Pennsylvania Department of Health
 OAK RIDGE REHABILITATION & HEALTHCARE CENTER
Patient Care Inspection Results

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OAK RIDGE REHABILITATION & HEALTHCARE CENTER
Inspection Results For:

There are  183 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.
OAK RIDGE REHABILITATION & HEALTHCARE CENTER - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on a Medicare/Medicaid Recertification, State Licensure, Abbreviated Complaint, and Civil Rights Compliance Survey completed on May 10, 2024, it was determined that Oak Ridge Rehabilitation & Healthcare Center was not in compliance with the following requirements of 42 CFR Part 483 Subpart B Requirements for Long Term Care Facilities and the 28 PA Code Commonwealth of Pennsylvania Long Term Care Licensure Regulations.




 Plan of Correction:


483.60(i)(1)(2) REQUIREMENT Food Procurement,Store/Prepare/Serve-Sanitary: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(i) Food safety requirements.
The facility must -

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

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

Based on a review of select facility policy, observation, and staff interview, it was determined that the facility failed to maintain acceptable practices for the storage and service of food to prevent the potential for contamination and microbial growth in food, which increased the risk of food-borne illness, in the dietary department and the second floor and Memory Care Unit resident food storage areas.

Findings include:

Food safety and inspection standards for safe food handling indicate that everything that comes in contact with food must be kept clean and food that is mishandled can lead to foodborne illness. Safe steps in food handling, cooking, and storage are essential in preventing foodborne illness. You cannot always see, smell, or taste harmful bacteria that may cause illness according to the USDA (The United States Department of Agriculture, also known as the Agriculture Department, is the U.S. federal executive department responsible for developing and executing federal laws related to food).

A review of a facility policy entitled "Food Storage" and was last reviewed by the facility on November 27, 2023, indicated that items shall be stored by using appropriate methods to ensure the highest level of food safety.
Pantry or kitchenette areas will be cleaned and sanitized daily by dining service staff. Dining services staff will discard outdated items.

The initial tour of the dietary department was conducted with the facility's food services manager on May 7, 2024, at 9:40 a.m., revealed the following unsanitary practices with the potential to introduce contaminants into food and increase the potential for food-borne illness, were identified:

An observation of the dietary department's beverage station revealed that the juice and thickened juice dispensing guns were dangling by their hoses and in contact with bulk juice boxes that were on metal wire shelves. Additionally, the juice dispensing guns had a buildup of a red, gel like substance inside of the nozzle.

Observations of the dry storage room revealed that there was clean resident dishware, plastic bins, and beverage pitchers that were not covered.

Observations of dietary staff performing dish room duties revealed that there were several racks of thermal bowls and cups, identified as cleaned by the CDM, that were placed directly next to carts of dirty dishes and pans.

Observations inside of the dish room revealed that there was a large metal wire storage rack with cleaned cooking equipment and supplies placed directly next to dirty carts and dirty items.

Several small black flies (three or more) were observed flying around the dish room and the CDM confirmed that "drain flies" were commonly observed in the area due to damp and wet conditions.

Observations of the 2nd floor dining area on May 9, 2024, at 9:57 a.m., revealed food particles and debris on the floor underneath the dining tables. A accumulation of dirt was observed on the floor around perimeter of the room and in the corners and an accumulation of dust and debris on the windowsills. On entry to the dining room, on the right side there was a brown substance spilled down the wall and a dead large-winged bug on the floor under a wheelchair. Inside of the meal service area dried food was observed stuck to the side of the plate warmers and dirt and debris on the floor collected behind the equipment.

Further observations of the 2nd floor dining area and resident food storage room revealed that inside of the refrigerator there were nine 4-ounce chocolate shakes that were not dated. Once defrosted, shakes should be used within 14-days as per the manufacturers' instructions and thaw dates could not be determined. Small black dead bugs were observed inside of the ceiling light cover.

During observations of the Memory Care Unit's pantry/kitchenette area on May 9, 2024, at 10:50 a.m., a build-up of dirt and debris was observed on the floor under the cabinets and in the corners of the room. The outside of stainless-steel reach-in refrigeration door was splattered with food and felt sticky.

Observations of the Memory Care dining area revealed that there was a tray of cleaned thermal mugs placed on a tray that was stained and visibly dirty.

During an interview with the Nursing Home Administrator (NHA) on May 9, 2024, at 1:45 p.m., confirmed that the facility failed to ensure that the dietary department and resident pantry/kitchenette food storage were maintained in a sanitary manner and foods were to be labeled and dated to prevent the potential of food-borne illness.


28 Pa. Code 201.18 (e) (2.1) Management

28 Pa. Code 211.6 (f) Dietary Services





 Plan of Correction - To be completed: 06/25/2024

1) Cited areas were corrected.
2) NHA/Designee will audit the dietary department and resident pantry/kitchenette food storage were maintained in a sanitary manner and foods were to be labeled and dated to prevent the potential of food-borne illness.
3) NHA/Designee will provide education to dietary department on cleaning rotation of equipment/utensils, Food Storage policy, Labeling and Dating of Food, Food Availability, Pantry or Kitchenette, Meal Time Observation for Food Acceptance & Food Replacement.
4) NHA/Designee will complete random audits of dietary department and resident pantry kitchenette and food storage areas weekly x 4 weeks and monthly x 2 to ensure food storage areas are maintained in a sanitary manner and foods are labeled and dated to prevent the potential of food-borne illness and all areas are clean. Results of audits will be reported and reviewed by the Quality Assurance Performance Improvement Committee and changes will be made as needed.

483.90(i)(4) REQUIREMENT Maintains Effective Pest Control Program: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.
§483.90(i)(4) Maintain an effective pest control program so that the facility is free of pests and rodents.
Observations:

Based on observation, facility pest service records and resident and staff interview, it was determined that the facility failed to maintain an effective pest control program.

Findings include:

During the initial tour of the kitchen that was conducted on May 7, 2024, at 9:40 a.m., inside of the dish room several small black flies (three or more) were observed flying around a large metal wire storage rack of clean cooking equipment and supplies. The CDM confirmed the observations and stated that "drain flies" are frequently observed in the area due to the damp environment.

Observations of the 2nd floor dining area on May 9, 2024, at 9:57 a.m., revealed small dead black bugs on floor, on the windowsills, and the air-conditioning units. The windowsill was loose and gaps to the outside were present. A dead, large-winged insect was observed on the floor below an unoccupied wheelchair.

An interview with the facility's Director of Maintenance on May 9, 2024, at 10:40 a.m., revealed that pest treatments were performed to floor drains in the dietary department, but the employee was unable to provide documented evidence that regular treatments were performed to deter pest activity in the kitchen area.

During an interview Resident 90, a cognitively intact resident, on May 9, 2024, at approximately 1:15 p.m., revealed that there were small dark insects flying around the resident. Resident 90 stated that it was a normal occurrence to see insects flying around the facility and that it bothered them when eating meals.

A review of the facility's most recent monthly pest control report dated April 5, 2024, at 12:09 p.m., revealed that routine pest control was performed for rodent and insects. The pest control technician noted that door gap/damage to cafeteria double main doors leading out to courtyard need repair and that cracks or damage along the building's exterior allowed pest access and need to be secured, such as loose air conditioning covers.

Further interview with the maintenance director on May 9, 2024, confirmed that the facility was not able to provide evidence that the facility acted upon the issues identified by the facility's pest control company and that the facility performed routine and preventative measures to deter entrance and reduce and eliminate the presence of the pests in the facility




28 Pa. Code 201.18 (e)(2.1) Management








 Plan of Correction - To be completed: 06/25/2024

1) Facility areas identified by the pest control technician have been addressed.
2) Maintenance performed routine and preventative measures to deter entrance and reduce and eliminate the presence of the pests in the facility.
3) NHA/Designee will provide education to Maintenance on facility Pest Control Policy and monthly monitoring systems to deter pest entrance.
4) Random audit of Kitchen drains, dining rooms and resident rooms will be completed weekly for 12 weeks to ensure areas are free of insects. Results of audits will be reported and reviewed by the Quality Assurance Performance Improvement Committee and changes will be made as needed.

483.75(g)(1)(i)-(iii)(2)(i); 483.80(c) REQUIREMENT QAA Committee: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.
§483.75(g) Quality assessment and assurance.
§483.75(g) Quality assessment and assurance.
§483.75(g)(1) A facility must maintain a quality assessment and assurance committee consisting at a minimum of:
(i) The director of nursing services;
(ii) The Medical Director or his/her designee;
(iii) At least three other members of the facility's staff, at least one of who must be the administrator, owner, a board member or other individual in a leadership role; and
(iv) The infection preventionist.

§483.75(g)(2) The quality assessment and assurance committee reports to the facility's governing body, or designated person(s) functioning as a governing body regarding its activities, including implementation of the QAPI program required under paragraphs (a) through (e) of this section. The committee must:
(i) Meet at least quarterly and as needed to coordinate and evaluate activities under the QAPI program, such as identifying issues with respect to which quality assessment and assurance activities, including performance improvement projects required under the QAPI program, are necessary.

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



Based on review of facility documents and staff interviews, it was determined that the facility failed to ensure that the Medical Director or designee was in attendance at monthly Quality Assurance Process Improvement (QAPI) Committee meetings for four of four months (January 2024 through April 2024)

Findings include:

A review of QAPI Committee meeting sign-in sheets for the period of January 2024 through April 2024, revealed that the Medical Director or other physician was not in attendance, virtually or in-person, at the QA meetings held from January 2024 through April 2024, missing 4 monthly meetings (January 2024 through April 2024).

Interview with the administrator on May 9, 2024, at 12:00 PM confirmed that the a physician failed to attend the facility's QAPI meetings on a monthly/quarterly basis.



28 Pa. Code 211.2(d)(5)(6)(7)(8)(10) Medical director

28 Pa. Code 201.18 (e)(2)(3)(4) Management.


















 Plan of Correction - To be completed: 06/25/2024

1) Facility is unable to retroactively correct the alleged deficient practice.
2) QAPI meeting held on 5/15/24 with attendance of the IDT team and Medical Director.
3) NHA/Designee will provide education IDT and Medical Director on the facility QAPI policy which includes the need for proper attendance and sign in sheet including the Medical Director, at least quarterly.
4) NHA/Designee will audit the facility QAPI minutes and sign in sheets Monthly X 3 to ensure necessary team members are in attendance and policy is being followed. Results of audits will be reported and reviewed by the Quality Assurance Performance Improvement Committee and changes will be made as needed.

483.10(i)(1)-(7) REQUIREMENT Safe/Clean/Comfortable/Homelike Environment:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
§483.10(i) Safe Environment.
The resident has a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

The facility must provide-
§483.10(i)(1) A safe, clean, comfortable, and homelike environment, allowing the resident to use his or her personal belongings to the extent possible.
(i) This includes ensuring that the resident can receive care and services safely and that the physical layout of the facility maximizes resident independence and does not pose a safety risk.
(ii) The facility shall exercise reasonable care for the protection of the resident's property from loss or theft.

§483.10(i)(2) Housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior;

§483.10(i)(3) Clean bed and bath linens that are in good condition;

§483.10(i)(4) Private closet space in each resident room, as specified in §483.90 (e)(2)(iv);

§483.10(i)(5) Adequate and comfortable lighting levels in all areas;

§483.10(i)(6) Comfortable and safe temperature levels. Facilities initially certified after October 1, 1990 must maintain a temperature range of 71 to 81°F; and

§483.10(i)(7) For the maintenance of comfortable sound levels.
Observations:


Based on observation and staff interview, it was determined that the facility failed to provide housekeeping services to maintain a clean environment on one of three resident units (third floor dementia unit).

Findings include:

An observation May 8, 2024, at 10 AM in the large dining room floor on the third floor dementia unit revealed that the floor was sticky, dirty and soiled with dried liquid stains. Dirt, dried liquid stains and food crumbs were observed on the window sills in the dining room.

The floor in resident room 316 was dirty and sticky. A strong urine odor emanated from the resident's mattress.

In resident room 310 B, there was a broken floor tile under the resident's bed. On the wall next to the door was damaged with deep gouges in the surface and the wallpaper was heavily soiled.

The floor in resident room 320 was dirty and sticky.

The floor in resident room 324, was dirty, with dirt accumulated around the perimeter of the room.

During an interview May 9, 2024, the interim Nursing Home Administrator stated that resident rooms and dining/activity areas should be maintained in a clean and sanitary manner.


28 Pa. Code 201.18 (e)(2.1) Management







 Plan of Correction - To be completed: 06/25/2024

1) Identified areas have been cleaned and repaired as identified.
2) Audit of Area 3 to determine what resident rooms and dining/activity areas will be maintained in a clean and sanitary manner. Cleaning and preventative maintenance schedules will be maintained.
3) NHA/Designee will provide education to all facility staff on safe, clean, comfortable, and homelike environment.
4) NHA/ Designee will complete random audits of community room rounds 5 days a week x 4 weeks then weekly x 8 weeks to ensure a safe, clean, comfortable, and homelike environment is maintained. Results of audits will be reported and reviewed by the Quality Assurance Performance Improvement Committee and changes will be made as needed.

483.70(e)(1)-(3) REQUIREMENT Facility Assessment: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.
§483.70(e) Facility assessment.
The facility must conduct and document a facility-wide assessment to determine what resources are necessary to care for its residents competently during both day-to-day operations and emergencies. The facility must review and update that assessment, as necessary, and at least annually. The facility must also review and update this assessment whenever there is, or the facility plans for, any change that would require a substantial modification to any part of this assessment. The facility assessment must address or include:

§483.70(e)(1) The facility's resident population, including, but not limited to,
(i) Both the number of residents and the facility's resident capacity;
(ii) The care required by the resident population considering the types of diseases, conditions, physical and cognitive disabilities, overall acuity, and other pertinent facts that are present within that population;
(iii) The staff competencies that are necessary to provide the level and types of care needed for the resident population;
(iv) The physical environment, equipment, services, and other physical plant considerations that are necessary to care for this population; and
(v) Any ethnic, cultural, or religious factors that may potentially affect the care provided by the facility, including, but not limited to, activities and food and nutrition services.

§483.70(e)(2) The facility's resources, including but not limited to,
(i) All buildings and/or other physical structures and vehicles;
(ii) Equipment (medical and non- medical);
(iii) Services provided, such as physical therapy, pharmacy, and specific rehabilitation therapies;
(iv) All personnel, including managers, staff (both employees and those who provide services under contract), and volunteers, as well as their education and/or training and any competencies related to resident care;
(v) Contracts, memorandums of understanding, or other agreements with third parties to provide services or equipment to the facility during both normal operations and emergencies; and
(vi) Health information technology resources, such as systems for electronically managing patient records and electronically sharing information with other organizations.

§483.70(e)(3) A facility-based and community-based risk assessment, utilizing an all-hazards approach.
Observations:


Based on staff interviews and a review of documentation provided by the facility, it was determined that the facility failed to timely review and update its facility wide assessment in order to identify the specific personnel and resources presently available and/or required, which are necessary to care for its current resident population.

Findings include:

At the time of the survey ending May 10, 2024, the facility had reviewed its facility assessment on April 15, 2024, to determine the specific and unique needs of its resident population and the available and accessible resources to meet these needs on a daily basis and during emergent situations.

The facility provided a facility assessment tool to the survey team on May 7, 2024. There was no documentation on the form that identified and addressed the needs of the locked third floor unit, Dementia/Memory care unit. The form did not include any focus on the care and needs of the 61 residents with documented diagnosis of Dementia/Alzheimers disease and 43 residents residing on the locked dementia unit.

A review of the results of surveys completed by the state survey agency on January 25, 2024 and February 27, 2024, revealed deficient facility practice was identified related to the facility's failure to provide adequate dementia care and behavioral health care services for residents with dementia or behavioral symptoms to meet their psychosocial needs and maintain resident safety. Instances of resident to resident abuse were also cited during both surveys. During this current survey ending May 10, 2024, the facility was also cited for failing to provide behavioral health services to meet the mental health needs of a resident with a diagnosed mental disorder.

There was no evidence that the facility updated its facility-wide assessment in a timely manner to address available, and necessary, resources for making staffing and operating budget decisions while managing the resident census to ensure that the facility had the necessary staff resources, with the necessary skills and competencies, to care for its current resident population in a manner that met minimum licensure and certification standards.

The facility assessment presented to the survey team during the survey ending May 10, 2024, did not include updated comprehensive data with respect to its current resident population and updated resources necessary to competently and safely care for the residents in the facility with dementia, behaviors and mental health needs.

Refer F740

28 Pa. Code 201.14(a) Responsibility of licensee

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
















 Plan of Correction - To be completed: 06/25/2024

1) Facility is unable to retroactively correct alleged deficient practice.
2) NHA updated the facility assessment and reviewed with the IDT team.
3) NHA/Designee will provide education to IDT Team on PA Facility Assessment Policy to include the need for quarterly review and updates as needed.
4) NHA to review the Facility Assessment quarterly to ensure updated and accurate. Results of audits will be reported and reviewed by the Quality Assurance Performance Improvement Committee and changes will be made as needed.

483.60(f)(1)-(3) REQUIREMENT Frequency of Meals/Snacks at Bedtime: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.
§483.60(f) Frequency of Meals
§483.60(f)(1) Each resident must receive and the facility must provide at least three meals daily, at regular times comparable to normal mealtimes in the community or in accordance with resident needs, preferences, requests, and plan of care.

§483.60(f)(2)There must be no more than 14 hours between a substantial evening meal and breakfast the following day, except when a nourishing snack is served at bedtime, up to 16 hours may elapse between a substantial evening meal and breakfast the following day if a resident group agrees to this meal span.

§483.60(f)(3) Suitable, nourishing alternative meals and snacks must be provided to residents who want to eat at non-traditional times or outside of scheduled meal service times, consistent with the resident plan of care.
Observations:

Based on observation, review of facility scheduled meal times and select facility policy, and resident and staff interviews the facility failed to ensure the provision of a nourishing (satisfying to the resident) evening snack when greater than 14 hours elapsed from the supper meal to breakfast the next day for residents including four residents of 23 sampled (Residents 72, 5, 64, and 41).

Findings include:

Review of the facility's Snacks Policy last reviewed by the facility February 2024, indicated that it is the facility policy to provide the resident with adequate nutrition.

Review of the facility's scheduled (not exact times may fluctuate +/- 15 minutes) meal times revealed 15 hours between the evening meal and the next day's breakfast meal.

During a group interview with six alert and oriented residents on May 8, 2024, at 10:00 AM, all four residents (Residents 72, 5, 64, and 41) in attendance stated that snacks are not routinely offered to them in the evenings. The residents stated they would like to receive an evening/bedtime snack. Residents reported that when they have requested a snack, one is provided for them but if they do not ask, then none is offered or received.

Residents residing on the Dementia unit also have a 15 hour time gap between dinner and breakfast, but there was no evidence that these residents are offered a nourishing snack at bedtime.

During an interview on May 9, 2024, at approximately 11:00 AM the administrator failed to provide documented evidence that residents were routinely offered and provided with a bedtime/evening snack.


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






 Plan of Correction - To be completed: 06/25/2024

1) Facility unable to retroactively correct mealtimes being greater than 14 hours elapsed from supper meal to breakfast the next day.
2) Facility unable to retroactively correct alleged noncompliance. Facility mealtimes have been changed so there is less than 14 hours elapsed from dinner to breakfast.
3) NHA/Designee will educate all facility staff on the Frequency of Meals Policy. Education to include residents right to be provided and offered HS snacks nightly.
4) NHA/Designee will complete random audits weekly x 4 then monthly x 2 to ensure if the possibility of more than 14 hours may lapse between supper to breakfast the next day a nourishing snack is provided at hs. Results of audits will be reported and reviewed by the Quality Assurance Performance Improvement Committee and changes will be made as needed.

483.45(g)(h)(1)(2) REQUIREMENT Label/Store Drugs and Biologicals:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
§483.45(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 a review of select facility policy and manufacturer's directions for use, observations, and staff interview, it was determined that the facility failed to ensure adherence to pharmacy supplies expiration/use by dates on two of three resident units (First and Second Floor).

Findings include:

A review of facility policy entitled "Storage of Medications" with a review date of November 27, 2023, revealed that medications and biologicals are stored in the packaging and nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe and sanitary manner. If the facility has discontinued, outdated, or deteriorated medications or biologicals the dispensing pharmacy is contacted for instructions regarding returning or destroying these items. Medication refrigeration are stored in a refrigerator located in the medication room at the nurse's station or other secured location separately from food with temperature ranges 36 degrees Fahrenheit to 46 degrees Fahrenheit. Multi-dose vials that have been opened or accessed are dated and discarded within 28 days unless the manufacturer specifies a shorter or longer date for the open vial.

A review of facility policy entitled "Irrigation Solutions" with a review date of November 27, 2023, revealed irrigation solutions are labeled with a date and time immediately upon opening.

Observations on May 9, 2024, at 9:00 AM of the facility's second floor medication room revealed the following:

Snap secure Foley catheter securement device that expired on January 31, 2024.

There was no resident name or instructions on an opened tube of Santyl Collagenase 30 grams (gm) observed in the treatment cart.

A box of 27 povidone/iodine swab stick antiseptic expired on October 2023.

An opened 100 milliliter (ml) and 250 ml bottle of Normal Saline Irrigation Solution 0.9% (NSS) without a date when it was opened.

An opened 16 fluid ounce bottle of alcohol 70% without a date.

An opened 16 fluid ounce bottle of hydrogen peroxide 3% without a date.

Two 16 fluid ounce bottles of hydrogen peroxide 3% that expired July 2021.

There were 17 BD Eclipse Needle 25-gauge by one inch that expired on January 31, 2024.

There were 14 needleless sterile (germ free) connectors that expired on the following dates: March 2023, April 2023, June 2023, July 2023.

Two bottles of 100 count Assure Platinum Blood Glucose testing strips that expired on February 23, 2024.

There were five 24-gauge by 0.55-inch safety needle that expired on April 1, 2024.

One central line tray with chloro-prep that included two masks, gloves, towel, tape, antiseptic skin prep, film dressing, two gauze, measuring device, and forceps that expired on October 31, 2021.

Three Opti foam heel wound dressing that expired October 2023.

Ten urostomy pouches 2.5 inches expired January 2023.

An opened sterile foley catheter insertion tray.

Urine BD vacutainer culture and sensitivity transfer straw kit preservative 4.0 ml expired February 2024.

Sterile urine cups expired February 2023 and January 2024.

Comfort foam Ag wound dressing with soft silicone adhesive and silver four inches by five inches expired April 12, 2024.

20 Bisacodyl medicated laxative suppositories expired January 2023.

An opened multi-vial bottle of Apisol injection (intradermal solution used to diagnose tuberculosis) 5 units/0.1 ml without a date of when it was opened failing to follow facility policy for multidose medications.

The medication refrigerator was observed to have a thick layer of ice in the freezer area with scattered dark colored substances and a pile of frozen paper towels. This medication refrigerator held medications and vaccines. There was no evidence of documented temperatures monitoring as noted in facility policy.

Employee 1 Licensed Practical Nurse (LPN) confirmed the observed findings above.

During an interview with the Nursing Home Administrator (NHA) and Director of Nursing (DON) on May 10, 2024, at approximately 12:30 PM confirmed expired pharmacy products should have been removed from the storage room and discarded, the Apisol solution and Bisacodyl medication should have been sent back to the pharmacy and the medication refrigerator should have been defrosted and cleaned with temperatures being monitored and documented.



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

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








 Plan of Correction - To be completed: 06/25/2024

1) Expired supplies were immediately discarded.
2) Med/storage rooms will be audited monthly for expired supplies and discarded as indicated.
3) NHA/Designee will provide education to nursing staff and central supply regarding Medication Labeling and Storage policy.
4) NHA/Designee will complete random audits will be completed on med/storage areas weekly x 4 then monthly x 2 to ensure no expired meds or supplies are stored. Results of audits will be reported and reviewed by the Quality Assurance Performance Improvement Committee and changes will be made as needed.

483.45(c)(3)(e)(1)-(5) REQUIREMENT Free from Unnec Psychotropic Meds/PRN Use:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
§483.45(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 interviews, it was determined that the facility failed to attempt a gradual dose reduction of psychoactive medications for two residents out of 23 sampled (Resident 52 and 77).

Findings include:

A review of Resident 52's clinical record revealed the resident was admitted to the facility on April 24, 2018, with diagnoses to include dementia.

The resident had a physician order initially dated April 25, 2018, for Trazadone 100 mg (antidepressant) by mouth at hour of sleep (HS) for insomnia. The resident also had a physician order dated dated April 28, 2018, for Lexapro 10 mg (antidepressant) one time a day for depression .

A review of a pharmacist consult to the physician dated December 1, 2023 reveled a request for a gradual dose reduction (GDR) for the Lexapro and Trazadone.

There was no physician documentation of the clinical necessity of the duplicate antidepressant drug therapy.

The physician's response was solely to disagree with the recommendation with no explanation of the individualized clinical rationale.

The facility was unable to provide documented evidence to support the continued use of the current dose of Lexapro and Trazadone or evidence that a gradual dose reduction attempt of the psychoactive medications conducted in the past year.

A review of Resident 77's clinical record revealed admission to the facility on March 6, 2021, with diagnoses to include dementia with unspecified severity without behavioral, psychotic, mood disturbance and anxiety, and bipolar disorder.

A physician order dated March 3, 2023, at 1:47 PM for Depakote Extended Release (ER) 250 milligrams (mg) (medication used to treat seizures and some psychiatric disorders) by mouth at bedtime for bipolar disorder and an additional order for Depakote ER 500 mg by mouth at bedtime to equal 750 mg for bipolar disorder. The resident also had a physician order dated July 18, 2023, at 6:01 PM for Olanzapine 2.5 mg (antipsychotic drug) by mouth daily for bipolar disorder. A physician order dated October 23, 2023, at 8:24 AM was also noted for Escitalopram Oxalate 10 mg (antidepressant) by mouth daily for major depressive disorder, recurrent severe with psychotic symptoms.

A review of "Consultant Pharmacist Recommendation to Prescriber" dated February 28, 2024, revealed that the pharmacist recommended that the physician consider a dose reduction of the resident's Olanzapine to determine the minimal effective dose. The physician's response was "no gradual dose reduction (GDR) at this time (elaborate) clinical deterioration, no behaviors noted."

A review of "Consultant Pharmacist Recommendation to Prescriber" dated February 28, 2024, revealed a recommendation for the physician to consider a dose reduction of the resident's Depakote to determine the minimal effective dose. The physician's response was the same, noting "no GDR at this time (elaborate) stable clinical deterioration possible no behaviors noted."

A review of "Consultant Pharmacist Recommendation to Prescriber" dated April 16, 2024, revealed a recommendation for the physician to consider a dose reduction of the resident's Escitalopram Oxalate to determine the minimal effective dose. The physician's response was to disagree with the recommendation, indicating that this dose works well for this patient.

A review of the resident's clinical record, including progress notes dated from January 2024 through May 2024, revealed no documented evidence of behaviors.

The facility was unable to provide documented evidence to support the continued use of the current dosages of Olanzapine, Escitalopram Oxalate, and Depakote, or evidence that a GDR of the psychoactive medication's for Resident 77 was conducted in the past year.

During an interview with the Nursing Home Administrator (NHA) and Director of Nursing (DON) on May 10, 2024, at approximately 12:45 PM, confirmed the lack of GDR attempts for the psychoactive drugs prescribed for Resident 52 and 77.


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

28 Pa. Code 211.2 (d)(3)(9) Medical Director

28 Pa. Code 211.5 (f) Clinical records









 Plan of Correction - To be completed: 06/25/2024

1) GDRs for Resident #52 and Resident #77 were addressed, and recommendations followed.
2) DON/designee will audit current residents April GDR requests to ensure addressed by MD.
3) DON/Designee will provide education to medical professionals, extenders, social work and licensed staff on Tapering Meds and Gradual Drug Dose Reduction Policy.
4) DON/designee will complete random audits monthly x 2 on pharmacy GRD recommendations to ensure timely review. Results of audits will be reported and reviewed by the Quality Assurance Performance Improvement Committee and changes will be made as needed.

483.40 REQUIREMENT Behavioral Health Services: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.
§483.40 Behavioral health services.
Each resident must receive and the facility must provide the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. Behavioral health encompasses a resident's whole emotional and mental well-being, which includes, but is not limited to, the prevention and treatment of mental and substance use disorders.
Observations:

Based on review of clinical records and resident and staff interview it was determined that the facility failed to ensure each resident was provided with the necessary behavioral health care and services to meet the needs of two residents out of 23 sampled (Residents 90 and 28) to maintain the residents' highest practicable physical, mental, and psychosocial well-being).

Findings include:

A review of clinical record revealed that Resident 90 was admitted to the facility on December 6, 2023, with diagnoses that include adjustment disorder (a short-term condition arising due to difficulty in managing stressful changes that can lead to significant impairment in functioning) with mixed anxiety, depression (mood disorder with experiences of persistent symptoms of sadness), major depressive disorder (mental health disorder having episodes of depression that can be dangerous or life threatening if untreated), and acute stress reaction (occurs after an unexpected life crisis or traumatic event).

A quarterly Minimum Data Set assessment (MDS - a federally mandated standardized assessment process conducted at specific intervals to plan resident care) dated March 13, 2024, revealed that the resident was cognitively intact, requiring extensive assistance with activities of daily living (ADL).

A review of Resident 90's "Psychological Services Supportive Care" progress note dated February 20, 2024, revealed that the resident reported she has been struggling for a while with health issues. The resident stated that a few months ago she was receiving rehab therapy to strengthen her legs and was unable to stand, called an ambulance and when they arrived she endured a traumatizing experience that led to her braking two bones in her leg requiring surgery. She stated that she is struggling in therapy now at this facility due to this experience and grows very anxious when the therapists are helping her to stand. The progress note indicated that the Clinician will continue to work with the patient to develop a rapport and learn patients' history, recommend follow-up as needed.

During an interview with Resident 90 on May 7, 2024, at 10:10 AM the resident stated that she has not seen psychiatric services since approximately February 2024 and has not been given any explanation as to why. The resident continued to explain that when she was provided these services, they were tele-health (over the phone) and she did not feel as though the psychologist was listening to her as evidenced by their child making loud noises in the background causing distractions and being agreeable by saying "yeah, sure" after everything the resident said. She stated that she did not feel comfortable during these telephone consultations but really felt that she needed for services because she has been having nightmares of a recent traumatizing event that happened leading her to this facility with the inability to walk. She stated that she is sad all the time and wonders if this is how she will have to spend the rest of her retirement, laying in a bed for the rest of her life. She feels as though she would benefit from therapy and would prefer it to be in person.

There was no documented evidence that Resident 90 was provided follow-up psych services treatment between February 20, 2024, through the time of the survey ending May 10, 2024, and that the facility had evaluated the appropriateness and effectiveness of the telehealth services provided to support this resident's mental health needs.

Review of the clinical record revealed that Resident 28 was admitted to the facility on September 9, 2024, and had diagnoses, which included schizoaffective disorder (a mental health disorder that is marked by a combination of schizophrenia symptoms, such as hallucinations or delusions, and mood disorder symptoms, such as depression or mania).

Review of Resident 28's clinical record revealed she was deemed a PASRR (Pennsylvania preadmission screening resident review) level II, with specialized mental health services to be provided by the facility.

Review of a Psychological evaluation dated October 19, 2023, indicated that Resident 28 had increased anxiety symptoms. Recommendations included individual psychotherapy follow up in four weeks to monitor residents symptoms.

Further review of the resident's clinical record conducted during survey ending May 10, 2024, revealed the resident was not seen by psychological services until March 25, 2024.

During an interview with the Director of Nursing (DON) and Nursing Home Administrator (NHA), on May 10, 2024, at approximately 12:40 PM the NHA confirmed that Resident 90 had not received psychological/psychiatric services as recommended for follow-up during the period of February 20, 2024 and May 10, 2024 and Resident 28 had not received services between October 19, 2023 and March 25, 2024.


28 Pa. Code 201.29 (a) Resident rights










 Plan of Correction - To be completed: 06/25/2024

1) Resident #90 and Resident # 28 were seen by Vital psych services 5/13/2024.
2) Social Services/designee will audit current residents to ensure they are provided with the necessary behavioral health care and services if needed and that residents with a Level 2 PASRR receive specialized mental health services.
3) Social Services/Designee will provide education to residents concerning the Behavior Health Services available to them. If the Resident is unable to understand the Behavior Health Services available, then the Resident's Representative will receive the information/education.
4) Social Services / designee will complete random audits weekly x 4 weeks then monthly x 2 on residents are provided with the necessary behavioral health care and services if needed and that residents with a Level 2 PASRR receive specialized mental health services. Results of audits will be reported and reviewed by the Quality Assurance Performance Improvement Committee and changes will be made as needed.


483.25(e)(1)-(3) REQUIREMENT Bowel/Bladder Incontinence, Catheter, UTI:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
§483.25(e) Incontinence.
§483.25(e)(1) The facility must ensure that resident who is continent of bladder and bowel on admission receives services and assistance to maintain continence unless his or her clinical condition is or becomes such that continence is not possible to maintain.

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

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

Based on a review of clinical records, select facility policy and investigative reports and staff interviews it was determined that the facility failed to assess and implement individualized measures planned to meet the toileting needs of one resident out of three residents sampled with a decline in continence (Resident 27).

Findings included:

A review of a facility policy entitled "Urinary Incontinence - Clinical Protocol" that was last reviewed by the facility on November 27, 2023, indicated that as part of the initial assessment, the physician will help identify individuals with impaired urinary continence. The staff and physician will review the progress of individuals with impaired continence until continence is restored or improved as much as possible, or if it is identified that further improvement is unlikely. This should include documentation of a resident's response to attempt interventions such as scheduled toileting, prompted voiding, or medications used to treat incontinence.

A review of Resident 27's clinical record revealed that the resident was admitted to the facility on February 5, 2024, and readmitted following a hospitalization on February 24, 2024, with diagnoses that included congestive heart failure [is a progressive heart disease that affects pumping action of the heart muscles that causes fatigue, shortness of breath], abnormal gait (changes in walking patterns) and mobility, and dysphasia (difficulty swallowing).

The resident's plan of care, dated February 5, 2024, identified that the resident was incontinent of bowel and bladder and was at risk for impaired skin integrity related to impaired mobility and incontinence with planned interventions to periodically evaluate the resident's pattern of urination and episodes of incontinence, apply barrier cream post incontinent episodes, and assist of two-person with toileting.

A 5-day Minimum Data Set (MDS) assessment dated February 12, 2024, indicated that the resident was moderately cognitive impaired with a BIMS (brief interview for mental status - a tool to assess cognitive status) of 12, was occasionally incontinent of bladder and frequently incontinent of bowel and was not on a bladder or bowel retraining program.

Resident 27's readmission MDS assessment dated March 2, 2024, revealed that the resident had a decline in bladder continence from occasionally incontinent to frequently incontinent with no bladder or bowel retraining program in place.

A review of the resident's clinical record revealed that a wound care consultant progress note was completed by the Nurse Practitioner dated March 20, 2024, noting that Resident 27 had developed a small stage 2 pressure ulcer [partial-thickness skin loss into but no deeper than the dermis and includes intact or ruptured blisters] to the right buttocks.

A review of the resident's Survey Documentation Reports (a summary report of staff's task/intervention completion) dated for the months of February 2024, March 2024, and April 2024 revealed no evidence that the facility had developed and implemented interventions to address the resident's decline in urinary incontinence in an attempt to restore normal bladder function to the extent possible for this resident, which would also prevent incontinence related complications, such as skin breakdown.

During an interview with the Director of Nursing (DON) on May 9, 2024, at 9:45 a.m., confirmed that the facility was unable to provide evidence of the facility's response to the decline in urinary continence and the implementation of measures designed to decrease urinary incontinency and prevent incontinence related complications.



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

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






 Plan of Correction - To be completed: 06/25/2024

1) Resident 27 passed away.
2) DON/designee will audit currents residents that have a noted decline in bowel and bladder continence to assess and implement individualized measures planned to meet their toileting needs.
3) DON/Designee will provide education to nursing staff on Urinary Incontinence -Clinical Protocol and Urinary Continence and Incontinence – Assessment and Management.
4) DON/designee to complete random audits weekly X 4 then monthly x 2 on residents with a noted decline per MDS report in bowel/bladder continence to ensure Bowel and Bladder Evaluation completed in PCC and appropriate programing initiated. Results of audits will be reported and reviewed by the Quality Assurance Performance Improvement Committee and changes will be made as needed.

483.10(j)(1)-(4) REQUIREMENT Grievances:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
§483.10(j) Grievances.
§483.10(j)(1) The resident has the right to voice grievances to the facility or other agency or entity that hears grievances without discrimination or reprisal and without fear of discrimination or reprisal. Such grievances include those with respect to care and treatment which has been furnished as well as that which has not been furnished, the behavior of staff and of other residents, and other concerns regarding their LTC facility stay.

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

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

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

Based on a review of clinical records and grievances filed with the facility and resident and staff interviews, it was determined that the facility failed to demonstrate timely and adequate efforts to resolve resident grievances including those voiced by two out of 23 residents sampled (Residents 76 and 90).

The findings include:

A review of clinical record revealed that Resident 76 was admitted to the facility on June 30, 2021, with diagnoses that include gastroesophageal reflux disease ([GERD] occurs when stomach acid frequently flows back into the esophagus) with esophagitis (inflammation or irritation of esophagus, the pipe that carries food from mouth to stomach) and muscle weakness.

An annual Minimum Data Set assessment (MDS - a federally mandated standardized assessment process conducted at specific intervals to plan resident care) dated February 14, 2024, revealed that the resident was cognitively intact, requiring moderate assistance with activities of daily living (ADL).

A "Grievance/Concern Form" filed by Resident 76's guardian on May 3, 2024, on behalf of the resident revealed that the resident would like to talk to dietary staff about her current preferences. The facility's noted results and findings of the grievance were that the dietary manager went to discuss the resident's preferences. The facility resolution was that the dietary manager reviewed preferences with the resident, guardian and resident were informed.

During an interview with Resident 76 on May 7, 2024, at 9:44 AM the resident stated that she was on a full liquid diet, and she was tired of the food/beverages the facility provided her to eat on this diet. She stated that she never receives a bedtime snack because of this diet, and she wanted to discuss her preferences with someone that could help her with this problem.

During a follow-up interview with Resident 76 on May 9, 2024, at 11:10 AM the resident stated that no facility staff had yet visited her to discuss anything related to her food preferences with her, and she was upset.

A review of clinical record revealed that Resident 90 was admitted to the facility on December 6, 2023, with diagnoses that include irritable bowel syndrome - diarrhea ([IBS-D] frequent episodes of diarrhea with abdominal pain) and need for assistance with personal care.
A quarterly MDS dated March 13, 2024, revealed that the resident was cognitively intact, requiring extensive assistance ADLs.

During an interview with Resident 90 on May 7, 2024, at 10:10 AM the resident stated that she had filed a grievance with the facility related to staff's failure to answer her call bell on the 11:00 PM to 7:00 AM shift three weeks ago. She stated that staff came in after about 45 minutes, after she initially rang the call bell, and said they would be right back, but never returned leaving her incontinent of bowel and bladder for 15 hours. The resident stated that to date she has not heard anything back from staff related to this grievance filed.

There was no indication that the facility had timely evaluated the resident's complaints regarding untimely call bell response and improper incontinence care. There was no documented evidence at the time of the survey ending May 10, 2024, that the resident's grievance was addressed or investigated by the facility.

At the time of the survey ending May 10, 2024, the facility was unable to provide documented evidence that it had determined if the residents' felt that their complaints or grievances had been resolved through any efforts taken by the facility in response to the residents' expressed concerns regarding food preferences, untimely call bell response and proper incontinence care.

During an interview with the Nursing Home Administrator (NHA) and Director of Nursing (DON) on May 10, 2024, at 12:30 PM, were unable to provide documented evidence that the facility had followed up with the residents to ascertain the effectiveness of the facility's efforts in resolving their complaints regarding dietary and nursing services.


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

28 Pa. Code 201.29 (a)(c) Resident rights

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






 Plan of Correction - To be completed: 06/25/2024

1) Resident #76 and #90 grievances have been completed to resident satisfaction.
2) NHA/ Designee will audit grievances from the last 7 days to ensure they were completed timely and adequate efforts made to resolve resident grievances.
3) NHA/Designee will provide education to all facility staff on Grievance policy/procedures. Education will include the grievance process and completion in 5 days once the grievance officer has received the grievance.
4) NHA/Designee will complete random audits will be completed weekly X 12 weeks to ensure grievances are completed to ascertain the effectiveness of the facility's efforts regarding dietary and nursing services. Results of audits will be reported and reviewed by the Quality Assurance Performance Improvement Committee and changes will be made as needed.

483.10(a)(1)(2)(b)(1)(2) REQUIREMENT Resident Rights/Exercise of Rights:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
§483.10(a) Resident Rights.
The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility, including those specified in this section.

§483.10(a)(1) A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the resident.

§483.10(a)(2) The facility must provide equal access to quality care regardless of diagnosis, severity of condition, or payment source. A facility must establish and maintain identical policies and practices regarding transfer, discharge, and the provision of services under the State plan for all residents regardless of payment source.

§483.10(b) Exercise of Rights.
The resident has the right to exercise his or her rights as a resident of the facility and as a citizen or resident of the United States.

§483.10(b)(1) The facility must ensure that the resident can exercise his or her rights without interference, coercion, discrimination, or reprisal from the facility.

§483.10(b)(2) The resident has the right to be free of interference, coercion, discrimination, and reprisal from the facility in exercising his or her rights and to be supported by the facility in the exercise of his or her rights as required under this subpart.
Observations:


Based on a review of clinical records and select facility policy, observation and staff and resident interviews it was determined that the facility failed to provide care in a manner that maintains the personal dignity, privacy and quality of life of two residents out of 23 sampled (Resident 49 and 90).

Findings include:

A facility policy entitled "Dignity" with a review date of November 27, 2023, revealed that residents are always treated with dignity and respect. The facility culture supports dignity and respect for resident's by honoring resident goals, choices, preferences values, and beliefs. This begins on admission and continues throughout the resident's facility stay. Demeaning practices and standards of care that compromise dignity are prohibited staff are expected to promote dignity and assist residents by helping to promptly response to a resident's request for toileting assistance.

An observation on May 8, 2024 at 9 AM, revealed no curtains, shades or blinds on the windows in resident room 302, occupied by Resident 49. The window in this resident room is at ground level facing the street and the resident and the interior of his room were clearly visible from the outside of the building

Clinical record review revealed Resident 49 was admitted to the facility on December 12, 2017, with diagnosis to include dementia and exhibited behaviors including moving the furniture in his room and removing window coverings as observed during the survey on May 8, 2024.

During an interview May 8, 2024 at 1 PM, the acting Director of Nursing stated that in the past Resident 49 had removed the window coverings in his room and the facility had never replaced them or explored alternative window coatings or coverings that would maintain the resident's privacy and that he wouldn't be able to remove.

During an interview conducted May 7, 2024, at 10:11 AM with Resident 90, who was cognitively intact, alert, and oriented, the resident stated that a nurse aide who works on the 11:00 PM to 7:00 AM shift failed to assist her with care when the resident rang her call bell. The aide responded after approximately 45 minutes to say, "I will be right back" and then never returned leaving the resident incontinent of bowel and bladder for 15 hours. The resident stated that when she initially arrived at the facility she was "man handled" during transfers using a mechanical lift causing her increased anxiety, as she recently had a traumatizing experience with a transfer that led to her breaking her leg and requiring surgery.

During an interview with the Nursing Home Administrator (NHA) and Director of Nursing (DON) on May 10, 2024, at approximately 12:45 PM revealed that the facility failed to demonstrate that residents are consistently treated with dignity and respect, including timely response to their requests for assistance to promote their quality of life in the facility.


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

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

28 Pa. Code 201.29 (a) Resident Rights





 Plan of Correction - To be completed: 06/25/2024

1) Resident # 49 window covering were placed in Residents room. Resident #90 issue could not be corrected.
2) Audit completed of current resident rooms to ensure window coverings are in place. Interview with alert and oriented residents on 2nd floor to determine if call bells are being answered timely and needs met.
3) NHA/Designee will provide education to all facility staff on Dignity/Residents Rights policy and procedures. Education to include protection of resident privacy, including bodily privacy during assistance with bodily care and during treatment procedures.
4) NHA/designee will complete random audits weekly X 4 weeks then monthly x 2 on non-clinical rounds that window coverings are in place and resident dignity is maintained. NHA/designee will complete random Audits weekly X 4 weeks then monthly x 2 to ensure call bells are being answered timely and resident needs are met. Results of audits will be reported and reviewed by the Quality Assurance Performance Improvement Committee and changes will be made as needed.

483.12(a)(1) REQUIREMENT Free from Abuse and Neglect:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
§483.12 Freedom from Abuse, Neglect, and Exploitation
The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms.

§483.12(a) The facility must-

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

Based on review of clinical records, select facility policy and investigative reports resident and staff interview, it was determined that the facility failed to ensure that one resident was free from physical abuse out of 23 sampled residents (Resident 85).

Findings including

A review of the current facility policy titled "Abuse Policy", last reviewed by the facility November 27, 2023, revealed that residents have the right to be free from abuse. Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting in physical harm, pain, or mental anguish. Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. The facility's goal is to achieve and maintain an abuse-free environment.

A review of Resident 85's clinical record revealed that she was admitted to the facility on June 8, 2022, with diagnoses that included Alzheimer's disease [is a gradually progressive type of brain disorder that causes problems with memory, thinking and behavior], symbolic dysfunction [is a concept that refers to the breakdown in communication caused by misinterpretation or misunderstanding of symbols that can significantly impact the ability to effectively communicate and understand one another] , and moderate depressive disorder [is a mental health disorder having episodes of psychological depression]. A quarterly Minimum Data Set (MDS) assessment dated February 22, 2024, indicated that the resident was severely cognitively impaired with a BIMS (brief interview for mental status - a tool to assess cognitive status) score of 4.

Resident 85's plan of care initiated June 1, 2023, identified that the resident had behaviors related to Alzheimer's dementia, bipolar disorder, major depressive disorder. The resident was noted as physically aggressive toward others, verbally aggressive toward others, verbally aggressive towards staff when being redirected, and liked to incite chaos/riles other peers. The resident's goal was to be free of harming self or others during periods of combativeness, display fewer episodes of behavior problems, remain injury free related to behaviors, and have no adverse effects related to behaviors. Planned interventions were to encourage the resident to stay in dayroom for increased supervision and activity, keep the resident safe during episodes of behaviors and attempt to redirect, provide a calm safe environment when the patient's frustrations escalate and allow time to voice feelings, and behavior tracking even fifteen minutes checks.

A review of Resident 60's clinical record revealed that the resident was admitted to the facility on August 12, 2023, with diagnoses that included encephalopathy [is a medical term used to describe a disease that affects brain structure or function and causes altered mental state and confusion], amnesia (a condition characterized by the inability of a person to recall facts or previous experiences), and cerebrovascular disease [is a term for conditions that affect blood flow to your brain that can result in stroke, brain bleed, aneurysm (a bulge in the wall of an artery that can rupture and cause bleeding inside the body and often leads to death)]. A quarterly MDS assessment dated February 14, 2024, indicated that the resident was severely cognitively impaired with a BIMS score of 5.

Resident 60's plan of care dated August 23, 2023, identified that the resident has behaviors such as increased agitation as evidence by banging on door, delusional thoughts, accusatory towards others, exit seeking, combativeness, and physically aggressive with peers. The resident's goal was to be free of harming self or others during periods of combativeness and would have no adverse effects related to behaviors. Planned interventions were to approach the resident in a calm manner to avoid frustration and behavior escalation, attempt distraction during behavioral episodes (offering to watch sports, engaging in conversation about pets, offering music), Attempt to redirect resident when exhibiting behaviors, provide a calm safe environment when the patient's frustrations escalate. Additionally, when Resident 60's behavior escalates and unable to be redirected, assure safety, and attempt to remove other residents surrounding the resident.

Nursing progress notes in Resident 60's clinical record completed by Employee 4, a licensed practical nurse (LPN) dated April 22, 2024, at 2:33 p.m., revealed that the resident \ had been pacing about nurses' station with clothes in hand and demanding that the door be opened for her to go home. Staff attempted to redirect with calls to the resident's sister, change in environment to a quiet area, and encouraged the resident to participate in activities with effect. Resident 60 was seated in the resident's room at this time.

An incident report completed by the Director of Nursing (DON) dated April 22, 2024, at 8:15 p.m., revealed that Resident 60 and Resident 85 were seated at different tables in the Dementia Unit Dayroom. Staff witnessed Resident 85 saying something to Resident 60 as she walked by her table, but staff did not hear what Resident 85 said to Resident 60. Resident 60 \ was witnessed pulling Resident 85 by her hair. Staff intervened by separating and removing the residents from the dining dayroom. RN assessment completed with no injuries noted to either resident. Both residents offered no complaints of pain/injury and the responsible parties (RPs) and physicians for both residents notified.

A review of an Employee Statement form completed by Employee 6, a nurse aide (NA), dated April 22, 2024, (no time noted), revealed that she last observed Resident 60 in the dining room at 8:00 p.m. and prior this incident Resident 60 was observed packing up her clothes and kept insisting that she \ was going home, staff redirected to her room. Employee 6 indicated that the incident occurred at 8:15 p.m. in the dining room where she observed Resident 85 arguing with another resident. Resident 60 went over to Resident 85 and began yelling at her. Resident 85 had a plate in her hand and as I \ went over to split the residents up, Resident 60 \ grabbed Resident 85 by her hair and drug her to the ground. I separated both residents and got nurses.

Employee 6's witness statement indicated that Resident 85 was on the floor after being released from the grip of Resident 60's hand on her hair.

A review of an Employee Statement form completed by Employee 5, a LPN, dated April 22, 2024, (no time noted), revealed that she last observed Resident 60 at 8:10 p.m. sitting in the dining room eating snacks. Prior to the incident, Employee 5 indicated that the resident \ had been constantly insisting that she was going home, and her clothes were packed by the door and resident redirected back to her room.

Further review of employee witness statements of the resident-to resident altercation completed by Employee 8, a NA, dated April 22, 2024, revealed that she last saw Resident 85 at 8:15 p.m. in the dayroom sitting in a chair. Employee 8 noted that another resident \ pulled her by the fair and the resident went to the floor.

A progress note in the clinical record completed by Employee 5, a LPN, dated April 22, 2024, at 10:04 p.m., revealed that residents \ were sitting at different tables in the dayroom. The resident was sitting at a table with another resident and one of the aides, disagreeing with a resident not involved in the incident. This was when the aggressor \ came over to table and was yelling at the resident \ before the aide \ could get there to intervene and separate. She \ pulled the resident \ by the hair to the ground. Nurse aide immediately separated residents. The resident \ went to her room. Responsible party (RP) and physician made aware.

Further review of Resident 60's clinical record of a nursing progress note completed by Employee 9, a Registered Nurse (RN), dated April 22, 2024, at 10:10 p.m., revealed that she was made aware of a resident-to-resident incident that occurred at 8:15 p.m. RN came to floor to see the two residents involved separated and resident \ who had hair pulled sitting by the nurse's station. The resident aggressor \ was in her room pacing with no signs of being a harm to self or others. Residents assessed by RN, no signs of injury or distress noted. Vital signs within normal limits. Resident (victim) \ stated in follow up that she "feels safe in her environment" and doesn't recall the incident events. Both families were called and notified. MD made aware with no new orders. The local police department was called, and a report was made, as well as the Aging Agency notified.

The facility failed to protect and ensure that Resident 85 was safe and free from physical abuse perpetrated by Resident 60. The facility was aware Resident 60 behaviors had escalated prior to incident and it was known that Resident 60 has a history of physical aggression.

During an interview with the Director of Nursing (DON) on May 9, 2024, at 1:15 p.m., confirmed that the facility was aware of Resident's 60's behaviors and that the facility failed toe ensure that Resident 85 was from physical abuse perpetrated by Resident 60, a resident with known aggressive behaviors and escalated behaviors prior to incident that occurred on April 22, 2024, at 8:15 p.m.



28 Pa. Code 201.29(a)(c)(d) Resident rights

28 Pa. Code 201.14(a) Responsibility of Licensee

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






 Plan of Correction - To be completed: 06/25/2024

1) Residents #85 and #60 will continue to be followed by Vital Psych services. Care Plans have been updated for individualized interventions for redirection.
2) Care Plans of current residents with behaviors have been reviewed and updated with individualized interventions for redirection.
3) NHA/Designee will provide education to facility Nursing, Social Service and Activity staff on Behavioral Assessment, Intervention and Monitoring Policy and the Abuse Policy. Education will include training on dementia behaviors and interventions to deescalate.
4) NHA/designee will complete random audits weekly X4 weeks then monthly x 2 during the morning meeting process by reviewing progress notes and MAR behavior documentation for aggressive and escalated behaviors. Results of audits will be reported and reviewed by the Quality Assurance Performance Improvement Committee and changes will be made as needed.

483.12(b)(1)-(5)(ii)(iii) REQUIREMENT Develop/Implement Abuse/Neglect Policies:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
§483.12(b) The facility must develop and implement written policies and procedures that:

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

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

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

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

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

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

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

Based on a review of the facility's abuse prevention policy and clinical records and staff interview, it was determined that the facility failed to implement their established abuse prohibition policy and procedures for responding to incidents of resident abuse for one resident out of 23 sampled (Resident 85).

Findings include:

A review of the current facility policy titled "Abuse Policy", last reviewed by the facility November 27, 2023, revealed that the facility's abuse prevention/intervention program included training all staff and practitioners' ways to resolve conflicts appropriately. Assessing, care planning, and monitoring residents with needs and behaviors that may lead to conflict or neglect and assessing residents with signs and symptoms of behavior problems and developing and implementing care plans to address behavioral issues. The facility's response to abuse includes an assessment and assessment data will include injury assessment, signs of recent fall, pain assessment, current behavior, all current medications, vital signs, behaviors over the past 24-hours, all active diagnoses, and any recent labs. The nurse will report any findings to the physician. As a part of the initial assessment, the physician will help identify risk factors for abuse within the facility, for example, significant number of residents with unmanaged and problematic behaviors.

An incident report completed by the Director of Nursing (DON) dated April 22, 2024, at 8:15 p.m., revealed that Resident 60 and Resident 85 were seated at different tables in the Dementia Unit Dayroom. Staff witnessed Resident 85 saying something to Resident 60 as she walked by her table, but staff did not hear what Resident 85 said to Resident 60. Resident 60 \ was witnessed pulling Resident 85 by her hair. Staff intervened by separating and removing the residents from the dining dayroom. and removed both residents from the dayroom. RN assessment complete with no injuries noted. Both residents offered no complaints of pain/injury and the responsible parties (RPs) and physicians for both residents notified.

A review of an Employee Statement form completed by Employee 6, a nurse aide (NA), dated April 22, 2024, (no time noted), revealed that she last observed Resident 60 in the dining room at 8:00 p.m. and prior this incident Resident 60 was observed packing up her clothes and kept insisting that she \ was going home staff redirected to her room. Employee 6 indicated that the incident occurred at 8:15 p.m. in the dining room where she observed Resident 85 arguing with another resident. Resident 60 went over to Resident 85 and began yelling at her. Resident 85 had a plate in her hand and as I \ went over to split the residents up, Resident 60 \ grabbed Resident 85 by her hair and drug her to the ground. I separated both residents and got nurses. Employee 6 stated that Resident 85 was on the floor after being released from the grip of Resident 60's hand on her hair.

A review of a nursing progress note in Resident 60's clinical record that was completed by Employee 9, a Registered Nurse (RN), dated April 22, 2024, at 10:10 p.m., revealed that she was made aware of a resident-to-resident incident that occurred at 8:15 p.m. RN came to floor to see the two residents involved separated and resident \ who had hair pulled sitting by the nurse's station. The resident aggressor \ was in her room pacing with no signs of being a harm to self or others. Residents assessed by RN, no signs of injury or distress noted. Vital signs within normal limits. Resident (victim) \ stated in a follow up that she "feels safe in her environment" and doesn't recall the incident events. Both families were called and notified. MD made aware with no new orders. The local police department was called, and a report was made, as well as the Aging Agency notified.

There was no documented evidence that the RN conducted and documented the results of a thorough physical assessment of Resident 85 after she was pulled to the ground by her hair by Resident 60 as indicated in the facility's Abuse Policy, to include documenting the results of the applicable assessment data, pain assessment, the resident's current behavior, all current medications, behaviors over the past 24-hours, all active diagnoses, and any recent labs. The nurse will report any findings to the physician. The RN solely noted no signs of injury or distress and vital signs within normal limits, and the resident feels safe in her environment.

The facility failed ensure that their Abuse Policy was fully implemented by licensed nursing staff, a RN, as evidenced by the Employee 9's failure to conduct a thorough assessment of Resident 85, a victim of physical abuse.

During an interview with the Director of Nursing (DON) on May 9, 2024, at 1:15 p.m., revealed that the facility failed to provide documented evidence that a thorough physical assessment was completed by a RN after an incident of physical abuse of Resident 85 as noted in the response procedures in their abuse prohibition policy.


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

28 Pa. Code 211.5 (f) Medical records






 Plan of Correction - To be completed: 06/25/2024

1) Resident #85 incident cannot be retroactively corrected.
2) Any resident involved in an incident or accident will have a complete RN assessment.
3) NHA/designee will educate staff on the facility's Abuse Prevention/Intervention Program included training on registered nurse to immediately examine the resident and findings of the examination must be recorded in the resident's medical record.
4) NHA/designee will audit that a thorough physical assessment was completed by a RN after an incident of physical abuse weekly x4 weeks then monthly x 2. Results of audits will be reported and reviewed by the Quality Assurance Performance Improvement Committee and changes will be made as needed.

483.12(c)(2)-(4) REQUIREMENT Investigate/Prevent/Correct Alleged Violation: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(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 a review of clinical records, select facility incident reports, and the facility's abuse prohibition policy and staff interview it was determined that the facility failed to thoroughly investigate potential neglect of five residents out of 23 sampled (Residents 99, 43, 17, 46, and 97).

Findings included:

A review of the facility's policy, entitled "Abuse Policy" last reviewed by the facility November 2023, indicated that a complete investigation will be conducted. "Neglect is defined as the failure of the facility, its employees or service providers to provide goods and services to a resident that necessary to avoid physical harm, pain, mental anguish or emotional distress. Neglect occurs when the facility is aware of or should have been aware of goods or services that a resident requires but the facility fails to provide them to the resident, that has resulted in or may result in physical harm, pain, mental anguish, or emotional distress."

A review of medication errors in the facility for the month of April 2024, revealed that on April 27, 2024, Employee 10 (RN) left her shift at approximately 8:00 p.m. It was subsequently discovered, after Employee 10 left the facility, that the nurse did not administer all scheduled medications to five residents, (Residents 99, 43, 17, 46, and 97), during medication pass approximately between 4 PM - 5:30 PM on that date. Employee 10 signed the residents' Medication Administration Records indicating that all medications had been administered to the residents as scheduled but they were not administered as noted on the MAR as they were located in the medication cart.

Further review of these medication errors from April 27, 2024, revealed:

Resident 99, who was admitted to the facility on June 17, 2023, with diagnoses to include dementia, did not receive two medications, atorvastatin 80 mg tab and metropolol tartrate 25 mg tab, that Employee 10 signed out at 1700 (5 PM), the resident's medications were discovered in medication cart by other staff approximately between 8:00 and 9:00 p.m.

Resident 43, who was admitted to the facility on August 12, 2023, with diagnoses to include diabetes, did not receive one medication Sevelamer 800 mg 3 tabs, which was signed out at 1630 (4:30 PM) by Employee 10 and were discovered in medication cart between approximately 8:00 PM and 9:00 PM.

Resident 17, who was admitted to the facility on September 28, 2015, with diagnoses to include dementia, did not receive three medications: dipyridamole 25/100mg, atorvastatin 40 mg, and memantine 10 mg that Employee 10 signed out at 1700 (5 PM) and were later discovered in medication cart between approximately 8:00 PM and 9:00 pm.

Resident 46, who was admitted to the facility on July 22, 2021, with diagnoses to include cerebral infarction, did not receive three medications atorvastatin 40 mg, and Eliquis 5 mg that Employee 10 signed out at 1700 (5 PM), and hydroxyzine 25 mg Employee 10 signed out at 1800 (6 PM), and were discovered in remaining in the medication cart between approximately 8:00 PM and 9:00 PM.

Resident 97, who was admitted to the facility on May 11, 2023, with diagnoses to include diabetes, did not receive three medications Eliquis 5 mg, metformin 500 mg, and Toresmide 20 mg signed out at 1700 (5 PM) by Employee 10 were discovered in medication cart between approximately 8:00 PM and 9:00 PM on April 27, 2024.

Review of above residents' clinical records revealed there was no documentation in any of the above resident records indicating that the residents did not receive their medications as prescribed and scheduled on April 27, 2024.

At the time of the survey ending May 10, 2024, there was no documented evidence that the facility had investigated the potential neglect of these residents by Employee 10. The facility did not obtain any witness statements from staff working the evening in question or from cognitively intact residents.

Interview with the administrator and director of nursing on May 10, 2024, at 10:00 a.m., were unable to provide evidence that the facility completed a thorough investigation to rule out neglect of Residents 99, 43, 17, 46, and 97.



28 Pa. Code 201.14 (a) Responsibility of licensee

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

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

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










 Plan of Correction - To be completed: 06/25/2024

1) Medication Error Reports completed for Residents #99, #43, #17, #46, and #97.
2) Current residents' medications for the last 7 days will be audited to ensure timely administration.
3) DON/Designee will educate licensed staff on Medication Administration and Abuse Policy and Procedures. All medication errors will be investigated for the potential of neglect.
4) DON/ designee will complete audits of medication carts to determine if meds given as per MD orders weekly x4 weeks then monthly x 2. Results of audits will be reported and reviewed by the Quality Assurance Performance Improvement Committee and changes will be made as needed.

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


Based on observation, clinical record review and staff interview, it was determined that the facility failed to identify a resident's need for monitoring of the resident's respiratory status and oxygen use on the resident's comprehensive care plan for one resident out of 23 sampled (Resident 102).

Findings include:


According to the American Thoracic Society, oxygen (O2) is a medication that requires a prescription from a healthcare provider. The provider will prescribe your O2 at a specific flow rate and a specific number of hours per day. It is very important that O2 is used as prescribed. Using too little O2 may put a strain on the heart and brain, causing heart failure, fatigue, or memory loss. Using too much O2 can also be a problem. For some patients, using too much O2 can cause them to slow their breathing to dangerously low levels. It is important to wear O2 as your provider ordered it. If the patient starts to experience headaches, confusion, or increased sleepiness after using supplemental O2, the patient may be getting too much.

A review of the clinical record of Resident 102 revealed admission to the facility on June 22, 2023, with diagnoses, which included shortness of breath ([SOB]labored breathing) and urinary retention (inability to voluntarily empty the bladder completely or partially).

A review of the resident's plan of care, initially dated July 6, 2023, revealed that the resident has behaviors related to yelling out, verbally aggressive with care, taking oxygen off, unplugging oxygen, attempting to climb out of bed, attempts to wheel wheelchair down hall carrying oxygen, refuses treatments and strikes out at others. Interventions included administer medications per physician's orders, approach the resident in a calm manner, attempt to redirect, encourage the resident to ask questions when concerned with their medical condition, give support, keep safe, monitor and document episodes of inappropriate behaviors and notify the physician, observe and report changes in mental status caused by situational stressors, offer assistance, offer psychologist/psychiatric services as needed, offer choices to promote self-worth.

However, the resident's care plan did not include interventions planned to monitor the resident's respiratory status related to his behaviors of unplugging the and removing the oxygen, such as observing for signs and symptoms of respiratory distress, checking the resident's oxygen saturation level (measurement of oxygen in blood normal limits are 95%-100%) or when to notify the nurse when the resident removes his oxygen therapy or turns off the concentrator.

A quarterly Minimum Data Set assessment (MDS - a federally mandated standardized assessment process conducted at specific intervals to plan resident care) dated February 7, 2024, revealed that the resident was severely cognitively impaired.

A physician order was noted April 18, 2024, at 2:25 AM for humidified oxygen liters, at four liters per minute via nasal cannula, continuous every shift related to SOB.

During an observation on May 7, 2024, at approximately 8:49 AM revealed the resident sitting in his wheelchair in his room sleeping wearing nasal cannula with the oxygen concentrator turned off. Employee 2 Registered Nurse (RN) confirmed this observation and stated that the resident will continuously turn the oxygen concentrator off.

During an observation on May 8, 2024, at approximately 12:40 PM the resident was seated in a wheelchair in the dayroom sleeping. The resident was wearing a nasal cannula, but the oxygen concentrator was turned off. Staff were present in this area, but were not observed to attempt to turn the concentrator back on to deliver continuous O2 as ordered. Employee 3, Licensed Practical Nurse (LPN), confirmed this observation.

During an interview May 10, 2024, at 12:30 PM, the Director of Nursing (DON) and Nursing Home Administration (NHA) confirmed that the resident's care plan failed to include planned measures for monitoring the resident's respiratory status and continuous oxygen usage.



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








 Plan of Correction - To be completed: 06/25/2024

Resident #102 Care Plan was updated to reflect removal of oxygen and updated to reflect oxygen sats as ordered.
2) DON/designee to audit current residents on oxygen that liter flow reflect current orders and Care Plan updated to reflect same.
3) DON/Designee will provide education to nursing staff on Comprehensive, Person-Centered Care Plan Policy as it pertains to respiratory status and O2 usage to ensure nursing has the correct O2 flow and interventions planned to monitor
the resident's respiratory status.
4) DON/designee will complete random audits weekly X 4 monthly x 2 of resident's respiratory care plan includes planned measures for monitoring the resident's respiratory status and oxygen use. Results of audits will be reported and reviewed by the Quality Assurance Performance Improvement Committee and changes will be made as needed.

483.25(i) REQUIREMENT Respiratory/Tracheostomy Care and Suctioning:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
§ 483.25(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 observation, clinical record review and staff interview it was determined that the facility failed to consistently administer oxygen (O2) as ordered for one out of 23 sampled residents (Resident 7).


Findings included:

According to the American Thoracic Society, O2 is a medication that requires a prescription from a healthcare provider. The provider will prescribe your O2 at a specific flow rate and a specific number of hours per day. It is very important that O2 is used as prescribed. Using too little O2 may put a strain on the heart and brain, causing heart failure, fatigue, or memory loss. Using too much O2 can also be a problem. For some patients, using too much O2 can cause them to slow their breathing to dangerously low levels. It is important to wear O2 as your provider ordered it. If the patient starts to experience headaches, confusion, or increased sleepiness after using supplemental O2, the patient may be getting too much.

A review of the clinical record of Resident 7 revealed admission to the facility on October 14, 2020, with diagnoses that include a history of falling, hemiplegia/paresis (severe or complete loss of strength or paralysis on one side of the body) following a cerebral infarction (stroke) affecting the left non-dominant side.

The resident had a current physician order dated October 14, 2021, at 5:31 PM for O2 therapy at 2 liters per minute (L/min) via nasal cannula as needed for shortness of breath.

A modified annual Minimum Data Set assessment (MDS - a federally mandated standardized assessment process conducted at specific intervals to plan resident care) dated February 7, 2024, revealed that the resident was severely cognitively impaired, requiring extensive assistance with activities of daily living (ADL).

An observation on May 7, 2024, at 10:00 AM revealed Resident 7's O2 concentrator (machine delivering oxygen therapy) was turned on and running at 3 L/min which was not consistent with physician's orders.

An observation on May 9, 2024, at 11:46 AM revealed Resident 7's O2 concentrator was turned on and again running at 3 L/min failing to follow physician's orders. Employee 2 Licensed Practical Nurse (LPN) confirmed this observation.

Interview with the Nursing Home Administrator (NHA) and Director of Nursing (DON) on May 10, 2024, at approximately 12:45 PM, confirmed that the physician's order for supplemental O2 was not followed for Resident 7.


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









 Plan of Correction - To be completed: 06/25/2024

1) Resident # 7 O2 flow meter rate was corrected immediately and maintained.
2) DON/designee will audit current residents with O2 to ensure flow rate is correct per MD order.
3) DON/Designee will provide education to licensed staff on Oxygen Administration.
4) DON/designee will complete random audits weekly x4 weeks then monthly x 2 for residents ordered oxygen to ensure appropriate flow rate setting. Results of audits will be reported and reviewed by the Quality Assurance Performance Improvement Committee and changes will be made as needed.

483.25(l) REQUIREMENT Dialysis:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
§483.25(l) Dialysis.
The facility must ensure that residents who require dialysis receive such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences.
Observations:

Based on review of clinical records and select facility policy, observations, and staff interviews it was determined that the facility failed to provide person-centered care and coordination of individualized resident services for one of one residents sampled receiving hemodialysis (Resident 51).

Findings include:

A review of a facility policy entitled "Care of a Resident with End-Stage Renal Disease" that was last reviewed by the facility on November 27, 2023, indicated that a resident's compressive care plan would reflect the resident's needs related to end stage renal disease [(ESRD) is a condition where the kidney reaches advanced state of loss of function. This causes changes in urination, fatigue, swelling of feet, high blood pressure, and loss of appetite].

A review of Resident 51's clinical record revealed that he was most recently admitted to the facility on April 10, 2024, with diagnoses that included end stage renal disease with hemodialysis [is a procedure where a dialysis machine and a special filter called an artificial kidney, or a dialyzer, are used to clean blood] and dementia [is the loss of cognitive functioning, thinking, remembering, and reasoning, to such an extent that it interferes with a person's daily life and activities].

A review of Resident 51's plan of care dated April 10, 2024, indicated that the resident has an impaired genitourinary status related to end-stage renal disease (ESRD) and planned interventions included to coordinate resident's care in collaboration with the dialysis center Monday, Wednesday, and Friday at 4:30 AM, monitor dialysis access site and report to physician of signs or symptoms of bleeding or signs of infection: redness, swelling, local warmth, tenderness.

A physician order dated April 10, 2024, indicated that the resident's scheduled dialysis time is 4:00 a.m., on Monday, Wednesday, and Friday, and the resident's wife may transport the resident.

However, the resident's care plan did not include the resident's specific schedule preferences and provisions to meet Resident 51's care needs related to transportation plans and meal schedule related to dialysis schedule.

During an interview with the facility's Director of Nursing (DON) on May 9, 2024, at 10:00 a.m., confirmed that Resident 51's care plan of care failed to include preferred transportation and meal accommodations required for dialysis schedule and daily routine on dialysis days.



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




 Plan of Correction - To be completed: 06/25/2024

1) Resident #51 has been discharged to home.
2) Current Dialysis resident care plans were updated to include scheduled preferences and provisions as it relates to transportation and meals for Dialysis.
3) DON/Designee will provide education to facility Nursing and Dietary staff on Dialysis Policy and Procedures including preferred transportation and meal accommodations. Education to include documentation of resident transportation and meal preferences on the Care Plan.
4) DON/designee will complete random audit weekly x 4 weeks the monthly x 2 on Dialysis residents for preferred transportation and meal preferences. Results of audits will be reported and reviewed by the Quality Assurance Performance Improvement Committee and changes will be made as needed.

483.20(f)(5), 483.70(i)(1)-(5) REQUIREMENT Resident Records - Identifiable Information: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(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 review of clinical records, observation and staff interviews it was determined that the facility failed to maintain and accurate and complete clinical records for two out of 23 residents reviewed.

Findings included:


The Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, 21.145 Functions of the Licensed Practical Nurse (LPN) (a) The LPN is prepared to function as a member of the health-care team by exercising sound judgement based on preparation, knowledge, skills, understandings, and past experiences in nursing situations. The LPN participates in the planning, implementation, and evaluation of nursing care in settings where nursing takes place. 21.148 Standards of nursing conduct (a) A licensed practical nurse shall: (5) Document and maintain accurate records.

According to the American Nurses Association Principles for Nursing Documentation, nurses document their work and outcomes and provide an integrated, real-time method of informing the health care team about the patient status. Timely documentation of the following types of information should be made and maintained in a patient's EHR (electronic health record) to support the ability of the health care team to ensure informed decisions and high-quality care in the continuity of patient care:
problems
with other health care professionals regarding the patient
with and education of the patient, family, and the patient ' s designated support person and other third parties.

A review of the clinical record of Resident 7 revealed admission to the facility on October 14, 2020, with diagnoses that included a history of falling, hemiplegia/paresis (severe or complete loss of strength or paralysis on one side of the body) following a cerebral infarction (stroke) affecting the left non-dominant side.

A modified annual Minimum Data Set assessment (MDS - a federally mandated standardized assessment process conducted at specific intervals to plan resident care) dated February 7, 2024, revealed that the resident was severely cognitively impaired, requiring extensive assistance with activities of daily living (ADL).

During an observation on May 7, 2024, at 10:30 AM the resident was observed sleeping in a wheelchair with her legs elevated. A scabbed area, was observed on the resident's left lower extremity, measuring approximately 5.0 x 0.5 centimeters (cm) without drainage, open to air.

A review of the resident's clinical record conducted during the survey ending May 10, 2024, revealed no documented evidence of this skin injury, a nursing assessment of the resident's injury or the cause of the injury.

During an interview with the Director of Nursing (DON) on May 7, 2024, at 11:00 AM confirmed there was no evidence of any documentation of an assessment on Resident 102's injury on the left lower leg.

A review of the clinical record of Resident 43 revealed admission to the facility on July 8, 2023, with diagnoses that include type 2 diabetes mellitus ([T2DM] a condition resulting in insufficient production of insulin causing high blood sugar) and explosion and rupture of boil (red, swollen, painful and pus-filled area under the skin).

A quarterly MDS dated February 6, 2024, revealed that the resident was cognitively intact, requiring extensive assistance from staff with ADLs.

A review of progress notes dated March 7, 2024, at 10:00 AM revealed that the resident stated that she has a history of boils, and was complaining of a boil to her left inner labia majora (the larger outer folds of the female external genitals). Upon staff inspection, of the area it was noted to be open and appeared to have burst. The physician was made aware with orders to clean the area with soap and water every shift and as needed with changes and peri-care.

A physician's order dated March 8, 2024, at 10:51 AM indicated Ichthammol External Ointment (a topical salve medication) 20% apply to affected area topically two times a day related to explosion and rupture of boil.

A review of the Treatment Administration Record (TAR) for the month of March 2024 revealed that that staff administered the prescribed treatment of Ichthammol Ointment prescribed from March 9, 2024, until March 19, 2024.

A review of documents titled "Skin Inspection" dated March 18, 2024, at 9:39 AM revealed that there were no new observed skin issues.

A review of the resident's clinical record conducted during the survey ending May 10, 2024, revealed no documented evidence of the healing progress, status or condition of the resident's boil, or the date it had resolved. There was no evidence of documentation provided that an ongoing assessment, wound tracking, or resolution of Resident 43's skin boil was performed.

Interview with the DON and Nursing Home Administrator (NHA) on May 10, 2024, at approximately 12:45 PM confirmed there was no nursing documentation in the resident's clinical record tracking the healing and resolution of the resident's boil.



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

28 Pa. Code 211.5 (f) Medical records







 Plan of Correction - To be completed: 06/25/2024

1) Resident #7 scabbed area treated, and care plan updated; Incident Report completed. Resident #43 area was resolved, care plan updated.
2) Nursing staff will complete head to toe body audits on current residents and complete appropriate wound documentation as indicated.
3) DON/Designee will provide education to nursing staff on Charting and Documentation policy.
4) DON/Designee will complete random audits 5 x week x 4 weeks then weekly x 8 during clinical meeting of skin injuries, wound tracking. Care plans will be updated to reflect any additional orders and treatments. Results of audits will be reported and reviewed by the Quality Assurance Performance Improvement Committee and changes will be made as needed.

483.90(g)(1)(2) REQUIREMENT Resident Call System: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.
§483.90(g) Resident Call System
The facility must be adequately equipped to allow residents to call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area from-

§483.90(g)(1) Each resident's bedside; and
§483.90(g)(2) Toilet and bathing facilities.
Observations:


Based on observation and staff interviews it was determined that the facility failed to ensure call bells were accessible to one of 23 residents sampled (Resident 52).

Findings include:

Observation on May 9, 2024, at 9 AM revealed that in resident room 328, in which Resident 52, a severely, cognitively impaired resident resided, but was not in the room at the time of the observation there was no call bell connected to the wall outlet or anywhere these in the room. There was no alternate method for use as a call bell, such as a tap bell noted in the resident's room. There were 2 plugs placed into the wall outlet call bell unit. The plugs were utilized to circumvent the alarm when the outlet is unplugged.

Interview with Employee 4 (licensed practical nurse) on May 9, 2024, at 9:05 AM confirmed the observation that Resident 52 did not have access to a call bell to summon staff assistance while in bed and verified that call bells are to be placed within reach of the residents and each resident's bedside.

Interview with the Nursing Home Administrator on May 9, 2024, at approximately 1 PM, verified that call bells are to be placed at each resident's bedside.



28 Pa. Code 205.67 (j) Electric Requirements for existing and new construction










 Plan of Correction - To be completed: 06/25/2024

1) The call bell was placed in Resident #52 room.
2) Maintenance will complete an audit on current resident rooms to ensure functioning call bells are in place.
3) NHA Designee will provide education to all facility staff on Resident Call System to ensure all call bells are functional and in place.
4) NHA/Designee will complete random audits of 5 resident rooms per week X 12 weeks to ensure call bell is functional. Results of audits will be reported and reviewed by the Quality Assurance Performance Improvement Committee and changes will be made as needed.

483.90(i)(5) REQUIREMENT Smoking Policies:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
§483.90(i)(5) Establish policies, in accordance with applicable Federal, State, and local laws and regulations, regarding smoking, smoking areas, and smoking safety that also take into account nonsmoking residents.
Observations:

Based on observation, review of select facility policy and clinical records, and staff interview, it was determined that the facility failed to implement established procedures to assure safe smoking ability for one resident out of one resident identified as a current smoker (Resident 34).

Findings include:

During an onsite survey beginning May 7, 2024, a policy was observed on facility bulletin board indicating that the facility was a non-smoking facility that smoking is not permitted within the facility or on facility grounds. During entrance conference on May 7, 2024, at 9:30 a.m. the Nursing Home Administrator stated that one resident, Resident 34 was a current smoker.

Review of Resident 34's clinical record revealed that the resident was admitted to the facility on November 10, 2023, with diagnoses to have included chronic obstructive pulmonary disease (COPD).

Review of Resident 34's plan of care, reviewed during the survey ending May 10, 2024, revealed no care plan to address the resident's smoking until surveyor inquiry on May 8, 2024.

The facility did not have a smoking policy to address the decision to allow Resident 34 to smoke at the non-smoking facility and grounds until brought to the facility's attention during survey ending May 10, 2024.

Interview with the Nursing Home Administrator and Director of Nursing on May 09, 2024 at 9:15 a.m. were unable to provide evidence that Resident 34's smoking was addressed in a care plan and a revised smoking policy was created.



28 Pa. Code 209.3 (a)(c) Smoking.






 Plan of Correction - To be completed: 06/25/2024

1) Facility updated Smoking Policy to include Resident #34 special smoking agreement.
2) NHA/designee will complete an audit of current residents confirm that any resident who smokes has implement interventions to assure safe smoking.
3) NHA/Designee will provide education to all staff on updated facility Smoking Policy. Education to include that policy states the facility is nonsmoking but has entered into a contract with 1 resident, who smokes one cigarette one day per week. Prior to admission potential residents are informed of facility policy and the extent the facility can accommodate their smoking or non-smoking preferences.
4) NHA/designee will complete random audits weekly X 4 weeks then monthly x 2 on new admissions to ensure that facility smoking policy is being followed. Results of audits will be reported and reviewed by the Quality Assurance Performance Improvement Committee and changes will be made as needed.

§ 201.27 LICENSURE Advertisement of special services.:State only Deficiency.
A facility may not advertise special services offered unless the service is under the direction and supervision of personnel trained or educated in that particular special service, such as, rehabilitation or physical therapy by a registered physical therapist; occupational therapy by a registered occupational therapist; skilled nursing care by registered nurses; special diets by a dietitian; or special foods.

Observations:

Based on review of facility documents and online marketing, observations and staff interview, it was determined that the facility advertised the offering of specialized services without demonstrating evidence of adequate direction and supervision of these specialized services.


Findings include:

A review of a facility website marketing information revealed that it included in the services and amenities provided to residents included a specialized Memory Care Unit.

The description of the facility's "Memory Care Unit" indicated that the facility provides residents with the supervision, safety, and engagement they need to live fulfilling lives. Residents with dementia or memory loss are encouraged to participate in activities focused on improving motor skills, recall, and how they process the events of daily life.

There was no documented evidence at the time of the survey that the facility advertised "Memory Care Unit" was under the direction and supervision of personnel trained or educated in that particular special service.

During an interview May 10, 2024 at approximately 11 AM the interim Nursing Home Administrator confirmed that the facility advertised and promoted the Memory Care Unit as a special service offered at the facility but was unable to demonstrate the provision of specialized care, services and activities programming by staff possessing speciality training, education, competencies and skills in the specialty care area.











 Plan of Correction - To be completed: 06/25/2024

1. The facility does not have a special unit. It offers "Memory Care Services". The website will be changed to reflect this.
2. Nursing Home Administrator will review the facility website for any other changes.
3. The Facility will modify the website so as not to include any services that are not offered at the facility.
4. Nursing Home Administrator will audit the website monthly for three months to verify the correct language is advertised. The Quality Assurance Performance Committee will review findings of these audits and make changes as needed.

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