Pennsylvania Department of Health
 WEXFORD HEALTHCARE CENTER
Patient Care Inspection Results

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
WEXFORD HEALTHCARE CENTER
Inspection Results For:

There are  196 surveys for this facility. Please select a date to view the survey results.

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WEXFORD HEALTHCARE CENTER - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on an Medicare/Medicaid Recertification survey, State Licensure survey, Civil Rights Compliance survey, and complaint surveys completed on October 31, 2024, it was determined that Wexford Healthcare Center had deficiencies that have the potential for minimal harm to residents as related to the 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:


483.35(d)(7) REQUIREMENT Nurse Aide Peform Review-12 hr/yr In-Service: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.
§483.35(d)(7) Regular in-service education.
The facility must complete a performance review of every nurse aide at least once every 12 months, and must provide regular in-service education based on the outcome of these reviews. In-service training must comply with the requirements of §483.95(g).
Observations:

Based on review of facility policy, personnel records and staff interview it was determined that the facility failed to complete annual performance evaluations for five out of five nurse aide personnel records Nurse Aide (NA) Employee E26, E27, E30, E31, and E33).

Findings include:

Review of facility "Wexford Employee Handbook" dated 10/24/24, indicated section 3.5 Job Description and Performance Evaluations states it's important to understand what is in your job description. It forms the basis for the annual performance evaluation that you will receive from your supervisor. You and your supervisor will meet at least once a year to review your job performance.

Review of NA Employee E26's personnel record indicated she was hired to the facility on 7/28/21.

Review of NA Employee E27's personnel record indicated she was hired to the facility on 6/21/22.

Review of NA Employee E30's personnel record indicated she was hired to the facility on 10/3/05.

Review of NA Employee E31's personnel record indicated she was hired to the facility on 9/5/10.

Review of NA Employee E33's personnel record indicated she was hired to the facility on 4/3/15.

Review of personnel records did not include an annual performance evaluation based on the date of hire for NA Employee E26, E27, E30, E31, and E33.

During an interview on 10/31/24, at 12:05 p.m. Regional Human Resource Employee E12 confirmed that the facility failed to complete annual performance evaluations for five out of five NA personnel records (NA Employee E26, E27, E30, E31, and E33) as required.


28 Pa Code: 201.20 (a)(b)(c)(d) Staff development.


 Plan of Correction - To be completed: 12/17/2024

1. All identified performance evaluations have been completed.
2. All residents have the potential to be affected by this alleged deficient practice. Facility will review prior 6 months to ensure all employees are up to date with performance evaluations.
3. Administrator/designee will educate employee life cycle manager on importance of timely completion of annual employee evaluation for all employees.
4. Administrator/designee will audit all performance evaluations weekly x 4 weeks to ensure they are all completed in a timely manner.
5. Administrator/Designee will report findings of audit results to QAPI monthly for 3 months and randomly thereafter to ensure compliance is sustained.

483.75(a)(1)-(4)(b)(1)-(4)(f)(1)-(6)(h)(i) REQUIREMENT QAPI Prgm/Plan, Disclosure/Good Faith Attmpt:This is a less serious (but not lowest level) deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
§483.75(a) Quality assurance and performance improvement (QAPI) program.
Each LTC facility, including a facility that is part of a multiunit chain, must develop, implement, and maintain an effective, comprehensive, data-driven QAPI program that focuses on indicators of the outcomes of care and quality of life. The facility must:

§483.75(a)(1) Maintain documentation and demonstrate evidence of its ongoing QAPI program that meets the requirements of this section. This may include but is not limited to systems and reports demonstrating systematic identification, reporting, investigation, analysis, and prevention of adverse events; and documentation demonstrating the development, implementation, and evaluation of corrective actions or performance improvement activities;

§483.75(a)(2) Present its QAPI plan to the State Survey Agency no later than 1 year after the promulgation of this regulation;

§483.75(a)(3) Present its QAPI plan to a State Survey Agency or Federal surveyor at each annual recertification survey and upon request during any other survey and to CMS upon request; and

§483.75(a)(4) Present documentation and evidence of its ongoing QAPI program's implementation and the facility's compliance with requirements to a State Survey Agency, Federal surveyor or CMS upon request.

§483.75(b) Program design and scope.
A facility must design its QAPI program to be ongoing, comprehensive, and to address the full range of care and services provided by the facility. It must:

§483.75(b)(1) Address all systems of care and management practices;

§483.75(b)(2) Include clinical care, quality of life, and resident choice;

§483.75(b)(3) Utilize the best available evidence to define and measure indicators of quality and facility goals that reflect processes of care and facility operations that have been shown to be predictive of desired outcomes for residents of a SNF or NF.

§483.75(b) (4) Reflect the complexities, unique care, and services that the facility provides.

§483.75(f) Governance and leadership.
The governing body and/or executive leadership (or organized group or individual who assumes full legal authority and responsibility for operation of the facility) is responsible and accountable for ensuring that:

§483.75(f)(1) An ongoing QAPI program is defined, implemented, and maintained and addresses identified priorities.

§483.75(f)(2) The QAPI program is sustained during transitions in leadership and staffing;
§483.75(f)(3) The QAPI program is adequately resourced, including ensuring staff time, equipment, and technical training as needed;

§483.75(f)(4) The QAPI program identifies and prioritizes problems and opportunities that reflect organizational process, functions, and services provided to residents based on performance indicator data, and resident and staff input, and other information.

§483.75(f)(5) Corrective actions address gaps in systems, and are evaluated for effectiveness; and

§483.75(f)(6) Clear expectations are set around safety, quality, rights, choice, and respect.

§483.75(h) Disclosure of information.
A State or the Secretary may not require disclosure of the records of such committee except in so far as such disclosure is related to the compliance of such committee with the requirements of this section.

§483.75(i) Sanctions.
Good faith attempts by the committee to identify and correct quality deficiencies will not be used as a basis for sanctions.
Observations:
Based on review of facility documentation and staff interview it was determined that the facility failed to maintain and implement an effective Quality Assurance and performance improvement program that focuses on outcome by failing to implement a QAPI for 11 previously cited citations.

Findings include:

Review of Plan of Correction from Full Health Survey ending 10/27/23, indicated the following citations:
F550
F565
F585
F600
F677
F684
F686
F689
F693
F760
F880

Facility indicated that the above citations: results of the audits would be forwarded to the facility QAPI committee for further review and recommendation until substantial compliance is maintained.

During an interview on 10/31/24, at 2:51 p.m. Nursing Home Administrator confirmed that the facility had multiple repeat deficiencies and failed to maintain and implement an effective QAPI program that focuses on outcome.

28 Pa. Code 201.14(a)Responsibility of licensee.
28. Pa. Code 201.18(a)(b)(3)e(1)(3)(4)Management.






 Plan of Correction - To be completed: 12/17/2024

1. Facility will make certain that QAPI plans are in place to improve the deliver of care and services to its residents.
2. All residents have the potential to be affected by this alleged deficient practice. Facility to review current QAPI policy/program at QAPI meeting.
3. RDO will educate NHA on QAPI Policy
4. All audits will be reviewed at QAPI meetings with any deficiencies noted being reviewed and discussed by QAPI committed. Any current plans deemed ineffective for maintaining compliance will be adjusted.
5. Administrator/designee will review results of plan of correction audits for effectiveness in maintaining ongoing compliance monthly during QAPI meeting and make further plans of action as warranted. Results will be reviewed with QAPI committee.

483.60(i)(1)(2) REQUIREMENT Food Procurement,Store/Prepare/Serve-Sanitary:This is a less serious (but not lowest level) deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
§483.60(i) Food safety requirements.
The facility must -

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

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

Based on a review of facility policies, observations and staff interviews it was determined that the facility failed to properly label and date food products in the Main Kitchen (Main Kitchen) and failed to properly label and date food in one of two nursing unit pantries (Third Floor Unit Pantry) which created the potential for food borne illness.

Findings Include:

Review of the facility policy "Food Storage: Cold Foods" last reviewed 10/24/24, and previously reviewed 9/9/23, indicated that all foods will be wrapped or stored in covered containers, labeled, and dated, and arranged in a manner to prevent cross contamination.

During an observation and interview in the Main Kitchen walk-in freezer, on 10/27/24, at 9:30 a.m., an open bag of chicken breast was found to be unsealed, unlabeled and undated, and an open package of ravioli was found to be opened, unlabeled, and undated. Assistant Food Service Supervisor Employee E16 confirmed that the facility failed to properly store, label, and date opened food packages to prevent foodborne illness.

During an observation on 10/27/24, at 12:30 p.m. the third-floor unit pantry refrigerator contained:

containers of vanilla reduced sugar Med pass 2.0 not labeled with date opened.
container of thickened lemon water not labeled with date opened.
container of Panera broccoli cheddar soup not labeled with name or date opened.
box of cheddar biscuits in the freezer not labeled with name or date opened.

During an interview completed on 10/27/24, at 12:34 p.m. Licensed Practical Nurse (LPN) Employee E6 confirmed the above observation and that the facility failed to properly label and date food in one of two nursing unit pantries (Third Floor Unit Pantry) which created the potential for food borne illness.

28 Pa. Code 201.14(a)Responsibility of licensee.
28 Pa. Code 201.18(b)(1) Management.
28 Pa. Code 211.6c Dietary services.


 Plan of Correction - To be completed: 12/17/2024

1. Open packages of chicken breast and ravioli that were not labeled were discarded. Non-Labeled open items in the third floor pantry refrigerators were discarded.
2. All residents have the potential to be affected by this alleged deficient practice. A full sweep of the kitchen was completed to ensure all open food was labeled and stored properly. A full sweep of all pantries has been completed to ensure all open items are dated and stored appropriately.
3. Administrator/Designee will educate all dining services staff and all nursing staff on proper labeling and storage of open food and refrigerated items.
4. Administrator/Designee will audit 5X weekly X 2 weeks and then 3X weekly X 2 weeks kitchen storage areas and nursing pantries to ensure all open items are labeled and stored appropriately.
5. Administrator/Designee will report findings of audit results to QAPI monthly for 3 months and randomly thereafter to ensure compliance is sustained.

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

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

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

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

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

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

Based on review of facility documentation, observations, resident and staff interviews it was determined that the facility failed to offer residents the opportunity to vote for the May 2024 election and the facility failed to provide a dignified dining experience for one of three Residents (Resident R43).

Findings include:

Review of the facility policy "Resident Rights" dated 10/24/24, and previously dated 9/9/23, indicated that residents' care will be provided in a safe and respectful manner.

Review of resident council meeting minutes for six months failed to include information of the facility asking the residents about voting.

During a resident group on 10/30/24, at 11:40 a.m. residents indicated that they were not offered the ability to vote in this election (November 2024), and in past elections four residents indicated they wanted to vote.

During an interview on 10/31/24, at 8:54 a.m. Activity Director Employee E9 confirmed that the facility failed to have documentation showing that all residents in the facility were asked about voting and could not find documentation for May of 2024 and that the facility failed to offer voting to all residents.

Review of the clinical record revealed that Resident R43 was admitted to the facility on 1/22/16.

Review of Resident 43's MDS (Minimum Data Set, periodic assessment of resident care needs) dated 8/9/24, indicated diagnoses of high blood pressure, dementia (a group of symptoms that affects memory, thinking and interferes with daily life), and muscle weakness.

Review of Resident R43's physician's order dated 5/3/24, indicated that Resident R43 requires self-feeding assistance during meals.

During an observation on 10/27/24, at 1:03 p.m. Resident R43 was seated in her chair beside her bed while being fed by Nurse Aide (NA) Employee E20. NA Employee E20 was standing beside Resident R43 while she was feeding Resident R43.

During an interview on 10/27/24, at 1:04 p.m. NA Employee E20 confirmed that she failed to provide a dignified dining experience for Resident R43, as she was standing while feeding Resident R43.

28 Pa. Code 201.1(i)Resident rights.



 Plan of Correction - To be completed: 12/17/2024

1. Facility unable correct past voting non-compliance. Facility immediately educated employees likely to have been the employee witnessed to have been standing while feeding resident.
2. All residents have the potential to be affected by this alleged deficient practice. Dining room was checked to ensure no other residents were being while the employee was standing up.
3. Administrator/Designee will educate Activities Director on the importance of the resident's right to vote, having proper procedures in place to ensure those choosing to vote are able to do so, and the process is documented accordingly. Director of Nursing or Designee will educate all nursing staff on providing a dignified dining experience for residents which includes sitting while feeding residents.
4. Director of Nursing/Designee will audit random areas of the center to ensure no employees are feeding residents while standing 5 X week for 2 weeks and then 3 X for 2 weeks.
5. Director of Nursing/Designee will report findings of audit results to QAPI monthly for 3 months and randomly thereafter to ensure compliance is sustained. Administrator will report on results of voting education and process in QAPI monthly for 1 year.

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

Based on review of facility documentation, resident and staff interview it was determined that the facility failed to maintain an effective pest control program for two of three floors ( first and second floors).

Findings include:

During an interview on 10/30/24, at 9:02 a.m. Resident R73 stated that she/he had a mouse in her room in June of 2024.

During an interview on 10/30/24, at 11:00 a.m. County Ombudsman confirmed that during a visist with resident R73 they observed mouse droppings around the room of Resident R73.

Review of facility documentation resident concerns, showed residents from 2nd floor having multiple concerns regarding seeing mice.

During observations on 10/31/24, at 12:10 p.m. Director of Maintenance Employee E36 showed an outside door that has rusted out on the bottom coroner of the door where they believe the mice are coming in.

During an interview on 10/31/24, at 12:20 p.m. Director of Maintenance Employee E36 confirmed that Resident R73 did have a hole in an outside wall and mouse droppings were in the room. Director of Maintenance Employee E36 confirmed that residents on the second floor did report seeing mice. The last reported mouse citing was last week on the first floor in a storage room. Director of Maintenance Employee E36 confirmed that the facility failed to maintain ineffective pest control program.

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


 Plan of Correction - To be completed: 12/17/2024

1. Past non-compliance with ineffective pest control unable to be corrected.
2. All residents have the potential to be affected by this alleged deficient practice. Pest Control has made extra visit to facility to ensure effective of pest control services. Pest control services will continue at a minimum of 1X per month or as frequent as needed if issues are identified.
3. Administrator/Designee will educate maintenance director on importance of effective pest control services.
4. Administrator/Designee will audit 10 resident rooms on each floor 3X per week X 4 weeks to ensure effective pest control.
5. Administrator/Designee will report findings of audit results to QAPI monthly for 3 months and randomly thereafter to ensure compliance is sustained.

483.80(a)(1)(2)(4)(e)(f) REQUIREMENT Infection Prevention & Control: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.
§483.80 Infection Control
The facility must establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections.

§483.80(a) Infection prevention and control program.
The facility must establish an infection prevention and control program (IPCP) that must include, at a minimum, the following elements:

§483.80(a)(1) A system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon the facility assessment conducted according to §483.71 and following accepted national standards;

§483.80(a)(2) Written standards, policies, and procedures for the program, which must include, but are not limited to:
(i) A system of surveillance designed to identify possible communicable diseases or
infections before they can spread to other persons in the facility;
(ii) When and to whom possible incidents of communicable disease or infections should be reported;
(iii) Standard and transmission-based precautions to be followed to prevent spread of infections;
(iv)When and how isolation should be used for a resident; including but not limited to:
(A) The type and duration of the isolation, depending upon the infectious agent or organism involved, and
(B) A requirement that the isolation should be the least restrictive possible for the resident under the circumstances.
(v) The circumstances under which the facility must prohibit employees with a communicable disease or infected skin lesions from direct contact with residents or their food, if direct contact will transmit the disease; and
(vi)The hand hygiene procedures to be followed by staff involved in direct resident contact.

§483.80(a)(4) A system for recording incidents identified under the facility's IPCP and the corrective actions taken by the facility.

§483.80(e) Linens.
Personnel must handle, store, process, and transport linens so as to prevent the spread of infection.

§483.80(f) Annual review.
The facility will conduct an annual review of its IPCP and update their program, as necessary.
Observations:

Based on review of facility policy, observations, and staff interviews, it was determined that the facility failed to properly monitor resident's personal refrigerators to ensure that food is properly stored and maintained for four of four residents (Resident R7, R47, R77, and R101) failed to maintain proper infection control practices related to care of indwelling urinary catheters (tube inserted in the bladder to drain urine) for two of three residents reviewed (Residents R48 and R113) and failed to provide a safe and sanitary environment to help prevent the potential for cross contamination for one of two medication rooms (Third Floor Medication Room).

Findings include:

Review of facility policy "Storage of Resident Food" dated 10/24/24, indicated it is the policy of the facility to provide resident centered care that meets the psychosocial, physical and emotional needs and concerns of the residents. Residents have the option of bringing food into the facility or have family or friends bring into the facility as long as safe storage guidelines are followed to protect the resident. The facility recognizes and supports resident's need and right to bring in food from outside sources but still maintain safety and sanitary conditions for storage and consumption. Residents must agree to allow staff to monitor and log the refrigerator temperatures and expiration of food items.

Review of facility policy "Catheter Care" dated 9/19/23, and last reviewed 10/24/24, indicated to check that collection bag is not on the floor and is draining properly and secured allowing for no reflux of urine back to the bladder.

Review if the facility policy "Storage of Medications" dated 9/19/23, and last reviewed 10/24/24, indicated medications and biologicals are stored safely, securely, and properly. Refrigerated medications are kept in closed and labeled containers with internal and external medications separated from each other.

Review of the facility policy "Infection Prevention Program: dated 9/19/23, and last reviewed 10/24/24, indicates it is the policy of this facility to provide resident centered care that meets the psychosocial, physical and emotional needs and concerns of the residents. Residents have a right to reside in a safe environment that promotes health and reduces the risk of acquiring infections.

During an observation on 10/27/24, at 9:30 a.m. Resident R47 had a small personal refrigerator on his bedside nightstand.

During an observation on 10/27/24, at 10:40 a.m. Resident R7 had a small, personal refrigerator on her bedside nightstand which contained two plastic bowls with no date or labels, and no temperature log that included daily monitoring for Resident R7's personal refrigerator.

During an observation on 10/27/24, at 2:03 p.m. the contents inside Resident R101's refrigerator included two frozen dinners, condiments such as mayonnaise, ketchup, pickles, wrapped food in aluminum foil with no dates, two personal bowls with no dates, and a fast-food bag with sandwiches in it not dated.

During an observation on 10/27/24, at 2:05 p.m. there was no temperature log that included daily monitoring for Resident R47's personal refrigerator.

During an observation on 10/27/24, at 10:10 a.m. Resident R101 had a small personal refrigerator on her bedside nightstand.

During an observation on 10/27/24, at 2:18 p.m. the contents inside Resident R47's refrigerator included, 14 yogurt, four yogurt in freezer, four small containers of milk (one expired 10/24/24), blueberries, grapes, and an orange.

During an observation on 10/27/24, at 2:20 p.m. there was no thermometer inside, and no temperature log that included daily monitoring for Resident R101's personal refrigerator.

During an interview on 10/27/24, at 2:30 p.m. Licensed Practical Nurse (LPN) Employee E6 confirmed that the facility failed to properly monitor resident's personal refrigerators to ensure that food is properly stored and maintained for Residents R47 and R101.

During an observation and interview completed on 10/27/24, at 10:01 a.m. Resident R77 was noted to have a personal refrigerator in his room. Resident R77 stated "my wife brings me in food, and my boost". No refrigerator log was noted in the room.

During an interview and observation on 10/27/24 at 1:05 p.m. LPN Employee E6 opened the refrigerator and pulled out a thermometer. LPN Employee E6 stated, "There is a thermometer, I can't answer if they check the temperatures," and confirmed there was not a temperature log that included daily monitoring for Resident R77's personal refrigerator.

During an interview on 10/28/24, at 10:28 a.m. the Director of Nursing confirmed that the facility failed to ensure that expiration of food items and refrigeration temperatures were monitored for Resident R7.

Review of the clinical record indicated Resident R48 was admitted to the facility on 4/30/24.

Review of Resident R48's MDS dated 9/26/24, indicated diagnoses of neurogenic bladder (bladder problems due to disease or injury of the nervous system involved in the control of urination), and quadriplegia (paralysis of all four limbs).

Review of a physician order dated 9/27/24, indicated the resident has a suprapubic catheter for neuromuscular dysfunction of the bladder.

During an observation on 10/27/24, at 10:22 a.m. Resident R48's catheter collection bag was observed lying on the floor on the right side of the resident's bed with no dignity cover present.

During an interview on 10/27/24, at 11:05 a.m. Registered Nurse (RN) Employee E2 confirmed Resident R48's catheter collection bag was on the floor with no dignity cover.

During an interview on 10/27/24, at 11:05 a.m. RN Employee E2 confirmed that the facility failed to maintain proper infection control practices related to Resident R48's indwelling urinary catheter as required.

Review of Resident R113's admission record dated 9/21/24, and readmitted on 10/1/24.

Review of Resident R113's MDS assessment (MDS-Minimum Data Set assessment: periodic assessment of resident care needs) dated 10/8/24, indicated that Resident R113 had diagnoses that included acute respiratory failure (the body is not receiving sufficient oxygen), anxiety disorder (a medical condition creating a sense of acute fear, restlessness, and worry), history of falling, neuromuscular disfunction of bladder (central nervous system lacks communication for urinary function and urgency). The diagnoses were current upon review.

Review of Resident R113's physician order dated 10/1/24, indicated to provide indwelling catheter, change indwelling catheter and bag as needed.

During observations on 10/27/24, at 9:19 a.m. the following was observed in Resident R113 room:
Resident R113 was observed resting in bed. Resident R113's was observed with a clear line leading to a catheter bag. The catheter bag was observed on the floor with clear fluid in the bag.

During an interview on 10/27/24, at 9:24 a.m. RN Employee E2 confirmed that the facility failed to maintain infection control with the use of a catheter for Resident R113.

During an observation on 10/27/24, at 12:19 p.m. the Third Floor Medication Room freezer contained:
white ice packs
soft blue cloth comfort ice packs
blue ice packs

During an interview completed on 10/27/24, at 12:25 p.m. LPN Employee E6 removed all the ice packs and stated, "I have never seen these before (the blue soft ones) these blue ones look like the ones they use for knee surgeries there are no names on them," and confirmed the facility failed to provide a safe and sanitary environment to help prevent the potential for cross contamination for one of two medication rooms (Third Floor Medication Room).


28 Pa. code: 201.14 (a) Responsibility of licensee.
28 Pa. Code: 201.18 (b) (1) (e) (1) Management.
28 Pa. Code: 211.10 (d) Resident care policies.
28 Pa. Code: 211.12 (d) (1) (2) (5) Nursing services


 Plan of Correction - To be completed: 12/17/2024

1. The refrigerator in rooms for Residents 7,47, 77, and 101 had the temperature in their refrigerator and freezer checked, the refrigerators were checked for expired food. R4 catheter orders were checked and updated according to policy. Foleys were removed from the floor and foleys were replaced with foleys with covers, Ice packs were removed from the freezer
2. All residents have potential to be affected by these alleged deficient practices, a list of residents with refrigerators in their room ere obtained, all had temp logs applied and temperatures taken. Night shift will be responsible to maintain the temperatures and to remove food as it expires.All catheters will be monitored by the infection control nurse or designee and as new orders are written, Infection control nurse or designee will monitor freezers for ice packs
3. Director of nursing or designee will educate nursing staff on foley catheters protocol, checking temperatures of residents refrigerators and freezers, removing expired food from the freezers and refrigerators and ice packs in the freezer, this will be audited by the infection control nurse or designee five times a week for two weeks and three time a week for two weeks.
4. The results of these audits will be reviewed at the monthly QAPI meeting. The plan will be updated as needed

483.45(g)(h)(1)(2) REQUIREMENT Label/Store Drugs and Biologicals:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
§483.45(g) Labeling of Drugs and Biologicals
Drugs and biologicals used in the facility must be labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable.

§483.45(h) Storage of Drugs and Biologicals

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

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

Based on review of facility policy, observation and staff interview, it was determined that the facility failed to make certain that refrigerated medications are stored at proper temperatures for one of four medication rooms (Third Floor Medication Room), failed to store medications properly and securely in medication carts, failed to secure treatment carts on two out of five treatment carts (Second Floor C1-Nursing unit, and D Unit Treatment carts), failed to ensure a medication room was properly locked (Second Floor D Wing Medication Room), failed to properly store medical supplies and biologicals in one of two medication rooms (Second Floor D Wing Medication Room), failed to store treatments for residents properly to prevent cross contamination for three of four medication carts (First floor RP Medication cart and Second Floor D Wing Medication cart, Third floor East medication cart), failed to store all biologicals in a safe, secure manner for one of three residents (Resident R104) failed to label open medications with a date on one of two medication carts (Third Floor East Wing cart) and in one of four medication rooms (Third Floor medication refrigerator).

Findings include:

Review of facility "Storage of Medications" policy dated 10/24/24, indicated that medications and biologicals are stored safely, securely, and properly, following manufacturer ' s recommendations or those of the supplier. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel or staff members lawfully authorized to administer medications. This includes medication rooms, carts, and medication supplies are locked when they are not attended. Orally administered medications are stored separately from externally used medications and treatments. When the original seal of manufacturer ' s container or vial is initially broken, the container or vial will be dated. The nurse shall place a "date opened" sticker on the medication and the expiration date will be 30 days from opening. Medications must be poured just prior to administering, prepare one resident's medication at a time.

Review of the facility policy "Medication administration" dated 9/19/23, last reviewed on 10/24/24 indicated the facility should maintain a temperature log in the storage area to record temperatures at least once a day.

Review of Tuberculin (TB) (a solution that is administered as an aide in the diagnosis of tuberculosis- a lung infection) manufactures guidelines on 10/31/24, at 2:04 p.m. indicated vials in use more than 30 days should be discarded due to losing the effect of the medication.

During a tour of the C1 unit on 10/27/24, at 9:05 a.m. two treatment carts were observed outside of room 238. Both treatment carts were observed unlocked.

During an interview on 10/27/24, at 9:06 a.m. Registered Nurse (RN) Employee E15 agreed that the treatment carts were both unlocked and confirmed that the facility failed to secure treatment carts on the C1 nursing unit as required.

During an observation on 10/28/24, at 9:37 a.m. on the Second Floor D Unit, the Employee Breakroom door was propped open and a Treatment Cart containing medications was found to be unlocked, and inside the Employee Breakroom.

During an interview on 10/28/24, at 9:47 a.m. Interim Unit Manager Employee E25 confirmed that the facility failed to properly secure a medication cart while not in use on the Second Floor D Unit.

During a tour of Second Floor D Wing unit on 10/28/24, at 12:40 p.m. the medication room was propped open with a garbage can and was not locked.

During an observation on 10/28/24, at 12:42 p.m. Licensed Practical Nurse (LPN) Employee E8 asked someone to pull the garbage can out of the doorway because "The door shouldn't be open. A resident could get in there".

During an interview on 10/28/24, at 12:44 p.m. LPN Employee E8 confirmed the medication room was not properly locked (Second Floor D Wing Medication Room).

During an observation in Second Floor D Wing Mediation Room on 10/28/24, at 12:45 p.m. a vial of TB solution was stored in the medication storage refrigerator, however failed to have a date of which it was opened and failed to have an expiration date on it.

During an interview on 10/28/24, at 12:50 p.m. LPN Employee E8 confirmed that there was no open or expiration date on the vial of TB solution.

During a medication cart review on 10/29/24, at 2:04 p.m. it was observed that there were multiple used tubes of treatments on the medication cart. Items observed were:

- Metronidazole (a cream used for wound care of a cancer lesion)
- Diclofenac (a cream used for pain)- four tubes for four different residents.

During an interview on 10/29/24, at 2:33 p.m. LPN Employee E4 confirmed that the above would be considered treatments and should be on the treatment cart.

During a medication cart review on 10/30/24, at 8:53 a.m. it was observed that there were two tubes of treatments on the medication cart. Items observed were:

- Triamcinolone (a cream used for various sin conditions)
- Diclofenac - did not contain residents' information.

During an interview on 10/30/24, at 9:58 a.m. LPN Employee E5 confirmed that the above would be considered treatments and should be on the treatment cart.

During an interview on 10/30/24, at 2:35 p.m. the Director of Nursing confirmed that the facility failed to ensure a medication room was properly locked (Second Floor D Wing Medication Room), failed to properly store medical supplies and biologicals in one of two medication rooms (Second Floor D Wing Medication Room), and failed to store treatments for residents properly to prevent cross contamination for two of four medication carts ( First floor RP Medication cart and Second Floor D Wing Medication cart).

During an observation on 10/27/24, at 10:18 a.m. a white jar labeled nystatin/Silvadene cream (medication applied to the skin used to treat fungal infections) was observed on Resident R104's nightstand.

During an interview on 10/27/24, at 10:19 a.m. Licensed Practical Nurse (LPN) Employee E6 stated "I can't justify why it's in there" removed the white jar from nightstand and confirmed the facility failed to store biologicals in a safe, secure, and orderly manner for one of three residents (Resident R93).

During a medication cart review on 10/28/24, at 09:38 a.m. the following was observed on the third-floor East wing medication cart:

Top drawer:
cup labeled 304 A containing three brown capsules.
cup labeled 304 B containing one pink and one white pill.
cup labeled 312 A containing a crushed white substance.
cup labeled 312 B containing one yellow capsule, one white pill and one pink pill.
cup labeled 313A containing one red capsule, one white oblong pill, one green and white capsule.
cup labeled 313B containing one blue pill, one white pill, 1/2 of a white pill, two yellow oval shaped pills, one brown pill, two pink pills and one yellow pill.
Novolin Insulin Flex Pen drawn up at 16 units.
Lantus Insulin Pen drawn up at 15 units.
Fiasp -Aspart Insulin Pen drawn up at 6 units.
Bottom Drawer:
bottle Geri -tussin house stock not labeled with date opened.
bottle lactulose not labeled with date opened.
bottle guaiasorb DM not labeled with date opened.
bottle nystatin liquid not labeled with date opened.
tube of diclofenac gel.

During an interview completed on 10/28/24 at 9:38 a.m. Registered Nurse (RN) Employee E11 confirmed the above observations and that the facility failed to properly secure prepared medications, label open medications and properly store biologicals in one of eight medication carts (third floor East wing cart).

During an observation and interview on 10/27/24, at 12:19 p.m. of the third-floor medication room the following was discovered:
full-size medication refrigerator temperature log was blank for the following dates: 10/14/24, 10/17/24, 10/18/24 ,10/21/24 ,10/22/24, and 10/23/24.
vial containing Tuberculin not labeled with date opened.
smaller narcotic refrigerator temperature log was blank for the following dates: 10/14/24, 10/17/24, 10/18/24 ,10/21/24 ,10/22/24 ,10/23/24.

During an interview completed on 10/27/24, at 12:19 p.m. RN Employee E6 confirmed the above observations and that the facility failed to label open medications with a date in one of four medication rooms (Third Floor medication refrigerator) and failed to monitor refrigerator temperatures in one of four medication rooms. (Third Floor medication room).

28 Pa. Code 211.9(a)(1) Pharmacy Services.
28 Pa. Code 211.12(d)(1) Nursing Services.


 Plan of Correction - To be completed: 12/17/2024

1. The third floor med room refrigerators temperature were obtained, documented on the log and found in range. The treatment cart on C and D unit were locked upon discovery on 10/27/24 and 10/28/24. The medication room was secured on 10/28/24 as stated in the deficiency. The undated TB solution was disposed of. The medicated treatments were removed from the medication cart and placed in the treatment cart. The medicated treatment located in R101 room was removed at time of discovery as stated in the deficiency. The medications found in cups in the medication cart on the third floor were disposed of at time of discovery.
2. All residents have the potential to be affected by the alleged deficient practice. An audit of all medication carts, treatment carts, medication rooms, and resident rooms was completed on 10/30/24 to ensure medications were secured, stored at safe temperatures, dated when opened and placed in correct storage area. All medication carts were assessed at this time to ensure no pre-poured medications were found as well.
3. Director of Nursing /designee will in-service licensed nursing staff on safe, secure, proper medication storage. Director of Nursing/Designee will audit 10 resident rooms 5 times weekly for 2 weeks and 3 times weekly for 2 weeks to ensure that no medications are stored inappropriately in resident rooms. Director of Nursing/Designee will audit 3 medication carts and 3 treatment carts 5 times a week for 2 weeks and 3 times a week for 2 weeks to ensure opened items are dated and stored correctly and no pre-poured medications found. Director of Nursing/designee will audit 3 medication rooms 5 times weekly times 2 weeks, then 3 times weekly for 2 weeks to ensure they are secured, refrigerator temperatures are logged and all medications dated when opened.
4. Director of Nursing Designee will report in monthly QAPI meetings the results of findings monthly X 3 months and randomly thereafter.

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

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

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

Based on review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to ensure appropriate treatment and services were provided for residents with an indwelling urinary catheter (a tube inserted in the bladder to drain urine) for three of four residents reviewed (Residents R42, R48, and R107).

Findings include:

Review of facility policy "Catheter Care" dated 9/19/23, and last reviewed 10/24/24, indicated catheter care at the bedside is performed to promote cleanliness and dignity and is performed by the nursing staff twice daily for residents who have an indwelling catheter. Check that collection bag is not on the floor and is draining properly and secured allowing for no reflux of urine back to the bladder.

Review of the clinical record indicated Resident R42 was admitted to the facility on 8/28/24.

Review of Resident R42's Minimum Data Set (MDS- a periodic assessment of care needs) dated 10/15/24, indicated the diagnosis of anemia (low iron in the blood), cerebral palsy (movement disorder), and benign prostatic hyperplasia (BPH-enlargement of the prostate gland)

Review of R42 physician order dated 10/8/24, indicated the resident has a foley catheter (flexible tube that drains urine from the bladder through the urethra) The order failed to include the amount of fluid needed to insert for balloon inflation/securement (the balloon keeps catheter in the bladder) or a diagnosis for the foley catheter.

During an interview completed on 10/31/24 at 10:19 a.m. Registered Nurse (RN) Employee E3 confirmed the order did not include the amount of fluid needed for balloon inflation/securement or a diagnosis for the foley catheter and the facility failed to ensure appropriate treatment and services were provided for a resident with a foley catheter (Resident R42)

Review of the clinical record indicated Resident R48 was admitted to the facility on 4/30/24.

Review of Resident R48's MDS dated 9/26/24, indicated diagnoses of neurogenic bladder (bladder problems due to disease or injury of the nervous system involved in the control of urination), and quadriplegia (paralysis of all four limbs).

Review of a physician order dated 9/27/24, indicated the resident has a suprapubic catheter (a catheter inserted into the bladder via an incision in the lower abdomen) for neuromuscular dysfunction of the bladder.

Review of a physician order dated 7/23/24, indicated to flush suprapubic catheter daily with 60 milliliters of sterile water or normal saline solution in the afternoon.

During an observation on 10/27/24, at 10:22 a.m. Resident R48's catheter collection bag was observed lying on the floor on the right side of the resident's bed with no dignity cover present. During this same observation, an irrigation syringe used to flush Resident R48's catheter and a bottle of sterile water were on Resident R48's bedside dresser. Both the syringe and bottle of sterile water were open and neither had an open date present.

During an interview on 10/27/24, at 11:05 a.m. RN Employee E2 confirmed Resident R48's catheter collection bag was on the floor with no dignity cover and the irrigation syringe and bottle of sterile water were open with no open date present.

During an interview on 10/27/24, at 11:05 a.m. RN Employee E2 confirmed that the facility failed to ensure appropriate indwelling urinary catheter treatments and services were provided for Resident R48 as required.

Review of the clinical record revealed that Resident R107 was admitted to the facility on 9/30/24.

Review of Resident 107's MDS dated 10/7/24, indicated diagnoses of high blood pressure, intracerebral hemorrhage (when a ruptured blood vessel causes bleeding inside the brain), and dysphagia (difficulty swallowing).

Review of a physician's order dated 10/26/24, indicated that Resident R107 has a Foley catheter (a flexible tube that drains urine from the bladder into a collection bag) for a neurogenic bladder.

During an observation on 10/27/24, at 11:49 a.m. Resident R107 was observed resting in bed with no dignity cover on her urine collection bag.

During an interview on 10/27/24, at 12:02 p.m. RN Employee E18 confirmed that the facility failed to ensure appropriate indwelling urinary catheter treatments and service were provided for Resident R107 as required.

28 Pa. Code 201.14(a) Responsibility of licensee.
28 Pa. Code 201.29(a)(c)(d)(j) Resident rights.
28 Pa. Code 211.10(c)(d) Resident care policies.
28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.



 Plan of Correction - To be completed: 12/17/2024

1. Resident 42 had his urinary catheter order updated to reflect balloon size and reason for use. Residents 48 and 107 were provided drainage bags with privacy covers, ensured drainage bags were not resting on the floor and removed the open and undated syringe and sterile water.
2. All residents have the potential to be affected by the alleged deficient practice. An audit was conducted or residents with urinary catheters to ensure orders contained balloon size and reason for use and that all had been provided privacy bags and kept off of the floor.
3. Director of Nursing /designee will in-service nursing staff on urinary catheter orders, dignity and infection control related to catheter care. Director of Nursing/Designee will audits of new catheter orders 5 times weekly for 2 weeks and 3 times weekly for 2 weeks. Director of Nursing/Designee will audit 5 residents with catheters for dignity and infection control 5 times weekly for 2 weeks and then 3 times a week for 2 weeks.
4. Director of Nursing Designee will report in monthly QAPI meetings the results of findings monthly X 3 months and randomly thereafter.

483.24(c)(1) REQUIREMENT Activities Meet Interest/Needs Each Resident: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(c) Activities.
§483.24(c)(1) The facility must provide, based on the comprehensive assessment and care plan and the preferences of each resident, an ongoing program to support residents in their choice of activities, both facility-sponsored group and individual activities and independent activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community.
Observations:

Based on a review of the clinical record and staff interviews, it was determined that the facility failed to provide an ongoing program of activities to meet the interests of and support the physical, mental, and psychosocial well-being of each resident for six of six residents (Residents R1 and R112 and Residents R200, R201, R202, and R203).

Findings include:

Review of facility policy "Activities Program" dated 9/19/23, and last reviewed 10/24/24, indicated the facility is to provide resident centered care that meets the psychosocial, physical and emotional needs and concerns of the residents. The activity program is designed to encourage restoration to self-care and maintenance of normal activity that is geared to the individual resident's needs. The activity program consists of individual and small and large group activities which are designed to meet the needs and interests of each resident and includes social activities, indoor and outdoor activities, activities away from the facility, religious programs, creative activities, intellectual and educational activities, exercise activities, individualized activities, in-room activities, and community activities.

During a resident group interview on 10/30/24, at 11:16 a.m. Residents R200, R201, R202 and R204 indicated that the activities don't always meet their needs. Residents stated that the activity calendar can change and activities don't take place, and they are unaware of when the changes are going to take place.

Review of the clinical record indicated Resident R1 was admitted to the facility on 2/22/24.

Review of Resident R1's Minimum Data Set (MDS - a periodic assessment of care needs) dated 9/9/24, indicated diagnoses of high blood pressure, muscle weakness, and dependence on wheelchair.

Review of Resident R1's care plan dated 2/23/24, indicated the resident will participate in socialization and recreation activities to decrease isolation, improve mood, and increase peer interaction. Interventions include provide socialization, leisure, and/or recreation activities per the resident's wishes and to offer and encourage attendance and involvement in facility activities.

During an interview on 10/27/24, at 9:59 a.m. Resident R1 stated, "The facility has a lot of group activities but I am unable to participate in them currently. No one from Activities comes in to do activities with me in my room, but I would like them to."

Review of Resident R1's clinical record for October 2024, revealed the facility failed to provide an ongoing program of activities to meet the resident's interests. Review of Resident R1's "Activity Participation" indicated that no activities were offered to Resident R1 during October of 2024.

Review of the clinical record indicated Resident R112 was admitted to the facility on 5/24/23.

Review of the clinical record MDS dated 5/22/24, indicated Resident R112 was admitted with the following diagnosis cerebral palsy, and epilepsy.

During an interview on 10/29/24, at 9:24 a.m. Resident R112 indicated that she enjoys activities, but they don't come in the room anymore.

Review of Resident R112 MDS dated 5/22/24, activities and preferences indicated activity preferences of:music,animals and favorite activities. No care plan was indicated for activities.

Review of Resident R112 clinical doucmentation for September, and October failed to indicate any activities were provided.

During an interview on 10/31/24, at 8:55 a.m. Activities Director Employee E9 confirmed that activities have changed without notifying residents.

During an interview on 10/31/24, at 9:06 a.m. Activities Director Employee E9 stated, "Some resident's don't like to come out of their rooms. I ask them what they like to do and I try to bring them activities that they would like. I do not recall doing activities with Resident R1 in her room. She has never participated in group activities."

During an interview on 10/31/24, at 9:13 a.m. Activities Director Employee E9 confirmed there was no documentation to indicate that Resident R1 was offered activities during October 2024.

During an interview on 10/31/24, at 9:10 a.m. Activities Director Employee E9 confirmed there was no documention to indicate that resident R112 was offered activities during September and October 2024.

During an interview on 10/31/24, at 9:13 a.m. Activities Director Employee E9 confirmed that the facility failed to provide an ongoing program of activities to meet the interests of and support the physical, mental, and psychosocial well-being of each resident for two of six residents (Residents R1, R112, and Residents R200, 201, 202, and 203).

28 Pa. Code: 201. 18(b)(3) Management.
28 Pa. Code: 207.2(a) Administrators Responsibility.



 Plan of Correction - To be completed: 12/17/2024

1. R1 and R112's care plans were adjusted to reflect the desire to have activities in their room. Activities were offered in their rooms. Resident Council meeting was held to determine what types of activities residents preferred on a monthly basis and how residents wished to be notified in advanced of any changes to the activities calendar.
2. All residents have the potential to be affected by this alleged deficient practice. All residents will be interviewed to gather their activity preferences and documented accordingly.
3. Administrator/Designee will educate all activities staff on the need for residents to have activities that meet their needs and document their participation in those activities, in addition to proper notification of residents for any activity calendar changes.
4. Administrator/Designee will audit for proper notification to residents for any activity calendar changes weekly X 4 weeks. Administrator/designee will also audit for documented activity participation or refusal 5X weekly for 2 weeks and 3X weekly for 2 weeks.
5. Administrator/Designee will report findings of audit results to QAPI monthly for 3 months and randomly thereafter to ensure compliance is sustained.

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 review of clinical records and observations, as well as staff and resident interviews, it was determined that the facility failed to provide Activity of Daily Living (ADL) assistance for four out of nine sampled residents (Resident R27, R46, R48, and R87).

Findings include:

The facility "Routine resident care" policy dated 9/19/23, indicated that routine resident care is not necessarily clinical, but is necessary for quality of life. Provide routine daily care by a certified nursing assistant. Routine care includes but is not limited to the following: bathing, dressing and toileting.

Review of Resident R27's admission record indicated he was originally admitted on 6/10/19, and readmitted on 6/11/24.

Review of Resident R27's MDS assessment (MDS-Minimum Data Set assessment: periodic assessment of resident care needs) dated 6/18/24, indicated that he had diagnoses that included diabetes (a metabolic disorder impacting organ function related to glucose levels in the human body), peripheral vascular disease (PVD- a narrowing of the blood vessels in the legs), hypertensive heart disease (a condition characterized by long term heart conditions and high blood pressure), anxiety disorder (a medical condition creating a sense of acute fear, restlessness, and worry), and spinal stenosis (a narrowing of the spaces within the spine, which causes pain and weakness). The diagnoses were current upon review.

Review of Resident R27's MDS assessment dated 6/18/24, indicated that Section GG0100A-Self care (resident's need for assistance with bathing, dressing, using the toilet) was coded "2" for help needed from another person.

Review of Resident R27's care plan dated 6/20/24, indicated that Resident R27 was dependent for shower/bathe. Helper does all of the effort with two or more staff.

Review of Resident R27's October 2024 shower documentation indicated there was no shower provided on 10/2/24, 10/26/24, and 10/30/24.

During an interview on 10/27/24, at 1:10 p.m. Resident R27 was interviewed and stated the following: "I never had my beard trimmed. The Nurse aide did not get me a shower last night and they do not want to do showers."

Review of clinical record indicated that Resident R46 was admitted on 9/10/24.

Review of Resident R46's MDS dated 9/17/24, indicated diagnoses of high blood pressure, dementia (a group of symptoms that affects memory, thinking and interferes with daily life), and muscle weakness.

Review of Resident R46's MDS assessment dated 9/17/24, indicated that Section GG0100A-Self-care (resident's need for assistance with bathing, dressing, using the toilet) was coded "2" for help needed from another person.

Review of Resident R46's care plan dated 9/10/24, indicated that Resident R46 was dependent for shower/bathe. Helper does all of the effort with assistance of one person.

Review of Resident R46's October 2024 shower documentation indicated there was no shower provided on 10/10/24, 10/14/24, and 10/28/24.

Review of the clinical record indicated Resident R48 was admitted to the facility on 4/30/24.

Review of Resident R48's MDS dated 9/26/24, indicated diagnoses of neurogenic bladder (bladder problems due to disease or injury of the nervous system involved in the control of urination), and quadriplegia (paralysis of all four limbs). Section GG - Functional Abilities and Goals, Question GG01130E - Shower/bathe self: indicated Resident R48 was coded "1" dependent, helper does all of the effort.

Review of Resident R48's care plan dated 6/4/24, indicated that Resident R48 was dependent for shower/bathe. Helper does all of the effort with two or more staff.

Review of Resident R48's October 2024 shower documentation indicated there was no shower or bath provided on 10/3/24, 10/7/24, 10/10/24, 10/14/24, 10/21/24, 10/24/24, and 10/28/24.

During an interview on 10/27/24, at 10:18 a.m. Resident R48 stated, "I go three weeks without getting a shower. I'm supposed to get showers on Mondays and Thursdays, I have never gotten a shower twice a week here."

Review of Resident R87's admission record indicated he was admitted to the facility on 9/20/24.

Review of Resident R87's MDS dated 9/27/24, indicated diagnoses of high blood pressure, depression, and dementia (a group of symptoms that affects memory, thinking and interferes with daily life).

Review of Resident R87's care plan dated 9/30/24, indicated that Resident R87 was dependent for shower/bathe. Helper does all of the effort with two or more staff.

Review of Resident R87's September 2024 shower documentation indicated no showers were provided since admission.

Review of Resident R87's October 2024 shower documentation indicated no shower was provided on 10/3/2024, 10/10/2024, 10/17/2024, 10/21/24, 10/24/24, and 10/28/24.

During an interview on 10/30/24, at 2:52 p.m the Director of Nursing (DON) confirmed that the facility failed to provide Activity of Daily Living (ADL) assistance for Residents R27, R46, R48, and R87, as required.

28 Pa. Code: 201.14(a) Responsibility of licensee.
28 Pa. Code: 201.18(e)(6) Management.
28 Pa. Code: 211.12(a)(c)(d)(1)(2)(3)(4) Nursing services.
28 Pa. Code: 201.20 Staff development.


 Plan of Correction - To be completed: 12/17/2024

1. Residents 27, 46, 48 and 87 have received showers as of 11/21/24.
2. All residents have the potential to be affected by the alleged deficient practice. All residents were interviewed regarding if they are receiving showers.
3. Director of Nursing /designee will in-service nursing staff on residents receiving showers at least twice weekly. Director of Nursing/Designee will audit 10 residents shower documentation 5 times weekly for 2 weeks and 3 times weekly for 2 weeks.
4. Director of Nursing Designee will report in monthly QAPI meetings the results of findings monthly X 3 months and randomly thereafter.

483.15(d)(1)(2) REQUIREMENT Notice of Bed Hold Policy Before/Upon Trnsfr:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
§483.15(d) Notice of bed-hold policy and return-

§483.15(d)(1) Notice before transfer. Before a nursing facility transfers a resident to a hospital or the resident goes on therapeutic leave, the nursing facility must provide written information to the resident or resident representative that specifies-
(i) The duration of the state bed-hold policy, if any, during which the resident is permitted to return and resume residence in the nursing facility;
(ii) The reserve bed payment policy in the state plan, under § 447.40 of this chapter, if any;
(iii) The nursing facility's policies regarding bed-hold periods, which must be consistent with paragraph (e)(1) of this section, permitting a resident to return; and
(iv) The information specified in paragraph (e)(1) of this section.

§483.15(d)(2) Bed-hold notice upon transfer. At the time of transfer of a resident for hospitalization or therapeutic leave, a nursing facility must provide to the resident and the resident representative written notice which specifies the duration of the bed-hold policy described in paragraph (d)(1) of this section.
Observations:

Based on review of facility policy, clinical record review, and staff interviews, it was determined that the facility failed to notify the resident or resident's representative of the facility bed-hold policy (an agreement for the facility to hold a bed for an agreed upon rate during a hospitalization) for six of six resident hospital transfers (Residents R20, R36, R41, R42, R48, and R101).

Findings include:

Review of facility policy "Bed Hold Policy" dated 9/19/23, and last reviewed 10/24/24, indicated it is the intent of the facility to obtain the proper authorization to hold a resident bed when the resident returns to the hospital or goes on a leave. The bed hold authorization form may be signed prior to the patient leaving the building, or within 24 hours of the resident leaving the facility or the following business day if the resident leaves on the weekend or a holiday. If applicable according to state law if the bed hold authorization form cannot be signed prior to the resident leaving and needs to be mailed, it must be mailed certified return receipt requested by the Business Office Manager or designee. The Admissions Director or designee will notify the resident and/or responsible party of the days available under their Medicaid benefits or the private pay cost associated with holding the bed will be explained, within 24 hours of the patient leaving the facility, or the following business day if the patent leaves on the weekend or a holiday.

Review of the clinical record indicated Resident R20 was admitted to the facility on 11/6/23.

Review of Resident R20's Minimum Data Set (MDS - a periodic assessment of care needs) dated 10/10/24, indicated diagnoses of high blood pressure, depression, and heart failure (a progressive heart disease that affects pumping action of the heart muscles).

Review of Resident R20's clinical record indicated the resident was transferred to the hospital on 2/6/24, and returned to the facility on 2/13/24.

Review of Resident R20's clinical record failed to include documented evidence that the resident or the resident's representative were provided with written information about the facility's bed hold policy at the time of the transfer to the hospital on 2/6/24.

Review of the clinical record indicated Resident R36 was admitted to the facility on 12/30/23.

Review of Resident R36's MDS dated 8/22/24, indicated diagnoses of high blood pressure, hyponatremia (low levels of sodium in the blood), and unsteadiness on feet.

Review of Resident R36's clinical record indicated the resident was transferred to the hospital on 7/4/24, and returned to the facility on 7/9/24.

Review of Resident R36's clinical record failed to include documented evidence that the resident or the resident's representative were provided with written information about the facility's bed hold policy at the time of the transfer to the hospital on 7/4/24.

Review of the clinical record indicated Resident R41 was admitted to the facility on 11/6/23.

Review of Resident R41's MDS dated 10/10/24, indicated diagnoses of high blood pressure, peripheral vascular disease (PVD, circulatory condition in which narrowed blood vessels reduce blood flow to the limbs), and dependence on supplemental oxygen.

Review of Resident R41's clinical record indicated the resident was transferred to the hospital on 1/11/24, and returned to the facility on 1/12/24.

Review of Resident R41's clinical record failed to include documented evidence that the resident or the resident's representative were provided with written information about the facility's bed hold policy at the time of the transfer to the hospital on 1/11/24.

Review of the clinical record indicated Resident R42 was admitted to the facility on 8/1/24.

Review of Resident R42's MDS dated 10/15/24, indicated diagnoses of anemia (low iron in the blood), atrial fibrillation (A-fib- irregular and rapid heartbeat), and heart failure (failure of the heart to function properly).

Review of Resident R42's clinical record indicated the resident was transferred to the hospital on 10/1/24, and returned to the facility on 10/18/24.

Review of Resident R42's clinical record failed to include documented evidence that the resident or the resident's representative were provided with written information about the facility's bed hold policy at the time of the transfer to the hospital on 10/1/24.

Review of the clinical record indicated Resident R48 was admitted to the facility on 4/30/24.

Review of Resident R48's MDS dated 9/26/24, indicated diagnoses of neurogenic bladder (bladder problems due to disease or injury of the nervous system involved in the control of urination), and quadriplegia (paralysis of all four limbs).

Review of Resident R48's clinical record indicated the resident was transferred to the hospital on 5/28/24, and returned to the facility on 6/4/24.

Review of Resident R48's clinical record failed to include documented evidence that the resident or the resident's representative were provided with written information about the facility's bed hold policy at the time of the transfer to the hospital on 5/28/24.

Review of the clinical record indicated Resident R101 was admitted to the facility on 7/4/23.

Review of Resident R101's MDS dated 7/27/24, indicated diagnoses of depression, muscle weakness, and cancer (occur when cells in the body grow and divide uncontrollably, which can lead to the development of tumors and the spread of disease throughout the body).

Review of Resident R101's clinical record indicated the resident was transferred to the hospital on 1/16/24, and returned to the facility on 1/19/24.

Review of Resident R101's clinical record failed to include documented evidence that the resident or the resident's representative were provided with written information about the facility's bed hold policy at the time of the transfer to the hospital on 1/16/24.

During an interview on 10/30/24, at 2:52 p.m. the Director of Nursing confirmed that the facility failed to notify the resident or resident's representative of the facility bed-hold policy for six of six resident hospital transfers as required for six of six resident hospital transfers (Residents R20, R36, R41, R42, R48, and R101).

28 Pa. Code 201.29 (a) (c.3) (2) Resident rights.


 Plan of Correction - To be completed: 12/17/2024

1. Facility not able to correct past bed hold non-compliance
2. All residents have the potential to be affected by this alleged deficient practice. All resident discharges in the prior 30 days were reviewed for appropriate bed hold documentation.
3. Administrator/Designee will educate admissions/business office manager/and supervisors on bed hold notice process upon transfer.
4. Administrator/Designee will audit all hospital discharges weekly X 4 weeks to ensure all required bed hold notification.
5. Administrator/Designee will report findings of audit results to QAPI monthly for 3 months and randomly thereafter to ensure compliance is sustained.

483.15(c)(1)(i)(ii)(2)(i)-(iii) REQUIREMENT Transfer and Discharge Requirements:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
§483.15(c) Transfer and discharge-
§483.15(c)(1) Facility requirements-
(i) The facility must permit each resident to remain in the facility, and not transfer or discharge the resident from the facility unless-
(A) The transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in the facility;
(B) The transfer or discharge is appropriate because the resident's health has improved sufficiently so the resident no longer needs the services provided by the facility;
(C) The safety of individuals in the facility is endangered due to the clinical or behavioral status of the resident;
(D) The health of individuals in the facility would otherwise be endangered;
(E) The resident has failed, after reasonable and appropriate notice, to pay for (or to have paid under Medicare or Medicaid) a stay at the facility. Nonpayment applies if the resident does not submit the necessary paperwork for third party payment or after the third party, including Medicare or Medicaid, denies the claim and the resident refuses to pay for his or her stay. For a resident who becomes eligible for Medicaid after admission to a facility, the facility may charge a resident only allowable charges under Medicaid; or
(F) The facility ceases to operate.
(ii) The facility may not transfer or discharge the resident while the appeal is pending, pursuant to § 431.230 of this chapter, when a resident exercises his or her right to appeal a transfer or discharge notice from the facility pursuant to § 431.220(a)(3) of this chapter, unless the failure to discharge or transfer would endanger the health or safety of the resident or other individuals in the facility. The facility must document the danger that failure to transfer or discharge would pose.

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

Based on clinical record review, facility policy, and staff interview, it was determined that the facility failed to make certain that the necessary resident information was communicated to the receiving health care provider for six of six residents with facility-initiated transfers (Residents R20, R36, R41, R42, R48, and R101).

Findings include:

Review of facility policy "Transfer and Discharge Policy" dated 9/19/23, last reviewed 10/24/24, indicated information provided to the receiving provider must include a minimum of the following: contact information of the practitioner responsible for the care of the resident, resident representative information including contact information, advance directive information, all special instructions or precautions for ongoing care as appropriate, comprehensive care plan goals, and all other necessary information, including a copy of the residents discharge summary, as applicable, and any other documentation, as applicable, to ensure a safe and effective transition of care.

Review of the clinical record indicated Resident R20 was admitted to the facility on 11/6/23.

Review of Resident R20's Minimum Data Set (MDS - a periodic assessment of care needs) dated 10/10/24, indicated diagnoses of high blood pressure, depression, and heart failure (a progressive heart disease that affects pumping action of the heart muscles).

Review of Resident R20's clinical record indicated the resident was transferred to the hospital on 2/6/24.

Review of Resident R20's clinical record revealed no documented evidence that the facility had communicated specific information to the receiving health care provider for the residents transferred and expected to return, which included the resident's care plan goals, advanced directive information, specific instructions for ongoing care, resident representative information, and all information necessary to meet the resident's specific needs at the receiving facility.

Review of the clinical record indicated Resident R36 was admitted to the facility on 12/30/23.

Review of Resident R36's MDS dated 8/22/24, indicated diagnoses of high blood pressure, hyponatremia (low levels of sodium in the blood), and unsteadiness on feet.

Review of Resident R36's clinical record indicated the resident was transferred to the hospital on 7/4/24.

Review of Resident R36's clinical record revealed no documented evidence that the facility had communicated specific information to the receiving health care provider for the residents transferred and expected to return, which included the resident's care plan goals, advanced directive information, specific instructions for ongoing care, resident representative information, and all information necessary to meet the resident's specific needs at the receiving facility.

Review of the clinical record indicated Resident R41 was admitted to the facility on 10/5/18.

Review of Resident R41's MDS dated 10/9/24, indicated diagnoses of high blood pressure, peripheral vascular disease (PVD, circulatory condition in which narrowed blood vessels reduce blood flow to the limbs), and dependence on supplemental oxygen.

Review of Resident R41's clinical record indicated the resident was transferred to the hospital on 1/11/24.

Review of Resident R41's clinical record revealed no documented evidence that the facility had communicated specific information to the receiving health care provider for the residents transferred and expected to return, which included the resident's care plan goals, advanced directive information, specific instructions for ongoing care, resident representative information, and all information necessary to meet the resident's specific needs at the receiving facility

Review of the clinical record indicated Resident R42 was admitted to the facility on 8/1/24.

Review of Resident R42's MDS dated 10/15/24, indicated diagnoses of anemia (low iron in the blood), atrial fibrillation(A-fib- irregular and rapid heartbeat), and heart failure (failure of the heart to function properly).

Review of Resident R42's clinical record indicated the resident was transferred to the hospital on 10/1/24.

Review of Resident R42's clinical record revealed no documented evidence that the facility had communicated specific information to the receiving health care provider for the residents transferred and expected to return, which included the resident's care plan goals, advanced directive information, specific instructions for ongoing care, resident representative information, and all information necessary to meet the resident's specific needs at the receiving facility.

Review of the clinical record indicated Resident R48 was admitted to the facility on 4/30/24.

Review of Resident R48's MDS dated 9/26/24, indicated diagnoses of neurogenic bladder (bladder problems due to disease or injury of the nervous system involved in the control of urination), and quadriplegia (paralysis of all four limbs).

Review of Resident R48's clinical record indicated the resident was transferred to the hospital on 5/28/24.

Review of Resident R48's clinical record revealed no documented evidence that the facility had communicated specific information to the receiving health care provider for the residents transferred and expected to return, which included the resident's care plan goals, advanced directive information, specific instructions for ongoing care, resident representative information, and all information necessary to meet the resident's specific needs at the receiving facility.

Review of the clinical record indicated Resident R101 was admitted to the facility on 7/4/23.

Review of Resident R101's MDS dated 7/27/24, indicated diagnoses of depression, muscle weakness, and cancer (occurs when cells in the body grow and divide uncontrollably, which can lead to the development of tumors and the spread of disease throughout the body).

Review of Resident R101's clinical record indicated the resident was transferred to the hospital on 1/16/24.

Review of Resident R101's clinical record revealed no documented evidence that the facility had communicated specific information to the receiving health care provider for the residents transferred and expected to return, which included the resident's care plan goals, advanced directive information, specific instructions for ongoing care, resident representative information, and all information necessary to meet the resident's specific needs at the receiving facility.

During an interview on 10/30/24, at 2:52 p.m. the Director of Nursing confirmed that there was no evidence that the necessary information was communicated to the receiving health care institution or provider upon transfer as required for six of six residents with facility-initiated transfers (Residents R20, R36, R41, R42, R48, and R101).

28 Pa. Code 201.29 (a)(c.3)(2) Resident rights.


 Plan of Correction - To be completed: 12/17/2024

1. We are unable to correct past non-compliance of transfers of resident 20, 36,41,42,48 and 101.
2. All residents have the potential to be affected by the alleged deficient practice. An audit of all hospital transfers from 10/15/24 to 10/31/24 was completed for evidence that adequate documentation was provided to receiving facility.
3. Director of Nursing /designee will in-service staff licensed nursing staff on providing receiving facility the necessary information to meet the residents specific needs and utilizing the acute care transfer document checklist. Director of Nursing/Designee will audit all hospital transfers for adequate transfer information 5 times weekly for 2 weeks and 3 times weekly for 2 weeks.
4. Director of Nursing Designee will report in monthly QAPI meetings the results of findings monthly X 3 months and randomly thereafter.

483.10(h)(1)-(3)(i)(ii) REQUIREMENT Personal Privacy/Confidentiality of Records:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
§483.10(h) Privacy and Confidentiality.
The resident has a right to personal privacy and confidentiality of his or her personal and medical records.

§483.10(h)(l) Personal privacy includes accommodations, medical treatment, written and telephone communications, personal care, visits, and meetings of family and resident groups, but this does not require the facility to provide a private room for each resident.

§483.10(h)(2) The facility must respect the residents right to personal privacy, including the right to privacy in his or her oral (that is, spoken), written, and electronic communications, including the right to send and promptly receive unopened mail and other letters, packages and other materials delivered to the facility for the resident, including those delivered through a means other than a postal service.

§483.10(h)(3) The resident has a right to secure and confidential personal and medical records.
(i) The resident has the right to refuse the release of personal and medical records except as provided at §483.70(h)(2) or other applicable federal or state laws.
(ii) The facility must allow representatives of the Office of the State Long-Term Care Ombudsman to examine a resident's medical, social, and administrative records in accordance with State law.
Observations:

Based on review of facility policy, observations, and staff interview it was determined that the facility failed to maintain the confidentiality of residents' medical information for three out of six resident rooms (Resident R12, R75, and R83), and one out of four medication carts (100 RP Wing Med cart).

Findings include:

The facility "Health Insurance Portability and Accountability Act (HIPAA)" policy dated 10/2424, indicated that the facility requires providers and others to implement security measures to guard the integrity and confidentiality of medical information.

During a tour on 10/27/24, at 9:45 a.m. the following was observed:

At 9:47 a.m. Resident R12's room was observed with a sign beside his bed which stated "Float heels when in bed with use of heel boots and wedge/pillow to maintain heels off bed at all times".

At 9:55 a.m. Resident R75's room was observed with a sign above her bed which stated "Upright for all oral intake, open all containers, cut food into bite size pieces, put straws in liquids, make sure food is within reach, remove garbage from tray, go in during meal and encourage her to eat".

At 10:15 a.m. Resident R83's room was observed with a sign above her bed which stated "Upright for all food/drink, small single bites, at times she is more willing to drink then eat-so if she is not eating offer drinks, offer liquids via straw".

During an interview on 10/27/24, at 2:25 p.m. Licensed Practical Nurse Employee E6 stated, "I don't know who put the signs up but they should not be there".

During an interview on 10/27/24, at 2:45 p.m. the Director of Nursing (DON) confirmed that the facility failed to maintain the confidentiality of residents' medical information for three out of six resident rooms (Residents R12, R75, and R83).

During a medication administration observation on 10/28/24, at 8:49 a.m. Registered Nurse (RN) Employee E7 walked away from the medication cart that was across the hallway to administer medication and left the computer screen open for any passerby to see confidential information.

During an interview on 10/28/24, at 2:45 p.m. DON confirmed that that the facility failed to maintain the confidentiality of residents' medical information for two out of four medication carts (100 RP Wing Med cart).

28 Pa. Code 201.29(j) Resident rights.
28 Pa. Code 211.5(b) Clinical records.


 Plan of Correction - To be completed: 12/17/2024

1. Upon notification, computers screens were closed and signs were removed from identified resident rooms.
2. All residents have the potential to be affected by this alleged deficient practice. Sweep of entire building was completed to ensure no other computers were left open with resident information left unattended. Sweep of building was conducted with all signs containing HIPAA related information in resident rooms removed.
3. Director of Nursing/Designee will educate all nursing staff on keeping laptops closed or in private mode when unattended and not having non-approved signs in resident rooms that contain resident's personal information.
4. Administrator/Designee will audit 5 med carts and 10 random resident rooms 5 X per week for 2 weeks and 3 X per week for 2 weeks to ensure no health information is left visible on a computer screen and no non-approved signs are in resident rooms.
5. Administrator/Designee will report findings of audit results to QAPI monthly for 3 months and randomly thereafter to ensure compliance is sustained.

483.10(f)(5)(i)-(iv)(6)(7) REQUIREMENT Resident/Family Group and Response:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
§483.10(f)(5) The resident has a right to organize and participate in resident groups in the facility.
(i) The facility must provide a resident or family group, if one exists, with private space; and take reasonable steps, with the approval of the group, to make residents and family members aware of upcoming meetings in a timely manner.
(ii) Staff, visitors, or other guests may attend resident group or family group meetings only at the respective group's invitation.
(iii) The facility must provide a designated staff person who is approved by the resident or family group and the facility and who is responsible for providing assistance and responding to written requests that result from group meetings.
(iv) The facility must consider the views of a resident or family group and act promptly upon the grievances and recommendations of such groups concerning issues of resident care and life in the facility.
(A) The facility must be able to demonstrate their response and rationale for such response.
(B) This should not be construed to mean that the facility must implement as recommended every request of the resident or family group.

§483.10(f)(6) The resident has a right to participate in family groups.

§483.10(f)(7) The resident has a right to have family member(s) or other resident representative(s) meet in the facility with the families or resident representative(s) of other residents in the facility.
Observations:

Based on review of facility policy, resident council minutes, group and staff interview it was determined that the facility failed to respond to resident concerns and grievances identified during resident council meeting for six of six months reviewed (May 2024 to October 2024).

Findings include:

Review of facility policy dated 10/24/24, "Resident Grievance" indicated: "Grievance: an official statement of a complaint over something believed to be wrong or unfair."

Review of Resident Council minutes from May 2024 to October 2024 indicated the following concerns:

5/7/24: call bells, 3/11 staff not giving good care, and staff not wearing name tags.
6/4/24: agency aides don't know residents and are rude, want to know staff to resident ratio, why don't wear name tags and introduce themselves, and staff don't wear name tags.
7/2/24: shortage in linens not smelling fresh, not enough oxygen on nursing unit, agency aides not answering call bells.
8/6/24: shortage in linen, vending machine that accepts credit cards, staff not wearing name tags.
9/3/24: vending machine that accepts credit cards, staff not wearing name tags, oxygen tanks on floors, some residents not getting showers.
10/1/24: vending machine that accepts credit cards, staff wearing name tags and evening activities.

Resident group meeting on 10/30/24, at 11:35 a.m. residents (total group) agreed that their concerns are on-going, they do not get answers or resolutions to their concerns but are told the facility is working on their concerns.

During an interview on 10/31/24, at 8:45 a.m. Activity Director Employee E9, confirmed that there was no documentation to be provided for follow up of residents' concerns from resident council meetings, and that the facility failed to respond to resident concerns and grievances identified during resident council.

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


 Plan of Correction - To be completed: 12/17/2024

1. Resident council meeting was held to give feedback and respond to prior 6 months of resident council concerns. All concerns and feedback were documented appropriately.
2. All residents have the potential to be affected by this alleged deficient practice. Resident council meeting was held to address any additional concerns related to prior or current resident council meetings either past or present.
3. Administrator/Designee will educate Activities Director on proper resident council minutes which include feedback from appropriate departments regarding concerns/questions raised during resident council meetings.
4. Resident Council Minutes will be audited monthly X 2 months to ensure all concerns have been addressed and responded to appropriately.
5. Administrator/Designee will report findings of audit results to QAPI monthly for 3 months and randomly thereafter to ensure compliance is sustained.

483.10(c)(7) REQUIREMENT Resident Self-Admin Meds-Clinically Approp:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
§483.10(c)(7) The right to self-administer medications if the interdisciplinary team, as defined by §483.21(b)(2)(ii), has determined that this practice is clinically appropriate.
Observations:

Based on review of facility policies, observations, resident and staff interviews, it was determined that the facility failed to determine the ability to self-administer medications for three of 10 residents (Residents R17, R50, and R71).

Findings include:

Review of facility policy "Medication Administration" dated 10/24/24, indicated a resident-centered, individualized approach to medication administration will be used for administering medications as possible. Safety and avoiding adverse effects are considered a high priority for medication administration and may preclude some preferences. Remain with resident until the medication is swallowed. Do not leave medication at bedside.

Review of the clinical record revealed that Resident R17 was admitted to the facility on 5/15/24.

Review of Resident R17's MDS (Minimum Data Set, periodic assessment of resident care needs) dated 8/28/24, indicated diagnoses of high blood pressure, respiratory failure (when the lungs cannot get enough oxygen), and low back pain.

Review of Resident R17's physician's order failed to include an order for self-administration of medications.

Review of Resident R17's care plan on 10/27/24, failed to include self-administration of medication management.

Review of Resident R17's clinical record indicated the absence of a Self-Administration of Medication assessment.

During an observation on 10/27/24, at 10:21 a.m. Resident R17 was observed holding a medication cup full of medications in her hand and no nursing staff present in her room.

During an interview on 10/27/24, at 10:23 a.m. Registered Nurse (RN) Employee E18 confirmed that Resident R17 was left unattended with medications.

Review of the clinical record indicated Resident R50 was admitted to the facility on 5/31/24.

Review of Resident R50's MDS dated 10/3/24, indicated diagnoses of high blood pressure, anxiety (a feeling of worry, nervousness, or unease), and Alzheimer's Disease (a progressive disease that destroys memory and other important mental functions).

Review of a physician order dated 9/30/24, indicated to administer Lorazepam (a controlled medication used to treat anxiety) 0.5 milligrams every six hours for anxiety.

Review of Resident R50's physician orders failed to include an order for self-administration of medications.

Review of Resident R50's care plan on 10/27/24, failed to include self-administration of medication management.

Review of Resident R50's clinical record indicated the absence of a Self-Administration of Medication assessment.

Review of a Behavior Note completed by RN Employee E5 stated, "Resident R50's granddaughter was visiting when I brought her grandmother Ativan. As she was leaving, she approached me and expressed that the nurse should remain in the room while administering the Ativan; otherwise, her grandmother might not take it and "will be climbing the walls". I reassured her that her grandmother consistently takes her medication in my presence, and the only reason I left the Ativan with her was that they were enjoying coffee together. On her way out, the granddaughter handed me an Ativan she found on the floor, expressing concern that previous nurses may have left pills in the room, resulting in her grandmother not receiving her medication. I explained that we had not noticed any behavioral issues with her grandmother, indicating she had been properly medicated. I also pointed out that her roommate had spilled a full cup of medications, which included Ativan, and it was more likely to belong to her. The granddaughter was skeptical of my explanation and requested to speak with the nursing supervisor."

During an interview on 10/31/24, at 10:21 a.m. the Director of Nursing (DON) stated that the expectation is that nurses will remain with residents during medication administration and confirmed that RN Employee E5 should have remained with Resident R50 while administering Ativan.

Review of the clinical record indicated Resident R71 was admitted to the facility on 10/19/22.

Review of Resident R71's MDS dated 8/14/24, indicated diagnoses of high blood pressure, anxiety (a feeling of worry, nervousness, or unease), and unsteadiness on feet.

Review of a physician order dated 12/4/23, indicated to apply Biofreeze External Gel 4% to posterior (back of) neck two times a day.

Review of Resident R71's physician orders failed to include an order for self-administration of medications.

Review of Resident R71's care plan on 10/27/24, failed to include self-administration of medication management.

Review of Resident R71's clinical record indicated the absence of a Self-Administration of Medication assessment.

During an observation on 10/27/24, at 9:36 a.m. a bottle of Biofreeze was observed on Resident R71's bedside table.

During an interview on 10/27/24, at 10:10 a.m. RN Employee E1 confirmed that she left the bottle of Biofreeze in Resident R71's room.

During an interview on 10/28/24, at 2:45 p.m. the DON confirmed that the facility failed to determine the ability to self-administer medications for three of 10 residents (Residents R17, R50, and R71).

28 Pa. Code 201.14(a) Responsibility of Licensee.
28 Pa. Code: 211.10(c)(d) Resident care policies.
28 Pa. Code: 211.12(d)(1)(5) Nursing services.
28 Pa. Code: 211.9(a)(1) Pharmacy services.


 Plan of Correction - To be completed: 12/17/2024

1. Residents 17, 50 and 79 were assessed for self-administration of medication. Assessment determined that none of the 3 were appropriate or interested in self-administering their medications. Employee 18, 5, and received education regarding self-administering medication process and observing residents take medications.
2. All residents have the potential to be affected by the alleged deficient practice. An audit of all resident rooms and common area was competed by the Director of Nursing and no other medications were noted to be left with residents.
3. Director of Nursing /designee will in-service licensed nursing staff on the process for residents to self-administer medications and steps of medication administration to include observing the resident take the medication. Director of Nursing/Designee will audit medication pass to 5 residents 5 times weekly for 2 weeks and 3 times weekly for 2 weeks to ensure that medications are not left with resident unless steps of self-administration of medications process is in place. Director of Nursing/Designee will audit 5 residents for self-administration of mediations 5 times a week for 2 weeks then 3 times a week for 2 weeks.
4. Director of Nursing Designee will report in monthly QAPI meetings the results of findings monthly X 3 months and randomly thereafter.

483.10(g)(2)(i)(ii)(3) REQUIREMENT Right to Access/Purchase Copies of Records: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)(2) The resident has the right to access personal and medical records pertaining to him or herself.
(i) The facility must provide the resident with access to personal and medical records pertaining to him or herself, upon an oral or written request, in the form and format requested by the individual, if it is readily producible in such form and format (including in an electronic form or format when such records are maintained electronically), or, if not, in a readable hard copy form or such other form and format as agreed to by the facility and the individual, within 24 hours (excluding weekends and holidays); and
(ii) The facility must allow the resident to obtain a copy of the records or any portions thereof (including in an electronic form or format when such records are maintained electronically) upon request and 2 working days advance notice to the facility. The facility may impose a reasonable, cost-based fee on the provision of copies, provided that the fee includes only the cost of:
(A) Labor for copying the records requested by the individual, whether in paper or electronic form;
(B) Supplies for creating the paper copy or electronic media if the individual requests that the electronic copy be provided on portable media; and
(C)Postage, when the individual has requested the copy be mailed.

§483.10(g)(3) With the exception of information described in paragraphs (g)(2) and (g)(11) of this section, the facility must ensure that information is provided to each resident in a form and manner the resident can access and understand, including in an alternative format or in a language that the resident can understand. Summaries that translate information described in paragraph (g)(2) of this section may be made available to the patient at their request and expense in accordance with applicable law.
Observations:

Based on facility policy, resident representative and staff interview it was determined that the facility failed to provide medical record access for one of four residents (Closed Resident Record R177).

Findings include:

Review of "Resident Rights" dated 10/24/24, indicated: "Residents have the right to access all resident records, including clinical records (medical records and reports) promptly. The residents legal guardian has the right to look at all of the residents medical records and make important decisions on the residents behalf/"

Facility documentation indicated Closed Record Resident R177 was admitted on 1/6/22.

Facility documentation indicated Closed Record Resident R177 had diagnosis of unspecified dementia, anxiety disorder, and cognitive communication deficient. Which remained current as of the MDS (minimum data set a periodic assessment of basic needs) on 8/13/24.

Review of Closed Resident Record R177 progress notes indicated contact with the financial POA for medical decisions on the following days:

9/8/24 - facility called Power of Attorney (POA) asking if they wanted the Closed Record Resident to be sent out for further surgical evaluation, or to control her pain here, opted to send out to hospital for further investigation- 911 called and Director of Nursing (DON) notified.

9/8/24 - family was resident sent out.

9/8/24 - 2nd contact notified (listed as friend on admit sheet) regarding swollen and bruised ankle.

8/13/24 - notified Closed Record Resident R177 POA about weight gain.

8/8/24- left voice mail for POA about weight change.

Phone interview on 10/31/24, at 1:15 p.m. Closed Record Resident R177 POA indicated the following she was and (still currently) the financial POA and had been since 2013, the facility contacted her to make medical and financial decision to include when she was sent out to the hospital. Closed record Resident R177 POA requested CR Resident R177 clinical records but was told she could not have the records. The facility did not assist the POA with getting the medical POA.

During an interview on 10/31/24, at 1:40 p.m.. the following was confirmed by Corporate Employee E35, that the facility did use the financial POA as responsible party to make medical decisions for Closed Record Resident R177, and the facility was aware of the request, but did not give the records to the POA. The facility failed to provide medical record access to Closed Record resident R177 POA.

28 Pa. Code 201.29(a)Resident rights.


 Plan of Correction - To be completed: 12/17/2024

1. Identified resident has a financial power of attorney only. Medical records may be released for a billing or financial related reason.
2. All residents have the potential to be affected by this alleged deficient practice. All medical record requests in the previous 30 days will be audited to ensure medical records were released to individuals with proper authority. All residents with dementia diagnosis will be audited to ensure spouse/medical POA/guardian is in place to make medical decisions.
3. Administrator/Designee will educate medical records coordinator to ensure there is a spouse/medical POA/guardian in place for all residents with a dementia diagnosis on admission.
4. All residents with dementia diagnosis will be audited weekly X 4 weeks to ensure there is a spouse/medical POA/guardian in place.
5. Administrator/Designee will report findings of audit results to QAPI monthly for 3 months and randomly thereafter to ensure compliance is sustained.

483.90(d)(2) REQUIREMENT Essential Equipment, Safe Operating Condition:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
§483.90(d)(2) Maintain all mechanical, electrical, and patient care equipment in safe operating condition.
Observations:

Based on observations and staff interview it was determined that the facility failed to maintain essential equipment heating units for three rooms on the second floor (238, 239, and 251).

Findings include:

During observations on the second floor the following was observed:

10/27/24: 1:01 p.m. Rooms 238 and 239 heater removed from wall area open to outside.
10/27/24: 1:12 p.m. Room 251 heater removed from wall area open to outside.

During an interview on 10/27/24, at 1:30 p.m. Nursing Home Administrator (NHA) confirmed that the facility failed pulled the heaters from the above rooms for other rooms in the facility,.

During an interview on 10/27/24, at 1:30 p.m. NHA confirmed that the facility failed to maintain essential equipment with heating units being removed from 3 resident rooms, for other rooms that heating units weren't working.

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


 Plan of Correction - To be completed: 12/17/2024

1. Heaters have been ordered and will be installed in rooms 238, 239 and 251 immediately upon arrival, or no later than 12/17/2024.
2. All residents have the potential to be affected by this alleged deficient practice. Full sweep of facility was completed to identify every empty room with a heater not in place, with heaters to be installed no later than 12/17/2024
3. Administrator/Designee will educate maintenance director on importance of heater being in place at all times in every resident room.
4. Administrator/Designee will audit 10 resident rooms on each floor 3X per week X 4 weeks to ensure heaters are in place.
5. Administrator/Designee will report findings of audit results to QAPI monthly for 3 months and randomly thereafter to ensure compliance is sustained.

483.60(d)(3) REQUIREMENT Food in Form to Meet Individual Needs: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.
§483.60(d) Food and drink
Each resident receives and the facility provides-

§483.60(d)(3) Food prepared in a form designed to meet individual needs.
Observations:

Based on facility policy, observation, and staff interviews, it was determined that the facility failed to provide food in a form to meet individuals' needs in one of two residents ordered an NPO (nothing by mouth) diet.

Findings include:

Review of the facility policy "Resident Rights" last reviewed 10/24/24, and previously reviewed 9/9/23, indicated that the facility will provide resident centered care that meets the psychosocial, physical and emotional needs and concerns of the residents. Safety of residents, visitors, and employees is a top priority of care.

Review of the clinical record revealed that Resident R107 was admitted to the facility on 9/30/24.

Review of Resident 107's MDS (Minimum Data Set, periodic assessment of resident care needs) dated 10/7/24, indicated diagnoses of high blood pressure, Intracerebral hemorrhage (when a ruptured blood vessel causes bleeding inside the brain), and dysphagia (difficulty swallowing). Section K0520 indicated that Resident 107 received nutrition through a feeding tube while she was a resident.

Review of Resident R107's physician's orders on 10/27/24, indicated that resident was ordered an NPO diet on 10/25/24.

During an observation on 10/27/24, at 11:49 a.m. Resident R107 was observed resting in bed with a large Styrofoam cup full of ice water marked "Oral Care", and another large Styrofoam cup full of water marked "G-tube (a flexible tube that is surgically inserted into the stomach to provide nutrition, hydration or medication) flush" on her bedside table.

During an interview on 10/27/24, at 12:02 p.m. Registered Nurse (RN) Employee E18 confirmed that Resident R107 was not allowed to drink anything by mouth and that water was left at her bedside, however RN Employee E18 felt that it was allowed "Since I marked the cups".

During an interview on 10/27/24, at 12:52 p.m. the Director of Nursing (DON) confirmed that a resident that was NPO should not be left any fluids at bedside in the event that the resident, staff, visitors, or other residents could provide the resident with a drink, and that the facility failed to ensure that Resident R107's diet order was enforced as NPO as ordered.

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


 Plan of Correction - To be completed: 12/17/2024

1. The water for flush and the glass of water for mouth care were removed from the resident's bedside.
2. All residents with tube feeding have potential to be affected by this alleged deficient practice. All residents with tube feedings and were nothing by mouth were checked for fluids at their bedside.
3. The nurse that was care for this resident was educated by the Director of Nursing that flushes and mouth care fluid are not to be kept at the bedside. Nurses will be educated by the Director of nursing or designee that no fluid is to be kept at the bedside, Audits to confirm no fluid is at bedside will be done five times a week for two weeks and three times a week for two weeks
4. The results of these audits will be reviewed at the monthly QAPI meeting. The plan will be updated as needed

483.55(a)(1)-(5) REQUIREMENT Routine/Emergency Dental Srvcs in SNFs: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.
§483.55 Dental services.
The facility must assist residents in obtaining routine and 24-hour emergency dental care.

§483.55(a) Skilled Nursing Facilities
A facility-

§483.55(a)(1) Must provide or obtain from an outside resource, in accordance with with §483.70(f) of this part, routine and emergency dental services to meet the needs of each resident;

§483.55(a)(2) May charge a Medicare resident an additional amount for routine and emergency dental services;

§483.55(a)(3) Must have a policy identifying those circumstances when the loss or damage of dentures is the facility's responsibility and may not charge a resident for the loss or damage of dentures determined in accordance with facility policy to be the facility's responsibility;

§483.55(a)(4) Must if necessary or if requested, assist the resident;
(i) In making appointments; and
(ii) By arranging for transportation to and from the dental services location; and

§483.55(a)(5) Must promptly, within 3 days, refer residents with lost or damaged dentures for dental services. If a referral does not occur within 3 days, the facility must provide documentation of what they did to ensure the resident could still eat and drink adequately while awaiting dental services and the extenuating circumstances that led to the delay.
Observations:

Based on review of facility policy, resident clinical records, and resident and staff interviews, it was determined that the facility failed to provide routine and emergency dental services for one of two residents (Resident R27).

Findings include:

The facility "Dental services" policy dated 9/19/23, indicated that the facility will assist the resident in obtaining routine and 24-hour emergency dental services.

Review of Resident R27's admission record indicated he was originally admitted on 6/10/19, and readmitted on 6/11/24.

Review of Resident R27's MDS assessment (MDS-Minimum Data Set assessment: periodic assessment of resident care needs) dated 6/18/24, indicated that he had diagnoses that included diabetes (a metabolic disorder impacting organ function related to glucose levels in the human body), peripheral vascular disease (PVD- a narrowing of the blood vessels in the legs), hypertensive heart disease (a condition characterized by long term heart conditions and high blood pressure), anxiety disorder (a medical condition creating a sense of acute fear, restlessness, and worry), and spinal stenosis (a narrowing of the spaces within the spine, which causes pain and weakness). The diagnoses were current upon review.

Review of Resident R27's care plan dated 6/26/24, indicated to provide oral hygiene.

Review of Resident R27's clinical record and consultation visits did not include routine dental services since his admission on 6/11/24.

During an interview on 10/27/24, at 1:10 p.m. Resident R27 stated the following: "I never had my beard trimmed. There is no barber in this place. No podiatrists either. I never saw a dentist; he was here last week and I need two teeth to come out."

During an interview on 10/30/24, at 8:59 a.m. Medical records/Ancillary services coordinator Employee E14 stated: "I coordinate dental, vision, and hearing. Resident R27 is not on the list. I have emailed them multiple times. Resident R27 has not been seen for dental. I will have to look at the vision."

During an interview on 10/30/24, at 1:52 p.m. the Nursing Home Administrator (NHA) confirmed that the facility failed to provide routine dental services to Resident R27 as required.

28 Pa Code 211.15(a) Dental services


 Plan of Correction - To be completed: 12/17/2024

1. Resident 1 was seen by dentist.
2. All residents have potential to be affected by this alleged deficient practice. All residents will be asked by the ADON or designee if they would like to see the dentist.
3. The Director of nursing or designee will educate the ADON to ask new admissions if they would like to see the dentist, This will be audited by the unit manager or designee to ensure it has been done.
4. The results of these audits will be reviewed at the monthly QAPI meeting. The plan will be updated as needed

483.45(f)(2) REQUIREMENT Residents are Free of Significant Med Errors: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.
The facility must ensure that its-
§483.45(f)(2) Residents are free of any significant medication errors.
Observations:

Based on review of facility policy, clinical record review and staff interview it was determined that the facility failed to make certain that residents are free from significant medication errors for two of eight residents (Resident R73 and R173).

Findings include:

Review of facility policy "Missed Medication/Medication Error" dated 10/24/24, indicated the following: Medication error/incident - any physician/provider prescribed medication that is not administered to the resident as prescribed regardless of the category or the reason for not providing the medication."

Review of manufactures of guidelines for Trulicity (a type 2 diabetes medication that helps your body release own insulin - given weekly) indicated: "Recommendations regarding missed dose - If a dose is missed, instruct patients to administer the dose as soon as possible if there are at least 3 days (72 hours) until the next scheduled dose."

Review of the clinical record indicated Resident R73 was admitted to the facility on 5/24/23.

Review of Resident R73 MDS assessment (Minimum Data Set - a periodic assessment of resident care needs) dated 5/22/24, indicated the diagnosis of epilepsy/seizure disorder (a disorder in which nerve cell activity in the brain is disturbed, causing seizures), psychotic disorder (a mental disorder characterized by a disconnection from reality) and mastocytosis (a rare disorder characterized by abnormal accumulation and activation of mast cells in the skin, bone marrow and internal organ).

Review of Resident R73 clinical record indicated the following:
10/29/24 Cromolyn Sodium (a medication used to prevent the release of substances in the body that cause inflammation) Oral Concentrate MG (milligrams)/5ML (milliliters) Give 15 ml by mouth four times a day for mastocytosis: medication on order, will administer once available - this was documented at 22:45, 17:35, 13: 48, and 8:06.
10/28/24 Cromolyn Sodium Oral Concentrate MG/5ML Give 15ml by mouth four times a day for mastocytosis - Med not available in house.
10/23/24 Cromolyn Sodium Oral Concentrate MG/5ML Give 15ml by mouth four times a day for mastocytosis - request for refill sent ot pharmacy waiting for supply from the pharmacy.
10/16/24 Cromolyn Sodium Nasal Aerosol Solution 5.2 MG/ACT 1 spray in each nostril four times a day for mastocytosis 12:07 - Meds not available.

During an interview on 10/29/24, at 9:27 a.m. Resident R73 said that she/he has missed medications doesn't feel as well as when she/he gets medications as ordered.

Resident R173 was admitted to the facility on 10/11/24.

Review of Resident R173 admit sheet indicated diagnosis of type II Diabetes Mellitus (chronic disease that occurs when the body doesn't use insulin properly, resulting in high blood sugar levels), and end stage real dependence (a permanent condition that occurs when the kidneys are no longer able to function).

Review of clinical progress notes dated 10/19/24, indicated Trulicity Subcutaneous Solution Pen-injector 0.75MG/0.5ML Inject .75mg subcutaneously one time a week every Saturday for DM (diabetes mellitus) - medication not available in house, called Pharmacy script syringe to be delivered soon as possible.

Review of Resident R173 clinical record failed to show where medication was given.
Review of Resident R173 record failed to indicate the physician was notified.

During an interview on 10/31/24, at 2:22 p.m. Director of Nursing confirmed that Resident R73 and Resident R173 had missed ordered medication and that the facility failed to get the medication to the residents as ordered and this led to the significant medication error.

28 Pa. Code 211.3(a)(b)c(d)e(1)(2)(3)(4) Verbal and telephone orders.



 Plan of Correction - To be completed: 12/17/2024

1. Residents 73 and 173 physician s were notified of medications not being available, there were no new orders.
2. All residents have the potential to be affected by this alleged deficient practice. All residents MARs were reviewed from 10/31/24-11/5/24. No other medications were unavailable during that time
3. The director of Nursing or designee will educate the nursing staff that if medication is not available in the Omnicell or medicine cart the physician will be called. The Director of Nursing or designee will audit the administration report five times a week for two weeks and three times a week for two weeks.
4. The results of these audits will be reviewed at the monthly QAPI meeting. The plan will be updated as needed.

483.45(c)(3)(e)(1)-(5) REQUIREMENT Free from Unnec Psychotropic Meds/PRN Use:This is a less serious (but not lowest level) deficiency and 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(e) Psychotropic Drugs.
§483.45(c)(3) A psychotropic drug is any drug that affects brain activities associated with mental processes and behavior. These drugs include, but are not limited to, drugs in the following categories:
(i) Anti-psychotic;
(ii) Anti-depressant;
(iii) Anti-anxiety; and
(iv) Hypnotic

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

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

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

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

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

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

Based on facility policy, clinical record review, and staff interview it was determined the facility failed to identify a diagnosed specific condition for treatment for one of three residents receiving psychotropic medication reviewed (Resident R93)

Findings Include:

Review of facility policy "Resident Rights " dated 9/19/23, last reviewed 10/24/24, indicated to provide resident centered care that meets the psychosocial, physical and emotional needs and concerns of the resident.

Review of the admission record indicated that Resident R93 was admitted to the facility on 7/5/24.

Review of Resident R93's care plan revised on 8/27/24, indicated resident R93 uses anti-psychotic medication due to behaviors: verbal outburst, violently shoving items or throwing items, tearful. Observe for side effects of anti-psychotic medications.

Review of Resident R93's Minimum Data Set (MDS- a periodic assessment of care needs) dated 8/7/24, indicated the diagnoses of hypertension (high blood pressure), viral hepatitis (inflammation of liver due to a viral infection), and anxiety disorder. Section N - Medications, N0415A indicated that Resident R93 was taking, and indication noted for use of Antipsychotic medication.

Review of Resident R93's physician orders dated 10/12/24, indicated trazadone 50mg give 1/2 tablet (medication used to treat depression, anxiety and insomnia) at bedtime for mood. The physician orders for antipsychotic medication failed to identify a diagnosed specific condition for treatment.

Review of physician order dated 10/16/24, indicated risperdal 1mg (medication used to improve mood, thoughts, and behaviors) every morning and bedtime for mood. The physician orders for antipsychotic medication failed to identify a diagnosed specific condition for treatment.

During an interview on 10/30/24, at 1:28 p.m. Registered Nurse (RN) Employee E17 confirmed the facility failed to identify a diagnosed specific condition for treatment and stated "it should say like disorder" for one of three residents receiving psychotropic medication reviewed (Resident R93).

28 Pa Code 211.5(f) Medical 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: 12/17/2024

1. Residents 93 had his Risperdal order updated to reflect diagnosis of dementia with agitation. were assessed for self-administration of medication.
2. All residents have the potential to be affected by the alleged deficient practice. An audit of all resident receiving antipsychotic medications for appropriate diagnosis for use was completed.
3. Director of Nursing /designee will in-service licensed nursing staff on psychotropic medications requiring appropriate diagnosis for use. Director of Nursing/Designee will audit all new psychotropic medication orders for diagnosis 5 times weekly for 2 weeks and 3 times weekly for 2 weeks.
4. Director of Nursing Designee will report in monthly QAPI meetings the results of findings monthly X 3 months and randomly thereafter.

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 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(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 on clinical record review, facility policy review, and staff interviews, it was determined that the facility failed to ensure Medication Regimen Reviews were completed by the facility after the consultant pharmacist recommendations were made for three out of 12 months (November 2023, March 2024, and April 2024).

Findings include:

The facility "Medication Regimen Review" policy last reviewed 9/9/23 and 10/24/24, indicated that monthly medication review will be performed by a licensed pharmacist. The pharmacist will report any irregularities to the attending physician, the facilities medical director and director of nursing, and these reports must be acted upon in a timely manner that meets the needs of the residents.

Review of Resident R47's admission record indicated he was admitted to the facility on 10/13/16.

Review of Resident R47's MDS assessment (Minimum Data Set assessment: MDS -a periodic assessment of resident care needs) dated 8/26/24, indicated his diagnoses included high blood pressure, depression, and diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time).

Review of Resident R47's clinical pharmacy review notes on 10/31/24, at 9:00 indicated the following:

November 2023- see notes.
December 2023- no recommendations.
January 2024 - no recommendations.
February 2024- see notes.
March 2024- see notes.
April 2024- see notes.
May 2024- no recommendations.
June 2024 - no recommendations.
July 2024- no recommendations.
August 2024- no recommendations.
September 2024- no recommendations.
October 2024- no recommendations.

During an interview on 10/31/24, at 10:15 a.m. the Director of Nursing (DON) stated "I could only find February 2024 pharmacy review" and failed to produce November 2023, March 2024, and April 2024 pharmacy recommendations that were made.

During an interview on 10/31/24, at 10:19 a.m. the DON confirmed that the facility failed to ensure Medication Regimen Reviews were completed by the facility after the consultant pharmacist recommendations were made for three out of 12 months (November 2023, March 2024, and April 2024).

28 Pa Code: 201.14 (a) Responsibility of licensee.
28 Pa. Code 211.5(f) Clinical records.
28 Pa. Code 211.9 (k) Pharmacy services.


 Plan of Correction - To be completed: 12/17/2024

1. Resident 47 pharmacy recommendations unable to be located. A review of Resident 47's medication revealed no irregularities and no recommendations.
2. All residents have the potential to be affected by this alleged deficient practice. All residents will pharmacy recommendations will be reviewed for prior 60 days to ensure proper follow-up.
3. The Director of Nursing was educated by the Regional Nurse to review and retain the recommendations. The recommendations will be audited monthly times three months.
4. The results of these audits will be reviewed at the monthly QAPI meeting. The plan will be updated as needed.

483.45(a)(b)(1)-(3) REQUIREMENT Pharmacy Srvcs/Procedures/Pharmacist/Records: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 Pharmacy Services
The facility must provide routine and emergency drugs and biologicals to its residents, or obtain them under an agreement described in §483.70(f). The facility may permit unlicensed personnel to administer drugs if State law permits, but only under the general supervision of a licensed nurse.

§483.45(a) Procedures. A facility must provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident.

§483.45(b) Service Consultation. The facility must employ or obtain the services of a licensed pharmacist who-

§483.45(b)(1) Provides consultation on all aspects of the provision of pharmacy services in the facility.

§483.45(b)(2) Establishes a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation; and

§483.45(b)(3) Determines that drug records are in order and that an account of all controlled drugs is maintained and periodically reconciled.
Observations:


Based on review of facility policy, observation and staff interview it was determined the facility failed to dispose or reconcile discontinued medication in a timely manner for one of two medication rooms reviewed (Second floor D Wing Medication room).

Findings:

Review of facility "Storage of Medications" policy dated 10/24/24, indicated that medications and biologicals are stored safely, securely, and properly, following manufacturer ' s recommendations or those of the supplier. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel or staff members lawfully authorized to administer medications. This includes medication rooms, carts, and medication supplies are locked when they are not attended.

Review of facility "Returning Medications to the Pharmacy" policy dated 10/24/24, indicated unused medication are returned to the provider pharmacy for credit whenever possible. For each medication returned, the medication is scanned in the Return for Credit application available in the pharmacy ' s customer portal. Once all scanning is complete, the medication disposition form should be printed. One copy should be retained by the facility and the second copy should be placed with the medication for return.

During a medication room review on 10/28/24, at 12:40 p.m. four blister pack of medications was observed in an opened tote in the medication room, which was unlocked. The medications observed were:

- Zoloft (used for depression) 100 mg - 13 pills.
- Warfarin (used to thin blood) 4 mg - 4 pills.
- Warfarin 1mg - 12 pills.
- Repaglinide (used for high blood sugar) 0.5 mg - 18 pills.

During an interview on 10/28/24, at 12:45 p.m. Licensed Practical Nurse (LPN) Employee E8 stated, "We don't have any paperwork to complete prior to sending medications back to the pharmacy. No accountability or disposition of the medication is tracked anywhere that i know. They just put them in the tote."

During an interview on 10/28/24, at 2:45 p.m. the Director of Nursing confirmed that the facility failed to dispose or reconcile discontinued medication in a timely manner for one of two medication rooms reviewed (Second floor D Wing Medication room).


28 Pa. Code211.12(d)(1)(3)(5) Nursing services.


 Plan of Correction - To be completed: 12/17/2024

1. Unable to correct past- pharmacy disposition noncompliance
2. All residents have the potential to be affected by this deficient practice. Pharmacy representative was notified of need for pharmacy disposition form. Once pharmacy disposition form is delivered, full house audit of all discontinued meds will be conducted and will be returned to pharmacy utilizing correct disposition form.
3. The Director of Nursing or designee will inservice the nursing staff on using the disposition of medicine form. Audit of discontinued medicine will be done five times a week times two weeks then two times a week times two weeks.
4. The results of these audits will be taken to the monthly QAPI meeting and the plan will be updated as needed.

483.25(i) REQUIREMENT Respiratory/Tracheostomy Care and Suctioning:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
§ 483.25(i) Respiratory care, including tracheostomy care and tracheal suctioning.
The facility must ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals and preferences, and 483.65 of this subpart.
Observations:

Based on review of facility policy, clinical records, observations and staff interviews, it was determined that the facility failed to provide appropriate respiratory care and maintain oxygen equipment for two of two residents (Resident R71 and Resident R113).

Findings include:

The facility "Oxygen therapy: using concentrators" policy dated 9/19/23, indicated that a concentrator is a medical device used for oxygen supplementation. A physician's order is required for residents on oxygen concentrators. Filters and machines are to be cleaned weekly.

Review of the clinical record indicated Resident R71 was admitted to the facility on 10/19/22.

Review of Resident R71's Minimum Data Set (MDS - a periodic assessment of care needs) dated 8/14/24, indicated diagnoses of high blood pressure, anxiety (a feeling of worry, nervousness, or unease), and unsteadiness on feet.

Review of a physician order dated 9/25/23, indicated to change oxygen tubing every week and as needed every Saturday night shift.

During an observation on 10/27/24, at 9:34 a.m. Resident R71's nasal cannula tubing was dated "9/29" and the humidification bottle (a medical device used to enhance moisture and reduce dryness of supplemental oxygen) was empty with no date present.

During an interview on 10/27/24, at 10:10 a.m. Registered Nurse (RN) Employee E1 confirmed Resident R71's nasal cannula tubing was dated "9/29" and the humidification bottle was empty with no date present. During this interview, RN Employee E1 confirmed that the facility failed to provide appropriate respiratory care and maintain oxygen equipment for Resident R71 as required.

Review of Resident R113's admission record dated 9/21/24, and readmitted on 10/1/24.

Review of Resident R113's MDS assessment (MDS-Minimum Data Set assessment: periodic assessment of resident care needs) dated 10/8/24, indicated that Resident R113 had diagnoses that included acute respiratory failure (the body is not receiving sufficient oxygen), anxiety disorder (a medical condition creating a sense of acute fear, restlessness, and worry), history of falling, neuromuscular disfunction of bladder (central nervous system lacks communication for urinary function and urgency). The diagnoses were current upon review.

Review of Resident R113's care plan dated 10/2/24, indicated to administer oxygen at ten liters via nasal cannula.

Review of Resident R113's physician order dated 10/1/24, indicated to clean Resident R113's oxygen concentrator every seven days or as needed.

Review of Resident R113's physician order dated 10/1/24, indicated to change Resident R113's oxygen tubing and humidifier every seven days or as needed.

During observations on 10/27/24, at 9:19 a.m. the following was observed in Resident R113 room:
Resident R113 was observed resting in bed. Two concentrators were observed in his room and connected to his oxygen line. Both oxygen concentrators were set to "5" liters of concentrated oxygen. There was no date on the oxygen line and no date on the humidifier water-containers for each oxygen concentrator.

During an on 10/27/24, at 9:24 a.m. RN Employee E2 confirmed that the facility failed to provide appropriate respiratory care and maintain oxygen equipment for Resident R113 as required.

28 Pa. Code: 201.29(i) Resident Rights.
28 Pa. Code 211.10(c)(d) Resident Care Policies.
28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.


 Plan of Correction - To be completed: 12/17/2024

1. Resident 113 and resident 71 had their oxygen tubing and water bottle changed.
2. All residents that use oxygen have the potential to be affected by this deficient practice. All residents that have oxygen had their tubing and water bottle changed and dated.
3. The Director of Nursing or designee will educate the 11-7 shift that all oxygen tubing and the water bottles need to be changed and dated every week. Director of Nursing or designee will audit oxygen tubing and water bottle five times weekly for two week and three times weekly for two weeks to ensure dates are current and equipment has been changed.
4. Results of these audits will be taken to the monthly QAPI meeting and the results reviewed. The plan will be updated as needed.

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, observations, and staff interview, it was determined the facility failed to provide to provide appropriate care and services to residents receiving tube feedings for one of two residents reviewed (Residents R85).

Findings Include:

A review of the facility policy "Medication Administered by Enteral Tube" (surgically placed device through an artificial opening in the abdominal wall) dated 10/24/24, indicates this policy addresses guidance for the clinical administration of medications through a G-tube (surgically placed device used to give direct access to the stomach). Equipment needed but no inclusive to 60cc piston syringe, the syringe is dated upon opening and changed daily.

Review of the clinical record indicated Resident R85 was admitted to the facility on 8/31/23.

Review of Resident R85's Minimum Data Set (MDS- a periodic assessment of care needs) dated 10/11/24, indicated the diagnosis of hypertension (high blood pressure), diabetes (high sugar in the blood), and dysphagia (difficulty swallowing)

Review of resident R85's physician orders dated 4/11/24, indicate enteral feed order one time a day at 10:00 a.m. clear volume fed in the last 24 hours on the pump. Confirm volume to be fed at 1200ml and then turn on.

Review of Resident 85's care plan with revision dated 10/24/23, indicates Resident R85 requires a tube feeding due to dysphagia, administer flushes per MD order.

During an observation on 10/27/24, at 9:43 a 60cc syringe was sitting in an opened package on the dresser inside of a cup, the syringe failed to be labeled with a date or time.

During an interview completed on 10/27/24, at 9:43 a.m. Registered Nurse (RN) Employee E6 confirmed the flush syringe did not have the date opened on it as required and stated "I just used it this morning and I didn't put the date on it because I didn't have a marker" and confirmed that the facility failed to provide appropriate care and services to residents receiving tube feedings for one of two residents reviewed (Residents R85).

28 Pa. Code: 201.18(b)(1) Management.
28 Pa. Code: 211.10(c) Resident care policies.
28 Pa. Code: 211.12(d)(1) Nursing services.



 Plan of Correction - To be completed: 12/17/2024

1. Resident 85 had her syringe exchanged for a clean one.
2. All residents have the potential to be affected by the alleged deficient practice. An audit of Tube feeding syringes, tube feeding bags and flush bags to insure all bags were dated within 24 hours. Also during this audit it was verified that there was no water at the bedside.
3. The Director of Nursing or designee will in-service nursing staff that the tube feeding syringe, tube feeding bags and flush bags will all be dated every night. Each nurse on the next shift will monitor this equipment for current dates. The DON or designee will audit the syringes and feeding tube to insure all have been dated and exchanged every twenty-four hours. Audits will be performed five times a week time two weeks and three times a week for two weeks.
4. Results of these audits will be taken to the monthly QAPI meeting and the results reviewed. The plan will be updated as needed.

483.25(d)(1)(2) REQUIREMENT Free of Accident Hazards/Supervision/Devices: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(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 review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to perform timely and accurate post-fall documentation and failed to ensure that a resident received neurological assessments after an incident involving a fall for one of five residents (Resident R50).

Findings include:

Review of facility policy "Fall Prevention and Management" dated 9/19/23, and last reviewed 10/24/24, indicated after a resident fall, staff should complete the "Post Fall Assessment". If the resident hit their head or the fall was unwitnessed, complete Neuro Checks per policy. Complete the Fall Follow Up at least twice each day for three days unless the resident's condition is such that it should be continued longer.

Review of the clinical record indicated Resident R50 was admitted to the facility on 5/31/24.

Review of Resident R50's MDS dated 10/3/24, indicated diagnoses of high blood pressure, anxiety (a feeling of worry, nervousness, or unease), and Alzheimer's Disease (a progressive disease that destroys memory and other important mental functions).

Review of a Telehealth Notification note dated 9/16/24, at 11:04 p.m. completed by Nurse Practitioner Employee E22 stated, "Nurse called to report unwitnessed fall. Contusion (bruise) to right side of head with small bump. Range of motion within normal limits for patient. Neuro checks normal. May use ice pack and Tylenol. Call with acute changes."

Review of a nursing progress note dated 9/17/24 at 12:06 a.m. completed by Registered Nurse (RN) Employee E21 stated, "Resident had an unwitnessed fall, she said she is trying to fix the bedside table then she slipped and fell. Contusion (bruise) noted on the right side on her head, ROM (range of motion) normal, vitals normal. Supervisor informed, called physician. Supervisor, informed hospice as well as the family member."

Review of Resident R50's clinical record failed to indicate that a Post Fall Assessment was completed after the resident's unwitnessed fall on 9/16/24.

Review of a "Neuro Check Eval" indicated neurological assessments should be performed every 15 minutes for one hour, every one hour for four hours, and every four hours for 16 hours, and then daily for four days.

Review of Resident R50's "Neuro Check Eval" dated 9/16/24, indicated only 11 neurological checks were completed out of 16 opportunities.

Review of a nursing progress note dated 9/23/24 at 11:30 p.m. completed by RN Employee E23 stated, "I was notified of the resident having had a fall. The roommate notified the nurse aide that the resident had fallen and gotten herself back up and in bed. VS wnl (vital signs within normal limits). She stated she slid into chair, fell back onto wheelchair while returning from bathroom. Called physician, notified RP (responsible party). Neuro checks started per protocol. No new orders, unless change of condition."

Review of Resident R50's clinical record indicated that the Post Fall Assessment and Fall Follow Up were completed by RN Employee E24 on 10/5/24. Review of the Post Fall Assessment and Fall Follow Up indicated they were completed due to the resident having a fall on 9/23/24.

Review of Resident R50's "Neuro Check Eval" dated 9/23/24, indicated only six neurological checks were completed out of 16 opportunities.

During an interview on 10/31/24, at 10:21 a.m. the Director of Nursing confirmed that the facility failed to timely and accurately complete the post-fall documentation for Resident R50's falls on 9/16/24, and 9/23/24, and failed to complete neurological assessments per facility policy after Resident R50's falls on 9/16/24, and 9/23/24.

28 Pa. Code: 201.14(a) Responsibility of licensee.
28 Pa. Code: 201.18(e)(1) Management.
28 Pa. Code: 207.2(a) Administrator's responsibility.
28 Pa. Code: 211.10(d) Resident care policies.


 Plan of Correction - To be completed: 12/17/2024

1. Resident 50 did not have any negative neurological outcomes from alleged deficient practice. She was assessed by Physician Assistant on 9/24/2024.
2. All residents have the potential to be affected by the alleged deficient practice. An audit of all residents who had unwitnessed falls or fall with head injury from 11/1-11/15/24 for neuro checks and post fall assessment completion was completed.
3. Director of Nursing /designee will in-service licensed nursing staff on the fall policy and completion of neuro-checks. Director of Nursing/Designee will audit all falls 5 times weekly for 2 weeks and 3 times weekly for 2 weeks to ensure that post fall assessment and neuro checks are completed fully and timely,
4. Director of Nursing Designee will report in monthly QAPI meetings the results of findings monthly X 3 months and randomly thereafter.

483.25(b)(2)(i)(ii) REQUIREMENT Foot 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(b)(2) Foot care.
To ensure that residents receive proper treatment and care to maintain mobility and good foot health, the facility must:
(i) Provide foot care and treatment, in accordance with professional standards of practice, including to prevent complications from the resident's medical condition(s) and
(ii) If necessary, assist the resident in making appointments with a qualified person, and arranging for transportation to and from such appointments.
Observations:

Based on review of facility policy, resident clinical records, resident and staff interview, it was determined that the facility failed to provide adequate and timely podiatry care for one of three sampled residents (Resident R27).

Findings include:

The facility "Foot care" policy dated 9/19/23, indicated that it is the policy to provide resident centered care. Foot care will be provided by nursing personnel for those residents unable to perform the task. Diabetic residents and those with chronic circulatory problems will be treated by licensed professionals

Review of Resident R27's admission record indicated he was originally admitted on 6/10/19, and readmitted on 6/11/24.

Review of Resident R27's MDS assessment (MDS-Minimum Data Set assessment: periodic assessment of resident care needs) dated 6/18/24, indicated that he had diagnoses that included diabetes (a metabolic disorder impacting organ function related to glucose levels in the human body), peripheral vascular disease (PVD- a narrowing of the blood vessels in the legs), hypertensive heart disease (a condition characterized by long term heart conditions and high blood pressure), anxiety disorder (a medical condition creating a sense of acute fear, restlessness, and worry), and spinal stenosis (a narrowing of the spaces within the spine, which causes pain and weakness). The diagnoses were current upon review.

Review of Resident R27's care plan dated 6/20/24, indicated to observe Resident R27 for edema of legs and feet.

Review of Resident R27's clinical records and consultation visits did not include routine podiatry services.

During observations on 10/27/24. at 12:00 p.m. Resident R27 was observed in his bed. His left leg was observed purple below the left knee and around his left calf.

During an interview on 10/27/24, at 1:10 p.m. Resident R27 was interviewed and stated the following: "I never had my beard trimmed. There is no barber in this place. No podiatrist either."

During an interview on 10/29/24, at 9:25 a.m. Receptionist/Ancillary services coordinator Employee E13 stated the following: "I coordinate the podiatry lists. The podiatrist separately bills the insurance company. Resident R27 is not on my list at all. Podiatry comes in twice a month. If a nurse notices someone needs seen, they will asks me to put them on the podiatry list."

During an interview on 10/29/24, at 1:14 p.m. Receptionist/Ancillary services coordinator Employee E13 stated: "the Podiatrist contacted me and stated that he has never seen Resident R27. He was never placed on the podiatry list."

During an interview on 10/29/24, at 2:35 p.m. the Director of Nursing (DON) stated there were no documented refusal of podiatry services from Resident R27, and information relayed was relayed to DON that the facility failed to provide adequate and timely podiatry care to Resident R27 as required.

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


 Plan of Correction - To be completed: 12/17/2024

1. Resident # 27 is scheduled for next podiatry services visit on 11/25/2024
1. 2 All residents have the potential to be affected by this alleged deficient practice and audit was completed by Director of Nursing/designee for all residents who may need podiatry services.
2. Director of Nursing (DON)/Designee will educate all nursing staff and scheduler on the importance of scheduling podiatry services timely when it is needed. Director Of Nursing / Designee will audit that any new residents admitted who may need podiatry services have it scheduled 5 X weekly for 2 weeks then 3 times a week for 2 weeks
3. Director of Nursing/Designee will report findings of audit results to QAPI monthly for 3 months, and randomly thereafter to ensure compliance is sustained.

483.25(b)(1)(i)(ii) REQUIREMENT Treatment/Svcs to Prevent/Heal Pressure Ulcer: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(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 observations and resident and staff interviews, it was it was determined that the facility failed to obtain physician orders for negative pressure wound therapy devices (NPWT or wound vac - used to draw out fluid and infection from a wound to help it heal) for one of three residents (Resident R107), and failed to obtain physician treatment orders for an as needed dressing for one of three residents (Resident R64).

Findings include:

Review of facility policy "Skin Care and Wound Management" dated 9/19/23, last reviewed 10/24/24, indicated residents admitted with or develop skin integrity issues will receive treatment and as indicated.

Review of facility policy "Physician Orders" dated 9/19/23, last reviewed 10/24/24, indicated it is the policy of this facility to provide resident centered care that meets the psychosocial, physical and emotional needs and concerns of the resident.

Review of the admission record indicated Resident R107 was re-admitted to the facility on 10/25/24.

Review of Resident R107's Minimum Data Set (MDS- a periodic assessment of care needs) dated 10/7/24, indicated the diagnoses of hypertension (high blood pressure),anemia (low iron in the blood) and neurogenic bladder (nervous system condition that affects the way the bladder works). Section M - Wound care, M1200E indicated that Resident R107 received pressure ulcer/injury care.

Review of Resident R107's physician order dated 10/28/24, indicated: cleanse sacrum with 0.125% dakins solution apply NPWT at 125mmhg cover with transparent film. Change Monday, Wednesday, Friday and as needed every day shift. Monitor to make sure it is running at all times. Start date 10/30/24.

During an interview on 10/30/24, at 11:39 a.m. Registered Nurse (RN) Employee E18 confirmed the facility failed to obtain orders for the wound vac that included the frequency for the suction setting and interventions for treatment for displacement or malfunction of the wound vac.

Review of the admission record indicated Resident R64 was re-admitted to the facility on 1/12/2019.

Review of Resident R64's Minimum Data Set (MDS- a periodic assessment of care needs) dated 8/28/24 indicated the diagnosis of hypertension (high blood pressure), anemia (low iron in the blood) and diabetes (high sugar in the blood). Section M - Wound care, M1200E indicated that Resident R64 received pressure ulcer/injury care.

Review of Resident R64's physician orders dated 10/23/24 indicated right lateral malleolus (heel) cleanse with wound cleanser, apply Medi-honey and silver alginate and cover with border gauze. every day shift Monday, Wednesday, Friday for Wound Care

During an interview completed on 10/29/24, at 9:45 a.m. Licensed Practical Nurse (LPN) Employee E6 stated " I did it yesterday and Sunday I did it two days in row" and confirmed the facility failed to obtain physician treatment orders for an as needed dressing for one of three residents (Resident R64).

28 Pa. Code: 201.29(i) Resident Rights.
28 Pa. Code 211.10(c)(d) Resident Care Policies.
28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.


 Plan of Correction - To be completed: 12/17/2024

1. Resident 107 had orders added for frequency of suction and interventions for malfunction or displacement. Resident 64 received an order for PRN treatment.
2. All residents have the potential to be affected by the alleged deficient practice. An audit of all resident's treatment orders to ensure PRN orders in place completed.
3. Director of Nursing /designee will in-service nursing staff on wound treatment orders to have PRN orders by 12/17/24. Director of Nursing/Designee will audit all new treatment orders for PRN orders 5 times weekly for 2 weeks and 3 times weekly for 2 weeks.
4. Director of Nursing Designee will report in monthly QAPI meetings the results of findings monthly X 3 months and randomly thereafter.

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 review of facility policy, clinical records, and staff interviews, it was determined that the facility failed to notify physicians of increased and decreased Capillary Blood Glucose (CBG) levels as per physician's order for two of three sampled residents (Residents R5 and R88) and failed to document appropriate interventions for a resident with hypoglycemia (low blood glucose) for one of three sampled residents (Resident R5).

Findings include:

The facility "Blood glucose point of care" policy dated 9/19/23, indicated that point of care testing for blood glucose levels is a lab test that is performed at the bedside by a nurse. Record results and contact provider per physician orders if out of range.

The Centers for Disease Control defines diabetes as: Diabetes Mellitus is a chronic (long-lasting) health condition that affects how your body turns food into energy. Most of the food you eat is broken down into sugar (also called glucose) and released into your bloodstream. When your blood sugar goes up, it signals your pancreas to release insulin. Insulin acts like a key to let the blood sugar into your body's cells for use as energy. If you have diabetes, your body either doesn't make enough insulin or can't use the insulin it makes as well as it should. When there isn't enough insulin or cells stop responding to insulin, too much blood sugar stays in your bloodstream. Over time, that can cause serious health problems, such as heart disease, vision loss, and kidney disease. Hypoglycemia is a condition that occurs when blood glucose is lower than normal, usually below 70 milligrams per deciliter (mg/dl). If left untreated, hypoglycemia may lead to weakness, confusion, unconsciousness, arrhythmias and even death. People with Diabetes Mellitus may be prescribed injectable insulin to assist in maintaining acceptable levels of CBG's. Hyperglycemia, or high blood glucose, occurs when there is too much sugar in the blood. This happens when your body has too little insulin. Hyperglycemia is blood glucose greater than 125 mg/dL while fasting (not eating for at least eight hours, or a blood glucose greater than 180 mg/dL one to two hours after eating. If you have hyperglycemia and it's untreated for long periods of time, you can damage your nerves, blood vessels, tissues, and organs. Damage to blood vessels can increase your risk of heart attack and stroke, and nerve damage may also lead to eye damage, kidney damage and non-healing wounds.

Review of Resident R5's admission record indicated she was admitted on 1/13/20, and readmitted on 7/7/23.

Review of Resident R5's MDS assessment (MDS-Minimum Data Set assessment: periodic assessment of resident care needs) dated 5/24/24, indicated she had diagnoses that included diabetes (a metabolic disorder impacting organ function related to glucose levels in the human body), chronic kidney disease (a loss of kidney function resulting in the swelling of feet, fatigue, high blood pressure and changes in urination), hypertension (a condition impacting blood circulation through the heart related to poor pressure), and chronic obstructive pulmonary disease (COPD: a disease characterized by persistent respiratory symptoms involving breathlessness, coughing, and obstructed airflow to the lungs). These diagnoses were current upon review.

Review of Resident R5's care plan dated 4/4/24, indicated to administer insulin injections per orders.

Review of Resident R5's physician orders dated 8/23/24, indicated to administer insulin (Aspart) subcutaneously with blood glucose monitoring, provide medication before meals three times per the following protocol:
0-70= notify the physician
70-140 = 0 units
141-180 = 2 units
181-220 =4 units
221-260 = 6 units
261-300 = 8 units
301-400 = 10 units
401-999 = 12 units and call physician

Review of Resident R5's vitals records from June 2024 to July 2024, indicated the following blood glucose measurements:
7/9/24= 64 mg/dl
10/6/24= 417 mg/dl
10/7/24= 64 mg/dl
10/9/24= 427 mg/dl

Review of Resident R5's clinical records and physician documents did not include notifications to the physician as ordered related to the abnormal blood glucose levels on 7/9/24, 10/6/24, 10/7/24, and 10/9/24.

Review of Resident R5's clinical records, nurse notes and physician documents did not include interventions for hypoglycemia for 10/7/24.

During an interview on 10/29/24, at 11:05 a.m. Registered Nurse (RN) Employee E4 confirmed that the facility failed to notify a physician of increased and decreased Capillary Blood Glucose (CBG) levels as per physician's order and failed to document appropriate interventions for Resident R5 as required.

Review of the clinical record indicated Resident R88 was admitted to the facility on 8/31/23, and readmitted on 6/10/24.

Review of Resident R88's MDS dated 9/7/24, indicated diagnoses of high blood pressure, diabetes, and muscle weakness.

Review of a physician order dated 10/9/24, indicated to check the resident's blood sugar level before meals and at bedtime. Notify provider if blood sugar is less than 70 mg/dL or greater than 250 mg/dL.

Review of Resident R88's care plan dated 5/31/24, indicated to administer insulin injections per orders.

Review of Resident R88's vitals records for October 2024, indicated the following blood glucose measurements:

10/27/24 12:26 p.m. = 252.0 mg/dL
10/26/24 8:13 p.m. = 389.0 mg/dL
10/24/24 8:49 p.m. = 375.0 mg/dL
10/24/24 4:15 p.m. = 288.0 mg/dL
10/21/24 9:23 p.m. = 367.0 mg/dL
10/21/24 12:31 p.m. = 287.0 mg/dL
10/20/24 8:28 p.m. = 340.0 mg/dL
10/19/24 9:15 p.m. = 325.0 mg/dL
10/19/24 4:21 p.m. = 305.0 mg/dL

Review of Resident R88's progress notes from 10/19/24, through 10/27/24, failed to include documentation that a physician was notified of Resident R88's abnormal blood glucose levels on the dates listed above.

During an interview on 10/29/24, at 2:10 p.m. the Director of Nursing confirmed that the facility failed to follow physician orders and notify a physician of abnormal blood glucose readings for Resident R88 as ordered.

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




 Plan of Correction - To be completed: 12/17/2024

1. Resident 5 had a review of her FSBS levels on 10/16/24 by her primary care physician with no new orders. Resident 88 had a review of her FSBS levels by Physician Assistant on 10/30/24 with changes made to parameters.
2. All residents have the potential to be affected by this alleged deficient practice. Facility audit will be completed by Director of Nursing/Designee and review all residents with orders for notification to MD to ensure MD was notified of out of range reading.
3. Licensed Nursing in facility will be educated by Director of Nursing/Designee on following MD orders to notify MD of out of range readings with Accucheck. Director of Nursing /Designee will audit accucheck readings out of range to ensure they have MD notification 5X week for 2 weeks, then 3 times a week for 2 weeks.
4. Director of Nursing will report results of findings to QAPI monthly X 3 months and randomly thereafter.

483.12(b)(5)(i)(A)(B)(c)(1)(4) REQUIREMENT Reporting of Alleged Violations: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)(1) Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures.

§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, clinical record review, reports submitted to the State, and resident and staff interviews, it was determined that the facility failed to report allegations of neglect in the required timeframe one of three residents (Resident R48).

Findings include:

Review of facility policy "Abuse, Neglect and Misappropriation" dated 10/24/24, indicated neglect is the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. For alleged violations of neglect, exploitation, misappropriation of resident property, or mistreatment that do not result in serious bodily injury, the facility must report the allegation no later than 24 hours.

Review of the clinical record indicated Resident R48 was admitted to the facility on 4/30/24.

Review of Resident R48's MDS dated 9/26/24, indicated diagnoses of neurogenic bladder (bladder problems due to disease or injury of the nervous system involved in the control of urination), and quadriplegia (paralysis of all four limbs).

During an interview on 10/27/24, at 10:37 a.m. Resident R48 stated, "I didn't have my call bell available last night from 11 p.m. to 5 a.m. No one rounded on me last night from 11 p.m. to 5 a.m. The aide who put me to bed last night around 9 p.m. did it by herself, she used a Hoyer (a mechanical lift) to put me back to bed by herself when there should have been two people. The aide I have today told me that she would get me up yesterday before lunch and shave me. She didn't get me up until after lunch and she didn't shave me because she said I was rude."

During an interview on 10/27/24, at 11:28 a.m. the Nursing Home Administrator (NHA) and Director of Nursing (DON) were made aware by the State Agency of the allegations of neglect that Resident R48 had made during an interview on 10/27/24, at 10:37 a.m.

A review of incidents submitted to the State on 10/28/24, at 1:28 p.m. included Resident R48's allegation that an aide failed to shave him, but failed to include the neglect allegations involving not having his call bell available and not being rounded on by nursing staff for six hours and the allegation that one aide used a Hoyer lift to put him back to bed.

During an interview on 10/29/24, at 2:35 p.m. the DON confirmed that the facility failed to report allegations of neglect in the required timeframe as required for one of three residents (Resident R48).

28 Pa. Code 201.14(a)(c.)(e.) Responsibility of licensee.
28 Pa. Code 201.18(b)(1)(3)(e)(1) Management.
28 Pa. Code 201.20(b) Staff development.
28 Pa. Code 211.10(c.)(d) Resident care policies.


 Plan of Correction - To be completed: 12/17/2024

1. Allegation of abuse reported to DOH
2. All residents have the potential to be affected by this alleged deficient practice. All reportable for the prior 30 days were reviewed and compared to statements to ensure all components were included in the reportable with no details being excluded or left out.
3. Administrator/Designee will educate Director of Nursing on need to include all elements of the reported statement when reported allegations of abuse in the event reporting system.
4. Administrator/Designee will audit weekly X 4 weeks all reportable incidents to ensure all relevant elements from the investigation have been included in the reported event.
5. Administrator/Designee will report findings of audit results to QAPI monthly for 3 months and randomly thereafter to ensure compliance is sustained.

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

§483.12(a) The facility must-

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

Based on review of facility documents, facility policy, clinical records, resident representative interview, and staff interviews, it was determined that the facility failed to provide appropriate goods and services to prevent physical neglect for two of four residents (Resident R87 and R107).

Findings include:

Review of facility "Abuse, Neglect and Misappropriation" policy dated 9/9/23 and 10/24/24, indicated it is the policy of the facility to provide resident centered care that meets the psychosocial, physical and emotional needs and concerns of the residents. It is the intent of the facility to prevent abuse, mistreatment, or neglect of residents or the misappropriation of their property, corporal punishment and involuntary seclusion and to provide guidance to direct staff to manage any concerns or allegations of abuse, neglect or misappropriation of their property.

Review of the clinical record indicated Resident R87 was admitted to the facility on 9/20/24.

Review of Resident R87's Minimum Data Set (MDS - a periodic assessment of care needs) dated 9/27/24, indicated diagnoses of high blood pressure, depression, and dementia (a group of symptoms that affects memory, thinking and interferes with daily life). Section GG0130 is coded as a "1", indicating dependent for toileting hygiene.

Review of Resident R87's care plan dated 9/30/24, indicated toileting hygiene - Dependent. Helper does all of the effort or two or more helper assists.

During an interview on 10/27/24, at 12:26 p.m. a resident representative reported an allegation of neglect to State Agency concerning incontinent care being completed timely and that evening shift is the worse shift. During allegation of neglect, it was reported that resident was not changed for nine hours on 10/16/24.

During an interview on 10/27/24, at 1:15 p.m. the Nursing Home Administrator stated he was familiar with the neglect allegation and was able to provide documentation dated 10/17/24, regarding the investigation that was conducted related to the event.

During review of documentation provided by the facility on 10/28/24, at 10:35 a.m. indicated that the resident was observed to have been incontinent. This was observed by resident representative and other staff members once it was brought to their attention. The incident was discussed with the employee assigned to resident in which she responded, "I had not changed her since earlier in the morning".

During review of documentation provided by the facility on 10/28/24, at 11:02 a.m. indicated that the facility substantiated the allegation of neglect that was made for Resident R87.

During an interview on 10/30/24, at 10:15 a.m. Nursing Home Administer (NHA) stated "We did the investigation and the alleged perpetrator resigned from the facility".

During an interview on 10/30/24, at 10:37 a.m. NHA confirmed that the facility failed to ensure that residents were free from neglect for Resident R87.

Review of the clinical record revealed that Resident R107 was admitted to the facility on 9/30/24.

Review of Resident 107's MDS dated 10/7/24, indicated diagnoses of high blood pressure, intracerebral hemorrhage (when a ruptured blood vessel causes bleeding inside the brain), and dysphagia (difficulty swallowing).

Review of Resident R107's clinical record revealed a progress note from Physician Assistant (PA) Employee E34 dated 10/30/24, at 5:36 p.m. that stated the following: "Very critical K (potassium level) in a non-verbal patient. Full code. Will transfer to ER (Emergency Room). K was 5.5 on the 10/29/24, now 6.8. Transfer to ER. "

Review of Resident R107's clinical record revealed a nursing progress note dated 10/31/24, at 9:20 a.m. that stated the following: "To go into ER due to elevated potassium."

During an observation on 10/31/24, at approximately 9:30 a.m. State Agency witnessed Resident R107 being transferred into an ambulance.

During an interview on 10/31/24, at 12:53 p.m. PA Employee E34 stated that she had been contacted the evening of 10/30/24, regarding Resident R107's high potassium level via a telehealth visit in which she instructed the nurse who contacted her to send Resident R107 to the hospital. When PA Employee E34 was asked if she meant for Resident R107 to be sent to the hospital the following morning, she replied "No. I wanted her sent out right then". PA Employee E34 added that the conversation with facility staff and the contents of the consult are recorded and that there are audio files to support her instructions.

During an interview on 10/31/24, at 2:22 p.m. the Director of Nursing (DON) confirmed that Resident R107 was not sent out to the hospital on the evening of 10/30/24, as instructed, and that the expectation would have been to send Resident R107 to hospital directly after having received the order to do so. DON confirmed that the facility neglected to address Resident R107's change in condition in a timely manner.

28 Pa. Code: 201.14(a) Responsibility of licensee
28. Pa Code 201.18(b)(1)(e)(1) Management.
28 Pa. Code 201.29(j) Resident rights.
28. Pa. Code 211.12(d)(1)(5) Nursing services.


 Plan of Correction - To be completed: 12/17/2024

1. Resident 87 had a skin assessment completed and was not found to have adverse effects to her skin integrity related to neglect. Employee involved in this investigation is no longer employed. Resident 107 returned to the facility on 10/31/24. Registered Nurse who received order to send to the hospital on 10/30/24 received education on 10/31/24.
2. All residents have the potential to be affected by the alleged deficient practice. Like residents were interviewed for allegations of neglect. No further concerns found. An audit of all provider visits from 11/6-11/8/24 was completed to ensure all orders were carried out.
3. Director of Nursing /designee will in-service staff on abuse and neglect and licensed nursing staff to be educated on timely completion of physician orders. Director of Nursing/Designee will conduct random resident interviews concerning neglect on 5 residents 5 times weekly for 2 weeks and 3 times weekly for 2 weeks. Director of Nursing/Designee will audit provider visits to ensure timely follow up on orders received 5 times weekly for 2 weeks and then 3 times a week for 2 weeks.
4. Director of Nursing Designee will report in monthly QAPI meetings the results of findings monthly X 3 months and randomly thereafter.

483.10(j)(1)-(4) REQUIREMENT Grievances: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(j) Grievances.
§483.10(j)(1) The resident has the right to voice grievances to the facility or other agency or entity that hears grievances without discrimination or reprisal and without fear of discrimination or reprisal. Such grievances include those with respect to care and treatment which has been furnished as well as that which has not been furnished, the behavior of staff and of other residents, and other concerns regarding their LTC facility stay.

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

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

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

Based on review of facility policy, resident council interview, observations of resident areas and nursing units, and staff interviews it was determined that the facility failed to ensure anonymous grievance forms are readily accessible for resident use on one of three floors (Second floor).

Findings include:

The facility "Resident grievance" policy dated 2/20/24, indicated that the facility will maintain a secure box, in an area accessible to residents and visitors, for reporting grievances in writing and anonymously. Multiple boxes may be required in the facility to ensure that all residents are able to exercise their right to file grievances anonymously.

During a resident group interview on 10/30/24, at 11:45 a.m the residents stated they do not know where the grievance box is, where the concern forms are or who the grievance officer is.

During observations on 10/31/24, at 9:42 a.m. observations of the Second floor D-wing lounge was observed locked. A sign was observed on the outside of the door and it stated: "closed for renovation." The Second floor D-wing lounge was observed with the facility grievance box and it was observed empty without any grievance forms.

During observations on 10/31/24, at 9:46 a.m. the Lounge across from Room 246 was observed without a grievance box or forms for resident use.

During observations on 10/31/24, at 9:49 a.m. the Second floor Savor lounge was observed without any grievances box or grievance form for resident use.

During an interview on 10/31/24, at 11:30 a.m. Nursing Home Adminstrator (NHA) confirmed that the facility failed to have a private grievance box available to residents, with the grievance box on the second floor being in the second floor lounge which is inaccessible to residents due to renovations.

During an exit interview on 10/31/24, at 5:10 p.m. information was disseminated to the Nursing Home Administrator (NHA) and the Director of Nursing (DON) that the facility failed to ensure anonymous grievance forms are readily accessible for resident use on the Second floor.

28 Pa. Code 201.29(l)Resident rights.
28 Pa. Code 201.18e(4)Management.


 Plan of Correction - To be completed: 12/17/2024

1. Grievance Box on the second floor lounge has been relocated into hallway.
2. All residents have the potential to be affected by this alleged deficient practice. All grievance boxes were audited to ensure they are in a common areas that can be utilized at all times.
3. Administrator/Designee will educate social worker on need for grievance boxes to be accessible on each floor by all residents at all times.
4. Administrator/Designee will audit grievance boxes weekly x 4 week to ensure they are accessible by all residents on each floor.
5. Administrator/Designee will report findings of audit results to QAPI monthly for 3 months and randomly thereafter to ensure compliance is sustained.

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 facility policy, clinical records, and staff interview it was determined the facility failed to notify the physician of a change of condition for one of eight residents (Resident R173).

Findings include:

Review of facility policy "Notification of Change in Condition", dated 10/24/24, indicated "Compliance Guidelines: The center must inform the resident, consult with the residents physician when there is a change requiring notification."

Resident R173 was admitted to the facility on 10/11/24.

Review of Resident R173 admit sheet indicated diagnosis of type II Diabetes Mellitus (chronic disease that occurs when the body doesn't use insulin properly, resulting in high blood sugar levels), and end stage real dependence (permanent condition that occurs when the kidneys are no longer able to function).

Review of clinical progress notes dated 10/19/24, indicated Trulicity Subcutaneous Solution Pen-injector ( a type 2 diabetes medication that helps your body release own insulin - given weekly) 0.75MG/0.5ML Inject 0.75mg subcutaneously one time a week every Saturday for DM (diabetes mellitus) - medication not available in house, called Pharmacy script syringe to be delivered soon as possible.

Review of Resident R173 clinical record failed to show where medication was given.
Review of Resident R173 record failed to indicate the physician was notified.

During an interview on 10/31/24, at 8:47 a.m. Director of Nursing confirmed that the facility failed to notify the physician of Resident R173 not being given Trulicity as ordered once a week.

28 Pa. Code 201.14(a)ce Responsibility of licensee.
28 Pa. Code 201.18(b)(1)e(1)Management.



 Plan of Correction - To be completed: 12/17/2024

1. The nurse practitioner for resident 173 was notified of missing Trulicity 10-19-24 dose.
2. All residents have the potential to be affected by the alleged deficient practice. An audit of all residents for missed medication without physician notification was completed for the dates 11/12/24 through 11/18/24.
3. Director of Nursing /designee will in-service licensed nursing staff on notifying the physician of missed medications related to not being available. Director of Nursing/Designee will audit resident missed medication review 5 times weekly for 2 weeks and 3 times weekly for 2 weeks to ensure that physician notification occurs.
4. Director of Nursing Designee will report in monthly QAPI meetings the results of findings monthly X 3 months and randomly thereafter.

483.35(g)(1)-(4) REQUIREMENT Posted Nurse Staffing Information:Least serious deficiency but affects more than a limited number of residents, staff, or occurrences. This deficiency has the potential for causing no more than a minor negative impact on the resident but is not found to be throughout this facility.
§483.35(g) Nurse Staffing Information.
§483.35(g)(1) Data requirements. The facility must post the following information on a daily basis:
(i) Facility name.
(ii) The current date.
(iii) The total number and the actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift:
(A) Registered nurses.
(B) Licensed practical nurses or licensed vocational nurses (as defined under State law).
(C) Certified nurse aides.
(iv) Resident census.

§483.35(g)(2) Posting requirements.
(i) The facility must post the nurse staffing data specified in paragraph (g)(1) of this section on a daily basis at the beginning of each shift.
(ii) Data must be posted as follows:
(A) Clear and readable format.
(B) In a prominent place readily accessible to residents and visitors.

§483.35(g)(3) Public access to posted nurse staffing data. The facility must, upon oral or written request, make nurse staffing data available to the public for review at a cost not to exceed the community standard.

§483.35(g)(4) Facility data retention requirements. The facility must maintain the posted daily nurse staffing data for a minimum of 18 months, or as required by State law, whichever is greater.
Observations:

Based on an observation and staff interviews, it was determined that the facility failed to prominently display Nurse Staffing Information for two of five days (10/30/24 and 10/31/24).

Findings include:

During an observation on 10/31/24, at 11:05 a.m. Receptionist Employee E19 failed to locate the current nurse staffing information at the facility's receptionist desk.

During an interview on 10/31/244, at 11:07 a.m. Receptionist Employee E19 confirmed that the facility nurse staffing information was from 10/29/24.

During an interview on 10/31/24, at 11:10 a.m. Receptionist Employee E19 stated, "I hope that's changed. I guess it's my job to do that, nobody really showed me how to do it"

During an interview on 10/31/24, at 11:12 a.m. the Nursing Home Administrator confirmed that the facility failed to prominently display Nurse Staffing Information for two of five days (10/30/24 and 10/31/24), as required.

28 Pa. Code 211.12 (d)(1)(3)(4) Nursing services


 Plan of Correction - To be completed: 12/17/2024

1. Correct nurse staff information was posted in prominent place.
2. All residents have the potential to be affected by this alleged deficient practice. Facility unable to correct past non-compliance for this alleged deficient practice.
3. Administrator/designee will educate staffing coordinator on importance of daily posting of nursing staffing information per regulation.
4. Administrator/designee will audit nurse staff posting 5X week X 2 week and then 3X week X 2 weeks.
5. Administrator/Designee will report findings of audit results to QAPI monthly for 3 months and randomly thereafter to ensure compliance is sustained.

51.3 (c) LICENSURE NOTIFICATION:State only Deficiency.
51.3 Notification

(c) A health care facility shall
provide similar notice at least 60
days prior to the effective date it
intends to cease providing an existing
health care service or reduce it
licensed bed complement.
Observations:

Based on observations and staff interview it was determined that the facility failed to provide notification to the department that it had reduced the number of licensed beds in operation.

Findings include:

During observations on all nursing units 10/31/24, from 11:00 a.m. the following were notified:

Room 110 - licensed for two beds - has one bed.
Room 111 - licensed for two beds - has one bed.
Room 112 - licensed for two beds - has one bed.
Room 113 - licensed for two beds - has one bed.
Room 114 - licensed for three beds - has two beds.

Room 204 - licensed for two beds -has one bed.
Room 208 - licensed for two beds - has one bed.
Room 217 - licensed for two beds - has one bed.
Room 218 - licensed for two beds - has one bed.
Room 223 - licensed for two beds - has one bed.
Room 225 - licensed for three beds - has two beds.
Room 226 - licensed for three beds - has two beds.

Room 302 - licensed for two beds - has one bed.
Room 303 - licensed for two beds - has one bed.
Room 308 - licensed for two beds -has one bed.
Room 321 - licensed for two beds - has one bed.
Room 325 - licensed for three beds - has two beds.
Room 326 - licensed for three beds - has two beds.

During an interview on 10/31/24, at 12:00 p.m. Nursing Home Administrator, confirmed that the facility failed to provide notification to the department that it had reduced the number of licensed beds in operation.




 Plan of Correction - To be completed: 12/17/2024

Wexford Healthcare Center has no intention to reduce the number of licensed beds in operation. Wexford healthcare center is drafting a temporary restriction in occupancy letter to send to regional office of department of health. TRO will be delivered to Regional Office by 11/27/2024. TRO will consist of request for 12 months while facility is able to develop plan to re-open restricted beds.

RDO will educate NHA on proper notification of regional office of Department of health on advance notice of similar changes in operations whether they affect licensed bed count or not.

Restricted unoccupied rooms will be audited weekly X 4 weeks to ensure they are in good condition and ready to be utilized in the event of an emergency.

Administrator/Designee will report findings of audit results to QAPI monthly for 3 months and randomly thereafter to ensure compliance is sustained.

51.3 (g)(1-14) LICENSURE NOTIFICATION:State only Deficiency.
51.3 Notification

(g) For purposes of subsections (e)
and (f), events which seriously
compromise quality assurance and
patient safety include, but not
limited to the following:
(1) Deaths due to injuries, suicide
or unusual circumstances.
(2) Deaths due to malnutrition,
dehydration or sepsis.
(3) Deaths or serious injuries due
to a medication error.
(4) Elopements.
(5) Transfers to a hospital as a
result of injuries or accidents.
(6) Complaints of patient abuse,
whether or not confirmed by the
facility.
(7) Rape.
(8) Surgery performed on the wrong
patient or on the wrong body part.
(9) Hemolytic transfusion reaction.
(10) Infant abduction or infant
discharged to the wrong family.
(11) Significant disruption of
services due to disaster such as fire,
storm, flood or other occurrence.
(12) Notification of termination of
any services vital to continued safe
operation of the facility or the
health and safety of its patients and
personnel, including, but not limited
to, the anticipated or actual
termination of electric, gas, steam
heat, water, sewer and local exchange
of telephone service.
(13) Unlicensed practice of a
regulated profession.
(14) Receipt of a strike notice.

Observations:

Based on facility policy review, resident clinical records, resident and staff interviews, it was determined that the facility failed to report an accident resulting in a hospitalization within 24 hours to the appropriate state agency for one of three incidents (Resident R22).

Findings include:

The facility "Occurrence incident reporting" policy dated 9/19/23, indicated occurrences or incidents will be investigated using the risk protocol. Occurrences are entered, reported, tracked and investigated using the online program with reference to the specific type of incident. State reportable incidents will be reported as required using the method outlined by the state.

Review of Resident R22's admission record indicated she was admitted 12/19/23.

Review of Resident R22's MDS assessment (MDS-Minimum Data Set assessment: periodic assessment of resident care needs) dated 9/5/24, indicated she had diagnoses that included hypertension (a condition impacting blood circulation through the heart related to poor pressure), history of falling, muscle weakness, and Chondrocalcinosis (a form of arthritis causing crystallize calcium deposits in the joints). These diagnoses were current upon review.

Review of Resident R22's census report indicated she was hospitalized on 5/25/24.

Review of Resident R22's clinical nurse progress note dated 5/25/24, indicated the following: at 10:45 p.m. Nurse aid yelled for help because Resident R22 was bleeding from her right leg. Resident R22 was alert and oriented and with appropriate pain response. Resident R22's sustained a right leg skin tear approximately 5x1.5 c.m. and approximately 1.5 deep. Resident R22 stated she was moving from wheelchair to bed and hit something. Supervisor notified and telehealth notified. Advised to be sent out to the hospital. EMS transport came in at 11:15 p.m. Family was notified and aware.

Review of Resident R22's SBAR (Situation; Background; Appearance; Review) assessment dated 5/25/24, indicated Resident R22 had a skin tear and to send to the emergency room.

Review of facility documents of incidents taking place on 5/25/24, indicated the accident occurred due to Resident R25 transferring herself.

Review of facility documents did not include a report to the State involving the accident resulting in Resident R22's hospitalization.

During an interview on 10/28/24, at 9:22 a.m. Resident R22 stated the following: "been here since Christmas. I had an accident. I had to have stitches. I was trying to get up to my wheelchair. I have a hard time to stand up. I hit my calf on the wheelchair. The back of my calf. I called staff right away. Things are ok since then."

During an interview on 10/29/24, at 1:18 p.m. the Director of Nursing (DON) confirmed that the facility failed to report an accident resulting in a hospitalization within 24 hours to the appropriate state agency.



 Plan of Correction - To be completed: 12/17/2024

1. Resident R22 incident was reported to Department of Health
2. All residents have the potential to be affected by this alleged deficient practice. All incidents in the prior 30 days were reviewed to ensure all reportable incidents had been reported as per regulatory requirements.
3. Administrator/Designee will educate Director of Nursing on reportable incidents and reporting them timely to department of health.
4. Administrator/Designee will audit all incidents weekly X 4 weeks to ensure all reportable incidents are reported per regulation.
5. Administrator/Designee will report findings of audit results to QAPI monthly for 3 months and randomly thereafter to ensure compliance is sustained.

51.3 (k) LICENSURE NOTIFICATION:State only Deficiency.
51.3 Notification

(k) The notification requirements
of this section do not require a
facility, in providing a notification
under subsection (e) or (f), to
include information which is deemed
confidential and not reportable to the
Department under other provisions of
federal or State law or regulations.
Observations:

Based on review of the facility's Covid-19 Documentation, it was determined that the facility failed to notify the State Agency (SA) in writing of positive COVID-19 staff cases that could affect resident health and safety.

Findings include:

Review of reports submitted to the local State field office from 10/20/24, to 10/29/24, failed to include a report that a staff member had tested positive for COVID-19.

During an interview on 10/29/24, at 1:36 p.m. Infection Preventionist Employee E10 stated, "We had two employees test positive for COVID-19 last week, the first one on Wednesday. I don't have access to report that to the State (SA). Usually the Nursing Home Administrator (NHA) or Director of Nursing (DON) are the ones who report positive cases to the State."

During an interview on 10/29/24, at 2:35 p.m. the DON stated, "I'm not sure who is responsible for reporting positive COVID-19 cases."

During an interview on 10/29/24, at 2:35 p.m. the DON confirmed that the facility failed to notify the State Agency in writing of positive COVID-19 staff cases that could affect resident health and safety.


 Plan of Correction - To be completed: 12/17/2024

6. Employee who tested positive for COVID-19 was reported to Department of Health
7. All residents have the potential to be affected by this alleged deficient practice. All employees testing positive for COVID-19 in the prior 90 days were reviewed to ensure they were reported appropriately to department of health.
8. Administrator/Designee will educate Director of Nursing on reportable COVID-19 cases
9. Administrator/Designee will audit all positive COVID-19 tests weekly X 4 weeks to ensure all reportable cases are reported per regulation.
10. Administrator/Designee will report findings of audit results to QAPI monthly for 3 months and randomly thereafter to ensure compliance is sustained.

§ 201.14(a) LICENSURE Responsibility of licensee.:State only Deficiency.
(a) The licensee is responsible for meeting the minimum standards for the operation of a facility as set forth by the Department and by other Federal, State and local agencies responsible for the health and welfare of residents. This includes complying with all applicable Federal and State laws, and rules, regulations and orders issued by the Department and other Federal, State or local agencies.

Observations:

Based on state regulations, staff interview, and review of the facility's Infection Control Meeting attendance records, it was determined that the facility failed to ensure that all of the required nine multidisciplinary members (laboratory personnel) were present at the Infection Control Meetings for four of four quarters (Quarter 4 of 2023, Quarters 1, 2, and 3 of 2024).

Findings include:

Review of Act 52 (The Act of March 20, 2002, P.L. 154, No. 13), known as the Medical Care Availability and Reduction of Error (MCARE) Act, Chapter 4, Section 403(1) Infection Control plan states, "A health care facility... shall develop and implement an internal infection control plan that shall include... a multidisciplinary committee including representatives from each of the following if applicable to that specific health care facility." A review of the applicable members at infection control meetings include medical staff, administration, laboratory personnel, nursing staff, pharmacy staff, physical plant personnel, patient safety officer, a community member, and a member of the infection control team.

Review of the facility's Infection Control Meeting Sign In sheets dated November 2022, December 2022, January 2023, February 2023, March 2023, April 2023, May 2023, June 2023, July 2023, August 2023, and September 2023, failed to reveal that a medical staff member, laboratory personnel, physical plant personnel, and a member from the community were in attendance.

Review of the facility's Infection Control Meeting attendance for Quarter 4 of 2023 failed to reveal that laboratory staff were in attendance.

Review of the facility's Infection Control Meeting attendance for Quarter 1 of 2024 failed to reveal that laboratory staff were in attendance.

Review of the facility's Infection Control Meeting attendance for Quarter 2 of 2024 failed to reveal that laboratory staff were in attendance.

Review of the facility's Infection Control Meeting attendance for Quarter 3 of 2024 failed to reveal that laboratory staff were in attendance.

During an interview on 10/29/24, at 1:36 p.m. Infection Preventionist Employee E10 confirmed that the facility failed to ensure that all of the required nine multidisciplinary members (laboratory personnel) were present at the Infection Control Meetings for four of four quarters (Quarter 4 of 2023, Quarters 1, 2, and 3 of 2024).


 Plan of Correction - To be completed: 12/17/2024

1. Past non-compliance unable to be corrected for failure of laboratory to attend infection control meetings.
2. All residents have the potential to be affected by this alleged deficient practice. Prior 3 months of infection control meetings have been reviewed with laboratory representative.
3. Administrator/Designee will educate infection preventionist on need for all multidisciplinary team members, including lab personnel to attend at minimum quarterly infection prevention meetings.
4. Administrator/Designee will audit lab personnel attendance at infection control meetings quarterly X 2 quarters
5. Administrator/Designee will report findings of audit results to QAPI monthly for 3 months and randomly thereafter to ensure compliance is sustained.

§ 204.2(a) LICENSURE Building Plans.:State only Deficiency.
(a) A licensee or prospective licensee shall submit its plans for construction, alteration or renovation to the Department. The Department will post instructions for submissions on its public website.

Observations:

Based on observations and staff interview it was determined that the facility failed to notify the department of renovations to a common second floor lounge area.

Findings include:

During observation on 10/31/24, at 11:30 a.m second floor lounge area was locked and unaccessible to residents, renovations and work in progress were taking place.

During an interview on 10/31/24, at 11:32 a.m. Nursing Home Administrator (NHA) confirmed that the lounge had a leak and the facility was in the process of repairing the leaking and fixing the lounge area.

During an interview on 10/31/24, 11:35 a.m. NHA confirmed that the facility failed to notify the Deparment of renovations the second floor lounge area prior to renovations.


 Plan of Correction - To be completed: 12/17/2024

1. Closure of second floor lounge was reported to DOH.
2. All residents have the potential to be affected by this alleged deficient practice. Full building sweep of all resident areas was completed to identify any other resident areas currently closed off for repair/construction.
3. RDO will educate NHA on reporting any resident area that is closed down to residents for repair/remodeling.
4. Administrator/Designee will audit facility weekly X 4 weeks to ensure all resident areas that are closed down to residents for repair/renovations have been reported to DOH.
5. Administrator/Designee will report findings of audit results to QAPI monthly for 3 months and randomly thereafter to ensure compliance is sustained.

35 P. S. § 448.809b LICENSURE Photo Id Reg:State only Deficiency.
Law amended July 11, 2022 Act 79 2022 HB 2604

(1) The photo identification tag shall include a recent
photograph of the employee, the employee's first name, the
employee's title and the name of [the health care facility or
employment agency.] any of the following:
(i) The health care facility.
(ii) The health system.
(iii) The employment agency.
(iv) The fictitious name of an entity under
subparagraph (i), (ii) or (iii) which is registered with
the Department of State under 54 Pa.C.S. Ch. 3 (relating
to fictitious names) or a successor statute.

(2) The title of the employee shall be as large as possible
in block type and shall occupy a one-half inch tall strip as
close as practicable to the bottom edge of the badge.


(3) Titles shall be as follows:
(i) A Medical Doctor shall have the title "Physician."
(ii) A Doctor of Osteopathy shall have the title
"Physician."
(iii) A Registered Nurse shall have the title
"Registered Nurse."
(iv) A Licensed Practical Nurse shall have the title
"Licensed Practical Nurse."
(v) All other titles shall be determined by the
department. Abbreviated titles may be used when the title
indicates licensure or certification by a Commonwealth
agency.

(4)A notation, marker or indicator included on an identification badge that differentiates employees with the same first name is considered acceptable in lieu of displaying an employee's last name.


Observations:

Based on observations, facility documents, and staff interviews, it was determined that the facility failed to make certain that staff members displayed identification badges to include a name, title, and a photo as required for six of six employees (Employee E17, E28, E29, E31, E32, and Director of Nursing (DON).

Finding include:

Review of the Photo Identification Tag Regulation indicates that staff must wear a photo identification tag that shall include a recent photograph of the employee, the employee's first name, the employee's title and the name of the health care facility or employment agency.

Review of the facility "Employee Handbook" indicated that all personnel must wear a nametag at all times. These nametags must be worn above the waist and clearly visible at all times while on duty.

During an observation and interview on 10/27/24, at 12:00 p.m. Nurse Aide (NA) Employee E28 was observed working without a nametag. NA Employee E28 confirmed that she did not have a nametag and had been employed 1 week and had not been issued a nametag.

During an observation and interview on 10/27/24, at 12:05 p.m. Activities Aide (AA) Employee E29 was observed working without a nametag. AA Employee E29 stated that she has employed at the facility for one and a half years and has not been issued a nametag. She added "I could be anybody" regarding residents being able to identify her.

During an observation and interview on 10/27/24, at 12:07 p.m. Nurse Aide (NA) Employee E31 was observed working without a nametag. NA Employee E31 stated that she was not issued a new nametag after her name change more than one year ago.

During an observation an interview on 10/27/24, at 12:14 p.m. Housekeeper Employee E32 was observed working without a nametag and had a piece of tape with her name written on it adhered to her clothing. Housekeeper Employee E32 stated that she had a nametag but did not bring it to work.

During an observation an interview on 10/27/24, at 12:49 p.m. the DON was observed working without a nametag. DON stated she has been employed for one and a half weeks but was not issued a nametag.

During an observation an interview on 10/28/24, at 9:435 a.m. the Registered Nurse (RN) Employee E17 was observed working without a nametag and had a piece of tape with her name written on it adhered to her clothing. RN Employee E17 stated that she had not been issued a name tag.

During an interview on 10/28/24, at 10:15 a.m. the Nursing Home Administrator confirmed that the facility failed to make certain that Employees E17, E28, E29, E31, E32, and DON properly wore photo identification tags with the require information displayed as required.


 Plan of Correction - To be completed: 12/17/2024

1. Immediate sweep of facility completed educating employees on requirement to wear name badges at all times.
2. All residents have the potential to be affected by this alleged deficient practice. A full audit of the employee will be conducted to determine any employees who do not currently have a name tag that need one ordered.
3. Administrator/Designee will educate all employees on requirement to wear name tag at all times while at work.
4. Administrator/Designee will audit 10 random employees 5X weekly X 2 weeks and then 3X weekly X 2 weeks for compliance with name tag requirement.
5. Administrator/Designee will report findings of audit results to QAPI monthly for 3 months and randomly thereafter to ensure compliance is sustained.


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