Pennsylvania Department of Health
SQUIRREL HILL WELLNESS AND REHABILITATION CENTER
Patient Care Inspection Results

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SQUIRREL HILL WELLNESS AND REHABILITATION CENTER
Inspection Results For:

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SQUIRREL HILL WELLNESS AND REHABILITATION CENTER - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:
Based on a Medicare/Medicaid Recertification survey, State Licensure survey, and a Civil Rights Compliance and Abbreviated survey completed February 12,2024, it was determined that Squirrel Hill Wellness and Rehabilitation was not in compliance with the following requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care and the 28 Pa. Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.


 Plan of Correction:


483.12(a)(1) REQUIREMENT Free from Abuse and Neglect:This is a more serious deficiency but is isolated to the fewest number of residents, staff, or occurrences. This deficiency results in a negative outcome that has negatively affected the resident's ability to achieve his/her highest functional status.
§483.12 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 policies, clinical records, and staff interview, it was determined that the facility failed to make certain that residents were free from neglect that resulted in actual harm of a skin tear, and neglect of notifying a physician and procuring order for the care of the skin tear, for one of nine residents (Resident R164).

Findings include:

Review of "American Congress of Rehabilitation Medicine - Caregiver Guide and Instructions for Safe Bed Mobility" published 4/28/17, indicated bed mobility refers to activities such as scooting in bed, rolling, side-lying to sitting, and sitting to lying down.

Review of the United States Code of Federal Regulations (CFR), 42 CFR Freedom from Abuse, Neglect, and Exploitation defines neglect as "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."

Review of the facility policy. "Abuse, Neglect, and Exploitations" dated 10/2/23, previously reviewed 10/1/22, stated the facility will implement policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property.

Review of Resident R164's admission record indicated he was admitted to the facility on 1/6/24.

Review of Resident R164's Minimum Data Set (MDS -periodic assessment of care needs) dated 1/13/24, included diagnoses of heart failure (a progressive heart disease that affects pumping action of the heart muscles), chronic kidney disease (gradual loss of kidney function), and debility. Review of Resident R164's MDS assessments, Section GG - Functional Abilities and Goals, GG0170A, "Roll left and right", indicated that Resident R164 was dependent on staff (helper does all the effort). Resident does none of the effort to complete the activity. Or the assistance of two or more helpers is required for the resident to complete the activity.

Review of a physician's order dated 1/6/24, indicated Resident R164 required "Bed Mobility Assist x2."

Review of Resident R164's plan of care for "Assistance with activities of daily living" related to impaired mobility and weakness initiated 1/7/24, included the intervention that Resident R164 required the assistance of two staff members for bed mobility.

Review of Resident R164's Kardex (document that outlines the patient's ADLs, continence levels, and behaviors, as well as physician orders, advanced directives, diet, and allergies) dated as of 1/12/24, indicated that Resident R164 required bed mobility assistance of two staff members.

Review of Resident R164's January 2024 Documentation Survey Report (monthly calendar grid for a patient, showing the patient's tasks/intervention description) indicated that from 1/6/24, through 1/12/24, Resident R164 had bed mobility documented eight times, with five of those times documented as having required two persons.

Review of a transcribed statement dated 1/18/24, dictated to Therapy Director Employee E26 by Resident R164 indicated, "I was laying down and the aide was on the left side changing me, on Saturday. She rolled me over and down I went. I don't know what I hit my arm on. She rolled me to the right side. She went to the door and asked for help."

Review of a facility provided incident report dated 1/13/24, indicated "Resident fell from bed while being changed, fell onto his knees, a skin tear on his left forearm noted."

Review of an employee statement dated 1/17/24, written by Nurse Aide (NA)Employee E30 indicated, "To whom it may concern on Saturday 1-13-2024 (Resident R164) had fallen off the bed onto his knees during a roll for a brief change. I reported to Licensed Practical Nurse (LPN) Employee E31. She came in and flushed and wrapped his left forearm. Today I noticed the dressing she applied four days ago had still been there and was very dry and stuck. I reported it to (LPN Employee E32)."

Review of an employee statement (undated), written by LPN Employee E31, indicated, "I was called into the resident room by the aide. I met the resident on his knee, with a skin tear on his left forearm. I flushed it and applied dressing on his arm. The aide told me that he fell onto his knee during a change and hit his arm on the nightstand at his bed. I notified the physician, and his sister about the fall, filled out an incident report."

Review of Resident R164's progress notes failed to reveal when the physician and family were notified, or that a medical provider (physician or on-call provider) assessed Resident R164's skin tear.

Review of a physician's note dated 1/20/24, at 5:48 p.m. failed to include information related to the skin tear.

Review of Resident R164's physician orders failed to include an order for care of the skin tear sustained on 1/13/24, until 1/18/24.

Review of facility submitted information dated 1/18/24, revealed that on 1/13/24, NA Employee E30 provided incontinence care to Resident R164 alone (without additional staff members present), and confirmed that Resident R164 is a bed mobility assist of two.

During an interview and observation on 2/12/24, at 10:37 a.m. NA Employee E12 was asked how she knows what level of staff assistance for bed mobility is appropriate for a resident. NA Employee E12 stated she asks physical therapy. When asked what she would do if therapy staff were not present, NA Employee E12 stated she looks at the charting. When asked to demonstrate this, NA Employee E12 was unable to do so.

During an interview on 2/12/24, at 10:40 a.m. NA Employee E35 was asked how she knows what level of staff assistance for bed mobility is appropriate for a resident. NA Employee E35 stated she reviews the paper sheets at the nurse's station.

During an interview and observation on 2/12/24, at 10:42 a.m. NA Employee E33 was asked how she knows what level of staff assistance for bed mobility is appropriate for a resident. NA Employee E33 demonstrated entering the electronic point of care charting portal and opening the resident's Kardex to see the assistance level.

During an interview on 2/12/24, at 10:45 a.m. NA Employee E34 was asked how she knows what level of staff assistance for bed mobility is appropriate for a resident. NA Employee E34 stated she reviews the paper sheets at the nurses' station.

During an interview on 2/12/24, at 10:50 a.m. NA Employees E36, E37, and E38 were asked how they know what level of staff assistance for bed mobility is appropriate for a resident. They collectively stated that they would use the Kardex function in the electronic point of care charting portal.

During an interview on 2/12/24, at approximately 1:00 p.m., the Nursing Home Administrator confirmed that the facility failed to make certain that residents were free from neglect that resulted in actual harm of a skin tear, and neglect of notifying a physician and procuring order for the care of the skin tear, for one of nine residents.


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

28 Pa. Code 201.20(b)(1) Staff development.

28 Pa. Code 201.29(a) Resident rights.

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

28 Pa. Code 211.11(d) Resident care plan.

28 Pa Code 211.12(d)(1)(2)(5) Nursing services.


 Plan of Correction - To be completed: 04/04/2024

1. Resident R164 discharged from facility 1/21/2024.
2. The Don/Designee will review all past incidents and grievances x30 days to identify any concerns regarding abuse/neglect regarding residents.
3. Staff will be educated on the facility abuse and neglect policy by NHA or designee.
4. Licensed nursing staff will be educated on physician notification and physician orders by DON or designee.
5. Nursing staff will be educated on utilizing the Kardex and/or physician orders to determine resident required assistance for mobility and transfer status by DON or designee.
6. AAE Consulting Services will provide Directed In-Service to educate all staff on federal requirements found at F600- Free from abuse and neglect on the week of March 14, 2024.
7. All incidents and grievances will be audited by the DON/designee daily x 5 days, weekly x 3 weeks, and monthly x2 months to ensure proper transfer status was followed, and incidents requiring physician notification and/or orders were obtained. The DON or designee will audit wound treatments completed and documented daily x 5 days, weekly x 3 weeks, and monthly x2 months.
8. Audit results will be reviewed through the monthly QAPI process/meeting.

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

§483.25(d)(2)Each resident receives adequate supervision and assistance devices to prevent accidents.
Observations:
Based on review of facility policies, clinical records, and staff interview, it was determined that the facility failed to provide adequate supervision for two of nine residents (Residents R164 and R45) which resulted in actual harm of a skin tear to Resident R164 and a fractured bone spur and ligament injuries for Resident R45.

Findings include:

Review of "American Congress of Rehabilitation Medicine - Caregiver Guide and Instructions for Safe Bed Mobility" published 4/28/17, indicated bed mobility refers to activities such as scooting in bed, rolling, side-lying to sitting, and sitting to lying down.

Review of Resident R164's admission record indicated he was admitted to the facility on 1/6/24.

Review of Resident R164's Minimum Data Set (MDS -periodic assessment of care needs) dated 1/13/24, included diagnoses of heart failure (a progressive heart disease that affects pumping action of the heart muscles), chronic kidney disease (gradual loss of kidney function), and debility. Review of Resident R164's MDS assessments, Section GG - Functional Abilities and Goals, GG0170A, "Roll left and right", indicated that Resident R164 was dependent on staff (helper does all the effort). Resident does none of the effort to complete the activity. Or the assistance of two or more helpers is required for the resident to complete the activity.

Review of a physician's order dated 1/6/24, indicated Resident R164 required "Bed Mobility Assist x2."

Review of Resident R164's plan of care for "Assistance with activities of daily living" related to impaired mobility and weakness initiated 1/7/24, included the intervention that Resident R164 required the assistance of two staff members for bed mobility.

Review of Resident R164's Kardex (document that outlines the patient's ADLs, continence levels, and behaviors, as well as physician orders, advanced directives, diet, and allergies) dated as of 1/12/24, indicated that Resident R164 required bed mobility assistance of two staff members.

Review of Resident R164's January 2024 Documentation Survey Report (monthly calendar grid for a patient, showing the patient's tasks/intervention description) indicated that from 1/6/24, through 1/12/24, Resident R164 had bed mobility documented eight times, with five of those times documented as having required two persons.

Review of a transcribed statement dated 1/18/24, dictated to Therapy Director Employee E26 by Resident R164 indicated, "I was laying down and the aide was on the left side changing me, on Saturday. She rolled me over and down I went. I don't know what I hit my arm on. She rolled me to the right side. She went to the door and asked for help."

Review of a facility provided incident report dated 1/13/24, indicated "Resident fell from bed while being changed, fell onto his knees, a skin tear on his left forearm noted."

Review of an employee statement dated 1/17/24, written by Nurse Aide (NA)Employee E30 indicated, "To whom it may concern on Saturday 1-13-2024 (Resident R164) had fallen off the bed onto his knees during a roll for a brief change. I reported to Licensed Practical Nurse (LPN) Employee E31. She came in and flushed and wrapped his left forearm. Today I noticed the dressing she applied four days ago had still been there and was very dry and stuck. I reported it to (LPN Employee E32)."

Review of an employee statement (undated), written by LPN Employee E31, indicated, "I was called into the resident room by the aide. I met the resident on his knee, with a skin tear on his left forearm. I flushed it and applied dressing on his arm. The aide told me that he fell onto his knee during a change and hit his arm on the nightstand at his bed. I notified the physician, and his sister about the fall, filled out an incident report."

Review of Resident R164's progress notes failed to reveal when the physician and family were notified, or that a medical provider (physician or on-call provider) assessed Resident R164's skin tear.

Review of a physician's note dated 1/20/24, at 5:48 p.m. failed to include information related to the skin tear.

Review of Resident R164's physician orders failed to include an order for care of the skin tear sustained on 1/13/24, until 1/18/24.

Review of facility submitted information dated 1/18/24, revealed that on 1/13/24, NA Employee E30 provided incontinence care to Resident R164 alone (without additional staff members present), and confirmed that Resident R164 is a bed mobility assist of two.

During an interview and observation on 2/12/24, at 10:37 a.m. NA Employee E12 was asked how she knows what level of staff assistance for bed mobility is appropriate for a resident. NA Employee E12 stated she asks physical therapy. When asked what she would do if therapy staff were not present, NA Employee E12 stated she looks at the charting. When asked to demonstrate this, NA Employee E12 was unable to do so.

During an interview on 2/12/24, at 10:40 a.m. NA Employee E35 was asked how she knows what level of staff assistance for bed mobility is appropriate for a resident. NA Employee E35 stated she reviews the paper sheets at the nurses station.

During an interview and observation on 2/12/24, at 10:42 a.m. NA Employee E33 was asked how she knows what level of staff assistance for bed mobility is appropriate for a resident. NA Employee E33 demonstrated entering the electronic point of care charting portal and opening the resident's Kardex to see the assistance level.

During an interview on 2/12/24, at 10:45 a.m. NA Employee E34 was asked how she knows what level of staff assistance for bed mobility is appropriate for a resident. NA Employee E34 stated she reviews the paper sheets at the nurses' station.

During an interview on 2/12/24, at 10:50 a.m. NA Employees E36, E37, and E38 were asked how they know what level of staff assistance for bed mobility is appropriate for a resident. They collectively stated that they would use the Kardex function in the electronic point of care charting portal.

Review of Resident R45's admission record indicated she was admitted to the facility on 10/14/21.

Review of Resident 45's MDS dated 12/23/23, included diagnoses of Parkinson's disease (neuromuscular disorder causing tremors and difficulty walking) and history of a stroke. Review of Resident R45's MDS dated 4/23/23, indicated a Brief Interview of Mental Status (BIMS) of 15, which indicated the resident was cognitively intact, Section GG, Functional Abilities and Goals, indicated Resident R45 utilized a wheelchair. Additionally, transfer status is supervision or touching assistance. Resident R45 is mobile in the wheelchair.

Review of Resident R45's care plan did not address mobility throughout the facility or any leaves of absence unsupervised.

Review of a progress note dated 7/1/23, at 7:27 a.m. indicated "Called to lobby by security. noted that resident was locked in the bathroom. upon opening the door, she was noted to be lying on the floor with her w/c (wheelchair) tipped on her. assessed and noted three lacerations on her face. One above her left eye, one below her left eye and one on her right cheek. vitals stable. no change in loc (level of consciousness) resident sat in w/c until medics arrived."

Review of a physician's note dated 7/1/23, at 4:34 p.m. indicated Resident R45 was sent to the hospital for evaluation of head and facial injuries.

Review of hospital documentation dated 7/1/23, indicated that Resident R45 was found to have an acute fractured anterior osteophyte C3 (newly broken bone spur in the neck portion of the spine) and ligament injuries in the neck.

Review of a progress note dated 7/4/23, at 10:39 p.m. indicated Resident R45 returned from the hospital.

Review of an employee statement (undated) by Security Officer Employee E33 stated, "I was sitting at the desk, and I heard someone yelling for help. I got up and followed the sound and it was coming from the bathroom and the door was locked. I use my bank card to get in the bathroom and found (Resident R45) on the floor bleeding from the head/face. I paged staff code blue (need for immediate assistance)."

During an observation on 2/10/24, at 11:30 a.m., of the lobby restroom on the first floor failed to reveal call lights available for resident use in the restroom.

During an interview on 2/10/24, at 11:36 a.m., Maintenance Director Employee E27 confirmed that the lobby restrooms are not routinely locked, and there are not call lights present.

During an interview on 2/12/24, at approximately 1:00 p.m., the Nursing Home Administrator confirmed that the facility failed to provide adequate supervision for two of nine residents, which resulted in actual harm of a skin tear to Resident R164 and fractured bone spur and ligament injuries for Resident R45.


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

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

28 Pa. Code 201.20(b)(1) Staff Development.

28 Pa. Code 201.29(a) Resident rights.

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

28 Pa. Code 211.11(d) Resident care plan.

28 Pa Code 211.12(d)(1)(2)(5) Nursing services.


 Plan of Correction - To be completed: 04/04/2024

1. Resident R164 is no longer a resident at the facility.
2. The facility has since installed an elevator lock code to prevent resident movement to the lobby area unsupervised. Lobby bathroom kept locked.
3. The Don/Designee will review all past incidents and grievances x 30 days to identify any concerns regarding a lack of supervision of residents.
4. Nursing staff will be educated on utilizing the Kardex and/or physician orders/care plan to determine resident required assistance/supervision.
5. AAE Consulting Services will provide Directed In-Service on 3-14-24 to educate all staff on federal requirements found at F689- Free of Accidents Hazards/Supervision and Devices. Education to include family/MD notification and dressing change per order.
6. Incidents and grievances will be audited by the DON/designee daily x 5 days, weekly times 3 weeks, and monthly times 2 months to ensure proper supervision was provided. Audits to include documentation of dressing change completion and family/MD notification as needed.
7. Audit results will be reviewed through the monthly QAPI process/meeting.

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 policy, observation and staff interview, it was determined that the facility failed to properly maintain kitchen equipment in a sanitary condition creating the potential for cross contamination in the main kitchen of the facility (Main Kitchen).

During an observation of the Main Kitchen on 2/5/24, at 10:30 a.m. the following was observed:
-Flour bin, soiled outside, small bowl used as a scoop, stored directly in flour.
-Sugar bin, soiled outside.
-Floor soiled.
-Knives hanging on a magnetic wall holder were visibly dirty.
-Flying insects present in food preparation area.
-Water pooling in meal lids in a cart next to tray line.
-#2 refrigerator, a partially consumed 20-ounce bottle of soda.
-(2) dented large cans of peaches.
-Dishwasher room: dishes stored under table on clean side, face up.
-Mouse droppings observed behind the ice maker and under the handwashing sink.

During an observation of the Main Kitchen on 2/5/24, at 11:55 a.m. the Corporate Mobile Administrator was present in the kitchen, observing the tray line without a hair net on, and her hair hanging free.

During an observation of the Main Kitchen, completed on 2/6/24, at 8:10 p.m. two mice were observed in the Main Kitchen, in the area of the tray line.

Review of facility provided pest control records revealed the following:
-12/01/23: "Found in kitchen 8th floor, dining room 8th floor, rooms (Resident R45, R11, and R89)."
-12/20/23: "Talking with staff and found droppings on the 6th floor and kitchen and dish storage area."
-12/28/23: "Seen by tech in rooms (Resident R14, R59, and R45) and kitchen storage area. Staff reporting droppings spend on floors 5 thru 8."
-1/25/24: "Today I met with (Maintenance Employee E28) who stated there is a mouse issue still going on floors 4, 5, and 6. Also a roach issue is less but still in the kitchen. I inspected and treated the kitchen for roaches, applying a residual pest control solution to all perimeters and under machinery and pipes. Staff stating roaches are in the walls and behind the floor board trim. I treated entire area and dining room." "I will return next week to continue trapping and applying solution for roaches."

During an interview on 2/9/24, at 2:00 p.m. the Nursing Home Administrator confirmed that the facility failed to properly maintain kitchen equipment in a sanitary condition creating the potential for cross contamination in the main kitchen of the facility .


Pa Code: 211.6(c)(d)(f) Dietary services.


 Plan of Correction - To be completed: 04/04/2024

1. Observations in the main kitchen were corrected immediately. Pest control recommendations completed by the Maintenance Director.
2. Pest control company frequency increased to weekly visits to the main kitchen area and floors 4/5/6.
3. Daily work assignments in the kitchen are completed and updated to include cleaning/sanitizing food prep and serve areas before each meal service. A deep clean room schedule is in process for floors 4/5/6.
4. Education for kitchen staff on kitchen sanitation will be completed by the NHA. Education for nursing and kitchen staff will be completed by maintenance director/designee on the process for notifying appropriate staff for any pest concerns.
5. Audits of kitchen cleanliness/nursing units will be completed daily x 5 days, weekly x 4 weeks, and monthly x 2 months.
6. Audit results will be reviewed through the monthly QAPI process/meeting.

483.95(g)(1)-(4) REQUIREMENT Required In-Service Training for Nurse Aides: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.
§483.95(g) Required in-service training for nurse aides.
In-service training must-

§483.95(g)(1) Be sufficient to ensure the continuing competence of nurse aides, but must be no less than 12 hours per year.

§483.95(g)(2) Include dementia management training and resident abuse prevention training.

§483.95(g)(3) Address areas of weakness as determined in nurse aides' performance reviews and facility assessment at § 483.70(e) and may address the special needs of residents as determined by the facility staff.

§483.95(g)(4) For nurse aides providing services to individuals with cognitive impairments, also address the care of the cognitively impaired.
Observations:

Based on review of facility policy, staff education records, and staff interviews, it was determined that the facility failed to conduct at least 12 hours of in-service education, within 12 months of their hire date anniversary, for nurse aides as required for five of five nurse aides (Employees E11, E12, E13, E14, and E15).

Finding include:

Review of the policy "Inservice Training" dated 10/2/23, indicated it is the policy of this facility to develop, implement, and maintain an effective training program for all new and existing staff, individuals providing services under a contractual arrangement, and volunteers, consistent with their expected roles.

Review of Nurse Aide (NA) Employees E11, E12, E13, E14, and E15 education records with hire date greater than 12 months revealed the following:

Nurse Aide (NA) Employee E12 had a hire date of 1/4/22, with 8.00 hours in-service education between 1/4/23, and 1/4/24.
NA Employee E12 had a hire date of 11/12/13, with 0.00 hours in-service education between 11/12/22, and 11/12/23.
NA Employee E13 had a hire date of 11/8/05, with 8.00 hours in-service education between 11/8/22, and 11/8/23.
NA Employee E14 had a hire date of 10/11/05, with 8.00 hours in-service education between 10/11/22, and 10/11/23.
NA Employee E15 had a hire date of 1/6/15, with 8.00 hours in-service education between 1/6/23, and 1/6/24.

During an interview on 2/7/24, at approximately 12:40 p.m. the Nursing Home Administrator that the facility failed to provide documentation of the required 12 hours annual in-service education within 12 months of their hire date anniversary for five of five nurse aides.

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

28 Pa. Code: 201.20(c) Staff Development.


 Plan of Correction - To be completed: 04/04/2024

1. 12-hour in-service education for Aides Training to be provided to employees E11, E12, E13, E14, E15.
2. A whole house audit completed to confirm staff have completed 12-hour in-service education for Aides Training or training will be provided.
3. A monthly audit will occur by HR Director/ designee monthly to assure completion of the continuing education program for all new hires.
4. Findings from the audits will be presented at the quarterly QAPI meeting for review and recommendations.

483.90(i)(4) REQUIREMENT Maintains Effective Pest Control Program:This is a less serious (but not lowest level) deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents.  This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
§483.90(i)(4) Maintain an effective pest control program so that the facility is free of pests and rodents.
Observations:
Based on facility policy, observations, resident and staff interviews, and review of pest control documentation it was determined that the facility failed to maintain an effective pest control program so that the facility was free of pests in the Main Kitchen and on three of three nursing units (First Floor).

Findings include:

Review of the facility policy "Pest Control Program" dated 10/2/23, indicated it is the policy of this facility to maintain an effective pest control program that eradicates and contains common household pests and rodents.

During an observation of the Main Kitchen on 2/5/24, at 9:20 a.m. mouse traps were observed in the kitchen storage area.

During an interview on 2/5/24, at 9:20 a.m. Kitchen Manager Employee E29 confirmed that there is a current concern with mice in the Main Kitchen.

During an interview on 2/5/24, at 10:02 a.m. Resident R11 stated, "The mice are terrible. The traps aren't working." "One of the girls screamed when she came in my room. She was afraid of the mouse."

During an observation on 2/5/24, at 10:06 a.m. of the Fifth-Floor dining room, mouse droppings were observed in multiple corners of the room.

During an interview on 2/5/24, at 10:20 a.m. Resident R7 stated, "I saw two go under the dresser."

During an interview and observation on 2/5/24, at 11:05 a.m. Resident R15 state he has mice in his room and he has chips have blue duct tape over mouse chewed holes. Stated they have eaten though his plastic jello containers. When advised that he should not keep mouse-chewed bags, Resident R15 stated he would throw them away, but he wants to keep them to show people. Resident R15 stated he has caught a mouse in his mouse trap that is on his personal shelving unit. Stated they climb up the walls.

During an interview on 2/5/24, at 1:35 p.m. Resident R57 confirmed she has seen mice in her room.

During an interview and observation on 2/7/24, at 2:20 p.m. Resident R15 had mouse traps in his room, and personal food items that had mice chewed through them. (Observation or statement from resident, ask Kelly.) During a follow-up interview on 2/7/24, at 9:58 a.m. Resident R15 stated he still has mice in his room and "he's sick of it."

During interviews and observations completed on 2/6/24, in the Main Kitchen, Fourth, Fifth, and Sixth Floor nursing units, the following was observed:
-8:10 p.m. Two mice were observed in the Main Kitchen, in the area of the tray line.
-8:40 p.m. Fifth-floor lounge had multiple mouse traps present.
-8:42 p.m. Mouse was observed running across the floor in Resident R11's room.
-8:45 p.m. Three nurse aides confidentially stated they all have seen mice on multiple occasions. "Every day, every night, every floor."
-8:47 p.m. Unit Manager stated, "They come out of the air conditioner, there's a hole in the floor or wall behind it."
-8:49 p.m. Licensed Practical Nurse Employee E24 confirmed she has seen mice on the nursing unit.
-8:51 p.m. Resident R91 stated, "Yeah, he runs back and forth, I [displayed shaking bed footboard] to keep him away."
-8:54 p.m. Resident R110 stated, "I seen two of them yesterday. That's why I'm leaving."
-9:00 p.m. LPN Employee E25 stated, "I've seen one" and motioned to Resident R15's room. "He had one he caught on a glue trap and threw it in the garbage. But it got loose. It was running around the can. I had to dispose of that."
-9:03 p.m. Resident R15 "They eat through my canvas bags, they destroy my snacks. I keep moving things higher and higher."
-9:06 p.m. Resident R44 confirmed that she has seen mice on the unit.
-9:10 p.m. Resident R35, when asked if he has seen mice, stated, "Not tonight, but I have."
-9:11 p.m. Resident R18 stated, "There was a mouse in my room." When asked what day, Resident R18 stated, "Today."
-9:14 p.m. Resident R51 stated he had seen a mouse earlier in the day.

During an interview on 2/8/24, at 9:05 a.m. Dialysis Employee E2 stated on 1/29/24, she observed the two mouse droppings on Resident R93's dialysis port dressing.

During an interview on 2/8/24, at 9:00 a.m. Dialysis Employee E1 stated that on 1/29/24, Resident R93 arrived to dialysis. She (Dialysis Employee E1) moved Resident R93's gown to access the dialysis port and observed two mouse droppings laying on top of the clear dressing covering the dialysis post access site.

During an interview on 2/8/24, at 12:05 p.m. Therapy Director Employee E26 stated, "I have seen dropping on the counter in the kitchen area."

During an observation and interviews completed on the Fourth Floor Nursing Unit on 2/8/24, between 11:00 a.m. and 1:00 p.m. the following was observed:
-Mouse droppings present by the whirlpool bath.
-Dead gnats in the bathtub.
-Holes observed Resident R14's wall, Resident R14 stated, "That's where they come in and out of." Stated she keeps the garbage can covered to keep the mice out." Mouse traps were observed with hair on them.

During an observation and interviews completed on the Fifth Floor Nursing Unit on 2/8/24, between 11:00 a.m. and 1:00 p.m. the following was observed:
- Resident R68 stated she has seen mice.
- Environmental Services Employee E stated she has seen mice.
- Resident R89 stated "I saw one last night, goes under the closet."

During an observation and interviews completed on the Sixth Floor Nursing Unit on 2/8/24, between 11:00 a.m. and 1:00 p.m. the following was observed:
-Resident R8 stated she has seen something small by her bed about the size a of small potato, which she thought was a mouse.
-Resident R106 stated she sees mice in her room and has had mouse droppings on her bedside table.

During an observation of the Seventh Floor Nursing Unit (not currently housing residents) on 2/8/24, between 12:00 p.m. and 1:00 p.m. the following was observed:
- Outside of elevator on 7th floor- mouse dropping noted.

During a confidential resident group interview held 2/7/24, at 1:00 p.m. four of seven residents stated that they have had mice in their rooms. Resident RG5 stated "you should hear the aides scream at night when they see the mice."

Review of an anonymously submitted complaint dated 2/2/24, indicated, "All staff is aware!! All staff has witnessed!! The facility is infested with mice & rats!! They are by the dozens in the kitchen when the nurses and aids entered at night to get snacks when the kitchen forgot to deliver them to the floors for the diabetics!! They had to fight off the rodents to get to the snacks and juice for the residents. They are on every floor in residents rooms, they scream at night about them running around the rooms the ones that are alert enough to yell out and able to see them!" "It's approx 10/15 rooms on each floor except floor 7 is closed from residents but I was told they are running wild up there due to nobody being on that level it's empty not being used. They are in the hallways in the dining rooms. All CNA's (nurse aides) are aware and nurses especially the ones that work the evening and night shift. They been complaining and nothing is being done. Sticky paper traps put down that are not catching anything. Upper management aware, maintenance is the one placing the traps. They are coming in from the door located by the dumpsters right under the door. It hasn't been fixed. The residents should not have to live in these conditions with rodents running around their rooms. Not to mention their had to be feces from these rodents all through the kitchen, where they are preparing their food! That's just foul! This has been an issue since before I was made aware of it at least 2 months ago and it's only gotten worse not better. A CNA witnessed more than 10 during an 8 hour shift on the 5 the floor the other night I was told! Something has to be done, they should not be permitted to take new residents until this problem is controlled. They should be shut down or the residents moved out is there what if one gets bit by a rat! They are not seen as much duriung the day shift due to the amount of movement of people around the facility! As soon as it quiets down around "eightish" pm they start coming out of the woodwork literally! After the kitchen workers leave the kitchen they are like scavengers, running wild in the kitchen! Please do something on these resident behalf's as well as the staff that has to worn under these conditions because they need there job! I lasted 1 shift there but my best friend endures this daily and had been afraid to file a claim in fear of retaliation. This needs to be a priority mice and rats carry disease and infection and they around these people and around their food on the daily basis, and have them for sometime! And it's not just one or two in the building! If I would have to guesstimate, I would say there's at least 200 + in that building. And that is not an exaggeration.!! We watched 22 of them enter the building under that door in the side with the dumpsters the 1 day I worked when we were out there at night smoking! 22 in approximately 15 minutes! They multiply very quickly, so 200 was being nice about it! The facility is more worried about filling their beds than getting rid of the rodents! Thank you, A concerned medical worker!"

Review of facility provided pest control records revealed the following:
-12/01/23: "Found in kitchen 8th floor, dining room 8th floor, rooms (Resident R45, R11, and R89)."
-12/20/23: "Talking with staff and found droppings on the 6th floor and kitchen and dish storage area."
-12/28/23: "Seen by tech in rooms (Resident R14, R59, and R45) and kitchen storage area. Staff reporting droppings spend on floors 5 thru 8."
-1/25/24: "Today I met with (Maintenance Employee E28) who stated there is a mouse issue still going on floors 4, 5, and 6. Also a roach issue is less but still in the kitchen. I inspected and treated the kitchen for roaches, applying a residual pest control solution to all perimeters and under machinery and pipes. Staff stating roaches are in the walls and behind the floor board trim. I treated entire area and dining room I then was shown to rooms on floors 4, 5, and 6. 6th floor - 3 rooms traps and glueboards placed. 5th floor 3 rooms traps and glueboards spied 4th floor 1 room (Maintenance Employee E28) stating they are catching about 2 per week on glueboards. I will return next week to continue trapping and applying solution for roaches."

During an interview on 2/9/24, at 2:00 p.m. the Nursing Home Administrator confirmed that the facility failed to maintain an effective pest control program.

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

28 Pa. Code 207.2 Administrator's responsibility.


 Plan of Correction - To be completed: 04/04/2024

1. Noted findings during survey corrected immediately. Resident R93 had no negative outcomes.
2. Resident rooms checked for food items and proper food storage. Rooms cleaned/sanitized. Resident food reimbursed if needed.
3. Pest control completed an initial sweep/treatment sweep of facility. Pest control interventions are ongoing. Visits increased weekly to address pest control concerns. Mouse trap methods evaluated during pest control visits. Trap recommendations implemented by pest control company upon visits. Facility provided plastic storage totes for residents to store food items in. Residents provided a copy of the food policy. The food policy to be added to the next resident council meeting agenda.
4. Education on the resident food policy provided to nursing and housekeeping staff.
5. Audits of proper resident food storage will be completed daily x 5 days, weekly x 4 weeks, and monthly x 2 months. Audits for completion of pest control recommendations will be conducted weekly x 12 weeks.
6. Results of audits will be reviewed by QAPI committee for further review and recommendations.

483.80(a)(3) REQUIREMENT Antibiotic Stewardship Program:This is a less serious (but not lowest level) deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents.  This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
§483.80(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)(3) An antibiotic stewardship program that includes antibiotic use protocols and a system to monitor antibiotic use.
Observations:
Based on review of the facility's infection control policies and procedures and staff interview, it was determined that the facility failed to implement an antibiotic stewardship program for nine of eleven months (May 2023, June 2023, August 2023, September 2023, and October 2023).

Findings include:

Review of facility policy "Antibiotic Stewardship Program" last reviewed 10/2/23, indicated it is the facility policy to optimize treatment of infections while reducing the adverse events associated with antibiotic use. It was indicated the facility must monitor antibiotic use on a monthly basis.

Review of the facility's Infection Control surveillance for March 2023, through February 2024, failed to include documentation to indicate that antibiotic monitoring was completed for March 2023, April 2023, May 2023, June 2023, July 2023, August 2023, September 2023, October 2023, and November 2023.

During an interview on 2/7/24, at 11:58 a.m. the Infection Preventionist Employee E41 confirmed that the facility was unable to locate and provide documentation to indicate that antibiotic monitoring was completed for March 2023, April 2023, May 2023, June 2023, July 2023, August 2023, September 2023, October 2023, and November 2023.

During an interview on 2/7/24, at 12:17 p.m. the Director of Nursing confirmed that the facility failed to implement an antibiotic stewardship program for nine of eleven months (March 2023, April 2023, May 2023, June 2023, July 2023, August 2023, September 2023, October 2023, and November 2023).

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: 04/04/2024

1. Unable to retroactively complete Antibiotic Stewardship program.
2. Antibiotic Stewardship program to be implemented and meetings completed quarterly.
3. RDO will educate NHA and DON on regulations requiring antibiotic stewardship in relation to infection control and proper antibiotic usage.
4. DON or designee will complete audits for new antibiotic usage and to ensure antibiotic stewardship program is in place weekly x4 weeks and monthly x2 months.
5. Results of audits will be reviewed by QAPI committee for further review and recommendations.

483.80(a)(1)(2)(4)(e)(f) REQUIREMENT Infection Prevention & Control: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.
§483.80 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 §483.70(e) 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 facility policies, clinical record review, observations, and staff interviews, it was determined the facility failed to implement measures to prevent the potential for cross contamination during a dressing change for two of two residents (Resident R18 and R9); failed to implement an infection control program that included a system of surveillance to identify possible communicable diseases or infections for 10 of 11 months (March 2023, April 2023, May 2023, June 2023, July, August 2023, September 2023, and October 2023, November 2023, and January 2024); and failed to conduct an assessment to identify where Legionella and other opportunistic waterborne pathogens could grow and spread, and implement measures to prevent growth.

Findings include:

Review of facility policy "Infection Prevention and Control Program" last reviewed 10/2/23, indicated the facility must have a system of surveillance is utilized for prevention, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual agreement based upon accepted national standards. It was indicated COVID-19 testing should be repeated every 3-7 days until no new cases are identified for at least 14 days. It was indicated the water management program must include control measures and testing protocols.

Review of facility policy "Water Management Program Policy" last reviewed 10/2/23, indicated it is the facility policy to establish water management plans for reducing the risk of legionellosis and other opportunistic pathogens (are conditions (meaning adverse effects on human health, such as death, disability, illness or disorders) caused by pathogenic micro-organisms that are transmitted by water.) in the facility's water systems based on nationally accepted standards. It was indicated the facility must maintain documentation that describes the facility's water system and a copy is kept in the facility's water management program binder.

Review of the clinical record indicated that Resident R18 was admitted to the facility on 11/30/22.

Review of the Resident R18's clinical record indicated active diagnoses of muscle weakness, anxiety, and anemia (deficiency of healthy red blood cells in blood).

During an observation on 2/7/24, at 9:59 a.m. Unit Manager, Licensed Practical Nurse (LPN) Employee E40 failed to perform hand hygiene prior to and after removing Resident R18's right lower leg wound dressing. Unit Manager, Employee E40 failed to clean the scissors used to remove Resident R18's dressing before and after.

During an interview on 2/7/24, at 10:07 a.m. Unit Manager, LPN, Employee E40 confirmed the above observations during the dressing removal for Resident R18 and that the facility failed to implement measures to prevent the potential for cross contamination during a dressing change.

Review of the clinical record indicated that Resident R9 was admitted to the facility on 11/30/22.

Review of the Resident R9's clinical record indicated active diagnoses of high blood pressure, anxiety, and osteoarthritis (a degenerative joint disease, which destroys tissues of the joint.)

During an observation of Resident R9's dressing change on 2/8/24, at 10:28 a.m. Infection Preventionist, Employee E41 failed to disinfect the bedside table before and after placing down supplies, and failed to apply a barrier under the resident's wound to prevent cross contamination.

During an interview on 2/8/24, the Director of Nursing confirmed the facility failed to implement measures to prevent the potential for cross contamination during a dressing change for two of two residents (Resident R18 and R9)

Review of the facility's Infection Control documentation for the previous 11 months (March 2023 - January 2024), failed to reveal surveillance for tracking infections for residents for 9 of 11 months (March 2023, April 2023, May 2023, June 2023, July, August 2023, September 2023, and October 2023, November 2023.)

Review of the facility's January 2024 COVID-19 line listing report indicated the facility's last positive was on 1/6/24.

During an interview on 2/7/24, at 11:58 a.m. Infection Preventionist, Employee E41, confirmed the facility failed to provide evidence COVID-19 testing and surveillance was completed after 1/6/24.

During an interview on 2/7/24, at 1:51 p.m. the Director of Nursing confirmed that the facility was unable to locate and provide documentation to indicate that surveillance for tracking infections was performed during (March 2023, April 2023, May 2023, June 2023, July, August 2023, September 2023, and October 2023, November 2023, and January 2024).

Review of the facility's Water Management Program Binder failed to include documentation that describes the facility's water system and plan for reducing the risk of legionellosis and other opportunistic pathogens.

During an interview on 2/8/24, at 1:37 p.m. the Nursing Home Administrator confirmed the facility failed to conduct an assessment to identify where Legionella and other opportunistic waterborne pathogens could grow and spread, and implement measures to prevent growth.

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: 04/04/2024

1. Infection Control program and water management program to be completed and implemented.
2. Residents R9 and R18 have had no residual effects of the dressing changes from potential cross contamination.
3. RDO will educate NHA and DON on regulations requiring an Infection Control Program to be implemented and meetings completed quarterly.
4. RDO will educate NHA and DON on regulations requiring a facility water management program that included a system of surveillance to identify possible communicable diseases and an active water management plan for reducing the risk of legionellosis and other opportunistic pathogens.
5. The DON or designee will educate all licensed nurses on dressing change policy and procedures to prevent the potential for cross contamination.
6. The DON or designee will complete a dressing change observation daily x 5 days, weekly x3 weeks and monthly x2 months.
7. The DON or designee will complete audits for facility infection tracking and to ensure the infection prevention program is in place weekly x 4 weeks and monthly x2 months.
8. The NHA will complete facility audit for water management program monthly x 3 months to ensure program is in place.
9. Results of audits will be reviewed by QAPI committee for further review and recommendations.

483.10(c)(6)(8)(g)(12)(i)-(v) REQUIREMENT Request/Refuse/Dscntnue Trmnt;Formlte Adv Dir: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)(6) The right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.

§483.10(c)(8) Nothing in this paragraph should be construed as the right of the resident to receive the provision of medical treatment or medical services deemed medically unnecessary or inappropriate.

§483.10(g)(12) The facility must comply with the requirements specified in 42 CFR part 489, subpart I (Advance Directives).
(i) These requirements include provisions to inform and provide written information to all adult residents concerning the right to accept or refuse medical or surgical treatment and, at the resident's option, formulate an advance directive.
(ii) This includes a written description of the facility's policies to implement advance directives and applicable State law.
(iii) Facilities are permitted to contract with other entities to furnish this information but are still legally responsible for ensuring that the requirements of this section are met.
(iv) If an adult individual is incapacitated at the time of admission and is unable to receive information or articulate whether or not he or she has executed an advance directive, the facility may give advance directive information to the individual's resident representative in accordance with State law.
(v) The facility is not relieved of its obligation to provide this information to the individual once he or she is able to receive such information. Follow-up procedures must be in place to provide the information to the individual directly at the appropriate time.
Observations:
Based on review of the facility policy, clinical records, and staff interviews it was determined that the facility failed to provide the opportunity to formulate an advance directive (written instructions such as a living will or durable power of attorney for health care for when the individual is incapacitated) for seven of the 12 residents reviewed (Resident R76, R93, R104, R106, R111, R265, R266).

Findings Include:

A review of the facility policy "Advanced Directives" reviewed 10/1/22 and 10/1/22, indicated the facility will comply with the requirements related to maintaining written policies and procedures regarding advance directives, including provisions to inform and provide written information to all adult residents concerning the right to accept or refuse medical or surgical treatment and formulate an advance directive.

A review of the clinical record indicated Resident R76 was admitted to the facility on 10/20/2023, with diagnoses that include diabetes, broken lower leg, and high blood pressure.

A review of the clinical record failed to reveal an advance directive or documentation that Resident R76 was given the opportunity to formulate an Advanced Directive.

A review of the clinical record indicated Resident R93 was admitted to the facility on 12/8/2023, with diagnoses that include diabetes, and seizures (sudden, uncontrolled electrical disturbance in the brain which can cause changes in behavior, movements, feelings, and consciousness).

A review of the clinical record failed to reveal an advance directive or documentation that Resident R93 was given the opportunity to formulate an Advanced Directive.

A review of the clinical record indicated Resident R104 was admitted to the facility on 2/8/2023, with diagnoses that include tracheostomy (a medical procedure that involves creating an opening in the neck in order to place a tube into a person ' s trachea, or windpipe), diabetes and high blood pressure.

A review of the clinical record failed to reveal an advance directive or documentation that Resident R104 was given the opportunity to formulate an Advanced Directive.

A review of the clinical record indicated Resident R106 was admitted to the facility on 10/17/2023, with diagnoses that include high blood pressure, blood clots in lungs, and acute pain.

A review of the clinical record failed to reveal an advance directive or documentation that Resident R106 was given the opportunity to formulate an Advanced Directive.

A review of the clinical record indicated Resident R111 was admitted to the facility on 1/13/2024, with diagnoses that include diabetes, and high blood pressure.

A review of the clinical record failed to reveal an advance directive or documentation that Resident R111 was given the opportunity to formulate an Advanced Directive.

A review of the clinical record indicated Resident R265 was admitted to the facility on 10/14/2023, with diagnoses that include stroke (an interruption of the blood flow within your brain that causes the death of brain cells), diabetes and high blood pressure.

A review of the clinical record failed to reveal an advance directive or documentation that Resident R265 was given the opportunity to formulate an Advanced Directive.

A review of the clinical record indicated Resident R266 was readmitted to the facility on 1/18/2024, with diagnoses that include End stage renal disease (when the kidneys permanently fail to work), diabetes, dementia (loss of thinking, remembering, and reasoning to such an extent that it interferes with a person's daily life and activities).

A review of the clinical record failed to reveal an advance directive or documentation that Resident R266 was given the opportunity to formulate an Advanced Directive.

During an interview on 2/7/2024, at 11:30 a.m. Social Worker Employee E3 confirmed that the clinical record did not include documentation that Resident R76, R93, R104, R106, R111, R265, and R266, were afforded the opportunity to formulate Advance Directives.



 Plan of Correction - To be completed: 04/04/2024

1. Residents R76, R93, R104, R106, R111, R265, R266 will be offered the opportunity to complete an Advanced Directive.
2. Residents in the facility will be reviewed to ensure an advanced directive is in place or have been offered to complete one by social services/designee.
3. The facility social services and licensed nurses will be educated on the Advanced Directives policy and federal requirements to have the opportunity to complete an advance directive.
4. Audits will be completed by the SSD/Designee weekly x 4 then monthly x 2 months, of all new admissions to ensure residents are provided the opportunity to complete advanced directives.
5. Audit results will be reviewed through the monthly QAPI process/meeting.

483.95(e) REQUIREMENT Infection Control Training: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.
§483.95(e) Infection control.
A facility must include as part of its infection prevention and control program mandatory training that includes the written standards, policies, and procedures for the program as described at §483.80(a)(2).
Observations:

Based on review of facility policy and documents, and staff interview, it was determined that the facility failed to provide training on Infection Control for four of nine staff members (Employees E12, E6, E16, and E17).

Findings include:

Review of the policy "Inservice Training" dated 10/2/23, indicated it is the policy of this facility to develop, implement, and maintain an effective training program for all new and existing staff, individuals providing services under a contractual arrangement, and volunteers, consistent with their expected roles.

Review of the "Facility Assessment" updated 12/28/23, indicated the training program content at a minimum included "Infection Control."

Review of facility provided documents and training record for E12, E6, E16, and E17 revealed the following staff members did not have documented training on Infection Control.

Nurse Aide (NA) Employee E12 had a hire date of 1/12/13, failed to have Infection Control in-service education between 11/12/22, and 11/12/23.
Licensed Practical Nurse (LPN) Employee E6 had a hire date of 10/5/21, failed to have Infection Control in-service education between 10/5/22, and 10/5/23.
Licensed Practical Nurse (LPN) Employee E16 had a hire date of 1/1/00, failed to have Infection Control in-service education between 1/1/23, and 1/1/24.
Therapy Employee E17 had a hire date of 11/11/21, failed to have Infection Control in-service education between 11/11/22, and 11/11/23.

During an interview on 2/7/24, at approximately 12:40 p.m. the Nursing Home Administrator confirmed that the facility failed to provide training on Infection Control for four of nine staff members.

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

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

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


 Plan of Correction - To be completed: 04/04/2024

1. Infection Control training to be provided to employees E12, E6, E16 and E17.
2. A whole house audit completed to confirm all staff have completed Infection Control Training.
3. A monthly audit will occur by HR Director/ designee monthly to assure completion of the continuing education program for all new hires.
4. Findings from the audits will be presented at the quarterly QAPI meeting for review and recommendations.

483.95(c)(1)-(3) REQUIREMENT Abuse, Neglect, and Exploitation Training: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.
§483.95(c) Abuse, neglect, and exploitation.
In addition to the freedom from abuse, neglect, and exploitation requirements in § 483.12, facilities must also provide training to their staff that at a minimum educates staff on-

§483.95(c)(1) Activities that constitute abuse, neglect, exploitation, and misappropriation of resident property as set forth at § 483.12.

§483.95(c)(2) Procedures for reporting incidents of abuse, neglect, exploitation, or the misappropriation of resident property

§483.95(c)(3) Dementia management and resident abuse prevention.
Observations:

Based on review of facility policy and documents, and staff interview, it was determined that the facility failed to provide training on Abuse, Neglect, and Exploitation for four of nine staff members (Employees E12, E6, E16, and E17).

Findings include:

Review of the policy "Inservice Training" dated 10/2/22, indicated it is the policy of this facility to develop, implement, and maintain an effective training program for all new and existing staff, individuals providing services under a contractual arrangement, and volunteers, consistent with their expected roles.

Review of the "Facility Assessment" updated 12/28/23, indicated the training program content at a minimum included "Abuse, Neglect, and Exploitation."

Review of facility provided documents and training record for E12, E6, E16, and E17 revealed the following staff members did not have documented training on Abuse, Neglect, and Exploitation.

Nurse Aide (NA) Employee E12 had a hire date of 1/12/13, failed to have Abuse, Neglect, and Exploitation in-service education between 11/12/22, and 11/12/23.
Licensed Practical Nurse (LPN) Employee E6 had a hire date of 10/5/21, failed to have Abuse, Neglect, and Exploitation in-service education between 10/5/22, and 10/5/23.
Licensed Practical Nurse (LPN) Employee E16 had a hire date of 1/1/00, failed to have Abuse, Neglect, and Exploitation in-service education between 1/1/23, and 1/1/24.
Therapy Employee E17 had a hire date of 11/11/21, failed to have Abuse, Neglect, and Exploitation in-service education between 11/11/22, and 11/11/23.

During an interview on 2/7/24, at approximately 12:40 p.m. the Nursing Home Administrator confirmed that the facility failed to provide training on Abuse, Neglect, and Exploitation for four of nine staff members.

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

28 Pa Code: 201.18 (b)(1) Management.
28 Pa Code: 201.20 (a)(c) Staff development.


 Plan of Correction - To be completed: 04/04/2024

1. Abuse, Neglect, and Exploitation Training to be provided to employees E2, E4, E5, E6, E8 and E9.
2. A whole house audit completed to confirm all staff have completed abuse training.
3. A monthly audit will occur by HR Director/ designee monthly to assure completion of the continuing Abuse, Neglect, and Exploitation Training education program.
4. Findings from the audits will be presented at the quarterly QAPI meeting for review and recommendations.

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 manufacturer ' s guidelines, observations, and staff interview, it was determined that the facility failed to make certain that medications and medication supplies were properly stored and/or disposed of in one of three medication rooms (Fifth-floor medication room).

Findings include:

Review of the facility policy "Medication Storage" dated 10/2/23, indicated the facility will ensure all medications housed on our premises will be stored in the pharmacy and/or medication rooms according to the manufacturer's recommendations.

During an observation of the Fifth-floor medication room on 2/5/24, at 1:10 p.m. revealed the following"
-(5) DeClogger (g/j tube declogger tool) with an expiration date of 1/31/23
-(1) Needle with an expiration date 7/31/23.
-(54) Syringes with an expiration date 5/1/23.
-(87) Syringes with an expiration date 3/13/23.
-(1) IV Administration set (tubing for infusing intravenous fluids) with an expiration date 5/15/23.
-(74) Tuberculosis syringes with needle with an expiration date 7/11/21.
-(51) Safety syringes with an expiration date 10/30/23.
-(1) pair of sterile gloves, not in packaging.
-(2) colostomy bags not in packaging.
- IV tubing not in packaging.
-(12) hemorrhoidal suppositories with an expiration date of 01/2023.

During an interview on 2/5/24, at 1:30 p.m., LPN Employee E10 confirmed the above observation.

During an interview on 2/12/24, at approximately 1:00 p.m. the Nursing Home Administrator confirmed that the facility failed to make certain that medications were properly stored in one of three medication rooms.

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

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

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

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


 Plan of Correction - To be completed: 04/04/2024

1. Expired medication was disposed of.
2. Facility medications, supply rooms and treatment carts will be audited for proper disposal of expired medications and supplies.
3. DON or Designee to educate nurses on proper storage of medication policy, including disposing of expired supplies.
4. DON or Designee to audit for expired products, 1 treatment cart and 2 supply areas daily x5 days, weekly x3 weeks and monthly x2 months.
5. Audit results will be reviewed through the monthly QAPI process/meeting.

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

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

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

§483.45(c)(5) The facility must develop and maintain policies and procedures for the monthly drug regimen review that include, but are not limited to, time frames for the different steps in the process and steps the pharmacist must take when he or she identifies an irregularity that requires urgent action to protect the resident.
Observations:
Based on review of the clinical records and staff interview, it was determined that the facility failed to provide documentation that medication regimen reviews were completed for three of five residents (Resident R82, R15, and R26).

Findings include:

During the survey, pharmacy completed medication regimen reviews were requested from the facility for Residents R82, R15, and R26.

During an interview on 2/9/24, at 11:54 a.m. the Director of Nursing confirmed that the facility changed pharmacy providers, and was unable to produce any recommendations prior to December 2023.

During an interview on 2/12/24, at approximately 1:00 p.m. the Nursing Home Administrator confirmed that the facility failed to provide documentation of medication regimen reviews for three of five residents.


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


 Plan of Correction - To be completed: 04/04/2024

1. Facility is unable to retroactively correct concern of drug regimen reviews being completed prior to December 2023. Drug regimen review completed on cited residents.
2. Pharmacy completes monthly drug regimen reviews for residents.
3. The NHA will educate the DON on the medication regimen review process and proper storage of medication regimen review documents. NHA will educate pharmacist on medication regimen review process.
4. The NHA will audit medication regimen reviews for completion and addressed by MD as needed and filed monthly x 3 months.
5. Audit results will be reviewed through the monthly QAPI process/meeting.

483.35(a)(1)(2) REQUIREMENT Sufficient Nursing Staff: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.
§483.35(a) Sufficient Staff.
The facility must have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment required at §483.70(e).

§483.35(a)(1) The facility must provide services by sufficient numbers of each of the following types of personnel on a 24-hour basis to provide nursing care to all residents in accordance with resident care plans:
(i) Except when waived under paragraph (e) of this section, licensed nurses; and
(ii) Other nursing personnel, including but not limited to nurse aides.

§483.35(a)(2) Except when waived under paragraph (e) of this section, the facility must designate a licensed nurse to serve as a charge nurse on each tour of duty.
Observations:
Based on review of facility policy, resident interviews, clinical record review, and confidential staff interviews, it was determined that the facility failed to have sufficient nursing staff to provide nursing and related services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of four of four residents (Resident R15, R26, R105, and R109).

Findings include:

Review of the facility policy "Medication Administration" last reviewed 10/1/22 and 10/2/23, indicated medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manor to prevent contamination or infection.

Review of the facility policy "Nursing Services and Sufficient Staff" last reviewed 10/1/22 and 10/2/23, indicated the facility will supply services by sufficient numbers of each of the following personnel types on a 24-hour basis to provide nursing care to all residents in accordance with resident care plans.

-Except when waived, licensed nurses; and
-Other nursing personnel, including but not limited to nurse aides.

Review of the facility policy "Provision of Quality Care" last reviewed 10/1/22 and 10/3/23, indicated each resident will be provided care and services to attain or maintain his/her highest practicable physical, mental, and psychosocial well-being.

Review of the facility policy "Offering/Serving Bedtime Snacks", last reviewed 10/1/22 and 10/2/23, indicated it is the practice of this facility to offer and serve residents with a nourishing snack in accordance with their needs, preferences and requests at bedtime on a daily basis.

The "Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual," which provides instructions and guidelines for completing required Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2019, indicated that a BIMS (Brief Interview of Mental Status) is a brief screener that aids in detecting cognitive impairment. Scores from a BIMS assessment suggests the following distributions:

13 - 15: cognitively intact
8 - 12: moderately impaired
0 - 7: severe impairment

Review of the clinical record indicated Resident R15 was admitted to the facility on 2/8/23, with diagnoses that included diabetes, high blood pressure, and depression.

Review of the MDS dated 1/15/24, indicated the diagnoses remain current. Further review of the MDS indicated Resident R15's BIMS score was a 15, indicating he is cognitively intact.

Review of the physician orders indicated Resident R15 was ordered:

On 2/8/23, Atorvastatin 40 mg, at bedtime (to help reduce cholesterol)
On 2/8/23, Montelukast Sodium 10mg, at bedtime (for allergies)
On 2/8/23, Pramipexole 0.75 mg, at bedtime (for restless leg syndrome- a condition characterized by a nearly irresistible urge to move the legs)
On 2/8/23, Quetiapine Fumarate 100mg at bedtime (for psychosis- a mental condition in which thought, and emotions are so affected that contact is lost with external reality)
On 2/8/23, Trazodone 200mg, at bedtime (for depression)
On 2/9/23, Cetirizine 5mg, once a day (for seasonal allergies)
On 2/9/23, Voltaren Gel, apply to both knees, 4 gm every day (for pain)
On 2/9/23, Menthol External Patch 5 %, remove patch that was placed on in the morning (for pain)
On 5/3/23, Zolpidem 10mg at bedtime (for insomnia-problems falling and staying asleep)
On 5/8/23, Senna 17.2 mg, a day (for constipation)
On 5/16/23, Lyrica 100mg, three times daily (for neuropathy-a condition of one or more peripheral nerves, causing numbness or weakness)
On 5/22/23, Lantus Insulin 43 units, every twelve hours (for diabetes)
On 5/22/23, Metformin 500mg, twice a day (for diabetes)
On 8/17/23, Give Diabetic snack at bedtime.

Review of Resident R15 ' s Medication Administration Record (MAR) indicated on 2/1/24, the above medications were not signed off, indicating they were not given.

Review of the care plan date 10/17/23, indicated to administer medications as ordered. Monitor/document for side effect and effectiveness.

During a resident interview on 2/6/24, at 11:05 a.m. Resident R15 stated, "I don't always get a bedtime snack," and "sometimes we don't have a nurse and I don't receive my medication."

Review of the clinical record indicated Resident R26 was admitted to the facility on 3/9/23, with diagnoses that included diabetes, high blood pressure, and depression.

Review of the MDS dated 11/13/23, revealed the diagnoses remain current and indicated Resident R26's BIMS score was blank, however resident was able to answer questions appropriately.

Review of the physician orders indicated Resident R26 was ordered:

On 3/9/23, Divalproex sodium 1000 mg, at bedtime (for mood disorder).
On 3/9/23, Risperidone 3 mg, at bedtime (for psychosis)
On 3/9/23, Benztropine Mesylate 0.5mg, two times a day (an anti-tremor medication).
On 3/9/23, Gemfibrozil 600 mg two times a day (for prevention of high cholesterol).
On 3/10/23, Give diabetic snack at bedtime.
On 11/6/23, Voltaren Gel 1%, 2 gm, to lower back two times a day.
On 1/17/24, Buspirone 7.5 mg, three times a day (for anxiety).
On 1/30/24, Gabapentin 500mg, three times a day (for neuropathy).

Review of Resident R26's Medication Administration Record (MAR) indicated on 2/1/24, the above medications were not signed off, indicating they were not given.

Review of the care plan date 11/30/23, indicated to administer medications as ordered. Monitor/document for side effect and effectiveness.

During a resident interview on 2/5/24, at 10:52 a.m. Resident R26 stated she sometimes gets her medications and diabetic snacks.

Review of the clinical record indicated Resident R105's was admitted to facility on 1/9/24, with diagnoses that included diabetes, stoke (necrotic tissue in the brain resulting loss of blood and oxygen to the brain), and dementia (a group of symptoms that affects memory, thinking and interferes with daily life).

Review of the MDS dated 1/16/24, revealed the diagnoses remain current and indicated a BIMS score of 5, indicating severe impairment.
Review of the physician orders indicated Resident R105 was ordered:

On 1/9/24, Atorvastatin 80 mg, at bedtime
On 1/9/24, Give diabetic snack at bedtime.
On 1/9/24, Lantus 10 units, at bedtime
On 1/9/24, Carvedilol 25mg, twice a day (for high blood pressure)
On 1/9/24, Gabapentin 300mg, twice a day
On 1/9/24, Hydralazine 100mg, three times a day (for high blood pressure)

Review of Resident R105 ' s Medication Administration Record (MAR) indicated on 2/1/24, the above medications were not signed off, indicating they were not given.

Review of the care plan date 1/11/24, indicated to administer medications as ordered. Monitor/document for side effect and effectiveness.

During a resident interview on 2/5/24, at 10:52 a.m. Resident R105 was not able to answer question appropriately when asked if she was given her medication or diabetic snacks.

Review of the clinical record indicated Resident R109 was admitted to the facility on 1/15/24, with diagnoses that included stroke cancer and high blood pressure.

Review of the MDS dated 1/15/24, indicated the diagnoses remain current. Further review of the MDS revealed BIMS score was an eleven, indicating she is moderately cognitively impaired.

Review of the physician orders indicated Resident R109 was ordered:

On 1/15/24, Aricept 5mg, at bedtime (for dementia)
On 1/15/24, Olanzapine 10mg, at bedtime (for bipolar disorder-a disorder associated with mood swings ranging from depressive lows to manic highs)
On 1/15/24, Senna 17.2 mg, at bedtime
On 1/15/24, Aspirin 81 mg, twice a day
On 1/15/24, Buspirone 15 mg, twice a day (for anxiety disorder)
On 1/15/24, Lamotrigine 50mg, twice a day (for bipolar disorder)
On 1/15/24, Tylenol 1000 mg three times daily (for pain)
On 1/15/24, Bupropion 75 mg, four times a day (for depression)

Review of Resident R109 ' s Medication Administration Record (MAR) indicated on 2/1/24, the above medications were not signed off, indicating they were not given.

Review of the care plan date 1/18/24, indicated to administer medications as ordered. Monitor/document for side effect and effectiveness.

During a resident interview on 2/5/24, at 10:52 a.m. Resident R109 stated he was unsure if he received all of his medications.

Review of facility deployment staffing sheet for a 24-hour period for 2/1/24, failed to indicate a licensed nursing staff on floor 6 on 3-11 shift.

During an interview on 2/12/24, at 9:27 a.m. with the Scheduling Coordinator Employee E42 confirmed the deployment staffing sheets for 2/1/24 was correct.

During an interview on 2/12/24, at 1:30 p.m. the Director of Nursing (DON) confirmed that the facility failed to have sufficient nursing staff to provide nursing and related services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for Residents R15, R26, R105, and R109.


28 Pa. Code: 201.29(j) Resident rights.

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

28 Pa. Code: 211.12(d)(1)(2)(3)(4) Nursing services.


 Plan of Correction - To be completed: 04/04/2024

1. Resident R15 had no negative outcomes from missed medication. Resident R26 had no negative outcomes from not receiving medication or diabetic snacks on occasion. Resident R105 had no negative outcomes. Resident R109 had no negative outcomes. Family/Physician notified of missed medications.
2. The facility is offering hiring incentives such as sign-on bonuses, referral bonuses for current staff, and recently increased registered nurse wages. Daily staffing meetings are held to confirm sufficient staffing. On-call rotation and pick up shifts posted.
3. The NHA/designee will educate the scheduling coordinator and DON on sufficient nurse staffing.
4. Licensed staff will be educated on timely medication administration/documentation/notification of appropriate parties.
5. A staffing audit will be completed by the scheduling coordinator or designee weekly x 3 weeks and monthly x 2 months.
6. The results of the audit will be reviewed through the monthly QAPI process/meeting.

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 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(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 review of national accepted guidelines for pressure ulcers, and staff interview, it was determined that the facility failed to provide prescribed treatment and services related to the care of pressure ulcers for two of five residents (Resident R6 and R50).

Findings include:

Review of the facility policy, "Pressure Injury Surveillance" dated 10/2/23, indicated a system of surveillance is utilized for preventing, identifying, reporting, and investigating any new or worsened pressure injuries in the facility.

Review of the facility policy, "Wound Treatment Management" dated 10/2/23, indicated wound treatments will be provided in accordance with physician orders, including the cleansing method, type of dressing, and frequency of dressing changes.

Review of the clinical record indicated Resident R6 was admitted to the facility on 1/9/13.

Review of the Minimum Data Set (MDS - periodic assessment of care needs) dated 1/11/24, included the diagnoses of diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time) and heart failure (a progressive heart disease that affects pumping action of the heart muscles), and hemiplegia (paralysis of one side of body). Review of Section M: Skin Conditions, indicated Resident R6 had one Stage 3 pressure ulcer (full-thickness skin and tissue loss).

Review of a physician's order dated 11/21/23, indicated to cleanse left lateral leg with Dakin 1/4 strength (wound cleanser used to prevent and treat skin and tissue infections), apply collagen (a type of protein-based dressing) to wound base, pack moistened gauze with Dakin's 1/4 strength with super absorbent dressing one time a day for Stage 3 pressure ulcer.

Review of a physician's order dated 12/6/23, indicated weekly skin checks must be completed by a licensed nurse every Monday on the 3 p.m. to 11 p.m. shift.

Review Resident R6's care plan dated 12/25/23, indicated to administer treatments as ordered. If resident refuses treatment, confer with the resident interdisciplinary team and family to determine why and try alternative methods to gain compliance and document alternative methods.

Review of Resident R6's clinical record failed include weekly skin assessment as ordered from 1/7/24, through 1/13/24, and 1/28/24, through 2/3/24.

Review of Resident R6's TAR for January 2024 indicated the following missing documentation:
1/2/24: Resident refused, no documentation of alternative methods attempted to gain compliance.
1/5/24: No documentation of treatment being completed, left blank.
1/7/24: Progress note stated resident "kept yelling out at me. didn't want me to do it at this time. will try again if i have time this shift. re-educated on the importance of wound care and infection." No follow-up documentation.
1/9/24: No documentation of treatment being completed, left blank.
1/12/24: No documentation of treatment being completed, left blank.
1/15/24: No documentation of treatment being completed, left blank.
1/22/24: Progress note stated "sleeping to late in shift he stated just got to this side of hall." No follow-up documentation.
1/26/24: No documentation of treatment being completed, left blank.
1/28/24: Resident refused, no documentation of alternative methods attempted to gain compliance.

During an interview on 2/9/24, at 10:20 a.m. the Director of Nursing confirmed the facility failed to provide weekly skin assessments and 10 of 31 treatments as ordered for Resident R6.

Review of the clinical record indicated Resident R50 was admitted to the facility on 9/14/23.

Review of the Minimum Data Set (MDS - periodic assessment of care needs) dated 12/21/23, included the diagnoses of diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time) and heart failure (a progressive heart disease that affects pumping action of the heart muscles). Review of Section M: Skin Conditions, indicated Resident R50 had one unstageable pressure ulcers (full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar).

Review Resident R50's care plan for skin impairment, updated 1/4/24, indicated that Resident R50 had a Stage II pressure ulcer (partial-thickness skin loss with exposed middle layer of skin), with an intervention of administering wound treatments as ordered.

Review of a progress note dated 1/4/24, at 4:54 p.m. indicated "It was reported that resident had new area on buttocks. resident seen by Wound Care NP. resident has S2PI (Stage II pressure injury) on left buttocks. measures 3.5 x 4 cm (centimeters). no drainage. no c/o pain."

Review of Resident R50's TAR for January 2023 indicated the following missing documentation:
1/1/24: No documentation of treatment being completed, left blank.
1/2/24: No documentation of treatment being completed, left blank.
1/3/24: No documentation of treatment being completed, left blank.
1/4/24: No documentation of treatment being completed, left blank.
1/8/24: No documentation of treatment being completed, left blank.
1/9/24: No documentation of treatment being completed, left blank.
1/11/24: Indicated completed by prior nurse. No documentation of prior nurse completing.
1/18/24: No documentation of treatment being completed, left blank.
1/20/24: No documentation of treatment being completed, left blank.
1/21/24: No documentation of treatment being completed, left blank.
1/24/24: Indicated completed by prior nurse. No documentation of prior nurse completing.
1/27/24: Indicated "Passed meds only on South Cart."
1/29/24: No documentation of treatment being completed, left blank.
1/30/24: No documentation of treatment being completed, left blank.

During an interview on 2/12/23, at approximately 1:00 p.m. the Nursing Home Administrator and confirmed the facility failed to provide prescribed treatment and services related to the care of pressure ulcers for two of five residents.

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


 Plan of Correction - To be completed: 04/04/2024

1. Facility is unable to retroactively correct concern of physicians not being notified of missed treatments and assessments. Resident R6 and R50 wounds were evaluated and had no negative outcomes.
2. Residents with wounds were evaluated by the wound nurse to identify any missing treatment and services to residents and physician was notified of same.
3. Licensed staff will be educated by the DON/designee on the facility "Pressure Injury Surveillance" and "Wound Treatment Management" policies.
4. The DON/Designee with audit all wounds for assessment and treatments as ordered daily x5 days, weekly x 3 weeks and monthly x 2 months.
5. Audit results will be reviewed through the monthly QAPI process/meeting.

483.25 REQUIREMENT Quality of Care: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 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 and failed to assess residents for hyperglycemia (high blood glucose) and hypoglycemia (low blood glucose), for five of eight residents reviewed (Residents R26, R59, R105, R111, and R265), and the facility failed to accurately assess one resident resulting in harm by hospitalization for hypoglycemia for one of five residents (Resident R59).

Findings include:

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 the facility policy "Blood Glucose Monitoring" reviewed 10/2/23, indicated the facility will perform blood glucose monitoring as per physician ' s orders. Report critical test results to the physician timely. Document the procedure.

Review of the facility policy "Notification of Change" last reviewed 10/2/23, indicated the facility must inform the resident, consult with the resident ' s physician and/or notify the resident ' s family member or legal representative when there is a change requiring such notification. Circumstances requiring notification include accidents resulting in injury or potential to require physician intervention, significant change in the resident ' s physical, mental, or psychosocial condition such as deterioration in health, mental or psychosocial status including clinical complications, and circumstances that require a need to alter treatment including new treatment, discontinuation of current treatment due to acute conditions or exacerbation of a chronic condition.

Review of the facility policy "Documentation in the Medical Record" last reviewed 10/2/23, indicated each resident ' s medical record shall contain an accurate representation of the actual experiences of the resident and include enough information to provide a picture of the resident ' s progress through complete, accurate, and timely documentation.

Review of the facility policy "Provision of Quality Care" last reviewed 10/2/23, indicated based on comprehensive assessments, the facility will ensure that residents receive treatment and care by qualified persons in accordance with professional standards of practice, the comprehensive person-centered care plans, and the residents ' choice.

Review of the facility policy "Accidents and Supervision" last reviewed 10/2/23, indicated the facility shall establish and utilize a systematic approach to address resident risk and environmental hazards to minimize the likelihood of accidents. Various sources provide information about hazards and risk factors for each resident and may include environmental rounds, medical history, physical exam, and individual observation.

Review of the facility policy "Hypoglycemia Management" last reviewed 10/2/23, indicated effective management of hypoglycemia is important to ensure that the resident does not have further decline in their condition. The facility will identify residents that are at risk for hypoglycemia and observe them for signs and symptoms of low blood glucose. A bedside blood glucose test should be bedside blood glucose test should be administered for any resident reporting or experiencing symptoms of hypoglycemia such as: shakiness, nervousness or anxiousness, sweating, chills or clammy skin, fast heartbeat, irritability , confusion, dizziness or lightheadedness, hunger, nausea, pallor, feeling sleepy, weakness or having no energy, blurred or impaired vision, tingling or numbness in the lips, tongue or cheeks, headaches, coordination problems, and/or seizures. If the blood glucose reading is 70 mg/dL or below, the nurse will utilize the hypoglycemic protocol as per the practitioner ' s orders, with follow up blood glucose's as indicated, and notify the practitioner of the results as ordered. Nursing will continue to follow up and observe for any further hypoglycemic episodes post treatment and notify the practitioner of any changes. The blood sugar(s) and treatment will be documented as per facility protocol (e.g., resident chart, MAR, eMAR, etc.).

Review of the facility policy "Physician, Physician Assistant, Nurse Practitioner or Clinical Nurse Specialist Lab Notification" last reviewed 10/2/23, indicated the facility must promptly notify the attending physician, physician assistant, nurse practitioner, or clinical nurse specialist of labs that fall outside of clinical reference range in accordance with facility policies and procedures for notification of a practitioner or per ordering physician ' s orders. If the order does not include a parameter, it will be considered "non-immediate" unless clinical judgement and/or resident condition indicate otherwise. In this case, the result will be considered to be "immediate". Example of "immediate Notification" include a CBG with meals and at bedtime, notify if less than 70 or greater than 300. For immediate notifications document notification and result of condition.

Review of the clinical record indicated Resident R26 was admitted to the facility on 3/9/23, with diagnoses that included diabetes, high blood pressure, and depression.

Review of Resident R26' s Minimum Data Set (MDS - a mandated assessment of a resident's abilities and care needs) dated 11/13/23, indicated the diagnoses remain current.

Review of a physician ' s order dated 2/3/24, indicated to inject Humalog (fast-acting insulin that starts to work about 15 minutes after injection, peaks in about 1 hour, and keeps working for 2 to 4 hours) insulin per sliding scale, if blood glucose is greater than 341 give 12 units and call the doctor.

Review of the clinical record electronic Medication Administration Record (eMAR) revealed that the resident's CBG's were as follows:

On 2/6/24, at 11:36 a.m. the CBG was noted to be 372.

Review of Resident's eMAR and clinical progress notes indicated the resident was not assessed for hyperglycemia, the blood glucose was not monitored for effectiveness of treatment, failed to follow interventions of the care plan, and the physician was not notified of abnormal results on the above listed dates.

Review of the care plan dated 3/9/23, indicated diabetes medications as ordered by doctor. Monitor/document for side effects and effectiveness. Monitor/document/report to MD as needed signs and symptoms of hyper-/hypoglycemia.

Review of a clinical record indicated Resident R59 was re-admitted to the facility on 1/7/22, with diagnoses that included diabetes, depression, and migraines.

Review of the MDS dated 11/15/23, indicated the diagnoses remain current.

Review of physician ' s orders dated 9/22/23 through 1/30/24, indicated to check blood sugar with meals. Further review revealed a physician order dated 11/10/23 through 1/26/24, Accucheck without coverage two times a day was ordered. A physician order dated 11/25/23, indicated to give glargine (long-acting type of insulin that works slowly, over about 24 hours) insulin 42 units one time a day.

Review of Resident R59's eMAR revealed that the resident's CBG's were as follows:

On 11/18/23, at 07:52 a.m. CBG was noted to be 65.
On 11/18/23, at 12:24 p.m. CBG was noted to be 59.
On 12/30/23, at 9:54 a.m. CBG was noted to be 56.
On 1/13/24, at 12:25 p.m. CBG was noted to be 44.
On 1/18/23, at 9:47 a.m. CBG was noted to be 44.

A review of Resident R59's eMAR and clinical progress notes indicated the resident was not assessed for hypoglycemia, failed to follow interventions of the care plan, blood sugar was not rechecked, and the physician was not notified of abnormal results.

Review of a Palliative Care Note dated 1/24/24, indicated no reported concerns from staff.

Review of a progress note dated 1/29/24, at 7:59 a.m. revealed Resident R59 was ambulating in his room and fell striking the back of his head. Resident was transferred to the local emergency room.

Review of Resident R59 ' s hospital records dated 1/29/24, indicated the EMS reported a CBG of 40. He was admitted to the hospital for the fall and hypoglycemia. On arrival to the hospital, he received Dextrose 50% injection 50 mL via IV (intravenous) push. Resident R59 was discharged on 1/31/24, with new insulin orders of Lantus (long-acting type of insulin that works slowly, over about 24 hours) 21 units every morning, Lispro (fast-acting insulin that starts to work about 15 minutes after injection, peaks in about 1 hour, and keeps working for 2 to 4 hours) low dose per sliding scale, and glucagon (natural hormone your body makes that works with other hormones and bodily functions to control glucose) 1mg as needed for hypoglycemia.

A review of Resident R59's care plan dated 4/23/21, indicated to diabetic medication as ordered by doctor, Monitor/document for side effects and effectiveness. Fasting serum blood sugar as ordered by doctor. Report symptoms of hypoglycemia: sweating, tremor, confusion, lack of coordination, and/or staggered gait. Obtain and monitor lab/diagnostic work as ordered, report results to MD and follow up as indicated. Resident to have a bedtime snack.

Review of the clinical record indicated Resident R105 was admitted to the facility on 1/9/24, with diagnoses that included diabetes, dementia (group of symptoms affecting memory, thinking and social abilities), and cerebral infarction (stroke - results in an area of necrotic tissue in the brain, caused by disrupted blood supply and restricted oxygen supply).

Review of physician orders dated 1/9/24, indicated to give Humalog insulin per sliding scale, if blood glucose is greater than 341, give 6 units and call the MD.

Review of the clinical record electronic Medication Administration Record (eMAR) revealed that the resident's CBG's were as follows:

On 1/18/24, at 6:47 p.m. CBG was noted to be 361.
On 1/20/24, at 12:41 p.m. CBG was noted to be 415.
On 1/20/24, at 7:06 p.m. CBG was noted to be 444.
On 1/26/24, at 12:55 p.m. CBG was noted to be 442.
On 1/31/24, at 5:19 p.m. CBG was noted to be 416.
On 2/5/24, at 1:29 p.m. CBG was noted to be 342.

Review of Resident R105's eMAR and clinical progress notes indicated the resident was not assessed for hyperglycemia, the blood glucose was not monitored for effectiveness of treatment, failed to follow interventions of the care plan, and the physician was not notified of abnormal results on the above listed dates.

Review of the care plan dated 1/12/24, indicated to diabetic medications as ordered by doctor, monitor/document for side effects and effectiveness. Fasting serum blood sugar as ordered by doctor. Monitor/document/report to MD as needed for signs and symptoms of hyperglycemia.

Review of the clinical record indicated Resident R111 was admitted to the facility on 1/13/24, with diagnoses that included diabetes, obesity, and autistic disorder (a group of developmental disabilities that can cause significant social, communication and behavioral challenges).

Review of physician orders dated 1/18/24, indicated Accucheck two times a day for monitoring, and Lantus insulin 5 units in the evening.

Review of the clinical record electronic Medication Administration Record (eMAR) revealed that the resident's CBG's were as follows:

On 2/3/24, at 8:39 p.m. CBG was noted to be 445.

Review of Resident 111's eMAR and clinical progress notes indicated the resident was not assessed for hyperglycemia, the blood glucose was not monitored for effectiveness of treatment, and the physician was not notified of abnormal results on the above listed dates.

Review of the care plan dated 1/15/24, indicated to diabetes medication as ordered by doctor, monitor/document for side effects and effectiveness. Monitor/document/report to MD as needed for signs and symptoms of hyperglycemia.

Review of the clinical record indicated Resident R265 was admitted to the facility on 10/14/23, with diagnoses that included diabetes, cancer, and high blood pressure.

Review of Resident R265' s MDS dated 12/27/23, indicated the diagnoses remain current.

Review of a physician ' s order dated 10/13/23, indicated to give a cup of orange juice with five packs of sugar, repeat in 30 minutes. If blood glucose is less than 100 give another cup of orange juice, repeat blood glucose in 30 minutes. Give diabetic snack at bedtime. Glucose gel 15 grams by mouth as needed for hypoglycemia. Further review of a physician ' s order dated 10/14/23, indicated to give Humalog insulin per sliding scale, blood glucose less than 70 initiate hypoglycemic protocol and call MD, if blood glucose is greater than 401 give 12 units and call MD.

Review of the clinical record electronic Medication Administration Record (eMAR) revealed that the resident's CBG's were as follows:

On 11/3/23, at 4:54 p.m. CBG was noted to be 468.
On 11/22/23, at 5:19 p.m. CBG was noted to be 429.
On 12/7/23, at 8:13 a.m. CBG was noted to be 67.
On 12/8/23, at 4:07 p.m. CBG was noted to be 403.
On 12/14/23, at 10:17 a.m. CBG was noted to be 411.
On 12/15/23, at 4:00 p.m. CBG was noted to be 489.
On 1/20/24, at 9:04 a.m. CBG was noted to be 54.
On 2/3/24, at 4:52 p.m. CBG was noted to be 573.

Review of Resident's eMAR and clinical progress notes indicated the resident was not assessed for hypo-/hyperglycemia, the blood glucose was not monitored for effectiveness of treatment, failed to follow interventions of the care plan, and the physician was not notified of abnormal results on the above listed dates.

Review of the care plan dated 10/18/23, indicated to monitor/document/report to MD as needed signs and symptoms of hyper-/hypoglycemia.

During an interview on 2/7/24, at 11:33 a.m. Licensed Practical Nurse (LPN) Employee E5 stated she would check the doctor ' s orders for parameters. If blood glucose was greater than 400, she would call the doctor, give ordered insulin, and recheck in 15-30 minutes. If blood glucose was less than 70, she would call the doctor, give orange juice or glucose gel, and recheck in 15-30 minutes. She would document the incident in MAR and progress notes

During an interview on 2/7/24, at 11:40 a.m. Registered Nurse (RN) Employee E6 stated for blood sugars over 400, they would check the parameters, give the baseline insulin, complete an assessment, and call the provider. If the blood sugar was less than 70 they would offer a snack, complete an assessment, call the doctor, and monitor the resident.

During an interview on 1/25/24, at 11:45 a.m. RN Employee E7 stated for blood sugars over 400, they would check the orders for parameters, give the ordered insulin, complete an assessment and call the doctor. If the blood sugar was less than 70, follow protocol, offer snack, complete assessment, and recheck in 15 minutes. They would document in the vital signs and progress notes.

During an interview on 2/7/24, at 11:50 a.m. LPN Employee E8 stated for blood sugars less than 70 they would give snack, notify the doctor and recheck in 15 minutes. For blood sugars over 300-500, they would give the ordered insulin, notify the doctor, and recheck in 30 minutes. They would document in the progress notes.

During an interview on 2/7/24, at 12:00 p.m. RN Employee E9 stated for blood glucose less than 100, she would check the doctor orders, alert the supervisor, and recheck in 15 minutes. For blood glucose greater that 300, they would alert the supervisor, call the doctor and family, and give the ordered insulin. They would document in incident in the MAR and progress notes.

During an interview on 2/7/24, at 2:45 p.m. the Director of Nursing confirmed the facility failed to notify the doctor of a change in condition related to blood glucose, failed to follow the care plan interventions, and failed to recheck blood sugars for Residents R26, R59, R105, R111, R265, and confirmed the facility failed accurately assess Resident R59 resulting in harm with Resident R59 going to the hospital.

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

28 Pa. Code 201.29(d) 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: 04/04/2024

1. Facility is unable to retroactively correct concern of physicians not being notified of abnormal CBG levels or assessed for abnormal levels for Residents R56, R26, R105, and Resident R265.
2. RN assessments on all listed residents completed with no ill effects noted. Director of Nursing reviewed the blood glucoses with the attending physicians for all listed residents.
3. The Director of Nursing or designee will educate licensed nurses on facility's policies "Physician, Physician Assistant, Nurse Practitioner or Clinical Nurse Specialist Lab Notification", "Documentation in the Medical Record", "Notification of Change" and "Blood Glucose Monitoring" policies.
4. The Director of Nursing or designee will audit to review CBG monitoring summaries for residents who require CBG testing and ensure resident assessment and physician notifications are made when an abnormal blood glucose level is recorded. These audits will be completed daily x 5 days, then weekly x 3 weeks and then monthly for 2 months.
5. Audit results will be reviewed through the monthly QAPI process/meeting.

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 record reviews, resident interview and observations, and staff interviews, it was determined that the facility failed to provide Activity of Daily Living (ADL) assistance for 11 of 32 residents (Resident R12, R13, R22, R33, R37, R42, R54, R57, R80, R98, and R108)

Findings Include:

Review of the facility policy "Activities of Daily Living (ADLs)" dated 10/2/23, indicated that the facility will provide care and services for the following activities of daily living:
-Bathing, dressing, grooming, and oral care.
-Transfer and Ambulation.
-Toileting.
-Eating to include meals and snacks.
-Using speech, language, or other functional communication systems.

Review of Resident R37's admission record indicated he was admitted to the facility on 5/2/19.

Review of the Minimum Data Set (MDS - periodic assessment of care needs) dated 11/8/23, included diagnoses of dementia (a group of symptoms that affects memory, thinking and interferes with daily life), chronic obstructive pulmonary disease (COPD, a group of progressive lung disorders characterized by increasing breathlessness), and muscle weakness. Review of Section GG - Functional Abilities and Goals indicated that Resident R37 required substantial/ maximal assistance with personal hygiene.

Review of a nurse practitioner's progress noted dated 1/5/24, at 12:15 p.m. revealed, "Nursing expressing concerns regarding left lower quadrant round skin tear currently undergoing dressing changes by wound care. Focused exam: round, approximately penny-sized wound over LLQ (left lower quadrant of the abdomen) with yellow discharge. No streaking, no swelling. VSS (vital signs stable). Wound appears to have the shape of the resident's long fingernails. Upon inspection of fingernails, fecal matter found inside long nails." "Will start doxycycline 100mg po BID x 5 (oral antibiotic medication taken by mouth, twice per day for five days) and will continue to monitor area. Ordered continued wound care and fingernail care per nursing policy."

Review of Resident R109's admission record indicated resident was admitted on 1/15/24.

Review of Resident R109's MDS assessment (Minimum Data Set Assessment: A periodic assessment of resident care needs) dated 1/22/24, indicated she was admitted with the following diagnoses, stroke (necrotic tissue in the brain resulting loss of blood and oxygen to the brain), cancer ( a disease caused by uncontrolled division of abnormal cells in a part of the body), hypertension (high blood pressure in the arteries).

During an interview and observation on 2/5/24, at 10:04 a.m. Resident R109 stated that she does not like to have chin hair and she "feels embarrassed". Resident R109 was noted to have a large amount of facial hair on her chin.

During an observation on 2/8/24, at 1:55 p.m. Resident R109 was resting in bed with a large amount of facial hair on her chin.

During an interview on 2/8/24, at 2:01 p.m. Licensed Practical Nurse (LPN) Employee E8 confirmed the facial hair.

During an observation on 2/5/24, at 1:30 p.m. Resident R80 was observed in bed greasy appearing, unkempt hair.

During an interview on 2/5/24, at 1:31 p.m. Resident R12 stated that sometimes she doesn't get showers, or they are delayed.

During an observation on 2/5/24, at 1:35 p.m. Resident R57 was observed in a soiled shirt, with a brown substance smeared on it.

During an observation on 2/5/24, at 1:36 p.m. Resident R98 was observed in bed. The bed linen appeared unclean.

During an observation on 2/5/24, at 1:47 p.m. Resident R42 was noted to have facial hair on her chin, in a gown.

During an observation on 2/5/24, at 1:50 p.m. Resident R33 was noted to have unkempt hair and long fingernails. His shoes were observed to be very dirty.

During an observation on 2/5/24, at 1:52 p.m. Resident R22 was noted to have long, jagged fingernails, with a brown substance under them. Resident R22 stated he would like his beard trimmed.

During an observation on 2/7/24, at 10:05 a.m. Resident R80 was observed in bed with a soiled brief.

During an observation on 2/7/24, at 10:22 a.m. Resident R13 was observed in bed with a food-soiled, red sweatshirt on. Resident R13 had been observed wearing this sweatshirt on 2/5/24, and 2/6/24.

During an observation on 2/12/24, at 10:48 a.m. Resident R54 was observed with long unkempt hair and beard. Resident R54 was noted to have long fingernails with a brown substance under them.

During an interview on 2/12/24, at approximately 1:00 p.m. the Nursing Home Administrator confirmed the facility failed to provide Activity of Daily Living assistance for 11 of 32 residents.

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)(4) (d)(1)(2)(3) Nursing services.

28 Pa. Code: 201.20 Staff development.


 Plan of Correction - To be completed: 04/04/2024

1. Resident R37's nails have been trimmed to an appropriate length and cleaned. Resident R37 has updated wound treatment orders. Resident R109's facial hair has been trimmed. Resident R80 has been bathed and had hair washed. R12 has been showered. R57's clothing has been changed. Resident R98's bed linens have been changed. Resident R42's facial hair has been trimmed. R33 Was offered a shower, fingernail cut and cleaning. Resident R22 was provided nail care and beard trimmed. R80's brief was changed promptly. R13 was offered a shower, clothing was changed and laundered. R54 is no longer a resident at the facility.
2. A whole house sweep was completed for nail care, hair care and clean linens.
3. Nursing staff will be educated on the facility's Activities of daily living policy and educated on personal cleanliness and documenting care in the EHR, as well as notifying the nurse if the resident refuses care.
4. Audits of personal care completion, including bathing, clothing change, nail and hair care, and linen cleanliness with documentation will be completed on 10% of residents daily x 5 days, weekly x 3 weeks, and monthly x 2 months.
5. Audit results will be reviewed through the monthly QAPI process/meeting.

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

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

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

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

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

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

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

§483.10(i)(7) For the maintenance of comfortable sound levels.
Observations:
Based on review of facility policy, observations, and staff interview, it was determined that the facility failed to maintain a clean, homelike environment for five of five nursing units (third, fourth, fifth, sixth, and seventh nursing units).

Findings include:

Review of the facility policy "Safe and Homelike Environment" last reviewed 10/1/22 and 10/2/23, indicated the facility will provide a safe, clean, comfortable, and homelike environment. Housekeeping and maintenance services will be provided as necessary to maintain a sanitary, orderly, and comfortable environment. The facility will provide and maintain bed and bath linens that are clean and in good condition. The facility will provide and maintain adequate and comfortable lighting levels in all areas. The facility will minimize odors by disposing of soiled linens promptly and reporting lingering odors and bathrooms needing cleaning to housekeeping department, and any furniture in disrepair to maintenance promptly.

Review of the facility policy "Resident Environmental Quality" last reviewed 10/1/22, and 10/2/23, indicated the facility shall provide sufficient space and equipment in dining, health services, recreation, and program areas to enable staff to provide residents with needed services.

Review of the facility policy "Cleaning and Disinfection of Resident-Care Equipment: last reviewed 10/1/22, and 10/2/23, indicated resident-care equipment can be a source of indirect transmission of pathogens. Reusable resident-care equipment will be cleaned and disinfected in accordance with current CDC recommendations in order to break the chain of infection.

During an observation of resident sixth floor nursing unit on 2/8/24, at 8:47 a.m. revealed mouse droppings in the cabinet over the sink in the sixth-floor dining room,

During an interview on 2/8/24, at 8:50 a.m. Nurse Aide (NA) Employee E4 confirmed the sixth-floor dining room is used by residents for meals.

During observations of the seventh-floor nursing unit on 2/8/24, between 10:25 a.m. and 11:40 a.m. the following was observed:

Room 709 - paper towels laying in toilet, strong smell of urine in the room.
Room 707 - dirty spoon on the bedside table, garbage can with used disposable gloves, used cups. B bed dresser missing pull handles on the dresser, dirty linens left rolled up on B bed.
Room 710 - dried brown substance on floor, floor dirty
Room 711 - outlet not attached to wall between beds, plastic clock on wall broken (plastic busted apart)
Room 712 - used empty urinal left on floor by B bed, candy papers on the floor, toilet dirty with brown substance, bathroom light over sink plastic is busted.
Room 733 - toilet with dried brown substance, garbage can full, empty yogurt containers visible, floor sticky, dried yellow-orange substance on floor by B bed.
Room 716 - resident belongings on bed, resident mail on the floor, resident soft-pro leg braces on dresser, used oxygen concentrator in room, B bed with wires showing on wall behind bed from over the bed light.
Room 716 - 717 shared bathroom with used urinal with brown sludge in the bottom
Room 717 - A bed dresser missing pull handles on two drawers
Room 715 - heating unit dismantled, missing the cover and knobs, night light has metal pulled away from the wall.
Room 714 - two sets of wheelchair legs, two wash basins three gallon size zipper storage bags with condiments, crackers, cookies, approximately 20 sugar packets, and an oxygen concentrator with humidifier dated 8/27/23.
Room 727 - A bed with dirty linens and blankets on bed, 11 mouse droppings observed on the blanket, heating unit dismantled, bathroom sink pipes dismantled, bathroom toilet with brown stains and multiple live and dead flies in the toilet. Water damage noted over window, baseboard moulding pulling away from the wall
Room 731 - Clean Utility Room - large garbage can full of empty gallon containers of juice and iced tea, packs of teddy graham and goldfish noted in drawers, open food noted in drawer with ant observed crawling across the drawer.

During observations of the sixth-floor nursing unit on 2/8/24, between 1:30 p.m. and 2:00 p.m. the following was observed:

Room 616 - walls dirty, baseboards dirty
Room 617 - floor in bathroom dirty
Room 618 - floor dirty, mouse trap behind door, plaster damage above window, ceiling tile missing in bathroom, mouse droppings in bathtub, heater vent dirty
Room 619 - heater vent dirty, dirty floor, ceiling with unfinished repair
Room 624 - metal night light cover pulled away from the wall
Room 614 - metal night light cover pulled away from the wall
Room 621 - metal night light cover pulled away from the wall
Room 620 - bathroom light without light cover
Room 638 - sixth-floor Resident Dining Room - Christmas decorations and Christmas tree stored in the corner of the room.

During observations of the fifth-floor nursing unit on 2/8/24, between 1:00 p.m. and 2:00 p.m. the following was observed:

Lounge has tub cleaner and bleach in resident accessible cabinets, in unsupervised lounge. The radiator appeared broken and soiled.
Kitchenette: Non-functioning icemaker has water pooling in the bottom.
Linen closet floor not clean.
Room - 524 Smells of urine;
Room - 522 soiled floor;
Room - 527W (Empty bed, Door occupied) Staff member lunch bag and personal items on dresser.
Room - 504 dust built up on vent,
Room - 512 Ceiling, bathroom wall, floor. Vent-filthy,
Room - 505 Filthy vent,
Room - 506- Tub dirty,
Room - 507 -floor, toilet, toilet paper, stool on toilet and seat
Room - 509 paper towel dispenser, dirty floors in bathroom ,
Room - 524-bed side table dirty, wall coloring on wall, dirty toilet seat in restroom , dirty mirrors,
Room - 523- dirty basin under window bed,
Room - 514 dirty wall in bathroom
Room - 522-dirty floor,
Room - 520- dirty walls, floors,
Room - 516-dirty walls
Room - 517-dirty floor in bathroom
Room - 518-dirty vent, dirty toilet, raised toilet seat, dirty paper towel dispenser, dirty sink dirty trashcan located in room
5th floor ice machine-build-up noted, not clean, dirty microwave,
Shower room, smells like urine, smells moldy, damage to ceiling tile
Hallway-dirty floors

During observations of the fourth-floor nursing unit on 2/8/24, between 1:15 p.m.- 2:15p.m. the following was observed:

Room 401 - Soiled baseboards, linens on floor, bathroom floor soiled, bedpan on bathroom floor;
Room 425 - soiled linen on floor;
Room 418 - Walls soiled, dirty linen on floor and chair, soiled privacy curtain and overbed table, dirty linens in bathroom and dirty sink.
Room 422 - open, dirty food containers. soiled mattress. BR - toilet seat soiled. bed pan on floor;
Room 414 - dirty floor and curtain. BR basins on floor, dirty floor, hole behind toilet;
Room 423 - no privacy curtains, baseboard/cove molding missing, toilet dirty.
Room 424 - Food in vent, dirty walls, gnats.
Room 417 - Dirty toilet and floor.
Room 419 - Dirty walls and floor;
Room 420 - Soiled curtains;
Room 415 - Visibly soiled light switches in room and bathroom;
Vending Area: door has hole in the bottom to outside, walls dirty, broken bedside table, garbage can lid on table, cobwebs in corner, black substance (possibly mold, will confirm) by vending machines,
Kitchenette: floors and countertops dirty
Dining Room: Dirty sink, missing cabinet door, baseboards dirty and coming away from wall, walls and windows soiled, brown ceiling tiles, refrigerator dirty. Chairs soiled.

During observations of the third-floor nursing unit on 2/8/24, between 12:30 p.m.- 1p.m. the following was observed:

Therapy Room - Refrigerator dirty on outside, food splashed on wall in kitchen, sink dirty, heater vent in therapy room dirty, bathroom floor dirty, bathtub dirty, window sills dirty, walls throughout damaged

Unit three hallway - garbage in hall way, brown ceiling tiles, doors dirty, floors dirty, walls dirty

During an Interview on 2/8/24, at 1:55 p.m. Licensed Practical Nurse (LPN) Employee E8 confirmed the concerns regarding the sixth-floor resident rooms and confirmed decorations should not be stored in the resident dining room.

During an interview on 2/9/24, at 11:00 a.m. the Nursing Home Administrator stated the seventh-floor nursing unit was last used in December 2023 for COVID positive residents and the seventh-floor nursing unit has not been cleaned since the residents were moved to other floors. The NHA confirmed the facility failed to maintain a clean, comfortable, homelike environment for five of five nursing units (third, fourth, fifth, sixth, and seventh nursing units).

28 Pa Code: 201.29 (k) Resident rights.

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




 Plan of Correction - To be completed: 04/04/2024

1. Facility will rectifying all listed concerns noted during survey.
2. The Nursing Home Administrator/Designee will complete a walk-through audit of resident areas to ensure a clean, home-like environment is provided to all residents.
3. The Regional Director of Operations/designee will educate the Nursing Home Administrator on the facility's "Safe and Homelike Environment", "Resident Environmental Quality", and "Cleaning and Disinfection of Resident-Care Equipment" policies. The NHA will educate all maintenance and housekeeping staff on the above policies. All staff will be educated on the procedure placing/communicating maintenance and housekeeping orders as needed.
4. The Nursing Home Administrator or designee will complete a walk-through audit of units daily x 5 days, then 2x/week for 3 weeks, and then monthly for two months to ensure the facility is providing a clean, home-like environment for residents.
5. Audit results will be reviewed through the monthly QAPI process/meeting.

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

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

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

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

Findings include:

A review of the facility policy "Grievance/Concern Resolution" reviewed 10/1/22 and 10/2/23, indicated the facility utilizes a grievance form to identify concerns and track via a monthly log.

During an observation on 2/8/24, at 8:42 a.m. revealed the grievance box and concern forms were not accessible due to two dining chairs placed in front of the grievance box and the grievance official information was not posted.

During an observation on 2/8/24, at 8:44 a.m. revealed the concern forms were not accessible by wheelchair, and the grievance official information was not posted.

During an observation on 2/8/24, at 8:47 a.m. revealed the concerns forms were not accessible by wheelchair. The grievance official information was posted in 10 font print, and not easily accessible to residents.

During an interview on 2/8/24, at 8:55 a.m. Social Worker Employee E3 confirmed the boxes were not at a level that was accessible to residents and visitors in a wheelchair, and the facility failed to post the grievance official contact information on the fourth, fifth, and sixth floor nursing units.


28 PA Code: 201.18(e)(4) Management.

28 PA Code: 201.29(a)(b)(c) Resident rights.


 Plan of Correction - To be completed: 04/04/2024

1. Grievance forms were placed, and official contact information postings were immediately updated at all grievance boxes on all floors upon identification by surveyor. Grievance boxes have been lowered on all units to make them accessible from a wheelchair.
2. Residents will be notified and reoriented to the grievance procedure, grievance official, grievance box accessibility and availability of forms at the next scheduled resident council meeting. Residents who do not attend resident council will be notified of the grievance procedure by DOSS or designee.
3. Education was provided to the Social Worker and Activities Director by NHA on ensuring forms are available, proper height of grievance boxes, and posting of the grievance official.
4. Audits will be completed by the NHA or designee weekly x 4 weeks, then monthly x 2 months to ensure boxes, postings and forms are available for resident use.
5. Audit results will be reviewed through the monthly QAPI process/meeting.
483.12(c)(2)-(4) REQUIREMENT Investigate/Prevent/Correct Alleged Violation:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
§483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must:

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

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

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

Based on review of facility policy, clinical record review, investigation documentation, and staff interviews, it was determined that the facility failed to conduct a thorough investigation to rule out neglect and/or abuse for one of ten sampled residents (Resident R24).

Findings include:

Review of facility policy "Abuse, Neglect, and Exploitation" dated 10/1/22, last reviewed 10/2/23, indicated an immediate investigation is warranted when suspicion of abuse, neglect occurs. It was indicated all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegation must be identified and interviewed. A complete and thorough investigation must be documented.

Review of the clinical record indicated that Resident R24 was admitted to the facility on 4/19/19.

Review of Resident R24's Minimum Data Set (MDS - a periodic assessment of care needs) dated 9/13/23, indicated diagnoses hypertension (high blood pressure), anxiety disorder, and muscle weakness.

Review of Resident R24's care plan initiated 4/2/20, last reviewed 2/9/24, indicated the resident uses disposable briefs, and to check resident every two hours and assist with toileting as needed.

Review of Resident R24's progress note dated 9/28/23, at 5:27 p.m. entered by Social Services Director, Employee E3 stated "concern reported" involving resident care. "OAPS notified."

Review of the Event Reporting System report submitted to the Department of Health on 10/1/23, indicated on 9/29/23, during the nurse aide working the 11:00 p.m. to 7:00 a.m. shift went into Resident R24's room to check on her. While in her room the nurse aide noticed that Resident R24 had dry urine on her sheets and a saturated brief. Resident was assessed by wound nurse and had redness noted to coccyx area.

Review of a witness statement written by NA, Employee E46, dated 9/28/23, stated as he was completing his rounds, Resident R24 "had mold growing on her skin and bed and brief." It was indicated the resident appeared she hasn't been cared for in days.

During an interview on 2/9/24 at 9:46 a.m. NA Employee E47 stated, Resident R24 was found sitting in old urine, she stated "the jelly stuff in the brief was coming out, it was so saturated."

During an interview on 2/7/24, at 1:35 p.m. the Director of Nursing (DON) confirmed the facility failed to identify and obtain witness statements from Resident R24, the alleged perpetrator, witnesses, and others who might have knowledge of the allegation neglect.

During an interview on 2/9/24, at 10:38 a.m. the DON confirmed that the facility failed to conduct a thorough investigation to rule out neglect and/or abuse as required for one of ten sampled residents (Resident R24).

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

28 Pa. Code: 201.14 (c)(e) Responsibility of licensee.

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


 Plan of Correction - To be completed: 04/04/2024

1. Resident R24 has been discharged from the facility.
2. The Don/Designee will review all past incidents and grievances x 30 days to identify any concerns regarding incomplete investigations.
3. The DON and NHA will be educated by the Regional Director of Operations/designee on completing thorough investigations and required documentation.
4. Nursing staff will be educated on abuse/neglect policy by DON/designee.
5. Incidents and/or grievances will be audited by the DON/designee daily x 5 days, weekly x 3 weeks, and monthly times 2 months to ensure investigations are complete and thoroughly investigated.
6. Audit results will be reviewed through the monthly QAPI process/meeting.

483.90(g)(1)(2) REQUIREMENT Resident Call System:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
§483.90(g) Resident Call System
The facility must be adequately equipped to allow residents to call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area from-

§483.90(g)(1) Each resident's bedside; and
§483.90(g)(2) Toilet and bathing facilities.
Observations:
Based on review of facility policy, observations and staff interview, it was determined that the facility failed to maintain call bell equipment for one of five residents (Resident R81).

Findings include:

The facility "Call Lights: Accessibility and Timely Response" policy dated 7/1/23, indicated the facility must adequately be equipped with a call light at reach resident's bedside to allow residents to call for assistance. It was indicated staff will report problems with a call light or call system immediately to the supervisor.

During an interview on 2/5/24, at 12:25 p.m. Resident R81 stated she never had a call bell that worked. Resident R81 was observed pressing her call bell and the light above the room did not turn on.

During an interview on 2/5/24, at 12:31 a.m. Licensed Practical Nurse (LPN), Employee E39 confirmed the light above the Resident R81's room was not working.

During an interview on 2/6/24, at 10:14 a.m. Unit Manager, LPN Employee E40 confirmed that the facility failed to maintain call bell equipment for Resident R81 as required.

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


 Plan of Correction - To be completed: 04/04/2024

1. Resident R81 was provided with a working call bell.
2. A whole house audit was completed to ensure all call bells functioning properly.
3. The DON/designee will provide education to all clinical and maintenance staff of the requirements that all residents have a working call bell available, and procedure if a call light is noted to be working improperly.
4. The DON/designee will audit 5 call bells for function weekly x4 weeks and monthly x 2 months.
5. Results of audits will be reviewed by QAPI committee for further review and recommendations.

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 and clinical record, observation and staff interviews it was determined that the facility failed to make certain that residents are free from significant medication errors for one of four residents (Resident R70).

Findings include:

Review of Resident R70's Minimum Data Set (MDS-periodic review of care needs) dated 11/25/23, indicated the resident was admitted on 8/23/23, with diagnoses of high blood pressure, diabetes (a disease that occurs when your blood glucose, or blood sugar, is too high), and depression.

Review of Resident R70's physician order dated 11/1/23, instructed the nurse to administer Humalog 100 unit/ml, subcutaneously (under the skin), before meals as per the following sliding scale:
-If 0-300, inject 0 units
-If 301-600, inject 5 units
-If 601 or greater, call physician

During an observation of Resident R70's medication administration on 2/8/24, at 9:52 a.m. LPN, Employee E24 confirmed Resident R70's Humalog was ordered for administration before meals. During an observation and interview, Resident R70 indicated she already ate her breakfast. LPN, Employee E24 administered 5 units of Humalog and confirmed she failed to administer Resident R70's Humalog before the resident had her breakfast.

During an interview on 2/8/24, at 12:05 p.m. the Director of Nursing confirmed that the facility failed to make certain that residents are free from significant medication errors for one of four residents (Resident R70).

28 Pa Code: 211.9 (a) Pharmacy services.

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


 Plan of Correction - To be completed: 04/04/2024

1. Resident R70 suffered no ill effects from late administration of medication.
2. Facility is unable to retroactively correct concerns of medications not being given in a timely manner to residents. The attending physician was notified.
3. Licensed nursing staff will be educated on the facility Medication Administration policy, which includes timeliness of medication administration.
4. The DON/Designee will audit to ensure that medications are administered in a timely manner. Audits for five residents per day x 5 days, weekly x3 weeks and monthly x 2months.
5. Audit results will be reviewed through the monthly QAPI process/meeting.

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 clinical record review and staff interviews, it was determined that the facility failed to make certain a resident's medication regimen was free from potentially unnecessary medication for one of four sampled residents (Resident R31).

Findings include:

The facility "Gradual Dose Reduction of Psychotropic Drugs" policy dated 10/2/23, indicated residents who use psychotropic drugs receive gradual dose reductions and behavioral interventions unless clinically contraindicated, in an effort to discontinue these drugs.

The facility "Use of Psychotropic Medication" policy dated 10/2/23, indicated resident are not given psychotropic drugs (any drug that affects brain activities associated with mental processes and behavior) unless the medication is necessary to treat a specific condition, as diagnosed and documented in the clinical record, and the medication is beneficial to the resident, as demonstrated by monitoring and documentation of the resident ' s response to the medication(s).

Review of the clinical record indicated Resident R31 was admitted to the facility on 6/2/21.

Review of Resident R31's Minimum Data Set (MDS - a periodic assessment of care needs) dated 12/5/23, indicated diagnoses of hypertension (high blood pressure), schizophrenia (constant feeling of sadness and loss of interest), and Bipolar Disorder (a mental condition marked by alternating periods of elation and depression).

Review of Resident R31's physician order dated 6/2/21, indicated to consult psychology as needed.

Review Resident R31's physician's order dated 3/27/18, indicated to administer 7.5 milligrams (mg) of Mirtazapine (an antidepressant) by mouth at bedtime for disruptive mood dysregulation disorder.

Review of Resident R31's care plan dated 12/13/23, indicated to consult with pharmacy and physician to consider dose reduction when clinically appropriate.

Review of a Resident R31's psych consult dated 2/1/24, indicated the following recommendations from the provider:
- Gradual Dose Reduction (GDR): Discontinue Mirtazapine 7.5 mg by mouth at bedtime due to sedation on more than three occasions and monitor response.

Review of Resident R31's physician orders on 2/9/24, indicated the resident's order for 7.5 milligrams (mg) of Mirtazapine at bedtime was active.

Review of Resident R31's clinical record from 2/1/24, through 2/9/24, failed to indicate a rationale why the Mirtazapine 7.5 mg by mouth at bedtime was not discontinued as recommended.

During an interview on 2/9/24, at 10:38 a.m. the Director of Nursing (DON) confirmed that the facility failed to make certain a resident's medication regimen was free from potentially unnecessary medication for one of four sampled residents (Resident R31).

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

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

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


 Plan of Correction - To be completed: 04/04/2024

1. Resident R31's Mirtazapine has since been discontinued and behaviors are being monitored.
2. Residents receiving psych services and using psychotropic drugs will be reviewed for any outstanding GDR recommendations.
3. Licensed nursing staff will be educated on the "Gradual Dose Reduction of Psychotropic Drugs" and "Use of Psychotropic Medication" policies to ensure staff understand the GDR recommendations process.
4. The DON/ Designee will audit all residents receiving psych services for any outstanding GDR recommendations weekly x 4 weeks and monthly X 2 months.
5. Audit results will be reviewed through the monthly QAPI process/meeting.

483.40(b)(1) REQUIREMENT Treatment/Srvcs Mental/Psychoscial Concerns: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.
§483.40(b) Based on the comprehensive assessment of a resident, the facility must ensure that-
§483.40(b)(1)
A resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder, receives appropriate treatment and services to correct the assessed problem or to attain the highest practicable mental and psychosocial well-being;
Observations:
Based on a review of clinical records, facility policy, and staff interview, it was determined that the facility failed to provide services to a resident with a substance use disorder for one of two residents (Resident R23).

Findings include:

Review of the SAMHSA (Substance Abuse and Mental Health Services Administration) publication, "Opioid Overdose" updated 2/1/24, indicated signs and symptoms of opioid overdose may be:
-Face is extremely pale and/or feels clammy to the touch.
-Limp body.
-Pinpoint pupils.
-Fingernails or lips have a purple or blue color
-Vomiting or making gurgling noises
-Difficulty to awaken or are unable to speak
-Breathing or heartbeat slows or stops

Review of the facility policy "Provision of Quality of Care" dated 10/2/23, indicated each resident will be provided care and services to attain or maintain his/her highest practicable physical, mental, and psychosocial well-being.

Review of the clinical record indicated Resident R23 was admitted to the facility on 9/7/23.

Review of Resident R23's Minimum Data Set (MDS- assessment of a resident's abilities and care needs) dated 1/22/24, included diagnoses of end stage renal disease (ESRD, an inability of the kidneys to filter the blood), depression, and cocaine abuse.

Review of hospital discharge paperwork dated 9/7/23, indicated Resident R23 had been admitted, on 8/18/23, to the hospital for detox and dialysis arrangement; Resident R23 had stopped taking his suboxone (buprenorphine-naloxone, medication that can be used to treat narcotic dependence) two days prior and started sniffing heroin. Stated he "snorted two bags of heroin."

Review of a physician's note dated 9/10/23, at 6:09 p.m. indicated Resident R23 "Was at shelter and admitted for detox and rehab. History of polysubstance abuse and heroin abuse. He was on suboxone and at times on methadone and now transitioned to suboxone. Also, history of cocaine and alcohol abuse."

Review of Resident R23's plan of care developed 9/7/23, failed to include focuses, goals, or interventions related to substance or alcohol abuse, recognizing overdose, or the use of overdose reversal agents such as Narcan.

Review of Resident R23's physcian orders failed to include an order for Narcan or other opioid reversal agent until 12/13/23.

Review of a progress note dated 10/25/23, at 3:07 p.m. stated, "911 here to take pt (patient) to hospital for altered mental status. Informed paramedics that pt will need drug tox (drug toxicology test) once he gets to the hospital."

Review of a progress note dated 10/25/23, at 3:17 p.m. stated, "Resident admitted to using heroin and smoking crack (smokeable cocaine) to EMTs (emergency medical technicians).

Review of a progress note dated 10/27/23, at 11:23 a.m. Resident signed a behavior contract (an agreement between the resident and the facility to abide by facility policies, such as not to use illegal drugs, submission to room/belongings/mail checks, submission to drug testing, and police notification if illegal substances or paraphernalia are found.

Review of a progress note dated 12/14/23, at 10:53 a.m. that Resident R23 was transferred to the hospital from his dialysis appointment due to increased lethargy, pinpoint pupils, and difficulty to arouse.

During a follow-up communication on 2/13/24, at 7:59 p.m., Social Services Director Employee E3 confirmed that the facility provides the option of virtual Narcotics Anonymous or Alcoholics Anonymous meetings for residents.

Review of Resident R23 clinical record failed to include any documentation that he was provided information or offered the opportunity of participating in Narcotics or Alcoholics Anonymous meetings.

During an interview on 2/12/24, at approximately 1:00 p.m. the Nursing Home Administrator confirmed that the facility failed to provide services to a resident with a substance use disorder for one of two residents (Resident R23).


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

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


 Plan of Correction - To be completed: 04/04/2024

1. Resident R23 remains at the facility. Resident is ordered Narcan. Social Services met with Resident R23 to provide information and offer the opportunity of participating in virtual Narcotics or Alcoholics Anonymous meetings. Resident R23's care plan was updated to include focuses, goals, or interventions related to substance or alcohol abuse, recognizing overdose, and the use of overdose reversal agents such as Narcan. Narcan is on hand in facility for residents with a Narcan order.
2. A whole house audit will be completed on all residents to identify residents with a history of active substance abuse. The care plan was updated, and these residents were offered the opportunity of participating in virtual Narcotics or Alcoholics Anonymous meetings.
3. Licensed staff will be educated on signs/symptoms of substance abuse, interventions, and care planning residents for substance abuse disorders. The NHA/Designee will educate the Social Services employees on requirements noted at regulation F742.
4. New admissions will be audited by the DON/designee for substance abuse screening, and substance abuse care planning, and offer of participation in substance abuse meetings daily x 5 days, weekly x 3 weeks and monthly x 2 months.
5. Audit results will be reviewed through the monthly QAPI process/meeting.

483.25(a)(1)(2) REQUIREMENT Treatment/Devices to Maintain Hearing/Vision: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(a) Vision and hearing
To ensure that residents receive proper treatment and assistive devices to maintain vision and hearing abilities, the facility must, if necessary, assist the resident-

§483.25(a)(1) In making appointments, and

§483.25(a)(2) By arranging for transportation to and from the office of a practitioner specializing in the treatment of vision or hearing impairment or the office of a professional specializing in the provision of vision or hearing assistive devices.
Observations:
Based on clinical record review, observations, and staff interviews, it was determined that the facility failed to ensure that residents receive proper treatment and assistive devices to maintain vision abilities for one of ten residents (Resident R31).

Findings include:

Review of Title 42 Code of Federal Regulations (CFR) Vision and hearing states to ensure that residents receive proper treatment and assistive devices to maintain vision and hearing abilities.

Review of the clinical record indicated that Resident R31 was admitted to the facility on 6/2/21.

Review of Resident R31's "Admission/Readmission Screen V2- V2" report dated 6/3/21, indicated the resident had blurred vision in his right eye and no deficits in his left. It was indicated he wears glasses.

Review of the Minimum Data Set (MDS - a period assessment of care needs) dated 12/5/23, indicated diagnoses of hypertension (high blood pressure), coronary artery disease condition where the major blood vessels supplying the heart are narrowed), and dry eye syndrome of bilateral lacrimal glands (a common condition that occurs when your tears aren't able to provide adequate lubrication for your eyes). Section B- Hearing, Speech, and Vision indicated the resident had adequate vision. It was indicated the resident does not wear corrective lenses.

Review of a Resident R31's care plan dated 12/13/23, indicated the resident requires eye glasses.

Review of Resident R31's progress note dated 1/27/24, entered by Licensed Practical Nurse (LPN), Employee E 43 stated resident is blind and he requires total care for Activities of Daily Living (ADL-are self-care activities that are important for health maintenance and independent living.)

During an observation on 2/5/24, at 1:15 p.m. Resident R31 was observed sitting in his room in his wheelchair screaming out "Help, I can't see." Resident R31 when asked what was wrong, he indicated he needs a new set of eyes. The resident was not wearing glasses.

During an interview on 2/9/24, at 9:02 a.m. Nurse Aide (NA) Employee E 37 confirmed that Resident R31 did not have his glasses on and stated he is blind. It was indicated the resident requires a complete set up for meals.

During an interview on 2/9/24, at 9:11 a.m. LPN, Employee E10 stated interventions to care for a resident who has sensory deficit, such as blindness will be found in the care plan.

During an interview on 2/9/24, at 10:33 a.m. the Director of Nursing confirmed that the facility failed to ensure that residents receive proper treatment and assistive devices to maintain vision abilities for one of ten residents for one of ten residents (Resident R31)..

Review of Resident R31's progress note dated 2/10/24, entered by Activities Director, Employee E21 stated resident is blind, constantly yells out his name. This behavior has increased. "When he is asked why he is yelling, he says he is blind."

Review of Resident R31's clinical record from 1/27/24, through 2/10/24, failed to indicate the facility assisted the resident with making an eye doctor appointment.

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

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


 Plan of Correction - To be completed: 04/04/2024

1. Resident R31 has had an appointment scheduled.
2. A whole house audit was completed to identify any residents who require appointments with the eye doctor.
3. Licensed nursing staff will be educated on the requirement and the process for scheduling vision appointments. Staff education on alerting appropriate parties for broken/missing glasses will be conducted by DON or designee.
4. The DON/designee will audit all residents scheduled for vision appointments weekly x 4 weeks and monthly x 2 months to ensure appointments are scheduled and/or completed.
5. Audit results will be reviewed through the monthly QAPI process/meeting.

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

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

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

§483.25(g)(3) Is offered a therapeutic diet when there is a nutritional problem and the health care provider orders a therapeutic diet.
Observations:
Based on review of facility policies, clinical records, and staff interviews, it was determined that the facility failed to make certain that weight loss was identified and addressed and identify needs for increased nutrition for one of five residents (Resident R23).

Findings include:

Review of the facility job description for the Dietitian included to monitor residents for weight changes, nutrition support, and skin breakdown, and make recommendations as needed.

Review of the facility policy, "Weight Monitoring" last reviewed 10/2/23, indicated that the facility will use a systemic approach to optimize a resident's nutritional status, to include identifying and assessing each resident's nutritonal status and risk factors, evaluate and analyze the assessment information, develop and consistently implement pertinent approaches and monitor the effectiveness of this and revise as necessary. Interventions will be identified, implemented and modified as appropriate, consistent with the resident's assessed needs, choices, preferences, goals and current professional standards to maintain acceptable parameters of nutritional status.

Review of the facility policy, "Nutritional Management" last reviewed 10/2/23, indicated that the facility will provide care and services to each resident to ensure the resident maintains acceptable parameters of nutritonal status in the context of the resident's overall condition. The dietitian shall use data gathered from the nutritional assessment to estimate the resident's calorie, nutrient, and fluid needs and whether intake is adequate to meet those needs. Current standards of practice/formulas are used in calculating these estimates.

GUIDANCE
Significant weight loss is defined as:
5% or greater in one month
7.5% or greater in three months
10% or greater in six months

Altered Nutrient intake, absorption, and utilization: Poor intake, continuing or unabated hunger, or a change in the resident's usual intake that persists for multiple meals, may indicate an underlying condition or illness. Examples of causes include, but are not limited to:

o An inadequate amount of food or fluid, including insufficient tube feedings.
o Diseases and conditions such as cancer, diabetes mellitus, advanced or uncontrolled heart or lung disease, infection and fever, liver disease, kidney disease, hyperthyroidism, mood disorders, gastrointestinal disorders, pressure injuries or other wounds, and repetitive movement disorders (e.g., wandering, pacing, or rocking).

Resident R23 was admitted to the facility on 9/07/23 with diagnoses that included End Stage Renal Disease (ESRD - medical condition in which a person's kidneys cease functioning on a permanent basis leading to the need for a regular course of long-term dialysis or a kidney transplant to maintain life) and Hepatitis C. The Minimum Data Set (MDS - periodic assessment of care needs) dated 1/22/24, included additional diagnoses of depression and cocaine abuse.

A review of Resident R23's weight record included the following weights:
9/13/23167 pounds
10/12/23160 poundsa loss of 4% in one month
11/8/23156.2 pounds
12/8/23157.7 pounds
1/14/24151 poundsa loss of 5.6& in three months
2/1/24139.9 poundsa significant loss of 15.5% in six months

Review of Resident R23's nutrition noted dated 10/23/23, inidcated resident remains at nutrition risk related to dialysis. Weight trends show a non significant weight loss. Current nutrition POC (plan of care) remains appropriate.

Review of Resident R23's nutrition note dated 11/17/23, indicated a non significant weight loss of 4% in one month. No new RD (Registered Dietitian) recommendations at this time.

Review of Resident R23's nutrition note dated 12/12/23, indicated to continue on liberalized diet and encourage protein intake.

Further reivew of Resident R23's clinical record failed to reveal documentation or interventions to address the gradual weight loss or the significant weight loss determined in February 2024, or any further assessment of Resident R23's nutritional status including risk factors of ESRD. Review of the documentation revealed that no further nutrition interventions were implemented.

During an interview on 2/20/24, at 12:30 p.m., the Nursing Home Administrator confirmed that the facility failed to make certain weight loss was identified and addressing a timely manner and to identify needs for increased nutrition.

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

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




 Plan of Correction - To be completed: 04/04/2024

1. A full nutrition evaluation was completed for R23. Nutrition interventions in place.
2. A registered dietitian completed a whole house audit to identify any residents with significant weight loss. The results of the audit determined the need for a full nutrition evaluation and an appropriate nutrition intervention was put in place for residents.
3. The Regional Director of Operations will educate the dietitian on the facility "Nutritional Management" policy.
4. A registered dietitian will audit weight losses daily x 5 days, weekly x4 weeks, and monthly x2 months.
5. Results of audits will be reviewed through the monthly QAPI process/meeting.

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 R47).

Findings include:

The facility policy entitled "Care and Treatment of Feeding Tubes" (delivery of food or medication via tube surgically inserted into stomach) dated 10/2/23, indicated the facility must utilize feeding tubes in accordance with current clinical standards of practice, with interventions to prevent complications to the extent possible. It was indicated the resident's plan of care will direct staff regarding proper positioning of residents consistent with resident's individual needs.

Review of admission record indicated Resident R47 admitted to the facility on 7/3/19.

Review of Resident R47's Minimum Data Set (MDS- periodic assessment of care needs) dated 11/3/23, indicated diagnoses of cerebral palsy (a neurological condition that can present as issues with muscle tone, posture and/or a movement disorder), seizure disorder (sudden, uncontrolled burst of electrical activity in the brain), and hemiplegia (paralysis of one side of body). Section K- Swallowing/Nutritional Status indicated the resident had a feeding tube while a resident.

Review of a physician order dated 10/3/23, indicated that Resident R47 was to receive Osmolite 1.2 via G-tube (a tube inserted through the belly that brings nutrition directly to the stomach) at a rate of 80 ml (milliliters) per hour, with a 30 ml water flush every hour, from 12:00 p.m. to 8:00 a.m.

Review of R47's care plan dated 11/22/23, indicated the resident needs his head of bed elevated at 45 degrees during and thirty minutes after the tube feed.

During an observation on 2/5/24, at 1:11 p.m. Resident R47 was observed lying flat in bed with his tube feed infusing. The resident's head of bed failed to be elevated at 45 degrees.

During an interview on 2/5/24, at 1:13 p.m. Unit Manager, LPN Employee E40 confirmed Resident R47 head of bed was not elevated to 40 degrees while receiving his tube feed.

During an interview on 2/9/24, at 10:38 a.m. the Director of Nursing confirmed the facility failed to provide to provide appropriate care and services to residents receiving tube feedings for one of two residents reviewed (Residents R47).

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

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

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


 Plan of Correction - To be completed: 04/04/2024

1. Resident R47 was examined by the Nurse and suffered no lasting effects from being laid flat with G-tube running.
2. A whole house audit of all residents with G-tubes will be completed to ensure none are lying flat while feedings are running.
3. Nursing staff will be educated on the facility "Care and Treatment of Feeding Tubes" policy, which includes resident positioning when a feeding tube is in place and running.
4. Residents with a feeding tube will be audited daily x 5 days, weekly x 3 weeks, and monthly times 2 months to ensure proper positioning is provided.
5. Audit results will be reviewed through the monthly QAPI process/meeting.

483.35(d)(7) REQUIREMENT Nurse Aide Peform Review-12 hr/yr In-Service:Least serious 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 has the potential for causing no more than a minor negative impact on the resident.
§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 personnel records and staff interview it was determined that the facility failed to provide nursing staff annual performance evaluations based on the date of hire for five of five nurse aides (Employees E11, E12, E13, E14, and E15).

Findings include:

During an interview on 2/12/24, at approximately 1:00 p.m. the Nursing Home Administrator confirmed the facility failed to provide nursing staff annual performance evaluations based on the date of hire for five of five nurse aides.

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

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


 Plan of Correction - To be completed: 04/04/2024

1. Nurse Aides were contacted to complete their 12-hour training, training is ongoing and to be completed by April 4th 2024. If not completed NA will be removed from the schedule.
2. The NHA/designee will educate the scheduler and HR director on the requirements for nurse aides and their role in assisting them in completing the required trainings.
3. HR Director/designee will track annual nurse aide trainings.
4. A whole house audit will be completed on all nurse aides and their trainings. If trainings are not complete staff will be contacted to complete it or be removed from the schedule.
5. New hire files within the last 60 days will be audited by HR Director/Designee monthly to ensure training is done upon hire and annually. Monthly audits will remain ongoing.
6. Audit results will be reviewed through the monthly QAPI process/meeting.

483.95(i) REQUIREMENT Behavioral Health Training:Least serious 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 has the potential for causing no more than a minor negative impact on the resident.
§483.95(i) Behavioral health.
A facility must provide behavioral health training consistent with the requirements at §483.40 and as determined by the facility assessment at §483.70(e).
Observations:

Based on review of facility policy and documents, and staff interview, it was determined that the facility failed to provide training on Behavioral Health for nine of nine staff members (Employees E11, E12, E13, E14, E15, E6, E16, E17, and E18).

Findings include:

Review of the policy "Inservice Training" dated XXXX, indicated it is the policy of this facility to develop, implement, and maintain an effective training program for all new and existing staff, individuals providing services under a contractual arrangement, and volunteers, consistent with their expected roles.

Review of the " Facility Assessment " updated 12/28/23, indicated the training program content at a minimum included " Behavior Management, Residents and Family "

Review of facility provided documents and training record for E11, E12, E13, E14, E15, E6, E16, E17, and E18 revealed the following staff members did not have documented training on Behavioral Health.

Nurse Aide (NA) Employee E11 had a hire date of 1/4/22, failed to have Behavioral Health in-service education between 1/4/23, and 1/4/24.
Nurse Aide (NA) Employee E12 had a hire date of 1/12/13, failed to have Behavioral Health in-service education between 11/12/22, and 11/12/23.
NA Employee E13 had a hire date of 11/8/05, failed to have Behavioral Health in-service education between 11/8/22, and 11/8/23.
NA Employee E14 had a hire date of 10/11/05, failed to have Behavioral Health in-service education between 10/11/22, and 10/11/23.
NA Employee E15 had a hire date of 1/6/15, failed to have Behavioral Health in-service education between 1/6/23, and 1/6/24.
Licensed Practical Nurse (LPN) Employee E6 had a hire date of 10/5/21, failed to have Behavioral Health in-service education between 10/5/22, and 10/5/23.
Licensed Practical Nurse (LPN) Employee E16 had a hire date of 1/1/00, failed to have Behavioral Health in-service education between 1/1/23, and 1/1/24.
Therapy Employee E17 had a hire date of 11/11/21, failed to have Behavioral Health in-service education between 11/11/22, and 11/11/23.
Therapy Employee E18 had a hire date of 12/27/15, failed to have Behavioral Health in-service education between 12/27/22, and 12/27/23.

During an interview on 2/7/24, at approximately 12:40 p.m. the Nursing Home Administrator confirmed that the facility failed to provide training on Behavioral Health for nine of nine staff members.

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

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

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


 Plan of Correction - To be completed: 04/04/2024

1. Behavioral Health Training to be provided to employees E11, E12, E13, E14, E15, E6, E16, E17, and E18 .
2. A whole house audit completed to confirm staff have completed Behavioral Health Training.
3. A monthly audit will occur by HR Director/ designee monthly to assure completion of the continuing education program for all new hires.
4. Findings from the audits will be presented at the quarterly QAPI meeting for review and recommendations.

483.95(f)(1)(2) REQUIREMENT Compliance and Ethics Training:Least serious 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 has the potential for causing no more than a minor negative impact on the resident.
§483.95(f) Compliance and ethics.
The operating organization for each facility must include as part of its compliance and ethics program, as set forth at §483.85-

§483.95(f)(1) An effective way to communicate the program's standards, policies, and procedures through a training program or in another practical manner which explains the requirements under the program.

§483.95(f)(2) Annual training if the operating organization operates five or more facilities.
Observations:

Based on review of facility policy and documents, and staff interview, it was determined that the facility failed to provide training on Compliance and Ethics for nine of nine staff members (Employees E11, E12, E13, E14, E15, E6, E16, E17, and E18).

Findings include:

Review of the policy "Inservice Training" dated 10/2/23, indicated it is the policy of this facility to develop, implement, and maintain an effective training program for all new and existing staff, individuals providing services under a contractual arrangement, and volunteers, consistent with their expected roles.

Review of the " Facility Assessment " updated 12/28/23, indicated the training program content at a minimum included " Compliance and Ethics. "

Review of facility provided documents and training record for E11, E12, E13, E14, E15, E6, E16, E17, and E18 revealed the following staff members did not have documented training on Compliance and Ethics.

Nurse Aide (NA) Employee E11 had a hire date of 1/4/22, failed to have Compliance and Ethics in-service education between 1/4/23, and 1/4/24.
Nurse Aide (NA) Employee E12 had a hire date of 1/12/13, failed to have Compliance and Ethics in-service education between 11/12/22, and 11/12/23.
NA Employee E13 had a hire date of 11/8/05, failed to have Compliance and Ethics in-service education between 11/8/22, and 11/8/23.
NA Employee E14 had a hire date of 10/11/05, failed to have Compliance and Ethics in-service education between 10/11/22, and 10/11/23.
NA Employee E15 had a hire date of 1/6/15, failed to have Compliance and Ethics in-service education between 1/6/23, and 1/6/24.
Licensed Practical Nurse (LPN) Employee E6 had a hire date of 10/5/21, failed to have Compliance and Ethics in-service education between 10/5/22, and 10/5/23.
Licensed Practical Nurse (LPN) Employee E16 had a hire date of 1/1/00, failed to have Compliance and Ethics in-service education between 1/1/23, and 1/1/24.
Therapy Employee E17 had a hire date of 11/11/21, failed to have Compliance and Ethics in-service education between 11/11/22, and 11/11/23.
Therapy Employee E18 had a hire date of 12/27/15, failed to have Compliance and Ethics in-service education between 12/27/22, and 12/27/23.

During an interview on 2/7/24, at approximately 12:40 p.m. the Nursing Home Administrator confirmed that the facility failed to provide training on Compliance and Ethics for nine of nine staff members.

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

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

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


 Plan of Correction - To be completed: 04/04/2024

1. Compliance and Ethics Training to be provided to employees E11, E12, E13, E14, E15, E6, E16, E17, and E18 .
2. A whole house audit completed to confirm staff have completed Compliance and Ethics Training or training will be provided.
3. A monthly audit will occur by HR Director/ designee monthly to assure completion of the continuing education program for all new hires.
4. Findings from the audits will be presented at the quarterly QAPI meeting for review and recommendations.

483.95(d) REQUIREMENT QAPI Training:Least serious 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 has the potential for causing no more than a minor negative impact on the resident.
§483.95(d) Quality assurance and performance improvement.
A facility must include as part of its QAPI program mandatory training that outlines and informs staff of the elements and goals of the facility's QAPI program as set forth at § 483.75.
Observations:

Based on review of facility policy and documents, and staff interview, it was determined that the facility failed to provide training on Quality Assurance and Performance Improvement (QAPI) for nine of nine staff members (Employees E11, E12, E13, E14, E15, E6, E16, E17, and E18).

Findings include:

Review of the policy "Inservice Training" dated 10/2/23, indicated it is the policy of this facility to develop, implement, and maintain an effective training program for all new and existing staff, individuals providing services under a contractual arrangement, and volunteers, consistent with their expected roles.

Review of the "Facility Assessment" updated 12/28/23, indicated the training program content at a minimum included "QAPI."

Review of facility provided documents and training record for E11, E12, E13, E14, E15, E6, E16, E17, and E18 revealed the following staff members did not have documented training on QAPI.

Nurse Aide (NA) Employee E11 had a hire date of 1/4/22, failed to have QAPI in-service education between 1/4/23, and 1/4/24.
Nurse Aide (NA) Employee E12 had a hire date of 1/12/13, failed to have QAPI in-service education between 11/12/22, and 11/12/23.
NA Employee E13 had a hire date of 11/8/05, failed to have QAPI in-service education between 11/8/22, and 11/8/23.
NA Employee E14 had a hire date of 10/11/05, failed to have QAPI in-service education between 10/11/22, and 10/11/23.
NA Employee E15 had a hire date of 1/6/15, failed to have QAPI in-service education between 1/6/23, and 1/6/24.
Licensed Practical Nurse (LPN) Employee E6 had a hire date of 10/5/21, failed to have QAPI in-service education between 10/5/22, and 10/5/23.
Licensed Practical Nurse (LPN) Employee E16 had a hire date of 1/1/00, failed to have QAPI in-service education between 1/1/23, and 1/1/24.
Therapy Employee E17 had a hire date of 11/11/21, failed to have QAPI in-service education between 11/11/22, and 11/11/23.
Therapy Employee E18 had a hire date of 12/27/15, failed to have QAPI in-service education between 12/27/22, and 12/27/23.

During an interview on 2/7/24, at approximately 12:40 p.m. the Nursing Home Administrator confirmed that the facility failed to provide training on QAPI for nine of nine staff members.

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

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

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


 Plan of Correction - To be completed: 04/04/2024

1. Quality Assurance Training to be provided to employees E11, E12, E13, E14, E15, E6, E16, E17, and E18 .
2. A whole house audit completed to confirm staff have received Quality Assurance Training.
3. A monthly audit will occur by HR Director/ designee monthly to assure completion of the QAPI training for all new hires.
4. Findings from the audits will be presented at the quarterly QAPI meeting for review and recommendations.

483.95 REQUIREMENT Training Requirements:Least serious 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 has the potential for causing no more than a minor negative impact on the resident.
§483.95 Training Requirements
A facility must develop, implement, and maintain an effective training program for all new and existing staff; individuals providing services under a contractual arrangement; and volunteers, consistent with their expected roles. A facility must determine the amount and types of training necessary based on a facility assessment as specified at § 483.70(e). Training topics must include but are not limited to-
Observations:

Based on review of facility policy and staff interviews, it was determined that the facility failed to implement and maintain an effective training program for individuals providing services under contractual arrangement, consistent with their expected roles.

Findings include

Review of the policy "Inservice Training" dated 10/2/23, indicated it is the policy of this facility to develop, implement, and maintain an effective training program for all new and existing staff, individuals providing services under a contractual arrangement, and volunteers, consistent with their expected roles.

During an interview on 2/6/24, at approximately 2:00 p.m. Human Resources Director Employee E19 confirmed that the facility does not have a current training program, and is unable to provide complete education records for facility employees.

During an interview on 2/7/24, at approximately 12:40 p.m. the Nursing Home Administrator confirmed the facility failed to implement, and maintain an effective training program for individuals providing services under contractual arrangement, consistent with their expected roles.

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


 Plan of Correction - To be completed: 04/04/2024

1. The facility training Program to be completed and implemented.
2. The NHA/Designee will educate Human Resources staff on the facility required "Training Program Policy" and meeting requirements.
3. The NHA/Designee will audit implementation of the training program for all existing and new hire staff daily x5 days, weekly x3 and monthly x2.
4. Findings from the audits will be presented at the quarterly QAPI meeting for review and recommendations.
483.95(a) REQUIREMENT Communication Training:Least serious 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 has the potential for causing no more than a minor negative impact on the resident.
§483.95(a) Communication.
A facility must include effective communications as mandatory training for direct care staff.
Observations:

Based on review of facility policy and documents, and staff interview, it was determined that the facility failed to provide training on effective communication for nine of nine staff members (Employees E11, E12, E13, E14, E15, E6, E16, E17, and E18).

Findings include:

Review of the policy "Inservice Training" dated 10/2/23, indicated it is the policy of this facility to develop, implement, and maintain an effective training program for all new and existing staff, individuals providing services under a contractual arrangement, and volunteers, consistent with their expected roles.

Review of the "Facility Assessment" updated 12/28/23, indicated the training program content at a minimum included "Effective Communication."

Review of facility provided documents and training record for E11, E12, E13, E14, E15, E6, E16, E17, and E18 revealed the following staff members did not have documented training on effective communication.

Nurse Aide (NA) Employee E11 had a hire date of 1/4/22, failed to have effective communication in-service education between 1/4/23, and 1/4/24.
Nurse Aide (NA) Employee E12 had a hire date of 1/12/13, failed to have effective communication in-service education between 11/12/22, and 11/12/23.
NA Employee E13 had a hire date of 11/8/05, failed to have effective communication in-service education between 11/8/22, and 11/8/23.
NA Employee E14 had a hire date of 10/11/05, failed to have effective communication in-service education between 10/11/22, and 10/11/23.
NA Employee E15 had a hire date of 1/6/15, failed to have effective communication in-service education between 1/6/23, and 1/6/24.
Licensed Practical Nurse (LPN) Employee E6 had a hire date of 10/5/21, failed to have effective communication in-service education between 10/5/22, and 10/5/23.
Licensed Practical Nurse (LPN) Employee E16 had a hire date of 1/1/00, failed to have effective communication in-service education between 1/1/23, and 1/1/24.
Therapy Employee E17 had a hire date of 11/11/21, failed to have effective communication in-service education between 11/11/22, and 11/11/23.
Therapy Employee E18 had a hire date of 12/27/15, failed to have effective communication in-service education between 12/27/22, and 12/27/23.

During an interview on 2/7/24, at approximately 12:40 p.m. the Nursing Home Administrator confirmed that the facility failed to provide training on effective communication for nine of nine staff members.

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

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

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


 Plan of Correction - To be completed: 04/04/2024

1. Effective Communication Training to be provided to employees E11, E12, E13, E14, E15, E6, E16, E17, and E18 .
2. A whole house audit completed to confirm all staff have completed Effective Communication Training or training will be provided.
3. A monthly audit will occur by HR Director/ designee to assure completion of the communication training for all new hires. Monthly audits to remain ongoing.
4. Findings from the audits will be presented at the quarterly QAPI meeting for review and recommendations.

483.95(b) REQUIREMENT Resident Rights Training: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.
§483.95(b) Resident's rights and facility responsibilities.
A facility must ensure that staff members are educated on the rights of the resident and the responsibilities of a facility to properly care for its residents as set forth at §483.10, respectively.
Observations:

Based on review of facility policy and documents, and staff interview, it was determined that the facility failed to provide training on Resident Rights for four of nine staff members (Employees E12, E6, E16, and E17).

Findings include:

Review of the policy "Inservice Training" dated 10/2/23, indicated it is the policy of this facility to develop, implement, and maintain an effective training program for all new and existing staff, individuals providing services under a contractual arrangement, and volunteers, consistent with their expected roles.

Review of the "Facility Assessment" updated 12/28/23, indicated the training program content at a minimum included "Resident Rights and Facility Responsibilities."

Review of facility provided documents and training record for E12, E6, E16, and E 17 revealed the following staff members did not have documented training on Resident Rights.

Nurse Aide (NA) Employee E12 had a hire date of 1/12/13, failed to have Resident Rights in-service education between 11/12/22, and 11/12/23.
Licensed Practical Nurse (LPN) Employee E6 had a hire date of 10/5/21, failed to have Resident Rights in-service education between 10/5/22, and 10/5/23.
Licensed Practical Nurse (LPN) Employee E16 had a hire date of 1/1/00, failed to have Resident Rights in-service education between 1/1/23, and 1/1/24.
Therapy Employee E17 had a hire date of 11/11/21, failed to have Resident Rights in-service education between 11/11/22, and 11/11/23.

During an interview on 2/7/24, at approximately 12:40 p.m. the Nursing Home Administrator confirmed that the facility failed to provide training on Resident Rights for four of nine staff members.

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

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

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


 Plan of Correction - To be completed: 04/04/2024

1. Residents Rights Training to be provided to employees E12, E6, E16, and E17.
2. A whole house audit completed to confirm all staff have completed Residents Rights training.
3. A monthly audit will occur by HR Director/ designee monthly to assure completion of the continuing education program for all new hires.
4. Findings from the audits will be presented at the quarterly QAPI meeting for review and recommendations.

§ 201.19(4) LICENSURE Personnel policies and procedures.:State only Deficiency.
(4) A determination by a health care practitioner that the employee, as of the employee's start date, is free from the communicable diseases or conditions listed in § 27.155 (relating to restrictions on health care practitioners).

Observations:
Based on review of employee personnel records and staff interview, it was determined that the facility failed to ensure personnel records included verification of employees' health status for three of five employees reviewed (Licensed Practical Nurse (LPN) Employee E20, Nurse Aide (NA) Employee E22, and Activities Aide Employee E23).

Findings include:

Review of LPN Employee E20's personnel file revealed the date of hire was 1/26/24.

Review of LPN Employee E20's personnel file did not include documentation by a licensed practitioner (e.g., physician, nurse practitioner, physcian's assistant) of verification that LPN Employee E20 was free from communicable disease or conditions.

Review of NA Employee E22's personnel file revealed the date of hire was 1/11/24.

Review of NA Employee E22's personnel file did not include documentation by a licensed practitioner of verification that NA Employee E22 was free from communicable disease or conditions.

Review of Activities Aide Employee E23's personnel file revealed the date of hire was 12/13/23.

Review of Activities Aide Employee E23's personnel file did not include documentation by a licensed practitioner of verification that Activities Aide Employee E23 was free from communicable disease or conditions.

During an interview on 2/12/24, at approximately 1:00 p.m., the Nursing Home Administrator confirmed that the facility failed to include verification of employees' health status for three of five employees.


 Plan of Correction - To be completed: 04/04/2024

1. Employees E20, E22, and E23 received proper documentation for their files indicating they are free from communicable diseases or conditions.
2. A whole house audit completed to confirm staff have proper documentation of employee health statuses.
3. A monthly audit will occur by the HR director or designee to confirm new hires have proper documentation of employee health status.
4. Findings from the audits will be presented at the quarterly QAPI meetings for review and recommendations.


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