Pennsylvania Department of Health
WHITESTONE CARE CENTER
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

WHITESTONE CARE CENTER
Inspection Results For:

There are 121 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.


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

Initial comments:

Based on a Medicare/Medicaid Recertification, State Licensure, Civil Rights Compliance, and Abbreviated Complaint survey completed on February 23, 2024, it was determined that Whitestone Care Center was not in compliance with the following requirements of 42 CFR Part 483 Subpart B Requirements for Long Term Care Facilities and the 28 PA Code Commonwealth of Pennsylvania Long Term Care Licensure Regulations.

Plan of Correction:

483.60(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 observation, review of select facility policy 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.

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 and Nutrition Services: Food Production and Food Safety" that was last reviewed by the facility on April 21, 2023, revealed that all items must be stored at least six (6) inches above the floor and all food removed from the freezer will be labeled with a pull date.

The initial tour of the kitchen was conducted with the certified dietary manager (CDM) on February 21, 2024, at 8:44 a.m., revealed the following unsanitary practices with the potential to introduce contaminants into food and increase the potential for food-borne illness, was identified:

Observations of the walk-in produce/dairy refrigerator revealed that there were several cases of juices that were directly on the floor.

Inside of the walk-in freezer there were several cases of frozen foods that were blocking the walkway and directly on the floor.

Observations of the dry storage area revealed several cases of dry foods on the floor.

An interview with the CDM confirmed that when food/food items are received that they should not be directly on the floor and should be stored 6-inches off the floor.

Observation of the cold production reach-in cooler revealed a full sheet tray of thawed 4-ounce shakes, which lacked a thaw or discard date. According to manufacturer's directions, the product had a 14-day shelf life after thawing. The CDM confirmed at the time of the observation that the tray of 4-ounce shakes should have included a thaw date and/or a discard date.

An interview with the Nursing Home Administrator (NHA) on February 21, 2024, at 2:15 p.m., confirmed that foods and beverages should be stored off the floor and labeled to ensure acceptable use.

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

28 Pa. Code 211.6 (f) Dietary Services

Plan of Correction - To be completed: 03/19/2024

Items were corrected at the time of survey. Pallets were in the kitchen to set food delivery on. Shakes were labeled appropriately at time of survey.
To identify the potential for like issues the RD/designee completed a tour of the kitchen to ensure there were no cases of juice that were directly on the floor, cases of frozen foods were not stored directly in the walkway and directly on the floor, and in the dry storage area had no cases of dry foods on the floor.
To prevent this from happening again the registered dietitian/designee will educate the dietary manager and dietary dept. on ensuring when deliveries are made they are stored on a pallet until put away and that when shakes are pulled from the freezer the pull and thaw date is present.
To monitor and maintain ongoing compliance the RD/designee will complete audits of food delivery weekly x 4 then monthly x2 to ensure delivery is not placed on floor and on the pallets, juices are stored appropriately and dry food storage area has food stored correctly.
To monitor and maintain ongoing compliance the dietary manager/designee will audit thawing of shakes 3 times a week x 4 weeks then monthly x 2 to ensure shakes have a pulled date sticker on them and thaw date when pulled from the freezer.

483.24(a)(2) REQUIREMENT ADL Care Provided for Dependent Residents:

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.

§483.24(a)(2) A resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene;

Observations:

Based on a review of select facility policy and clinical records and staff interviews, it was determined that the facility failed to ensure that residents dependent on staff for assistance with activities of daily living were the necessary care and services to maintain good personal hygiene by failing to shower residents at the scheduled/planned frequency for three out of 18 residents sampled (Residents 7, 31, and 1).

Findings include:

A review of a facility policy entitled "Resident Bath/Shower/Scheduling Policy" that was last reviewed by the facility on April 21, 2023, indicated that residents will be bathed or showered according to their preferences in order to maintain healthy hygiene and skin condition. Each resident will be scheduled to receive bathing a minimum of two times per week unless they prefer less frequent baths or state regulations requires more frequent bathing. When the bath or shower is complete, the nurse assistant (NA) will document the activity on the shower sheet or Point of Care [(POC) an electronic record keeping system that staff record assigned care tasks that they completed for each resident] of the electronic record. If the bath/shower cannot be given or the resident refuses, the nursing assistant will promptly report this to the Charge Nurse. The Charge Nurse will speak with the resident who refuses to ascertain why they are refusing and to determine if alternative arrangements that suit the resident can be made. If the resident continues to refuse, the Charge Nurse will document the resident's refusals in the medical record.

A review of Resident 7's clinical record revealed that the resident was initially admitted to the facility on December 12, 2012, with diagnoses that included hemiplegia (paralysis of one side of the body) and hemiparesis (muscular weakness or partial paralysis restricted to one side of the body) following unspecified cerebrovascular disease (includes a range of conditions that affect the flow of blood through the brain that alters the blood flow and can sometimes impair the brain's functions on either a temporary or permanent basis) affecting unspecified side, Alzheimer's dementia, Parkinson's disease (chronic and progressive movement disorder that initially causes tremor in one hand, stiffness or slowing of movement), and dysphagia (difficulty swallowing).

The resident's care plan, initiated May 6, 2015, and revised on September 23, 2023, indicated that the resident had activities of daily living (ADL) self-care deficit related to muscle weakness, advanced dementia, Parkinson's, S/P CVA, Hemiplegia/ Hemiparesis, and severely impaired cognition, and decreased range of motion (ROM) bilateral upper and bilateral lower extremities with a resident goal to maintain a clean, neat, and well-groomed appearance through next review. The care plan noted that the resident was non-ambulatory and required an assist of two with use of mechanical lift for transfers, and extensive to total assist of two staff for care to include bathing, dressing, toileting, and bed mobility. The resident's care plan indicated that staff were to shower the resident as per schedule (twice per week).

A review of the resident's shower task documentation report dated December 2023, revealed that staff showered Resident 7 on 12/1/2023, at 5:44 p.m., on 12/12/2023, at 2:59 p.m., and on 12/15/2023, at 10:03 p.m., providing the resident three showers out of eight scheduled/planned according to the shower schedule.

The resident's shower task documentation report dated January 2024, revealed that Resident 7 was showered on 1/5/2024, at 10:23 p.m., and on 1/12/2024, at 10:32 p.m.. The facility provided two showers out of eight scheduled for the resident.

Resident 7's shower task documentation report dated through survey ending February 23, 2024, revealed that staff showered the resident on 2/16/2024, at 5:07 p.m. To date, staff provided the resident one out of six scheduled showers.

There was no documented evidence that Resident 7 refused to be showered according to the schedule planned by the facility.

During an interview with the Director of Nursing (DON) on February 23, 2024, at approximately 11:45 a.m., revealed that Resident 7 should have received two showers per week.

A review of the clinical record revealed that Resident 31 was admitted to the facility on November 20, 2023, with diagnoses to include unspecified dementia (a condition that affects memory, thinking and interferes with daily life) and acute/chronic respiratory failure (lung condition where organs have inadequate oxygen supply due to fluid buildup in the lungs) with hypoxia (occurs when tissues and cells do not get enough oxygen to function correctly).

A review of Resident 31's care plan dated November 21, 2023, indicated that the resident required total assistance with bathing and hygiene related to chronic obstructive pulmonary disease (COPD, a chronic inflammatory lung disease that causes obstructed airflow from the lungs), muscle weakness and difficulty walking with interventions to have an assist of two staff members and use of a Hoyer lift (mechanical lift used to transfer residents) for transfers.

A review of Resident 31's task schedule for showers indicated that staff were to shower the resident every Monday and Friday.

A review of the resident's bathing records for November 2023, December 2023, January 2024, and February 2024 (as of the date of the survey ending February 23, 2024) revealed no evidence that the resident had been showered during these four months.

A review of the clinical record revealed that Resident 1 was admitted to the facility on January 4, 2024, with diagnoses to include unspecified dementia and a pressure ulcer stage two to the sacral region (partial thickness skin loss that extends into the bottom layers of the skin).

A review of Resident 1's care plan, revised on January 23, 2024, indicated that the resident required assistance from staff related to impaired mobility with planned interventions to have an assist of one staff member for bathing/hygiene and transfers.

A review of Resident 1's task schedule for showers indicated that the resident was to receive a shower every Monday and Thursday.

A review of the resident's bathing records for January 2024 and February 2024 revealed that staff showered the resident only once during the last two months through the time of the survey ending February 23, 2024.

During an interview on February 23, 2024, at approximately 2:00 PM, the Director of Nursing (DON) and Nursing Home Administrator (NHA) confirmed that the facility has not been able to consistently provide residents' showers as planned and that it was the facility's responsibility to ensure that residents that were dependent on staff for ADLs received timely and consistent assistance to maintain good personal hygiene and grooming.

28 Pa. Code 211.12 (d)(4)(5) Nursing services.

Plan of Correction - To be completed: 03/19/2024

The facility cannot retroactively correct past documentation for showers for resident 1, 7, and 31.
To identify like residents that have the potential to be affected the DON/designee will review current residents shower schedules to ensure all showers are scheduled and tasked appropriately to have documentation in the point of care to reflect showers given.
To prevent this from happening again the RDCS/designee educated the DON/ADON on how to review the shower schedule and documentation in point click care.
To prevent this from happening again the DON/designee will educate the nursing staff on the shower schedule, how to document showers in point click care, and refusals of shower.
To monitor and maintain ongoing compliance the DON/designee will audit shower documentation to ensure showers are documented appropriately in point click care 5 days a week x 4 weeks then monthly x 2. Interviews with two capable residents will be completed 5 days a week x 4 weeks then monthly x 2 to ensure showers are given. Observations of two incapable residents' showers will be completed 5 days a week x 4 weeks then monthly x 2 to ensure showers are given

483.25(b)(1)(i)(ii) REQUIREMENT Treatment/Svcs to Prevent/Heal Pressure Ulcer:

§483.25(b) Skin Integrity
§483.25(b)(1) Pressure ulcers.
Based on the comprehensive assessment of a resident, the facility must ensure that-
(i) A resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable; and
(ii) A resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing.

Observations:

Based on a review of clinical records, observations and staff and resident interviews it was determined that the facility failed to demonstrate the consistent implementation of measures planned to prevent pressure sore development for one resident out of two sampled with a pressure sore (Resident 18).

Findings included:

A review of Resident 18's clinical record revealed that the resident was initially admitted to the facility on June 15, 2021, with diagnoses that included Alzheimer's dementia, spinal stenosis (is a condition where spinal column narrows and compresses the spinal cord), ambulatory dysfunction, and anxiety.

Resident 18's current plan of care identified that the resident was at risk for skin breakdown related to decreased mobility and weakness and that the resident would have no preventable breakdown. Planned interventions included to turn and reposition every two hours, keep clean and dry, and to monitor for skin breakdown.

A review of a quarterly Minimum Data Set Assessment (MDS- a federally mandated standardized assessment process conducted periodically to plan resident care) assessment dated August 2, 2023, revealed that the resident had severe cognitive impairment and was dependent on staff for toileting, bathing, bed mobility and transfers.

A review of Resident 18's Survey Documentation Report (a summary report of staff's task/intervention completion) dated September 2023, revealed that there was no documented evidence that the planned pressure ulcer prevention intervention to turn and reposition every two hours was completed as planned.

A review of Resident 18's clinical record weekly wound assessment completed by Employee 2, a registered nurse (RN), dated September 27, 2024, at 3:11 a.m., revealed that the resident had a newly facility acquired developed moisture-associated skin damage (MASD - inflammation or skin erosion caused by prolonged exposure to moisture from sources such as urine, stool, sweat, wound drainage, saliva, or mucus) to the buttocks that measured 30.0 cm in length by 30.0 cm in width and zero (0) depth with no drainage, no odor. The immediate intervention was to apply veraseptine [skin treatment that forms a moisture barrier that prevents and helps heal skin irritations from urine, diarrhea, perspiration) twice per day and with each incontinence episode.

A progress note by the wound care specialist nurse practitioner (CRNP), dated September 28, 2024, at 8:45 a.m., revealed that the resident was evaluated due to a new skin impairment. The CRNP assessed that Resident 18 had a deep tissue injury (DTI - a localized area of maroon or purplish discoloration of intact skin or a blood-filled blister that forms due to shear and/or pressure). The area, (wound #1), to the sacrum measured 2.0 cm in length by 0.5 cm in width by 0.0 depth intact purplish non-blanchable epithelial tissue with pressure identified as the primary etiology.
A second DTI, (wound #2) was noted to the resident's left ischium (one of three bones of the pelvis) that measured 8.0 cm in length by 0.0 cm in depth intact purplish non-blanchable epithelial tissue with pressure identified as the primary etiology. A third area (wound #3) was noted to the sacral/perineal area with primary etiology as incontinence associated dermatitis with partial thickness that measured 0 cm in length by 0 cm in width by 0.0 cm in depth that had one hundred percent epithelial tissue and attached wound edges. The periwound was described as fragile, dermatitis, with scant amount of serous exudate. The recommended wound preventative measures were to continue on-going pressure reduction and turning/repositioning precautions, including pressure reduction to all boney prominences. Also, due to the resident's incontinence and increased risk of skin breakdown to continue protocol for swift incontinence management.

The resident's plan for maintenance of skin integrity was not revised to reflect the need and increased emphasis on the swiftness of incontinence management to ensure that staff provided prompt incontinence care at the frequency required to prevent further skin damage and to promote healing and prevent worsening of existing pressure sores.

The facility was unable to provide documented evidence that staff provided turning and repositioning at least, every two hours as care planned and Resident 18 received timely incontinence management in attempt to keep the resident clean and dry to prevent skin impairments.

During an interview with the Director of Nursing (DON) on February 23, 2024, at 10:33 a.m., the DON confirmed that the facility was unable to provide documented evidence that Resident 18 received timely and consistent repositioning and increased incontinence care in efforts to prevent the development of pressure sores.

Refer F690

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

Plan of Correction - To be completed: 03/19/2024

Resident # 18 pressure ulcers have healed. Cannot retroactively correct late documentation.
To identify like residents with the potential to be affected the DON/Designee will review current residents with pressure ulcers to ensure current preventative measures are implemented and care planned.
To prevent this from happening again the DON/designee will educate licensed staff and IDT on ensuring that preventative measures are implemented and care planned.
To monitor and maintain ongoing compliance the DON/Designee will audit current residents with pressure ulcers weekly x 4 then monthly x 2 to ensure preventative measures are implemented and care planned.
To monitor and maintain ongoing compliance the DON/designee will review new orders 5 days a week x 4 weeks then monthly x 2 to ensure any new preventative measures are implemented and care planned.

483.10(g)(14)(i)-(iv)(15) REQUIREMENT Notify of Changes (Injury/Decline/Room, etc.):

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(g)(14) Notification of Changes.
(i) A facility must immediately inform the resident; consult with the resident's physician; and notify, consistent with his or her authority, the resident representative(s) when there is-
(A) An accident involving the resident which results in injury and has the potential for requiring physician intervention;
(B) A significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications);
(C) A need to alter treatment significantly (that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment); or
(D) A decision to transfer or discharge the resident from the facility as specified in §483.15(c)(1)(ii).
(ii) When making notification under paragraph (g)(14)(i) of this section, the facility must ensure that all pertinent information specified in §483.15(c)(2) is available and provided upon request to the physician.
(iii) The facility must also promptly notify the resident and the resident representative, if any, when there is-
(A) A change in room or roommate assignment as specified in §483.10(e)(6); or
(B) A change in resident rights under Federal or State law or regulations as specified in paragraph (e)(10) of this section.
(iv) The facility must record and periodically update the address (mailing and email) and phone number of the resident
representative(s).

§483.10(g)(15)
Admission to a composite distinct part. A facility that is a composite distinct part (as defined in §483.5) must disclose in its admission agreement its physical configuration, including the various locations that comprise the composite distinct part, and must specify the policies that apply to room changes between its different locations under §483.15(c)(9).

Observations:
Based on a review of clinical records and select facility reports and staff interviews it was determined that the facility failed to timely consult with the physician regarding the potential need to alter treatment in response to a resident's increased pain following an unwitnessed fall for one resident out of 18 sampled (Resident 3).

Findings included:

Review of Resident 3's clinical record revealed that the resident was admitted to the facility on January 30, 2023, with diagnoses that included dementia, muscle weakness, history of fractures, age-related osteoporosis, and abnormal gait and mobility.

A review of an unwitnessed fall incident report that was completed by Employee 3, a registered nurse (RN), dated October 22, 2023, at 4:45 a.m., revealed that staff found Resident 3 sitting on her buttocks in her room on the right side of her bed. The resident reported to staff, "I was trying to hang the picture back on the wall." Employee 3 assessed the resident and noted that she had some pain/discomfort to her left elbow and an ice pack was applied and that the physician was notified.

An "eMAR - Medication Administration Note" completed by Employee 4, a licensed practical nurse (LPN) dated October 22, 2023, at 3:49 p.m., revealed that nursing administered the physician's ordered as needed (PRN) Acetaminophen Tablet (Tylenol - a non-opioid pain medication used to treat mild to moderate pain) 325 mg, 2 tablets to the resident in response to the resident offering complaints of left elbow pain. The resident reported pain at a level of 7 out of 10 (on a scale of 0-10, with 10 being the most severe).

An "eMAR - Medication Administration Note" completed by Employee 5, a LPN, dated October 23, 2023, at 8:57 p.m., revealed that a PRN Tylenol dose was administered for further complaints of severe pain post fall. The resident reported 7 out of 10, left elbow pain.

A review of a "Head to Toe Evaluation" completed by Employee 5, LPN, dated October 23, 2023, at 9:46 p.m., revealed that Resident 3 was assessed post fall occurrence and note with increased complaints (a resident reported 7 out of 10 pain level) of left elbow pain and swelling.

A progress note completed by Employee 5 on October 23, 2023, at 9:59 p.m., revealed that Resident 3's left elbow was warm to touch and swollen and to continue to monitor.

There was no documented evidence that nursing staff timely notified the resident's attending physician of the resident's increased and ongoing complaints of severe pain after the unwitnessed fall on October 22, 2023. The physician was not notified until October 24, 2023, according to an "eMAR - Medication Administration Note" completed by Employee 6, a RN, dated October 24, 2023, at 11:11 AM., which noted that Resident 3's attending physician was made aware of swelling to her left elbow with new orders to obtain an x-ray.

A review of a nursing progress note completed by the Director of Nursing (DON) dated October 24, 2023, at 2:00 p.m., revealed x-ray results that confirmed that Resident 3 sustained a left acute humeral fracture (is the medical name for breaking the bone in the upper arm). Resident 3's son was notified and declined to have the resident transferred to the hospital and requested to have a consult with an orthopedic (bone specialist) physician instead for treatment.

Interview with the Director of Nursing (DON) on February 23, 2024, at 10:15 a.m., confirmed that the facility failed to notify the physician of Resident 3's increased complaints of pain post an unwitnessed fall that resulted in a fracture to the resident's left upper arm.

Refer F697

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

28 Pa. Code 211.5(f) Clinical records

Plan of Correction - To be completed: 03/19/2024

Cannot retroactively correct past documentation in the medical record. Resident # 3 received two doses of acetaminophen which were effective for pain for the resident.
Step 2
To identify like residents the DON/designee will review current residents with new onset of pain to ensure MD notification was completed.
Step 3
To prevent this from happening again the DON/designee will complete education with licensed nurses to ensure that of a resident has new onset pain the MD is notified of new onset of pain.
Step 4
To monitor and maintain ongoing compliance the Don/designee will review current residents weekly x 4 then monthly x 2 to ensure any residents with new use of PRN pain medication or new onset of pain has the MD is notified.

483.20(g) REQUIREMENT Accuracy of Assessments:

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

Observations:

Based on a review of clinical records and the Resident Assessment Instrument and staff interviews, it was determined that the facility failed to ensure the Minimum Data Set Assessments (MDS - a federally mandated standardized assessment conducted at specific intervals to plan resident care) accurately reflected the status of one resident out of 19 sampled (Resident 13).

Findings include:

A review of the clinical record revealed that Resident 13 was admitted to the facility on September 5, 2019, with diagnoses to have included cardiovascular disease, renal insufficiency, and diabetes.

A review of Resident 13's quarterly review MDS Assessment dated November 7, 2023, revealed Section P - P0100. Restraints was coded as "D. Other" indicating that the resident had a form of restraints in place.

A review of Resident 13's clinical record failed to reveal that the resident had restraints in place as noted on the quarterly MDS assessment.

An interview with the Nursing Home Administrator (NHA) on February 22, 2024, at 2:00 p.m., revealed that Resident 13 did not have physician's orders for restraints or require restraints and confirmed that the quarterly MDS Assessment November 7, 2023, Section P - P0100. Restraints was coded in error to indicate that the resident had a restraint in place.

Plan of Correction - To be completed: 03/19/2024

Step 1
Resident # 13 had MDS revised at the time of survey.
Step 2
To identify like residents that have the potential to be affected the MDS coordinator/Designee will go back 14 days of MDS completed to ensure MDS section P0100D is coded correctly.
Step 3
To prevent this from happening again the Regional director of clinical reimbursement will educate the MDS team on appropriate coding of the MDS with focus on P0100D.
Step 4
To monitor and maintain ongoing compliance the Regional director of clinical reimbursement will audit 5 completed MDS weekly x 4 then monthly x 2 to ensure that the MDS is coded correctly with focus on P0100D.

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

§483.21(b) Comprehensive Care Plans
§483.21(b)(2) A comprehensive care plan must be-
(i) Developed within 7 days after completion of the comprehensive assessment.
(ii) Prepared by an interdisciplinary team, that includes but is not limited to--
(A) The attending physician.
(B) A registered nurse with responsibility for the resident.
(C) A nurse aide with responsibility for the resident.
(D) A member of food and nutrition services staff.
(E) To the extent practicable, the participation of the resident and the resident's representative(s). An explanation must be included in a resident's medical record if the participation of the resident and their resident representative is determined not practicable for the development of the resident's care plan.
(F) Other appropriate staff or professionals in disciplines as determined by the resident's needs or as requested by the resident.
(iii)Reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments.

Observations:

Based on clinical record review and resident and staff interview, it was determined that the facility failed to review and revise the care plan to include the plan to meet the resident's current discharge goal for one resident out of 18 sampled (Resident 64).

Findings include:

A review of clinical record revealed that Resident 64 was admitted to the facility on August 24, 2023, with diagnoses of anxiety and depression.

Review of a Quarterly Minimum Data Set assessment (MDS- a federally mandated standardized assessment process conducted at specific intervals to plan resident care) dated January 31, 2024, revealed that the resident was cognitively intact with a BIMS score of 15 (Brief Interview for Mental Status - a tool to assess cognitive function).

Review of Resident 64's care plan initially dated, September 17, 2023, indicated that the resident's discharge plan was to return home. Upon review at the time of the survey ending February 23, 2024, revealed no revisions were noted to that plan and goal to return home.

Review of social service progress notes dated during January 2024 and February 2024, revealed that the facility's social services director was dealing with outside agencies to assist Resident 64 to return home.

However, the resident's care plan had not but updated to reflect the current obstacles to her discharge home and the measures needed to meet that goal.

The social service director confirmed during interview on February 22, 2024, at approximately 1:30 p.m. that Resident 64's care plan had not been updated to reflect the resident's current discharge plans and measures, which need to be taken to meet that goal.

Plan of Correction - To be completed: 03/19/2024

Resident # 64 had care plan corrected.
To identify like residents that have the potential to be affected the SW/designee will review current residents discharge plan care plans to ensure care plan is reviewed, updated, and accurate to meet the resident's current discharge goal .
To prevent this from happening again the NHA/designee will educate the Social worker on ensuring that residents care plans are reviewed quarterly, annually, and with a significant change to ensure the care plan is reviewed, updated, and accurate to meet the resident's current discharge goal .
To monitor and maintain ongoing compliance the SW/designee will review 5 care plans weekly x 4 then monthly x 2 that had a quarterly, annually, or significant change MDS completed in that week to ensure the care plan was reviewed, updated, and accurate to meet the resident's current discharge goal.

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 a review of clinical records, select facility policy and investigative reports and staff interviews it was determined that the facility failed to implement an individualized incontinence management plan to assure timely services to meet the resident's assessed needs for one resident out of two sampled (Resident 18).

Findings included:

A review of a facility policy entitled "Continence Management Program" that was last reviewed by the facility on April 21, 2023, indicated that an incontinence plan is developed according to the resident's needs and capabilities. A "Continence Evaluation" will be conducted to determine if a 72-hour bowel and bladder tracking is indicated and licensed nurse will instruct the nursing assistants to complete the form. When a patten has been identified, a new Continence Evaluation will be completed and the licensed nurse will develop a toileting program, determining the approaches needed to achieve the goal(s) and establish the type of staff intervention needed to meet each individual resident's goal(s). The licensed nurse will select equipment and aids needed to be successful and note the interventions and will review the plan as needed to identify any necessary modifications.

A review of Resident 18's clinical record revealed that the resident was initially admitted to the facility on June 15, 2021, with diagnoses that included Alzheimer's dementia, spinal stenosis (is a condition where spinal column narrows and compresses the spinal cord), ambulatory dysfunction, and anxiety.

Resident 18's plan of care initiated June 29, 2021, identified that the resident was at risk for bladder and bowel incontinence related to impaired mobility and Alzheimer's dementia with a goal for the resident to be continent at all times through next review. Planned interventions included scheduled toileting 12:00 a.m. and 6:00 a.m., toilet with a.m. and p.m. care, and to check and change every two-hours.

A review of a quarterly Minimum Data Set Assessments (MDS- a federally mandated standardized assessment process conducted periodically to plan resident care) dated May 2, 2024, and August 2, 2023, revealed that the resident had severe cognitive impairment, was dependent on staff for activities of daily living (ADLs), and was frequently incontinent of bladder and bowel and not on a toileting program.

A review of Resident 18's clinical record weekly wound assessment completed by Employee 2, a registered nurse (RN), dated September 27, 2024, at 3:11 a.m., revealed that the resident had a newly facility acquired developed moisture-associated skin damage (MASD - inflammation or skin erosion caused by prolonged exposure to moisture from sources such as urine, stool, sweat, wound drainage, saliva, or mucus) to the buttocks that measured 30.0 cm in length by 30.0 cm in width and zero (0) depth with no drainage, no odor. The immediate intervention was to apply veraseptine [skin treatment that forms a moisture barrier that prevents and helps heal skin irritations from urine, diarrhea, perspiration) twice per day and with each incontinence episode.

A progress note by the wound care specialist nurse practitioner (CRNP), dated September 28, 2024, at 8:45 a.m., revealed that the resident was evaluated due to a new skin impairment. The CRNP assessed that Resident 18 had a deep tissue injury (DTI - a localized area of maroon or purplish discoloration of intact skin or a blood-filled blister that forms due to shear and/or pressure). The area, (wound #1), to the sacrum measured 2.0 cm in length by 0.5 cm in width by 0.0 depth intact purplish non-blanchable epithelial tissue with pressure identified as the primary etiology.
A second DTI, (wound #2) was noted to the resident's left ischium (one of three bones of the pelvis) that measured 8.0 cm in length by 0.0 cm in depth intact purplish non-blanchable epithelial tissue with pressure identified as the primary etiology. A third area (wound #3) was noted to the sacral/perineal area with primary etiology as incontinence associated dermatitis with partial thickness that measured 0 cm in length by 0 cm in width by 0.0 cm in depth that had one hundred percent epithelial tissue and attached wound edges. The periwound was described as fragile, dermatitis, with scant amount of serous exudate. The recommended wound preventative measures were to continue on-going pressure reduction and turning/repositioning precautions, including pressure reduction to all boney prominences. Also, due to the resident's incontinence and increased risk of skin breakdown to continue protocol for swift incontinence management.

The resident's plan for incontinence management and toileting was not revised to reflect the need and increased emphasis on the swiftness of incontinence management to ensure that staff provided prompt incontinence care at the frequency required to prevent further skin damage and to promote healing and prevent worsening of existing pressure sores.

A review of Resident 18's Survey Documentation Report (a summary report of staff's task/intervention completion) dated September 2023, revealed that there was no documented evidence that the planned check and change every two-hours was performed in effort to keep the resident's skin clean and dry.

Resident 18's clinical record revealed that last documented bladder and bowel evaluation was completed on January 20, 2022. The facility failed to timely reassess Resident 18's toileting needs and schedule to promptly implement an effective incontinence management and toileting plan to prevent incontinence related complications, such as MASD.

During an interview with the Director of Nursing (DON) on February 23, 2024, at 10:33 a.m., the DON confirmed that the facility was unable to provide documented evidence that Resident 18's incontinence needs were reassessed following the identification of the MASD and that a plan to provide prompt and frequent services for the resident's incontinence and toileting needs was implemented.

Refer F686

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

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

Plan of Correction - To be completed: 03/19/2024

Resident # 18 had a 3 day bowel and bladder diary initiated and reviewed to determine an appropriate bowel and bladder program.
To identify like residents that have the potential to be affected the DON/designee will review current residents on a toileting program or incontinence management programs such as check and change every 2 hours to ensure it remains appropriate to meet the resident's assessed needs.
To identify like residents that have the potential to be affected the DON/designee will review current residents to ensure a recent bowel and bladder assessment was completed and if needed a toileting program initiated.
To prevent this from happening again the DON/designee will educate nursing staff on ensuring toileting programs are completed per schedule, how to document the toileting program, how to complete a bowel and bladder assessment on admission.
To prevent this from happening again the RDCS will educate the ADON/DON on how to evaluate the 3 day bowel and bladder diary to ensure timely implementation of a toileting program if needed.
To monitor and maintain ongoing compliance the DON/designee will review 5 current residents on toileting programs and or incontinence management such as check and change every two hours weekly x 4 then monthly x 2 to ensure they are being completed and documented per schedule.
To monitor and maintain ongoing compliance the DON/designee will review 5 current residents weekly x 4 then monthly x 2 to ensure a recent bowel and bladder assessment was completed and if needed a toileting program initiated.
To monitor and maintain ongoing compliance the DON/designee will interview 5 capable residents and observe 5 incapable residents weekly x 4 then monthly x 2 to ensure bowel and bladder programs are being completed per schedule and check and change programs are being completed.

483.25(k) REQUIREMENT Pain Management:

§483.25(k) Pain Management.
The facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences.

Observations:
Based on a review of clinical records and select facility reports it was determined that the facility failed to timely recognize that a resident was experiencing increased pain after an unwitnessed fall, assure prompt evaluation of the cause of the pain and manage the resident's pain consistent with professional standards of practice for one resident out of 18 sampled (Resident 3).

Findings included:

Review of Resident 3's clinical record revealed that the resident was admitted to the facility on January 30, 2023, with diagnoses that included dementia, muscle weakness, history of fractures, age-related osteoporosis, and abnormal gait and mobility.

A review of an unwitnessed fall incident report that was completed by Employee 3, a registered nurse (RN), dated October 22, 2023, at 4:45 a.m., revealed that staff found Resident 3 sitting on her buttocks in her room on the right side of her bed. The resident reported to staff, "I was trying to hang the picture back on the wall." Employee 3 assessed the resident and noted that she had some pain/discomfort to her left elbow and an ice pack was applied and that the physician was notified.

An "eMAR - Medication Administration Note" completed by Employee 4, a licensed practical nurse (LPN) dated October 22, 2023, at 3:49 p.m., revealed that nursing administered the physician's ordered, as needed (PRN) Acetaminophen Tablet (Tylenol) 325 mg, 2 tablets, prescribed for administration to the resident every 8 hours, to the resident in response to the resident offering complaints of left elbow pain. However, the resident reported pain at a level of 7 out of 10 (on a scale of 0-10, with 10 being the most severe) at that time.

An "eMAR - Medication Administration Note" completed by Employee 5, a LPN, dated October 23, 2023, at 8:57 p.m., revealed that another dose of PRN Tylenol was administered, within five hours of the last dose, for the resident's further complaints of severe pain post fall. The resident reported 7 out of 10, left elbow pain.

There was no documented evidence that nursing staff timely consulted with the physician regarding the resident's increased pain, rated at level 7 out of 10, requiring repeat administration of Tylenol 325 mg 2 tablets.

A review of a "Head to Toe Evaluation" completed by Employee 5, LPN, dated October 23, 2023, at 9:46 p.m., revealed that Resident 3 was assessed post fall occurrence and note with increased complaints (a resident reported 7 out of 10 pain level) of left elbow pain and swelling.

A progress note completed by Employee 5 on October 23, 2023, at 9:59 p.m., revealed that Resident 3's left elbow was warm to touch and swollen and to continue to monitor.

There was no documented evidence that nursing staff timely notified the resident's attending physician of the resident's increased and ongoing complaints of severe pain after the unwitnessed fall on October 22, 2023, to ensure the resident's prescribed pain management regimen was consistent with the resident's current pain management needs.

The physician was not notified until October 24, 2023, according to an "eMAR - Medication Administration Note" completed by Employee 6, a RN, dated October 24, 2023, at 11:11 AM., which noted that Resident 3's attending physician was made aware of swelling to her left elbow with new orders to obtain an x-ray.

A review of a nursing progress note completed by the Director of Nursing (DON) dated October 24, 2023, at 2:00 p.m., revealed x-ray results that confirmed that Resident 3 sustained a left acute humeral fracture (is the medical name for breaking the bone in the upper arm). Resident 3's son was notified and declined to have the resident transferred to the hospital and requested to have a consult with an orthopedic (bone specialist) physician instead for treatment.

Interview with the Director of Nursing (DON) on February 23, 2024, at 10:15 a.m., confirmed that the facility failed to ensure a timely evaluation of the resident's current pain management needs following an unwitnessed fall and repeated complaints of increased pain after an unwitnessed fall, that resulted in a fracture to the resident's left upper arm.

Refer F697

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

28 Pa. Code 211.5(f) Clinical records

Plan of Correction - To be completed: 03/19/2024

Resident # 3 was recognized as having pain by professional nursing staff and was medicated daily x 2 days with PRN acetaminophen which was effective for the resident's pain. Follow up pain was a 0 on a scale of 1-10. Swelling was noted to left elbow on 10/23/24 and MD was notified as per assessment completed on 10/23/24.
Step 2
To identify like residents that have the potential to be affected the DON/designee will review current residents with new onset of pain to ensure resident has prompt evaluation of the cause of the pain and manage the resident's pain.
Step 3
To prevent this from happening again the DON/designee will educate licensed staff that if a resident has new onset pain to ensure resident has prompt evaluation of the cause of the pain and manage the resident's pain.
Step 4
To monitor and maintain ongoing compliance the DON/designee will review 5 residents weekly x 4 then monthly x 2 to ensure residents with new onset of pain has a prompt evaluation of the cause of the pain and manage the resident's pain.

483.45(f)(2) REQUIREMENT Residents are Free of Significant Med Errors:

The facility must ensure that its-
§483.45(f)(2) Residents are free of any significant medication errors.

Observations:

Based on review of resident clinical records, select facility policy, facility incident reports, and staff interview it was revealed that the facility failed to assure that one of 19 residents reviewed was free of significant medication errors (Resident 84).

Findings include:

A review of a current facility policy entitled "24 Hour Order Review", last reviewed by the facility April 2023 revealed a resident's record will be checked each night for new orders written in the past 24 hours. Further it was indicated if new orders were written, the nurse will verify the order has been transcribed correctly on the medication record.

A review of the clinical record revealed that Resident 84 was admitted to the facility on November 29, 2023, with a diagnosis of congestive heart failure.

The resident's hospital discharge orders included a list of medications the resident was to receive after discharge and upon admission to the skilled nursing facility, which included Xarelto (anticoagulant) 15 mg two times a day for 27 doses. The next dose was due on November 29, 2023. The instructions indicated that resident was then to begin Xarelto 20 mg with breakfast for 21 doses. A notation was written on the discharge orders to not start the 20 mg tablet before December 13, 2023.

A review of physician's orders initially dated November 29, 2023, revealed an order for Xarelto 15 mg two times a day and Xarelto 20 mg daily to begin on November 30, 2023.

The facility's nursing staff failed to accurately transcribe the physician orders for the Xarelto into the resident's clinical record and started the 20 mg dose on November 30, 2023, instead of following the hospital discharge orders to begin the Xarelto 20 mg daily on December 13, 2023. The facility staff failed to identify the transcription error when completing the 24 hour order review.

A review of a facility incident report dated December 7, 2023, at 3:30 PM revealed Resident 84 was administered additional doses of Xarelto. Upon review of the hospital discharge orders, Xarelto 20 mg was to start on December 13, 2023, and Xarelto 15 mg twice a day November 29, 2023. Both orders, Xarelto 15 mg BID and Xarelto 20 mg daily, were started upon the resident's admission, on November 29, 2023, and November 30, 2023, respectively.

Resident 84 received seven doses of Xarelto 20 mg daily, in addition to the Xarelto 15 mg she was receiving twice a day from November 30, 2023, until December 7, 2023.

An interview with the Director of Nursing on February 23, 2024, at approximately 2:00 PM confirmed that facility staff administered the incorrect dose of medication to Resident 84 and, failed to ensure the resident was free from significant medication errors.

This deficiency is cited as past non-compliance.

The facility's corrective action plan included the following:

On December 7th 2023, the physician was made aware and a new order was received to change the timing of the Xarelto. The resident and the resident's responsible party was made aware of the medication error. Resident 84 received a head to toe assessment with no ill effects noted.

To identify like residents that have the potential to be affected the DON or designee will review current residents on anticoagulants to ensure the order is correct and transcribed to the medication administration record correctly. To identify like residents that have the potential to be affected the DON or designee will review new admissions and readmissions in the past seven days to ensure all orders from the hospital were reconciled correctly into the residents' medical records.

To prevent this from occurring again the DON or designee will complete medication competencies on all current licensed nurses. To prevent this from occurring again the DON or designee will educate all the licensed nurses on the admission chart check form, transcribing medications, and the 24 Hour Order Review policy.

To monitor and maintain ongoing compliance the DON or designee will audit three random admissions weekly for four weeks then monthly for two months to ensure all orders from the hospital were reconciled correctly into the resident's medical record. To monitor and maintain ongoing compliance the DON or designee will audit five current residents on anticoagulants weekly for four weeks then monthly for two months to ensure the order is correct and transcribed on the medication administration record correctly.

The facility completed the plan of correction on December 10, 2023, as verified during the survey of February 23, 2024.

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

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

Plan of Correction - To be completed: 03/07/2024

Past noncompliance: no plan of correction required.

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 a review of select facility policies, observations, and staff interview, it was determined that the facility failed to label and identify use by/discard dates for multidose insulin and failed to store drugs and pharmacy supplies at appropriate temperatures for one of 19 residents sampled (Resident 50)

Findings include:

A review of facility policy entitled "Storage and Expiration Dating of Medications and Biologicals" last reviewed April 21, 2023, revealed that medications and biologics should have an expiration date for opened medications. If a multi-dose vial of an injectable medication has been opened the vial should be dated and discarded within 28 days. The facility should ensure that medications and biologicals are stored at their appropriate temperatures according to the United States Pharmacopeia guidelines for temperature ranges. Staff should monitor the temperature of vaccines twice a day. Refrigeration 36to 46

An observation of the first-floor medication cart on February 22, 2024, at approximately 8:55 AM revealed Resident 50's Lantus multidose vial 100 units/ml (insulin/glargine) was opened and in use. but not dated when it was opened for use.

An interview with Employee 1, RN (registered nurse), on February 22, 2024, at the time of the observation revealed that the Lantus insulin vial was not dated when opened and all insulins should be dated when opened and disposed of 28 days after opening.

An observation of the first-floor medication storage room performed on February 22, 2024, at 9:20 AM, revealed that the thermometer inside the small medication refrigerator, closest to the door, used to store insulins and other medications that required proper refrigeration, read 30-degrees Fahrenheit. A review of the manufacturer's directions for use of the insulin stored inside the refrigerator revealed that the insulin is to be stored in a refrigerator at approximately 36to 46There was no temperature log for this refrigerator to show that staff was checking the temperatures as noted in facility policy.

An interview with the Director of Nursing (DON) on February 22, 2024, at approximately 10:15 AM confirmed the facility failed to follow the policy for labeling and dating medications and failed to ensure that the insulin refrigerator was being monitored for appropriate temperature settings and that the medications were stored at acceptable temperatures.

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

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

Plan of Correction - To be completed: 03/19/2024

The facility cannon retroactively correct past temp logs. The refrigerator did have a thermometer and was at the appropriate temperature at time of survey.
The facility removed the insulin pen at time of survey that had no date for resident #50.
To identify like issues the ADON/designee will audit all medication refrigerators to ensure all refrigerators have a temp log.
To identify like residents that have the potential to be affected the ADON/designee will audit all medication carts and refrigerators to ensure all insulins are labeled and identify use by/discard dates for Multidose insulin
To prevent this from happening again the DON/designee will educate the licensed nursing staff on the appropriate storage of insulin and expiration dates for insulin.
To prevent this from happening again the DON/designee will educate licensed staff on ensuring all medication refrigerators have a temp log to prove temps are correct.
To monitor and maintain ongoing compliance the ADON/designee will audit medication carts 5 days a week x 4 weeks then monthly x 2 to ensure insulin is labeled and dated per policy.
To monitor and maintain ongoing compliance the ADON/designee will audit medication refrigerators 5 days a week x 4 then monthly x 2 to ensure the temp log is present and temp recorded on the log.

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