Pennsylvania Department of Health
VINCENTIAN HOME
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

VINCENTIAN HOME
Inspection Results For:

There are 122 surveys for this facility. Please select a date to view the survey results.

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VINCENTIAN HOME - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:

Based on an Medicaid/Medicare Recertification, State Licensure, Civil Rights Compliance, and a complaint survey completed on May 31, 2024, it was determined that Vincentian Home 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:

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

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

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

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

Plan of Correction - To be completed: 07/15/2024

Resident R17, R 38, R 93 continues to reside in the facility and have returned from hospitalization.
Licensed nursing employees will be educated on transfer/ discharge documentation.
The facility will act to protect residents in similar situations by ensuring the transfer documentation is sent. This will be accomplished by the Licensed Nurse.
Measures the facility will take to ensure practice does not recur include education will be provided to all the Licensed Nurses on transfer discharge documentation. This education will be provided by the DON/ADON/Designee.
Performance will be monitored by conducting transfer documentation audits in PCC. A minimum of 3 audits weekly for a period of four weeks, and monthly thereafter for a period of three months. Audits will be conducted by DON/ADON/Designee and results will be reported to the quarterly Quality Assurance Committee Meeting.

483.70(o)(1)-(4) REQUIREMENT Hospice Services:

§483.70(o) Hospice services.
§483.70(o)(1) A long-term care (LTC) facility may do either of the following:
(i) Arrange for the provision of hospice services through an agreement with one or more Medicare-certified hospices.
(ii) Not arrange for the provision of hospice services at the facility through an agreement with a Medicare-certified hospice and assist the resident in transferring to a facility that will arrange for the provision of hospice services when a resident requests a transfer.

§483.70(o)(2) If hospice care is furnished in an LTC facility through an agreement as specified in paragraph (o)(1)(i) of this section with a hospice, the LTC facility must meet the following requirements:
(i) Ensure that the hospice services meet professional standards and principles that apply to individuals providing services in the facility, and to the timeliness of the services.
(ii) Have a written agreement with the hospice that is signed by an authorized representative of the hospice and an authorized representative of the LTC facility before hospice care is furnished to any resident. The written agreement must set out at least the following:
(A) The services the hospice will provide.
(B) The hospice's responsibilities for determining the appropriate hospice plan of care as specified in §418.112 (d) of this chapter.
(C) The services the LTC facility will continue to provide based on each resident's plan of care.
(D) A communication process, including how the communication will be documented between the LTC facility and the hospice provider, to ensure that the needs of the resident are addressed and met 24 hours per day.
(E) A provision that the LTC facility immediately notifies the hospice about the following:
(1) A significant change in the resident's physical, mental, social, or emotional status.
(2) Clinical complications that suggest a need to alter the plan of care.
(3) A need to transfer the resident from the facility for any condition.
(4) The resident's death.
(F) A provision stating that the hospice assumes responsibility for determining the appropriate course of hospice care, including the determination to change the level of services provided.
(G) An agreement that it is the LTC facility's responsibility to furnish 24-hour room and board care, meet the resident's personal care and nursing needs in coordination with the hospice representative, and ensure that the level of care provided is appropriately based on the individual resident's needs.
(H) A delineation of the hospice's responsibilities, including but not limited to, providing medical direction and management of the patient; nursing; counseling (including spiritual, dietary, and bereavement); social work; providing medical supplies, durable medical equipment, and drugs necessary for the palliation of pain and symptoms associated with the terminal illness and related conditions; and all other hospice services that are necessary for the care of the resident's terminal illness and related conditions.
(I) A provision that when the LTC facility personnel are responsible for the administration of prescribed therapies, including those therapies determined appropriate by the hospice and delineated in the hospice plan of care, the LTC facility personnel may administer the therapies where permitted by State law and as specified by the LTC facility.
(J) A provision stating that the LTC facility must report all alleged violations involving mistreatment, neglect, or verbal, mental, sexual, and physical abuse, including injuries of unknown source, and misappropriation of patient property by hospice personnel, to the hospice administrator immediately when the LTC facility becomes aware of the alleged violation.
(K) A delineation of the responsibilities of the hospice and the LTC facility to provide bereavement services to LTC facility staff.

§483.70(o)(3) Each LTC facility arranging for the provision of hospice care under a written agreement must designate a member of the facility's interdisciplinary team who is responsible for working with hospice representatives to coordinate care to the resident provided by the LTC facility staff and hospice staff. The interdisciplinary team member must have a clinical background, function within their State scope of practice act, and have the ability to assess the resident or have access to someone that has the skills and capabilities to assess the resident.
The designated interdisciplinary team member is responsible for the following:
(i) Collaborating with hospice representatives and coordinating LTC facility staff participation in the hospice care planning process for those residents receiving these services.
(ii) Communicating with hospice representatives and other healthcare providers participating in the provision of care for the terminal illness, related conditions, and other conditions, to ensure quality of care for the patient and family.
(iii) Ensuring that the LTC facility communicates with the hospice medical director, the patient's attending physician, and other practitioners participating in the provision of care to the patient as needed to coordinate the hospice care with the medical care provided by other physicians.
(iv) Obtaining the following information from the hospice:
(A) The most recent hospice plan of care specific to each patient.
(B) Hospice election form.
(C) Physician certification and recertification of the terminal illness specific to each patient.
(D) Names and contact information for hospice personnel involved in hospice care of each patient.
(E) Instructions on how to access the hospice's 24-hour on-call system.
(F) Hospice medication information specific to each patient.
(G) Hospice physician and attending physician (if any) orders specific to each patient.
(v) Ensuring that the LTC facility staff provides orientation in the policies and procedures of the facility, including patient rights, appropriate forms, and record keeping requirements, to hospice staff furnishing care to LTC residents.

§483.70(o)(4) Each LTC facility providing hospice care under a written agreement must ensure that each resident's written plan of care includes both the most recent hospice plan of care and a description of the services furnished by the LTC facility to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, as required at §483.24.

Observations:

Based on a review of facility policy, resident clinical records, and staff interview, it was determined the facility failed to obtain a diagnosis for hospice services and to ensure the coordination of hospice services with facility services to meet the needs of each resident for end of life care for three of three residents (Resident R17, R53, R62).

Findings include:

Review of the facility policy "Hospice Services" dated 4/17/24, indicated that care for the dying resident shall be a collaborative effort between the staff of the designated hospice provider and the staff of the long term care facility. The facility will obtain information from hospice that includes names and contact information for hospice staff involved in the resident's care, and how to access the hospice's 24 hour on-call system.

Review of the clinical record revealed that Resident R17 was admitted to the facility on 8/10/13.

Review of Resident 17's MDS (Minimum Data Set- periodic assessment of resident care needs) dated 3/22/24, indicated diagnoses of multiple sclerosis (a disease that affects central nervous system), high blood pressure, and weakness. Section O - Special Treatments, Procedures, and Programs indicated hospice care while a resident.

Review of Resident R17's clinical record revealed a physician order dated 3/11/24, to admit to hospice, but did not include a diagnosis related to the need of hospice services.

Review of Resident R17's current comprehensive care plan failed to indicate a plan of care by the facility that displayed the coordination of hospice services by failing to included contact information for the hospice agency and how to access the hospice's 24 hour on-call system.

Review of the clinical record indicated Resident R53 was admitted to the facility on 4/9/21.

Review of Resident R53's MDS dated 5/7/24, indicated diagnoses of Alzheimer's Disease (a progressive disease that destroys memory and other important mental functions), depression (a constant feeling of sadness and loss of interest), and age-related physical debility. Section O - Special Treatments, Procedures, and Programs indicated hospice care while a resident.

Review of Resident R53's clinical record revealed a physician order dated 1/26/24, to admit to hospice services, but did not include a diagnosis related to the need of hospice services.

Review of Resident R53's comprehensive care plan failed to indicate a plan of care by the facility that displayed the coordination of hospice services by failing to include contact information for the hospice agency and how to access the hospice's 24 hour on-call system.

Review of the clinical record revealed that Resident R62 was admitted to the facility on 3/30/23.

Review of Resident 62's MDS dated 3/12/24, indicated diagnoses of cerebral infarction (necrotic tissue in the brain resulting loss of blood and oxygen to the brain), schizophrenia (a mental disorder characterized by delusions, hallucinations, disorganized speech and behavior), and abnormal posture.

Review of Resident R62's clinical record revealed a physician order dated 2/28/24, to admit to hospice, but did not include a diagnosis related to the need of hospice services.

Review of Resident R62's current comprehensive care plan failed to indicate a plan of care by the facility that displayed the coordination of hospice services by failing to included contact information for the hospice agency and how to access the hospice's 24 hour on-call system.

During an interview on 5/30/24, at 11:37 a.m. Director of Nursing confirmed that the facility failed to obtain a diagnosis for hospice services and to ensure the coordination of hospice services with facility services to meet the needs of each resident for end of life care for three of three hospice residents (R17, R53, and R62).

28 Pa. Code 211.2(a) Physician services

28 Pa. Code 211.11(d) Resident care plan

Plan of Correction - To be completed: 07/15/2024

Resident R17 continues reside in the facility. MD order reflects hospice diagnosis. Comprehensive care plan was updated to include hospice company and contact information. Resident R53 continues reside in the facility. MD order reflects hospice diagnosis. Comprehensive care plan was updated to include hospice company and contact information. Resident R62 continues reside in the facility. MD order reflects hospice diagnosis. Comprehensive care plan was updated to include hospice company and contact information.
The facility will act to protect residents in similar situations by conducting reviews of hospice orders with diagnosis and comprehensive hospice care plan information.
Measures the facility will take to ensure practice does not recur will include educational in-services by the DON/ADON/Designee to the licensed nurses, nurse aides. Educational in-services will include license nurses obtain MD order with supporting diagnosis. Education will also include the license nurse update comprehensive care plan to include hospice name and contact information.
Performance will be monitored by conducting audits for hospice orders with supporting diagnosis and hospice information on comprehensive. These audits will be conducted 3 audits weekly (for newly admitted hospice residents) for a period of four weeks, and monthly thereafter for a period of three months. Audits will be conducted by DON/ADON/Designee and results will be reported to the quarterly Quality Assurance Committee Meeting.

483.25 REQUIREMENT Quality of Care:

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

Plan of Correction - To be completed: 07/15/2024

Resident R174, R 382 no longer reside in the facility. Resident R 50, R 385 continue to reside in the facility. Resident R 50 had skin check performed on 6/6/24 and weekly labs were discontinued per MD. Resident R 385 had skin check completed on 6/4/24.
The facility will act to protect residents in similar situations by conducting reviews of weekly labs, weekly skin assessments and reconciliation of admission orders.
Measures the facility will take to ensure practice does not recur will include educational in-services by the DON/ADON/Designee to the licensed nurses and nurse aides. Educational in-services will include identification of assessments for weekly skin and labs. Education will also include reconciliation of admission orders process.
Performance will be monitored by conducting audits of completion of weekly skin assessments, weekly labs and admission reconciliation of medications. A minimum of 3 audits weekly for a period of four weeks, and monthly thereafter for a period of three months. Audits will be conducted by DON/ADON/Designee and results will be reported to the quarterly Quality Assurance Committee Meeting.

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

§483.15(c)(3) Notice before transfer.
Before a facility transfers or discharges a resident, the facility must-
(i) Notify the resident and the resident's representative(s) of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand. The facility must send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman.
(ii) Record the reasons for the transfer or discharge in the resident's medical record in accordance with paragraph (c)(2) of this section; and
(iii) Include in the notice the items described in paragraph (c)(5) of this section.

§483.15(c)(4) Timing of the notice.
(i) Except as specified in paragraphs (c)(4)(ii) and (c)(8) of this section, the notice of transfer or discharge required under this section must be made by the facility at least 30 days before the resident is transferred or discharged.
(ii) Notice must be made as soon as practicable before transfer or discharge when-
(A) The safety of individuals in the facility would be endangered under paragraph (c)(1)(i)(C) of this section;
(B) The health of individuals in the facility would be endangered, under paragraph (c)(1)(i)(D) of this section;
(C) The resident's health improves sufficiently to allow a more immediate transfer or discharge, under paragraph (c)(1)(i)(B) of this section;
(D) An immediate transfer or discharge is required by the resident's urgent medical needs, under paragraph (c)(1)(i)(A) of this section; or
(E) A resident has not resided in the facility for 30 days.

§483.15(c)(5) Contents of the notice. The written notice specified in paragraph (c)(3) of this section must include the following:
(i) The reason for transfer or discharge;
(ii) The effective date of transfer or discharge;
(iii) The location to which the resident is transferred or discharged;
(iv) A statement of the resident's appeal rights, including the name, address (mailing and email), and telephone number of the entity which receives such requests; and information on how to obtain an appeal form and assistance in completing the form and submitting the appeal hearing request;
(v) The name, address (mailing and email) and telephone number of the Office of the State Long-Term Care Ombudsman;
(vi) For nursing facility residents with intellectual and developmental disabilities or related disabilities, the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with developmental disabilities established under Part C of the Developmental Disabilities Assistance and Bill of Rights Act of 2000 (Pub. L. 106-402, codified at 42 U.S.C. 15001 et seq.); and
(vii) For nursing facility residents with a mental disorder or related disabilities, the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with a mental disorder established under the Protection and Advocacy for Mentally Ill Individuals Act.

§483.15(c)(6) Changes to the notice.
If the information in the notice changes prior to effecting the transfer or discharge, the facility must update the recipients of the notice as soon as practicable once the updated information becomes available.

§483.15(c)(8) Notice in advance of facility closure
In the case of facility closure, the individual who is the administrator of the facility must provide written notification prior to the impending closure to the State Survey Agency, the Office of the State Long-Term Care Ombudsman, residents of the facility, and the resident representatives, as well as the plan for the transfer and adequate relocation of the residents, as required at § 483.70(l).

Plan of Correction - To be completed: 07/15/2024

Resident R17, R 38, R 93 continues to reside in the facility and have returned from hospitalization.
Clinical employees will be educated on transfer/ discharge documentation to the ombudsman.
The facility will act to protect residents in similar situations by ensuring the transfer documentation is sent to the ombudsman. This will be accomplished by the social worker.
Measures the facility will take to ensure practice does not recur include education provided to all clinical staff regarding transfer/discharge documentation to Ombudsman. This education will be provided by the DON/ADON/Designee.
Performance will be monitored by conducting transfer documentation to ombudsman audits. A minimum of 3 audits weekly for a period of four weeks, and monthly thereafter for a period of three months. Audits will be conducted by DON/ADON/Designee and results will be reported to the quarterly Quality Assurance Committee Meeting.

483.10(c)(7) REQUIREMENT Resident Self-Admin Meds-Clinically Approp:

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

§483.10(c)(7) The right to self-administer medications if the interdisciplinary team, as defined by §483.21(b)(2)(ii), has determined that this practice is clinically appropriate.

Observations:

Based on review of facility policies, clinical records, observations, resident and staff interviews, it was determined that the facility failed to determine the ability to self-administer medications for one of six residents (Resident R114).

Findings include:

A review of the facility's policy "Medication Administration" dated 4/17/24, indicated that medications shall be administered only upon the order of physicians. No medication shall be left at the resident's bedside. The nurse administering the medication shall stay with the resident until the medication is taken. If a medication has been opened and is refused by a resident, it shall be destroyed.

Review of Resident R114's clinical record indicated she was admitted to the facility on 5/14/24.

Review of Resident R114's MDS (Minimum Data Set, periodic assessment of resident care needs) dated 5/20/24, indicated diagnosis of hypertension (high blood pressure in the arteries), osteoporosis (condition when the bones become brittle and fragile), and anxiety.

Review of Resident R114's physician orders failed to include an order for self-administration of medications.

Review of Resident R114's care plan dated 5/15/24, failed to include self-administration of medication management.

Review of Resident R114's clinical record failed to include a Self-Administration of Medication assessment.

During an observation on 5/28/24, at 10:25 a.m., revealed a medication cup with two oval pills inside sitting on the overbed table.

During an interview on 5/28/24, at 10:26 a.m., Resident R114 stated that she is not taking the two pills that were in the medication cup on her overbed table.

During an interview on 5/28/24, at 10:33 a.m., the Registered Nurse (RN) Employee E6 confirmed that two pills were at bedside and removed the medications.

During an interview on 5/28/24, at 3:15 p.m., the Director of Nursing confirmed that the medication was at bedside and the facility failed to determine the ability to self-administer medications for one of six residents (Resident R114).

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

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

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

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

Plan of Correction - To be completed: 07/15/2024

Resident R114 continues to reside in the facility and will be assessed for self-administration of medications by the licensed nurse.
Employee E6 will be counseled not leaving the medications in the residents room. In addition, if the residents are appropriate, to assess the residents for Self-Administration of Medications.
The facility will act to protect residents in similar situations by reviewing the opportunity to be assessed for Self-Administration of Medications for current residents. This will be accomplished by the Licensed Nurse.
Measures the facility will take to ensure practice does not recur include assessing residents for Self-Administration of Medications who are eligible by the Licensed Nurse. In addition, education will be provided to all the Licensed Nurses not to leave medications with a resident who has not been assessed for Self-Administration of medications. This education will be provided by the DON/ADON/Designee.
Performance will be monitored by conducting medication administration audits with the Licensed Nurses. A minimum of 3 audits weekly for a period of four weeks, and monthly thereafter for a period of three months. Audits will be conducted by DON/ADON/Designee and results will be reported to the quarterly Quality Assurance Committee Meeting.

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

§483.25(d) Accidents.
The facility must ensure that -
§483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and

§483.25(d)(2)Each resident receives adequate supervision and assistance devices to prevent accidents.

Plan of Correction - To be completed: 07/15/2024

Resident R13 continues reside in the facility. After incident she was sent to hospital for evaluation and returned to facility with a laceration. Employee involved with incident is no longer employed with facility. All staff was educated on proper bed mobility techniques. Resident R 54 and R 81continue to reside in the facility. Both residents have had completed neurological assessments within normal limits.
The facility will act to protect residents in similar situations by conducting reviews of neuro assessments post falls to ensure completion and educate staff on appropriate bed mobility techniques.
Measures the facility will take to ensure practice does not recur will include educational in-services by the DON/ADON/Designee to the licensed nurses and nurse aides. Educational in-services will include completion of the post fall neurological checks and bed mobility.
Performance will be monitored by conducting audits for completion of post fall neurological checks and proper bed mobility. These audits will be conducted 3 times for the first week. Then weekly for a period of four weeks, then monthly thereafter for a period of three months. Audits will be conducted by DON/ ADON/ Designee and results will be reported to the quarterly Quality Assurance Committee Meeting.

483.25(e)(1)-(3) REQUIREMENT Bowel/Bladder Incontinence, Catheter, UTI:

§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 review of facility policy, review of clinical records, observations, and staff interviews it was determined that the facility failed to ensure a physician order for a urinary catheter (insertion of a tube into the bladder to remove urine) for one of three residents (Resident R385), and failed to make certain that appropriate treatments and services were provided for the use of a urinary catheter as required for two of three residents (Resident R49, and R385).

Findings include:

Review of the facility policy "Indwelling urinary catheter insertion and Maintenance", dated 4/17/24, indicated that a resident should have a physician's order for a catheter that includes the type of catheter and the purpose for the catheter. Change catheters and drainage bags based on physician order.

Review of the clinical record revealed that Resident R49 was admitted to the facility on 4/21/22.

Review of Resident 49's MDS (Minimum Data Set- periodic assessment of resident care needs) dated 4/30/24, indicated diagnoses of Parkinson's disease (neuromuscular disorder causing tremors and difficulty walking), obstructive uropathy (a disorder of the urinary tract that occurs due to obstructed flow of urine) and muscle weakness. Section H0100 indicated the utilization of an indwelling catheter.

During an observation on 5/28/24, at 11:25 a.m. Resident R49 was in bed, with his urinary drainage bag hanging on the bed with no privacy cover.

During an interview on 5/28/24, at 11:59 a.m. Registered Nurse Employee E8 confirmed that the facility failed to implement the use of a privacy bag as required for Resident R49.

Review of clinical record indicated Resident R385 was admitted to the facility on 5/21/24.

Review of Resident R385's MDS dated 5/21/24, indicated diagnoses of diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time), heart failure (a progressive heart disease that affects pumping action of the heart muscles), and dysphasia (difficult swallowing).

Review of Resident R385's physicians orders on 5/28/24, at 2:15 p.m. indicated resident to have a foley catheter dignity bag cover on at all times, foley care every shift, and record and measure foley output.

Review of Resident R385's physicians orders dated 5/28/24, failed to indicate that Resident R385 had current orders for a foley catheter, size of catheter, when to change the foley catheter or a valid medical diagnosis for the foley catheter.

During an observation on 5/29/24, at 11:40 a.m. Resident R385 was in her bed and did not have a dignity bag covering her foley bag.

During an interview on 5/29/24, at 11:45 a.m. Registered Nurse (RN) Employee E7 stated, "Residents usually have all those foley orders but I don't see them".

During an interview on 5/29/24, at 11:47 a.m. Registered Nurse Employee E7 confirmed that the facility failed to implement the use of a privacy bag as required for Resident R385.

During an interview on 5/30/24, at 3:15 p.m. the Director of Nursing confirmed that the facility failed to ensure a physician order for a urinary catheter for one of three residents (Resident R385), and failed to make certain that appropriate treatments and services were provided for the use of a urinary catheter as required for two of three residents (Resident R49, and R385).

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

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

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

Plan of Correction - To be completed: 07/15/2024

Resident R385 continues reside in the facility. MD issued catheter order/ foley maintenance and privacy bag placed. Resident R 49 continues to reside in facility and a privacy bag was placed.
The facility will act to protect residents in similar situations by conducting reviews of foley catheter orders and privacy bag placement.
Measures the facility will take to ensure practice does not recur will include educational in-services by the DON/ADON/Designee to the licensed nurses and nurse aides. Educational in-services will include recognition of foley catheter orders from MD and application of privacy bags.
Performance will be monitored by conducting audits for foley catheter orders and placement of privacy dignity bags. These audits will be conducted 3 audits weekly for a period of four weeks, and monthly thereafter for a period of three months. Audits will be conducted by DON/ADON/Designee and results will be reported to the quarterly Quality Assurance Committee Meeting.

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

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

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

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

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

Plan of Correction - To be completed: 07/15/2024

Resident R78 MD saw resident and addressed weight issue loss, supplements in place. R382 has discharged from facility. Resident R114 continues to reside in the facility. Per MD daily weights were discontinued. Resident condition stable.
The facility will act to protect residents in similar situations by conducting reviews of daily weights per MD orders for loss or gain. Licensed staff will be educated to communicate changes to physician. CNA will obtain daily weight when direct by licensed staff.
Measures the facility will take to ensure practice does not recur will include educational in-services by the DON/ADON/Designee to the licensed nurses, nurse aides and dietician staff. Educational in-services will include notification to the MD for parameters of the weight orders. Recognizing and documenting significant weight loss and gain. Education on daily weights when ordered by MD.
Performance will be monitored by conducting audits for weight order parameters and obtaining ordered weights. These audits will be conducted 3 audits weekly for a period of four weeks, and monthly thereafter for a period of three months. Audits will be conducted by Dietician/ DON/ADON/Designee and results will be reported to the quarterly Quality Assurance Committee Meeting.

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

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

§483.45(h) Storage of Drugs and Biologicals

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

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

Observations:

Based on review of facility policy, observation, and staff interviews, it was determined that the facility failed to properly secure one of four medications carts reviewed (Building One Second Floor Low Side Med Cart).

Findings include:

Review of facility policy "Drug Acquisition, Storage, Inspection, and Dispensing" dated 4/17/24, indicated medications shall be stored in a secure manner. Lockable medication carts shall be used to store unit-of-use medications in the resident medication dose system. These carts shall be locked when not attended.

During an observation on 5/28/24, at 10:09 a.m. the Building One Second Floor Low Side Med Cart was observed unlocked and unattended with the top drawer pulled open.

During an interview on 5/28/24, at 10:10 a.m. Registered Nurse Employee E2 confirmed that the medication cart was unattended, unlocked, and the top drawer was pulled open.

During an interview on 5/28/24, at 1:31 p.m. the Nursing Home Administrator confirmed that the facility failed to properly secure one of four medications carts reviewed (Building One Second Floor Low Side Med Cart).

28 Pa. Code: 211.9(a)(1)(h)(k)(l)(1) Pharmacy services.
28 Pa. Code:211.12(d)(1)(2)(3)(5) Nursing services.

Plan of Correction - To be completed: 07/15/2024

Immediately the Nurse on the unit was educated about proper medication storage and locking the cart. This education is documented.
Measures the facility will take to ensure practice does not recur will include educational in-services by the DON/ADON/Designee to the licensed nurses. Educational in-services will include properly securing the medication cart at all times.
Performance will be monitored by conducting audits for locked medication carts and storage. These audits will be conducted 3 audits weekly for a period of four weeks, and monthly thereafter for a period of three months. Audits will be conducted by Dietician/ DON/ADON/Designee and results will be reported to the quarterly Quality Assurance Committee Meeting.

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