Pennsylvania Department of Health
SCOTTDALE HEALTHCARE & REHABILITATION CENTER
Patient Care Inspection Results

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SCOTTDALE HEALTHCARE & REHABILITATION CENTER
Inspection Results For:

There are  103 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.
SCOTTDALE HEALTHCARE & REHABILITATION CENTER - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:


Based on a Medicare/Medicaid Recertification, State Licensure, and Civil Rights Compliance survey completed on November 19, 2024, it was determined that Scottdale Healthcare and Rehabilitation Center was not in compliance with the following requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care Facilities and the 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.







 Plan of Correction:


483.12(b)(5)(i)(A)(B)(c)(1)(4) REQUIREMENT Reporting of Alleged Violations:This is a less serious (but not lowest level) deficiency and 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.
§483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must:

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

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


Based on review of the Older Adults Protective Services Act, facility policies, information provided by the facility and residents' clinical records, as well as staff interviews, it was determined that the facility failed to report timely allegations of abuse to the State Survey Agency (Department of Health) and to other state agencies in accordance with state law for three of 30 residents reviewed (Residents 131, 132, 133).

Findings include:

The Older Adults Protective Services Act, 1997-13, Section 701 (a)(1)(2), indicated that it was mandatory to report to the Protective Services agency. An employee or an administrator who has reasonable cause to suspect that a recipient is a victim of abuse shall immediately make an oral report to the agency. If applicable, the agency shall advise the employee or administrator of additional reporting requirements that may pertain under subsection (b). An employee shall notify the administrator immediately following the report to the agency. Within 48 hours of making the oral report, the employee or administrator shall make a written report to the agency. The agency shall notify the administrator that a report of abuse has been made with the agency.

The facility's policy regarding reporting and investigating abuse, neglect, exploitation, or misappropriation, dated December 7, 2023, revealed that if resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law. The administrator or the individual making the allegation immediately reports his or her suspicion to the following persons or agencies: The state licensing/certification agency responsible for surveying/licensing the facility, the local/state ombudsman, the resident's representative, adult protective services, law enforcement officials, the resident's attending physician, and the facility's medical director. "Immediately" is defined as within two hours of an allegation involving abuse or results in serious bodily injury, or within 24 hours of an allegation that does not involve abuse or results in serious bodily injury.

An admission Minimum Data Set (MDS) assessments (a federally-mandated assessment of a resident's abilities and care needs) for Resident 131, dated August 11, 2024, revealed that the resident was understood, could understand others, and had a diagnosis which included a hip fracture. A care plan for the resident, dated August 5, 2024, revealed that the resident required limited to extensive assistance from staff.

An interview statement with Resident 131, undated, revealed that Nurse Aide 1 was like a Marine Sergeant, she is nasty. She asked if Nurse Aide 1 could put her leg up because it was falling, and the nurse aide told her do it herself, to lift her foot up. She then asked for the bed control, and the nurse aide told her she could not have it to put her head up and down. The resident said that she always had it. Nurse Aide 1 said if they found out that she gave it to the resident, she would be fired, and she continued to be argumentative. The resident said that she just wanted Nurse Aide 1 out of her room. So, she told Nurse Aide 1 that her son lives right down the road, and she will call him and have him come and take her out of here. She said that she does not want Nurse Aide 1 to take care of her because she was scared of her.

An admission MDS assessment for Resident 132, dated August 2, 2024, revealed that the resident was understood, could understands others, and had diagnoses that included a fractured tibia (the shinbone, the larger of the two bones in the lower leg). A care plan for the resident, dated July 26, 2024, revealed that the resident required limited to extensive assistance from staff.

A statement completed by Nurse Aide 2, dated August 14, 2024, revealed that on August 13, 2024, while responding to Resident 132's light, the resident was telling her how she has not seen her in a while, and she had missed her. The nurse aide told her that she missed her too and asked how she has been. The resident told her how her therapy was helping her and how everyone but one person was nice to her. The nurse aide responded with, "Oh no, I'm sorry to hear that." The nurse aide asked her if she wanted to or felt comfortable speaking to her. The resident then told the nurse aide that she had an accident the night prior and Nurse Aide 1 went in and was being rude to her. She said that Nurse Aide 1 was upset with her and stated, "I'm done, I'm so f*****g done," and as the nurse aide put her table back beside her bed, Nurse Aide 1 knocked her pop down to the floor and did not pick it back up. Resident 132 had to pick up the soda.

An interview statement with Resident 132 completed by Registered Nurse 3, dated August 14, 2024, revealed that Nurse Aide 1 came in after the resident had an accident. Nurse Aide 1 came in all huffy and puffy because she had to change the resident's bed. Nurse Aide 1 told the resident you have to get out of bed, because I am not going to roll you, so then she knocked over the pop and stated, "I'm f*****g done." So, the resident cleaned up the pop and then Nurse Aide 1 came in to care for her roommate and was rude with her roommate and told her that she could not put the head of her bed up, and told her she could be fired if she gave her roommate the remote. As per the resident, this was not the first time. The first time it happened, she let it go. She just figured Nurse Aide 1 was tired or did not feel good.

An admission MDS assessment for Resident 133, dated July 11, 2024, revealed that the resident was understood, could understand others, and had a diagnosis which included heart failure (a serious condition that occurs when the heart is unable to pump enough blood and oxygen to the body's organs) and gastrostomy (a surgical procedure that creates an opening in the abdomen that allows a feeding tube to be inserted directly into the stomach). A care plan for the resident, dated September 10, 2024, revealed that the resident required extensive assistance from staff.

A statement completed by Nurse Aide 2, dated August 15, 2024, revealed that that night while helping Resident 133 into bed, the resident's wife had asked the Nurse Aide 2 if it was okay if she helped her husband with his urinal when he has to go. Nurse Aide 2 told her that if she wanted to, she was allowed to help him with his urinal. She then told Nurse Aide 2 that Nurse Aide 1 had come into his room one time as she was helping him with his urinal and snatched it out of her hand, and as she snatched out it out of her hand she was yelling at the resident's wife. The resident's wife also told Nurse Aide 2 that Nurse Aide 1 was always very aggressive with him and whips him back and forth in the bed. Nurse Aide 2 immediately came out of the room and notified the supervisor about the statement/accusations that the resident's wife had said.

Interview with Registered Nurse 3 on November 14, 2024, at 9:35 a.m. revealed that she interviewed Resident 131 on August 14, 2024, after learning that the resident had concerns with Nurse Aide 1 while interviewing Resident 132 after learning that she had care concerns with Nurse Aide 1.

There was no documented evidence until August 20, 2024, that the facility reported the allegations of possible abuse for Residents 131, 132, and 133 to the State Survey Agency (Department of Health), Protective Services agency, and the local police department.

Interview with the Director of Nursing on November 14, 2024, at 10:55 a.m. confirmed that the allegations of possible abuse for Residents 131, 132, and 133 were not reported to the State Survey Agency (Department of Health), Protective Services agency, or the local police department until August 20, 2024. She indicated that she was on vacation when the incidents occurred.

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

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





 Plan of Correction - To be completed: 12/27/2024

1. Nurse aide 1 was suspended pending investigation immediately after Director of nursing was made aware of encounters on 8-14-24. After investigation, nurse aide 1 was terminated due to poor customer service. Nurse aide 1 did not have any contact with the residents once investigation was initiated on 8-14-24.
2. House audit completed to ensure all allegations of abuse were reported timely for the last 2 months.
3. Nursing Home Administrator will re-educate Director of nursing on the requirements for reporting abuse/potential abuse allegations.
4. Nursing home Administrator/ designee will audit all allegations of abuse weekly to ensure they were reported timely for 2 months with results to the facility Quality Assessment and Assurance Committee.

483.45(a)(b)(1)-(3) REQUIREMENT Pharmacy Srvcs/Procedures/Pharmacist/Records:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
§483.45 Pharmacy Services
The facility must provide routine and emergency drugs and biologicals to its residents, or obtain them under an agreement described in §483.70(f). The facility may permit unlicensed personnel to administer drugs if State law permits, but only under the general supervision of a licensed nurse.

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

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

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

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

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


Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to maintain accountability for controlled medications (drugs with the potential to be abused) for three of 30 residents reviewed (Residents 12, 22, 26).

Findings include:

The facility's policy regarding the administration of oral medications, dated December 7, 2023, indicated that the nurse was to document all medications administered to each resident on the resident's medication administration record (MAR).

A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 12, dated September 19, 2024, indicated that the resident was understood and could understand others, required assistance with daily care needs, received antianxiety and opioid medications, was receiving oxygen therapy and hospice services, and had a diagnosis of congestive heart (the heart cannot pump blood well enough to meet the body's needs).

Physician's orders for Resident 12, dated September 11, 2024, included an order for the resident to receive 0.5 milligrams (mg) of Ativan (Lorazepam - a controlled medication used to treat anxiety) every four hours as needed for anxiety/restlessness for 14 days (end date of September 25, 2024).

A review of Resident 12's controlled drug record (a form that accounts for each tablet/pill/dose of a controlled drug)
for September 2024 revealed that a 0.5 mg tablet of Lorazepam was signed out for the resident on September 13, 2024, at 8:00 p.m. and September 23, 2024, at 10:30 p.m. However, the resident's clinical record, including the MAR and nursing notes, contained no documented evidence that the signed-out 0.5 mg doses of Lorazepam were administered to the resident on these dates and times.

A review of Resident 12's controlled drug record for October 2024 revealed that a 0.5 mg tablet of Lorazepam was signed out for the resident on October 26, 2024, at 12:00 a.m. and on October 27, 2024, at 10:30 p.m. However, the resident's clinical record, including the MAR and nursing notes, contained no documented evidence of an active physician's order for Lorazepam or that the signed-out doses were administered to the resident on these dates and times.

Physician's orders for Resident 12, dated April 11, 2024, included an order for the resident to receive 50 mg of Tramadol (narcotic pain reliever) every six hours as needed for moderate to severe pain.

A review of Resident 12's controlled drug record for August, September, and November 2024 revealed that a 50 mg tablet of Tramadol was signed out for the resident on August 10, 2024, at 6:30 a.m.; August 17, 2024, at 4:58 p.m. and 10:58 p.m.; August 23, 2024, at 7:35 a.m.; August 24, 2024, at 9:05 a.m.; September 2, 2024, at 1:37 p.m.; September 5, 2024, at 8:00 p.m.; September 8, 2024, at 8:10 a.m.; September 23, 2024, at 8:30 p.m.; September 24, 2024, at 12:17 a.m.; and on November 5, 2024 at 6:24 p.m. However, the resident's clinical record, including the MAR and nursing notes, contained no documented evidence that the signed-out 50 mg tablets of Tramadol were administered to the resident on these dates.

Interview with the Director of Nursing on November 13, 2024, at 2:35 p.m. confirmed that there was no documented evidence that staff administered the controlled drugs to Resident 12 on the above-mentioned dates and times.

An admission MDS assessment for Resident 22 dated October 4, 2024, revealed that the resident was cognitively intact, required assistance from staff for daily care needs, and had diagnoses that included anemia, high blood pressure, and chronic obstructive pulmonary disease.

Physician's orders for Resident 22, dated September 27, 2024, included an order for the resident to receive 0.25 milliliters (ml) of Morphine Sulfate (controlled pain medication) every two hours as needed for pain.

A review of Resident 22's controlled drug record (a form that accounts for each tablet/pill/dose of a controlled drug) for October and November 2024 revealed that 0.25 ml of Morphine was signed out for the resident on October 8, 2024, at 2:53 a.m.; October 31, 2024, at 1:00 a.m.; November 4 2024, at 12:23 a.m.; November 7, 2024, at 2:25 a.m.; November 13, 2024, at 3:55 a.m. However, the resident's clinical record, including the MAR and nursing notes, contained no documented evidence that the signed-out 0.25 ml doses of Morphine were administered to the resident on these dates.

An interview with the Director of Nursing on November 13, 2024, at 12:08 p.m. confirmed that there was no documented evidence that staff administered the controlled drugs to Resident 22 on the dates mentioned above.

An admission MDS assessment for Resident 26, dated October 8, 2024, revealed that the resident was cognitively intact, had pain, received routine and "as needed" pain medications, and received an opioid (narcotic pain medication).

Physician's orders for Resident 26, dated October 2, 2024, included an order for the resident to receive 5 mg of oxycodone (narcotic pain medication) every six hours as needed.

The resident's controlled drug record for October and November 2024 indicated that one dose of oxycodone was signed-out for administration to the resident on October 2 at 10:30 p.m., October 26 at 4:00 a.m., October 28 at 8:42 a.m., October 30 at 9:00 p.m., November 2 at 10:15 a.m., and November 8, 2024, at 9:00 p.m. However, the resident's clinical record, including the Medication Administration Records (MAR's) and nursing notes, contained no documented evidence that the signed-out doses of oxycodone were actually administered to the resident on these dates and times.

Interview with the Director of Nursing on November 13, 2024, at 1:58 p.m. confirmed that there was no documented evidence that staff administered the signed-out doses of oxycodone to Resident 26 on the above dates and times.

28 Pa. Code 211.9(h) Pharmacy Services.

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




 Plan of Correction - To be completed: 12/27/2024

1. Resident 12, 22 and 26 were not adversely affected and received their medications as needed.
2. Director of Nursing completed a facility sweep of all controlled substances at the time of the surveyor's observation. The Registered Nurse Supervisors are completing a 24 hour look back each day to ensure proper documentation of controlled substances are in place. Any discrepancies will be addressed immediately with nurses and management.
3. Director of nursing/ designee will re-educate all licensed nurses on complete documentation on the controlled drug record and electronic medical record.
4.. An audit of Medication Administration Records will be completed by the Director of Nursing or designee to ensure all medications signed on Controlled Drug Records are also documented on each corresponding resident's Medication Administration Record weekly for 4 weeks with results to the facility Quality Assessment and Assurance Committee.

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 clinical record reviews and staff interviews, it was determined that the facility failed to administer medications and obtain weights as ordered by the physician for two of 30 residents reviewed (Residents 5, 17).

Findings include:

A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 5, dated October 9, 2024, revealed that the resident was moderately cognitively intact, required assistance from staff for daily care needs and had diagnoses that included heart failure.

Physician's orders for Resident 5, dated October 7, 2024, included an order for the resident to receive 5 milligrams (mg) of Midodrine (a medication that treats low blood pressure) three times a day for hypotension (low blood pressure) and was to be held if the systolic blood pressure (the top number in a blood pressure reading) was greater than 130 millimeters of mercury (mmHg).

A review of Resident 5's Medication Administration Record (MAR) for October and November 2024 revealed that staff administered the 5 mg of Midodrine when the resident's blood pressure was 138/76 mmHg at 8:00 a.m. on October 8; 135/76 mmHg at 8:00 a.m. on October 14; 132/82 mmHg at 2:00 p.m. on October 14; 140/90 mmHg at 2:00 p.m. on October 30; 134/80 mmHg at 8:00 p.m. on October 30; 138/78 mmHg at 8:00 a.m. on November 1; 132/78 mmHg at 2:00 p.m. on November 1; 142/68 mmHg at 8:00 a.m. on November 2; 144/76 mmHg at 2:00 p.m. on November 2; 138/74 mmHg at 2:00 p.m. on November 5; 133/74 mmHg at 2:00 p.m. on November 11; and 138/71 mmHg at 8:00 p.m. on November 8, 2024.

Interview with the Director of Nursing on November 14, 2024, at 10:50 a.m. confirmed that Resident 5 received the Midodrine on the above dates and that staff should have held the medication as ordered.

A quarterly MDS assessment for Resident 17, dated October 10, 2024, indicated that the resident was cognitively impaired, required assistance with daily care needs, was on a diuretic medication, and had diagnoses that included chronic kidney disease Stage 3 (moderate to severe loss of kidney function) and congestive heart failure (the heart cannot pump blood as well as it should, causing weight gain due to fluid build up in the lungs and lower legs).

A physician's note for Resident 17, dated April 8, 2024, at 8:56 p.m., indicated that the resident had increased left upper extremity edema and bilateral lower extremity edema.

Physician's orders for Resident 17, dated April 17, 2024, included orders to increase the Lasix to 60 milligrams daily, obtain bloodwork in a week, and to weigh the resident weekly on Thursdays.

A review of Resident 17's MAR for May, June, August, September, October and November 2024 revealed that the resident was not weighed as ordered on May 2, June 13, June 20, June 27, August 8, August 29, September 5, October 10, October 17, October 31, and November 7, 2024, and no documentation in the clinical record to indicate that the weights were attempted and refused by the resident on those days.

Interview with the Director of Nursing on November 13, 2024, at 1:33 p.m. confirmed that Resident 17's weights were not obtained as ordered on the above-mentioned dates.

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



 Plan of Correction - To be completed: 12/27/2024

1. Resident 5 did not have any adverse reactions to medication administration. Resident 17 did not have any adverse effects from not being weighed according to physician orders. Physician notified.
2. Current residents with orders for parameters with medication administration and weights ordered with diuretic medications will be reviewed by the facility Director of Nursing or designee with the attending physician. The facility interdisciplinary team will review new orders with parameters and weekly weights during clinical standup.
3. Director of nursing/ Designee will re-educate Registered nurses and Licensed practical nurses on medication parameters and obtaining weekly weights due to diuretics.
4. Director of nursing/ designee will conduct 3 audits weekly for 6 weeks to ensure Registered Nurses and Licensed Practical nurses are following medication parameters obtaining weights due to diuretics and documenting correctly with results to the facility Quality Assessment and Assurance Committee.

483.15(c)(3)-(6)(8) REQUIREMENT Notice Requirements Before Transfer/Discharge:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
§483.15(c)(3) Notice before transfer.
Before a facility transfers or discharges a resident, the facility must-
(i) Notify the resident and the resident's representative(s) of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand. The facility must send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman.
(ii) Record the reasons for the transfer or discharge in the resident's medical record in accordance with paragraph (c)(2) of this section; and
(iii) Include in the notice the items described in paragraph (c)(5) of this section.

§483.15(c)(4) Timing of the notice.
(i) Except as specified in paragraphs (c)(4)(ii) and (c)(8) of this section, the notice of transfer or discharge required under this section must be made by the facility at least 30 days before the resident is transferred or discharged.
(ii) Notice must be made as soon as practicable before transfer or discharge when-
(A) The safety of individuals in the facility would be endangered under paragraph (c)(1)(i)(C) of this section;
(B) The health of individuals in the facility would be endangered, under paragraph (c)(1)(i)(D) of this section;
(C) The resident's health improves sufficiently to allow a more immediate transfer or discharge, under paragraph (c)(1)(i)(B) of this section;
(D) An immediate transfer or discharge is required by the resident's urgent medical needs, under paragraph (c)(1)(i)(A) of this section; or
(E) A resident has not resided in the facility for 30 days.

§483.15(c)(5) Contents of the notice. The written notice specified in paragraph (c)(3) of this section must include the following:
(i) The reason for transfer or discharge;
(ii) The effective date of transfer or discharge;
(iii) The location to which the resident is transferred or discharged;
(iv) A statement of the resident's appeal rights, including the name, address (mailing and email), and telephone number of the entity which receives such requests; and information on how to obtain an appeal form and assistance in completing the form and submitting the appeal hearing request;
(v) The name, address (mailing and email) and telephone number of the Office of the State Long-Term Care Ombudsman;
(vi) For nursing facility residents with intellectual and developmental disabilities or related disabilities, the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with developmental disabilities established under Part C of the Developmental Disabilities Assistance and Bill of Rights Act of 2000 (Pub. L. 106-402, codified at 42 U.S.C. 15001 et seq.); and
(vii) For nursing facility residents with a mental disorder or related disabilities, the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with a mental disorder established under the Protection and Advocacy for Mentally Ill Individuals Act.

§483.15(c)(6) Changes to the notice.
If the information in the notice changes prior to effecting the transfer or discharge, the facility must update the recipients of the notice as soon as practicable once the updated information becomes available.

§483.15(c)(8) Notice in advance of facility closure
In the case of facility closure, the individual who is the administrator of the facility must provide written notification prior to the impending closure to the State Survey Agency, the Office of the State Long-Term Care Ombudsman, residents of the facility, and the resident representatives, as well as the plan for the transfer and adequate relocation of the residents, as required at § 483.70(k).
Observations:


Based on clinical record reviews and staff interviews, it was determined that the facility failed to notify the resident and resident's representative in writing of the transfer and reason for hospitalization for seven of 30 residents reviewed (Residents 1, 5, 9, 14, 22, 23, 24.). This deficiency was cited as past noncompliance.

Findings include:

A nursing note for Resident 1, dated February 5, 2024, at 1:39 p.m., revealed that Resident 1 was being admitted to the hospital for osteomyelitis. There was no documented evidence that a written notice of Resident 1's transfer to the hospital was provided to the resident's representative and state ombudsman regarding the reason for transfer.

Nursing notes for Resident 5, dated September 26, 2024, at 3:06 a.m. and 5:36 a.m., revealed that the resident had a change in mental status with increased confusion, garbled speech, and bad chest pain. The physician was notified and the resident was sent to the hospital for evaluation. She was admitted to the hospital with chest pain, fever, abdominal pain, altered mental status, and leukocytosis (high white blood cell count). There was no documented evidence that a written notice of Resident 5's transfer to the hospital was provided to the resident's representative and state ombudsman regarding the reason for transfer.

A nursing note for Resident 9, dated October 11, 2024, at 11:22 p.m., indicated that the resident was very lethargic and her pulse oximetry (measures blood oxygen levels) initially was 78 percent on room air. Oxygen was applied at 4 liters per minute via nasal cannula (a small tube that delivers oxygen through the nasal passages) and her pulse oximetry increased to 91 percent. Her oxygen was turned up to 8 liters per minute via nasal cannula and her pulse oximetry increased to 99 percent. The resident was transferred to the emergency room for an evaluation. There was no documented evidence that a written notice of Resident 9's transfer to the hospital was provided to the resident's representative and state ombudsman regarding the reason for transfer.

A nursing note for Resident 14, dated April 6, 2024, revealed that the resident had chest pain that was radiating to the left upper extremity. The CRNP was notified and ordered the resident to be transferred to the local emergency room. There was no documented evidence that a written notice of Resident 14's transfer to the hospital was provided to the resident's representative and state ombudsman regarding the reason for transfer.

A nursing note for Resident 22, dated October 21, 2024, at 2:33 p.m., revealed that the resident had fallen in the bathroom. After the fall, the resident rolled to her right side because she was having pain to her left hip and wrist. The resident's left wrist was swollen and very painful to touch and the resident was unable to straighten her leg. The CRNP was notified and ordered the resident to be transferred to the local emergency room. A nursing note, dated October 21, 2024, at 11:59 p.m., revealed that Resident 22 was admitted with a left hip fracture and a left wrist fracture. There was no documented evidence that a written notice of Resident 22's transfer to the hospital was provided to the resident's representative and state ombudsman regarding the reason for transfer.

Nursing notes for Resident 23, dated October 1, 2024, at 9:38 a.m. and 12:37 p.m., revealed that the resident had severe left knee pain that was red/purple in color, was hot to tough, and had drainage from the incision site. She was transferred to the hospital and admitted with cellulitis (bacterial skin infection). There was no documented evidence that a written notice of Resident 23's transfer to the hospital was provided to the resident's representative and state ombudsman regarding the reason for transfer.

A nursing note for Resident 24, dated July 18, 2024, at 3:04 p.m., revealed that the resident had gastrointestinal pain with diarrhea, pain, and intermittent fever. An order was obtained to transfer the resident to the local emergency room. A nursing note, dated July 18, 2024, at 9:32 p.m., revealed that Resident 24 was being admitted with colitis and urinary tract infection. There was no documented evidence that a written notice of Resident 24's transfer to the hospital was provided to the resident's representative and state ombudsman regarding the reason for transfer.

Interview with the Director of Nursing on November 13, 2024, at 11:18 p.m. confirmed that the facility did not provide a written notice to the above residents and/or their representative when the residents were transferred to the hospital. She also confirmed that the facility did not notify the state ombudsman of transfers to the hospital. The Director of Nursing indicated that they had identified the issue of not providing written notices of the transfers to the hospital on October 25, 2024.

Following the identification on October 25, 2024, that they were not providing the written notices to the resident and/or the resident's representative and state ombudsman when the resident was transferred to the hospital, the facility's corrective actions included:

Education was provided to staff regarding the required written notice that was to be given to the resident and/or the resident's representative when the resident was transferred to the hospital. Education was provided to staff regarding the required notice to the state ombudsman when the resident was transferred to the hospital.

Audits were started on all residents that were transferred to the hospital.

The results of these audits will be brought to the Quality Assurance Performance Improvement committee for further analysis and corrective actions if necessary.

Review of the facility's corrective actions and interviews completed with staff regarding their re-education revealed that they were in compliance with F623 on November 11, 2024.

28 Pa. Code 201.25 Discharge Policy.

28 Pa. Code 201.29(f)(g) Resident Rights.




 Plan of Correction - To be completed: 12/09/2024

Past noncompliance: no plan of correction required.
483.20(b)(1)(2)(i)(iii) REQUIREMENT Comprehensive Assessments & Timing: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.
§483.20 Resident Assessment
The facility must conduct initially and periodically a comprehensive, accurate, standardized reproducible assessment of each resident's functional capacity.

§483.20(b) Comprehensive Assessments
§483.20(b)(1) Resident Assessment Instrument. A facility must make a comprehensive assessment of a resident's needs, strengths, goals, life history and preferences, using the resident assessment instrument (RAI) specified by CMS. The assessment must include at least the following:
(i) Identification and demographic information
(ii) Customary routine.
(iii) Cognitive patterns.
(iv) Communication.
(v) Vision.
(vi) Mood and behavior patterns.
(vii) Psychological well-being.
(viii) Physical functioning and structural problems.
(ix) Continence.
(x) Disease diagnosis and health conditions.
(xi) Dental and nutritional status.
(xii) Skin Conditions.
(xiii) Activity pursuit.
(xiv) Medications.
(xv) Special treatments and procedures.
(xvi) Discharge planning.
(xvii) Documentation of summary information regarding the additional assessment performed on the care areas triggered by the completion of the Minimum Data Set (MDS).
(xviii) Documentation of participation in assessment. The assessment process must include direct observation and communication with the resident, as well as communication with licensed and nonlicensed direct care staff members on all shifts.

§483.20(b)(2) When required. Subject to the timeframes prescribed in §413.343(b) of this chapter, a facility must conduct a comprehensive assessment of a resident in accordance with the timeframes specified in paragraphs (b)(2)(i) through (iii) of this section. The timeframes prescribed in §413.343(b) of this chapter do not apply to CAHs.
(i) Within 14 calendar days after admission, excluding readmissions in which there is no significant change in the resident's physical or mental condition. (For purposes of this section, "readmission" means a return to the facility following a temporary absence for hospitalization or therapeutic leave.)
(iii)Not less than once every 12 months.
Observations:


Based on review of the Resident Assessment Instrument User's Manual and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that comprehensive admission Minimum Data Set assessments were completed in the required timeframe for four of 30 residents reviewed (Residents 181, 182, 183, 184).

Findings include:

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 2024, indicated that an admission MDS assessment was to be completed no later than 14 days (admission date + 13 calendar days) following admission.

A comprehensive admission MDS assessment for Resident 181, dated July 29, 2024, revealed that the resident was admitted to the facility on July 23, 2024, and the resident's admission MDS assessment was dated as completed on August 7, 2024, which was 16 days after admission.

A comprehensive admission MDS assessment for Resident 182, dated August 11, 2024, revealed that the resident was admitted to the facility on August 5, 2024, and the resident's admission MDS assessment was dated as completed on August 19, 2024, which was 15 days after admission.

A comprehensive admission MDS assessment for Resident 183, dated August 18, 2024, revealed that the resident was admitted to the facility on August 12, 2024, and the resident's admission MDS assessment was dated as completed on August 26, 2024, which was 15 days after admission.

A comprehensive admission MDS assessment for Resident 184, dated June 18, 2024, revealed that the resident was admitted to the facility on June 12, 2024, and the resident's admission MDS assessment was dated as completed on June 26, 2024, which was 15 days after admission.

An interview with the Regional Registered Nurse Assessment Coordinator (RNAC - a registered nurse who is responsible for the completion of MDS assessments) on November 14, 2024, at 1:44 p.m. confirmed that Residents 181, 182, 183 and 184's admission MDS assessments were not completed within the required time frames.

28 Pa. Code 211.5(f) Clinical Records.




 Plan of Correction - To be completed: 12/27/2024

1. Residents 181, 182, 183 and 184 comprehensive assessments were completed.
2. Current residents will be reviewed by the facility Regional Director of Clinical Reimbursement or designee to ensure applicable comprehensive assessment is completed. MDS (Minimum Data Set) scheduled and in progress tabs will be reviewed in PointClickCare which is our electronic medical record during clinical standup with the interdisciplinary team for timing and completion deadlines to identify any assessments approaching completion deadlines and prioritize for completion.
3. The Regional Director of Clinical Reimbursement or designee will re-educate the facility interdisciplinary team on MDS completion deadlines for comprehensive assessments utilizing the RAI (Resident Assessment Instrument) manual.
4.. The Regional Director of Clinical Reimbursement or designee will conduct a random audit of completion for comprehensive MDS assessments 5 per week for 2 weeks and then monthly x1 with results to the facility Quality Assessment and Assurance Committee.

483.20(c) REQUIREMENT Qrtly Assessment at Least Every 3 Months: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.
§483.20(c) Quarterly Review Assessment
A facility must assess a resident using the quarterly review instrument specified by the State and approved by CMS not less frequently than once every 3 months.
Observations:


Based on review of the Resident Assessment Instrument Manual and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that quarterly Minimum Data Set assessments were completed within the required time frame for four of 30 residents reviewed (Resident 10, 11, 18, 29).

Findings include:

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 2024, indicated that the assessment reference date (ARD - the last day of the assessment's look-back period) of a quarterly MDS assessment must be no more than 92 days after the ARD of the most recent assessment of any type, and the assessment was to have a completion date (Section Z0500B) that was no later than the ARD plus 14 calendar days.

A quarterly MDS assessment for Resident 10 had an ARD of August 9, 2024, which was 93 days after the previous quarterly MDS assessment with an ARD of May 8, 2024.

A quarterly MDS assessment for Resident 11 had an ARD of August 3, 2024, but it was not completed (Section Z0500B) until August 19, 2024, which was two days late.

A quarterly MDS assessment for Resident 18 had an ARD of August 2, 2024, but it was not completed (Section Z0500B) until August 19, 2024, which was three days late.

A quarterly MDS assessment for Resident 29 had an ARD of August 4, 2024, which was 93 days after the previous quarterly MDS assessment with an ARD of May 3, 2024.

An interview with the Regional Registered Nurse Assessment Coordinator (RNAC - a registered nurse who is responsible for the completion of MDS assessments) on November 14, 2024, at 1:44 p.m. confirmed that the above referenced quarterly MDS assessments were not completed within the required time frames.

28 Pa. Code 211.5(f) Clinical Records.



 Plan of Correction - To be completed: 12/27/2024

A schedule was completed to ensure that all current residents will have OBRA assessments completed per RA I (resident assessment Instrument) manual. OBRA assessments are omnibus budget reconciliation act of 1990 which an admission, quarterly and annual assessments on each resident .
All new or readmitted residents will be added to the schedule on the Assessment Reference Date (ARD) of their initial admission assessment. Current residents will be reviewed by the Regional Director of Clinical Reimbursement/ designee to ensure applicable quarterly assessments are completed.
3. The Regional Director of Clinical Reimbursement or designee will re-educate the Registered Nurse Assessment Coordinator on schedule for setting ARD'S and completing MDS assessments per The Resident Assessment Instrument.
4. The Regional Director of Clinical Reimbursement or designee will audit 5 Minimum Data Sets per week for 1 month, then 5 per month for two months to assure that the Assessment Reference Date and the completion Date comply with the Resident Assessment Instrument with results to the facility Quality Assessment and Assurance Committee.

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


Based on review of the Resident Assessment Instrument User's Manual and clinical records, as well as staff interviews, it was determined that the facility failed to complete accurate Minimum Data Set assessments for three of 30 residents reviewed (Residents 5, 22, 23).

Findings include:

The Resident Assessment Instrument (RAI) User's Manual, which gives instructions for completing Minimum Data Set (MDS) assessments (required assessments of a resident's abilities and care needs), dated October 2024, revealed that Section N0415J1 Hypoglycemic Medications was to be coded if the resident took hypoglycemic medication during the seven-day look-back period and Section N0415K1 was to be coded if the resident took anticonvulsant medication during the seven-day look-back period

Physician's orders for Resident 5, dated October 3, 2024, included orders for the resident to receive 500 milligrams (mg) of Metformin (medication used to lower blood sugars) one time a day for diabetes. There was no physician's order for the resident to receive an anticonvulsant medication.

Review of the Medication Administration Record (MAR) for Resident 5, dated October 2024, revealed that staff had administered the Metformin during the seven-day look-back period.

A quarterly MDS assessment for Resident 5, dated October 9, 2024, revealed that Section N0415J1 was not coded, indicating that the resident did not receive hypoglycemic medication during the seven-day look-back assessment period and Section N0415K1 was coded, indicating that the resident received an anticonvulsant medication during the seven-day look-back period.

Interview with the Regional Registered Nurse Assessment Coordinator on November 14, 2024, at 12:20 p.m. confirmed that Resident 5 received a hypoglycemic medication during the look-back period, did not receive an anticonvulsant medication during the look-back period, and that the assessment was coded inaccurately.

The RAI User's Manual, dated October 2024, indicated that the intent of Section N was to record the number of days during the seven days of the assessment period that any type of injection, insulin, and/or select medications were received by the resident.

An admission MDS assessment for Resident 22, dated October 4, 2024, revealed that Section N0300 indicated that the resident received an injection on one day of the assessment period.

A review of Resident 22's Medication Administration Record (MAR) for September and October 2024 revealed that the resident did not receive any injections.

Interview with the Regional Registered Nurse Assessment Coordinator on November 14, 2024, at 12:18 p.m. confirmed that Resident 22 did not receive an injection during the look-back period and that the assessment was coded inaccurately.

The RAI User's Manual, dated October 2023, revealed that Section N0415E1 (Anticoagulant Medications - medications that thin the blood) was to be coded if the resident received an anticoagulant medication during the seven-day assessment period; Section N0415H1 Opioid Medications (narcotic medications used to treat pain) was to be coded if the resident used an opioid during the seven-day assessment period; and Section N0415K1 (Anticonvulsant Medications- used to treat seizure disorder) was to be coded if the resident used an anticonvulsant during the seven-day assessment period.

Physician's orders for Resident 23, dated October 8, 2024, included orders for the resident to receive 40 mg of Enoxaparin (an anticoagulant medication) subcutaneously (beneath the skin) one time a day and 5-325 mg of Percocet (a narcotic pain medication) every four hours as needed for pain. There was no physician's order for an anticonvulsant medication. The resident's MAR for October 2024 revealed that the resident received Enoxaparin and Percocet during the assessment's look-back period.

A significant change MDS assessment for Resident 23, dated October 14, 2024, revealed that sections N0415E1 and N0415J1 were not coded, indicating that the resident did not receive anticoagulant and opioid medications during the seven-day look-back assessment period, and Section N0415K1 was coded, indicating that the resident received an anticonvulsant medication during the seven-day look-back assessment period.

Interview with the Regional Registered Nurse Assessment Coordinator on November 14, 2024, at 12:20 p.m. confirmed that Resident 23 received anticoagulant and opioid medications, did not receive an anticonvulsant medication during the look-back period, and that the assessment was coded inaccurately.

28 Pa. Code 211.5(f) Clinical Records.




 Plan of Correction - To be completed: 12/27/2024

1.MDS (Minimum Data Set) sections coded in error on residents 5, 22 and 23 were modified in accordance with RAI (Resident Assessment Instrument) manual guidelines.
2. An audit on all current residents most recent MDS to ensure section N was coded accurately per the RAI manual guidelines.
3. The Regional Director of Clinical Reimbursement or designee will re-educate the facility RNAC (Registered Nurse Assessment Coordinator) on accurately coding sections N of the resident MDS in accordance with applicable RAI manual guidelines which is available in PointClickCare as a quick reference for each section. Point click care is the electronic medical record.
4. The Regional Director of Clinical Reimbursement or designee will conduct a random audit of MDS coding accuracy of sections N 5 x per week x 1 month, then 5 x per month x 2 months with results to the facility Quality Assessment and Assurance Committee.

483.21(b)(1)(3) REQUIREMENT Develop/Implement Comprehensive Care Plan: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.
§483.21(b) Comprehensive Care Plans
§483.21(b)(1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at §483.10(c)(2) and §483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following -
(i) The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under §483.24, §483.25 or §483.40; and
(ii) Any services that would otherwise be required under §483.24, §483.25 or §483.40 but are not provided due to the resident's exercise of rights under §483.10, including the right to refuse treatment under §483.10(c)(6).
(iii) Any specialized services or specialized rehabilitative services the nursing facility will provide as a result of PASARR recommendations. If a facility disagrees with the findings of the PASARR, it must indicate its rationale in the resident's medical record.
(iv)In consultation with the resident and the resident's representative(s)-
(A) The resident's goals for admission and desired outcomes.
(B) The resident's preference and potential for future discharge. Facilities must document whether the resident's desire to return to the community was assessed and any referrals to local contact agencies and/or other appropriate entities, for this purpose.
(C) Discharge plans in the comprehensive care plan, as appropriate, in accordance with the requirements set forth in paragraph (c) of this section.
§483.21(b)(3) The services provided or arranged by the facility, as outlined by the comprehensive care plan, must-
(iii) Be culturally-competent and trauma-informed.
Observations:


Based on clinical record reviews and staff interviews, it was determined that the facility failed to develop comprehensive care plans that included specific and individualized interventions to address the care needs of one of 30 residents reviewed (Resident 5).

Findings include:

A facility policy for Comprehensive Person-Centered Care Plans, dated December 7, 2023, included that a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Assessments of residents are ongoing and care plans are revised as information about the resident and resident's condition change.

A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 5, dated October 9, 2024, revealed that the resident was moderately cognitively impaired, was always incontinent of urine, and received an antibiotic.

Physician's orders, dated July 24, 2024, included orders for the resident to receive 100 milligrams (mg) of Macrobid (an antibiotic) twice a day for five days for a urinary tract infection (UTI). Physician's orders, dated August 4, 2024, included orders for the resident to receive 500 mg of Keflex (an antibiotic) four times a day for 10 days for a UTI. Physician's orders, dated October 19, 2024, included orders for the resident to receive 500 mg of Keflex (an antibiotic) one time a day for seven days for a UTI.

A nursing note, dated October 19, 2024, at 12:43 p.m., revealed that Resident 5's daughter was concerned about the resident's frequent UTI's.

There was no documented evidence that a care plan was developed to address Resident 5's specific and individualized care needs related to frequent UTI's.

Interview with the Director of Nursing on November 14, 2024, at 1:45 p.m. confirmed that an individualized care plan and interventions were not developed related to Resident 5's frequent UTI's.

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



 Plan of Correction - To be completed: 12/27/2024

1..Resident R5's care plan was updated to include care plan for frequent UTI's (Urinary Tract Infections).
2.All current residents being treated for Urinary tract infections had their care plans audited to assure that they had a care plan in place to address the infection
3.The facility Director of Nursing or designee will re-educate the licensed nursing staff on creating or updating care plans with any new diagnosis of Urinary tract infections or for residents with frequent urinary tract infections.
4. The Registerd Nurse Assessment Coordinator or designee will run a new order report weekly for 5 days to assure that all care plans have been updated appropriately for 1 month, then 2 days a week for 1 month with results of the audit presented at the monthly quality assurance meeting.

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


Based on review of facility polices and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that a resident's care plan was updated/revised to reflect the resident's specific care needs for one of 30 residents reviewed (Resident 16).

Findings include:

A facility policy for Comprehensive Person-Centered Care Plans, dated December 7, 2023, indicated that a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Assessments of residents are ongoing and care plans are revised as information about the resident and resident's condition change.

A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 16, dated September 10, 2024, indicated that the resident was cognitively intact, was understood and able to understand others, required assistance with care needs, received dialysis (treatment to remove extra fluid and waste from the blood when the kidneys are not able to), and had a diagnosis of end-stage renal disease (ESRD-kidneys no longer work as they should to meet the body's needs requiring dialysis or kidney transplant).

A review of Resident 16's clinical record and dialysis communication records indicated that the resident received dialysis on Mondays, Wednesdays, and Fridays; however, the care plan for Resident 16, dated December 21, 2023, indicated that she attended dialysis on Tuesdays, Thursdays, and Saturdays.

Interview with the Director of Nursing on November 14, 2024, at 9:25 a.m. confirmed that Resident 16's care plan was not revised to reflect that the resident received dialysis on Mondays, Wednesdays, and Fridays and it should have been.

28 Pa. Code 201.24(e)(4) Admission Policy.

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



 Plan of Correction - To be completed: 12/27/2024

1. Resident 16's care plan was updated to reflect her dialysis days which are Monday, Wednesday and Friday.
2. Current residents with orders for dialysis will be reviewed to ensure that the correct days for dialysis are listed in their care plan.
3. Director of nursing / designee will re-educate registered nurses and licenses practical nurses on updating orders and care plans when a resident has a change.
4. Director of nursing/designee will conduct 2 audits weekly for 6 weeks to ensure all updated/new orders regarding dialysis are placed and care planned accurately with results to the facility Quality Assessment and Assurance Committee.

483.25(e)(1)-(3) REQUIREMENT Bowel/Bladder Incontinence, Catheter, UTI: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(e) Incontinence.
§483.25(e)(1) The facility must ensure that resident who is continent of bladder and bowel on admission receives services and assistance to maintain continence unless his or her clinical condition is or becomes such that continence is not possible to maintain.

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

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


Based on review of facility policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that interventions were in place to prevent urinary tract infections for one of 30 residents reviewed (Resident 15) who had an indwelling urinary catheter.

Findings include:

The facility's policy regarding indwelling urinary catheters (a flexible tube inserted and held in the bladder to drain urine), dated December 7, 2023, revealed that indwelling urinary catheters would be used sparingly, for appropriate indications only. If an indwelling urinary catheter was needed, staff would monitor for and report complications such as evidence of symptomatic infection.

An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 15, dated October 30, 2024, revealed that the resident was cognitively intact and had an indwelling urinary catheter. A diagnosis record, dated November 2024, revealed the resident had a diagnosis of urinary retention.

Physician's orders for Resident 15, dated October 24, 2024, included an order for the resident to have an indwelling urinary catheter due to neurogenic bladder (a condition that causes loss of bladder control due to damage to the nervous system), and it was to be changed every 30 days for dislodgement or blockage and as needed. A care plan, dated October 28, 2024, indicated that staff were to secure the resident's catheter with a securement device.

Observations of Resident 15 on November 12, 2024, at 10:53 a.m. revealed that the resident was in his wheelchair and his catheter tubing was lying on the fall mat. Staff entered the room to give the resident a flu shot and left the room without repositioning the catheter tubing.

Interviews with the Director of Nursing on November 12, 2024, at 2:58 p.m. confirmed that Resident 15's catheter tubing should not have been in contact with the fall mat.

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




 Plan of Correction - To be completed: 12/27/2024

1.This was corrected at the time of survey. Resident 15 was discharged from facility.
2. House audit will be completed to ensure that catheter tubing is not touching the fall mat or floor.
3. Director of nursing or designee will re-educate all staff regarding catheter tubing not touching the fall mat or floor.
4. Director of Nursing/ Designee will conduct 3 audits weekly for 4 weeks to ensure foley catheter tubing is not on the floor with results to the facility Quality Assessment and Assurance Committee.

483.25(l) REQUIREMENT Dialysis: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(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 clinical record reviews and staff interviews, it was determined that the facility failed to ensure there was a physician's order to receive dialysis for one of 30 residents reviewed (Resident 16) who required dialysis.

Findings include:

A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 16, dated September 10, 2024, indicated that the resident was cognitively intact, was understood and able to understand others, required assistance with care needs, received dialysis (treatment to remove extra fluid and waste from the blood when the kidneys are not able to), and had a diagnosis of end-stage renal disease (ESRD - kidneys no longer work as they should, requiring dialysis or kidney transplant).

A review of Resident 16's clinical record and dialysis communication records revealed that the resident received dialysis treatment every Monday, Wednesday, and Friday. A care plan for Resident 16, dated December 21, 2023, indicated that the resident received dialysis services; however, there was no documented evidence in Resident 16's clinical record of an active physician's order for the resident to attend dialysis.

Interview with the Director of Nursing on November 14, 2024, at 9:25 a.m. confirmed that there was no documented evidence in Resident 16's clinical record of an active physician's order for the resident to attend dialysis and there should have been.

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



 Plan of Correction - To be completed: 12/27/2024

1. Resident 16 now has a physician order for dialysis.
2. House audit to be completed on all residents that receive dialysis to ensure that there is a physician order.
3. Director or Nursing/ designee will re-educate Registered nurses and Licensed practical nurses on placing orders for any dialysis patients.
4. Director of Nursing/designee will conduct 2 audits weekly for 4 weeks to ensure all residents receiving dialysis treatment have a dialysis order with results to the facility Quality Assessment and Assurance Committee.

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 review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that residents were free from unnecessary psychotropic medications, by failing to ensure that non-pharmacological (non-medication) behavioral interventions (individualized, non-pharmacological approaches to care), were attempted prior to the administration of "as needed" antianxiety medications for one of 30 residents reviewed (Resident 12).

Findings include:

The facility's policy regarding psychotropic medications (any medication that affects brain activities associated with mental processes and behavior), dated December 7, 2023, indicated that non-pharmacological approaches are used (unless contraindicated) to minimize the need for medications, permit the lowest possible dose, and allow for discontinuation of medications when possible.

A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 12, dated September 19, 2024, indicated that the resident was cognitively intact, was understood and able to understand others, required assistance with care needs, received antianxiety and opioid medications, was receiving oxygen therapy and hospice services, and had a diagnosis of congestive heart (the heart cannot pump blood well enough to meet the body's needs).

Physician's orders for Resident 12, dated September 11, 2024, included an order for the resident to receive 0.5 milligrams (mg) of Ativan (Lorazepam) (a controlled antianxiety medication) every four hours as needed for anxiety/ restlessness.

Review of the Medication Administration Record (MAR) for Resident 12 for September and October 2024 revealed that the resident was administered 0.5 mg of Ativan on September 14 at 10:47 p.m., September 15 at 5:11 p.m. and 11:02 p.m., September 21 at 10:07 p.m., September 24 at 12:17 a.m., September 29 at 8:44 p.m., October 1 at 10:01 p.m., and October 2 at 9:28 p.m. There was no documented evidence that non-pharmacological behavioral interventions were attempted prior to administering Ativan on the above-mentioned dates and times.

Interview with the Director of Nursing on November 13, 2024, at 1:33 p.m. confirmed that non-pharmacological interventions should have been attempted prior to the administration of as needed Ativan to Resident 12 on the above-mentioned dates and times.

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




 Plan of Correction - To be completed: 12/27/2024

1. Resident 12 had no adverse effects from alleged administration of Ativan without documentation of non-pharmacologic interventions prior to administration. Resident 12 order was updated to include documentation of nonpharmacologic medication attempted prior to utilization of pharmacologic intervention.
2. Current residents with orders for as needed psychotropic medications will be reviewed by the facility Director of Nursing or designee for supplementary documentation being added to the order for documentation of nonpharmacologic interventions prior to administration of medication.
3. The facility Director of Nursing or designee will re-educate facility licensed nursing employees on adding non-pharmacologic interventions to orders and documentation of interventions prior to administration of an as needed psychotropic medication.
4. The facility Director of Nursing or designee will conduct 5 random audits of psychotropic medications for documentation of nonpharmacologic interventions weekly for 4 weeks with results to the facility Quality Assessment and Assurance Committee.

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 clinical record reviews and staff interviews, it was determined that the facility failed to ensure that physician's orders were followed, resulting in significant medication errors for one of 30 residents reviewed (Resident 15).

Findings include:

An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 15, dated October 30, 2024, revealed that the resident was cognitively intact, received an anticoagulant (blood thinner), and had diagnoses that included atrial fibrillation (an abnormal heart rhythm).

Physician's orders for Resident 15, dated October 25, 2024, included an order for the resident to receive 3 milligrams (mg) of warfarin (blood thinning medication) daily for atrial fibrillation. However, the resident's Medication Administration Record for October 25, 2024, revealed that staff did not administer 3 mg of warfarin daily as ordered.

Physician's orders, dated October 28, 2024, included an order for the resident to receive 6 mg of warfarin at bedtime then 3 mg of warfarin on Tuesday October 29, 2024. However, the resident's Medication Administration Record for October 28, 2024, revealed that staff administered 9 mg of warfarin.

Physician's orders, dated October 29, 2024, included an order for the resident's PT/INR (prothrombin/ international normalized ratio- test to determine clotting time) be drawn. The PT/INR flow sheet for warfarin, dated October 30, 2024, indicated that the resident's INR was 2.3 (therapeutic range of 2 to 3) and the resident was to receive 3 mg of warfarin. However, there was no documented evidence of a physician's order to administer 3 mg of warfarin on October 30, 2024, and the resident's Medication Administration Record for October 30, 2024, revealed that staff did not administer 3 mg of warfarin.

Interview with the Director of Nursing on November 13, 2024, at 1:55 p.m. confirmed staff should have administered 3 mg warfarin on October 25 and 30, 2024, and administered the wrong dose of warfarin on October 28, 2024.

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




 Plan of Correction - To be completed: 12/27/2024

1. Resident 15 did not have any adverse reactions from the medication dose. Physician notified of medication dose.
2. House audit to be completed on all warfarin orders to ensure accuracy.
3. Director of Nursing/ Designee will educate all licensed nursing staff on ensuring that meds are ordered correctly when Warfarin dose is changed.
4. Director of nursing/designee will conduct 3 random audits weekly for 4 weeks to ensure coumadin is ordered correctly and being administered with the correct dose and time with results to the facility Quality Assessment and Assurance Committee.

483.75(c)(d)(e)(g)(2)(i)(ii) REQUIREMENT QAPI/QAA Improvement Activities: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.
§483.75(c) Program feedback, data systems and monitoring.
A facility must establish and implement written policies and procedures for feedback, data collections systems, and monitoring, including adverse event monitoring. The policies and procedures must include, at a minimum, the following:

§483.75(c)(1) Facility maintenance of effective systems to obtain and use of feedback and input from direct care staff, other staff, residents, and resident representatives, including how such information will be used to identify problems that are high risk, high volume, or problem-prone, and opportunities for improvement.

§483.75(c)(2) Facility maintenance of effective systems to identify, collect, and use data and information from all departments, including but not limited to the facility assessment required at §483.71 and including how such information will be used to develop and monitor performance indicators.

§483.75(c)(3) Facility development, monitoring, and evaluation of performance indicators, including the methodology and frequency for such development, monitoring, and evaluation.

§483.75(c)(4) Facility adverse event monitoring, including the methods by which the facility will systematically identify, report, track, investigate, analyze and use data and information relating to adverse events in the facility, including how the facility will use the data to develop activities to prevent adverse events.

§483.75(d) Program systematic analysis and systemic action.

§483.75(d)(1) The facility must take actions aimed at performance improvement and, after implementing those actions, measure its success, and track performance to ensure that improvements are realized and sustained.

§483.75(d)(2) The facility will develop and implement policies addressing:
(i) How they will use a systematic approach to determine underlying causes of problems impacting larger systems;
(ii) How they will develop corrective actions that will be designed to effect change at the systems level to prevent quality of care, quality of life, or safety problems; and
(iii) How the facility will monitor the effectiveness of its performance improvement activities to ensure that improvements are sustained.

§483.75(e) Program activities.

§483.75(e)(1) The facility must set priorities for its performance improvement activities that focus on high-risk, high-volume, or problem-prone areas; consider the incidence, prevalence, and severity of problems in those areas; and affect health outcomes, resident safety, resident autonomy, resident choice, and quality of care.

§483.75(e)(2) Performance improvement activities must track medical errors and adverse resident events, analyze their causes, and implement preventive actions and mechanisms that include feedback and learning throughout the facility.

§483.75(e)(3) As part of their performance improvement activities, the facility must conduct distinct performance improvement projects. The number and frequency of improvement projects conducted by the facility must reflect the scope and complexity of the facility's services and available resources, as reflected in the facility assessment required at §483.71. Improvement projects must include at least annually a project that focuses on high risk or problem-prone areas identified through the data collection and analysis described in paragraphs (c) and (d) of this section.

§483.75(g) Quality assessment and assurance.

§483.75(g)(2) The quality assessment and assurance committee reports to the facility's governing body, or designated person(s) functioning as a governing body regarding its activities, including implementation of the QAPI program required under paragraphs (a) through (e) of this section. The committee must:

(ii) Develop and implement appropriate plans of action to correct identified quality deficiencies;
(iii) Regularly review and analyze data, including data collected under the QAPI program and data resulting from drug regimen reviews, and act on available data to make improvements.
Observations:


Based on review of the facility's plans of correction for previous surveys, and the results of the current survey, it was determined that the facility's Quality Assurance Performance Improvement (QAPI) committee failed to maintain compliance with nursing home regulations and ensure that plans to improve the delivery of care and services effectively addressed recurring deficiencies.

Findings include:

The facility's deficiencies and plans of correction for the State Survey and Certification (Department of Health) survey ending December 20, 2023, revealed that the facility developed plans of corrections that included quality assurance systems to ensure that the facility-maintained compliance with cited nursing home regulations. The results of the current survey, ending November 14, 2024, identified repeated deficiencies related to a failure to develop comprehensive care plans, to update resident care plans, to follow physician's orders, to account for controlled medications, and following proper infection control practices.

The facility's plan of correction for a deficiency regarding developing comprehensive care plans, cited during the survey ending December 20, 2023, revealed that the facility developed a plan of correction that included completing audits and reporting the results of the audits to the QAPI committee for review. The results of the current survey, cited under F656, revealed that the facility's QAPI committee failed to successfully implement their plan to ensure ongoing compliance with regulations regarding the development of comprehensive care plans.

The facility's plan of correction for a deficiency regarding a failure to update resident care plans, cited during the survey ending December 20, 2023, revealed that the facility developed a plan of correction that included completing audits and reporting the results of the audits to the QAPI committee for review. The results of the current survey, cited under F657, revealed that the facility's QAPI committee failed to successfully implement their plan to ensure ongoing compliance with regulations regarding updating residents' care plans.

The facility's plans of correction for deficiencies regarding failure to follow physician's orders, cited during the survey ending December 20, 2023, revealed that the facility would complete audits and report the results of the audits to the QAPI committee for review. The results of the current survey, cited under F684, revealed that the facility's QAPI committee failed to successfully implement their plan to ensure ongoing compliance with regulations regarding following physician's orders.

The facility's plan of correction for a deficiency regarding the failure to account for controlled medications, cited during the survey ending December 20, 2023, revealed that the facility would complete audits and the results would be reviewed as part of quality assurance. The results of the current survey, cited under F755, revealed that the facility's QAPI committee was ineffective in correcting deficient practices related to the accountability of controlled medications.

The facility's plan of correction for a deficiency regarding following infection control practices, cited during the survey ending December 20, 2023, revealed that the facility would complete audits and report the results of the audits to the QAPI committee for review. The results of the current survey, cited under F880, revealed that the facility's QAPI committee was ineffective in maintaining compliance with the regulation regarding following infection control practices.

Refer to F656, F657, F684, F755, F880.

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

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



 Plan of Correction - To be completed: 12/27/2024

1. The facility Quality Assessment and Assurance Committee is overseen by the facility Nursing Home Administrator.
2. The facility Nursing Home Administrator will review prior deficiencies cited under F656, F657, F684, F755 and F880 with the members of the facility Quality Assessment and Assurance Committee.
3. The facility Nursing Home Administrator or designee will re-educate the Quality Assessment and Assurance Committee on their roles and responsibilities for monitoring of compliance with assigned deficiencies. The committee will review deficiencies cited during the annual survey with exit date of 11/14/2024 including reason for deficiency, plan of correction (education, audits) and progress toward compliance during the committee meeting.
4. The facility Nursing Home Administrator or designee will conduct random audits of facility plan of correction monthly x2 with results to the facility Quality Assessment and Assurance Committee.

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

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

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

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

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

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

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


Based on review of established infection control guidelines, facility policy, and residents' clinical records, as well as observations and staff interviews, it was determined that the facility failed to follow infection control guidelines from the Centers for Medicare/Medicaid Services (CMS) and the Centers for Disease Control (CDC) to reduce the spread of infections and prevent cross-contamination for two of 31 residents reviewed (Residents 9, 14).

Findings include:

CDC guidance on isolation precautions and Implementation of Personal Protective Equipment (PPE) use in Nursing Homes to Prevent Spread of Multidrug-Resistant Organisms (MDRO's - bacteria that have become resistant to certain antibiotics, and these antibiotics can no longer be used to control or kill the bacteria), dated July 12, 2022, indicates that MDRO transmission is common in skilled nursing facilities, contributing to substantial resident morbidity and mortality and increased healthcare costs. Enhanced Barrier Precautions (EBP) are an infection control intervention designed to reduce transmission of resistant organisms that employs targeted gown and glove use during high contact resident care activities. CMS updated its infection prevention and control guidance effective April 1, 2024. The recommendations now include the use of EBP during high-contact care activities for residents with chronic wounds or indwelling medical devices, regardless of their MDRO status, in addition to residents who have an infection or colonization with a CDC-targeted or other epidemiologically important MDRO when contact precautions do not apply.

The facility's policy regarding EBP, dated December 7, 2023, revealed that EBP's are indicated (when contact precautions do not otherwise apply) for residents infected or colonized with a CDC targeted or epidemiologically important MDRO, including Extended Spectrum Beta Lactamase (ESBL)-producing Enterobacterales. EBP's remain in place for the duration of the resident's stay. Signs are posted in the door or on the wall outside of the resident's room indicating the type of precautions and PPE required. PPE is available outside of the resident's rooms.

A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 9, dated September 13, 2024, indicated that the resident was cognitively intact, was understood and able to understand what was being said, required assistance with care needs, was occasionally incontinent of urine, and had diagnoses that included lung cancer and chronic obstructive pulmonary disease (COPD) (chronic lung disease making breathing difficult).

A physician's progress note for Resident 9, dated May 13, 2024, at 9:29 p.m., indicated that the resident's final urine culture showed that the resident had Extended Spectrum Beta Lactamase (ESBL) (an infection that makes bacteria resistant to many antibiotics) and was not susceptible to the Keflex (antibiotic) that was ordered and was ordered to receive intravenous (administration of fluids and/or medications directly into a person's vein) antibiotics.

Observations during the facility tour on November 13, 2024, at 8:30 a.m. revealed that Resident 9 was lying in bed. There was no signage on the door or on the wall outside the resident's room to indicate that the resident was on EBP, and there was no PPE observed in or outside the resident's room.

Interview with the Director of Nursing on November 13, 2024, at 9:47 a.m. confirmed that Resident 9 did not have EBP in place related to the resident's history of ESBL and should have.

A quarterly MDS assessment for Resident 14, dated September 12, 2024, revealed that the resident was cognitively intact, required assistance from staff for daily care needs, incontinent of both bowel and bladder, and had diagnosis that included high blood pressure, hemiplegia (weakness on one side of the body), and fibromyalgia (pain in muscles).

A Physician Progress note, dated January 16, 2024, at 6:49 p.m., revealed that Resident 14 was receiving IV antibiotics until January 18, 2024, for diagnosis of Extended Spectrum Beta Lactamase (ESBL) (an infection that makes bacteria resistant to many antibiotics). A urine culture, dated October 8, 2023, confirmed the resident had ESBL.

Observations during the facility tour on November 14, 2024, at 10:55 a.m. revealed that Resident 22 was lying in bed. There was no signage or notification of the resident being on EBP posted at the resident's room, and there was no PPE observed in or around the resident's room.

Interview with the Director of Nursing on September 16, 2024, at 9:23 a.m. confirmed that Resident 22 did not have EBP precautions in place for history of ESBL and should have.

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

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

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





 Plan of Correction - To be completed: 12/27/2024

1. Resident 14 was placed in Enhanced Barrier Precautions (EBP). Signage and Personal Protective Equipment was added to residents 14 and 22's room.
2. Current residents with histories of MDRO (multi-drug resistant organisms) will be reviewed to ensure enhanced barrier precautions are in place. The facility Infection Preventionist or designee will review 24-report 3 times a week for 4 weeks to ensure enhanced barrier precautions are initiated. The facility Quality Assessment and Assurance Committee meetings.
3. Director of nursing/ Designee will educate nursing staff on 0880 and the importance of ensuring all appropriate residents are placed in EBP upon admission or change of condition.
4. Director of nursing/ designee will conduct 3 audits weekly for 4 weeks to ensure all residents with a history of MRDOS are placed in Enhanced Barrier Precautions with results to the facility Quality Assessment and Assurance Committee.

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


Based on observations, as well as staff interviews, it was determined that the facility failed to maintain an effective preventative maintenance program for the walk-in-freezer.

Findings include:

Observations of the walk-in-freezer on November 12, 2024, at 9:26 a.m. and November 13, 2024, at 12:18 p.m. revealed that there was an accumulation of ice on the ceiling extending out from the condenser to the other side of the walk-in-freezer, as well as from the ceiling and extending down the four side walls, and multiple areas on the floor with an accumulation of ice.

Interview with the Dietary Manager on November 13, 2024, at 12:18 p.m. confirmed that there was an accumulation of ice on the ceiling extending out from the condenser to the other side of the walk-in-freezer, as well as from the ceiling and extending the down the four side walls, and multiple areas on the floor with an accumulation of ice.

Interview with the Director of Maintenance on November 13, 2024, at 12:25 p.m. revealed that he has been there six months and does not recall having the walk-in freezer worked on.

Interview with Maintenance Worker 4 on November 13, 2024, at 1:30 p.m. revealed that he does not have a manual for the walk-in freezer and that last summer they had a compressor go bad in the walk-in freezer, and they had a contracted vendor come in and replace the compressor at that time. He indicated that he does not recall having anyone come out to look at the walk-in freezer since then. He indicated that he did ask the service man what could be causing ice buildup and was advised that it could be a bad door seal or that staff are not shutting the door correctly.

28 Pa. Code 201.18(e)(6) Management.

28 Pa. Code 211.6(c) Dietary Services.




 Plan of Correction - To be completed: 12/27/2024

1. The accumulation of ice buildup was removed from the walk-in freezer.
2. Maintenance director inspected walk in freezer. All freon lines sealed, no outside air noted.
3. Maintenance Director called Greensburg Central refrigeration and they came to facility on 12/4/24 and inspected the walk-in freezer. Greensburg Central refridgeration repaired walk in freezer.
4. Maintenance director of designee will conduct 3 audits weekly for 4 weeks to ensure there is no ice build up in the walk in freezer with results to the facility Quality Assessment and Assurance Committee.
5. Monitoring be added to the facility's preventative maintenance schedule to ensure there is no ice buildup in the walk-in freezer.

483.95(a) REQUIREMENT Communication Training: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.
§483.95(a) Communication.
A facility must include effective communications as mandatory training for direct care staff.
Observations:


Based on review of facility documents and staff interview, it was determined that the facility failed to provide training on effective communication to nursing and other direct care staff for four of four employee files reviewed (Nurse Aide 5, Nurse Aide 6, Licensed Practical Nurse 7, Registered Nurse 8).

Findings include:

The facility's "Facility Assessment" (an assessment completed by the facility to thoroughly assess the needs of its resident population and the required resources to provide the care and services the residents need), dated July 17, 2024, revealed that the facility's training program includes an orientation process and ongoing training for all new and existing staff including managers, nursing, and other direct care staff, individuals providing services under contractual arrangement, and volunteers consistent with their expected roles. The content at a minimum included effective communication.

Review of the education record for Nurse Aide 5 revealed a hire date of September 25, 2023. However, there was no documented evidence that she received the facility's education regarding effective communication during the period of September 25, 2023, through September 25, 2024.

Review of the education record for Nurse Aide 6 revealed a hire date of October 7, 2023. However, there was no documented evidence that she received the facility's education regarding effective communication during the period of October 7, 2023, through October 7, 2024.

Review of the education record for Licensed Practical Nurse 7 revealed a hire date of October 11, 2023. However, there was no documented evidence that she received the facility's education regarding effective communication during the period of October 11, 2023, through October 11, 2024.

Review of the education record for Registered Nurse 8 revealed a hire date of September 18, 2023. However, there was no documented evidence that she received the facility's education regarding effective communication during the period of September 18, 2023, through September 18, 2024.

Interview with the Director of Nursing on November 13, 2024, at 12:08 p.m. confirmed that there was no documented evidence that Nurse Aide 5, Nurse Aide 6, Licensed Practical Nurse 7, and Registered Nurse 8 received the facility's education regarding effective communication.

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: 12/27/2024

1. Facility will ensure that all staff have had training on effective communication.
2. Human Resources will complete a whole house audit to ensure that all licensed staff received effective communication education.
3. Nursing home administer will re-educate human resources on the required education course of effective communication.
4. Human Resources/designee will conduct an audit on all new hires 2xs weekly for 4 weeks to ensure effective communication education was completed with results to the facility Quality Assessment and Assurance Committee

§ 201.20(a)(2) LICENSURE Staff development.:State only Deficiency.
(2) Restorative nursing techniques.
Observations:


Based on a review of employee education records, as well as staff interviews, it was determined that the facility failed to ensure that employees completed the required annual restorative nursing techniques education for two of four employee files reviewed (Licensed Practical Nurse 7, Registered Nurse 8).

Findings include:

Review of the education record for Licensed Practical Nurse 7 revealed a hire date of October 11, 2023. However, there was no documented evidence that she received the facility's annual education regarding restorative nursing techniques during the period of October 11, 2023, through October 11, 2024.

Review of the education record for Registered Nurse 8 revealed a hire date of September 18, 2023. However, there was no documented evidence that she received the facility's annual education regarding restorative nursing techniques during the period of September 18, 2023, through September 18, 2024.

Interview with the Director of Nursing on November 13, 2024, at 12:08 p.m. confirmed that there was no documented evidence that Licensed Practical Nurse 7 and Registered Nurse 8 received the facility's annual education regarding restorative nursing techniques.





 Plan of Correction - To be completed: 12/27/2024

1. All licensed nursing staff will receive education on restorative nursing techniques.
2. Human Resources will complete a whole house audit to ensure that all licensed staff received restorative nursing techniques education.
3. Nursing home administrator will re-educate human resources on the required education course of restorative nursing techniques.
4. Human Resources/ designee will conduct an audit on all new hires 2xs weekly for 4 weeks to ensure restorative techniques education was completed results to the facility Quality Assessment and Assurance Committee

§ 211.12(f.1)(2) LICENSURE Nursing services. :State only Deficiency.
(2) Effective July 1, 2023, a minimum of 1 nurse aide per 12 residents during the day, 1 nurse aide per 12 residents during the evening, and 1 nurse aide per 20 residents overnight.

Observations:


Based on review of nursing schedules and staffing information furnished by the facility, as well as staff interview, it was determined that the facility failed to ensure a minimum of one nurse aide (NA) per 10 residents on the day shift for eight of 14 days reviewed between October 13 through 19 and November 6 through 12, 2024. The facility also failed to ensure a minimum of one NA per 11 residents on the evening shift for 14 of 21 days between September 1 through 7, October 13 through 19, and November 6 through 12, 2024, and failed to ensure a minimum of one NA per 15 residents on the overnight shift for seven of 14 days between September 1 through 7 and November 6 through 12, 2024.

Findings include:

Review of facility census data indicated that on October 16 and 18, 2024, the facility census was 30, which required 3.00 NA's during the day shift. Review of the nursing time schedules revealed 2.00 NA's provided care on the day shift on October 16 and 18, 2024. Review of facility census data indicated that on November 6-8, 2024, the facility census was 31, which required 3.10 NA's during the day shift. Review of the nursing time schedules revealed 2.75 NA's provided care on the day shift on November 6-8, 2024. Review of facility census data indicated that on November 9 and 10, 2024, the facility census was 31, which required 3.10 NA's during the day shift. Review of the nursing time schedules revealed 3.00 NA's provided care on the day shift on November 9 and 10, 2024. Review of facility census data indicated that on November 11, 2024, the facility census was 30, which required 3.00 NA's during the day shift. Review of the nursing time schedules revealed 2.00 NA's provided care on the day shift on November 11, 2024.

Review of facility census data indicated that on September 1, 2024, the facility census was 26, which required 2.36 NA's during the evening shift. Review of the nursing time schedules revealed 2.00 NA's provided care on the evening shift on September 1, 2024. Review of facility census data indicated that on September 4 and 5, 2024, the facility census was 28, which required 2.55 NA's during the evening shift. Review of the nursing time schedules revealed 2.50 NA's provided care on the evening shift on September 4 and 5, 2024. Review of facility census data indicated that on October 13, 2024, the facility census was 29, which required 2.64 NA's during the evening shift. Review of the nursing time schedules revealed 2.50 NA's provided care on the evening shift on October 13, 2024. Review of facility census data indicated that on October 16, 2024, the facility census was 30, which required 2.73 NA's during the evening shift. Review of the nursing time schedules revealed 2.50 NA's provided care on the evening shift on October 16, 2024. Review of facility census data indicated that on October 17, 2024, the facility census was 29, which required 2.64 NA's during the evening shift. Review of the nursing time schedules revealed 2.50 NA's provided care on the evening shift on October 17, 2024. Review of facility census data indicated that on October 18, 2024, the facility census was 30, which required 2.73 NA's during the evening shift. Review of the nursing time schedules revealed 2.00 NA's provided care on the evening shift on October 18, 2024. Review of facility census data indicated that on October 19, 2024, the facility census was 30, which required 2.73 NA's during the evening shift. Review of the nursing time schedules revealed 2.50 NA's provided care on the evening shift on October 19, 2024. Review of facility census data indicated that on November 6, 2024, the facility census was 31, which required 2.82 NA's during the evening shift. Review of the nursing time schedules revealed 2.00 NA's provided care on the evening shift on November 6, 2024. Review of facility census data indicated that on November 7, 2024, the facility census was 31, which required 2.82 NA's during the evening shift. Review of the nursing time schedules revealed 2.50 NA's provided care on the evening shift on November 7, 2024. Review of facility census data indicated that on November 8, 2024, the facility census was 31, which required 2.82 NA's during the evening shift. Review of the nursing time schedules revealed 2.00 NA's provided care on the evening shift on November 8, 2024. Review of facility census data indicated that on November 10, 2024, the facility census was 31, which required 2.82 NA's during the evening shift. Review of the nursing time schedules revealed 2.50 NA's provided care on the evening shift on November 10, 2024. Review of facility census data indicated that on November 11, 2024, the facility census was 30, which required 2.73 NA's during the evening shift. Review of the nursing time schedules revealed 1.50 NA's provided care on the evening shift on November 11, 2024. Review of facility census data indicated that on November 12, 2024, the facility census was 28, which required 2.55 NA's during the evening shift. Review of the nursing time schedules revealed 2.50 NA's provided care on the evening shift on November 12, 2024.

Review of facility census data indicated that on September 1, 2024, the facility census was 26, which required 1.73 NA's during the overnight shift. Review of the nursing time schedules revealed 1.00 NA's provided care on the overnight on September 1, 2024. Review of facility census data indicated that on September 7, 2024, the facility census was 28, which required 2.55 NA's during the overnight shift. Review of the nursing time schedules revealed 2.50 NA's provided care on the overnight shift on September 7, 2024. Review of facility census data indicated that on November 6, 2024, the facility census was 31, which required 2.07 NA's during the overnight. Review of the nursing time schedules revealed 1.00 NA's provided care on the overnight shift on November 6, 2024. Review of facility census data indicated that on November 7-10, 2024, the facility census was 31, which required 2.07 NA's during the overnight shift. Reivew of the nursing time schedules revealed 2.00 NA's provided care on the overnight shift on November 7-10, 2024.

No additional excess higher-level staff were available to compensate for these deficiencies.

Interview with the Director of Nursing on November 19, 2024, at 12:39 p.m. confirmed that the facility did not meet the required NA-to-resident staffing ratios for the days listed above.



 Plan of Correction - To be completed: 12/27/2024

1. Nursing home administrator will re-educate the Director of nursing/scheduler on staffing ratio regulations that were effective on July 1, 2023.
2. Bonuses will be offered as incentive to pick up Certified Nursing Assistant (CNA) shifts. Human Resources will continue to work on hiring additional certified nursing assistants.
3. Daily staffing meetings will be held. Nursing home Administrator, Director of nursing, scheduler and human resources will be available/present.
4. Nursing home administrator/ designee will complete a 4 week look out at daily staffing meeting for 8 weeks to identify that the CNA ratios are being met, as well as monitor the daily/weekly staffing sheets results to the facility Quality Assessment and Assurance Committee

§ 211.12(f.1)(4) LICENSURE Nursing services. :State only Deficiency.
(4) Effective July 1, 2023, a minimum of 1 LPN per 25 residents during the day, 1 LPN per 30 residents during the evening, and 1 LPN per 40 residents overnight.
Observations:


Based on review of nursing schedules and staffing information furnished by the facility, as well as staff interview, it was determined that the facility failed to ensure a minimum of one Licensed Practical Nurse (LPN) per 25 residents on the day shift for one of seven days and failed to ensure a minimum of one LPN per 40 residents on the overnight shift for one of seven days for September 1 through September 7, 2024.

Findings include:

Review of facility census data indicated that on September 2, 2024, the facility census was 26, which required 1.04 LPN's during the day shift. Review of the nursing time schedules revealed 1.00 LPN's provided care on the day shift on September 2, 2024.

Review of facility census data indicated that on September 2, 2024, the facility census was 26, which required 1.00 LPN's during the overnight shift. Review of the nursing time schedules revealed 0.50 LPN's provided care on the overnight shift on September 2, 2024.

No additional excess higher-level staff were available to compensate for these deficiencies.

Interview with the Director of Nursing on November 19, 2024, at 12:39 p.m. confirmed that the facility did not meet the required LPN-to-resident staffing ratio for the day listed above.




 Plan of Correction - To be completed: 12/27/2024

1. Nursing home administrator will re-educate the Director of nursing/scheduler on staffing ratio regulations that were effective on July 1, 2023.
2. Bonuses will be offered as incentive to pick up Licensed Practical Nursing (LPN) shifts. Human Resources will continue to work on hiring additional licensed practical nurse.
3. Daily staffing meetings will be held. Nursing home Administrator, Director of nursing, scheduler and human resources will be available/present.
4. Nursing home administrator/ designee will complete a 4 week look out at daily staffing meeting for 8 weeks to identify that the LPN ratios are being met, as well as monitor the daily/weekly staffing sheets results to the facility Quality Assessment and Assurance Committee


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