Pennsylvania Department of Health
SCENERY HILL HEALTHCARE AND REHABILITATION CENTER
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

SCENERY HILL HEALTHCARE AND REHABILITATION CENTER
Inspection Results For:

There are 83 surveys for this facility. Please select a date to view the survey results.

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


SCENERY HILL HEALTHCARE AND REHABILITATION CENTER - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:

Based on a Medicare/Medicaid Recertification survey, State Licensure survey, and Civil Rights Compliance survey completed on May 30, 2024, it was determined that Scenery Hill Healthcare and Rehabilitation Center was not in compliance with the following requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care Facilities and the 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.

Plan of Correction:

483.25(d)(1)(2) REQUIREMENT Free of Accident Hazards/Supervision/Devices:

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(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 facility policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that the resident environment was a free of accident hazards as is possible, by failing to complete safety assessments for air mattress use for three of 18 residents reviewed (Residents 20, 44, 47).

Findings include:

The facility's policy regarding air mattresses, dated February 15, 2024, indicated that the facility would would provide residents with a bed that met their needs and was comfortable, and air mattresses were reserved for residents with pressure ulcers.

A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 20, dated May 15, 2024, revealed that the resident was cognitively intact, had limited range of motion of the lower extremities, and had a pressure ulcer.

Physician's orders for Resident 20, dated February 23, 2024, included an order for the resident's bed to be equipped with a low air loss mattress (designed to distribute the patient's body weight over a broad surface area and help prevent skin breakdown.) for a Stage III pressure ulcer (full thickness tissue loss, subcutaneous fat may be visible, but bone, tendon, or muscle is not exposed). The resident's care plan, dated February 26, 2024, revealed that the resident had a pressure sore and used an air mattress. There was no documented evidence that the use of an air mattress was assessed for potential safety hazards prior to the air mattress being placed on Resident 20's bed.

Observations on May 29, 2024, at 8:19 a.m. and 11:53 a.m. revealed that Resident 20 was in bed with an air mattress in place.

An admission MDS assessment for Resident 44, dated March 1, 2024, revealed that the resident was cognitively intact, had limited range of motion of the upper and lower extremities, and had one Stage II pressure ulcer, two Stage III pressure ulcers, and six venous and arterial ulcers present on admission.

Physician's orders for Resident 44, dated March 21, 2024, included an order for the resident's bed to be equipped with a low air loss mattress. There was no documented evidence that the use of an air mattress was assessed for potential safety hazards prior to the air mattress being placed on Resident 44's bed.

Observations on May 28, 2024, at 11:20 a.m. revealed that Resident 44 was in bed with an air mattress in place.

An admission MDS assessment for Resident 47, dated May 1, 2024, revealed that the resident was cognitively intact, had limited range of motion of the upper and lower extremities, and had diagnoses that included a stroke.

Physician's orders for Resident 47, dated May 9, 2024, included an order for the resident's bed to be equipped with a low air loss mattress with bolsters (raised edges). The resident's care plan, dated April 26, 2024, revealed that the resident used an air mattress. was no documented evidence that the use of an air mattress was assessed for potential safety hazards prior to the air mattress being placed on Resident 47's bed.

Observations on May 30, 2024, at 11:43 a.m. revealed that Resident 47 was in bed with an air mattress in place.

Interview with the Director of Nursing on May 30, 2024, at 10:30 a.m. confirmed that there were no specific assessments completed to ensure that the use of an air mattress was safe for Residents 20, 44, and 47.

28 Pa. Code 211.10(c)(d) Resident Care Policies.

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

Plan of Correction - To be completed: 07/09/2024

1.) The Director of Nursing (DON) immediately completed the air mattress safety assessments on the residents identified.

2.) The DON then reviewed all other residents on an air mattress and safety assessment were completed. No safety concerns were identified.

3.) The DON will educate the licensed staff on when they will complete air mattress safety assessments. The license staff will check the user-defined assessment tab daily.

4.) The DON or designee will audit completion at the daily weekday meeting for five days, then weekly for three weeks, then monthly for one month. The results of this audit will be reviewed by the Quality Assurance Performance Improvement (QAPI) committee for discussion.

5.) The date of compliance is July 9, 2024.

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

§483.60(i) Food safety requirements.
The facility must -

§483.60(i)(1) - Procure food from sources approved or considered satisfactory by federal, state or local authorities.
(i) This may include food items obtained directly from local producers, subject to applicable State and local laws or regulations.
(ii) This provision does not prohibit or prevent facilities from using produce grown in facility gardens, subject to compliance with applicable safe growing and food-handling practices.
(iii) This provision does not preclude residents from consuming foods not procured by the facility.

§483.60(i)(2) - Store, prepare, distribute and serve food in accordance with professional standards for food service safety.

Observations:

Based on review of policies, as well as observations and staff interviews, it was determined that the facility failed to store food and wash dishes in accordance with professional standards for food service safety, by failing to ensure that food was discarded in a timely manner and that the dishwasher had an appropriate washing cycle temperature.

Findings include:

The facility's dietary policy regarding food storage, dated February 15, 2024, revealed that food was stored in a manner that complied with safe food handling practices.

Observations in the kitchen on May 28, 2024, at 9:02 a.m. revealed that there was a plastic container of pizza sauce that was dated May 19, 2024. Interview with the Dietary Manager on May 28, 2024, at 9:13 a.m. revealed that the sauce should have been discarded after seven days.

Manufacturer's instructions for the Ecolab ES-2000 Dish machine, dated 2009, indicated that the washing operational temperature was to be 120 degrees Fahrenheit (F).

Observations of the dishwasher on May 30, 2024, at 12:32 p.m. revealed that the wash cycle of the dish machine only reached a washing temperature of 100 degrees F. The Dietary Manager indicated that she did not have any temperature concerns that morning.

Interview with the Nursing Home Administrator on May 30, 2024, at 1:03 p.m. confirmed that the manufacturer's instructions indicated that the dish machine's operational temperature was to be 120 degrees F.

28 Pa. Code 211.6(f) Dietary Services.

Plan of Correction - To be completed: 07/09/2024

1.) We immediately discarded the pizza sauce. We also immediately adjusted the water temperature to be above 120 degrees.

2.) We performed an audit of the cooler to ensure there were no other food containers that were past the discard date, and none were found. We immediately rewashed all the dishes from the meal in question.

3.) The Dietary Department's closing checklist will include a date check for all open cooler items. Any items noted to be outdated the following day will be posted on the dietary department's communication board for the morning shift to act upon. The dishwasher temp log will include a temperature check with each of the two carts for each meal thereby having a mid-run check.

4.) The Dietary department will be educated by the NHA, who has dietary qualifications, on the new dating procedures and the new temperature check procedures. These new procedures will be audited by the NHA daily for 5 days then weekly for 3 weeks and monthly for one month. The results of these audits will be reviewed by the Quality Assurance Performance Improvement committee for discussion. Any negative results will be addressed by the committee.

5.) The date of compliance is July 9, 2024.

483.12(b)(1)-(5)(ii)(iii) REQUIREMENT Develop/Implement Abuse/Neglect Policies:

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(b) The facility must develop and implement written policies and procedures that:

§483.12(b)(1) Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property,

§483.12(b)(2) Establish policies and procedures to investigate any such allegations, and

§483.12(b)(3) Include training as required at paragraph §483.95,

§483.12(b)(4) Establish coordination with the QAPI program required under §483.75.

§483.12(b)(5) Ensure reporting of crimes occurring in federally-funded long-term care facilities in accordance with section 1150B of the Act. The policies and procedures must include but are not limited to the following elements.

§483.12(b)(5)(ii) Posting a conspicuous notice of employee rights, as defined at section 1150B(d)(3) of the Act.

§483.12(b)(5)(iii) Prohibiting and preventing retaliation, as defined at section 1150B(d)(1) and (2) of the Act.

Observations:

Based on review of policies, clinical records, and investigation documents, as well as staff interviews, it was determined that the facility failed to complete a Nurse Aide Registry verification for one of five nurse aides reviewed upon hire (Nurse Aide 1).

Findings include:

The facility's abuse policy, dated February 15, 2024, revealed that the facility will not employ or otherwise engage individuals who have had a finding entered into the state Nurse Aide Registry concerning abuse, neglect, exploitation, mistreatment of residents or misappropriation of their property.

The personnel file for Nurse Aide 1 revealed that she was hired May 10, 2024. However, there was no documented evidence until May 28, 2024, at 9:41 a.m. that the nurse aide's standing on the Pennsylvania Nurse Aide Registry was verified.

Interview with the Human Resources Director on May 30, 2024, at 12:57 p.m. confirmed that there was no documented evidence until May 28, 2024, that Nurse Aide 1's standing on the Pennsylvania Nurse Aide Registry was verified.

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

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

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

Plan of Correction - To be completed: 07/09/2024

1.) While this aide was a rehire from the previous November where we did run the registry check, we immediately reran her certification through the nurse aide registry and no issues were found.

2.) We immediately checked the nurse aide license registry checks in the employee files of all current nurse aides, and all were available and current.

3.) The new hire file verification form will now include the nurse aide registry check for all new hires. This form is to be completed prior to any new hires starting on the floor. The Nursing Home Administrator (NHA) will educate the Human Resources Director on the change in the new hire form to include the registry check.

4.) The NHA or designee will audit the next five (5) nurse aide new hires to ensure the registry check was completed prior to starting on the floor. The results of this audit will be reviewed by the Quality Assurance Performance Improvement (QAPI) committee for discussion. Any negative results will be addressed by the committee.

5.) The date of compliance is July 9, 2024.

483.75(c)(d)(e)(g)(2)(i)(ii) REQUIREMENT QAPI/QAA Improvement Activities:

§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 maintain compliance with nursing home regulations and ensure that plans to improve the delivery of care and services effectively addressed recurring deficiencies.

Findings include:

The facility's deficiencies and plans of correction for State Survey and Certification (Department of Health) survey ending June 22, 2024, revealed that the facility developed plans of correction that included quality assurance systems with audits to ensure that the facility maintained compliance with cited nursing home regulations. The results of the audits were to be reported to the QAPI committee for review. The results of the current survey, ending May 30, 2024, identified repeated deficiencies regarding ensuring that the resident's environment was free of accident hazards, preventing issues with the accountability of controlled medications (drugs with the potential to be abused), and ensuring that clinical records were complete and accurately documented.

The facility's plans of correction for deficiencies regarding ensuring that the resident environment was free of accident hazards, cited during the survey ending on June 22, 2023, revealed that audits would be conducted and the results of the audits would be brought before the QAPI committee for further monitoring. The results of the current survey, cited under F689, revealed that the QAPI committee was ineffective in maintaining compliance with the regulation regarding ensuring that the environment was free of accident hazards.

The facility's plan of correction for a deficiency regarding the failure to account for controlled medications, cited during the survey ending June 22, 2023, revealed that the facility would complete audits and the results would be reviewed as part of quality assurance. The results of the current survey, cited under F755, revealed that the facility's QAPI committee was ineffective in correcting deficient practices related to the accountability of controlled medications.

The facility's plans of correction for deficiencies regarding complete medical record documentation, cited during the surveys ending on June 22, 2023, revealed that audits would be conducted and the results of the audits would be brought before the QAPI committee for further monitoring. The results of the current survey, cited under F842, revealed that the QAPI committee was ineffective in maintaining compliance with the regulation regarding complete medical records.

Refer to F689, F755, F842.

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

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

Plan of Correction - To be completed: 07/09/2024

1.) The facility cannot retroactively correct. The Governing Body reviewed and revised its written policies and procedures for their QAPI plan and program. QAPI program will include an assessment of how feedback, data, and information are obtained, collected, and used to identify problems, opportunities for improvement, and to develop and monitor performance indicators. The governing Body implemented a new QAPI template tool that allows QAPI members to insert and track their data and information.

2.) The Governing Body reviewed and revised its written policies and procedures for their QAPI plan and program. QAPI program will include an assessment of how feedback, data, and information are obtained, collected, and used to identify problems, opportunities for improvement, and to develop and monitor performance indicators. The governing Body implemented a new QAPI template tool that allows QAPI members to insert and track their data and information.

3.) The governing Body/designee will train the NHA who will then train the QAPI committee members on the reviewed and revised policies and procedures for their QAPI plan and program. Training will also cover the new QAPI template to be implemented where QAPI members can insert and track their data and information. Training will include how information is obtained, collected, and used to identify problems, reporting, tracking, investigating, analyzing, opportunities for improvement, and to develop and monitor performance indicators.

4.) The NHA will audit the minutes of the special QAPI meeting addressing the plan of correction on the statement of deficiencies from both this and last year's annual surveys. This audit will include a review of the committee's identification of the root cause analysis using the iterative interrogative technique; "The 5 Why's". The results of these audits will be discussed with the governing body for accuracy and applicability. The governing body review will occur with the QAPI committee.

5.) The date of compliance is July 9, 2024. This plan of correction was developed in conjunction with the governing body.

483.20(f)(5), 483.70(i)(1)-(5) REQUIREMENT Resident Records - Identifiable Information:

§483.20(f)(5) Resident-identifiable information.
(i) A facility may not release information that is resident-identifiable to the public.
(ii) The facility may release information that is resident-identifiable to an agent only in accordance with a contract under which the agent agrees not to use or disclose the information except to the extent the facility itself is permitted to do so.

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

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

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

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

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

Observations:

Based on clinical record reviews and staff interviews, it was determined that the facility failed to ensure that clinical records were complete and accurately documented for three of 18 residents reviewed (Residents 6, 20, 28).

Findings include:

A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 6, dated March 14, 2024, revealed that the resident was usually understood, could understand others, had pain occasionally, received pain medication as needed, and received an opioid (a controlled pain medication).

Physician's orders for Resident 6, dated December 28, 2023, included an order for the resident to receive one 2.5 milligram (mg) tablet of oxycodone (narcotic pain reliever) every four hours as needed for severe pain (pain scale 7-10 out of 10).

Resident 6's controlled drug record (a form that accounts for each dose of a controlled drug) for May 2024 indicated that one dose of oxycodone was signed out for administration to the resident on May 9, 2024, at 2:27 a.m. However, the resident's clinical record, including the Medication Administration Record (MAR) and nursing notes, contained no documented evidence that the signed-out dose of oxycodone was actually administered to the resident on this date and time.

Resident 6's MAR for May 2024 indicated that one dose of oxycodone was administered to the resident on May 10, 2024, at 2:32 a.m. However, the resident's controlled drug record contained no documented evidence that the oxycodone was signed out to be administered to the resident on this date and time.

Interview with the Director of Nursing on May 30, 2024, at 9:25 a.m. confirmed that Resident 6's MAR was not documented accurately. She indicated that the nurse was working night shift and that the administration of the oxycodone on May 10, 2024, at 2:32 a.m. on the resident's MAR should have been documented as being administered on May 9, 2024, at 2:27 a.m.

A quarterly MDS assessment for Resident 20, dated May 15, 2024, indicated that the resident was alert and oriented and had diagnoses that included diabetes.

Physician's orders for Resident 20, dated February 10, 2024, included an order for the resident to receive 2 liters per minute of oxygen using nasal cannula (tubes inserted into the nostrils to deliver oxygen) as needed for shortness of breath. The resident's care plan, dated March 26, 2024, indicated that 2 liters of oxygen was to be administered as needed for shortness of breath.

Observations on May 28 at 10:28 a.m. and May 29, 2024, at 11:53 a.m. revealed that Resident 20 was in bed with oxygen on at 2 liters per minute. However, the resident's MAR for May 2024 revealed that there was no documented evidence that Resident 20 received oxygen on May 28 or 29, 2024.

Interview with the Director of Nursing on May 30, 2024, at 11:58 a.m. confirmed that Resident 20's oxygen use on May 28 and 29, 2024, was not documented in the resident's clinical record.

A significant change MDS assessment for Resident 28, dated May 16, 2024, revealed that the resident was understood, could understand others, was cognitively intact, had hospice services, received pain medication as needed, and received an opioid medication.

Physician's orders for Resident 28, dated May 23, 2024, included an order for the resident to receive 10 mg of Morphine Sulfate (narcotic pain reliever) every four hours as needed for pain.

Resident 28's MAR for May 2024 indicated that one dose of Morphine Sulfate was administered to the resident on May 25, 2024, at 9:04 a.m. However, the resident's controlled drug record contained no documented evidence that the oxycodone was signed-out to be administered to the resident on this date and time.

Interview with the Director of Nursing on May 30, 2024, at 10:27 a.m. confirmed that Resident 28's MAR was not accurately documented.

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

Plan of Correction - To be completed: 07/09/2024

1.) The DON immediately provided on the spot education with the license staff member and reviewed the records for other residents with as needed narcotic(s). No further concerns identified. The DON immediately assessed the resident and notified the physician. The oxygen order was changed to routine.

2.) The DON immediately reviewed the records for other residents with as needed narcotic(s) and no further issues were identified. The DON reviewed other as needed oxygen orders and none were found.

3.) The DON will educate the license staff on proper documentation when administering as needed narcotics. The third shift licenses staff member will complete nightly MAR checks against the as needed narcotic control sheet to ensure completion. The DON will educate the license staff on proper oxygen documentation. The as needed oxygen orders will be audited nightly by the license staff on third shift.

4.) The DON or designee will audit the nightly checks at the daily weekday meeting for five days, then weekly for three weeks, then monthly for one month. The results of this audit will be reviewed by the Quality Assurance Performance Improvement (QAPI) committee for discussion. The DON or designee will audit the nightly checks at the daily week day meeting for five days, then weekly for three weeks, then monthly for one month. The results of this audit will be reviewed by the Quality Assurance Performance Improvement (QAPI) committee for discussion.

The date of compliance is July 9, 2024.

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

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

§483.45(h) Storage of Drugs and Biologicals

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

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

Observations:

Based on review of facility policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that medications were stored in a secure manner, and failed to securely store medications for one of 18 residents reviewed (Resident 28).

Findings include:

The facility's policy regarding medication administration, dated February 15, 2024, indicated that residents are allowed to self-administer medications when specifically authorized by the attending physician and in accordance with procedures for self-administration of medications. During administration of medications, no medications are kept on top of the cart. Medications and biologicals were to be stored safely, securely, and properly. Only licensed nurses, pharmacy personnel, and those lawfully authorized to administer medications were allowed access to medications.

Observations on May 29, 2024, at 7:32 a.m. revealed that there was an unattended medication cart sitting in the hallway between resident rooms 2 and 4 with a medication souffle cup that contained medications in applesauce. Licensed Practical Nurse 2 came down the hallway, took the medication souffle cup, and went into resident room 2.

Interview with Licensed Practical Nurse 2 on May 29, 2024, at 7:54 a.m. confirmed that the medication souffle cup containing the medications should not have been left on top of the medication cart. She indicated that she got called to an emergency.

Interview with the Director of Nursing on May 29, 2024, at 11:40 a.m. confirmed that the medications should not have been left on the medication cart when the medication cart was unattended.

A significant change MDS assessment for Resident 28, dated May 16, 2024, revealed that the resident was understood, could understand others, was cognitively intact, required assistance for daily care needs, and had diagnoses that included chronic obstructive pulmonary disease (COPD - inflammatory lung disease).

Physician's orders for Resident 28, dated May 10, 2024, included an order for the resident to receive two sprays of Flonase (allergy relief nasal spray) every morning for allergies and one puff of Trelegy Ellipta Inhalation Aerosol Powder Breath 200-62.5-25 micrograms for COPD.

Observations of Resident 28 on May 29, 2024, at 11:33 a.m. revealed that she was in bed eating lunch, and there were two medications (a brown bottle of Flonase nasal spray and a Trelegy Ellipta inhaler) on the overbed table. Resident 28 said the nurse forgot to take the medications back. Interview with Licensed Practical Nurse 2 at 11:39 a.m. revealed that she forgot to take the medications.

Interview with the Director of Nursing on May 30, 2024, at 1:51 p.m. confirmed that Resident 28's medications should have been returned and secured in the medication cart after administration and not kept at bedside.

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

Plan of Correction - To be completed: 07/09/2024

1.) The DON immediately assessed the resident and notified the physician. No adverse reactions identified, and no new orders were received.

2.) The DON immediately provided spot on education with the licensed staff member and checked all other rooms for unattended medications. No furthers concerns identified.

3.) The DON will educate license staff on the standards of care, including medications not to be left unattended at bedside unless self-administration assessment is completed.

4.) The DON or designee will audit medication administration pass daily for five days, then weekly for three weeks, then monthly for one month. The results of this audit will be reviewed by the Quality Assurance Performance Improvement (QAPI) committee for discussion.

5.) The date of compliance is July 9, 2024.

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

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

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

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

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

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

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

Observations:

Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to maintain accountability for controlled medications (drugs with the potential to be abused) for three of 18 residents reviewed (Residents 6, 28, 47).

Findings include:

The facility's policy regarding controlled substances, dated February 15, 2024, indicated that the nurse administering the medication is responsible for recording the name of the resident receiving the medication; name, strength, and dose of the medication; time of administration; method of administration; quantity of the medication remaining; and signature of the nurse administering the medication.

The facility's policy regarding medication administration, dated February 15, 2024, indicated that the resident's Medication Administration Record (MAR) is initialed by the person administering the medication, in the space provided under the date, and on the line for that specific medication dose administration.

A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 6, dated March 14, 2024, revealed that the resident was usually understood, could understand others, had pain occasionally, received pain medication as needed, and received an opioid (a controlled pain medication).

Physician's orders for Resident 6, dated December 28, 2023, included an order for the resident to receive one 2.5 milligram (mg) tablet of oxycodone (narcotic pain reliever) every four hours as needed for severe pain (pain scale 7-10 out of 10).

Resident 6's controlled drug record (a form that accounts for each dose of a controlled drug) for May 2024 indicated that one dose of oxycodone was signed out for administration to the resident on May 27, 2024, at 5:00 a.m. However, the resident's clinical record, including the MARs and nursing notes, contained no documented evidence that the signed-out dose of oxycodone was actually administered to the resident on this date and time.

Interview with the Director of Nursing on May 30, 2024, at 9:25 a.m. confirmed that there was no documented evidence that staff administered the signed-out dose of oxycodone to Resident 6 on the above date and time.

A significant change MDS assessment for Resident 28, dated May 16, 2024, revealed that the resident was understood, understands others, was cognitively intact, had hospice services, received pain medication as needed, and received an opioid medication.

Physician's orders for Resident 28, dated May 16, 2024, included an order for the resident to receive one 5-325 mg tablet of hydrocodone-acetaminophen (narcotic pain reliever) every six hours as needed for severe pain (pain scale 7-10 out of 10) for chronic pain.

Resident 28's controlled drug record for May 2024 indicated that one dose of hydrocodone-acetaminophen was signed out for administration to the resident on May 24, 2024, at 8:49 p.m. However, the resident's clinical record, including the MARs and nursing notes, contained no documented evidence that the signed-out doses of hydrocodone-acetaminophen were actually administered to the resident on this date and time.

Interview with the Director of Nursing on May 30, 2024, at 10:27 a.m. confirmed that there was no documented evidence that staff administered the signed-out dose of hydrocodone-acetaminophen to Resident 28 on the above dates and times.

An admission MDS assessment for Resident 47, dated May 1, 2024, revealed that the resident was cognitively intact, had pain frequently, received pain medication as needed, and received an opioid.

Physician's orders for Resident 47, dated April 25 and May 11, 2024, included an order for the resident to receive 5 mg of oxycodone every four hours as needed for severe pain (pain scale 7-10 out of 10).

Resident 47's controlled drug record for April and May 2024 indicated that one dose of oxycodone was signed out for administration to the resident on April 26 at 4:00 p.m., May 5 at 9:51 p.m., May 10 at 9:01 p.m., and May 13, 2024, at 5:30 p.m. However, the resident's clinical record, including the MAR and nursing notes, contained no documented evidence that the signed-out doses of oxycodone were actually administered to the resident on these dates and times.

Interview with the Director of Nursing on May 30, 2024, at 10:29 a.m. confirmed that there was no documented evidence that staff administered the signed-out doses of oxycodone to Resident 47 on the above dates and times.

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

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

Plan of Correction - To be completed: 07/09/2024

1.) The DON assessed the residents and notified the physician of the documentation error. All medications were administered within 'as needed' timeframe allotted, and no further orders were received. The Director of Nursing also conducted an investigation into these discrepancies and all medications are accounted for; the issue identified was charting and a dating error.

2.) The DON immediately reviewed the records for other residents with as needed narcotic(s) and no further issues were identified.

3.) The DON will educate the license staff on proper documentation when administering narcotics as needed. The third shift licenses staff member will complete nightly MAR checks against the as needed narcotic control sheet to ensure completion. Any documentation discrepancies will be reported to the DON for investigation.

4.) The DON or designee will audit the nightly checks at the daily weekday meeting for five days, then weekly for three weeks, then monthly for one month. The results of this audit will be reviewed by the Quality Assurance Performance Improvement (QAPI) committee for discussion.

5.) The date of compliance is July 9, 2024.

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

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.

§483.15(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 clinical records and staff interviews, it was determined that the facility failed to notify the resident's representative in writing regarding the reason for hospitalization for one of 18 residents reviewed (Resident 29).

Findings include:

A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 39, dated March 11, 2024, indicated that the resident was cognitively intact, required assistance from staff for her daily care needs, had diagnoses that included heart failure and kidney failure, and was on hemodialysis (a process for removing excess water, solutes, and toxins from the blood in people whose kidneys can no longer perform these functions naturally).

Resident 29's niece was listed in the clinical record as the responsible party and first emergency contact.

Nursing notes for Resident 29 on December 25 and 30, 2023; January 25, 2024; March 1, 2024; and May 26, 2024, indicated that the resident was transferred to the hospital for further evaluation, treatment and admission.

MDS discharge assessments for Resident 29, dated December 25 and 30, 2023; January 25, 2024; March 1, 2024; and May 26, 2024, revealed that the resident was admitted to the hospital on those dates.

There was no documented evidence in Resident 29's clinical record to indicate that the resident's representative was notified in writing of the purpose for the resident's transfers and admissions to the hospital from December 2023 through May 2024.

Interview with the Social Services Director on May 30, 2024, at 4:10 p.m. confirmed that there was no documentation that the resident's representative was notified in writing of Resident 29's transfers and hospitalizations from December 2023 through May 2024, because the facility makes verbal notification only.

Interview with the Director of Nursing on May 30, 2024, at 4:22 p.m. confirmed that there was no documentation that the resident's representative was notified in writing of Resident 29's transfers and hospitalizations from December 2023 through May 2024.

28 Pa. Code 201.25 Discharge Policy.

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

Plan of Correction - To be completed: 07/09/2024

1.) Resident R-29's POA, niece was immediately notified that she was to receive a written letter regarding this resident's recent hospital transfers. The niece stated that she prefers the phone calls that we had provided vs. a written letter; we informed her that both were required.

2.) The last 30 days of transfers were audited to ensure that any transfer that required written notification was completed.

3.) At the daily weekday clinical meeting, any transfer out of the building will be reviewed and this review will include the medical record notes of the written transfer notice sent to the appropriate party. The Social Services Director will be educated by the NHA on this new process.

4.) The NHA or designee will audit transfers out of the building for the next 30 days to ensure all responsible parties were notified in writing of the transfer. The results of this audit will be reviewed by the Quality Assurance Performance Improvement committee for discussion. Any negative results will be addressed by the committee.

5.) The date of compliance is July 9, 2024.

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