Nursing Investigation Results -

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

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

SQUIRREL HILL WELLNESS AND REHABILITATION CENTER
Inspection Results For:
There are 280 surveys for this facility. Please select a date to view the survey results.

Surveys don't appear on this website until at least 41 days have elapsed since the exit date of the survey.


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, State Licensure, Civil Rights compliance, and an Abbreviated Survey in Response to two complaints completed on March 14, 2022, it was determined that Squirrel Hill Wellness and Rehabilitation Center was not in compliance with the following requirements of 42 CFR Part 483, Subpart B, Requirements for Long-Term Care and the 38 PA Code, Commonwealth of Pennsylvania Long-Term Care Licensure Regulations.

Plan of Correction:

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.

Plan of Correction - To be completed: 04/13/2022

1. Resident 5, 74, 85, 94, 102, 121, 139 and 345 have been informed by the Director of Social Services or designee if they would like to fill out a Advanced Directive.

2. Resident 5, 74, 85, 94, 102, 121, 139 and 345 signed or declined Advance Directives when asked by the Director of Social Services or designee on The Advance Director Questioner

3. Director of Social Services and Admissions Director was educated by the Administrator on the Advance Directive Questioner

4. New Residents will be communicated with on the Advance Directive Questioner by the Director of Social Services or designee upon admission to the facility.

5. A one time audit will be performed by the Director of Social Services or designee on all residents to insure the Advance Directive Questioner is filled out by all in-house residents.

6. An audit will be performed by the Director of Social Services or designee on all new admissions and residents returning from the hospital to ensure the Advance Directive Questioner is up to date and sign

7. Results of the audit by the director of Social Services or designee will be reviewed by the Administered or designee in the facilities Quality Assurance meeting for the next three meetings.

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

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

Plan of Correction - To be completed: 04/13/2022

1. no ill effects were noted to resident 5, 123, 347 due to staff member not priming insulin pen before administration of prescribed insulin

2. no ill effects noted to residents 67 and 96 when medication was not available to administer.

3. Licensed staff will be educated by the Director of Nursing or designee on priming insulin pens with 2 units of insulin before administrating prescribed physician ordered insulin to the resident.

4. An audit will be performed by the Director of Nursing or designee 5 times per week for three weeks then three times per week for two weeks on insulin administration and priming of 2 units of insulin prior to administrating by the med nurse.

5. All licensed nurses will perform a proper insulin pen administration competency by the Director of Nursing or designee.

6. Audits will be performed on 4 licensed nurses per day by the Director of Nursing or designee 5 times per week for the next three weeks then weekly for the next two weeks

7. Licensed staff were educated by the Director of Nursing or designee on if medication is unavailable in the emergency box or Omnicell, to notify the physician, and Pharmacy and to document corrected action if medication was given or not.

8. Audits will be performed by the Director of Nursing or designee 5 times per week for the next three weeks then 3 times a week for two weeks on medication availability which consist of if medication is unavailable if physician, and Pharmacy were notified and corrected documentation performed of medication outcome.

9. Results of the education and audits by the Director of Nursing or designee will be reviewed by the Administrator or designee in the Felicities Quality Assurance meeting for the next three meetings.

483.45(f)(1) REQUIREMENT Free of Medication Error Rts 5 Prcnt or More:

�483.45(f) Medication Errors.
The facility must ensure that its-

�483.45(f)(1) Medication error rates are not 5 percent or greater;

Plan of Correction - To be completed: 04/13/2022

1. no ill effects were noted to resident 5, 123, 347 due to staff member not priming insulin pen before administration of prescribed insulin

2. Licensed staff will be educated by the Director of Nursing or designee on priming insulin pens with 2 units of insulin before administrating prescribed physician ordered insulin to the resident.

3. An audit will be performed by the Director of Nursing or designee 5 times per week for three weeks then three times per week for two weeks on insulin administration and priming of 2 units of insulin prior to administrating by the med nurse.

4. All licensed nurses will perform a proper insulin pen administration competency by the Director of Nursing or designee.

5. Audits will be performed on 4 licensed nurses per day by the Director of Nursing or designee 5 times per week for the next three weeks then weekly for the next two weeks

6.. Results of the education and audits by the Director of Nursing or designee will be reviewed by the Administrator or designee in the Felicities Quality Assurance meeting for the next three meetings.

483.25 REQUIREMENT Quality of Care:

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

Plan of Correction - To be completed: 04/13/2022

1. Resident 108 and 342 enteral feedings were adjusted by the Director of Nursing or designee per physicals orders.

2. there was no ill effects noted to resident 108 and 342 due to not following physicians orders on enteral feedings.

3. No ill effects noted to resident 21 and 140 due to not following physicians orders by notification to physician when blood sugars our below or above ordered perimeter's.

4. no ill effects noted to resident 108, 342, 97, and 139 for not obtaining weekly weights per physician orders.

5. Licensed staff have been educated for the director of Nursing or designee on enteral feedings and following physicians orders on fluid volume.

6. Licensed staff were educated by the Director of Nursing or designee on notification of physician if residents blood sugars or outside the ordered perimeters

7. Licensed staff were educated by the Director of Nursing or designee on following physician orders on weekly weights.

8. an audit will be performed by the Director of Nursing or designee on all enteral feedings to ensure physicians order are followed three times a week for the next three weeks, then weekly for the next two weeks.

9. An audit will be performed by the Director of Nursing or designee on weekly weights to ensure weights or performed per physician orders weekly for the next three weeks.

10. An Audit will be performed by the Director of Nursing or designee, on all resident glucose levels to ensure parameters are followed and physician notification is obtained 5 times per week for three weeks then 3 times per week for two weeks.

11. Resident glucose levels and weekly weights will be discussed in the facilities clinical meeting 5 times per week by the Director of Nursing or designee.

12. Results of the education and audits by the Director of Nursing or designee will be reviewed in the facilities Quality Assurance meeting by the Administrator or designee for the next three meetings.

483.10(f)(5)(i)-(iv)(6)(7) REQUIREMENT Resident/Family Group and Response:

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

�483.10(f)(5) The resident has a right to organize and participate in resident groups in the facility.
(i) The facility must provide a resident or family group, if one exists, with private space; and take reasonable steps, with the approval of the group, to make residents and family members aware of upcoming meetings in a timely manner.
(ii) Staff, visitors, or other guests may attend resident group or family group meetings only at the respective group's invitation.
(iii) The facility must provide a designated staff person who is approved by the resident or family group and the facility and who is responsible for providing assistance and responding to written requests that result from group meetings.
(iv) The facility must consider the views of a resident or family group and act promptly upon the grievances and recommendations of such groups concerning issues of resident care and life in the facility.
(A) The facility must be able to demonstrate their response and rationale for such response.
(B) This should not be construed to mean that the facility must implement as recommended every request of the resident or family group.

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

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

Observations:
Based on facility policy and documentation, resident and staff interviews interview, it was determined that the facility failed to demonstrate response to grievances from resident council for eight of eight months ( July 2021, August 2021, September 2021, October 2021, November 2021, December 2021, January 2022, and February 2022).

Findings include:

Review of the facility policy "Grievance/Concern Resolution" dated 11/10/21, indicated to resolve resident concerns in a timely manner, facility utilizes a grievance form to identify concerns and track via a monthly log.

A review of resident council meeting minutes indicated the following concerns:

July 2021: develop cleaning area for common area to stay tidy, request of variety of additional activities, workshop classes for internet and technology services, additional phones, remotes and batteries, and clock, more advertisement on laundry services.

August 2021: residents request vehicle to be able to go out to appointments

September 2021: more art activities, casino night in place of being able to go out to the casino, residents would like an accommodation or starfish program setup to acknowledge staff that go above and beyond, would like evening snacks to be offered and not having to ask

October 2021: residents want to have more choice in their meal orders, residents would like laundry cleaned and returned faster.

November 2021: celebrate birthdays with a small cake, residents suggested having a liaison to collect concerns and bring them to the next resident council.

December 2021: tarp or some sort of protection from the elements on the back porch, request for more phones, remote controls, and batteries.

January 2022: more options on menu, request of more phones, TV remote controls, batteries, weatherization of smoking area, faster turnaround in laundry.

February 2022: turnaround time for laundry, clocks for each unit lounge, request for more frequent linen changes.

During an interview on 3/9/22, at 10:30 a.m. and 10:50 a.m. Residents indicated that residents' concerns are not being addressed and are on-going.

During an interview on 3/9/22, at 2:28 p.m. Director of Social Services Employee E16 confirmed that residents have on-going concerns and the facility is not using concern forms to follow upon resident council and could not produce documentation showing they addressed the residents' concerns.

28 Pa. Code 201.18 e(1)Management.
Previously cited 12/23/19, 9/23/21

Plan of Correction - To be completed: 04/13/2022

1. All request and concerns from July 2021 thru Feb 2022 at the residents council, were written up on the facilities grievance forms by the Director of Social Services or designee, and was addressed and discussed with the resident council president, on 3/10/2022 and was resolved on 3/11/2022

2. Resolved concerns will be addressed in the resident council meeting on 3/30/2022 by the Director of Social Services or designee.

3. Remotes, batteries, clocks and phones were purchased and received by the Maintenance Director or designee and given out to those residents that did not have remotes or phones. Batteries were used to replaced those that needed to be replaced.

4. Extra staff were hired by the Housekeeping Director to assist faster turn around of linen and personal belongings

5. The facility housekeeping will continue to clean the lounge areas and the Housekeeping Manager or designee will assess area through out the day to insure the area is still clean.

6. The Activity Department will discuss with the residents to see who has the interested or the ability to participate in a workshop or class for internet and technology services. If enough interested is mentioned a workshop will be set up.

7. The request for a vehicle to be able to go out to appointments, The facility is contracted with a medical transport service to provided transportation services for appointments.

8. The request for casino night have been placed on the activity calendar by the Activity Director or designee for the month of March.

9. The facility recognizes outstanding employees with the employee of the month program. Residents will been informed by the Activity Director or designee during the resident council meeting for March, of any staff member they would like to be acknowledge that go above and beyond.

10. All Pantry's are stocked with snacks by the Dietary staff or designee. Nursing staff will be educated by the Director of Nursing or designee to offer snacks to all residents in the evening shift hours.

11. New dietary management system has been in place to offer residents more choices in their meals. (optima solutions) by the Dietary Manager

12. A monthly birthday party for all residents with a birthday in that month is celebrated once a month by the Activity Director or designee.

13. At the March resident council meeting, residents will be informed by the Activity Director or designee that they can address concerns individual or can act as a liaison for their floor.

14. The request for a tarp of some sort of protection from the elements on the back porch is unable to be accommodated for safety reasons. The patio is used as a smoking area and for outdoor activities as weather is permitted.

15. The Activity Director and social service director has been educated by the Administrator on grievance forms and when a residents has concerns during the resident council meeting.

16. The Activity Director or designee and director of Social Services, will meet after the residents council meetings to audit concerns or request from the residents monthly. The concerns or request will be reviewed and placed on the facilities grievance forms and addressed with the appropriate departments for resolution.

17. The concern or grievance forms addressed by the Activity Director or designee and Director of Social Services will be reviewed at the facilities quality assurance meeting monthly by the Administrator or designee, for the next three meetings.

483.10(f)(10)(iv)(v) REQUIREMENT Notice and Conveyance of Personal Funds:

�483.10(f)(10)(iv) Notice of certain balances.
The facility must notify each resident that receives Medicaid benefits-
(A) When the amount in the resident's account reaches $200 less than the SSI resource limit for one person, specified in section 1611(a)(3)(B) of the Act; and
(B) That, if the amount in the account, in addition to the value of the resident's other nonexempt resources, reaches the SSI resource limit for one person, the resident may lose eligibility for Medicaid or SSI.

�483.10(f)(10)(v) Conveyance upon discharge, eviction, or death.
Upon the discharge, eviction, or death of a resident with a personal fund deposited with the facility, the facility must convey within 30 days the resident's funds, and a final accounting of those funds, to the resident, or in the case of death, the individual or probate jurisdiction administering the resident's estate, in accordance with State law.

Plan of Correction - To be completed: 04/16/2022

1. Residents 500,501,502,503,504,505,506,507,508,509,
510,511,512,513,514,515,516,517,518,519, 520,521,522,523,524,525,526,527,528, will have money reimbursed back to them, their responsible party or state, by the facilities outside vendor source Quality Healthcare by 4/7/2022.

2. Quality Healthcare personal have been re-educated by the Administrator on resident refunds policy and procedure.

3. Ann audit will be performed by the Medical Records director of any resident that has left the building or CTB to insure any left over money in the residents account will be refunded within 30 days.

4. Results of the audit performed by the Medical Director will be reviewed in the facilities Quality Assurance meeting by the Administrator or designee for the next three meetings.

483.10(f)(10)(vi) REQUIREMENT Surety Bond-Security of Personal Funds:

�483.10(f)(10)(vi) Assurance of financial security.
The facility must purchase a surety bond, or otherwise provide assurance satisfactory to the Secretary, to assure the security of all personal funds of residents deposited with the facility.

Observations:
Based on review of facility documents and staff interview it was determined that the facility failed to have authorization forms for responsibility of resident trust fund for one of three residents reviewed (Resident R529).

Findings include:

Review of "Patient Trust Fund " dated 3/4/22, indicated that Resident R529 Had $8,383.24

Review of facility documentation failed to include authorization for Resident R529 account.

During an interview on 3/14/22, at 12:54 p.m. Nursing Home Administrator confirmed that the facility failed to have authorization forms for responsibility of Resident R529's account.

28 Pa. Code:201.18e(1)Management.
Previously cited 12/23/19 and 9/23/21

Plan of Correction - To be completed: 04/13/2022

1. Resident 529 signed authorization and agreement to handle resident funds form after discussion from Director of Social Services.

2. Director of Social Services was educated by the Administrator or designee on release forms that are required to manage residents trust funds.

3. Current residents who have a trust fund within the facility will be audited by the Administrator or designee, to ensure an Authorization and agreement to handle residents funds is present, any missed signatures, facility will attempt to retrieve from the RP

4. Education and audits performed by the Director of Social Services or designee and the Administrator or designee will be reviewed by the Administrator or designee in the facilities Quality Assurance Meeting for the next three meetings

483.10(i)(1)-(7) REQUIREMENT Safe/Clean/Comfortable/Homelike Environment:

�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.

Plan of Correction - To be completed: 04/13/2022

1. Repairs to Resident 717, 718, 719, 720, 721, 714, 723, 724, 704, 712, and 705 were completed by the Maintenance director or designee.

2. The areas identified by resident 119, 80, 124, 27, 75, 100, 19, 141, 104, 115, 93, 95, and 117 as we3ll as handrail near room 715 have been repaired by the Maintenance director or designee.

3. All Maintenance staff were educated on homelike environment by the Administrator.

4. Education will be provided to the clinical staff by the Director of Nursing or designee to fill out maintenance request on repairs needed to residents areas.

5. Maintenance staff will be educated by the Administrator or designee to review maintenance request daily for needed repairs.

5. A full house audit will be performed by the Maintenance Director or designee to insure area to walls are repaired, night lights are functioning, and handrails are repaired.

6. Repairs will be made to all areas of concern by the Maintenance Director or designee.

7. An ongoing monthly audit will be performed by the Maintenance Director or designee of residents areas to insure areas are in good repair.

8. Results of the audit by the Maintenance director or designee will be reviewed in the faculties' Quality Assurance meeting by the Administrator or designee for the next three meetings

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

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

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

Observations:

Based on review of facility policies, closed resident records and staff interview, it was determined that the facility failed to acquire and document a physician's order for one out of five closed resident records (Closed Resident Record R142).

Findings include:

The facility "Resident discharge" policy last reviewed on 11/10/21, a resident may be discharge to his home or another facility. A discharge order signed within 24 hours shall be adequate.

Closed Resident Record R142's admission record admitted 1/26/22, and re-admitted on 2/3/22, with diagnoses that included dysfunction of the bladder, hypertension, chronic obstructive pulmonary disease (COPD-a disease characterized by persistent respiratory symptoms involving breathlessness, coughing, and obstructed airflow to the lungs), and Urinary tract infection (UTI-infection of urinary tract system).

Closed Resident Record R142's MDS assessment (MDS-Minimum Data Set Assessment: periodic assessment of resident care needs ) dated 2/7/22, indicated that the diagnoses remained current.

Closed Resident Record R142's nurse progress note dated 2/7/22, indicated that Nurse on duty received a call from his doctor stating that he and his family requested that he be discharged to the hospital. They feel as though he needs further treatment for his condition that cannot be provided at the facility. Staff spoke with Closed Resident Record R142's daughter and he was transported to Hospital via paramedics.

Closed Resident Record R142's physician orders did not indicate a signed order for him to discharge out to the hospital.

During an interview on 3/09/22, at 11:51 a.m. the Director of Nursing (DON) confirmed that the facility failed to document a physician's order for Closed Resident Record R142's as required.

28 Pa Code: 201.25 Discharge policy.
Previously cited 12/23/19

28 Pa Code: 201.29 (f) Resident rights.
Previously cited 12/23/19

28 Pa Code: 201.29 (g) Resident rights
Previously cited 12/23/19

Plan of Correction - To be completed: 04/13/2022

1.Hospital transfer order obtained for resident 142 by the Director of Nursing

2. Education was provided by the Director of Nursing or designee to all licensed staff to obtain physicians order to transfer to hospital

3. Physician order to transfer residents out to the hospital will be reviewed by the Director of Nursing or designee in the facilities clinical morning meeting.

4. An audit will be performed by the Director of Nursing or designee on all residents transfer to the hospital to insure a Physician order is obtained to transfer out of the facility 5 times per week for the next 3 weeks then weekly for the next two weeks.

5. Results of the audit and education performed by the Director of Nursing or designee will be reviewed by the Administrator or designee in the facilities Quality assurance meeting for the next three meetings.

483.25(l) REQUIREMENT Dialysis:

�483.25(l) Dialysis.
The facility must ensure that residents who require dialysis receive such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences.

Observations:

Based on review of facility policy, closed records and staff interview it was determined that the facility failed to acquire a dialysis service physician's order for one out of five closed resident Records (Closed Resident Record CR241).

Findings include:

The "Dialysis care" policy last reviewed on 11/10/21, indicated that hemodialysis devices may only be accessed by medical personnel who have received training and demonstrated clinical competency regarding use of these devices. The facility will approve a fully executed contract with a dialysis provider. The patient will be assessed as indicated and an order on the chart for dialysis to include location, days, and times.

Review of Closed Resident Record CR241's admission record indicated she was admitted on 2/4/22, with diagnoses that included hypertension (high pressure in arteries impacting blood flow), diabetes (metabolic disorder impacting organ function related to glucose levels in the human body), end stage renal disease (gradual loss of kidney function). and Chronic obstructive pulmonary disease (COPD-a disease characterized by persistent respiratory symptoms involving breathlessness, coughing, and obstructed airflow to the lungs).

Review of Closed Resident Record CR241's MDS assessment (MDS-Minimum Data Set Assessment: periodic assessment of resident care needs), dated 2/5/22, indicated that the diagnoses were current upon review.

Review of Closed Resident Record CR241's care plan dated 2/5/22, indicated a careplan for dialysis.

Review of Closed Resident Record CR241's nurse progress notes dated 2/5/22, indicated she was awaiting pickup for dialysis on lobby via wheelchair van. CR241's nurse progress note on 2/5/22, she returned from dialysis with her husband.

Review of Closed Resident Record CR241's physician's orders did not include an order to go out to dialysis, the days of dialysis services, and the location of dialysis services.

During an interview on 3/08/22, at 5:04 p.m. the Nursing Home Administrator (NHA) confirmed that the facility failed to acquire a dialysis service physician's order for Closed Resident Record CR241 as required.

28 Pa. Code: 201.14(a) Management

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

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

28 Pa Code: 211.2 (a )(c)(d)(1)(2) Physician Services.

Plan of Correction - To be completed: 04/13/2022

1. A one time audit will be performed by the Director of Nursing or designee on all dialysis residents' to insure physician orders are obtained for Dialysis including days of dialysis services and location of dialysis upon admission.

2. an audit will be performed by the Director of Nursing or designee on new dialysis residents and return from the hospital dialysis residents to insure physicians orders are obtained for Dialysis, Dialysis location and dialysis days of service.

3. All licensed staff will be educated by the Director of Nursing or designee on physician orders that include an order to go out to dialysis, the days of dialysis services, and the location of dialysis services.

4. Review of the physician orders for dialysis will be performed by the Director of nursing or designee as part of the facilities clinical meeting 5 times per week.

5. Results of the audit and education performed by the Director of Nursing or designee will be reviewed in the facilities monthly Quality Assurance meting by the Administrator or designee for the next three meetings.

� 201.19 LICENSURE Personnel policies and procedures.:

Personnel records shall be kept current and available for each employe and contain sufficient information to support placement in the position to which assigned.

Observations:
Based on review of personnel records and staff interviews, it was determined that the facility failed to maintain complete and accurate records for five of seven employees (Employee E5, E11, E12, E13, E14).

Findings include:

Review of the personnel records for Dishwasher Employee E5, with a hire date of 1/4/22, lacked reference checks.

Review of the personnel records for Licensed Practical Nurse Employee E11, with a hire date of 12/14/21, lacked reference checks.

Review of personnel records for Security Employee E12, with a hire date of 2/15/22, lacked reference checks.

Review of personnel records for Dietary Employee E13, with a hire date of 1/4/22, lacked reference checks.

Review of personnel records for Temporary Nurse Aide E14, with a hire date of 2/1/22, lacked reference checks.

During an interview on 3/9/22, at 9:45 a.m., the Human Resources Director Employee E15 confirmed that Employee E5, E11, E12, E13, and E14 personnel record did not include reference checks.

Plan of Correction - To be completed: 04/13/2022

1. Departments Heads responsible for interviewing and hiring of new staff, have been educated by the Administrator to obtain reference checks prior to employment.

2. Audit will be performed by the Human Resource Director or designee of all new hires in the past three months to insure reference checks were obtained.

3. Audits will be performed by the Human Resource Director or designee monthly to insure all reference checks on new hires are completed.

4.results of the audit performed by the Human Resource Director or designee will be reviewed by the Administrator or designee in the facilities Quality Assurance meeting for the next three meetings

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