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

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

LIBERTY CENTER FOR REHABILITATION AND NURSING
Inspection Results For:

There are 134 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.


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

Initial comments:

Based on a Medicare/Medicaid Recertification survey, State Licensure survey, Civil Rights Compliance survey, and an abbreviated survey in response to one complaint completed on August 1, 2024, it was determined that Liberty Center for Rehab and Nurtsing was not in compliance with the following requirements for Long Term Care and the 28 Pa. Code, Commonwealth of Pennsylvania Long Term Care Regulations as they relate to the health portion of the survey.

Plan of Correction:

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

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.

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

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

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

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

Observations:

Based on review of facility policy, clinical record review and interviews with staff, it was determined that the facility failed to ensure a Level ll PASARR was conducted for residents with mental disorders as required for four of four residents reviewed. (Residents R1, R3, R20 and R36).

Findings include:

Review of facility policy titled "Patient Access to Service and Record (PASR) Policy, not dated, revealed that the purpose of The PASARR screening is to ensure that individuals with mental illness and or intellectual disabilities are appropriately evaluated and placed in skilled nursing facilities with access to necessary services in compliance with federal and state regulations.

Further review of the facility policy revealed the process of the PASARR evaluation begins with a preadmission screening, all prospective residents will undergo a PASARR screening prior to admission, if an individual level 1 screening indicates a potential mental illness, a level ll evaluation will be completed. Admission to the facility will be contingent upon completion of the PASARR process to ensure the facility can meet the identified needs of the individual.

Continued review of the policy revealed that the facility will conduct regular audits to ensure compliance with PASARR requirements.

Review of Resident R1's quarterly MDS (minimum data set- a mandatory periodic resident assessment tool) dated May 3, 2024, revealed that the resident was admitted to the facility on August 7, 2021, and the resident had a Level ll PASARR (Pennsylvania Preadmission Screening Resident Review- a process for screening and evaluating all residents for mental disorders and intellectual disabilities) condition related to a serious mental illness. Continued review of the MDS assessment revealed that the resident had a diagnosis of Schizophrenia (a serious mental debilitating health condition that effects a person's thoughts, feelings, and behavior, characterized by hallucinations, delusions, disorganized thinking and behavior).

Review of Resident R 1's Level 1 PASARR form, dated February 21, 2018, revealed the resident met the criteria to have a Level ll evaluation.

Continued review of the clinical record revealed that there was no indication in the record that a Level ll PASARR evaluation had been completed.

Review of Resident R3 quarterly MDS (minimum data set- a mandatory periodic resident assessment tool dated May 17, 2024, revealed that the resident was admitted to the facility on February 22, 2023, and that the resident had a Level ll PASARR condition related to a serious mental illness. Continued review of the MDS assessment revealed that the resident had a diagnosis of Schizophrenia (a serious mental debilitating health condition that effects a person's thoughts, feelings, and behavior, characterized by hallucinations, delusions, disorganized thinking, and behavior., anxiety disorder, ( a type of mental health condition that involves persistent and excessive worry ) and psychotic disorder(a severe mental disorder that causes abnormal thinking and perception) .

Review of Resident R3's Level 1 PASARR form, dated August 14, 2018, revealed the resident met the criteria to have a Level ll evaluation.

Continued review of the clinical recorded revealed that there was no indication in the record that a level ll PASARR evaluation had been completed.

Review of resident R20's quarterly MDS (minimum data set- a mandatory periodic resident assessment tool dated June 5, 2024, revealed that the resident was admitted to the facility on May 31, 2019, and readmitted July 23, 2021, that the resident had a Level ll PASARR condition related to a serious mental illness. Continued review of the MDS assessment revealed that the resident had a diagnosis of Schizophrenia (a serious mental debilitating health condition that effects a person's thoughts, feelings, and behavior, characterized by hallucinations, delusions, disorganized thinking, and behavior, and a diagnosis of depression (a mental disorder that involves depressed mood of loss of pleasure of interest in activities for long periods of time).

Review of Resident R 20's Level 1 PASARR form, dated May 23, 2019, revealed the resident met the criteria to have a Level ll evaluation.

Continued review of the clinical recorded revealed that there was no indication in the record that a level ll PASARR evaluation had been completed.

Interview with Employee Interview with employee E23, social worker, on July 31, 2024 at 2:20 p.m. confirmed that a level ll PASARR evaluation had not been completed for Residents R1, R3, and R20 as required.

Clinical record review revealed Resident R36 was admitted to the facility July 14, 2022 with a diagnosis that included but not limited to Post Traumatic Stress Disorder (mental illness triggered by a terrifying event, either experiencing it or witnessing it), Bipolar Disorder (mental illness that causes mood episodes that ranges from extremely high to extremely low), Dementia (the loss of cognitive functioning that interferes with daily life), and Anxiety (mental health condition that involves persistent and excessive worry).

Review of Resident R36 PASARR 1 form, dated July 12, 2022, revealed that Resident R36 met the criteria to have a Level II PASARR evaluation completed.

Continued review of the clinical record revealed that there was no indication in the record that a Level II PASARR evaluation had been completed.

Interview with Employee E23, social worker, on August 01, 2024 at 11:51 a.m, confirmed Level II PASARR evaluation had not been completed for Residents R36 as required.

28 Pa. Code 201.14(a) Responsibility of licensee

Plan of Correction - To be completed: 09/20/2024

1. Residents identified in 2567 with inaccurate PASARRs had their records revised to reflect the current diagnosis by the Social Services Director.

2. An audit of current residents' PASARRs will be completed by the Social Services Director/Designee to ensure that they correctly reflect the residents' current diagnoses. Any concerns identified during the audit will be corrected immediately.

3. The Social Services Director/Designee will be re-educated on the components of this regulation with an emphasis on ensuring that residents' PASARRs accurately reflect their diagnoses.

4. The Social Services Director/Designee will conduct random audits of 10 residents' PASARRs, 1x week x4 weeks, biweekly x2 months, then monthly x3 months to ensure the components of this regulation are being met and PASARRs are accurate.

The findings of these quality monitoring efforts will be reported to the Quality Assurance/Performance Improvement Committee until monthly and/or until substantial compliance is met. The Quality Monitoring schedule will be modified based on findings.

483.90(i) REQUIREMENT Safe/Functional/Sanitary/Comfortable Environ:

§483.90(i) Other Environmental Conditions
The facility must provide a safe, functional, sanitary, and comfortable environment for residents, staff and the public.

Observations:

Based on observations and staff interviews, it was determined that the facility failed to ensure a safe, functional, and sanitary environment for residents, staff, and the public on four out of four nursing units. (A, B, C, D nursing units)

Findings include:

On July 29, 2024, from 10:33 a.m. to 11:06 a.m. observations were conducted on the D unit revealed the following:

Room D15 had no baseboard from the door to the bedside dresser, the room had a strong urine smell and sticky floors.

Room D25 bed by the window had a missing shelf from the dresser, large, ripped cardboard box was on the floor with the box being overloaded with random resident's items in the box.

Room D14 window bed had boxes and random bags on the floor which cluttered the pathway to get around the resident's rooms.

Room D17 there was stool in the bathroom floor and all around the toilet, the bed next to the door had no baseboard from the door to the bed dresser. The room had sticky floors, strong stool smell in the room. Resident's closet did not have a right side doorknob.

On July 29, 2024, at 11:07 a.m. the assistant of director of nursing, Employee E4 confirmed the above observations.

On July 29, 2024, at 12:51 p.m. the second floor D unit dining floor was missing a baseboard on the left side by the sink and two tiles are missing from the floor and 6 tiles are broken off. Administrator Employee E1 confirmed the observations.

On July 29, 2024, at 1:14 p.m. observation revealed that Resident R4 in room D20 had no call bell. Call bell was observed to be cut off and hanging wires from the light above the bed. Resident R18 in Room D22 had her call bell ripped and disconnected from the wall. Maintenance Director, Employee E7 confirmed the observations.

Room D22 The cover of the internet outlet is detached from the wall.

Room D21 was missing a full door to the closet and 1 drawer was broken. Resident R78 had a missing call bell wire. License nurse, Employee E9 confirmed the above observations.

On July 29, 2024, at 2:45 p.m. an interview with the Maintenance Director, Employee E7 confirmed that call bells were broken on the following units: C wing-rooms C4, C5. B unit rooms B16, B17, B18, B24. Nursing unit A had the following rooms with the broken call bell: A2, A4, A9, A10, A11. Employee E7 reported that he was unaware of the broken call bells and emphasized the need for an in-service session for all nursing staff to ensure they alert maintenance when a call bell isn't functioning.

Observation conducted during the tour of the first-floor unit A wing together with DON (Director of Nursing) Employee E2 revealed that Room# 00009-A, the call bell did not work, Room# 00022-B the call bell did not work, Room# 00010-B, the call bell prong was inserted not into the call bell socket. Further observation revealed that the call bell cord was cut from the base of the call bell plug/prong and did not have a cord and did not have a call button attached.

Observation conducted during the tour of the first-floor unit B wing together with Employee E2 revealed that room 00016-2, the call bell cord was not clipped to the bed and call bell was not within reach of the resident, room# 00016-1 did not have a cord, room# 00017-1, call bell did not work, room# 00017-2, call bell did not work, room# 00018- 2, call bell was not working. Interview with Resident R8 (resident who lives in room# 00018-2, revealed that the call bell has not been working for a month now. Further, Resident R8 also revealed that he reported it a couple times but was never fixed, Room# 00020, call bell . was on the floor next to roommate's bed, further, the call bell was not within reach of the resident, room# 00025-1 the call bell was not clipped to the bed and was on the floor under bed-2 out of reach of resident, room# 00024-1, the call bell cord was cut from the base of the call bell plug/prong, there was no cord and there was no call button.

Plan of Correction - To be completed: 09/20/2024

1. Noted deficiencies identified in the 2567 have been corrected.

2. rooms will be audited to ensure that call bells are working, furniture is in proper condition, tiles and baseboards are attached, rooms are free of clutter, floors and bathrooms are clean, internet outlet covers are attached to the wall, and call bells are attached and in working order.

3. IDT will be educated on components of this regulation to ensure there is a safe, functional, sanitary, and comfortable environment. Staff will be educated on the importance of reporting any environmental issues immediately to the proper staff member.

4. The designee will conduct random audits of 10 residents' rooms 1x per week for 4 weeks, biweekly for 2 months, then monthly for 3 months to ensure the components of this regulation are being met and that there is a safe, functional, sanitary, and comfortable environment.

The findings of these quality monitoring efforts will be reported to the Quality Assurance/Performance Improvement Committee monthly and/or until substantial compliance is met. The Quality Monitoring schedule will be modified based on findings.

483.80(d)(1)(2) REQUIREMENT Influenza and Pneumococcal Immunizations:

§483.80(d) Influenza and pneumococcal immunizations
§483.80(d)(1) Influenza. The facility must develop policies and procedures to ensure that-
(i) Before offering the influenza immunization, each resident or the resident's representative receives education regarding the benefits and potential side effects of the immunization;
(ii) Each resident is offered an influenza immunization October 1 through March 31 annually, unless the immunization is medically contraindicated or the resident has already been immunized during this time period;
(iii) The resident or the resident's representative has the opportunity to refuse immunization; and
(iv)The resident's medical record includes documentation that indicates, at a minimum, the following:
(A) That the resident or resident's representative was provided education regarding the benefits and potential side effects of influenza immunization; and
(B) That the resident either received the influenza immunization or did not receive the influenza immunization due to medical contraindications or refusal.

§483.80(d)(2) Pneumococcal disease. The facility must develop policies and procedures to ensure that-
(i) Before offering the pneumococcal immunization, each resident or the resident's representative receives education regarding the benefits and potential side effects of the immunization;
(ii) Each resident is offered a pneumococcal immunization, unless the immunization is medically contraindicated or the resident has already been immunized;
(iii) The resident or the resident's representative has the opportunity to refuse immunization; and
(iv)The resident's medical record includes documentation that indicates, at a minimum, the following:
(A) That the resident or resident's representative was provided education regarding the benefits and potential side effects of pneumococcal immunization; and
(B) That the resident either received the pneumococcal immunization or did not receive the pneumococcal immunization due to medical contraindication or refusal.

Observations:

Based on Review of clinical record, review of facility policy and interview with staff, it was determined that the facility failed to ensure that residents were provided with education regarding the benefits and potential side effects of influenza immunization for three of three residents (Residents R85, R8 and R17).

Findings:

Review facility policy on "Influenza Vaccine" revealed that under Section "Policy Statement", all residents and employees who have no medical contraindications to the vaccine will be offered the influenza vaccine annually to encourage and promote the benefits associated with vaccination against influenza. The facility shall provide pertinent information about the significant risks and benefits of vaccines to staff and residents or residents legal representatives. For example, risk factors that have been identified for specific age groups or individuals with risk factors such as such as allergies and pregnancy. Under section "Policy Interpretation and Implementation". #1 Between October 1st and March 31st each year, the influenza vaccine will be offered to residents and employees unless the vaccine is medically contraindicated, or the resident or employee has already been immunized. #2 employees hired or residents admitted between October 1st and March 31st, will be offered the vaccine within 5 working days of the employee's job assignment or the resident's admission to the facility. #4 Prior to the vaccination, the resident or resident's legal representative, will be provided information and education regarding the benefits and potential side effects of the influenza vaccine.

Review of Resident R85's clinical record revealed that Resident R85 was admitted to the facility on March 12, 2024.
Further review of resident R85's clinical record revealed no documented evidence that Resident R85 or Resident R85's representative was provided education regarding the benefits and potential side effects of influenza immunization.

Review of Resident R8 clinical record revealed that Resident R8 was admitted to the facility on November 1, 2017.
Further review of Resident R8's clinical record revealed no documented evidence that Resident R8 or Resident R8's representative was provided education regarding the benefits and potential side effects of influenza immunization.

Review of Resident R17's clinical record revealed that resident R17 was admitted to the facility on January 11, 2024.
Further review of Resident R17's clinical record revealed no documented evidence that Resident R17 or Resident R17's representative was provided education regarding the benefits and potential side effects of influenza immunization.

Interview with the DON (Director of Nursing) Employee E2 conducted on July 31, 2024, at 1:14pm confirmed that the facility did not have documented evidence that residents or resident representatives were provided with education regarding the benefits and potential side effects of influenza immunization. Further Employee E2 also revealed that moving forward, the facility will initiate a form for influenza education and documentation.

28 Pa. Code 201.14(a) Responsibility of licensee

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

Plan of Correction - To be completed: 09/20/2024

1. No residents were affected by this alleged deficient practice. We are unable to retroactively educate.

2. We have updated our consent form for the flu or PNA vaccine, and it now includes proof of education on the risks and benefits of the vaccinations.

3. The DON, ADON, Unit Manager, and Licensed Nurses will be in-serviced regarding the Influenza and Pneumococcal Vaccine Policy and Procedure, and on educating residents or their representatives on the importance and side effects of the vaccinations.

4. The DON/designee will audit the vaccination education provided to residents, 1x week x4 weeks, biweekly x2 months, then monthly x3 months.

The findings of these quality monitoring efforts will be reported to the Quality Assurance/Performance Improvement Committee until monthly and/or until substantial compliance is met. The Quality Monitoring schedule will be modified based on findings.

483.12(a)(1) REQUIREMENT Free from Abuse and Neglect:

This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.

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

§483.12(a) The facility must-

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

Plan of Correction - To be completed: 09/20/2024

1. Resident #R137 was assessed at the time of the incident, and no concerns were identified. The employee involved in this incident was suspended immediately and terminated after an investigation.

2. Current facility residents will be interviewed to ensure that they have not experienced any instances of abuse while in the facility. Residents who are unable to be interviewed had comprehensive skin assessments completed to ensure no physical signs of abuse are present.

3. Current facility staff will be re-educated on the components of this regulation with an emphasis on ensuring that residents are free from abuse, neglect, misappropriation of resident property, and exploitation as defined by the regulation.

4. The Abuse Coordinator/Designee will conduct random audits consisting of resident interviews and record reviews of 10 residents, 1x week x4 weeks, biweekly x2 months, then monthly x3 months to ensure that residents are free from abuse, neglect, misappropriation of resident property, and exploitation as defined by the regulation.

The findings of these quality monitoring efforts will be reported to the Quality Assurance/Performance Improvement Committee until monthly and/or until substantial compliance is met. The Quality Monitoring schedule will be modified based on findings.

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

§483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must:

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

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

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

Observations:

Based on review of clinical records, resident and staff interviews and review of facility policy, it was determined that the facility failed to conduct a complete and though investigation to rule out abuse related to one of one allegation of potential sexual abuse. (Resident R11)

Findings include:

Review of facility policy titled Abuse Prevention Program" dated January 1, 2022, revealed the primary purpose of the policy is for the residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. The following implementations are indicated in the prevention program; Separate the residents, identify what happened, notify each resident's representative of the incident ;review the events with the Nursing Supervisor and Director of Nursing, consult with the Attending Physician to identify treatable conditions such as acute psychosis that may have caused or contributed to the problem; make any necessary changes in the care plan approaches to any or all of the involved individuals; document in the resident's clinical record all interventions and their effectiveness; consult psychiatric services as needed for assistance in assessing the resident, identifying causes, and developing a care plan for intervention and management as necessary or as may be recommended by the Attending Physician or Interdisciplinary Care Planning Team; complete a Report of Incident/Accident form and document the incident, findings, and any corrective measures taken in the resident's medical/clinical record; and Report incidents, findings, and corrective measures to appropriate agencies as outlined in our facility's abuse reporting policy.

Review of Resident R11's quarterly MDS (minimum data set- a mandatory periodic resident assessment tool) dated July, 2, 2024, revealed that the resident was admitted to the facility on November 2, 2023, with diagnoses of Schizophrenia (a serious mental debilitating health condition that effects a person's thoughts, feelings, and behavior, characterized by hallucinations, delusions, disorganized thinking, and behavior., anxiety disorder, ( a type of mental health condition that involves persistent and excessive worry ) and psychotic disorder(a severe mental disorder that causes abnormal thinking and perception) ,and Bipolar disorder (a mental health condition that causes unusual intense shifts in mood, energy and behavior). Resident R11 was determined to be cognitively impaired with a BIMS (Brief interview for mental status- a mandatory tool used to screen cognitive conditions of residents) score of 14.

Review of Resident R11's care plan, initiated January 11, 2024, revealed that Resident R11 has been identified as having a behavior problem related to pretending to be asleep and putting self on the floor. Resident R11 is also noted to refuse medications. Interventions included to monitor for behavior episodes, attempt to determine underlying cause, document behavior and potential causes.

Review of resident's clinical records revealed a psychological note dated May 16, 2024, written by Employee E24, stated that "He addressed complaints about him touching another resident and coming to her door when she did not welcome him. He denied touching resident, or going to her door, even talking with her despite a few different reports by staff and his peers witnessing him doing so".

Review of Resident R42 's quarterly MDS dated May 2, 2024 revealed that the resident was admitted to the facility on April 14, 2023, with a diagnosis of Schizophrenia (a serious mental debilitating health condition that effects a person's thoughts, feelings, and behavior, characterized by hallucinations, delusions, disorganized thinking, and behavior., anxiety disorder, (a type of mental health condition that involves persistent and excessive worry )and psychotic disorder (a severe mental disorder that causes abnormal thinking and perception), dementia (a term used to describe a group of diseases and illness that effect thinking, memory, reasoning, personality an mood and behavior) and depression (a mental disorder that involves a depressed mood or loss of pleasure or interest in activities for long periods of time with symptoms affecting memory, thinking and social abilities.) Resident R42 was determined to be cognitively impaired with a BIMS (Brief interview for mental status- a mandatory tool used to screen cognitive conditions of residents) score of 8.

Review of Resident R42's psychotherapy progress note dated May 16, 2024, written by Employee E 24, revealed the Reason for visit was "Inappropriate peer/To help resident cope and handle the uncomfortable feelings. ...Resident shared about being uncomfortable with a peer. She agreed to set boundaries."

Further review of Resident R 42's psychotherapy progress notes written by Employee E 24 dated June 5, 2024 revealed "SW (Social Worker) met with/ the resident to discuss a concern she had about a male resident coming into her room. When what concern she had, she stated I have none, I'm over it, when asked what the concern was, she stated I was just mad at him because he was bringing up old stuff and I didn't want to hear it".

Interview with licensed nurse unit manager, Employee E 8 on July 31, 2024, at 11:25 a.m. revealed that this was not investigated as an incident, but she did take a statement from the resident, R42. The incident with Resident R11 was described as Resident R42 was taking a nap and Resident R11 entered her room and bothered her. Resident R42 left her room and went to the nurse's station and reported that Resident R11 entered her room and would not leave. Employee E8 spoke to Resident R 11, and he became angry. Employee then requested that Social Worker, Employee E42 speak with resident R11.

Interview with Resident R42 on July 31, 2024, at 11:45 am revealed Resident R11 lives on the floor, he came into her room and pulled at her arms, when asked what he wanted Resident R42 reported that he wanted her to hug and love him. Resident R42 repeatedly asked him to stop. Resident R42 reported the incident to Licensed nurse, Employee 8.

Second interview with Resident R42 on August 1, 2024 revealed that no residents have touched her, no residents have kissed her, no residents have exposed themselves to her . Resident R 42 stated "I feel safe".

Interview with Social Worker, Employee E24 on August 1, 2024, at 12:25 p.m. revealed that he was requested to speak to Resident R 11 by the staff due to his behavior. Employee E 4 revealed that he usually is notified by staff of residents that need to be assessed. Employee E24 counseled Resident R11 on boundaries and distance from Resident R42.

Employee E24 also assessed Resident R42; she has a history of abuse giving some concern of her relations with other male residents. The resident did not indicate that she felt unsafe.

28 Pa. Code 201.14 (a) Responsibility of Licensee

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

28 Pa. Code 211.12 (d) Nursing Services

Plan of Correction - To be completed: 09/20/2024

1. The investigation was completed and closed as required by the facility on 8/1/2024 regarding Resident #R42's allegation.

2. Current facility residents will be interviewed to ensure that they have not experienced any instances of abuse while in the facility. Residents who are unable to be interviewed had comprehensive skin assessments completed to ensure no physical signs of abuse are present. Resident records and grievances for the last 30 days are reviewed to ensure that no documented instances of potential abuse are overlooked or not reported as required by regulation.

3. The Nursing Home Administrator/Director of Nursing and Abuse Coordinator will be educated by the RDCO on the components of this regulation with an emphasis on ensuring that the facility conducts a complete and thorough investigation of any abuse allegation to rule out abuse as defined by the regulation.

4. The Abuse Coordinator/Designee will conduct random audits consisting of resident interviews and record reviews, including grievances of 10 residents, 1x week x4 weeks, biweekly x2 months, then monthly x3 months to ensure that any abuse allegations have had a complete and thorough investigation as required.

The findings of these quality monitoring efforts will be reported to the Quality Assurance/Performance Improvement Committee until monthly and/or until substantial compliance is met. The Quality Monitoring schedule will be modified based on findings.

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

§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 observation and staff interview, it was determined that the facility failed to ensure that the environment remained free of accident hazards for one out of the 37 residents reviewed and had residents would have appropriate supervision. (Resident R30)

Findings include:

A review of the clinical record indicated Resident R30 was admitted to the facility on February 22, 2022 with the following diagnosis schizophrenia ( chronic and severe mental disorder which includes hallucination, delusion, disorganized thinking, agitation or erratic behaviors) and major depressive disorder (feeling sadness, loss of interest, significant change in weight or appetite, feeling of worthlessness, difficult concentrating or making decisions).

Review of Resident R30's Minimum Data Set (MDS - a periodic assessment of care needs) dated May 3, 2024, revealed a Brief Interview for Mental Status (BIMS) of 15 which indicated that the resident was cognitively intact.

A comprehensive care plan was developed on June 9, 2022 which revealed that Resident R30 had behaviors such as manipulative behavior, refusing be seen by the wound team, accusing staff of giving wrong medication, refusing ADLs, video recording staff, likes to block the exit doors, non-compliant with isolation precautions, hoarding behavior and refusing staff assistance with cleaning.

An interview was held on July 29, 2029, at 11:41 a.m. with Resident R30 revealed an observation of three large 5 gallon bottles with blue substance being on the floor. When questioned what's the blue substance Resident R30 reported that cleaning supplies for his commode. When started to question what kind of cleaning supplies or how the resident received the cleaning supplies, Resident R30 started to become verbally aggressive frustrated.

An interview with Director of Nursing, Employee E2 on July 29, 2024, at 12:20 p.m. confirmed that Resident R30 had unknown cleaning supplies in his room on the floor and agreed to place the cleaning bottles into his closet under the locked lock. The lock and the key were provided to the resident.

On August 1, 2024, an observation was held with the Director of Nursing, Employee E2 which revealed Resident R30 no longer had the cleaning supplies in his room and reported that his family came in and took it away.

On July 29, 2024, at 11:06 a.m. second floor D nursing unit dining area had 6 resident sitting in the dining room who were not alert and oriented with no staff.

On July 30, 2024, at 10:10 a.m. first floor activity room had approximately 6-7 residents in the room with no supervision. Regional Nurse, Employee E15 confirmed the observations.

On August 1, 2024, at 9:47 a.m. Resident R5 was observed being outside on his own sleeping with no staff supervision. Nursing Aid, Employee E16 was in the hallway next to the activity room on B wing had to come to the window to identify the resident and reported that activity staff should be outside.

On August 1, 2024, at 9:42 a.m. a Resident R78 barricaded himself in the second-floor shower using his wheelchair and staff were observed to try to open the door.

On August 1, 2024, at 9:52 a.m. a Resident R78 was heard to be in the second-floor shower with no staff. Director of Nursing, Employee E2 walked in and confirmed that Resident R78 was taking a shower with no supervisor.

CFR. 483.25(d)(2) Accidents.

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

28 Pa Code 201.14(c) Responsibility of licensee

28 Pa Code 201.18(b)(1) Management

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

Plan of Correction - To be completed: 09/20/2024

1. Cleaning products were immediately removed from the facility. The resident had no ill effects from the cleaning products being stored in his room.

2. Current residents' rooms will be audited and assessed for the presence of chemicals. Residents and staff will be educated on the importance of proper supervision as mentioned in the 2567.

3. Staff will be educated about removing hazardous chemicals from resident rooms and ensuring that chemicals are locked in cabinets.

4. Random audits of 10 residents, 1x week x4 weeks, biweekly x2 months, then monthly x3 months will be conducted to ensure the components of this regulation are being met and residents' rooms are free from hazardous chemicals and that chemicals are stored in locked cabinets.

The findings of these quality monitoring efforts will be reported to the Quality Assurance/Performance Improvement Committee until monthly and/or until substantial compliance is met. The Quality Monitoring schedule will be modified based on findings.

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 clinical record review and staff interview, it was determined that the facility failed to ensure that a resident's medication regime was free from potentially unnecessary medications for one of four residents reviewed (Resident 68).

Findings include:

Facility policy titled "Policy for Psychotropic Use in Long-Term Care (LTC)", indicated that "The facility will adhere to all relevant federal, state, and local regulations regarding the use of psychotropic medications in LTC settings".

Clinical record review revealed Resident R68 was admitted to the facility February 09, 2022, with a diagnosis that included but not limited to Cerebral Infarction (disruption of blood supply to the brain that causes brain tissue death), Schizophrenia (mental health condition that affects how people think, feel, and behave), and Altered Mental Status.

Review of Resident R68's medication orders revealed a physician order initiated June 28, 2024 to administer Ativan 0.5 mg (anti-anxiety medication) orally (by mouth) every four hours as needed for anxiety. The medication order indicated a stop date of "indefinite", which lacked the required stop date within 14 days

Review of Resident R68's pharmacy notes to attending physician/prescriber dated July 11, 2024, revealed a recommendation "If you believe this resident's PRN order for Ativan is appropriate beyond 14 days- see CMS regulations below, then follow the instructions below: 1. if the PRN order is to continue, please document your rationale and indicate the duration of therapy in the resident's medical record or below. 2. Please write a new order, if it should continue, prior to the 14 days. Per CMS, this new order must include a duration of use, i.e 30 day, 60 day, 3 months, ect." The physician responded on July 11, 2024, "resident is on hospice and prone to agitation". The physician failed to indicate a duration of PRN Ativan.

Further review of clinical record revealed PRN Ativan 0.5 mg was ordered for anxiety. Resident R68 had no documented diagnosis for anxiety. The facility failed to ensure psychotropic medication was used to treat a specific condition as diagnosed and documented in the clinical record.

During an interview on August 01, 2024, at 10:25 am, Director of Nursing confirmed that Resident R68 lacked the required stop date within 14 days. During an interview on August 01, 2024, at 12:41 pm, Medical Director confirmed that Resident R68 lacked a proper diagnosis that was documented in the clinical record.

28 Pa. Code 211.2(d)(3) Medical director

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

Plan of Correction - To be completed: 09/20/2024

1. The MD was immediately called, and the stop date given for the use of PRN anti-anxiety medication. Resident #R68 was assessed, with no side effects from unnecessary psychotropic drug use.

2. Current residents will be audited to ensure that residents with PRN psychotropic drugs have an end date.

3. RN licensed nurses will be educated on the components of this regulation to ensure PRN psychotropic drugs are updated and that no unnecessary psychotropic drugs are given.

4. Random audits of 10 residents' clinical records, 1x week x4 weeks, biweekly x2 months, then monthly x3 months will be conducted to ensure the components of this regulation are being met and PRN psychotropic drugs are updated.

The findings of these quality monitoring efforts will be reported to the Quality Assurance/Performance Improvement Committee until monthly and/or until substantial compliance is met. The Quality Monitoring schedule will be modified based on findings.

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 clinical records, review of facility policy, observation, and staff and resident interviews, it was determined that the facility failed to ensure that all drugs and biologicals are stored and labeled in accordance with professional standards. For one of eighteen residents reviewed. (Resident R40).

Findings include:

Review of the facility policy and storage of medication revealed that under section policy statement, the facility stores all drugs and biologicals in a safe, secure and orderly manner under section "Policy Interpretation and Implementation" #1. Drugs and biologicals used in the facility are stored in locked compartments under proper temperature, light and humidity controls. #3 The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. #4. Drug containers that have missing, incomplete, improper, or incorrect labels are returned to the pharmacy for proper labeling before storing. #8 compartments, including but not limited to drawers, cabinets, rooms, refrigerators, carts, and boxes containing drugs and biologicals are locked when not in use. #12 Only persons authorized to prepare and administer medications have access to lock medications.

Observation conducted during tour of the first floor A unit on Jully 29, 2024 at 11:42 am revealed that Resident R40 was in bed awake.

Further observation revealed a tube of Medihoney on resident's overhead table which was next to her.

Interview with Resident R40 conducted at the time of the observation revealed that she has an ulcer on her bottom. Further, Resident R 40 revealed that a nurse left the Medihoney with her.

Interview with DON Employee E2 conducted at the time of the observation confirmed that the Medihoney was with resident R40. Further Employee E2 revealed that a nurse's aide left the medihoney with the resident.

Further interview with Employee E2 revealed that the Medihoney should not be with the resident and that it should have been stored in the locked treatment cart.

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

28 Pa. Code 211.12(d) Nursing services

Plan of Correction - To be completed: 09/20/2024

1. Medicated treatment was removed from Resident #R30's room immediately and disposed of. The resident had no ill effects from the treatment being in the room.

2. An audit of residents' rooms was conducted to ensure no medications are being stored in the residents' rooms.

3. The DON or designee will educate nursing staff on the proper storage of medications and medicated treatments, ensuring that none are left in resident rooms.

4. The DON/designee will conduct random audits of 10 residents, 1x week x4 weeks, biweekly x2 months, then monthly x3 months to ensure components of this regulation are being met and that staff are properly storing medications and none are left at the bedside.

The findings of these quality monitoring efforts will be reported to the Quality Assurance/Performance Improvement Committee until monthly and/or until substantial compliance is met. The Quality Monitoring schedule will be modified based on findings.

483.65(a)(1)(2) REQUIREMENT Provide/Obtain Specialized Rehab Services:

§483.65 Specialized rehabilitative services.
§483.65(a) Provision of services.
If specialized rehabilitative services such as but not limited to physical therapy, speech-language pathology, occupational therapy, respiratory therapy, and rehabilitative services for mental illness and intellectual disability or services of a lesser intensity as set forth at §483.120(c), are required in the resident's comprehensive plan of care, the facility must-

§483.65(a)(1) Provide the required services; or

§483.65(a)(2) In accordance with §483.70(g), obtain the required services from an outside resource that is a provider of specialized rehabilitative services and is not excluded from participating in any federal or state health care programs pursuant to section 1128 and 1156 of the Act.

Observations:

Based on review of facility policy, review of clinical records, observations and staff interviews, it was determined that the facility failed to assess the need for specialized occupational therapy services according to the professional standards of practice for one out of one resident reviewed for rehabilitation services (Resident R18).

Findings include:

Review of facility policy "Standards and Guidelines: Restorative Nursing Services" dated August, 2022, revealed that "To promote the resident's optimum function, a restorative nursing program may be developed by proactively identifying, care planning, and monitoring of a resident's assessments and indicators, Restorative nursing program refers to interventions that promote the resident's ability to adopt and adjust to living as independently and safely as possible. This concept actively focuses on achieving and maintaining optimal physical, mental and psychosocial functioning. Restorative programs may be initiated by nursing and/or therapy."

A review of the clinical record indicated Resident R18 was admitted to the facility on March 13, 2024 with the following diagnosis age-related osteoporosis (bones become weak and brittle due to aging), need for assistance with personal care, abnormalities of gait and mobility, muscle weakness, psychomotor deficit, lack of coordination, and dementia (range of progressive neurological disorders that affect memory, thinking, behavior, and the ability to perform everyday activities).

Review of Resident R18's Minimum Data Set (MDS - a periodic assessment of care needs) dated June 7, 2024, revealed a Brief Interview for Mental Status (BIMS) not recorded which means the resident was unable to participate in the assessment due to severe cognitive impairment.

A family interview was conducted on July 29, 2024, at 12:27 p.m. with Resident's R18 daughter who reported that her mother had not been walking and she needs assistance to walk.

An interview with the Rehabilitation Director, Employee E13 who reported that Resident R18 was discharged from physical therapy on June 10, 2024, and started a restorative program on June 11, 2024. The restorative nursing program included the following interventions: Ambulation - 140 feet in increments using a RW (Rolling Walker) with Contact Guard to Minimum Assistance (25-50% assistance) of 1 person, with verbal and tactile cues for direction, for AD (assistive device) maneuvering, for maneuvering around the obstacles and for increased hip and knee flexion to clear the floor. Second intervention was for transfers - 90 degree or 180 degree turns to facilitate SPT (stand pivot transfers) and STS (sit to stand transfers) with RW (Rolling Walker) with Contact Guard to Minimum Assistance (25-50% of assistance) of 1 person. These two-intervention needed to be done on daily bases. Further interview revealed that facility had a restorative aid, Employee E14 which last worked on June 11, 2024, when she was trained how to appropriately implement the two interventions for Resident R18. Then Employee E14 had life threatening event which placed her in a coma. Facility had not had any other staff provide restorative program to any residents.

On August 1, 2024, at approximately 10:30 a.m. an interview was conducted with Director of Nursing, Employee E2 who reported that Administrator oversees restorative program. The nursing staff do not provide restorative program to any of the residents.

On August 1, 2024, at 12:47 p.m. an interview was conducted with the Administrator, Employee E1 who reported that Restorative Aid, Employee E14 has not worked since June 11, 2024, and the facility has not trained any staff to implement the restorative program for any of the residents. Administrator, Employee E1 confirmed the facility intends to hire a new restorative aide; however, it has not provided the restorative program to any of its residents.

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

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

Plan of Correction - To be completed: 09/20/2024

1. Resident #R18 was immediately assessed to ensure that she had no contracture and no decline in her range of motion, transfer, and ambulation.

2. The facility assigned a CNA to the restorative program. Therapy has trained the CNA on the restorative program. Therapy evaluated and provided an updated list of our current residents who will need the restorative program.

3. NHA, DON, and DOR will be educated on the components of this regulation.

4. The designee will conduct random audits of 10 residents' clinical records, 1x week x4 weeks, biweekly x2 months, then monthly x3 months to ensure the components of this regulation are being met and a proper restorative program is in place.

The findings of these quality monitoring efforts will be reported to the Quality Assurance/Performance Improvement Committee until monthly and/or until substantial compliance is met. The Quality Monitoring schedule will be modified based on findings.

483.80(b)(1)-(4) REQUIREMENT Infection Preventionist Qualifications/Role:

§483.80(b) Infection preventionist
The facility must designate one or more individual(s) as the infection preventionist(s) (IP)(s) who are responsible for the facility's IPCP. The IP must:

§483.80(b)(1) Have primary professional training in nursing, medical technology, microbiology, epidemiology, or other related field;

§483.80(b)(2) Be qualified by education, training, experience or certification;

§483.80(b)(3) Work at least part-time at the facility; and

§483.80(b)(4) Have completed specialized training in infection prevention and control.

Observations:

Based on review of facility documentation and staff interview it was determined that the facility failed to ensure a designated infection prevention (IP) works at the facility focusing only on infection control at least part time as required one or more individuals servicing as infection Preventionist responsible for the facility's infection prevention plan.

Finding include:

Review of facility documentation identified the Director of Nursing (DON) fulfilled the job of Infection Preventionist. The DON works full time and was unable to provide valid proof that additional part time hours focusing only on infection control were completed in addition to his/her full time DON duties.

Review of the Infection preventionist (IP) job description revealed that the IP is responsible for the activities aimed at healthcare associated infections. The responsibilities include collecting, analyzing health data, and interpreting, implementing, and evaluating public health practices. The IP will conduct education and training on healthcare associated infections for staff and management.

Interview on July 31, 2024, at 1:40 p.m. with DON Employee E 2 revealed that she has been the IP and DON, she is able to divide her time. she states while working at infection control, her director of nursing assistant can cover the floor."

The Administrator and Director of Nursing were asked to provide official documentation that the DON was at the facility after her work hours conducting infection control business. There was no time stamped computer notes or punch report evidence provided that the DON worked additional hours .

28 Pa. Code 210.18(e)(1) Management

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

Plan of Correction - To be completed: 09/20/2024

1. No residents were affected by this alleged deficient practice.

2. The ADON has completed an approved Infection Preventionist Certification course and will test to complete certification by 9/05.

3. NHA/DON will be re-educated on the components of this regulation by the RDCO.

4. The NHA will ensure that the facility remains in compliance with this regulation if/when there is a change in the identified IP's employment status.

The findings of these quality monitoring efforts will be reported to the Quality Assurance/Performance Improvement Committee until monthly and/or until substantial compliance is met. The Quality Monitoring schedule will be modified based on findings.

483.90(d)(2) REQUIREMENT Essential Equipment, Safe Operating Condition:

§483.90(d)(2) Maintain all mechanical, electrical, and patient care equipment in safe operating condition.

Observations:

Based on observations of the food and nutrition department, and interview with staff, it had been determined that the facility failed to maintain essential food service equipment in a safe operating condition relating to a gas stove control knobs and kitchen exhaust fan.

Findings Include:

Review of facility policy titled "Supplies and Equipment, Environmental Services" revised February 2009, revealed equipment must be always ready for use at all times.

An initial tour of the main kitchen conducted on July 29, 2024, at 09:35 AM with employee E 25
with Dietary director, revealed the facility had five refrigerators, four are functioning and one is out of order, and a gas oven/ grill with no knobs to be used for igniting the flame and controlling the amount gas to the range for temperature adjustment.

Interview with Employee E17 on July 30, 2024, at 8:10 a.m. during breakfast preparation revealed that for an individual to use the stove without any knobs, in the kitchen there is a plastic knob on the shelf to be placed over the valve and turn. Employee E17 then demonstrated the knob, which was unsuccessful at turning the gas on. She tried again and the gas ignited. Employee E 17 revealed that she has been employee for six years and the oven has never worked in that period. There is another commercial convection oven that is used was the exhaust fan is functioning.

Review of the facility menus for the week of the survey revealed the entrchoices for lunch and dinner were sandwiches that included hot dogs, ham and cheese, roast beef sandwich, tuna salad, egg salad, turkey sandwich served with sides including potatoes salad , cole slaw, potato chips, cheese curls, corn salad, beet salad and tossed salad.

Interview with dietician employee E 26, revealed that kitchen is serving a "cold menu" due to the kitchen exhaust not functioning. Making the conditions in the kitchen intolerable for the kitchen staff. Employee E 26 provided evidence that the menus meet the dietary requirements and is a temporary menu.

Review of the exhaust fan manufactures manual revealed that the centrifugal upblast fan is the industry standard for efficient air extraction. Originally for the commercial kitchen industry, these fans have backward inclined blades that utilize centrifugal properties to remove the grease and particulates from the air stream while preventing excessive build-up on the blades.

Review of the National Fire Protection and Association which explicitly states the need for all components of the commercial kitchen exhaust system, including hoods, ducts, upblast exhaust fans, and fire-extinguishing systems, to be kept in working condition (4.1.3).

Interview with NHA Employee E1 revealed that the exhaust fan has been ordered and has provided the original estimate dated July 5, 2024. Employee E 1 also provided deposit payment dated July 19, 2024. Installation was determined to be the week of August 4, 2024.

28 Pa. Code 207.2(a) Administrators responsibility

28 Pa. Code 211.6(d) Dietary Services

Plan of Correction - To be completed: 09/20/2024

1. The exhaust fan was installed on 8/2/24. New knobs were ordered.

2. We will audit essential equipment in the kitchen to ensure it is properly working and with no missing parts.

3. The Maintenance Director and Director of Dietary will be educated on this regulation. Dietary staff will be educated to ensure they notify Maintenance immediately of any equipment not working properly or with missing parts.

4. The designee will audit essential equipment in the kitchen, 1x week x4 weeks, biweekly x2 months, then monthly x3 months to ensure components of this regulation are being met and that essential kitchen equipment is in proper working order.

The findings of these quality monitoring efforts will be reported to the Quality Assurance/Performance Improvement Committee until monthly and/or until substantial compliance is met. The Quality Monitoring schedule will be modified based on findings.

§ 211.12(f.1)(2) LICENSURE Nursing services. :

(2) Effective July 1, 2023, a minimum of 1 nurse aide per 12 residents during the day, 1 nurse aide per 12 residents during the evening, and 1 nurse aide per 20 residents overnight.

Observations:
Based on a review of nursing time schedules, it was determined that the facility failed to meet the minimum nurse aide (NA) to resident ratios for 4 of 21 days reviewed.

Findings Include:

The facility failed to meet the minimum NA to resident ratio of one NA per 11 residents on evening (3:00 p.m to 11:00 p.m) shift on February 22, 2024, February 24, 2024, and July 27, 2024.

The facility failed to meet the minimum NA to resident ratio of one NA per 15 residents on night (11:00 p.m to 07:00 a.m) shift on February 18, 2024.

On August 1, 2024 at approximately 9:43 a.m. the Human Resource and Scheduler, Employee E10 confirmed the facility did not meet the minimum NA to resident ratios for 4 of 21 days reviewed.

Plan of Correction - To be completed: 09/20/2024

1.Nursing schedules were reviewed to ensure the proper Nurse's Aid ratio on the morning, evening and overnight shifts.

2. NHA/designee will reeducate the scheduler and Director of Nursing on the correct Nurse's Aide ratio.

3. NHA/designee will audit the nursing schedules in advance daily x4 weeks to ensure Licensed Practical Nurses are being staffed at the proper ratio. Results will be shared at QA for 3 months.

§ 211.12(f.1)(3) LICENSURE Nursing services. :

(3) Effective July 1, 2024, a minimum of 1 nurse aide per 10 residents during the day, 1 nurse aide per 11 residents during the evening, and 1 nurse aide per 15 residents overnight.

Observations:

Based on a review of nursing time schedules, it was determined that the facility failed to meet the minimum nurse aide (NA) to resident ratios for 2 of 21 days reviewed.

The facility failed to meet the minimum NA to resident ratio of one NA per 10 residents on day (07:00 a.m to 3:00 p.m) shift on July 25, 2024 and July 29, 2024.

On August 1, 2024 at approximately 9:43 a.m. the Human Resource and Scheduler, Employee E10 confirmed the facility did not meet the minimum NA to resident ratios for 2 of 21 days reviewed.

§ 211.12(f.1)(4) LICENSURE Nursing services. :

(4) Effective July 1, 2023, a minimum of 1 LPN per 25 residents during the day, 1 LPN per 30 residents during the evening, and 1 LPN per 40 residents overnight.

Observations:

Based on a review of nursing time schedules, it was determined that the facility failed to meet the minimum licensed practical nurse (LPN) to resident ratios for 20 of 21 days reviewed.

Findings include:

Review of nursing schedules for 21 days from February 18, 2024 through February 24, 2024, May 22, 2024 through May 28, 2024, July 24, 2024 through July 30, 2024, revealed the following:

The facility failed to meet the minimum LPN to resident ratio of one LPN per 25 residents on day (07:00 a.m to 3:00 p.m) shift on February 18, 2024 through February 24, 2024, May 25, 2024 through May 26, 2024, July 27, 2024 through July 29, 2024.

The facility failed to meet the minimum LPN to resident ratio of one LPN per 30 residents on evening (3:00 p.m to 11:00 p.m) shift on February 24, 2024 and July 27, 2024.

The facility failed to meet the minimum LPN to resident ratio of one LPN per 40 residents on night (11:00 p.m to 07:00 a.m) shift on February 18, 2024 through February 24, 2024, May 22, 2024 through May 27, 2024, July 24, 2024 through July 30, 2024.

On August 1, 2024 at approximately 9:43 a.m. the Human Resource and Scheduler, Employee E10 confirmed the facility did not meet the minimum LPN to resident ratios for 20 of 21 days reviewed.

Plan of Correction - To be completed: 09/20/2024

Nursing schedules were reviewed to ensure the proper LPN ratios on the day and evening shifts.

NHA/designee will reeducate the scheduler Director of Nursing on the correct LPN ratio.

NHA/designee will audit the nursing schedules in advance daily x4 weeks to ensure LPNs are being staffed at the proper ratio. Results will be shared at QA for 3 months.

§ 211.12(f.1)(5) LICENSURE Nursing services. :

(5) Effective July 1, 2023, a minimum of 1 RN per 250 residents during all shifts.

Observations:

Based on a review of nursing time schedules, it was determined that the facility failed to meet the minimum licensed registered nurse (RN) to resident ratios for 1 of 21 days reviewed.

Findings include:

Review of nursing schedules for 21 days from June 27, 2024, to July 17, 2024, revealed the following:

The facility failed to meet the minimum RN to resident ratio of one RN to 250 residents on night (11:00 p.m. to 7:00 a.m.) shift on February 19, 2024.

On August 1, 2024 at approximately 9:43 a.m. the Human Resource and Scheduler, Employee E10 confirmed that there was no verification to verify that Director of Nursing, Employee E2 covered the night shift as an RN.

Plan of Correction - To be completed: 09/20/2024

1.Nursing schedules were reviewed to ensure the minimum licensed registered nurse (RN) to resident ratios meets the requirement.

2.NHA/designee will reeducate the scheduler and the Director of Nursing on the minimum licensed registered nurse (RN) to resident ratios.

3.NHA/designee will audit the nursing schedules in advance daily x4 weeks to ensure minimum licensed registered nurse (RN) to resident ratios are met. Results will be shared at QA for 3 months.

§ 211.12(i)(1) LICENSURE Nursing services.:

(1) Effective July 1, 2023, the total number of hours of general nursing care provided in each 24-hour period shall, when totaled for the entire facility, be a minimum of 2.87 hours of direct resident care for each resident.

Observations:

Based on a review of nursing time schedules, it was determined that the facility failed to provide a minimum of 2.87 hours of direct care for each resident for 8 of 21 days reviewed.

Findings include:

Review of nursing schedules for 21 days from February 18 through 22, 2024, revealed the following total nursing care hours below minimum requirements:

February 18, 2024: 2.68 care hours per resident.
February 19, 2024: 2.87 care hours per resident.
February 22, 2024: 2.82 care hours per resident.

On August 1, 2024, at approximately 9:43 a.m. the Human Resource and Scheduler, Employee E10 confirmed that facility did not meet the required minimum of 2.87 hours of direct care for each resident.

Plan of Correction - To be completed: 09/20/2024

Nursing schedules were reviewed to ensure the total hours of general nursing care for each 24-hour period meets the requirement.

NHA/designee will reeducate the scheduler and the Director of Nursing on the total hours of general nursing care for each 24-hour period.

NHA/designee will audit the nursing schedules in advance daily x4 weeks to ensure total hours of general nursing care for each 24-hour period are met. Results will be shared at QA for 3 months.

§ 211.12(i)(2) LICENSURE Nursing services.:

(2) Effective July 1, 2024, the total number of hours of general nursing care provided in each 24-hour period shall, when totaled for the entire facility, be a minimum of 3.2 hours of direct resident care for each resident.

Observations:

Based on a review of nursing time schedules, it was determined that the facility failed to provide a minimum of 3.2 hours of direct care for each resident for 8 of 21 days reviewed.

Findings include:

Review of nursing schedules for 21 days from February 18 through 22, 2024, revealed the following total nursing care hours below minimum requirements:

July 24, 2024: 3.16 care hours per resident.
July 25, 2024: 2.98 care hours per resident
July 27, 2024: 2.85 care hours per resident
July 28, 2024: 3.06 care hours per resident
July 29, 2024: 2.97 care hours per resident

On August 1, 2024, at approximately 9:43 a.m. the Human Resource and Scheduler, Employee E10 confirmed that facility did not meet the required minimum of 3.2 hours of direct care for each resident.

Plan of Correction - To be completed: 09/20/2024

1. Nursing schedules were reviewed to ensure the total hours of general nursing care for each 24-hour period meets the requirement.

2. NHA/designee will reeducate the scheduler and the Director of Nursing on the total hours of general nursing care for each 24-hour period.

3. NHA/designee will audit the nursing schedules in advance daily x4 weeks to ensure total hours of general nursing care for each 24-hour period are met. Results will be shared at QA for 3 months.

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