a month for two months and will continue monthly unless deemed no longer necessary by the Quality Assurance Performance Committee.

483.21(b)(1)(3) 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.
§483.21(b)(3) The services provided or arranged by the facility, as outlined by the comprehensive care plan, must-
(iii) Be culturally-competent and trauma-informed.
Observations:


Based on review of facility policy and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that a resident's care plan was created to reflect the resident's specific care needs for one of 48 residents reviewed (Resident 84).

A facility policy dated, October 13, 2023, revealed that the purpose of the interim care plan on admission and comprehensive care plans were driven by the CAA process to address resident concerns and resident unique characteristics, strengths, weakness, preferences, and needs which require interdisciplinary intervention. It will include diagnosis, activity level, diet, medication, treatments, limitations, and specific requests for therapeutic interventions and will provide directions to nursing services with the goal of maintaining health status and addressing acute and chronic illness or discharge plan while providing a safe and therapeutic environment thereby eliminating the need for hospitalization

A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 84, dated June 8, 2024, revealed that the resident was cognitively impaired, was clearly understood and able to understand others, required assistance with care needs, was receiving antipsychotic medications, and had diagnoses that included depression and dementia.

Physician's order for Resident 84, dated April 2, 2024, indicated that the resident was ordered 25 mg of Quetiapine (an antipsychotic medication) twice a day times day for depression/behaviors.

Clinical record review for Resident 84 revealed that there was no documented evidence that the care plan was created to reflect the resident's need for antipsychotic medications with a diagnosis of dementia.

Interview with the Director of Nursing on July 25, 2024, at 4:10 p.m. confirmed that Resident 84 did not have a care plan developed to reflect the need for antipsychotic medications with a diagnosis of dementia, and it should have been.

28 Pa. Code 201.24(e)(4) Admission Policy.

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


 Plan of Correction - To be completed: 08/30/2024

Preparation and/or execution of this plan of correction does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of federal and state law.
1. On 4/2/2024 Resident 84 was prescribed Quetiapine 25 milligrams twice daily for depression/behaviors. Review of resident 84 Medication Administration Record (MAR) validates medication has been administered as prescribed. Care plan for resident 84 was created on 8/11/2024 to reflect diagnosis of dementia with the need for antipsychotic medication as currently prescribed by physician to manage depression/behaviors.
2. The Quality Assurance Performance Improvement (QAPI) Nurse reviewed all residents with a current diagnosis of dementia and all residents that are currently prescribed antipsychotics to ensure a care plan is in place to reflect a dementia diagnosis/need for antipsychotic medications as prescribed.
3. The Registered Nurse Assessment Coordinator (RNAC) and Licensed Practical Nurse Assessment Coordinator (LPNAC) will be re-educated by the Quality Assurance Performance Improvement (QAPI) Nurse on the development/implementation of care plans as it relates to resident diagnosis's/new physician orders.
4. The Quality Assurance Performance Improvement (QAPI) Nurse or designee will audit the development/implementation of care plans of a sample size of five residents once a week beginning 8/12/24 for four weeks and then once a month for two months. All findings will be reported to the Quality Assurance Performance Committee. If deficient practices are identified additional corrective action will be taken.

483.10(c)(6)(8)(g)(12)(i)-(v) REQUIREMENT Request/Refuse/Dscntnue Trmnt;Formlte Adv Dir: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(c)(6) The right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.

§483.10(c)(8) Nothing in this paragraph should be construed as the right of the resident to receive the provision of medical treatment or medical services deemed medically unnecessary or inappropriate.

§483.10(g)(12) The facility must comply with the requirements specified in 42 CFR part 489, subpart I (Advance Directives).
(i) These requirements include provisions to inform and provide written information to all adult residents concerning the right to accept or refuse medical or surgical treatment and, at the resident's option, formulate an advance directive.
(ii) This includes a written description of the facility's policies to implement advance directives and applicable State law.
(iii) Facilities are permitted to contract with other entities to furnish this information but are still legally responsible for ensuring that the requirements of this section are met.
(iv) If an adult individual is incapacitated at the time of admission and is unable to receive information or articulate whether or not he or she has executed an advance directive, the facility may give advance directive information to the individual's resident representative in accordance with State law.
(v) The facility is not relieved of its obligation to provide this information to the individual once he or she is able to receive such information. Follow-up procedures must be in place to provide the information to the individual directly at the appropriate time.
Observations:


Based on review of clinical records, as well as staff interviews, it was determined that the facility failed to ensure that the resident and/or resident representative had an opportunity to develop an advance directive or assist in formulating an advance directive for three of 48 residents reviewed (Residents 3, 7, 55).

Findings include:

A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 3, dated July 3, 2024, revealed that the resident was cognitively impaired, was understood and able to understand others, required assistance with care needs, and had a diagnosis of dementia. A review of the resident's clinical record revealed no evidence that the resident or their representative was informed of their rights to develop advance directives and no documented evidence that they were provided an opportunity and assistance to formulate one if they chose to do so.

A significant change MDS assessment for Resident 7, dated May 26, 2024, revealed that the resident was cognitively impaired, was usually understood and usually understood others, required assistance with care needs, and had diagnoses that included hemiplegia (paralysis or weakness to one side of the body due to brain injury) and stroke. A review of the resident's clinical record revealed no evidence that the resident or their representative was informed of their rights to develop advance directives and no documented evidence that they were provided an opportunity and assistance to formulate one if they chose to do so.

A quarterly MDS assessment for Resident 55, dated April 25, 2024, revealed that the resident was cognitively impaired, was understood and understood others, required assistance with care needs, and had a diagnosis of dementia. A review of the resident's clinical record revealed no evidence that the resident or their representative was informed of their rights to develop advance directives and no documented evidence that they were provided an opportunity and assistance to formulate one if they chose to do so.

An interview with the Social Service Director on July 25, 2024, at 9:36 a.m. confirmed that the above residents did not have an advance directive. She stated that there was no official admission's person, and there was no official process in place to address advance directives with residents and/or their representatives on admission or periodically during their stay. She revealed that if the residents did not have an advance directive, they were not offered or assisted with formulating one.

28 Pa. Code 201.29(a)(d) Resident Rights.




 Plan of Correction - To be completed: 08/30/2024

Preparation and/or execution of this plan of correction does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of federal and state law.
1. Residents #3, #7, and #55 or their responsible person, have documented evidence that they were informed of their rights to develop advance directives, and they were provided the opportunity and assistance to formulate one if they chose to do so.
2.Assistant Administrator, or designee, reviewed all current residents to ensure the resident or their responsible person have documented evidence that they were informed of their rights to develop advance directives, and they were provided the opportunity and assistance to formulate one if they chose to do so.
3.Assistant Administrator will provide education Director of Social Services, Director of Nursing, and Assistant Director of Nursing regarding the Advance Directive Acknowledgement form signed upon admission and located in the Administrative File for each resident. This form will be attached to the electronic health record for the resident, under the Social Services section, by the Admissions/Transitions of Care Coordinator or designee.
4. Assistant Administrator, or designee, will audit all new admissions to ensure the resident or their responsible person have documented evidence that they were informed of their rights to develop advance directives, and they were provided the opportunity and assistance to formulate one if they chose to do so for one month, then 2 new admissions monthly for three months. All findings will be reported to the Quality Assurance Performance Committee. If deficient practices are identified additional corrective action will be taken.


483.10(g)(17)(18)(i)-(v) REQUIREMENT Medicaid/Medicare Coverage/Liability Notice:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
§483.10(g)(17) The facility must--
(i) Inform each Medicaid-eligible resident, in writing, at the time of admission to the nursing facility and when the resident becomes eligible for Medicaid of-
(A) The items and services that are included in nursing facility services under the State plan and for which the resident may not be charged;
(B) Those other items and services that the facility offers and for which the resident may be charged, and the amount of charges for those services; and
(ii) Inform each Medicaid-eligible resident when changes are made to the items and services specified in §483.10(g)(17)(i)(A) and (B) of this section.

§483.10(g)(18) The facility must inform each resident before, or at the time of admission, and periodically during the resident's stay, of services available in the facility and of charges for those services, including any charges for services not covered under Medicare/ Medicaid or by the facility's per diem rate.
(i) Where changes in coverage are made to items and services covered by Medicare and/or by the Medicaid State plan, the facility must provide notice to residents of the change as soon as is reasonably possible.
(ii) Where changes are made to charges for other items and services that the facility offers, the facility must inform the resident in writing at least 60 days prior to implementation of the change.
(iii) If a resident dies or is hospitalized or is transferred and does not return to the facility, the facility must refund to the resident, resident representative, or estate, as applicable, any deposit or charges already paid, less the facility's per diem rate, for the days the resident actually resided or reserved or retained a bed in the facility, regardless of any minimum stay or discharge notice requirements.
(iv) The facility must refund to the resident or resident representative any and all refunds due the resident within 30 days from the resident's date of discharge from the facility.
(v) The terms of an admission contract by or on behalf of an individual seeking admission to the facility must not conflict with the requirements of these regulations.
Observations:


Based on clinical record reviews and staff interviews, it was determined that the facility failed to provide the required notice to the resident or the resident's representative following the end of their Medicare coverage or a 48-hour advanced notice for one of three residents reviewed (Resident 122).

Findings include:

A Skilled Nursing Facility (SNF) Beneficiary Protection Notification Review form, completed by the facility and dated July 23, 2024, revealed that Medicare coverage for Resident 122 started on April 21, 2024, and that her last covered day was May 8, 2024. The form indicated that the facility initiated discontinuation from Medicare Part A coverage and that the resident's benefit days were not exhausted. The form was signed by the resident on May 6, 2024. The facility had no documented evidence that the resident was issued a SNF Beneficiary Protection Notification form or an Advanced Beneficiary Notice (ABN) notice as required.

Interview with Social Worker on July 24, 2024, at 2:28 p.m. confirmed that Resident 122 did not have an ABN completed timely. She forgot to issue any ABN notices for any residents.

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



 Plan of Correction - To be completed: 08/30/2024

 Preparation and/or execution of this plan of correction does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of federal and state law.
1. Director of Social Services provided Resident #122's representative with the Advanced Beneficiary Notice.
2.Director of Social Services, or designee, will audit Notice of Medicare Noncoverage issued July 25, 2024, or after to ensure there is documented evidence that the resident was issued an Advanced Beneficiary Notice as required.
3.The Assistant Administrator will provide reeducation to the Director of Social Services on the requirements for issuing the Advanced Beneficiary Notice.
4. Assistant Administrator, or designee will audit all issued Medicare Notices of Noncoverage to ensure Advanced Beneficiary Notice was issued as required for one month, then 2 per month for three months. All findings will be reported to the Quality Assurance Performance Committee. If deficient practices are identified additional corrective action will be taken.

483.10(h)(1)-(3)(i)(ii) REQUIREMENT Personal Privacy/Confidentiality of Records: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(h) Privacy and Confidentiality.
The resident has a right to personal privacy and confidentiality of his or her personal and medical records.

§483.10(h)(l) Personal privacy includes accommodations, medical treatment, written and telephone communications, personal care, visits, and meetings of family and resident groups, but this does not require the facility to provide a private room for each resident.

§483.10(h)(2) The facility must respect the residents right to personal privacy, including the right to privacy in his or her oral (that is, spoken), written, and electronic communications, including the right to send and promptly receive unopened mail and other letters, packages and other materials delivered to the facility for the resident, including those delivered through a means other than a postal service.

§483.10(h)(3) The resident has a right to secure and confidential personal and medical records.
(i) The resident has the right to refuse the release of personal and medical records except as provided at §483.70(i)(2) or other applicable federal or state laws.
(ii) The facility must allow representatives of the Office of the State Long-Term Care Ombudsman to examine a resident's medical, social, and administrative records in accordance with State law.
Observations:


Based on review of policies, as well as observations and staff interviews, it was determined that the facility failed to provide confidentiality of residents' personal health information during medication administration for one of 48 residents reviewed (Resident 137).

Findings include:

The facility policy regarding privacy of health information, dated October 13, 2023, indicated that the resident's health information needs to remain private.

Observations during medication administration on July 25, 2024, at 8:27 a.m. revealed that Licensed Practical Nurse 1 walked away from the medication cart to assist Resident 137 with something. Resident 137's personal health information was visible on the computer screen, which was facing the hallway.

Interview with Licensed Practical Nurse 1 on July 25, 2024, at 8:33 a.m. confirmed that she should have covered the residents' personal information when leaving the medication cart by securing the computer screen.

Interview with the Director of Nursing on July 25, 2024, at 11:51 a.m. confirmed that the computer screen with Resident 137's personal health information should have been covered when the nurse was not attending the medication cart.

28 Pa. Code 211.5(b) Clinical Records.




 Plan of Correction - To be completed: 08/30/2024

Preparation and/or execution of this plan of correction does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of federal and state law.
1. The Licensed Practical Nurse 1 will receive a disciplinary council with reeducation on the resident right to Personal Privacy / Confidentiality of records. Resident 137 personal health information was not visualized nor compromised.
2. The Director of Nursing assessed all 8 Nursing Units with standard of practice observed of covering the computer screen with a blank sheet of paper with no protected Health Information visible. Acceptable standards of practice is if suddenly called away from the medication cart is to close laptop or cover the screen with blank paper.
3. The Director of Nursing or designee will reeducate the Licensed Professional Staff on Personal Privacy and Confidently of records as an essential function of the licensed professional staff.
4.The Director of Nursing or designee will audit weekly for four weeks, then once a month for two months. If deficient practices are identified additional corrective actions will be taken.


483.10(j)(1)-(4) REQUIREMENT Grievances: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(j) Grievances.
§483.10(j)(1) The resident has the right to voice grievances to the facility or other agency or entity that hears grievances without discrimination or reprisal and without fear of discrimination or reprisal. Such grievances include those with respect to care and treatment which has been furnished as well as that which has not been furnished, the behavior of staff and of other residents, and other concerns regarding their LTC facility stay.

§483.10(j)(2) The resident has the right to and the facility must make prompt efforts by the facility to resolve grievances the resident may have, in accordance with this paragraph.

§483.10(j)(3) The facility must make information on how to file a grievance or complaint available to the resident.

§483.10(j)(4) The facility must establish a grievance policy to ensure the prompt resolution of all grievances regarding the residents' rights contained in this paragraph. Upon request, the provider must give a copy of the grievance policy to the resident. The grievance policy must include:
(i) Notifying resident individually or through postings in prominent locations throughout the facility of the right to file grievances orally (meaning spoken) or in writing; the right to file grievances anonymously; the contact information of the grievance official with whom a grievance can be filed, that is, his or her name, business address (mailing and email) and business phone number; a reasonable expected time frame for completing the review of the grievance; the right to obtain a written decision regarding his or her grievance; and the contact information of independent entities with whom grievances may be filed, that is, the pertinent State agency, Quality Improvement Organization, State Survey Agency and State Long-Term Care Ombudsman program or protection and advocacy system;
(ii) Identifying a Grievance Official who is responsible for overseeing the grievance process, receiving and tracking grievances through to their conclusions; leading any necessary investigations by the facility; maintaining the confidentiality of all information associated with grievances, for example, the identity of the resident for those grievances submitted anonymously, issuing written grievance decisions to the resident; and coordinating with state and federal agencies as necessary in light of specific allegations;
(iii) As necessary, taking immediate action to prevent further potential violations of any resident right while the alleged violation is being investigated;
(iv) Consistent with §483.12(c)(1), immediately reporting all alleged violations involving neglect, abuse, including injuries of unknown source, and/or misappropriation of resident property, by anyone furnishing services on behalf of the provider, to the administrator of the provider; and as required by State law;
(v) Ensuring that all written grievance decisions include the date the grievance was received, a summary statement of the resident's grievance, the steps taken to investigate the grievance, a summary of the pertinent findings or conclusions regarding the resident's concerns(s), a statement as to whether the grievance was confirmed or not confirmed, any corrective action taken or to be taken by the facility as a result of the grievance, and the date the written decision was issued;
(vi) Taking appropriate corrective action in accordance with State law if the alleged violation of the residents' rights is confirmed by the facility or if an outside entity having jurisdiction, such as the State Survey Agency, Quality Improvement Organization, or local law enforcement agency confirms a violation for any of these residents' rights within its area of responsibility; and
(vii) Maintaining evidence demonstrating the result of all grievances for a period of no less than 3 years from the issuance of the grievance decision.
Observations:


Based on review of facility policies and grievance records, as well as resident and staff interviews, it was determined that the facility failed to make ongoing efforts to resolve a grievance regarding dietary complaints for one of 48 residents reviewed (Resident 5).

Findings include:

The facility's policy regarding grievances, dated October 13, 2023, indicated that it is the policy of the facility to acknowledge any resident grievance and actively work toward a resolution. The grievance official and/or designee will meet with the party filling the grievance to discuss findings and necessary corrective action.

A review of the facility's grievance logs for six months revealed no grievances related to food; however, minutes from the resident council meeting on April 29, 2024, revealed that Resident 5 had concerns with hot food. She documented that it would be nice to have the hot meal cart at all meals. The meals are hotter and taste better.

A memo from the Director of Resident and Community Engagement, dated May 2, 2024, revealed that she had spoken with the Dietary Director regarding food concerns including temperatures of food. The Dietary Director stated she would have dietary check to make sure the temperatures are taken properly and food is served at correct temperature. A memo with attached education and a signature page, dated May 4, 2024, revealed that the Dietary Director spoke with dietary staff to make sure temperatures were taken for each meal.

Observations of the lunch meal tray line and distribution on July 24, 2024, at 12:14 p.m. revealed that trays were delivered to Benjamin court on a metal, open cart on warmed plates covered by a warmed-plate cover. The cart was not enclosed or insulated. A total of three trays were passed to that unit. The first tray was passed at 12:20 p.m. and the last tray passed was at 12:25 p.m. A test tray for temperature was sampled at 12:25 p.m. The temperature of the foods were as follows: French fries were 108 degrees Fahrenheit (F), the hamburger was 116 degrees (F), and the soup was 153 degrees (F). The French fries and hamburger were cool to taste. Dietary Aide 2, who was temping the foods at the time of the test tray, stated that the food could always be heated up in the microwave if needed.

Interview with the Dietary Director on July 25, 2024, at 8:48 a.m. revealed that they have one insulated cart to keep food warm during transport. She stated that the units that have steam tables do not need them and stated she may suggest that they get a couple more.

Interview with the Dietary Director on July 25, 2024, at 3:16 p.m. confirmed that dietary staff had been educated on taking food temperatures in the kitchen and that she would have to re-educate them.

28 Pa. Code 201.29(i) Resident Rights.




 Plan of Correction - To be completed: 08/30/2024

Preparation and/or execution of this plan of correction does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of federal and state law.
1.Director of Dining Services interviewed Resident 5 who is a resident on Villa David Garden regarding her grievance of food temperatures. The resident stated that since August 1, 2024, she has been satisfied with the food temperature. Food temperature logs support that the food temperatures have been satisfactory. Revised practice of Burlodge carts used on 4 units Villa Claire Courtyard, Villa Claire Garden and Villa David Courtyard and Villa David Garden; Steam wells on Villa Elizabeth and Villa Francis; and Villa Benjamin Courtyard and Villa Benjamin Garden is the meal delivery plan.
2. Resident Council held on July 30, 2024, at 2 pm revealed no grievances regarding food which included food temperatures.
3. The Director of Dining Services provided education to the Dietary Staff on the use of the Burlodge Cart use on 4 units Villa Claire Courtyard, Villa Claire Garden and Villa David Courtyard and Villa David Garden; Steam wells are utilized on Villa Elizabeth and Villa Francis and Villa Benjamin Courtyard and Villa Benjamin Garden attend the main Dining Room for meals. Director of Nursing or designee will provide education to the nursing staff on assessing for complaints of cold food recognizing those who may eat in their room may be at a higher risk for these complaints with taking the individual's satisfaction part of the education.
4. The Director of Dining Services or designee will perform a random audit of 10 residents weekly for four weeks, then once a month for two months and will continue monthly unless deemed no longer necessary by the Quality Assurance Performance Committee.

483.12(a)(1) REQUIREMENT Free from Abuse and Neglect: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 Freedom from Abuse, Neglect, and Exploitation
The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms.

§483.12(a) The facility must-

§483.12(a)(1) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion;
Observations:


Based on review of facility policies, clinical records, and investigation documents, as well as staff and resident interviews, it was determined that the facility failed to ensure that residents were free from abuse and neglect for one of 48 residents reviewed (Resident 63).

Findings include:

The facility's abuse policy, dated October 13, 2023, indicated that residents have the right to be free from any verbal, sexual, physical, and mental abuse; corporal punishment; involuntary seclusion; exploitation; and misappropriation of resident property. Residents must not be subjected to abuse by anyone, including but not limited to facility staff, other residents, consultants or volunteers, staff or other agencies serving the individual, family members or legal guardians, friends or other individuals. The intent of the policy is to develop and maintain a proactive process of detection and prevention of resident mistreatment, neglect, abuse, and misappropriation of property. Any staff member found guilty of abusing, neglecting or mistreating residents will be discharged immediately.

A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 63, dated, May 29, 2024, revealed that the resident was cognitively impaired, was sometimes understood and sometimes understood others, required assistance with care needs, and had diagnoses that included dementia, Alzheimer's disease, and anxiety.

A cognitive care plan for Resident 63, dated March 10, 2023, revealed that the family reported Resident 63 was triggered by showers and gets agitated around 10:00 to 10:30 a.m. and in the evening. A current care plan for Resident 63 regarding her activities of daily living revealed that she was afraid of showers and bathtubs.

A facility investigation document, dated January 29, 2024, at 10:30 a.m., revealed that on the morning of January 29, 2024, Nurse Aide 3 and Licensed Practical Nurse 4 were trying to give Resident 63 a shower, which she was refusing. The daughter-in-law, who is also an employee, was bringing other residents back from church and witnessed the interaction with the staff. The daughter-in-law was trying to talk Resident 63 into the shower when Nurse Aide 3 came up and gave Resident 63 a hug while picking her up at the waist and carried her on her hip down the hallway. Resident 63 called out "ouch" repeatedly until Nurse Aide 3 put her down. Resident 63 stated "that hurt" while rubbing her right hip. Licensed Practical Nurse 4 reported it to Registered Nurse Supervisor 5.

A written statement from Nurse Aide 3, dated January 29, 2024, revealed that on January 29, 2024, she was trying to get Resident 63 to go get a shower, and the resident was very difficult and needed to redirect. Licensed Practical Nurse 4 was present. Nurse Aide 3 stated she did give the resident a hug and lifted her and walked a few steps. She stated that is how she gets her to get a shower by joking with her and relaxing her nerves. She stated that it relaxes her nerves and calms her down a little every shower day. She stated that the resident was very combative and it takes more than one person to help shower her and she did not feel she was being abusive at all.

A written statement from Licensed Practical Nurse 4, dated January 29, 2024, revealed that she was walking Resident 63 to the shower room with Nurse Aide 3 when the resident started to give them a hard time and refused to get a bath. She stated that as this was happening, they saw the daughter-in-law, who is also an employee, and she also tried to calm the resident down explaining that she needed to get washed. As the daughter-in-law was explaining this, Nurse Aide 3 went over and gave the resident a hug and picked her up off the floor, holding her around her waist, and carried the resident on her hip all the way from room 3 to past the medication room. As she was doing this the resident was yelling "ouch" repeatedly, approximately three to four times until Nurse Aide 3 put her down. Resident 63 stated "that hurt" as she was rubbing her right hip. Nurse Aide 3 then proceeded to tell the daughter-in-law that "sometimes you just have to be stern with them and not give them an option." Licensed Practical Nurse 4 stated she did tell Nurse Aide 3 that they needed to be gentle and make sure they were not hurting the resident or causing harm. Licensed Practical Nurse 4 stated she discussed the situation with the daughter-in-law afterwards and they both felt the behavior was very inappropriate and reported the situation to Registered Nurse Supervisor 5.

A written statement from the daughter-in-law, dated January 29, 2024, revealed that around 10:30 a.m. on January 29, 2024, she was returning residents from mass and Licensed Practical Nurse 4 and Nurse Aide 3 were attempting to encourage Resident 63 to take a bath. Resident 63 was refusing and slightly agitated. She stopped to see if she could assist or talk to the resident about taking a bath. She stated that she, Licensed Practical Nurse 4, and Nurse Aide 3 were standing in the hallway on Elizabeth right past the nurse's station talking with the resident, and Nurse Aide 3 bent down and picked the resident up below the waist, around her thigh area, and carried her around the corner to take her to get a bath. After they turned the corner, Resident 63 yelled, "Ouch, you are hurting me, you are hurting me, put me down," and Nurse Aide 3 then put her down. Resident 63 stated that Nurse Aide 3 hurt her as she rubbed her right upper hip area. The resident's daughter-in-law stated she was concerned about the resident and walked with her around the corner to the front of the unit where she sat down and was shaken. She sat with her to calm her down and talked with her about taking a bath and she still refused. She stated that Nurse Aide 3 attempted one more time and when she opened the door to the shower room, the resident said no and returned to her room and laid down on her bed. The daughter-in-law also explained that perhaps evening would be a better time for a bath since the resident is usually appears to be in a better mood.

A nursing note for Resident 63, dated January 31, 2024, at 2:03 p.m. as a late entry for January 29, 2024, by Registered Nurse 6, revealed that the resident was observed sitting in a chair in the back dining room. The resident was agitated and resistant prior to her bath. The daughter-in-law attempted to calm the resident by talking with the resident. Nurse Aide 3 inappropriately attempted to assist the resident into the tub room. The actions were witnessed by Licensed Practical Nurse 4 and the daughter-in-law. The resident was assessed by Registered Nurse 6 after Licensed Practical Nurse 4 reported the incident. No redness, bruising, bumps or complaints of pain were voiced at time of the assessment. Vital signs were done, and the Medical Director was to see the resident in the morning. Nursing notes for Resident 63, dated January 31, 2024, revealed that the resident was seen by the Medical Director. No injuries or complaints of pain were noted.

Description of follow up-action, as documented on the event report for Resident 63, dated January 30, 2024, revealed that Nurse Aide 3 was immediately removed from the unit and sent home until the investigation was completed. Nurse Aide 3 was last trained on resident rights and abuse on July 20, 2023. Added to the description of follow up-action following investigation revealed that, as of February 1, 2024, Nurse Aide 3 was terminated.

An interview with Registered Nurse 6 on July 25, 2024, at 6:33 p.m. revealed that she was working the day of the incident with Resident 63 but did not witness the incident. She stated she was asked by Registered Nurse Supervisor 5 to assess the resident after the incident. She confirmed that Nurse Aide 3 was immediately removed from the facility.

An interview with the Director of Nursing on July 25, 2024, at 7:00 p.m. revealed that the investigation was completed by Assistant Director of Nursing 7 as she was on vacation at the time of the incident involving Resident 63. Assistant Director of Nursing 7 is no longer employed at the facility and could not be interviewed. The Director of Nursing confirmed that Nurse Aide 3 was sent home and not permitted to work pending the investigation, that all required agencies were notified, and that was she was terminated.

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

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

28 Pa. Code 201.29(a)(j) Resident Rights.

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




 Plan of Correction - To be completed: 08/30/2024

Preparation and/or execution of this plan of correction does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of federal and state law.

1. Resident 63 as of January 31, 2024, remained without pain because of the incident that occurred on 1/29/24. All required notification to the appropriate governing and regulatory agencies was completed in a timely manner meeting the state and federal reporting requirements. The employee Nurse Aide 3's employment was terminated as of 2/1/2024.
2. All allegations of Abuse and Neglect have been investigated as well as reported in a timely manner to the required regulatory agencies.
3. Director of Social Services or designee will reeducate facility staff on the Resident's Right to be Free of Abuse and Neglect. Rules of Conduct will also be a focus topic of education with zero tolerance for abuse or neglect.
4. The Director of Nursing or designee will audit weekly for four weeks, then once a month for two months for any allegations of abuse or neglect emphasizing to all employees zero tolerance.


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.
Observations:


Based on review of facility policies, clinical records, and facility investigation documents, as well as staff interviews, it was determined that the facility failed to prevent the misappropriation of medication for one of 48 residents reviewed (Resident 111).

Findings include:

The facility's policy regarding abuse, dated October 13, 2023, indicated that misappropriation included the deliberate misplacement, exploitation, or wrongful, temporary or permanent use of a resident's belongings or money without the resident's consent.

A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 111, dated May 28, 2024, revealed that the resident was cognitively intact, required extensive assistance for daily care needs, and had a diagnosis of chronic pain.

Physician's orders for Resident 111, dated May 29, 2024, included an order for the resident to receive one 350 milligrams (mg) tablet of Carisoprodol (a muscle relaxant) four times a day.

A facility investigation document, dated June 1, 2024, at 6:30 a.m. revealed that on June 1, 2024, at 6:30 a.m. Licensed Practical Nurse 8 attempted to perform the narcotic count; however, she could not locate the night shift nurse. Licensed Practical Nurse 8 noticed that Resident 111's controlled narcotic count for Carisoprodol 350 mg was incorrect reflecting a count of 56 pills instead of 55.

Licensed Practical Nurse 8 notified the Registered Nurse Supervisor that a controlled medication cassette for Resident 111 appeared to be tampered with. It was observed that slots 52 thru 56 of the blister foil pack had been broken and was covered with surgical tape. The pills that were in the opened areas on the blister pack did not appear to match the remaining pills.

Resident 111 was seen by the physician and was at his baseline with no change in mental or physical status. The alleged perpetrator was Licensed Practical Nurse 9, an agency nurse who left the facility before performing the controlled medication count at the end of the shift and had no further contact with residents.

The staffing agency that employed Licensed Practical Nurse 9 was notified of the event and was made aware that Licensed Practical Nurse 9 would be questioned during the investigation. The Director of Nursing spoke to Licensed Practical Nurse 9 and scheduled a meeting for June 4, 2024, at 10:00 a.m. to obtain her statement concerning the medication in question. Licensed Practical Nurse 9 did not come to the facility to give her statement and after several unsuccessful attempts to contact her, the Greensburg Police Department was called and came to the facility to identify the pills that were placed in the opened blister pack.

The investigation was completed on June 6, 2024, at 4:30 p.m. and the PA State Board of Nursing was notified of the event on June 7, 2024.

Interview with the Assistant Administrator on July 25, 2024, at 11:00 a.m. confirmed that the investigation initiated on June 1, 2024, at 6:30 a.m. was completed on June 6, 2024, at 4:30 p.m. and concluded that misappropriation of Resident 111's medication did occur.

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

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

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




 Plan of Correction - To be completed: 08/30/2024

Preparation and/or execution of this plan of correction does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of federal and state law.
1. The medication involved in the alleged theft was paid for by St. Anne Home as confirmed by the Billing Coordinator. There was no financial liability to the resident or family. The Agency Licensed Practical Nurse involved in this allegation is not permitted to return to the facility. The Greensburg State Police as well as PA State Board of the incident. There was no harm to the resident.
2. All allegations of misappropriation / exploitation have been investigated as well as reported in a timely manner to the required regulatory agencies.
3. Director of Social Services or designee will reeducate facility staff on the Resident's Right to be Free of Abuse and Neglect including Misappropriation of property. Rules of Conduct will also be reviewed.The Registered Nurse Supervisor has been educated and will monitor employees every shift for any erratic behaviors and immediately report to the Director of Nursing or designee which includes but is nit limited to Assistant Director of Nursing, Quality Assurance Performance Improvement Registered Nurse, or Infection Preventionist.
4. The Director of Nursing or designee will audit weekly for four weeks, then once a month for two months for any allegations of abuse or neglect emphasizing to all employees zero tolerance.


483.15(c)(3)-(6)(8) REQUIREMENT Notice Requirements Before Transfer/Discharge: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.
§483.15(c)(3) Notice before transfer.
Before a facility transfers or discharges a resident, the facility must-
(i) Notify the resident and the resident's representative(s) of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand. The facility must send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman.
(ii) Record the reasons for the transfer or discharge in the resident's medical record in accordance with paragraph (c)(2) of this section; and
(iii) Include in the notice the items described in paragraph (c)(5) of this section.

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

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

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

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


Based on review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to notify the ombudsman in writing regarding the reason for transfers/discharge to hospital for five of 48 residents reviewed (Residents 11, 47, 67, 73, 108).

Findings include:

The facility's policy regarding Emergent Facility Initiated Discharge/Transfer reporting to the Ombudsman, dated October 13, 2023, indicated that the facility is to report emergent facility discharges/transfers to the State Long Term Care Ombudsman on a monthly basis.

A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 11, dated August 18, 2024, revealed that the resident was cognitively impaired, was clearly understood and able to understand others, required assistance with care needs, was receiving antipsychotic medications, and had diagnoses that included hyponatremia (low sodium in the blood).

Nursing notes for Resident 11, dated September 3, 2024, at 10:27 a.m., revealed that the resident was agitated and was unable to be redirected. The resident then stood up and urinated on the floor. A friend of the resident reported that in the past when Resident 11 acted like this she was septic, and the resident was transported to the emergency room for evaluation.

There was no documented evidence that a written notice of Resident 11's transfer to the hospital was provided to the Ombudsman regarding the reason for transfer.

Interview with the Director of Nursing on July 25, 2024, at 2:21 p.m. confirmed that the facility did not notify the Ombudsman in writing regarding the reason for Resident 11's transfer/discharge to the hospital.

A quarterly MDS assessment for Resident 47, dated May 10, 2024, indicated that the resident was cognitively impaired, required assistance from staff for her daily care needs, and had diagnoses that included Parkinson's disease (a degenerative brain condition that affects muscle control and movement).

Nursing notes for Resident 47, dated February 1, 2024, at 4:28 p.m., revealed that the resident had a fall and complained of pain in the back of her head and left hip. Her left leg was externally rotated. She was sent to the hospital and was admitted with a hip fracture.

There was no documented evidence that a written notice of Resident 47's transfer to the hospital was provided to the Ombudsman regarding the reason for transfer.

Interview with the Director of Nursing on July 24, 2024, at 3:08 p.m. confirmed that the facility did not notify the Ombudsman in writing regarding the reason for Resident 47's transfer/discharge to the hospital.

An admission MDS assessment for Resident 67, dated April 6, 2024, indicated that the resident was cognitively intact, required assistance from staff for her daily care needs, and had diagnoses that included heart failure.

Nursing notes for Resident 67, dated July 2, 2024, at 10:28 a.m. revealed that the resident was sent to Independence Latrobe Hospital for evaluation.

There was no documented evidence that a written notice of Resident 67's transfer to the hospital was provided to the Ombudsman regarding the reason for transfer.

Interview with the Director of Nursing on July 25, 2024, at 10:10 a.m. confirmed that the facility did not notify the Ombudsman in writing regarding the reason for Resident 67's transfer/discharge to the hospital.

A quarterly MDS assessment for Resident 73, dated May 8, 2024, indicated that the resident was cognitively impaired, required assistance from staff for her daily care needs, and had a Stage 4 pressure ulcer (pressure wound with full thickness tissue loss with exposed bone, tendon or muscle).

Nursing notes for Resident 73, dated February 1, 2024, at 1:59 p.m., indicated that the resident was sent to the hospital for evaluation of an unstageable pressure injury (full-thickness pressure injuries in which the base is obscured by slough and/or eschar) to the sacrococcygeal region (lower part of the spine) for surgical debridement and was admitted.

There was no documented evidence that a written notice of Resident 73's transfer to the hospital was provided to the Ombudsman regarding the reason for transfer.

Interview with the Director of Nursing on July 24, 2024, at 3:08 p.m. confirmed that the facility did not notify the Ombudsman in writing regarding the reason for Resident 73's transfer/discharge to the hospital.

An admission MDS assessment for Resident 108, dated April 30, 2024, indicated that the resident was cognitively intact, required assistance from staff for her daily care needs, and had diagnoses that included stroke.

Nursing notes for Resident 108, dated July 18, 2024, at 5:35 p.m., revealed that the resident had a fall and was sent to the hospital for evaluation.

There was no documented evidence that a written notice of Resident 108's transfer to the hospital was provided to the Ombudsman regarding the reason for transfer.

Interview with the Director of Nursing on July 25, 2024, at 10:10 a.m. confirmed that the facility did not notify the Ombudsman in writing regarding the reason for Resident 108's transfer/discharge to the hospital.

28 Pa. Code 201.25 Discharge Policy.

28 Pa. Code 201.29(f)(g) Resident Rights.




 Plan of Correction - To be completed: 08/30/2024

Preparation and/or execution of this plan of correction does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of federal and state law.
1.Director of Social Services notified the Ombudsman in writing regarding the reason for transfer/discharge to hospital for Resident #11, Resident # 47, Resident #67, Resident #73, and Resident #108.
2. Director of Social Services, or designee, will audit transfers/discharges to hospital starting July 1, 2024, to ensure the Ombudsman was notified in writing regarding the reason for the transfer/discharge to the hospital.
3. Assistant Administrator will provide education to the Director of Social Services regarding facility policy on Emergent Facility Initiated Discharge/Transfer reporting to the State Long Term Care Ombudsman dated October 13, 2023.
4. Assistant Administrator, or designee, will audit the monthly reporting to the State Long Term Care Ombudsman for 4 months, then quarterly for one year. All findings will be reported to the Quality Assurance Performance Committee. If deficient practices are identified additional corrective action will be taken.

483.20(g) REQUIREMENT Accuracy of Assessments:Least serious deficiency but affects more than a limited number of residents, staff, or occurrences. This deficiency has the potential for causing no more than a minor negative impact on the resident but is not found to be throughout this facility.
§483.20(g) Accuracy of Assessments.
The assessment must accurately reflect the resident's status.
Observations:


Based on a review of the Resident Assessment Instrument User's Manual and clinical records, as well as staff interviews, it was determined that the facility failed to complete accurate Minimum Data Set assessments for three of 48 residents reviewed (Residents 45, 73, 77).

Findings include:

The Resident Assessment Instrument (RAI) User's Manual, which gives instructions for completing Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2023, revealed section O0100K1B (hospice) was to be coded yes if a resident was identified as being in a hospice program for terminally ill persons where an array of services is provided for the palliation and management of terminal illness and related conditions.

The care plan for Resident 45, dated February 15, 2022, included that the resident was receiving hospice services with Vitas hospice and hospice staff were to coordinate the care to facilitate the resident's and or the family's wishes for comfort and symptom management with respect and dignity and the resident's and family's requested comfort care/ hospice care.

A quarterly MDS assessment for Resident 45, dated July 8, 2024, revealed that Section O0100K1B was checked no, indicating that the resident did not receive hospice services as a resident.

The RAI User's Manual, dated October 2023, revealed that Section N0415A (Antipsychotic Medications - medications used to mental disorders) was to be coded if the resident took the medication during the seven-day look-back period.

Physician's orders for Resident 73, dated February 10, 2024, included an order for the resident to receive five milligrams of Aripiprazole (an antipsychotic medication) daily for depression. Resident 73's Medication Administration Record for May 2024 revealed that the resident was administered Aripiprazole during the seven-day look-back assessment period.

A quarterly MDS assessment for Resident 73, dated May 8, 2024, revealed that N0415A was not coded, indicating that she did not receive an antipsychotic medication during the seven-day look-back assessment period.

The RAI User's Manual, dated October 2023, revealed that Sections H0100 through H0300 were to gather information on the use of bowel and bladder appliances and urinary and bowel continence. Section H0100 was to be coded for each appliance that was used at any time in the past seven days. Select none of the above if none of the appliances A-D were used in the past seven days. Section H0300 was to be coded nine (9), not rated if during the seven-day look-back period the resident had an indwelling bladder catheter (a tube held in the bladder to drain urine) or other types of catheters or no urine output for the entire seven days.

A quarterly MDS assessment for Resident 73, dated May 8, 2024, revealed that Section H0100A was checked, indicating that the resident had an indwelling urinary catheter, and Section H0300 was coded with a zero (0), indicating that the resident was always continent of urine.

Physician's orders for Resident 73, dated February 10, 2024, included an order for the resident to have an indwelling foley catheter connected to the bedside drainage bag every shift. Resident 73's Treatment Administration Record for May 2024 revealed that she received catheter checks for connection to the drainage bag every shift during the review period.

The RAI User's Manual, which gives instructions for completing MDS assessments, dated October 2023, revealed that section O0100C1B (oxygen therapy) was to be coded yes if a resident was provided continuous or intermittent oxygen administered via mask, cannula, etc., delivered to a resident to relieve hypoxia in this item.

Physician's orders for Resident 77, dated February 10, 2024, included an order for the resident to be provided oxygen at a flow rate of 2 to 5 liters per minute (lpm) as need to maintain an oxygen saturation level of 91 percent or greater via nasal cannula (flexible tubes inserted into the nares to deliver oxygen).

A quarterly MDS assessment for Resident 77, dated June 4, 2024, revealed that Section O0100C1B was checked no, indicating that the resident did not receive oxygen therapy as a resident.

Interview with the Corporate Compliance Officer on July 25, 2024, at 5:13 p.m. confirmed that the MDS assessments listed above for Residents 45, 73 and 77 were not completed accurately.

28 Pa. Code 211.5(f) Clinical Records.



 Plan of Correction - To be completed: 08/30/2024

Preparation and/or execution of this plan of correction does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of federal and state law.
1. Resident 45 modification to the Minimum Data Set (MDS) section O0100K1B was completed on 7/26/24 to accurately reflect that resident received hospice services during the look-back assessment period. Resident 73 modification to the Minimum Data Set (MDS) section N0415A was completed on 8/9/24 to accurately reflect receiving antipsychotic medication during the seven-day look-back assessment period. Resident 73 modification to the Minimum Data Set (MDS) section H0300 was completed on 7/26/24 to reflect urinary continence as not rated due to resident having an indwelling bladder catheter during the seven-day look-back period. Resident 77 modification to the Minimum Data Set (MDS) section O0100C1B was completed on 7/26/24 to reflect oxygen therapy during the seven-day look-back period.
2. All quarterly Minimum Data Set (MDS) assessment sections H, O, and N completed May 1, 2024 through July 31, 2024 were reviewed for accuracy with modifications made as per the Resident Assessment Instrument (RAI).
3. The Registered Nurse Assessment Coordinator (RNAC) and Licensed Practical Nurse Assessment Coordinator (LPNAC) were re-educated by the Quality Assurance Performance Improvement (QAPI) Nurse on accurate coding and completion of quarterly Minimum Data Set (MDS) with emphasis on sections H, O, and N.
4. The Quality Assurance Performance Improvement (QAPI) Nurse or designee will audit the completion of quarterly Minimum Data Set (MDS) sections H, O, and N of a sample size of 5 residents once a week beginning 8/12/24 for four weeks and then once a month for two months. All findings will be reported to the Quality Assurance Performance Committee. If deficient practices are identified additional corrective action will be taken.


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