Pennsylvania Department of Health
CRAWFORD CARE CENTER
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

There are 74 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.


CRAWFORD CARE CENTER - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:

Based on a Medicare/Medicaid Recertification, State Licensure, and Civil Rights Compliance Survey and an Abbreviated Survey in response to two complaints completed on May 3, 2024, it was determined that Crawford Care 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:

483.10(g)(17)(18)(i)-(v) REQUIREMENT Medicaid/Medicare Coverage/Liability Notice:

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

§483.10(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.

Plan of Correction - To be completed: 06/17/2024

1. Resident R6, R52, and CR190 received a copy of the Medicare Non-Coverage Notice was provided and/or mailed to the identified residents. All current Medicare skilled residents that are required to be notified when a skilled service is being discontinued will be notified 48 hours prior to the service(s) being discontinued to allow the resident and/or responsible party to appeal the decision.
2. The Nursing Home Administrator, Social Service Director, and/or RNAC (Registered Nurse Assessment Coordinator) were educated on the Federal guideline, as well as, facility policy and procedure for providing the Notice of Medicare Non-Coverage form. The Nursing Home Administrator will monitor and audit all skilled nursing home patients to ensure all Non-Coverage Notifications are provided to the resident and/or responsible party timely. Audits will be performed three(3)times per week for one month then one(1) time monthly on-going.
3. The Nursing Home Administrator and/or designee will audit all skilled patients weekly to ensure that a copy of the Non-Coverage Notifications were provided to the resident and/or responsible party with a copy being placed in the residents' electronic medical record.
4. The Nursing Home Administrator and/designee will submit a copy of the Skilled Notification of Non-Coverage Audit to the QAPI (Quality Assessment Performance Improvement) Committee for review and recommendation at the monthly meeting.

483.75(g)(1)(i)-(iii)(2)(i); 483.80(c) REQUIREMENT QAA Committee:

§483.75(g) Quality assessment and assurance.
§483.75(g) Quality assessment and assurance.
§483.75(g)(1) A facility must maintain a quality assessment and assurance committee consisting at a minimum of:
(i) The director of nursing services;
(ii) The Medical Director or his/her designee;
(iii) At least three other members of the facility's staff, at least one of who must be the administrator, owner, a board member or other individual in a leadership role; and
(iv) The infection preventionist.

§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:
(i) Meet at least quarterly and as needed to coordinate and evaluate activities under the QAPI program, such as identifying issues with respect to which quality assessment and assurance activities, including performance improvement projects required under the QAPI program, are necessary.

§483.80(c) Infection preventionist participation on quality assessment and assurance committee.
The individual designated as the IP, or at least one of the individuals if there is more than one IP, must be a member of the facility's quality assessment and assurance committee and report to the committee on the IPCP on a regular basis.

Observations:

Based on review of facility policy, facility records, and staff interview, it was determined that the facility failed to provide evidence of a Quality Assurance and Performance Improvement (QAPI) Committee meeting for one of four quarterly QAPI Committee meetings reviewed occurring in 2023 and 2024 (First Quarter of 2024).

Findings include:

Review of facility policy entitled, "Quality Assurance and Performance Improvement (QAPI) Program" dated 2/27/2023 stated, "The committee meets monthly to review reports, evaluate data and monitor QAPI-related activities and make adjustments to the plans."

Review of the QAPI Committee Attendance Records revealed no evidence of a quarterly meeting for the First Quarter of 2024.

During an interview on 5/01/24, at 11:30 a.m. the Nursing Home Administrator confirmed that there was no evidence of a QAPI Committee meeting regarding the First Quarter meetings of 2024.

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

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

Plan of Correction - To be completed: 06/17/2024

1. QAPI (Quality Assessment Performance Improvement) Committee Meeting will be initiated and conducted quarterly per Federal Guidelines. The first QAPI meeting is scheduled for May 30, 2024.
2. The Nursing Home Administrator was educated by the Chief Nursing Officer/Vice-President of Operations on the Federal Guidelines for conducting QAPI meetings at least quarterly along with content and required participants.
3. The Chief Nursing Officer/Vice-President of Operations will monitor and audit all QAPI minutes to ensure that meetings are being conducted quarterly per Federal Regulation.
4. All QAPI audits will be submitted by the Nursing Home Administrator to the QAPI (Quality Assessment Performance Improvement) Committee for review and recommendations at the quarterly meeting.

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 policy, observations, and staff interview, it was determined that the facility failed to prevent the opportunity for potential unauthorized access of medications for one of five medication carts (Primrose Lane- memory care unit), failed to label a multi-dose insulin pen (medication to treat elevated blood sugar levels) with the date it was opened in one of five medication carts (Maple Lane), and failed to ensure that medications subject to abuse were stored in separately locked, permanently affixed compartment in one of three medication refrigerators (Blue Unit).

Findings include:

Review of the facility policy entitled "Administering Medications" dated 2/12/24, indicated that the medication cart must be kept closed and locked when out of the nurse's view.

Review of the facility policy entitled "Medication Labeling and Storage" dated 2/12/24, indicated that multi-dose vials/containers are dated when opened and discarded within 28 days unless the manufacturer specifies a shorter or longer date.

Review of the facility policy entitled "Controlled Substances" dated 2/12/24, indicated that controlled substances are separately locked in permanently affixed compartments.

Observation on 4/30/24, at 11:54 a.m. revealed the Primrose medication cart was in the central hallway by the nurse's station in the Memory Gardens unit unlocked and unattended, and at 11:59 a.m. Licensed Practical Nurse (LPN) Employee E2 entered the Memory Gardens unit.

During an interview at 11:59 a.m. LPN Employee E2 confirmed that the medication cart should be secured when not in view.

Observation on 5/02/24, at 12:53 p.m. revealed the Maple Lane medication cart contained an opened undated multi-dose insulin pen and the manufacturer's packaging was labeled to discard within 28 days of opening.

During an interview at that time, LPN Employee E4 confirmed that multi-dose vials/containers of medication are to be dated upon opening to ensure that staff discard them in a timely manner.

Observation on 5/02/24, at 1:00 p.m. revealed a locked refrigerator in the Blue Wing Medication Room that contained a locked clear plastic box intended to safely secure controlled medications and was affixed to the removable wire shelving and not permanently affixed.

At the time of the observation, LPN Employee E5 confirmed that the clear plastic box intended to safely secure controlled medications was not permanently affixed and could be removed from the refrigerator.

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

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

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

Plan of Correction - To be completed: 06/17/2024

1. All Schedule II medication lock boxes located in the refrigerator at the nursing stations have been permanently affixed within the units. Any open vials of insulin, insulin pens, or any medication that has a short shelf life and undated has been discarded.
2. All professional nursing staff were educated on Federal/State and Facility Policy and Procedure on labeling medications properly, discarding open, undated medication and the importance of locking medication carts when unattended.
3. The Director of Nursing and/or designee will audit all medication carts
and refrigerator locked boxes on all three(3) shifts to ensure all open medications are properly labeled and dated and medication carts are locked when unattended three(3) times per week for two(2) weeks, two(2) times per week for two(2), then monthly.
4. All audits will be submitted by the Director or Nursing and/or designee to the QAPI Committee for review and recommendation at the monthly meeting.

483.45(c)(3)(e)(1)-(5) REQUIREMENT Free from Unnec Psychotropic Meds/PRN Use:

§483.45(e) Psychotropic Drugs.
§483.45(c)(3) A psychotropic drug is any drug that affects brain activities associated with mental processes and behavior. These drugs include, but are not limited to, drugs in the following categories:
(i) Anti-psychotic;
(ii) Anti-depressant;
(iii) Anti-anxiety; and
(iv) Hypnotic

Based on a comprehensive assessment of a resident, the facility must ensure that---

§483.45(e)(1) Residents who have not used psychotropic drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record;

§483.45(e)(2) Residents who use psychotropic drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs;

§483.45(e)(3) Residents do not receive psychotropic drugs pursuant to a PRN order unless that medication is necessary to treat a diagnosed specific condition that is documented in the clinical record; and

§483.45(e)(4) PRN orders for psychotropic drugs are limited to 14 days. Except as provided in §483.45(e)(5), if the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she should document their rationale in the resident's medical record and indicate the duration for the PRN order.

§483.45(e)(5) PRN orders for anti-psychotic drugs are limited to 14 days and cannot be renewed unless the attending physician or prescribing practitioner evaluates the resident for the appropriateness of that medication.

Observations:
Based on review of facility policy and clinical records, and staff interview, it was determined that the facility failed to provide a clinical rationale for the continued use of a PRN (as needed) psychotropic (affecting the mind) medication beyond 14-days and failed to provide evidence that non-pharmacological interventions (interventions attempted to calm a resident other than medication) were attempted prior to the administration of a PRN psychotropic medication for four of 22 residents reviewed (Residents R81, R41, R43, and R2).

Findings include:

A facility policy entitled "Psychotropic Medication Use" dated 2/12/24, revealed that "Non-pharmacological approaches are used (unless contraindicated) to minimize the need for medications, permit the lowest possible dose, and allow for discontinuation of medications when possible ....For psychotropic medications that are NOT antipsychotics: If the prescriber or attending physician believes it is appropriate to extend the PRN order beyond 14 days, he or she will document the rationale for extending the use and include the duration of the PRN order."

Resident R81's clinical record revealed an admission date of 1/21/24, with diagnoses that included vitamin D deficiency, major depressive disorder, and pneumonia. A physician's order dated 3/4/24, identified to administer Lorazepam (anti-anxiety) 0.5 milligrams (mg) by mouth every 6 hours as needed for aggression and combativeness, and lacked the required stop date within 14 days or a clinical rationale for continued use beyond 14 days.

Review of the March 2024 and April 2024 medication administration record (MAR) for Resident R81 revealed that the PRN Lorazepam was used on 3/5/24, 3/7/24, 3/8/24, 3/9/24, 3/11/24, 3/12/24, 3/14/24, 3/16/24, 3/17/24, 3/19/24, 3/20/24, 3/22/24, 3/23/24, 3/24/24, 3/25/24, 3/26/24, 4/20/24, 4/23/24, 4/24/24, 4/25/24, 4/26/24, and 4/30/24. Review of the March and April 2024 MARs, and clinical record progress notes revealed that there was no evidence of non-pharmacological interventions attempted prior to the administration of the PRN Lorazepam for the 16 administrations of Lorazepam in March 2024 and six administrations of Lorazepam in April 2024.

Resident R41's clinical record revealed an admission date of 3/29/24, with diagnoses that included anxiety, dysphagia (difficulty swallowing), pain in left shoulder, and muscle weakness. A physician's order dated 3/29/24, identified to administer Lorazepam 0.5 mg by mouth as needed for anxiety, and lacked the required stop date within 14 days or a clinical rationale for continued use beyond 14 days.

Review of the March and April 2024 MARs for Resident R41 revealed that the PRN Lorazepam was used on 3/31/24, 4/5/24, 4/9/24, 4/13/24, 4/23/24, 4/24/24, 4/27/24, 4/29/24, and 4/30/24. Review of the March and April 2024 MARs, and clinical record progress notes revealed that there was no evidence of non-pharmacological interventions attempted prior to the administration of the PRN Lorazepam for the one administration of Lorazepam in March 2024 and three of eight administrations of Lorazepam in April 2024 (4/13/24, 4/23/24, and 4/29/24).

Review of Resident R43's clinical record revealed an admission date of 11/21/17, with diagnoses that included dementia, chronic obstructive pulmonary disease (a disease that obstructs air flow from the lungs), and peripheral vascular disease (a disease where your veins have trouble sending blood from your limbs back to your heart). A physician's order dated 3/26/24 to administer Lorazepam, 0.5 mg by mouth every six hours as needed for anxiety and lacked the required stop date within 14 days or a clinical rationale for continued use beyond 14 days.

Review of Resident R2's clinical record revealed an admission date of 1/12/21, with diagnoses that included dementia, weakness, and anxiety. A physician's order dated 5/1/24, to administer Lorazepam, 0.5 mg by mouth every four hours as needed for anxiety and lacked the required stop date within 14 days or a clinical rationale for continued use beyond 14 days.

During an interview on 5/2/24, at 2:35 p.m. the Assistant Director of Nursing confirmed that all the residents listed above had Lorazepam orders that lacked the required stop date within 14 days or a clinical rationale for continued use beyond 14 days and that R41's and R81's clinical record lacked evidence that non-pharmacological interventions were being attempted prior to administering Lorazepam.

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

Plan of Correction - To be completed: 06/17/2024

1. Resident R2, R41, R43, and R81, orders were reviewed for a PRN psychotropic medication, received an order for a stop date placed within 14 days. All current residents who have a physician's order for a PRN psychotropic medication received an order for a stop date placed within 14 days per the regulation. Prior to any psychotropic medication is given, a non-pharmacologic intervention must be attempted and a failed attempt to be documented prior to the use of the physician ordered psychotropic medication.
2. The Director of Nursing and Assistant Director of Nursing educated the professional nursing staff on non-pharmacologic approach prior to the use of physician ordered medication. The professional nursing staff were educated on the regulation of "Stop Dates" being applied to all PRN psychotropic medications. The Assistant Director of Nursing completed an audit of all current in-house residents to identify anyone on PRN psychotropic medication. New orders be reviewed to ensue a stop date or clinical rationale to continue beyond the 14-days
3. The Director of Nursing and/or Assistant Director of Nursing will audit all residents on PRN psychotropics to ensure a non-pharmacological intervention was attempted prior to medication given. The Director of Nursing and/or Assistant Director of Nursing will audit all residents on PRN psychotropics to ensure a 14 day stop date for three (3) times per week for two (2) weeks, then one (1) time per week for two weeks depending on audit outcomes and results.
4. The Psychotropic Audits will be submitted by the Director of Nursing to the QAPI Committee for review and recommendation at the monthly meeting.

483.21(b)(2)(i)-(iii) REQUIREMENT Care Plan Timing and Revision:

§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, and staff interview, it was determined that the facility failed to review and revise comprehensive care plans to reflect the current care and services for nine of 22 residents reviewed (Residents R40, R14, R30, R37, R81, R41, R43, R74, and R83).

Findings include:

A facility policy entitled, "Care Plans, comprehensive Person-Centered," dated 2/12/24, indicated that "the interdisciplinary team reviews and updates the care plan: when there has been a significant change in the resident's condition; when the desired outcome is not met; when the resident has been readmitted to the facility from a hospital stay; and at least quarterly (every three months) in conjunction with the required quarterly MDS (Minimum Data Set- standardized assessment tool that measures health status in nursing home residents)."

Resident R81's clinical record revealed an admission date of 1/21/24, with diagnoses that included vitamin D deficiency, major depressive disorder, and pneumonia.

Resident R81's care plan revealed a target date of 2/21/24, indicating that the care plan was not reviewed and revised to reflect the current care and services.

Resident R41's clinical record revealed an admission date of 3/29/24, with diagnoses that included dysphagia (difficulty swallowing), pain in left shoulder, and muscle weakness.

Resident R41's care plan revealed a target date of 4/18/24, indicating that the care plan was not reviewed and revised to reflect the current care and services.

Resident R74's clinical record revealed an admission date of 3/13/24, with diagnoses that included muscle weakness, unsteadiness on feet, and dysphagia.

Resident R74's care plan revealed a target date of 4/1/24, indicating that the care plan was not reviewed and revised to reflect the current care and services.

Resident R37's clinical record revealed an admission date of 8/10/20, with diagnoses that included heart failure, dementia, Schizophrenia (a serious mental illness that affects how a person thinks, feels, and behaves).

Resident R37's care plan revealed a target date of 2/22/24, indicating that the care plan was not reviewed and revised to reflect the current care and services.

Resident R40's clinical record revealed an admission date of 7/09/20, with diagnoses that included Parkinsonism (a motor syndrome that manifests as rigidity, tremors, and difficulty walking).

Resident R40's care plan revealed a target date of 3/22/24, indicating that the care plan was not reviewed and revised to reflect the current care and services.

Resident R14's admission record revealed an admission date of 3/27/24, with diagnoses that included end stage renal disease (a diseases where the kidneys no longer work to meet the body's needs).

Resident R14's care plan revealed a target date of 4/11/24, indicating that the care plan was not reviewed and revised to reflect the current care and services.

Review of Resident R43's clinical record revealed an admission date of 11/21/17, with diagnoses that included Dementia (a disease that affects short term memory and the ability to think logically).

Resident R43's care plan revealed a target date of 4/21/24, indicating that the care plan was not reviewed and revised to reflect the current care and services.

Review of Resident R30's clinical record revealed an admission date of 3/29/24, with diagnoses that included heart failure (a condition where the heart cannot supply the body with enough blood).

Resident R30's care plan revealed a target date of 4/15/24, indicating that the care plan was not reviewed and revised to reflect the current care and services.

Review of Resident R83's clinical record revealed an admission date of 3/16/24, with diagnoses that included retention of urine (a condition when the body is unable to empty all the urine from the bladder).

Resident R83's care plan revealed a target date of 4/5/24, indicating that the care plan was not reviewed and revised to reflect the current care and services.

During an interview on 5/2/24, at 2:00 p.m. the Registered Nurse Assessment Coordinator Employee E3 confirmed that the care plans for Residents R40, R14, R30, R37, R81, R41, R43, R74, and R83 were not reviewed and revised timely to reflect current resident care and services.

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

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

Plan of Correction - To be completed: 06/17/2024

1. Resident R14, R30, R37, R40, R41, R43, R74, R81, and R83 will be reviewed and revised to reflect the current care and services. All current residents will have their Care Plans reviewed and revised to reflect the resident's current care and services.
2. The IDT (Inter-Disciplinary Team) Team was educated on the Federal guidelines, RAI (Resident Assessment Instrument) Manual and facility policy and procedure on the update and revision of care plans to reflect the current care and service being received by the resident.
3. The Director of Nursing and/or designee will monitor and audit all care plans based on their scheduled MDS at the time of admission, quarterly, a change in condition, or discharge from the facility. The Director of Nursing and/or designee will audit 10 care plans for review and/or revision to reflect current care and services. Two (2) times per week for one (1) month.
4. The Director of Nursing and/or designee will submit Care Plan Audits to the QAPI Committee for review and recommendation at the monthly meeting.

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

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

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

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

Plan of Correction - To be completed: 06/17/2024

1. Resident R3, R14, R30, R41, R69, R74, R81, and R83 did not have a baseline care plan due to being past the 48 hour time frame and irrelevant, but did have completed comprehensive care plans by day twenty-one(21). Baseline Care Plans have been initiated on all new admission starting in May 2024.The Baseline Care Plan will contain initial goals of the resident, a summary of the residents' medications and dietary preferences, treatments administered by the facility and it's staff and any additional informational updates.
2. The Social Service Director was educated on the Federal guidelines of Baseline Care Plans by the Nursing Home Administrator. The Nursing Home Administrator will audit all new admissions to ensure Baseline Care Plans are completed and a copy will be provided to the resident and/or responsible party.
3. The Nursing Home Administrator will monitor and audit all new admissions three(3) times per week for one month, then once monthly to ensure Baseline Care Plans are completed timely and a copy is provided to the resident and/or responsible party.
4. All Baseline Care Plan Audits will be submitted to the QAPI (Quality Assessment Performance Improvement) Committee by the Nursing Home Administrator and/or designee for review and recommendation at the monthly meeting.

483.10(c)(1)(4)(5) REQUIREMENT Right to be Informed/Make Treatment Decisions:

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) Planning and Implementing Care.
The resident has the right to be informed of, and participate in, his or her treatment, including:

§483.10(c)(1) The right to be fully informed in language that he or she can understand of his or her total health status, including but not limited to, his or her medical condition.

§483.10(c)(4) The right to be informed, in advance, of the care to be furnished and the type of care giver or professional that will furnish care.

§483.10(c)(5) The right to be informed in advance, by the physician or other practitioner or professional, of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options and to choose the alternative or option he or she prefers.

Observations:

Based on review of facility documents and clinical records, and staff and family interviews, it was determined that the facility failed to fully inform and discuss the change of treatments for the medical management of a resident's clinical status and/or discuss alternate treatment options preferred by the resident's representative in advance of these changes for one of five residents reviewed for pharmacy recommendations (Resident R38).

Findings include:

The facility's admission packet provided to residents/representatives on admission revealed: all residents have the right to equal access to quality care regardless of diagnosis, severity of condition, or payment source; have to right to be fully informed of your medical condition in a language you can understand, and to participate in your person-centered care planning and treatment; and the right to refuse and/or discontinue medications and treatments (but this could be harmful to your health).

Resident R38's clinical record revealed an admission date of 10/26/17, with diagnoses including secondary hyperaldosteronism (hyperaldosteronism- is a condition in which one or both of your adrenal glands produce too much aldosterone [aldosterone is a hormone that helps regulate your blood pressure by controlling the levels of potassium and sodium in your blood]), kidney disease, heart disease, Alzheimer's Disease (progressive disease beginning with mild memory loss and possibly leading to loss of the ability to carry on a conversation and respond to the environment), severe intellectual disabilities, and psychosis (collection of symptoms that affect the mind, where there has been some loss of contact with reality).

Resident R38's clinical record included a pharmacy consultant "Note to Attending Physician/Prescriber" dated 10/24/23, that identified Resident R38 was receiving a combination of two medications (Valsartan- antihypertensive, and Spironolactone- diuretic) that may increase his/her potassium levels, and included a recommendation that the facility monitor Resident R38's potassium levels, and a physician's response of "Family declined" dated 10/30/23.

Further review of Resident R38's clinical record revealed a practitioner progress note dated 11/07/23, indicated "no diagnostic tests."

A court appointment of guardianship dated 9/25/23, indicated that Resident R38's brother was recognized as his/her legal guardian, and a POLST (Physician Order for Life Sustaining Treatment) dated 11/20/21, lacked evidence the Resident R38's legal guardian consented to withhold bloodwork and/or diagnostic testing.

Resident R38's clinical record lacked evidence that his/her responsible party received education to make an informed consent (the process in which a health care provider educates a patient about the risks, benefits, and alternatives of a given procedure or intervention) to refuse diagnostic tests and lacked evidence of a physician's order declining bloodwork and/or diagnostic testing.

Interview on 5/03/24, at 11:48 a.m. (via telephone) with Resident R38's legal guardian confirmed that he/she did not decline for the facility to obtain bloodwork and/or diagnostic testing.

Interview on 5/03/24, at 12:58 a.m. with the facility's Clinical Consultant Employee E6 confirmed that there was no evidence of informed consent from the family to not obtain bloodwork, and the facility was unable to determine the source of the physician's response of 'Family declined" to the pharmacy consultant "Note to Attending Physician/Prescriber" dated 10/24/23.

Interview on 5/03/24, at 12:12 p.m. with the Director of Nursing confirmed Resident R38's clinical record lacked evidence of a physician's order or a practitioner's note to obtain consent from the family to withhold bloodwork and/or diagnostic testing.

28 Pa. Code 201.14(a) Responsibility of licensee

28 Pa. Code 201.18(b)(1)(2)(3) Management

28 Pa. Code 201.29(a) Resident Rights

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

Plan of Correction - To be completed: 06/17/2024

1. Resident R38 has been notified of their current health care status discussed with the resident and resident responsible party. Any resident that currently receives care and services will be notified and fully informed of their health status, medical condition, including the risks and benefits of care and treatment options so the resident and/or responsible party can make an informed decision on the healthcare received.
2. The administrative and nursing staff was educated on the residents' right to be informed, in advance, of the risks and benefits associated with the care and services to be received. The Social Service Director and/or designee will review Resident Rights will all new admissions.
3. The Nursing Home Administrator and/or designee will monitor all new admissions and/or responsible parties to ensure they have the necessary health information to make informed decisions about their care. Existing residents and/or responsible parties will be interviewed during their scheduled care plan meeting to ensure they are being provided accurate information to make informed decisions affecting their care.
4. The Nursing Home Administrator will submit all interview audits to the QAPI (Quality Assessment Process Improvement) Committee for review and recommendation at the scheduled monthly meeting.

483.20(g) REQUIREMENT Accuracy of Assessments:

§483.20(g) Accuracy of Assessments.
The assessment must accurately reflect the resident's status.

Observations:
Based on review of clinical records and facility documentation, and staff interview, it was determined that the facility failed to complete the Minimum Data Set (MDS-periodic assessment of resident care needs) to accurately reflect the resident's status at the time of the assessment for two of 22 residents reviewed (Residents R14 and R57).

Findings include:

Resident R14's clinical record revealed an admission date of 3/27/24, with diagnoses that included end stage renal disease (a diseases where the kidneys no longer work to meet the body's needs), hypokalemia (low potassium levels), and hypertension (high blood pressure).

Resident R14's clinical record revealed that dialysis was ordered on 3/27/24, and Resident R14 received dialysis treatments on 3/30/24, and 4/2/24.

The five day MDS dated 4/3/24, Section O0100 J. Special Treatments, Procedures, and Programs category, dialysis was marked "No" indicating Resident R14 was not receiving dialysis treatments.

Resident R57's clinical record revealed an admission date of 1/15/24, with diagnoses that included hypertension (high blood pressure), anxiety, and type II diabetes.

Resident R57's order summary revealed that a Trulicity injection (an antihyperglycemic injection used to help control blood sugar, which is not classified as an insulin) was ordered on 1/15/24.

The Quarterly MDS dated 2/19/24, Medications Section N0350A indicated that Resident R57 received insulin one time.

During an interview on 5/2/24, at 2:00 p.m. Registered Nurse Assessment Coordinator Employee E3 confirmed that Section O - Special Treatments, Procedures, and Programs category J1 Dialysis of the five day MDS dated 4/3/24, was incorrectly coded for Resident R14 and should have been marked yes and that Section N - Medications category N0350A Insulin of the Quarterly MDS dated 2/19/24 was incorrectly coded for Resident R57 and should have been zero days.

28 Pa. Code 211.5(f)(iv) Medical records

Plan of Correction - To be completed: 06/17/2024

1. Resident R14 no longer resides at the facility and was discharged home. Resident R57's MDS (Minimum Data Set) was updated to reflect the proper coding for Trulicity (not insulin) with the # of days given. Any resident with physician order's for Trulicity will have their MDS's reviewed to ensure proper coding.
2. The RNAC (Registered Nurse Assessment Coordinator) will conduct an MDS (Minimum Data Set) audit for accuracy at the time of the scheduled assessment to ensure the MDS is current and accurate. The IDT (Inter-disciplinary) Team will be educated by the RNAC on the importance of accuracy for MDS assessment.
3. The Director of Nursing and/or designee will monitor and audit five(5) MDS assessments 3 times/week for two(2) weeks, two(2) times/week for two(2) weeks for accuracy.
4. All MDS Accuracy Audits will be submitted by the RNAC and/or designee to the QAPI Committee for review and recommendation at the monthly meeting.

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

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

Observations:
Based on review of facility policy and clinical records, and staff interview, it was determined that the facility failed to develop comprehensive care plans for two of 22 residents reviewed (Residents R14 and R64 ).

Findings include:

Review of facility policy entitled "Care Plans, Comprehensive Person Centered" dated 2/12/24, indicated "The comprehensive person centered care plan is developed within seven days of the completion of the required MDS assessment, and no more than 21 days after admission."

Review of Resident R14's clinical record revealed an admission date of 3/27/24, with diagnoses that included end stage renal disease (a diseases where the kidneys no longer work to meet the body's needs), hypokalemia (low potassium levels), and hypertension (high blood pressure).

Review of Resident R14's physician orders revealed an order for dialysis every Tuesday and Saturday. Further review of Resident R14's person centered plans of care revealed only a plan of care for nutrition.

Review of Resident R64' clinical record revealed an admission date of 4/10/24, with a diagnoses that included, urinary tract infection, Parkinson's Disease (involuntary muscle movements) and hypertension (high blood pressure).

Review of Resident R64's clinical record revealed that the comprehensive plan of care included only one area of assessment which was a plan for nutrition.

During an interview on 5/2/24, at 2:00 p.m. the Registered Nurse Assessment Coordinator confirmed that Residents R14 and R64's comprehensive plans of care were not completed within 21 days from admission.

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

Plan of Correction - To be completed: 06/17/2024

1. Resident R14 has discharged from the facility to the community. Resident R64
had assessments completed and a comprehensive was completed. All new admissions will have completed comprehensive care plans within 21 days of admission. All admissions from the end of survey date will be audited for completed care plans.
2. The Inter-disciplinary Team (IDT) was educated by the Director of Nursing on the timeliness (within 21 days of admission) and accuracy of comprehensive care plan.
3. The Director of Nursing and/or designee will audit comprehensive care plans of all new admission three (3) times per week for one month, then monthly until compliance is achieved ensuring timeliness and accuracy. Audits will continue until compliance is achieve.
4. All Care Plan Audits will be submitted by the Director of Nursing and/or designee to the QAPI Committee for review and recommendations at the monthly.

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

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

Plan of Correction - To be completed: 06/17/2024

1. Resident R43 and R69 had their humidification water bottles and O2 tubing replaced and dated. All residents with a physician's order for oxygen had their tubing changed and dated per facility policy. All current residents utilizing an oxygen concentrator had their filters cleaned or replaced with a new filter. Any resident with a physician's order requiring humidification had their bottles applied and/or exchanged.
2. The Central Supply person and nursing staff was educated on the facility policy and procedure of physician orders for exchanging, dating, applying humidification bottles and cleaning or replacing oxygen concentrator filters weekly. The Central Supply person will be responsible for monitoring and ensuring oxygen tubing is, humidification bottles are exchanged and dated properly and oxygen concentrators filters are cleaned or replaced.
3. The Director of Nursing and/or designee will audit all residents on oxygen to ensure tubing changes, dating, humidification bottles and filter cleaning and/or replacements is completed two(2) times per week for two(2) week then one(1) time per week for two(2) weeks. Audits will continue if compliance is still a concern.
4. All Oxygen tubing, Concentrator filter, and humidification bottle audits will be submitted by the Director of Nursing and/or designee to the QAPI (Quality Assessment Performance Improvement) Committee for review and recommendation at the monthly meeting.

483.25(l) REQUIREMENT Dialysis:

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

Observations:

Based on review of facility contract, clinical record, and staff interview, it was determined that the facility failed to maintain records relating to dialysis communication for one of one residents reviewed for dialysis (Resident R14).

Findings include:

Review of dialysis contract dated 2/12/24, indicated "Designated Resident Information, Facility shall ensure that all appropriate medical, social, administrative, and other information accompany all designated residents at the time of transfer to center. This information shall include ... appropriate medical records ... treatments being provided to designated resident, including medications and any changes in the patient's condition, change of medication, diet, or fluid intake ... any other information that will facilitate the adequate coordination of care as reasonably determined by center."

Review of facility's dialysis communication form entitled "Dialysis/Observation Communication Form" revealed that the top section was to be completed by the facility, which included treatments being provided to the resident, including medications and any changes in the patient's condition, change of medication, diet, or fluid intake and other information that will facilitate the adequate coordination of care.

Review of Resident R14's clinical record revealed an admission date of 3/27/24, with diagnoses that included end stage renal disease (a disease where the kidneys no longer work to meet the body's needs), hypokalemia (low potassium levels), and hypertension (high blood pressure).

Review of Resident R14's physician orders revealed an order for dialysis every Tuesday and Saturday with a time of 11:30 a.m.

Review of Resident R14's nursing documentation dated 3/27/24, revealed that he/she would have dialysis on the following Saturday 3/30/24, and then his/her normal dialysis days would be on Tuesday, Thursday, and Saturdays.

Review of Resident R14's clinical record lacked evidence of communication between the facility and dialysis clinic.

Interview with Registered Nurse Employee E1 on 5/2/24, at 12:16 p.m. revealed that Resident R14 received dialysis every Tuesday and Saturday and a communication form should be completed and sent with the resident with each transfer to dialysis.

During an interview on 5/2/24, at 2:35 p.m. the Assistant Director of Nursing confirmed there was no evidence of communication between the facility and dialysis clinic. He/she also confirmed that communication should be done with every dialysis treatment.

28 Pa. Code 211.5(f)(iv)(viii) Medical records

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

Plan of Correction - To be completed: 06/17/2024

1. Identified resident R-14 is no longer on hemodialysis. Resident R-14 has been admitted onto hospice services at the request of the resident and the support of his attending physician. There are no other residents within the facility that are on dialysis services.
2. All professional nursing staff was educated on Federal guidelines, facility policy and procedure for completing the dialysis communication form for any new resident admitted to the facility that is to receive hemodialysis at the local dialysis center.
3. The Director of Nursing and/or designee will audit all communication forms for any newly admitted residents that will be receiving dialysis.
4. All Dialysis Communication Form Audits will be submitted by the Director of Nursing and/or to the QAPI Committee for review and recommendation at the monthly meeting.

483.70(q)(1)-(5) REQUIREMENT Payroll Based Journal:

§483.70(q) Mandatory submission of staffing information based on payroll data in a uniform format.
Long-term care facilities must electronically submit to CMS complete and accurate direct care staffing information, including information for agency and contract staff, based on payroll and other verifiable and auditable data in a uniform format according to specifications established by CMS.

§483.70(q)(1) Direct Care Staff.
Direct Care Staff are those individuals who, through interpersonal contact with residents or resident care management, provide care and services to allow residents to attain or maintain the highest practicable physical, mental, and psychosocial well-being. Direct care staff does not include individuals whose primary duty is maintaining the physical environment of the long term care facility (for example, housekeeping).

§483.70(q)(2) Submission requirements.
The facility must electronically submit to CMS complete and accurate direct care staffing information, including the following:
(i) The category of work for each person on direct care staff (including, but not limited to, whether the individual is a registered nurse, licensed practical nurse, licensed vocational nurse, certified nursing assistant, therapist, or other type of medical personnel as specified by CMS);
(ii) Resident census data; and
(iii) Information on direct care staff turnover and tenure, and on the hours of care provided by each category of staff per resident per day (including, but not limited to, start date, end date (as applicable), and hours worked for each individual).

§483.70(q)(3) Distinguishing employee from agency and contract staff.
When reporting information about direct care staff, the facility must specify whether the individual is an employee of the facility, or is engaged by the facility under contract or through an agency.

§483.70(q)(4) Data format.
The facility must submit direct care staffing information in the uniform format specified by CMS.

§483.70(q)(5) Submission schedule.
The facility must submit direct care staffing information on the schedule specified by CMS, but no less frequently than quarterly.

Observations:

Based on facility requirements according to the Affordable Care Act (ACA), review of Payroll Based Journal (PBJ) Staffing Data Reports and staff interview, it was determined that the facility failed to electronically submit direct care staffing information for one of the last four quarters (Quarter Four of 2023).

Findings include:

Review of Section 6106 of the ACA requires facilities to electronically submit direct care staffing information (including agency and contract staff) based on payroll and other auditable data to the Centers for Medicare and Medicaid Services (CMS). Submission must be received by the end of the 45th calendar day (11:59 p.m. Eastern Standard Time) after the last day of each fiscal quarter to be considered timely.

First quarter reporting includes data from October 1st through December 31st and is due by February 14th. Second quarter reporting includes data from January 1st through March 31st and is due by May 15th. Third quarter reporting includes data from April 1st through June 30th and is due by August 14th. Fourth quarter reporting includes July 1st through September 30th and is due by November 14th.

Review of PBJ staffing data reports for fiscal year fourth quarter 2023 revealed the facility triggered for "Failed to Submit Data for the Quarter."

During an interview on 4/30/24, at 11:11 a.m. the Nursing Home Administrator confirmed that the PBJ report for Quarter Four for 2023 indicated "failed" for submission status and the facility did not meet the reporting requirement.

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

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

Plan of Correction - To be completed: 06/17/2024

1. The facility submitted incomplete employee data for the fourth(4th) quarter of 2023. Due to a change in ownership the facility was unable to acquire data from the previous owner causing the submission to be incomplete. The employee data for the first(1st) quarter of 2024 was submitted timely and accurately.
2. The Human Resource Coordinator was educated by the nursing home administrator on the Federal Guidelines (CMS) of accurately recording, tracking, and submitting employee data for Payroll Based Journal (PBJ).
3. The Nursing Home Administrator will monitor and audit employee data for accuracy and timeliness prior to submitting employee data to Payroll Based Journal (PBJ).
4. The Nursing Home Administrator will submit the PBJ audit to the QAPI committee for review and recommendations at the quarterly meeting.

§ 201.14(a) LICENSURE Responsibility of licensee.:

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

Observations:

Based on review of facility records and staff interview, it was determined that the facility failed to comply with the following requirements of MCARE Act 403(a)(1).

MCARE Act, Section 403(a)(1), 40 P.S. 1303.403(a)(1) - Infection Control Plan, states:

(a) Development and compliance - Within 120 days of the effective date of this section, a health care facility and an ambulatory surgical facility shall develop and implement an internal infection control plan that shall be established for the purpose of improving the health and safety of patients and health care workers and shall include:

(1) A multidisciplinary committee including representatives from each of the following, if applicable to the specific health care facility:
(i) Medical staff that could include the chief medical officer or the nursing home medical director.
(ii) Administration representatives that could include the chief executive officer, the chief financial officer or the nursing home administrator.
(iii) Laboratory personnel.
(iv) Nursing staff that could include a director of nursing or a nursing supervisor.
(v) Pharmacy staff that could include the chief of pharmacy.
(vi) Physical plant personnel.
(vii) A patient-safety officer.
(viii) Members from the infection control team, which could include an epidemiologist.
(ix) The community, except that these representatives may not be an agent, employee or contractor of the health care facility or ambulatory surgical facility.

1303.405(a)- Patient Safety Authority Jurisdiction states:

(a)The occurrence of a healthcare-associated infection is deemed a serious event. Written notification to the resident of the serious event should be documented.

Review of the facility Infection Control Program meeting documents, revealed that there was no laboratory personnel representation four of the five quarters reviewed (First, Second, and Third Quarters of 2023 and First Quarter of 2024.

During an interview on 5/01/24, at 2:55 p.m. the Infection Control Nurse confirmed that the Infection Control Program meetings lacked evidence of a laboratory personnel representation for the above identified meetings.

Plan of Correction - To be completed: 06/17/2024

1. Infection Control Meetings will be conducted quarterly to comply with the requirements of the MCARE Act 403(a)(1). The Infection Control Committee will consist of the following participants, Medical Director, Nursing Home Administrator, Laboratory representative, Director of Nursing, Pharmacy representative, Maintenance Director, Patient-Safety Officer, Infection Preventionist and a community member. Members of the Infection Control Committee will be contacted and invited one(1) month in-advance of the meeting. For any member that can not attend in person will have the option of calling into the facility and placed on speaker for participation.
2. Administrative staff and Nursing management will be educated on the requirements of conducting Infection Control Meetings at least quarterly by the Nursing Home Administrator. The Medical Director, Pharmacy, Laboratory representative, and community member will be invited to attend the Infection Control Meeting.
3. The Nursing Home Administrator will ensure that Infection Control Meetings will be conducted quarterly and all identified team members participate and attend. Attendance sheets will be completed and signed by each member that attends the meeting.
4. The Infection Preventionist will submit committee meeting minutes to the QAPI Committee for review and recommendation at the monthly meeting.

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