Pennsylvania Department of Health
 WALLINGFORD SKILLED NURSING AND REHABILITATION CENTER
Patient Care Inspection Results

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
WALLINGFORD SKILLED NURSING AND REHABILITATION CENTER
Inspection Results For:

There are  207 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.
WALLINGFORD SKILLED NURSING AND REHABILITATION CENTER - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:


Based on a Medicare/Medicaid Recertification Survey, State Licensure Survey, and Civil Rights Compliance Survey completed on June 24, 2024 it was determined that Wallingford Skilled Nursing and Rehabilitation Center was not in compliance with the following requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care and the 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations as they relate to the Health portion of the survey process.
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 Plan of Correction:


483.25(d)(1)(2) REQUIREMENT Free of Accident Hazards/Supervision/Devices:This is a more serious deficiency but is isolated to the fewest number of residents, staff, or occurrences. This deficiency results in a negative outcome that has negatively affected the resident's ability to achieve his/her highest functional status.
§483.25(d) Accidents.
The facility must ensure that -
§483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and

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


Based on clinical record review, facility policy and procedure review, and staff interview it was determined the facility failed to accurately assess and identify a newly admitted resident as a fall risk and develop interventions to prevent falls causing actual harm to Resident 263 who fell causing injuries that required hospitalization for one of 3 residents reviewed (Resident 263)

Findings include:

Review of facility policy and procedure titled "Assessment: Nursing" last revised March 2022, revealed "A nursing assessment will be performed by a licensed nurse for all patients within 24 hours of admission. Routine and focused assessments will be performed on an ongoing basis as needed. Assessments will be reviewed and certified as completed by an RN within 24 hours and all individuals who complete a portion of the assessment will sign and certify to the accuracy of the portion of the assessment, he/she completed".

Review of Resident 263's clinical record revealed the resident was admitted to the facility on December 15, 2023 from the hospital.

Review of Resident 263's documentation from the hospital revealed the resident went to the hospital and was admitted after a near syncope (fainting) episode during which she was hypotensive (low blood pressure) and had difficulty getting into her house. Further review of the hospital documentation revealed the resident was discharged with a diagnosis of Hypotension and Syncope.

Review of Resident 263's physical therapy documentation while in the hospital revealed the resident was determined to be at risk for falls and to have ambulation deficits, balance deficits, bed mobility deficits, strength deficits, transfer deficits and safety awareness deficits.

Review of Resident 263's facility diagnosis list revealed diagnosis of Hypotension (low blood pressure), Syncope (sudden, temporary drop in the amount of blood that flows to the brain), and collapse.

Review of Resident 263's Vital Signs revealed a blood pressure on December 17, 2023 at 9:32 P.M. of 102/45 (normal 120/80).

Review of Resident 263's admission assessment dated December 15, 2023 revealed the resident was determined to have no risk factors for falls related to history or fear of falls or factors such as current diagnosis or medications that would increase the risk for falls and there was no risk for falls due to the resident's presence or history of gait, strength, or balance factors.

Review of Resident 263's progress notes revealed a nursing entry dated December 18, 2023 at 2:53 a.m. that indicated "CNA (Certified Nursing Assistant) heard a noise and went into the room to check on patient and found her on the floor face down next to the bed. R (right) facial laceration at smile line measuring 4 cm (centimeters) and one of R eye measuring 1.5 cm. Peri orbital (eye) swelling noted on right side. EMS (Emergency Medical Services) called at 0233 (2:33 a.m.)".

Review of Resident 263's care plan revealed there was no care plan developed for risk for falls or interventions in place prior to the fall of December 18, 2023.

Resident 263 was inaccurately assessed at the time of admission as not being at risk for falls and there were no interventions in place to prevent falls leading to a fall with major injury that required hospitalization on December 18, 2023.

This information above was relayed to the Nursing Home Administrator on June 24, 2024 at 1:15 p.m.

28 Pa. Code 201.14(a) Responsibility of licensee

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

28 Pa. Code 201.29(c) Resident rights

28 Pa. Code 211.5(f) Clinical records

28 Pa. Code 211.11(d) Resident care plan

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


 Plan of Correction - To be completed: 08/06/2024

Resident R263 no longer resides at the facility.
DON and/or designee will re-educate licensed nurses on accurate assessments and identification of newly admitted residents fall risk, with interventions to prevent falls.
DON and/or designee will conduct an initial audit of all residents to ensure accurate assessment of fall risk, with interventions to prevent falls.
DON and/or designee will conduct weekly audits X 12 weeks to ensure accurate assessment of fall risk, with interventions to prevent falls.
DON and/or designee will review the findings of the audits at QAPI X 3 months.

483.45(c)(1)(2)(4)(5) REQUIREMENT Drug Regimen Review, Report Irregular, Act On:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
§483.45(c) Drug Regimen Review.
§483.45(c)(1) The drug regimen of each resident must be reviewed at least once a month by a licensed pharmacist.

§483.45(c)(2) This review must include a review of the resident's medical chart.

§483.45(c)(4) The pharmacist must report any irregularities to the attending physician and the facility's medical director and director of nursing, and these reports must be acted upon.
(i) Irregularities include, but are not limited to, any drug that meets the criteria set forth in paragraph (d) of this section for an unnecessary drug.
(ii) Any irregularities noted by the pharmacist during this review must be documented on a separate, written report that is sent to the attending physician and the facility's medical director and director of nursing and lists, at a minimum, the resident's name, the relevant drug, and the irregularity the pharmacist identified.
(iii) The attending physician must document in the resident's medical record that the identified irregularity has been reviewed and what, if any, action has been taken to address it. If there is to be no change in the medication, the attending physician should document his or her rationale in the resident's medical record.

§483.45(c)(5) The facility must develop and maintain policies and procedures for the monthly drug regimen review that include, but are not limited to, time frames for the different steps in the process and steps the pharmacist must take when he or she identifies an irregularity that requires urgent action to protect the resident.
Observations:


Based upon clinical record review, it was determined that the facility failed to ensure that medication irregularities were acted upon by a physician for four of five residents reviewed (Resident 16, 29, 77, and 137).

Findings include:

Review of Resident 16's Consultation Report for the Medication Regimen Review completed on September 1, 2023, revealed a recommendation to consider a trial dose reduction of Aripiprazole (anti-psychotic medication) to 2 mg at night.

Review of Resident 16's clinical record failed to reveal that the above recommendation was addressed by the physician.

Interview with the Director of Nursing on June 25, 2024, at 1:00 p.m., confirmed that the pharmacy recommendation made on September 1, 2024, was not addressed by the physician.

Review of Resident 29's Consultation Report for the Medication Regimen Review completed on February 1, 2024, revealed a recommendation for a dose reduction evaluation for the medications Clonazepam (Anti-anxiety medication), Haloperidol (Anti-psychotic medicines), and Escitalopram (ant- depressant medication).

Review of Resident 29's clinical record failed to reveal that the above recommendation was addressed by the physician.

Interview conducted with the DON on June 25, 2024, at 1:00 p.m., confirmed that the pharmacy recommendations made on February 1, 2024, were not addressed by the physician.

Review of Resident 77's Consultation report for the Medication Regimen Review completed on May 4, 2024 revealed the pharmacist recommended the facility only order as needed Xanax (anti-anxiety medication) for a duration of 14 days per CMS (Centers for Medicare and Medicaid) regulations. This recommendation was not addressed by the physician until June 24, 2024.

Interview conducted with the Director of Nursing on June 24, 2024 at 1:35 p.m. confirmed Resident 77 recommendations from the pharmacist on May 4, 2024 was not addressed timely.

Review of Resident 137's clinical record revealed Resident 137 was admitted into the facility on May 19, 2023, with a BIMS (Brief Interview of Mental Status) score of 3, indicating severely impaired cognition.

Review of Resident 137's clinical record including admission diagnoses of Dementia with Agitation, Dysphagia (swallowing disorder), Restlessness, Agitation, Psychosis, Depression, Seborrhea Capitis (skin condition), Anemia (low blood cells), and Hypokalemia (low potassium).

Review of Resident 137's clinical records revealed a physician order dated February 23, 2023, for Haloperidol Oral Tablet 1 mg. for psychosis.

Review of Resident 137's clinical records revealed a physician order dated June 2, 2023, for Olanzapine Oral Tablet 5 mg. for dementia with agitation.

Further review of Resident 137's clinical records revealed a physician order dated June 20, 2023, for Mirtazapine Tablet 7.5 mg. for depression.

Review of Resident 137's clinical record revealed that a MRR (Medication Record Review) was completed on January 4, 2024, with two recommendations, "1.) semi-annual dose reduction evaluation requested for the above medications, (Haloperidol 1mg, Olanzapine 5mg, Mirtazapine 7.5 mg). 2.) Periodically reevaluate duel antipsychotic use".

Further review of Resident 137's clinical record revealed that a MRR (Medication Record Review) was completed on May 10, 2024, with the recommendation, " trial dose reduction of the above medications requested, (Haloperidol 1mg, Olanzapine 5mg, Mirtazapine 7.5 mg)."

Review of Resident 137's clinical record failed to reveal documented evidence the pharmacist recommendations were addressed by the attending physician.

Interview with the Director of Nursing on June 24, 2024, at 1:35 p.m. confirmed there was no documented evidence of a response by the physician to the recommendations made by the consultant pharmacist.

483.45 Drug Regimen Review, Report Irregular, Act on
Previously cited 11/1/21, 12/30/22, 3/24/23, 8/25/23, 10/23/23

28 Pa. Code 211.5(f) Clinical records
Previously cited 11/1/21, 12/30/22, 3/24/23, 8/25/23, 10/23/23

483.45 Drug Regimen Review, Report Irregular, Act on
Previously cited 11/1/21, 12/30/22, 3/24/23, 8/25/23, 10/23/23

28 Pa. Code 211.5(f) Clinical records
Previously cited 11/1/21, 12/30/22, 3/24/23, 8/25/23, 10/23/23

28 Pa. Code 211.12(c) Nursing Services
Previously cited 8/25/23, 10/23/23,

28 Pa. Code 211.12(d)(3) Nursing Services
Previously cited 4/4/2023, 8/25/23, 10/23/23,

28 Pa. Code 211.12(d)(1)(5) Nursing Services
Previously cited 8/25/23, 10/23/23


 Plan of Correction - To be completed: 08/06/2024

Residents R16,R77 and R137 had no adverse effects related to Drug Regimen Review.
Regional Nurse to re-educate DON/Unit Mangers on importance of follow up to Pharmacy Recommendation's.
DON and/or designee will conduct an initial audit of all pharmacy recommendations in the last 30 days to ensure recommendations have been addressed.
DON and/or designee will conduct monthly audits x3 to ensure pharmacy recommendations have been reviewed.
DON and/or designee will report the findings of the audits to QAPI meetings x3 months.
483.45(c)(3)(e)(1)-(5) REQUIREMENT Free from Unnec Psychotropic Meds/PRN Use:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
§483.45(e) Psychotropic Drugs.
§483.45(c)(3) A psychotropic drug is any drug that affects brain activities associated with mental processes and behavior. These drugs include, but are not limited to, drugs in the following categories:
(i) Anti-psychotic;
(ii) Anti-depressant;
(iii) Anti-anxiety; and
(iv) Hypnotic

Based on a comprehensive assessment of a resident, the facility must ensure that---

§483.45(e)(1) Residents who have not used psychotropic drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record;

§483.45(e)(2) Residents who use psychotropic drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs;

§483.45(e)(3) Residents do not receive psychotropic drugs pursuant to a PRN order unless that medication is necessary to treat a diagnosed specific condition that is documented in the clinical record; and

§483.45(e)(4) PRN orders for psychotropic drugs are limited to 14 days. Except as provided in §483.45(e)(5), if the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she should document their rationale in the resident's medical record and indicate the duration for the PRN order.

§483.45(e)(5) PRN orders for anti-psychotic drugs are limited to 14 days and cannot be renewed unless the attending physician or prescribing practitioner evaluates the resident for the appropriateness of that medication.
Observations:


Based upon clinical record review, it was determined that the facility failed to ensure residents were free from unnecessary psychotropic medications by attempted dosage reductions and periodical reevaluation of psychotropic drug usage for three of five residents reviewed (Residents 16, 29, and 137).

Findings include:

Review of the facility's policy titled "Psychotropic Medication Use" dated December 1, 2007, revealed the facility should ensure that the ordering physician reviews the medication plan and considers a Gradual Dose Reduction (GDR) of psychotropic medications to find the lowest effective dose unless a GDR is clinically contraindicated. The physician should document the clinical rationale for why any additional attempted dose reduction at that time would be likely to impair the resident's function or increase distressed behavior.

Review of Resident 16's physician order dated September 1, 2023, revealed an order for Aripiprazole (anti-psychotic medication) 5 mg (milligram) given by mouth at bedtime for Major Depressive Disorder (MDD).

Review of Resident 16's clinical record failed to reveal the facility attempted to do a GDR for Resident 16's Aripiprazole.

Interview with the Director of Nursing (DON) on June 24, 2024, at 1:00 p.m., confirmed there was no attempt to perform GDR of Aripiprazole medication and no documentation of a physician's rationale for Resident 16.

Review of Resident 29's physician order dated March 31, 2016, revealed an order for Klonopin tablet (Anti-anxiety medication) 0.5 mg give one tablet by mouth at bedtime for anxiety,

Review of Resident 29's physician order dated July 1, 2021, revealed an order for Lexapro (Anti-depressant medication) 20 mg by mouth one time a day for depression.

Review of Resident 29's physician order dated October 6, 2021, revealed an order for Haloperidol Lactate Concentrate 2mg/ml given 1mg by mouth at bedtime for Dementia with behavioral disturbances.

Clinical records review failed to reveal that the facility attempted to do GDR for the Klonopin, Lexapro, and Haloperidol medication for Resident 29.

Interview with the Director of Nursing (DON) on June 24, 2024, at 1:00 p.m., confirmed that there was no attempt to perform GDR on Klonopin, Lexapro, and Haloperidol medications and no documentation of a physician's rationale for not attempting the GDR for Resident 29.

Review of Resident 137's clinical record revealed Resident 137 was admitted into the facility on May 19, 2023, with a BIMS (Brief Interview of Mental Status) score of 3, indicating severely impaired cognition.

Review of Resident 137's admission diagnoses revealed Dementia with Agitation, Dysphagia (difficulty swallowing), Restlessness, Agitation, Psychosis, Depression, Seborrhea Capitis (skin condition consisting of scaly patches, inflamed skin affecting oily areas of the body), Anemia (low blood cells), and Hypokalemia (low potassium).

Review of Resident 137's clinical records revealed a physician order dated February 23, 2023, for Haloperidol Oral Tablet 1 mg for psychosis.

Review of Resident 137's clinical records revealed a physician order dated June 2, 2023, for Olanzapine Oral Tablet 5 mg. for dementia with agitation.

Further review of Resident 137's clinical records revealed a physician order dated June 20, 2023, for Mirtazapine Tablet 7.5 mg. for depression.

Review of Resident 137's clinical record revealed that a MRR (Medication Record Review) was completed on January 4, 2024, with two recommendations, "1.) semi-annual dose reduction evaluation requested for the above medications, (Haloperidol 1mg, Olanzapine 5mg, Mirtazapine 7.5 mg). 2.) Periodically reevaluate duel antipsychotic use".

Further review of Resident 137's clinical record revealed that a MRR (Medication Record Review) was completed on May 10, 2024, with the recommendation, " trial dose reduction of the above medications requested, (Haloperidol 1mg, Olanzapine 5mg, Mirtazapine 7.5 mg)."

Review of Resident 137's clinical record failed to reveal documented evidence a trial dose reduction or a semi-annual dose reduction evaluation was performed.

Further review of Resident 137's clinical records failed to reveal documented evidence of periodical evaluations for dual antipsychotic drug usage was performed.

Interview with the Director of Nursing on June 24, 2024, at 1:35 p.m. confirmed there was no documented evidence that trial dose reductions, semi-annual dose reductions or periodical evaluations for dual antipsychotic drug usage was performed for Resident 137.

483.45 Drug Regimen Review, Report Irregular, Act on
Previously cited 11/1/21, 12/30/22, 3/24/23, 8/25/23, 10/23/23

28 Pa. Code 211.5(f) Clinical records
Previously cited 11/1/21, 12/30/22, 3/24/23, 8/25/23, 10/23/23

28 Pa. Code 211.12(c) Nursing Services
Previously cited 8/25/23, 10/23/23

28 Pa. Code 211.12(d)(3) Nursing Services
Previously cited 4/4/2023, 8/25/23, 10/23/23

28 Pa. Code 211.12(d)(1)(5) Nursing Services
Previously cited 8/25/23, 10/23/23



 Plan of Correction - To be completed: 08/06/2024

Residents R16, R29 and R137 had no adverse effects related to unnecessary psychotropic medications.
DON and/or designee will re-educate licensed nurse on gradual dose reduction and periodic review of psychotropic medications.
DON or designee will conduct an initial audit of residents receiving psychotropic medications in the last 90 days to ensure dose reduction and psychotropic review has been completed.
DON/designee will conduct monthly audit's x3 to ensure gradual dose reduction and psych tropic medication review has been completed.
DON/designee will report findings to QAPI montly x 3.

483.12(c)(2)-(4) REQUIREMENT Investigate/Prevent/Correct Alleged Violation:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
§483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must:

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

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

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

Based on review of facility policy and procedure, clinical record, and staff interview it was determined the facility failed to thoroughly investigate an injury of unknown origin for one of 24 residents reviewed. (Resident 264)

Findings include:

Review of Facility policy and procedure titled Accidents/Incidents, last revised on March 1, 2024 revealed, "When conducting an investigation the Administrator, DON, or designee will make every effort to ascertain the cause of the accident/incident ...Conduct witness interviews from all staff and visitors who may have knowledge of the accident/incident."

Review of Resident 264 progress notes revealed a nursing entry dated February 21, 2024 at 1:44 p.m. stating, "during rounds resident grimacing and moaning when left lower extremity moved, resident have limited to no movement of left leg, NP (Nurse Practitioner) seen and examined and resident with new order for stat (immediate) x-ray of the left hip, pelvis, and femur and knee".

Further review of Resident 264 progress notes revealed a nursing entry on February 21, 2024 at 4:48 p.m. stating "x-ray results received: moderately displaced intertrochanteric fracture of the left hip (hip fracture). New orders to send to the ER (emergency room)."

Review of the Incident Report for the injury to Resident 264 on February 21, 2024 revealed the resident was found to be non-mobile this am. STAT (meaning - immediately) x-rays ordered and resulted positive for moderately displaced fracture of the left hip. There were no witnesses listed and two statements from an LPN and a CNA who worked the 3-11 shift on February 20, 2024 and stated the resident was ambulating normally and provided no information as to the possible cause of the injury.

The facility failed to conduct a thorough investigation by not interview staff who cared for the resident on the shift the injury was identified, or the previous night shift staff assigned to the resident and were unable to determine a timeline of when the injury could have occurred or the cause of the injury.

Interview with the Director of Nursing on June 24, 2024 at 1:30 p.m., confirmed the investigation into Resident 264 hip fracture was not thoroughly completed.

28 Pa. Code 201.14(a) Responsibility of Licensee

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

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

28 Pa. Code 211.5(f) Clinical Records


 Plan of Correction - To be completed: 08/06/2024

Resident R264 no longer resides in the facility.
Director of Nursing (DON) and/or designee will conduct facility-wide education on the abuse prohibition policy to ensure a thorough investigation is conducted.
DON or designee will conduct an initial audit of incident reports of injury of unknown origin in the past 6 months to ensure a thorough investigation was conducted.
DON or designee will conduct weekly audits x 12 weeks of incident reports of injury of unknown origin to ensure a thorough investigation was conducted.
DON or designee will review the findings of the audits at QAPI meetings x 3 months.


483.25 REQUIREMENT Quality of Care:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
§ 483.25 Quality of care
Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices.
Observations:


Based on clinical records review and staff interview, it was determined that the facility failed to ensure medication ordered by the physician was followed for one of the 33 residents reviewed (Resident 70).

Findings include:

Review of Resident 70's diagnosis list includes Chronic Kidney Failure and Dependence on Hemodialysis (A process of purifying the blood of a person whose kidneys are not working normally).

Review of Resident 70's clinical record revealed the resident goes for dialysis services every Tuesday, Thursday, and Saturday at 10:00 a.m.

Review of the Resident 70's blood work dated June 4, 2024, revealed a Phosphorus level of 6.8 mg/dl (normal range 2.5- 4.5)

Review of Resident 70's physician's orders dated June 2, 2024, and June 13, 2024, revealed an order for Calcium Acetate (Phosphate binder) 667 mg one tablet by mouth with meals for elevated phosphorus. The medication was scheduled for 8:30 a.m., 12:30 p.m., and 5:00 p.m.

Review of Resident 70's medication administration record revealed that the medication was not administered on June 4, 6, 15, 18, and 20, 2024, at 12:30 p.m.

Interview with the Director of Nursing conducted on June 15, 2024, revealed that the medication was not administered due to the resident being out of the facility for dialysis.

The clinical records review failed to reveal the physician was notified of the missed medication until June 24, 2024.

The facility failed to ensure medication (Calcium Acetate) to treat elevated Phosphorus was followed.

28 Pa. Code 211.5(f) Clinical Records

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


 Plan of Correction - To be completed: 08/06/2024

Resident R70 has expired.
DON and/or designee will conduct re-education on medication administration with a focus on ensuring medications are not scheduled at dialysis times.
DON or designee will conduct an initial audit of all residents receiving dialysis to ensure medications are not scheduled during dialysis times.
DON or designee will conduct weekly audits X 12 weeks to ensure medications are not scheduled during dialysis times.
DON or designee will review the finding of the audits at QAPI meetings X 3 months.

483.25(g)(1)-(3) REQUIREMENT Nutrition/Hydration Status Maintenance:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
§483.25(g) Assisted nutrition and hydration.
(Includes naso-gastric and gastrostomy tubes, both percutaneous endoscopic gastrostomy and percutaneous endoscopic jejunostomy, and enteral fluids). Based on a resident's comprehensive assessment, the facility must ensure that a resident-

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

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

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

Based on clinical record review, it was determined that the facility failed to monitor and address significant weight changes in a timely manner for two of six residents reviewed for nutrition (Residents 54 and 60).

Findings include:

Review of Resident 54's weights revealed the resident had not been weighed since April 24, 2024.

Review of Resident 54's progress notes revealed a dietitian entry dated May 20, 2024 stating "No updated weight this month. Rt refused to be weighed .... Attempted to get weight again today but sit to stand scale is broken."

Review of Resident 54's clinical record revealed there was no other documentation of resident refusing to be weighed and there was no care plan developed for the resident related to refusals.

Interview with the Director of Nursing confirmed Resident 54 had not been weighed since April 24, 2024 and there was no other documented evidence Resident 54 had refused weights.

Interview with the Nursing Home Administrator on June 24, 2024 at 1:15 p.m. revealed the maintenance director had inspected the scale used for Resident 54 and it was in working order.

The facility failed to get at least monthly weight of Resident 54 to properly evaluate his nutritional status.

Observation of Resident 60 on June 20, 2024, at 9:00 a.m. revealed the resident had a PEG tube (percutaneous endoscopic gastrostomy - plastic tube inserted into the stomach to provide nutrition, hydration, and medication).

Review of Resident 60's care plan initiated November 6, 2016, revealed the resident was identified as at risk for alteration in nutrition status related to anoxic brain injury, dysphagia (difficulty swallowing), and the need for enteral nutrition, with an intervention to review weights and to notify the physician and responsible party of significant weight changes.

Review of Resident 60's weights revealed on June 2, 2024, the resident was recorded as weighing 147.6 pounds (lbs.). On June 4, 2024, the resident was recorded as weighing 158 lbs., a 10.4 lb., or 7.05% weight gain in two days.

Review of Resident 60's progress notes revealed a nutrition note on June 19, 2024, which stated: "Brief weight change note. Resident shows potential 7% wt gain x 2 days, and x 1 month, which is significant. Wts reviewed: 158# (6/4), 147.6# (6/2), 147.8# (5/3). Resident will need reweight to confirm 10.4# wt gain x 2 days. Reweight requested. No edema noted. Full weight change/nutrition assessment to follow once reweight is obtained and sig wt change is confirmed."

Review of Resident 60's weights as of June 24, 2024, failed to reveal that a reweight was obtained.

Interview with the Director of Nursing on June 24, 2024, at approximately 1:20 p.m. failed to reveal an explanation as to why a reweight for Resident 60 was not obtained.

28 Pa. Code 211.5(f) Clinical Records

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

28 Pa Code: 211.10(c) Resident care policies




 Plan of Correction - To be completed: 08/06/2024

Resident R54's monthly weight has been completed
Resident R60's reweight has been completed
DON and/or designee will re-educate licensed nurses and CNAs on the weight policy to ensure the facility monitors and addresses significant weight changes in a timely manner.
DON or designee will conduct an initial audit of all current residents to ensure they have a current monthly weight to ensure the facility monitors and address significant weight changes in a timely manner.
DON or designee will conduct random weekly audits x 12 weeks of 5 residents to ensure they have a current monthly weight to ensure the facility monitors and address significant weight changes in a timely manner.
DON or designee will review the findings of the audits at QAPI meetings x 3 months.

483.25(g)(4)(5) REQUIREMENT Tube Feeding Mgmt/Restore Eating Skills:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
§483.25(g)(4)-(5) Enteral Nutrition
(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)(4) A resident who has been able to eat enough alone or with assistance is not fed by enteral methods unless the resident's clinical condition demonstrates that enteral feeding was clinically indicated and consented to by the resident; and

§483.25(g)(5) A resident who is fed by enteral means receives the appropriate treatment and services to restore, if possible, oral eating skills and to prevent complications of enteral feeding including but not limited to aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, and nasal-pharyngeal ulcers.
Observations:

Based on Clinical record review and staff interview it was determined the facility failed to provide enteral nutrition (feeding delivered through a feeding tube) as ordered by the physician for one of five residents reviewed. (Resident 54)

Findings include:

Review of Resident 54's clinical record revealed the resident returned from the hospital on February 28, 2024 with a PEG tube (feeding tube- tube surgically inserted into the stomach when oral intake is not adequate).

Review of the physician orders revealed an order dated April 24, 2024 for Jevity 1.5 (tube feeding) running at 65 ml per hour starting at 5 p.m. and ending at 9 a.m. for a total of 1040 ml per day.

Review of resident 54's Medication Administration Record (MAR) for the months of April, May and June 2024 revealed there were no days where it was documented the resident received a total of 1040 ml per day as ordered by the physician.

Interview with the Director of Nursing on June 24, 2024 at 11:15 a.m. confirmed there was no documented evidence Resident 54 had received the amount of tube feeding as ordered by the physician.

28 Pa Code: 211.5(f) Clinical records

28 Pa code: 211.12(d)(1)(3)(5) Nursing services


 Plan of Correction - To be completed: 08/06/2024

Resident R54 had no adverse effects related to the enteral feeding.
DON and/or designee will re-educate licensed nurses on MAR documentation of enteral feeding total volume infused to ensure enteral nutrition is provided per physician order.
DON or designee will conduct an initial audit to ensure all residents with enteral nutrition are receiving enteral feeding per physician orders.
DON or designee will conduct random weekly audits x 12 weeks of 5 residents to ensure enteral nutrition is provided per physician orders.
DON or designee will review the findings of the audits at QAPI meetings x 3 months.


483.45(d)(1)-(6) REQUIREMENT Drug Regimen is Free from Unnecessary Drugs: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.
§483.45(d) Unnecessary Drugs-General.
Each resident's drug regimen must be free from unnecessary drugs. An unnecessary drug is any drug when used-

§483.45(d)(1) In excessive dose (including duplicate drug therapy); or

§483.45(d)(2) For excessive duration; or

§483.45(d)(3) Without adequate monitoring; or

§483.45(d)(4) Without adequate indications for its use; or

§483.45(d)(5) In the presence of adverse consequences which indicate the dose should be reduced or discontinued; or

§483.45(d)(6) Any combinations of the reasons stated in paragraphs (d)(1) through (5) of this section.
Observations:

Based on clinical record review, it was determined that the facility failed to ensure non-pharmalogical interventions (NPIs) were attempted prior to the administration of as-needed narcotic pain medication for one of thirty-three residents reviewed (Resident 98).

Findings include:

Review of Resident 98's physician's orders revealed an order dated October 25, 2023, for oxycodone (narcotic pain reliever) 5 milligrams (mg) give every 4 hours as needed, and document all NPIs prior to administering the medication.

Review of Resident 98's April 2024 Medication Administration Record (MAR) revealed the resident received as-needed oxycodone 5 mg a total of 21 times. Review of Resident 98's May 2024 MAR revealed the resident received as-needed oxycodone 5 mg a total of 20 times. Review of Resident 98's June 2024 revealed the resident received as-needed oxycodone 5 mg a total of 26 times as of June 21, 2024.

Further review of Resident 98's April 2024, May 2024, and June 2024 MARs and progress notes failed to reveal NPIs were documented prior to administering the resident's oxycodone 5mg.

Interview with the Director of Nursing on June 24, 2024, at approximately 1:25 p.m. confirmed the facility failed to document NPIs prior to administering Resident 98's as-needed pain medication.

28 Pa Code 211.5 (f) Clinical records

28 Pa code 211.10 (c) Resident care policies

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



 Plan of Correction - To be completed: 08/06/2024

Resident R98 had no adverse effects related to failed documentation of NPIs.
DON and/or designee to re=educate licensed nurse on the importance of documentation of NPI's prior to administration of PRN pain medications.
DON and/or designee will conduct an initial audit of residents receiving PRN pain medication for documentation of NPI's prior to administration of medication.
DON and/or designee will conduct audits x12 of MARS for documentation of NPI's prior to administration of PRN pain medication.
DON or designee will review findings of audit at QAPI meetings for x3 months.
483.50(a)(1)(i) REQUIREMENT Laboratory Services: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.
§483.50(a) Laboratory Services.
§483.50(a)(1) The facility must provide or obtain laboratory services to meet the needs of its residents. The facility is responsible for the quality and timeliness of the services.
(i) If the facility provides its own laboratory services, the services must meet the applicable requirements for laboratories specified in part 493 of this chapter.
Observations:


Based on clinical records review and staff interview, it was determined that the facility failed to perform laboratory services for one of the 33 residents reviewed (Resident 29).

Findings include:

Review of Resident 29's clinical records revealed Resident 29 had a diagnosis of Epilepsy (disorder in which nerve cell activity in the brain is disturbed causing seizures).

Review of Resident 29's physician order dated August 26, 2022, revealed an order for Depakote 750 mg in the morning and 500 mg at bedtime.

Review of Resident 29's physician's notes dated April 29, 2024, at 9:30 a.m., revealed "Today's order: TSH, CBC, CMP, and Depakote level for May 1, 2024."

Review of Resident 29's physician's notes dated May 22, 2023, at 3:49 p.m., revealed the Depakote level was ordered but not completed on May 1, 2024, then reorder for May 2023.

Clinical records review failed to reveal that Depakote level was completed on May 1, 2024, and/or May 23, 2024.

An interview conducted with the Director of Nursing on June 24, 2024, at 1:00 p.m., confirmed Depakote level was not completed until June 22, 2024.

The facility failed to ensure Resident 29's Depakote level was completed.

28 Pa. Code 211.5(f) Clinical Records

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


 Plan of Correction - To be completed: 08/06/2024

Resident R29's Depakote level was completed.
DON/designee will re-educate licensed nurses on laboratory services to ensure labs are obtained per physician's order.
Don/designee will conduct an initial audit of residents to determine who had lab orders in the past 30 days to ensure they were completed per physician orders.
Don/designee will conduct random weekly audits x12 weeks of 5 residents to ensure Labs were completed per physician orders.
DON/designee will review finding of audits at QAPI meeting x3 months.


483.50(b)(1)(i)(ii) REQUIREMENT Radiology/Other Diagnostic Services: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.
§483.50(b) Radiology and other diagnostic services.
§483.50(b)(1) The facility must provide or obtain radiology and other diagnostic services to meet the needs of its residents. The facility is responsible for the quality and timeliness of the services.
(i) If the facility provides its own diagnostic services, the services must meet the applicable conditions of participation for hospitals contained in §482.26 of this subchapter.
(ii) If the facility does not provide its own diagnostic services, it must have an agreement to obtain these services from a provider or supplier that is approved to provide these services under Medicare.
Observations:

Based on clinical record review, it was determined that the facility failed to ensure the radiological diagnostic studies were done in a timely manner for one of thirty-three residents reviewed (Resident 101).

Findings include:

Review of Resident 101's progress notes revealed a nurse's note dated April 2, 2024, which stated: "Resident return from schedule [doctor] appointment. Per [doctor] recommendation to check vitamin D level, increased vitamin D to 2000, Calcium 600 mg, Prolia [(medication used to treat bone loss)] injection [every] six months. Next office visit May 2024 for Dexa scan [(low-dose x-ray that measures bone density and risk for osteoporosis and fractures.)]"

Further review of Resident 101's progress notes revealed a nurse's note dated May 20, 2024, which stated: "Resident was supposed to go out on appointment this afternoon, transport did not show- up."

Further review of Resident 101's progress notes revealed a late entry nurse's note effective date May 20, 2024, which stated: "Resident was scheduled for a dexascan today. The order was placed for stretcher transport, [transportation company] called and said they cannot do stretcher today but could we send her in a wheelchair with an escort. We sent her via [wheelchair] with [nurse aide] escort but they were unable to complete the procedure due to not being able to get resident on table for testing. Upon arrival back at facility the scheduler was made aware of need for dexa scan to be rescheduled."

Further review of Resident 101's progress notes revealed a late entry nurse's note effective date June 17, 2024, which stated: "Transportation called to say they could not take resident to her appointment by stretcher as ordered but could take her by [wheelchair]. This nurse agreed that she could try it and go by [wheelchair] with an escort. Resident went for her dexascan appointment but was unable to be transferred to the table for test. Resident came back to [the] facility and request for another appointment sent."

Further review of Resident 101's progress notes revealed a nurse's note dated June 24, 2024, which stated: "Resident is scheduled for her dexascan this Friday [(June 28, 2024)]."

Interview with the Director of Nursing on June 24, 2024, at 12:05 p.m. confirmed that Resident 101's DEXA scan was delayed twice due to the resident being unable to transfer to the table from the wheelchair.

Pa. Code: 211.12(b) Nursing services

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

Pa. Code: 211.10(d) Resident care policies


 Plan of Correction - To be completed: 08/06/2024

Resident R101 Dexa scan was completed.
DON/designee will re-educate licensed nursing staff on ensuring Dexa scan studies are done in timely manner.
Don/designee will conduct an initial audit of residents to determine who had orders for a Dexa scan in the past 30 days to ensure they were completed in a timely manner per physician order.
DON/designee will conduct weekly audits x12 weeks of resident with a Dexa scan order to ensure completion in a timely manner.
DON/designee will report findings of audits to QAPI monthly x3 months.
§ 211.9(j.1) (1) - (5) LICENSURE Pharmacy services.:State only Deficiency.
(j.1) The facility shall have written policies and procedures for the disposition of medications that address all of the following:
(1) Timely and safe identification and removal of medications for disposition.
(2) Identification of storage methods for medications awaiting final disposition.
(3) Control and accountability of medications awaiting final disposition consistent with standards of practice.
(4) Documentation of actual disposition of medications to include the name of the individual disposing of the medication, the name of the resident, the name of the medication, the strength of the medication, the prescription number if applicable, the quantity of medication and the date of disposition.
(5) A method of disposition to prevent diversion or accidental exposure consistent with applicable Federal and State requirements, local ordinances and standards of practice.

Observations:

Based on clinical record review and staff interview, it was determined that the facility failed to document the disposition of the resident's medications including the name of the medication, strength of the medication, and quantity in the clinical record upon discharge of one of three closed records (Resident 161).

Findings include:

Review of Resident 161's clinical record revealed that on April 3, 2024, the resident was sent to the hospital for involuntary evaluation. Review of progress note of April 7, 2024 revealed resident's medications returned to pharmacy and/or wasted per facility policy.

Further review of the clinical record revealed no documentation of the name of the medication, strength of the medication, or quanity of medication.

Interview with the Director of Nursing on June 24, 2024, at 11:10 a.m. confirmed that the documentation was incomplete for the disposition of Resident 161's medications.



 Plan of Correction - To be completed: 08/06/2024

Resident R161 is no longer at facility.
DON/designee will re-educate licensed nurses on medication disposition and how to document upon discharge.
DON/designee will conduct weekly audits x12 weeks of discharged residents to ensure nursing dementated the disposition of the resident's medications including the name of the medication, strength of medication and quantity in the clinical record upon discharge.
Don/designee will review finds of the audits at QAPI x3 months
§ 211.12(f.1)(2) LICENSURE Nursing services. :State only Deficiency.
(2) Effective July 1, 2023, a minimum of 1 nurse aide per 12 residents during the day, 1 nurse aide per 12 residents during the evening, and 1 nurse aide per 20 residents overnight.

Observations:


Based on review of nursing time schedules, it was determined that the facility administrative staff failed to provide a minimum of one nurse aide per 12 residents during the day, one nurse aide per 12 residents during the evening, and one nurse aide per 20 residents overnight on 12 days for three weeks' staffing reviewed (Weeks of April 21, 2024, May 12, 2024, and June 17, 2024)

Findings include:

Review of the staffing for the weeks of April 21, 2024, May 12, 2024, and June 17, 2024 revealed the following dates and shifts did not meet the minimum requirements for nurse aide staffing ratios:

April 21, 2024, on the day and evening shifts
April 22, 2024 on the evening and night shifts
April 26, 2024 on the evening shift
May 12, 2024 on the day and evening shift
May 13, 2024 on the day, evening, and night shift
May 14, 2024 on the night shift
May 15, 2024 on the night shift
May 17, 2024 on the night shift
June 17, 2024 on the night shift
June 18, 2024 on the night shift
June 20, 2024 on the night shift
June 23, 2024 on the day shift

Interview with the Nursing Home Administrator and Director of Nursing on June 24, 2024, at approximately 1:15 p.m. confirmed the above findings.



 Plan of Correction - To be completed: 08/06/2024

No resident was adversely impacted due to the nursing aide assignment.
Administrator/designee will educate DON, Scheduling Manager and nursing supervisors and any members of nursing administration to ensure 1 nurse aide per 12 residents on day and evening shift and 1 nurse aide per 20 residents on night shift.
DON/designee will conduct daily autis to ensure the resident to CNA ration is within state guidelines to ensure the safety of all residents for 12 weeks.
DON/designee will review findings of the audits at QAPI for 3 months.
§ 211.12(f.1)(4) LICENSURE Nursing services. :State only Deficiency.
(4) Effective July 1, 2023, a minimum of 1 LPN per 25 residents during the day, 1 LPN per 30 residents during the evening, and 1 LPN per 40 residents overnight.
Observations:


Based on review of nursing time schedules, it was determined that the facility administrative staff failed to provide a minimum of one Licensed Practical Nurse (LPN) per 25 residents during the day shift, one LPN per 30 residents during the evening shift, and one LPN per 40 residents on the night shift for 15 days for three weeks' staffing reviewed (Weeks of April 21, 2024, May 12, 2024 and June 17, 2024)

Findings include:


Review of the staffing for the weeks of April 21, 2024, May 12, 2024 and June 17, 2024 revealed the following dates and shifts did not meet the minimum requirements for LPN staffing ratios:

April 21, 2024 on evening and night shift
April 24, 2024 on night shift
April 27, 2024 on night shift
May 12, 2024 on night shift
May 13, 2024 on night shift
May 14, 2024 on night shift
May 15, 2024 on night shift
May 17, 2024 on night shift
May 18, 2024 on night shift
June 17, 2024 on night shift
June 19, 2024 on night shift
June 20, 20204 on night shift
June 21, 2024 on night shift
June 22, 2024 on day and night shift
June 23, 2024 on night shift

Interview with the Nursing Home Administrator and Director of Nursing on June 24, 2024, at approximately 1:15 p.m. confirmed the above findings.



 Plan of Correction - To be completed: 08/06/2024

No residents were adversely impacted due to the staffing rations (LPN to residents).
Administrator/designee will educate DON, Scheduling manager, nursing supervisor and any member of nursing administration to ensure 1 LPN per 25 residents on day shift and 1 LPN per 30 residents on evening shift and 1 LPN per 30 residents on night shift.
DON/designee will conduct daily audits to ensure the resident to LPN ratio is within state guidelines to ensure the safety of all residents for 12 weeks.
DON/designee will review findings of the autids at QAPI meetings x3 months.
§ 211.12(f.1)(5) LICENSURE Nursing services. :State only Deficiency.
(5) Effective July 1, 2023, a minimum of 1 RN per 250 residents during all shifts.
Observations:


Based on review of nursing time schedules, it was determined that the facility administrative staff failed to provide a minimum of one Registered Nurse (RN) per 250 residents during the evening shift for four days for three weeks' staffing reviewed (Weeks of April 21, 2024, May 12, 2024, June 17, 2024.)

Findings include:

Review of the staffing for the weeks of April 21, 2024, May 12, 2024, June 17, 2024 revealed the following dates did not meet the minimum requirements for RN staffing ratios for the evening shift:

April 25, 2023 on night shift
May 16, 2024 on evening shift
June 18, 2024 on evening shift
June 23, 2024 on evening shift

Interview with the Nursing Home Administrator and Director of Nursing on June 24, 2024, at approximately 1:15 p.m. confirmed the above findings.


 Plan of Correction - To be completed: 08/06/2024

No residents were adversely impacted due to the staffing rations (RN to residents).
Administrator/designee will educate DON, Scheduling manager, nursing supervisor and any member of nursing administration to ensure 1 RN per 250 residents on all shifts.
DON/designee will conduct daily audits to ensure the resident to RN ratio is within state guidelines to ensure the safety of all residents for 12 weeks.
DON/designee will review findings of the audits at QAPI meetings x3 months.
§ 211.12(i)(1) LICENSURE Nursing services.:State only Deficiency.
(1) Effective July 1, 2023, the total number of hours of general nursing care provided in each 24-hour period shall, when totaled for the entire facility, be a minimum of 2.87 hours of direct resident care for each resident.

Observations:


Based on review of facility staffing data, it was determined that the facility failed to ensure the total number of general nursing care hours provided in each 24-hour period be a minimum of 2.87 hours per patient day (PPD) for six days of three weeks reviewed (Weeks of April 21, 2024, May 12, 2024, and June 17, 2024).

Findings include:

Review of facility staffing sheets revealed the following dates were below 2.87 hours PPD:

April 21, 2024 with a PPD of 2.78
April 22, 2024 with a PPD of 2.76
May 12, 2024 with a PPD of 2.55
June 17, 2024 with a PPD of 2.84
June 22, 2024 with a PPD of 2.74
June 23, 2024 with a PPD of 2.76

The facility staffing PPD being below the state minimum requirements was confirmed by the Nursing Home Administrator and Director of Nursing on June 24, 2024, at approximately 1:15 p.m.


 Plan of Correction - To be completed: 08/06/2024

No residents were adversely impacted due to the HPPD.
Administrator/designee will educate DON, Scheduling Manager, nursing supervisors and any members of nursing administration to ensure HPPD is above 2.87.
DON/designee will conduct daily audits to ensure HPPD is at 2.87 or above x12 weeks.
DON/designee will review findings of audits at QAPI meetings x 3 months.

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