Pennsylvania Department of Health
EMBASSY OF WOODLAND PARK
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

EMBASSY OF WOODLAND PARK
Inspection Results For:

There are 105 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.


EMBASSY OF WOODLAND PARK - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:

Based on a Medicare/Medicaid Recertification survey, State Licensure survey, and a Civil Rights Compliance survey completed on October 3, 2024, it was determined that Embassy of Woodland Park 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:

483.60(c)(1)-(7) REQUIREMENT Menus Meet Resident Nds/Prep in Adv/Followed:

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.

§483.60(c) Menus and nutritional adequacy.
Menus must-

§483.60(c)(1) Meet the nutritional needs of residents in accordance with established national guidelines.;

§483.60(c)(2) Be prepared in advance;

§483.60(c)(3) Be followed;

§483.60(c)(4) Reflect, based on a facility's reasonable efforts, the religious, cultural and ethnic needs of the resident population, as well as input received from residents and resident groups;

§483.60(c)(5) Be updated periodically;

§483.60(c)(6) Be reviewed by the facility's dietitian or other clinically qualified nutrition professional for nutritional adequacy; and

§483.60(c)(7) Nothing in this paragraph should be construed to limit the resident's right to make personal dietary choices.

Observations:

Based on a review of facility policy and the facility's written menus, as well as observations and staff and resident interviews, it was determined that the facility failed to follow their planned menu.

Findings include:

A facility policy, dated March 15, 2024, indicated that menus shall be written in advance and followed. Any menu substitutions shall be made in an emergency situation only and recorded on the substitution log.

An interview with a group of residents on October 1, 2024, indicated that the kitchen does not always serve what is on the menu.

Observations of the kitchen on September 30, 2024, at 9:58 a.m. revealed that staff were preparing meatloaf, mashed potatoes, mixed vegetables (carrots, green beans, and wax beans), and vanilla cake for lunch.

The facility's written and printed menu for the lunch meal on September 30, 2024, revealed that the residents were to receive meatloaf, mashed potatoes, Brussels sprouts, berry-topped yellow cake, coffee/tea, dinner roll, and margarine.

Observations of the lunch meal in the dining room on September 30, 2024, at 12:14 p.m. revealed that the facility prepared and served Prince Charles veggie blend (green beans, wax beans, and carrots).

Interview with Cook 6 on September 30, 2024, at 12:14 p.m. confirmed that she was unsure what was to be on the menu, but she did not have Brussels sprouts to serve for lunch. The only vegetable she had was a carrot, green bean, and wax bean mix.

Interview with the Dietary Manager on September 30, 2024, at 12:17 p.m. confirmed that she forgot to order Brussels sprouts and substituted with the Prince Charles mix. She did not inform residents or the resident council president of the menu change.

The facility's recipe for chicken breast citrus glazed (ground), undated, indicated that two fluid ounces of citrus wing sauce was to be served with one scoop of ground chicken.

Observations of tray line on October 1, 2024, at 12:08 p.m., revealed that the regular texture trays had a chicken breast dipped in a liquid glaze, but the scoop of ground chicken breast had poultry gravy added on top of the serving and not the citrus glaze.

A test tray on October 1, 2024, at 12:25 p.m. revealed that the chicken breast with citrus glaze of ground texture did not taste the same as the regular texture chicken breast. The ground chicken did not have a citrus glaze and had a poultry gravy flavor.

Interview with the Dietary Director on October 1, 2024, at 12:32 p.m. confirmed that the ground chicken did not have the citrus glaze and should have.

Plan of Correction - To be completed: 11/12/2024

Dietary staff will be educated on the facility policy regarding written menus to include notification to resident's regarding menu changes during emergency situations and utilization of substitution log.

The Dietary Manager or designee will complete a weekly audit x 4 weeks when completing order to assure that all items required for the week have been ordered.

The Dietary Manager or designee will complete random audits weekly x 4 weeks of different diet textures to assure that recipe is being followed.

The Dietary Manager will follow up with residents during food council to assure that no issues are noted with notification of menu changes.

Results of the audits will be reported and trended to the facilities Quality Assurance Steering Committee. The Committee will determine the frequency of the audits after the initial audits are completed and results are reviewed according to the trends recommendations and guidance via facility Quality Assurance Performance Improvement Plan (QAPI). The Quality Assurance Committee will continue to monitor quarterly that the process was effective for ongoing compliance.

483.60(i)(1)(2) REQUIREMENT Food Procurement,Store/Prepare/Serve-Sanitary:

§483.60(i) Food safety requirements.
The facility must -

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

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

Observations:

Based on review of facility policy, observations, and staff interviews, it was determined that the facility failed to prepare and store food in accordance with professional standards for food service safety.

Findings include:

A facility policy for food storage, dated March 15, 2024, revealed that all items being stored in the freezer must be labeled, dated, and sealed in the same manner and may be stored for the period of time per Hazardous Analysis Critical Control Point (HACCP - a systematic approach to the identification, evaluation, and control of food safety hazards) guidelines. Dry storage items must be six inches off the floor.

Observations of the main kitchen during the initial tour on September 30, 2024, at 9:55 a.m. revealed that there were two cardboard boxes of coffee on the floor stacked one on top of the other. Observations in the three-door freezer on September 30, 2024, at 9:58 a.m. revealed a box with approximately two thirds of a chocolate cake that was not dated, labeled, or sealed.

Interview with Dietary Director on September 30, 2024, at 10:08 a.m. confirmed that the coffee should not be stored directly on the floor and that the chocolate cake in the freezer should be dated, labeled, and sealed.

28 Pa. Code 211.6(f) Dietary Services.

Plan of Correction - To be completed: 11/12/2024

Undated items were discarded. Refrigerators and freezers were inspected for any items that were not labeled/dated.

Coffee boxes were removed from the floor of the pantry at the time of the incident

Dietary staff will be educated on the facilities policy regarding food storage and labeling

Dietary Manager or designee will complete a random audit weekly x 4 weeks in the kitchen freezer and refrigerators to assure that no unlabled item are noted.

The Dietary manager or designee will complete random weekly audits x 4 weeks of kitchen pantry to assure that no boxes are noted to be stored on the floor.

Results of the audits will be reported and trended to the facilities Quality Assurance Steering Committee. The Committee will determine the frequency of the audits after the initial audits are completed and results are reviewed according to the trends recommendations and guidance via facility Quality Assurance Performance Improvement Plan (QAPI). The Quality Assurance Committee will continue to monitor quarterly that the process was effective for ongoing compliance.

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

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

§483.10(i) Safe Environment.
The resident has a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

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

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

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

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

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

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

§483.10(i)(7) For the maintenance of comfortable sound levels.

Observations:

Based on review of policies, as well as observations and staff interviews, it was determined that the facility failed to maintain a clean and homelike environment for two of 38 residents reviewed (Residents 1, 39).

Findings include:

The facility's policy regarding cleaning and disinfecting, dated March 15, 2024, indicated that the facility was to provide a safe, comfortable, homelike environment.

A quarterly Minimum data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated September 3, 2024, revealed that the resident was cognitively intact, required staff assistance for care needs, used a wheelchair, and had diagnoses that included cerebral palsy (CP - neurological disorder that affects a person's ability to move, balance, and maintain posture.)

Observations on September 30, 2024, at 1:24 p.m. revealed that the resident was sitting in his electric wheelchair in his room. The carpet in his room was black and worn. An interview with the resident at the time revealed that he felt that the carpet was very dirty, and that the facility was planning on replacing the carpet with a different kind of flooring. Observations and interview with Resident 1 on October 1, 2024, at 3:30 p.m. revealed that the carpet in his room was still black and worn and that staff had attempted to clean the carpet but it had not changed the condition of it.

Interview with the Director of Maintenance on October 2, 2024, at 9:01 a.m. revealed that the carpet in Resident 1's room was very dirty and had been shampooed multiple times, but due to the current condition of the carpet, the ground-in dirt could not be removed. The Director of Maintenance also stated that the facility has discussed replacing the floor with a vinyl type of flooring, but there was no discussed timeline, no estimates, or planned work schedules.

An annual MDS assessment for Resident 39, dated September 24, 2024, revealed that the resident was cognitively intact and had diagnoses that included congestive obstructive pulmonary disease (a lung disease that makes it difficult to breath) and a history of congestive heart failure (a condition when the heart cannot pump enough blood to meet the body's needs). The resident was receiving continuous oxygen via nasal cannula (tubes that deliver oxygen into the nostrils).

Observations on October 2, 2024, at 10:45 a.m., 11:50 a.m., and 2:30 p.m. revealed that Resident 39 was lying in her bed with a stand-up fan blowing directly on her. The fan was noted to have a moderate amount of visible dirt and debris accumulated on the blade cover.

Interview with the Director of Maintenance on October 2, 2024, at 3:00 p.m. revealed that cleaning fans used by residents was not on their scheduled work list; however, if they are made aware of a dirty fan, they would then clean it.

Interview with the Director of Housekeeping on October 2, 2024, at 3:25 p.m. revealed that the fan belonged to Resident 39. She remarked that cleaning resident fans is not on their list of duties; however, if they are made aware of a dirty fan, they would then clean it. She confirmed that the fan was blowing directly on the resident with a moderate amount of dirt and debris accumulated on the blade cover, and that it should have been clean and it was not.

Interview with Director of Nursing on October 3, 2024, at 9:00 a.m. confirmed that Resident 39's fan cover should be clean, and it was not.

28 Pa. Code 201.29(j) Resident Rights.

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

Plan of Correction - To be completed: 11/12/2024

No ill effects to resident 1 related to carpet being discolored and worn

No ill effects to resident 39 related to debris on fan blade cover

Resident 39's fan blade cover cleaned at the time of the incident

Housekeeping staff educated on facility policy on providing a safe clean home like environment.

A baseline audit will be completed of all resident's fans to assure that no dirt or debris is noted to be built up on the fan

Resident's rooms audited, no carpeting is noted to be in any other resident rooms.

Flooring obtained for replacement to resident 1's room. Worn carpet to be completely removed and replaced with tile flooring

The housekeeping supervisor will institute a fan cleaning schedule for any resident's fans in room

The housekeeping supervisor or designee will complete random weekly audits x 4 weeks on resident's who prefer to have fan to assure fans are being cleaned thoroughly.

Results of the audits will be reported and trended to the facilities Quality Assurance Steering Committee. The Committee will determine the frequency of the audits after the initial audits are completed and results are reviewed according to the trends recommendations and guidance via facility Quality Assurance Performance Improvement Plan (QAPI). The Quality Assurance Committee will continue to monitor quarterly that the process was effective for ongoing compliance.

483.75(c)(d)(e)(g)(2)(i)(ii) REQUIREMENT QAPI/QAA Improvement Activities:

§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.

Plan of Correction - To be completed: 11/12/2024

No ill effects noted to residents related to repeat deficient practice of failure to maintain compliance related to providing a safe, clean, homelike environment; failure to develop and implement abuse and neglect policies; failure to develop resident care plans; failure to be free from accident hazards; failure to maintain a complete and accurate account of controlled medications; failure to label and store drugs and biologicals; failure to provide menus prepared in advance and menus followed to meet residents' needs; and failure to store, prepare, and serve food in a sanitary manner.

The facility will develop a Quality Assurance Performance Improvement plan to implement guidelines including the Quality Assurance Steering committee with utilization of Performance Improvement Projects. The facility will identify audits for completion including internal benchmarks to evaluate quality of care metrics. The Quality Assurance Steering Committee meets quarterly to review metrics and make necessary recommendations for changes in facility policy and procedures as needed.

The Regional Director of clinical services and/or designee will re-educate the Administrator on ensuring plans to improve the delivery of care and services are effectively addressed to prevent recurring deficiencies. Administrator and/or designee will re-educate Quality Assurance Steering Committee regarding the facility's Quality assurance performance improvement committee plan.

The Facility will complete their quarterly Quality Assurance Steering Committee and submit their minutes to the Administrator for review and guidance.Results of the audits will be reported and trended to the facility's Quality Assurance Steering Committee. The Quality Assurance Steering Committee will determine the frequency of the audits after the initial audits are completed and results are reviewed according to the trends recommendations and guidance via facility Quality Assurance Performance Improvement Plan (QAPI).

483.45(g)(h)(1)(2) REQUIREMENT Label/Store Drugs and Biologicals:

§483.45(g) Labeling of Drugs and Biologicals
Drugs and biologicals used in the facility must be labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable.

§483.45(h) Storage of Drugs and Biologicals

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

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

Observations:

Based on a review of facility policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to store medications properly for one of 38 residents (Resident 53) and failed to label multi-dose insulin pens with the date they were opened in one of one medication cart observed (300 Long).

Findings include:

The facility's policy regarding medication labeling and storage, dated March 15, 2024, revealed that multi-dose medications that have been opened or accessed are to be dated and discarded within 28 days unless the manufacturer specifies a shorter or longer date for the open medication. In addition staff are to prepare and observe the resident taking their medications.

A diagnosis record for Resident 53 revealed diagnoses that included cancer of the prostate, high blood pressure, and heart disease.

Observations on September 30, 2024, at 11:15 a.m. revealed that the resident was sleeping in his bed and he had a medicine cup full of pills on his bedside table. The medications included one large, white, round tablet; one small, cream, oval tablet; one large, brownish-tan, oval capsule; one red, oval tablet; three orange-colored, round tablets; one large, off-white capsule; and one small, white, round tablet; and one very small, round, white tablet.

A review of Resident 53's clinical record did not reveal that he was cleared to administer his own medications.

Interview with Licensed Practical Nurse 8 on September 30, 2024, at 11:15 a.m. revealed that she had poured them earlier in the shift and set them on his table because he likes to take them with his lunch. She stated she should not have left the medications at his bedside.

Observations of the 300 Long medication cart on October 2, 2024, at 1:00 p.m. revealed that there was a glargine insulin pen, a Basaglar insulin pen, and a Toujeo SoloStar insulin pen that were opened and not dated with the date they were opened. The Basaglar and glargine insulins were to be discarded after 28 days, and the Toujeo SoloStar insulin pen was to be discarded after 56 days.

Interview with Licensed Practical Nurse 9 on June 10, 2024, at 12:15 p.m. confirmed that the insulin pens should have been dated with the date they were opened.

Interview with the Nursing Home Administrator on October 3, 2024, at 9:00 a.m. confirmed that Resident 53's medications should not have been poured and left at his bedside, and that the insulin pens should have been dated with the date they were opened.

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

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

Plan of Correction - To be completed: 11/12/2024

Resident 53 suffered no ill effects related to his medications being left at his bedside.

Medical Director was updated regarding the medications being left at his bedside.

Nursing staff will be educated in regards to the procedure for administering medications and for administering medications correctly to those that are deemed capable of self-administering medications.

Nursing staff will be educated on proper medication storage and dating medications when opened.

Nurses involved in leaving medications at the bedside unattended will receive education and disciplinary action.

Resident 53 will be reassessed for medication self-administration competency.

Director of Nursing or designee will perform a baseline audit on medication passes performed by 4 different nurses.

Director of Nursing or designee will perform weekly audits on medication passes to ensure medications are not left at bedside. Audits will continue x 4 weeks.

Director of Nursing or designee will perform a baseline audit of all medication carts and treatment carts to ensure there are not expired or undated medications and treatments.

Director of Nursing or designee will perform weekly audits of the medication carts and treatment carts to ensure there are no expired or undated medications or treatments. Audits will continue x 4 weeks.

Results of the audits will be reported and trended to the facilities Quality Assurance Steering Committee. The Committee will determine the frequency of the audits after the initials are completed and results are reviewed according to the trends recommendations and the guidance via facility Quality Assurance Performance Improvement Plan (QAPI). The Quality Assurance Committee will continue to monitor quarterly that the process was effective and for ongoing compliance.

483.45(a)(b)(1)-(3) REQUIREMENT Pharmacy Srvcs/Procedures/Pharmacist/Records:

§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 facility 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 one of 38 residents reviewed (Resident 12).

Findings include:

The facility's policy for storage of controlled medications, dated March 15, 2024, revealed that when administering a controlled medication, the controlled drug record form must be signed when the medication is removed from the narcotic box, and the Medication Administration Record (MAR) must be signed after the medication is administered. Both documents must be signed.

A significant change Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 12, dated July 26, 2024, revealed that the resident was understood and able to understand, was moderately cognitively impaired, had pain management, had a Stage IV pressure ulcer (wound caused by pressure with bone or tendon exposure), was receiving an opioid (controlled drug), and received hospice care (end of life comfort care).

Interview with the Resident 12's spouse on September 30, 2024, at 1:01 p.m. revealed that he visits daily and that the resident has an open area on her buttocks and has received pain medication prior to dressing changes because she would cry and yell out during wound care.

Physician's orders for Resident 12, dated September 9, 2024, included an order for the resident to receive 0.5 milliliter (20 mg/1 ml) of Morphine Sulfate solution (a narcotic pain medication) every two hours as needed for wound care, shortness of breath, pain, and discomfort.

Review of Resident 12's controlled drug record (a form that accounts for each tablet/pill/dose of a controlled drug), dated August and September 2024, revealed that 0.5 ml of morphine (20 mg/1 ml) was signed out on the controlled drug record on September 6, 2024, at 1:30 p.m.; September 7, 2024, at 3:25 p.m.; and September 12, 2024, at 9:08 a.m.; however, they were not signed as administered on the MAR.

Interview with the Director of Nursing on October 3, 2024, at 2:09 p.m. confirmed that there was no documented evidence in the clinical records to indicate that the signed-out doses of controlled medications mentioned above were administered to Resident 12.

28 Pa. Code 211.9(h) Pharmacy Services.

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

Plan of Correction - To be completed: 11/12/2024

Resident 12 suffered no ill effects related to the narcotic administration being improperly documented.

Medical Director was updated regarding the discrepancy in narcotic sign-off forms.

Nursing staff will be educated in regards to the procedure for signing off narcotics which includes doing so in both the narcotic sign-off form and the MAR.

Nurses involved in the narcotic discrepancy will receive education and disciplinary action.

Director of Nursing or designee will perform a baseline audit on all residents with PRN (as needed) narcotic orders to ensure they have been signed out in both the narcotic sign-off form and the Medication Administration Record.

Director of Nursing or designee will perform weekly audits on all residents with PRN Morphine Sulfate orders to ensure the administered medication was signed out in both the narcotic sign-off form and the Medication Administration Record.

Results of the audits will be reported and trended to the facilities Quality Assurance Steering Committee. The Committee will determine the frequency of the audits after the initials are completed and results are reviewed according to the trends recommendations and the guidance via facility Quality Assurance Performance Improvement Plan (QAPI). The Quality Assurance Committee will continue to monitor quarterly that the process was effective and for ongoing compliance.

483.40(b)(3) REQUIREMENT Treatment/Service for Dementia:

§483.40(b)(3) A resident who displays or is diagnosed with dementia, receives the appropriate treatment and services to attain or maintain his or her highest practicable physical, mental, and psychosocial well-being.

Observations:

Based on clinical record reviews and staff interviews, it was determined that the facility failed to provide appropriate treatment and services for one of 38 residents reviewed (Resident 40) who had dementia.

Findings include:

A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 40, dated July 16, 2024, revealed that the resident was understood, could understand others, had no behaviors, and had diagnosis that included cerebrovascular accident/stroke and anxiety. A care plan for the resident, dated June 17, 2022, revealed that the resident has behaviors including screaming, yelling, refusal of care, throwing items, and being demanding of staff.

Observations of Resident 40 on September 30, 2024, at 11:48 a.m. during and after incontinence care provided by Nurse Aides 4 and 5 revealed that she saw snakes on her comforter and dinosaurs outside of her window. Both Nurse Aides 4 and 5 assured the resident that the snakes were not harmful and would be helpful during care and this was a good day for Resident 40 in regard to her behaviors as she was cooperative with care.

Observations of Resident 40 on October 1, 2024, at 3:40 p.m. revealed that she was in her bed, calling out for a nurse, and crying. She said that her husband was outside stuck on the fence and he needed help inside. Interview with Licensed Practical Nurse 7 on October 1, 2024, at 3:44 p.m. indicated this was Resident 40's baseline, she frequently calls out, cries, and looks for her family.

A care task record for Resident 40 from September 19, 2024 through October 2, 2024, was to be documented with any behavioral symptoms. There was no documented evidence that Resident 40's delusions or hallucinations were reported or any interventions were put in place. On October 1, 2024, at 4:31 p.m. it was documented that the resent was yelling. There was no documented evidence that any new interventions were attempted to address Resident 40's anxiety, anxiousness, confusion, and new hallucinations.

Interview with the Nursing Home Administrator on October 2, 2024, at 11:53 a.m. revealed that she spoke to the physician, and the physician felt that the resident's behaviors were dementia related and does not need outside psychological services, as the behaviors are up and down. The Nursing Home Administrator confirmed that the facility staff were following the plan of care, but there was no documented interventions that staff attempted to assist the resident.

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

Plan of Correction - To be completed: 11/12/2024

Resident 40 had no ill effects related to her behaviors.

Medical Director was notified regarding Resident 40's behaviors.

Resident 40's careplan was updated to reflect her behaviors and new interventions.

Nursing staff will be educated in regards to dementia residents with behaviors and ensuring they have the appropriate interventions in place.

Director of Nursing or designee will perform a baseline audit on all dementia residents with behaviors to ensure they have interventions in place and they are careplanned appropriately.

Director of Nursing or designee will perform weekly audits on all dementia residents with newly documented behaviors to ensure they have interventions in place and their careplan is updated. Audits will continue x 4 weeks.

Results of the audits will be reported and trended to the facilities Quality Assurance Steering Committee. The Committee will determine the frequency of the audits after the initials are completed and results are reviewed according to the trends recommendations and the guidance via facility Quality Assurance Performance Improvement Plan (QAPI). The Quality Assurance Committee will continue to monitor quarterly that the process was effective and for ongoing compliance.

483.35(d)(4)-(6) REQUIREMENT Nurse Aide Registry Verification, Retraining:

§483.35(d)(4) Registry verification.
Before allowing an individual to serve as a nurse aide, a facility must receive registry verification that the individual has met competency evaluation requirements unless-
(i) The individual is a full-time employee in a training and competency evaluation program approved by the State; or
(ii)The individual can prove that he or she has recently successfully completed a training and competency evaluation program or competency evaluation program approved by the State and has not yet been included in the registry. Facilities must follow up to ensure that such an individual actually becomes registered.

§483.35(d)(5) Multi-State registry verification.
Before allowing an individual to serve as a nurse aide, a facility must seek information from every State registry established under sections 1819(e)(2)(A) or 1919(e)(2)(A) of the Act that the facility believes will include information on the individual.

§483.35(d)(6) Required retraining.
If, since an individual's most recent completion of a training and competency evaluation program, there has been a continuous period of 24 consecutive months during none of which the individual provided nursing or nursing-related services for monetary compensation, the individual must complete a new training and competency evaluation program or a new competency evaluation program.

Observations:

Based on review of personnel files, as well as staff interviews, it was determined that the facility failed to verify registry verification prior to allowing individuals to work as a nurse aide for one of three newly hired nurse aides reviewed (Nurse Aide 3).

Findings include:

The personnel file for Nurse Aide 3 revealed that she was hired by the facility on July 10, 2024. However, there was no documented evidence that the facility verified the nurse aide's standing with the state nurse aide registry until October 2, 2024.

Interview with the Human Resources Director October 2, 2024, at 2:20 p.m. confirmed that Nurse Aide 3 did not have a nurse aide registry check completed prior to her start date and that she should have.

28 Pa. Code 201.29 Personnel Policies and Procedures.

Plan of Correction - To be completed: 11/12/2024

Nurse Aid Registry check was completed for Nurse Aid 3

Education will be provided to the Human Resources manager regarding requirements for nurse aid registry checks to be completed prior to hire

The Human Resources Manager will utilize the new hire checklist to assure that all pre-employment requirements are met.

A baseline audit of all Certified staff hired in the last 2 weeks will be completed to assure registry checks were completed.

The Human resources manager will complete audits on all certified new hires weekly x 4 weeks to assure that registry verification checks are completed.

Results of the audits will be reported and trended to the facilities Quality Assurance Steering Committee. The Committee will determine the frequency of the audits after the initial audits are completed and results are reviewed according to the trends recommendations and guidance via facility Quality Assurance Performance Improvement Plan (QAPI). The Quality Assurance Committee will continue to monitor quarterly that the process was effective for ongoing compliance.

483.25(d)(1)(2) REQUIREMENT Free of Accident Hazards/Supervision/Devices:

§483.25(d) Accidents.
The facility must ensure that -
§483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and

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

Observations:

Based on review of clinical records and facility investigation reports, as well as staff interviews, it was determined that the facility failed to ensure that the residents' environment remained free of accident hazards for residents for one of 38 residents reviewed (Resident 55).

Findings include:

A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 55, dated August 9, 2024, revealed that the resident was cognitively intact. An elopement risk for the resident, dated August 10, 2024, revealed that the resident was an elopement risk and that she required a Wanderguard bracelet (an electronic device that alarms when near the exit door).

A nursing note for Resident 55, dated December 12, 2023, at 3:18 p.m. revealed that the resident was visualized exiting the building. She had a history of verbalizing her desire to go home. Wanderguards had been attempted in the past; however, she usually removes them.

A nursing note for Resident 55, dated July 19, 2024, revealed that the resident was found outside the facility sitting on a bench. The resident's Wanderguard was not on her person and, therefore, did not sound to alert the staff that she was exiting the building.

There was no documented evidence that the facility attempted to prevent Resident 55 from exiting the building in any way other than the Wanderguard, which they were aware she was removing herself.

Interview with the Director of Nursing on October 3, 2024, at 12:54 p.m. confirmed that they were aware Resident 55 was removing her Wanderguard and that she was not happy residing at the facility; however, there were no further interventions in place to prevent her from leaving the building.

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

Plan of Correction - To be completed: 11/12/2024

Resident 55 had no ill effects associated with the elopement.

Resident 55's careplan was updated to reflect new interventions to help prevent elopement.

Nursing staff will be educated in regards to providing interventions to help prevent a high-risk resident from eloping and that their careplans reflect those interventions.

Director of Nursing or designee will peform a baseline audit of all residents that are high risk for elopement to ensure they have appropriate interventions in place and their careplans reflect those interventions.

Director of Nursing or designee will perform weekly audits of any new residents deemed to be high risk for elopement to ensure that they have appropriate interventions in place and their careplans reflect those interventions. Audits will continue x 4 weeks.

Results of the audits will be reported and trended to the facilities Quality Assurance Steering Committee. The Committee will determine the frequency of the audits after the initials are completed and results are reviewed according to the trends recommendations and the guidance via facility Quality Assurance Performance Improvement Plan (QAPI). The Quality Assurance Committee will continue to monitor quarterly that the process was effective and for ongoing compliance.

483.21(b)(2)(i)-(iii) REQUIREMENT Care Plan Timing and Revision:

§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 policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to revise/update care plans for two of 38 residents reviewed (Residents 39, 61).

Findings include:

The facility's policy regarding care plans, dated March 15, 2024, indicated that nurses and interdisciplinary team members were responsible for updating the resident's care plan to reflect changes in the resident's status.

A significant change Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 39, dated September 24, 2024, indicated that the resident was cognitively intact, required assistance from staff for her daily care needs, and had diagnoses that included, heart failure, and chronic pain.

Physician's orders for Resident 39, dated March 11, 2024, included an order for morphine sulfate solution (20 mg/ml), give one ml by mouth every eight hours for chronic pain.

Physician's orders for Resident 39, dated May 1, 2024, included an order for morphine sulfate solution (20 mg/ml), give one ml by mouth every two hours as needed for pain.

Physician's orders for Resident 39, dated June 12, 2024, included an order for a fentanyl transdermal (on the skin) pain patch 75 micrograms per hour, to be changed every three days, for chronic pain.

There was no documented evidence in Resident 39's clinical record to indicate that the care plan was updated to include multiple medications for pain management.

A significant change MDS assessment for Resident 61, dated September 6, 2024, indicated that the resident was cognitively intact, required assistance from staff for her daily care needs, and had diagnoses that included heart failure and non-traumatic brain dysfunction (a complex medical condition that impacts brain function and daily life).

A physician's order for Resident 61, dated August 30, 2024, included an order for a urinary catheter related to urinary retention. However, the resident's current care plan, dated February 20, 2020, included a care plan for bladder incontinence and the use of pantiliners (a thin pad worn to protect undergarments from stains).

Interview with the Director of Nursing on October 3, 2024, at 10:03 a.m. confirmed that Resident 39's care plan should have been updated to reflect that she was on multiple pain medications, and that Resident 61's care plan should have been updated to reflect that she did not have bladder incontinence and did not use pantiliners, and they were not.

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

Plan of Correction - To be completed: 11/12/2024

Residents 39 and 61 had no ill effects related to the facility not updating their careplans to reflect their change in status.

Resident 39's careplan was updated to reflect her usage of multiple pain medications for pain management.

Resident 61's careplan was updated to reflect her catheter placement and the discontinuation of panty liners and urinary incontinence.

Nursing staff will be educated regarding updating careplans to reflect a resident's change in condition.

Director of Nursing or designee to perform a baseline audit of careplans for residents with catheters and urinary and/or bowel incontinence to ensure that their careplans reflect their current urinary/bowel status.

Director of Nursing or designee to perform a baseline audit of careplans for residents with three or more pain medications ordered to ensure that their careplans reflect their current pain management system.

Director of Nursing or designee will perform weekly audits on all residents with new pain medications ordered to ensure their careplan was updated to reflect their current pain management system. Audits will continue x 4 weeks.

Director of Nursing or designee will perform weekly audits on all residents with new urinary and/or bowel incontinence and ensure that their careplans are updated to reflect the change in urinary status. Audits will continue x 4 weeks.

Results of the audits will be reported and trended to the facilities Quality Assurance Steering Committee. The Committee will determine the frequency of the audits after the initials are completed and results are reviewed according to the trends recommendations and the guidance via facility Quality Assurance Performance Improvement Plan (QAPI). The Quality Assurance Committee will continue to monitor quarterly that the process was effective and for ongoing compliance.

483.21(b)(1)(3) REQUIREMENT Develop/Implement Comprehensive Care Plan:

§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 review of policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to develop care plans for one of 38 residents reviewed (Resident 61).

Findings include:

The facility's policy regarding the development of care plans, dated March 15, 2024, indicated that the facility will develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective person-centered care of the residents and meet professional standards of quality care.

A significant change Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 61, dated September 6, 2024, indicated that the resident was cognitively intact, required assistance from staff for her daily care needs, and was frequently incontinent (two or more episodes of bowel incontinence, but at least one continent bowel movement) of bowel. Task records for the month of September 2024 were reviewed and indicated that Resident 61 did have two or more bowel incontinence episode weekly.

There was no documented evidence that a care plan was developed to address Resident 61's care needs related to bowel incontinence.

Interview with the Director of Nursing on October 3, 2024, at 10:03 a.m. confirmed that Resident 61 should have had a care plan developed for bowel incontinence and she did not.

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

Plan of Correction - To be completed: 11/12/2024

Resident 61 had no ill effects related to the facility not updating her careplan for bowel incontinence.

Resident 61's careplan was updated to reflect her bowel incontinence.

Nursing staff will be educated regarding updating careplans to reflect a resident's change in condition.

Director of Nursing or designee will perform a baseline audit of all the residents that have documented urinary and/or bowel incontinence to ensure their careplans are accurate. Audits will continue x 4 weeks.

Director of Nursing or designee will perform weekly audits on all residents with new urinary and/or bowel incontinence and ensure that their careplans are updated to reflect the change in urinary status. Audits will continue x 4 weeks.

Results of the audits will be reported and trended to the facilities Quality Assurance Steering Committee. The Committee will determine the frequency of the audits after the initials are completed and results are reviewed according to the trends recommendations and the guidance via facility Quality Assurance Performance Improvement Plan (QAPI). The Quality Assurance Committee will continue to monitor quarterly that the process was effective and for ongoing compliance.

483.12(b)(1)-(5)(ii)(iii) REQUIREMENT Develop/Implement Abuse/Neglect Policies:

§483.12(b) The facility must develop and implement written policies and procedures that:

§483.12(b)(1) Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property,

§483.12(b)(2) Establish policies and procedures to investigate any such allegations, and

§483.12(b)(3) Include training as required at paragraph §483.95,

§483.12(b)(4) Establish coordination with the QAPI program required under §483.75.

§483.12(b)(5) Ensure reporting of crimes occurring in federally-funded long-term care facilities in accordance with section 1150B of the Act. The policies and procedures must include but are not limited to the following elements.

§483.12(b)(5)(ii) Posting a conspicuous notice of employee rights, as defined at section 1150B(d)(3) of the Act.

§483.12(b)(5)(iii) Prohibiting and preventing retaliation, as defined at section 1150B(d)(1) and (2) of the Act.

Observations:

Based on review of policies and personnel files, as well as staff interviews, it was determined that the facility failed to ensure that the status of nursing licenses were checked with the State Board of Nursing for two of two nurses reviewed (Registered Nurse 1, Licensed Practical Nurse 2) and failed to complete a Nurse Aide Registry verification for one of three nurse aides reviewed (Nurse Aide 3).

Findings include:

The facility's policy regarding abuse prevention, dated March 15, 2024, indicated that the facility conducted background checks and will not knowingly employ or otherwise engage any individual who has disciplinary action in effect against his or her professional license by a state licensure board or registry as a result of a finding of abuse, neglect, exploitation, mistreatment of residents, or misappropriation of resident property.

The personnel file for Registered Nurse 1 revealed a start date of April 21, 2024. However, there was no documented evidence until October 2, 2024, that his license was verified with the State Board prior to him working.

The personnel file for Licensed Practical Nurse 2 revealed a start date of July 14, 2024. However, there was no documented evidence until October 2, 2024, that her license was verified with the State Board prior to her working.

The personnel file for Nurse Aide 3 revealed a start date of July 10, 2024. However, there was no documented evidence until October 2, 2024, that her standing on the Pennsylvania Nurse Aide Registry was verified.

Interview with the Human Resources Director on October 2, 2024, at 2:20 p.m. confirmed that Registered Nurse 1 had a start date of April, 21, 2024, and Licensed Practical Nurse 2 had a start date of July 14, 2024, and there was no evidence that their licenses were verified with the State Board of Nursing until October 2, 2024. She also confirmed that Nurse Aide 3 had a start date of July 10, 2024, and there was no evidence that a registry verification was completed prior to her start date.

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

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

Plan of Correction - To be completed: 11/12/2024

License verification checks were completed for Registered Nurse 1 and Licensed Practical Nurse 2

Nurse Aid Registry check was completed for Nurse Aid 3

Education will be provided to the Human Resources manager regarding requirements for license and registry checks being completed prior to hire.

The Human Resources Manager will utilize the new hire checklist to assure that all pre-employment requirements are met.

A baseline audit of all Licensed and Certified staff hired in the last 2 weeks will be completed to assure license and registry checks were completed.

The Human resources manager will complete audits on all licensed and certified new hires weekly x 4 weeks to assure that license and registry verification checks are completed.

Results of the audits will be reported and trended to the facilities Quality Assurance Steering Committee. The Committee will determine the frequency of the audits after the initial audits are completed and results are reviewed according to the trends recommendations and guidance via facility Quality Assurance Performance Improvement Plan (QAPI). The Quality Assurance Committee will continue to monitor quarterly that the process was effective for ongoing compliance.

483.10(g)(17)(18)(i)-(v) REQUIREMENT Medicaid/Medicare Coverage/Liability Notice:

Least serious deficiency but affects more than a limited number of residents, staff, or occurrences. This deficiency has the potential for causing no more than a minor negative impact on the resident but is not found to be throughout this facility.

§483.10(g)(17) The facility must--
(i) Inform each Medicaid-eligible resident, in writing, at the time of admission to the nursing facility and when the resident becomes eligible for Medicaid of-
(A) The items and services that are included in nursing facility services under the State plan and for which the resident may not be charged;
(B) Those other items and services that the facility offers and for which the resident may be charged, and the amount of charges for those services; and
(ii) Inform each Medicaid-eligible resident when changes are made to the items and services specified in §483.10(g)(17)(i)(A) and (B) of this section.

§483.10(g)(18) The facility must inform each resident before, or at the time of admission, and periodically during the resident's stay, of services available in the facility and of charges for those services, including any charges for services not covered under Medicare/ Medicaid or by the facility's per diem rate.
(i) Where changes in coverage are made to items and services covered by Medicare and/or by the Medicaid State plan, the facility must provide notice to residents of the change as soon as is reasonably possible.
(ii) Where changes are made to charges for other items and services that the facility offers, the facility must inform the resident in writing at least 60 days prior to implementation of the change.
(iii) If a resident dies or is hospitalized or is transferred and does not return to the facility, the facility must refund to the resident, resident representative, or estate, as applicable, any deposit or charges already paid, less the facility's per diem rate, for the days the resident actually resided or reserved or retained a bed in the facility, regardless of any minimum stay or discharge notice requirements.
(iv) The facility must refund to the resident or resident representative any and all refunds due the resident within 30 days from the resident's date of discharge from the facility.
(v) The terms of an admission contract by or on behalf of an individual seeking admission to the facility must not conflict with the requirements of these regulations.

Observations:

Based on clinical record reviews and staff interviews, it was determined that the facility failed to provide the required notice to the resident or the resident's representative following the end of their Medicare coverage for two of two residents reviewed (Residents 62, 95) who remained in the facility for long-term care.

Findings include:

A Skilled Nursing Facility (SNF) Beneficiary Protection Notification Review form, completed by the facility and dated July 30, 2024, revealed that Medicare coverage for Resident 62 started on July 11, 2024, and that her last covered day was July 30, 2024. The form indicated that the facility initiated discontinuation from Medicare Part A coverage and that the resident's benefit days were not exhausted. The SNF Beneficiary Protection Notification Review form was not issued at least 48 hours in advance. The Advanced Beneficiary Notice of Non-coverage for Resident 62 was not issued.

A SNF Beneficiary Protection Notification Review form, completed by the facility and dated July 8, 2024, revealed that Medicare coverage for Resident 95 started on June 19, 2024, and that her last covered day was July 10, 2024. The form indicated that the facility initiated discontinuation from Medicare Part A coverage and that the resident's benefit days were not exhausted. The Advanced Beneficiary Notice of Non-coverage for Resident 95 was not issued.

Interview with the Admissions Director on October 1, 2024, at 10:55 a.m. revealed that Resident 62's SNF Beneficiary Protection Notice was not issued timely and that she was unaware that the ABN was required when the resident remained in the facility.

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

Plan of Correction - To be completed: 11/12/2024

No ill effects to Resident 62 and Resident 95 related to untimely issuing of Skilled Nursing Facility Beneficiary Protection Notification Review Form and Advanced Beneficiary Notice of Non Coverage. .

Social services director was educated on timely administration of SNF Beneficiary Protection Notification Review Form and Advanced Beneficiary Notice of Non Coverage.

A baseline audit of current resident's receiving skilled therapy services completed to assure that notices are issued timely.

The social services director and or designee will complete random weekly audits on all resident's discharging from Medicare Part A stays to assure that the SNF Beneficiary Protection Notification Review Form and Advanced Beneficiary Notice of Non Coverage are issued timely if indicated.

Results of the audits will be reported and trended to the facilities Quality Assurance Steering Committee. The Committee will determine the frequency of the audits after the initial audits are completed and results are reviewed according to the trends recommendations and guidance via facility Quality Assurance Performance Improvement Plan (QAPI). The Quality Assurance Committee will continue to monitor quarterly that the process was effective for ongoing compliance.

§ 201.22(a) LICENSURE Prevention, control and surveillance of tuber:

(a) The facility shall have a written TB infection control plan with established protocols which address risk assessment and management, screening and surveillance methods, identification, evaluation, and treatment of residents and employees who have a possible TB infection or active TB.

Observations:

Based on review of personnel files, and the Centers for Disease Control (CDC) guidelines, as well as staff interviews, it was determined that the facility failed to ensure that all newly hired employees were screened for tuberculosis (TB), according to CDC guidelines, prior to providing services for one of five employees reviewed Nurse Aide 3.

Findings include:

The CDC's Guidelines for Preventing the Transmission of Mycobacterium Tuberculosis in the Healthcare Setting Volume 54/No. RR-17, dated December 30, 2005, revealed that baseline testing for TB was recommended for newly hired healthcare workers and could be conducted using the TST (tuberculin skin test) or a BAMT (blood test). If a newly hired worker had a documented negative TST in the previous 12 months, a single TST could be administered in the new setting.

Nurse Aide 3's personnel file revealed that she was hired on July 10 2024. Documentation revealed that she had a documented negative TST completed on April 24, 2024, and May 13, 2024; however, there was no documented evidence that she received a base line TST and/or BAMT from the facility.

Interview with the Human Resource Director on October 2, 2024, at 2:20 p.m. confirmed that Nurse Aide 3 did not receive a TST and/or BAMT prior to providing services at the facility and in accordance with CDC's guidelines.

Plan of Correction - To be completed: 11/12/2024

No ill effect related to Nurse Aid 3 not receiving Transmission of Mycobacterium Tuberculosis testing upon hire

Human Resources manager educated on Centers of Disease Control and Prevention (CDC) Guidelines for Preventing Transmission of Mycobacterium Tuberculosis

Human Resources manager will complete a weekly audit on all new hires x 4 weeks to assure that Tuberculosis testing is completed per CDC guidelines

The Facility will complete their quarterly Quality Assurance Steering Committee and submit their minutes to the Administrator for review and guidance. Results of the audits will be reported and trended to the facility's Quality Assurance Steering Committee. The Quality Assurance Steering Committee will determine the frequency of the audits after the initial audits are completed and results are reviewed according to the trends recommendations and guidance via facility Quality Assurance Performance Improvement Plan (QAPI).

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