Pennsylvania Department of Health
QUALITY LIFE SERVICES - SUGAR CREEK
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

QUALITY LIFE SERVICES - SUGAR CREEK
Inspection Results For:

There are 127 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.


QUALITY LIFE SERVICES - SUGAR CREEK - 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, and an Abbreviated survey in response to a complaint completed on June 14, 2024, it was determined that Quality Life Services- Sugar Creek was not in compliance with the following requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care and the 28 Pa. Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations

Plan of Correction:

483.60(a)(1)(2) REQUIREMENT Qualified Dietary Staff:

This is a less serious (but not lowest level) deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.

§483.60(a) Staffing
The facility must employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, taking into consideration resident assessments, individual plans of care and the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment required at §483.70(e)

This includes:
§483.60(a)(1) A qualified dietitian or other clinically qualified nutrition professional either full-time, part-time, or on a consultant basis. A qualified dietitian or other clinically qualified nutrition professional is one who-
(i) Holds a bachelor's or higher degree granted by a regionally accredited college or university in the United States (or an equivalent foreign degree) with completion of the academic requirements of a program in nutrition or dietetics accredited by an appropriate national accreditation organization recognized for this purpose.
(ii) Has completed at least 900 hours of supervised dietetics practice under the supervision of a registered dietitian or nutrition professional.
(iii) Is licensed or certified as a dietitian or nutrition professional by the State in which the services are performed. In a State that does not provide for licensure or certification, the individual will be deemed to have met this requirement if he or she is recognized as a "registered dietitian" by the Commission on Dietetic Registration or its successor organization, or meets the requirements of paragraphs (a)(1)(i) and (ii) of this section.
(iv) For dietitians hired or contracted with prior to November 28, 2016, meets these requirements no later than 5 years after November 28, 2016 or as required by state law.

§483.60(a)(2) If a qualified dietitian or other clinically qualified nutrition professional is not employed full-time, the facility must designate a person to serve as the director of food and nutrition services.
(i) The director of food and nutrition services must at a minimum meet one of the following qualifications-
(A) A certified dietary manager; or
(B) A certified food service manager; or
(C) Has similar national certification for food service management and safety from a national certifying body; or
D) Has an associate's or higher degree in food service management or in hospitality, if the course study includes food service or restaurant management, from an accredited institution of higher learning; or
(E) Has 2 or more years of experience in the position of director of food and nutrition services in a nursing facility setting and has completed a course of study in food safety and management, by no later than October 1, 2023, that includes topics integral to managing dietary operations including, but not limited to, foodborne illness, sanitation procedures, and food purchasing/receiving; and
(ii) In States that have established standards for food service managers or dietary managers, meets State requirements for food service managers or dietary managers, and
(iii) Receives frequently scheduled consultations from a qualified dietitian or other clinically qualified nutrition professional.

Observations:

Based on staff interviews, and employee file review, it was determined that the facility failed to employ a full-time qualified Food Service Director for ten of ten months (August 2023 through December 2023, and January 2024 through June 2024).

Finding include:

During an interview conducted at initial tour on 6/10/24, at 10:29 a.m. Food Service Director (FSD) Employee E3, stated that he was not a Certified Dietary Manager (CDM) and did not have any formal education or certificates in food service management. FSD Employee E3 stated that the facility employs a Registered Dietitian, but that he comes in building only two days per week.

During an interview on 6/10/24, at 2:29 p.m. Nursing Home Administrator (NHA) confirmed that FSD Employee E3 did not possess the appropriate qualifications as required.

Review of FSD Employee E2's employee file, revealed that he did not possess qualifications for Food Service Director, and had been employed at the facility since 8/9/23.

During an interview on 6/11/24, at 11:05 a.m. Registered Dietitian (RD) Employee E4 stated that he works in the facility two days per week and that he is only responsible for clinical duties. RD Employee E4 confirmed that the facility failed to employ a qualified FSD for ten of ten months

28 Pa. Code: 211.6(c)(d) Dietary services.

Plan of Correction - To be completed: 07/12/2024

Education will be provided to Human Resources on Training/Certification requirements for Dietary Management by Corporate CDM or designee.

Corporate CDM will provide part-time coverage to oversee the food service operations while Food service supervisor completes CDM requirement, Clinical RD will continue part-time coverage to complete resident assessments, individual plans of care and the number, acuity and diagnoses of the facility's resident population, facility assessment updated to reflect these changes

NHA or designee will monitor Food Service Supervisors progress with CDM course weekly until completion of program.

Audit will be completed by Corporate CDM for oversight of kitchen and RD's continued compliance with clinical assessments under completion of CDM certification of Food service supervisor.

483.15(c)(1)(i)(ii)(2)(i)-(iii) REQUIREMENT Transfer and Discharge Requirements:

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.

§483.15(c) Transfer and discharge-
§483.15(c)(1) Facility requirements-
(i) The facility must permit each resident to remain in the facility, and not transfer or discharge the resident from the facility unless-
(A) The transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in the facility;
(B) The transfer or discharge is appropriate because the resident's health has improved sufficiently so the resident no longer needs the services provided by the facility;
(C) The safety of individuals in the facility is endangered due to the clinical or behavioral status of the resident;
(D) The health of individuals in the facility would otherwise be endangered;
(E) The resident has failed, after reasonable and appropriate notice, to pay for (or to have paid under Medicare or Medicaid) a stay at the facility. Nonpayment applies if the resident does not submit the necessary paperwork for third party payment or after the third party, including Medicare or Medicaid, denies the claim and the resident refuses to pay for his or her stay. For a resident who becomes eligible for Medicaid after admission to a facility, the facility may charge a resident only allowable charges under Medicaid; or
(F) The facility ceases to operate.
(ii) The facility may not transfer or discharge the resident while the appeal is pending, pursuant to § 431.230 of this chapter, when a resident exercises his or her right to appeal a transfer or discharge notice from the facility pursuant to § 431.220(a)(3) of this chapter, unless the failure to discharge or transfer would endanger the health or safety of the resident or other individuals in the facility. The facility must document the danger that failure to transfer or discharge would pose.

§483.15(c)(2) Documentation.
When the facility transfers or discharges a resident under any of the circumstances specified in paragraphs (c)(1)(i)(A) through (F) of this section, the facility must ensure that the transfer or discharge is documented in the resident's medical record and appropriate information is communicated to the receiving health care institution or provider.
(i) Documentation in the resident's medical record must include:
(A) The basis for the transfer per paragraph (c)(1)(i) of this section.
(B) In the case of paragraph (c)(1)(i)(A) of this section, the specific resident need(s) that cannot be met, facility attempts to meet the resident needs, and the service available at the receiving facility to meet the need(s).
(ii) The documentation required by paragraph (c)(2)(i) of this section must be made by-
(A) The resident's physician when transfer or discharge is necessary under paragraph (c) (1) (A) or (B) of this section; and
(B) A physician when transfer or discharge is necessary under paragraph (c)(1)(i)(C) or (D) of this section.
(iii) Information provided to the receiving provider must include a minimum of the following:
(A) Contact information of the practitioner responsible for the care of the resident.
(B) Resident representative information including contact information
(C) Advance Directive information
(D) All special instructions or precautions for ongoing care, as appropriate.
(E) Comprehensive care plan goals;
(F) All other necessary information, including a copy of the resident's discharge summary, consistent with §483.21(c)(2) as applicable, and any other documentation, as applicable, to ensure a safe and effective transition of care.

Plan of Correction - To be completed: 07/12/2024

1) Facility transfer or discharge procedure updated to include residents care plan goals.
2) DON or designee will provide RN Staff education on the updated transfer or discharge procedure
3) DON or designee will monitor care plan goals sent with each Transfer or discharge daily x 5 days, weekly x 2 weeks.
4) Findings will be reviewed during QAPI Process for tracking and trending purposes
5) Date Certain July 12, 2024

483.25(f) REQUIREMENT Colostomy, Urostomy, or Ileostomy Care:

§483.25(f) Colostomy, urostomy,, or ileostomy care.
The facility must ensure that residents who require colostomy, urostomy, or ileostomy services, receive such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences.

Observations:

Based on facility policy review, clinical record review, resident, and staff interviews, it was determined that the facility failed to provide colostomy care and services consistent with professional standards of practice for two of two residents reviewed (Resident R58 and R262).

Findings include:

Review of facility policy "Ostomy Care" dated 4/8/24, indicated ostomy care will be provided for residents who have a urostomy, colostomy, or ileostomy. Ostomy appliances are changed and ostomy pouches are emptied as needed. The purpose of this policy is to maintain integrity of peristomal (around the stoma) skin, monitor condition of stoma (any opening in the body), manage odor, and promote resident's self-esteem.

Review of facility policy "Care Plan and Interdisciplinary Care Conferences- NU 6.1" dated 4/8/24, indicated an individualized care plan is initiated within 24 hours for each resident as part of the care delivery process. The care plan is a working tool that is reviewed and revised at specific intervals and as needed to reflect response to care and changing needs and goals.

Review of the clinical record indicated Resident R58 was admitted to the facility on 11/7/23.

Review of Resident R58's Minimum Data Set (MDS - a periodic assessment of care needs) dated 5/3/24, indicated diagnoses of diabetes (too much sugar in the blood), chronic pain, and ulcerative colitis (a chronic, inflammatory bowel disease that causes inflammation in the digestive tract). Section H indicated a colostomy (a surgical process that diverts bowel through an artificial opening in the abdominal wall) was present.

Observation of Resident R58 on 6/10/24, at 10:45 a.m. indicated she had a colostomy.

Review of physician order dated 11/7/23, indicated colostomy care every shift and as needed.

Review of Resident R58's care plan dated 11/12/23, failed to include the type of appliance, size of the appliance or wafer, and type of collection bag required for colostomy maintenance.

During an interview on 6/14/24, at 9:56 a.m. the Director of Nursing confirmed the facility failed to provide colostomy care and services consistent with professional standards of practice for Resident R58.

Review of the clinical record indicated Resident R262 was admitted to the facility on 6/3/24, and readmitted on 6/8/24, with diagnoses of diverticulitis of large intestine with perforation and abscess (inflammation of irregular bulging pouches in the wall of the large intestine), peritoneal abscess (a collection of pus or infected fluid that is surrounded by inflamed tissue inside the belly), and dementia (the loss of cognitive functioning - thinking, remembering, and reasoning - to such an extent that it interferes with a person's daily life and activities).

Review of Resident R262's "Clinician Admission H&P" assessment dated 6/5/24, indicated the resident was admitted from the hospital and had a new colostomy.

Review of Resident R262's care plan dated 6/5/24, failed to include care interventions related to resident R262's colostomy.

Review of Resident R262's clinical record from 6/5/24, through 6/12/24, failed to include an assessment of Resident R262's stoma to ensure adequate perfusion.

During an interview on 6/12/24, at 12:44 p.m. Licensed Nurse Assessment Coordinator (LNAC), Employee E9 confirmed the facility failed to implement a baseline care plan for Resident R262's colostomy.

During an interview on 6/12/24, at 1:06 p.m. the Nursing Home Administrator confirmed the facility failed to provide colostomy care and services consistent with professional standards of practice for Resident R262.

28 Pa. Code: 211.11 (a)(c)(d) Resident care plan
28 Pa. Code: 211.10(c) Resident care policies.
28 Pa. Code:211.12(d)(1) Nursing services.

Plan of Correction - To be completed: 07/12/2024

1) R58's and R262's care plan was updated to reflect her Ostomy care including type of appliance, size of the appliance or wafer, and type of collection bag required for colostomy maintenance on 6/12/24.
2) DON or designee Education will be completed with RNs, RNAC, and LPNAC for Ostomy care to be included on baseline care plans.
3) Audit will be completed for current Residents and new residents with Ostomies to verify Care plans, baseline care plans include Ostomy care, type of appliance, size of the appliance or wafer, and type of collection bag required for colostomy maintenance daily x 5 days, weekly x 2 weeks.
4) Findings will be reviewed during QAPI Process for tracking and trending purposes
5) Date Certain July 12, 2024

483.20(g) REQUIREMENT Accuracy of Assessments:

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

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

Observations:

Based on a review of Resident Assessment Instrument (RAI) User's Manual, clinical records, and staff interviews, it was determined that the facility failed to ensure that MDS assessments accurately reflected the resident's status for two of three residents (Resident R9 and Resident R58).

Findings include:

Review of facility policy "Resident Assessment: RAI/MDS/CAA Process" dated 4/8/24, indicated a minimum data set (MDS) will be completed for every resident within 14 days of admission and according to the Medicare and OBRA Guidelines. Refer to the MDS 3.0 manual for the requirements.

The Resident Assessment Instrument (RAI) User's Manual, which gives instructions for completing Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2023, indicated the following instructions:
-Section J - Health Conditions: Current Tobacco Use, Ask the resident if they used tobacco in any form during the 7-day look-back period. If the resident states that they used tobacco in some form during the 7-day look-back period, code 1, yes.

Review of the clinical record revealed that Resident R9 was admitted to the facility on 8/25/22.

Review of Resident R9's MDS (Minimum Data Set, periodic assessment of resident care needs) dated 5/17/24, indicated diagnoses of diabetes (too much sugar in the blood), high blood pressure, and abnormal posture.

Review of Resident R9's Admission MDS, Section J: Health Conditions, Question J1300 indicated that Resident R58 does not use tobacco.

Review of the facility list of residents that smoke, provided on 6/10/24, included Resident R9.

Review of smoking assessment completed on 5/15/24, confirmed that Resident R9 has chosen to smoke cigarettes,

Review of the clinical record indicated Resident R58 was admitted to the facility on 11/7/23.

Review of Resident R58's MDS dated 5/3/24, indicated diagnoses of diabetes, chronic pain, and ulcerative colitis (a chronic, inflammatory bowel disease that causes inflammation in the digestive tract).

Review of Resident R58's Admission MDS, Section J: Health Conditions, Question J1300 indicated that Resident R58 does not use tobacco.

Review of the facility list of residents that smoke, provided on 6/10/24, included Resident R58.

Review of smoking assessments completed on 11/7/23, 2/7/24, and 5/7/24, confirmed that Resident R58 has chosen to smoke cigarettes.

During an interview on 6/13/24, at 12:27 p.m. Registered Nurse Assessment Coordinator (RNAC) Employee E2 stated, "I'm pretty sure Resident R58 arrived to the facility smoking a cigarette."

During an interview on 6/13/24, at 12:27 p.m. RNAC Employee E2 confirmed that the facility failed to ensure that a MDS assessment accurately reflected Resident R58's tobacco use status.
During an interview on 6/14/24, at 10:57 a.m. the Director of Nursing confirmed that the facility failed to ensure that a MDS assessment accurately reflected Resident R9's tobacco use status.

28 Pa. Code: 211.12(d)(1)(2)(3)(5) Nursing Services.

Plan of Correction - To be completed: 07/12/2024

1) R9, R58 MDS were updated to reflect the use of Tobacco and modification were completed on 6/15/24 for R58 and 6/14/24 for R9 . Whole house audit will be completed to modify residents most recent annual or significant change MDS.
2) DON or designee will educate RN Assessment coordinator/LPN Assessment coordinator on including use of tobacco on assessments.
3) DON or Designee will monitor MDS assessments daily x 5 days, weekly x 2 weeks for compliance for accuracy with identifying Residents that use tobacco.
4) Findings will be reviewed during QAPI Process for tracking and trending purposes
5) Date Certain July 12, 2024

483.25 REQUIREMENT Quality of Care:

§ 483.25 Quality of care
Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices.

Observations:

Based on review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to notify the physician of increased Capillary Blood Glucose (CBG) levels as ordered for one of three residents (Resident R82) and obtain physician orders for a resident's wound for one of three residents (Resident R260).

Findings include:

Review of facility policy "Physician Orders- NU 2.18" dated 4/8/24, indicated physician orders are followed in accordance with good nursing principles and practices and are transcribed and carried out by persons legally authorized to do so. It was indicated treatments may not be administered to the resident without the written approval from the attending physician.

Review of facility policy "Nursing Services - NU 2.15" dated 4/8/24, indicated nursing care includes the provision of all prescribed medications and treatments, and nursing care will be provided within the scope of practice and in accordance with nursing standards of care.

Review of facility policy "Physician Notification - NU 2.17" dated 4/8/24, indicated upon identification of a resident who has clinical changes, a change in condition, or abnormal lab values, a licensed nurse will perform appropriate clinical observations and data collection and report to the physician as indicated.

The Centers for Disease Control defines diabetes as: Diabetes Mellitus is a chronic (long-lasting) health condition that affects how your body turns food into energy. Most of the food you eat is broken down into sugar (also called glucose) and released into your bloodstream. When your blood sugar goes up, it signals your pancreas to release insulin. Insulin acts like a key to let the blood sugar into your body's cells for use as energy. If you have diabetes, your body either doesn't make enough insulin or can't use the insulin it makes as well as it should. When there isn't enough insulin or cells stop responding to insulin, too much blood sugar stays in your bloodstream. Over time, that can cause serious health problems, such as heart disease, vision loss, and kidney disease. People with Diabetes Mellitus may be prescribed injectable insulin to assist in maintaining acceptable levels of CBG's. Hyperglycemia, or high blood glucose, occurs when there is too much sugar in the blood. This happens when your body has too little insulin. Hyperglycemia is blood glucose greater than 125 mg/dL while fasting (not eating for at least eight hours, or a blood glucose greater than 180 mg/dL one to two hours after eating. If you have hyperglycemia and it's untreated for long periods of time, you can damage your nerves, blood vessels, tissues and organs. Damage to blood vessels can increase your risk of heart attack and stroke, and nerve damage may also lead to eye damage, kidney damage and non-healing wounds.

Review of the clinical record indicated Resident R82 was admitted to the facility on 7/7/23.

Review of Resident R82's Minimum Data Set (MDS - a periodic assessment of care needs) dated 3/13/24, indicated diagnoses of high blood pressure, diabetes mellitus, and overactive bladder.

Review a physician order dated 12/13/23, indicated to check Resident R82's CBG in the morning, call physician if result is less than 60 mg/dL or greater than 400 mg/dL.

Review of the clinical record revealed Resident R82's CBGs were as follows:

3/14/24: 415 mg/dL
3/18/24: 458 mg/dL

Review of Resident R82's progress notes from 3/14/24 through 3/18/24, failed to include documentation that a physician was notified for Resident R82's abnormal high blood glucose levels on 3/14/24, and 3/18/24, as ordered.

During an interview on 6/14/24, at 10:53 a.m. the Director of Nursing (DON) confirmed that the facility failed to notify the physician of Resident R82's abnormal high blood glucose levels on 3/14/24, and 3/18/24, as ordered.

Review of Resident R260's admission record indicated the resident was admitted to the facility on 6/5/24, with the diagnoses of dementia (a general term for loss of memory, language, problem solving and other thinking abilities that are severe enough to interfere with daily life), fracture of one rib on right side, and high blood pressure.

Review of Resident R260's progress note dated 6/5/24, indicated the resident was admitted from the hospital after a fall. It was documented that the resident had a "large abrasion, with dried blood and below right elbow."

Review of Resident R260's clinical record from 6/5/24, through 6/10/24, failed to include an order for Resident R260's wound.

During an observation and interview on 6/10/24, at 11:45 a.m. Resident R260 was observed with a undated bandage on his right elbow. Resident R260 stated he had a skin tear from falling down the stairs at home.

During and observation and interview on 6/12/24, at 10:43 a.m. the Director of Nursing confirmed Resident R260's wound dressing located on his right elbow was undated. The DON confirmed the facility failed to ensure the facility obtained physician orders for Resident R260's wound.

28 Pa. Code 201.18 (b)(1) Management
28 Pa. Code 201.29(d) Resident Rights
28 Pa. Code 211.10 (c)(d) Resident Care policies
28 Pa. Code 211.12 (d)(1)(2)(3)(5) Nursing services

Plan of Correction - To be completed: 07/12/2024

1) R82's MD was notified on 6/14/24 of elevated Blood Sugar readings on 3/14/24 and 3/18/24
DON Completed assessment of R260 right elbow and added orders from MD on 6/12/24 for wound care.
2) RN and LPN staff will be educated on following physician order and notification when residents Blood sugars are outside of the order perimeters and verifying orders for resident with dressings
3) Audit will be completed for residents with Blood Sugar checks for readings outside of their parameters and notification for the past 2 weeks, and daily x 5 days, and weekly x 2 weeks. Whole house skin sweep will be completed to verify dressing have a current order.
4) Findings will be reviewed during QAPI Process for tracking and trending purposes
5) Date Certain July 12, 2024

483.25(g)(1)-(3) REQUIREMENT Nutrition/Hydration Status Maintenance:

§483.25(g) Assisted nutrition and hydration.
(Includes naso-gastric and gastrostomy tubes, both percutaneous endoscopic gastrostomy and percutaneous endoscopic jejunostomy, and enteral fluids). Based on a resident's comprehensive assessment, the facility must ensure that a resident-

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

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

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

Observations:

Based on a review of clinical record, and staff interview, it was determined that the facility failed to ensure a resident was offered sufficient fluid intake to maintain proper hydration and health for one of two residents (Resident R54).

Findings include:

Review of the "Nutrition/Hydration Management- NU 9.9" policy last reviewed 4/8/24, stated residents will receive care and support to enhance potential for attaining the highest level of nutrition and hydration status and the pleasure of eating. It is the facility's policy to provide safe and effective care to manage residents' nutrition and hydration needs.

Review of the clinical record revealed that Resident R54 was admitted to the facility on 9/1/22.

Review of Resident 54's MDS (Minimum Data Set, periodic assessment of resident care needs) dated 5/2/24, indicated diagnoses of dementia (the loss of cognitive functioning - thinking, remembering, and reasoning - to such an extent that it interferes with a person's daily life and activities), anxiety, and muscle weakness.

During an observation on 6/10/24, at 11:29 a.m. Resident R54 indicated she asked for water an hour ago. No water was observed at the resident's bedside. The resident was observed with a dry mouth. Resident R54 stated staff do not leave water at her bedside, and she has to ask for it. Resident R54 stated "I am always thirsty."

During an interview on 6/10/24, at 11:35 a.m. Nurse Aide (NA), Employee E5 stated "we are supposed to pass water every shift and in between." NA, Employee E5 confirmed the facility failed to offer sufficient fluid intake to maintain proper hydration and health for Resident R54.

During an observation and interview on 6/13/24, at 10:24 a.m. Resident R54 stated she wanted some water. No water was observed at the resident's bedside.

During an interview on 6/13/24, at 10:31 a.m. Activity Aide, Employee E6 confirmed Resident R54 did not have any water at bedside.

During an interview on 6/13/24, at 10:36 the Director of Nursing and Nursing Home confirmed the facility failed to ensure a resident was offered sufficient fluid intake to maintain proper hydration and health for one of two residents (Resident R54).

28 Pa. Code: 201.18(b)(1)(e)(1) Management
28 Pa. Code: 201.12(d)(1)(3)(5) Nursing services

Plan of Correction - To be completed: 07/12/2024

1) Nursing staff will provide all residents with water or beverage of choice in accordance with the Nutrition and Hydration Management policy.
2) DON or Designee will provide Education to nursing staff on the residents Nutrition/Hydration Management-policy
3) Audit will be completed daily x 5 days, weekly x 2 weeks to ensure residents will have beverage of choice at beside available.
4) Findings will be reviewed during QAPI Process for tracking and trending purposes
5) Date Certain July 12, 2024

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.

Observations:

Based on observations, interviews, and clinical record review, it was determined that the facility failed to provide appropriate respiratory care for one of three residents (Residents R75).

Findings include:

Review of the clinical record indicated that Resident R75 was admitted to the facility on 7/16/21, and readmitted on 4/29/24, with diagnosis of obstructive sleep apnea, (occurs when your breathing is interrupted during sleep, for longer than 10 seconds at least 5 times per hour (on average) throughout your sleep period), high blood pressure, and heart failure (a progressive heart disease that affects pumping action of the heart muscles. This causes fatigue, shortness of breath.)

Review of Resident R75's care plan dated 5/4/22, indicated the resident receives oxygen therapy for ineffective gas exchange.

Review of Resident 75's MDS (Minimum Data Set, periodic assessment of resident care needs) dated 5/8/24, indicated the resident receives oxygen therapy while a resident.

Review of Resident R75's physician's order dated 4/29/24, indicated to change and date oxygen tubing weekly for prevention.

Review of Resident R75's physician's order dated 4/29/24, indicated to change oxygen tubing for CPAP (Continuous Positive Airway Pressure machine that delivers pressurized air to your nose and mouth to treat sleep apnea) weekly for prevention.

During an observation on 6/10/24, at 11:14 a.m. Resident R75 CPAP oxygen tubing was observed not in use and on the ground.

During an observation on 6/12/24, at 9:07 a.m. Resident R75 nasal cannula oxygen tubing was observed not in use and on the ground.

During an interview on 6/12/24, at 9:10 a.m. Registered Nurse Employee E7 confirmed Resident R75's oxygen tubing was not stored properly when not in use and was on the ground. The facility failed to provide appropriate respiratory care for one of three residents (Residents R75).

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

28 Pa. Code 211.12(d)(1)(2)(3)(5) Nursing services.

Plan of Correction - To be completed: 07/12/2024

1) R75 O2 tubing was changed upon notification from site surveyor. Audit will be completed on residents with O2 and CPAP orders to ensure excess tubing was not on the floor and proper storage of tubing when not in use.
2) DON or designee will provide Education to nursing staff to ensure O2 and CPAP tubing in proper storage when not in use.
3) Audit will be completed by DON or designee to ensure O2 and CPAP tubing in proper storage when not in use daily x 5 days, weekly x 2 weeks.
4) Findings will be reviewed during QAPI Process for tracking and trending purposes
5) Date Certain July 12, 2024

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

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

§483.45(h) Storage of Drugs and Biologicals

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

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

Observations:

Based on review of facility policy, observation, and staff interviews, it was determined that the facility failed to date opened medications in one of three medication carts (Willow Medication Cart).

Findings include:

Review of facility policy "Storage of Medications" dated 4/8/24, indicated when the original seal of a manufacturer's container or vial is initially broken, the container or vial will be dated. Drugs dispensed in the manufacture's original container will carry the manufacturer's expiration date. Once opened, these will be good to use until the manufacturer's expiration date is reached unless the medication is in a multi-dose injectable vial, an ophthalmic medication, or an item for which the manufacturer has specified a usual life after opening.

During an observation on 6/12/24, at 8:42 a.m. of the Willow Medication Cart indicated the following medications not dated upon opening:
- Resident R41's TobraDex eye drops, no date opened.
- Resident R41's Muro 128 eye drops, no date opened.
- Resident R58's Lantus (prefilled pen to inject long acting insulin under the skin) pen, no date opened.
- Resident R58's Dorzolamide HCl-Timolol Maleate eye drops, no date opened.

During an interview on 6/12/24, at 8:48 a.m. Licensed Practical Nurse Employee E1 confirmed the above findings.

During an interview on 6/12/24, at 12:34 p.m. the Nursing Home Administrator confirmed that the facility failed to date opened medications in one of three medication carts (Willow Medication Cart).

28 Pa. Code: 201.14 (a) Responsibility of licensee.
28 Pa. Code: 201.18 (b)(1)(e)(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: 07/12/2024

1) R41 and R58's medications were discarded and replaced with new on 6/12/24 including date opened, Audit will be completed on Medication Carts to ensure no other medications are present without dates open.
2) DON or designee will provide Education to LPN, and RN's to ensure insulin pens are placed in plastic bag labeled with date opened and for residents ordered eye drop medication to ensure labeled with open date.
3) Audit will be completed daily x 5 days, 3 x a week x 4 weeks to ensure insulin pens and eye drop medications are labeled with open dates.
4) Findings will be reviewed during QAPI Process for tracking and trending purposes
5) Date Certain July 12, 2024

483.60(i)(4) REQUIREMENT Dispose Garbage and Refuse Properly:

§483.60(i)(4)- Dispose of garbage and refuse properly.

Observations:

Based on facility policy, observation, and staff interview it was determined that the facility failed to properly contain and dispose of garbage in one of one outside dumpsters to prevent the potential for rodent and insect infestation.

Findings include:

Review of facility policy "Waste Disposal", dated 4/8/24, indicated that trash will be deposited into a sealed container outside the premises.

During an observation of the facility's outdoor trash receptacle on 6/10/24, at 11:00 a.m. revealed approximately five empty boxes piled up outside of the dumpster.

During an interview on 6/10/24, at 11:00 a.m. Food Service Director Employee E93 confirmed that the facility failed to properly contain and dispose of garbage in the outside trash receptacles to prevent the potential for rodent and insect infestation.

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

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

Plan of Correction - To be completed: 07/12/2024

1) Upon notification from site surveyor, NHA and DON placed the cardboard boxes inside the garbage receptacle.
2) CDM or designee will complete Education with staff on the Waste Disposal policy
3) Dietary Supervisor or designee will monitor waste disposal area twice daily x 1 week , 3x week x 4 weeks.
4) Findings will be reviewed during QAPI Process for tracking and trending purposes
5) Date Certain July 12, 2024

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

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

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

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

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

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

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

Observations:

Based on clinical record review and staff interview, it was determined that the facility failed to ensure that clinical records were complete and accurate for one of six residents reviewed (Resident R260).

Findings include:

Review of the facility policy "Medical Records-The Medical Record" date 12/12/23, indicated that the medical record will contain complete and accurate documentation, which clearly identifies the resident, justifies the diagnoses, condition, treatment, care approaches, and responses to the care provided.

Review of Resident R260's admission record indicated the resident was admitted to the facility on 6/5/24, with the diagnoses of dementia (a general term for loss of memory, language, problem solving and other thinking abilities that are severe enough to interfere with daily life), fracture of one rib on right side, and high blood pressure.

Review of Resident R260's progress note dated 6/5/24, indicated the resident was admitted from the hospital after a fall. It was documented that the resident had a "large abrasion, with dried blood and below right elbow."

Review of Resident R260's "Non-Pressure Wound Tool: B-Shoulder/Arm V 5" report dated 6/5/24, indicated the resident's affected area was the left elbow. A description of the location of the wound stated "skin tear to left elbow with wide steri strips on, unable to measure skin tear." The facility failed to accurately document the anatomical location of Resident R260's skin tear.

During an observation and interview on 6/10/24, at 11:45 a.m. Resident R260 was observed with a bandage on his right elbow. Resident R260 stated he had a skin tear from falling down the stairs at home.

During and observation and interview on 6/12/24, at 10:43 a.m. the Director of Nursing confirmed Resident R260's wound was located on his right elbow confirmed the facility failed to ensure that clinical records were complete and accurate for one of six residents reviewed (Resident R260).

28 Pa. Code 211.5(f) Clinical Records
28 Pa. Code 211.12(d)(1)(5) Nursing services.

Plan of Correction - To be completed: 07/12/2024

1) R260's Admission assessment was struck out as incorrect documentations, and a new assessment completed with correct body location on 6/12/24. Will audit pressure wound Assessments in the past 7 days for accuracy and corrections will be made if needed.
2) DON or designee will provide education to nurses on how to identify correct body location for documentation.
3) Audit of Pressure wound assessments, documentation on location correctly identified will be completed daily x 5 days, and weekly x 2 weeks.
4) Findings will be reviewed during QAPI Process for tracking and trending purposes
5) Date Certain July 12, 2024

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 observation, staff interviews, resident interviews, it was determined the facility failed to maintain patient care equipment in a safe operating condition for one of three residents (Resident R11).

Findings include:

Review of the clinical record revealed that Resident R11 was admitted to the facility on 7/12/21.

Review of Resident 11's MDS (Minimum Data Set, periodic assessment of resident care needs) dated 5/10/24, indicated diagnoses of dementia (the loss of cognitive functioning - thinking, remembering, and reasoning - to such an extent that it interferes with a person's daily life and activities), morbid obesity, hemiplegia following cerebral infarction affecting left nondominant side (paralysis of left side of body following a stroke), and muscle weakness.

Review of facility provided documentation, it was indicated the facility initially reached out to the resident's wheelchair manufacturer to repair Resident R11's wheelchair on 3/14/24. Resident R11's order for her wheelchair part was not confirmed until 6/6/24, 84 days since the facility was aware Resident R11's wheelchair needed repaired.

During an interview on 6/11/24, at 11:59 a.m. Resident R11 indicated the right arm on her wheelchair has been broken for six weeks. Resident R11's right arm wheel chair was observed broken and easily disconnected if pulled.

During an interview on 6/12/24, at 11:19 a.m. and 12:21 p.m. the Nursing Home Administrator confirmed she was aware Resident R11's wheelchair needed repaired and failed to maintain patient care equipment in a safe operating condition..

28 Pa. code 207.2(a) Administrator's responsibility.

28 Pa. Code 207.4 Ice containers and storage.

Plan of Correction - To be completed: 07/12/2024

1) R11 wheel chair part was received and wheel chair was repaired on 6/19/24. Will completed audit on wheel chairs in use for proper working condition.
2) NHA or designee will provide Education to Environmental Service Director and Maintenance Staff on timely notification to suppliers for wheel chair parts.
3) Environmental Director or Designee will audit service requests for equipment repairs and receipt of parts in a timely manner weekly x 2 weeks
4) Findings will be reviewed during QAPI Process for tracking and trending purposes
4) Date Certain July 12, 2024

§ 205.6(a) LICENSURE Function of building.:

(a) No part of a building may be used for a purpose which interferes with or jeopardizes the health and safety of residents. Special authorization shall be given by the Department ' s Division of Nursing Care Facilities if a part of the building is to be used for a purpose other than health care.

Observations:

Based on observation and staff interview, it was determined that the facility failed to maintain kitchen area services designated for facility residents in four out of four nursing units (Maple, Hemlock, Willow, and Hickory).

Findings Include:

During an observation on 6/12/24, at 2:30 p.m. a Personal Care Home (PCH) was noted to be located at the far end of the facility's property.

During an interview on 6/13/24, at 11:22 a.m. Food Service Director Employee E3 stated that the kitchen staff cooks meals for the PCH and transports the meals to the PCH in their personal vehicles.

During an interview on 6/13/24, at 2:05 p.m. the Nursing Home Administrator confirmed that the facility failed to maintain kitchen area services designated for facility residents in four out of four nursing units as required.

Plan of Correction - To be completed: 07/12/2024

1) Personal Care Home meals will be prepared in the kitchen at Personal Care Home.
2) Education will be provided to dining staff for separation of food service operations between PCH and nursing facility
3) Audit will be conducted to ensure PCH meals are prepared at PCH location daily x 5 days, weekly x 2 weeks.
4) Findings will be reviewed during QAPI Process for tracking and trending purposes
5) Date Certain July 12, 2024

§ 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 review of nursing time schedules and staff interviews it was determined that the facility administrative staff failed to provide a minimum of one nurse aide per 12 residents during the day and evening shift for two of 21 days during the day shift (5/26/24, and 5/27/24), and five of 21 evening shifts (5/19/24, 5/20/24, 5/21/24, 5/24/24, and 5/26/24) and one nurse aide per 20 residents during the night shift on one of 21 days (5/24/24).

Findings include:

Review of facility census data, nursing time schedules from 5/19/24 through 6/1/24, and 6/7/24 through 6/13/24, revealed the following nurse aide staffing shortages.

Day shift:
Date Census Full time equivalents (FTE) present FTE required
5/26/24 106 8.0 8.83
5/27/24 106 8.5 8.83

Evening shift:
Date Census FTE present FTE required
5/19/24 105 8.5 8.75
5/20/24 106 8.75 8.83
5/21/24 106 8.5 8.83
5/24/24 105 8.5 8.75
5/26/24 106 8.5 8.83

Night shift:
Date Census FTE present FTE required
5/24/24 105 5.0 5.25

During an interview on 6/14/24, at 9:40 a.m. the Nursing Home Administrator confirmed the facility failed to provide a minimum of one nurse aide per 12 residents during the day and the evening, and one nurse aide per 20 residents during the night shift, with no additional excess higher-level staff to compensate this deficiency.

Plan of Correction - To be completed: 07/12/2024

1) DON or designee will review upcoming nursing schedules x 30 day to ensure staffing ratios are in compliance.
2) DON or designee will educate RN, and Labor manager on current staffing ratios/PPD requirements
3) DON, Labor Manager, and designee will participate in staff meetings to verify staffing ratios daily x 5 days, weekly x 2 weeks.

4) Findings will be reviewed during QAPI Process for tracking and trending purposes
5) Date Certain July 12, 2024

§ 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 review of nursing time schedules and staff interview it was determined that the facility administrative staff failed to provide a minimum of one licensed practical nurse (LPN) per 25 residents during the day shift on one of 21 days (5/25/24).

Findings include:

Review of facility census data, nursing time schedules from 5/19/24 through 6/1/24, and 6/7/24 through 6/13/24, revealed the following nurse aide staffing shortages.

Day shift:
Date Census Full time equivalents (FTE) present FTE required

5/25/24 105 5.0 5.25

During an interview on 6/14/24, at 9:40 a.m.. the Nursing Home Administrator confirmed the staffing shortages and that the facility failed to provide one LPN per 25 residents during the day shift as required with no additional excess higher-level staff to compensate this deficiency.

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