Pennsylvania Department of Health
 ATHENS NURSING AND REHABILITATION CENTER
Patient Care Inspection Results

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ATHENS NURSING AND REHABILITATION CENTER
Inspection Results For:

There are  65 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.
ATHENS NURSING AND REHABILITATION CENTER - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on a Medicare/Medicaid Recertification Survey, State Licensure Survey, Civil Rights Compliance Survey, and an Abbreviated Survey to review three Complaints, completed on June 14, 2024, it was determined that Athens Nursing and Rehabilitation Center was not in compliance with the following requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care and the 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.


 Plan of Correction:


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

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

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

Based on observation and staff interview, it was determined that the facility failed to store food items and maintain equipment in a safe and sanitary manner in the facility's main kitchen.

Findings included:

Initial tour of the facility's main kitchen on June 11, 2024, between 10:25 AM and 11:07 AM revealed the following:

The clear lights on the ceiling had multiple dead insects and debris accumulated in the protective covers.

There were opened bread products on a plastic rack near the kitchen entrance with no open dates that included the following: a partially used bag of hamburger buns, an open bag of hot dog buns, and a partially used loaf of bread.

A wire storage rack in front of the sink had a build-up of debris on the bottom protective cover/shelf.

There was a significant build-up of debris at the perimeter of the kitchen where the floor meets the wall.

There was an extensive build-up of dust inside of the steamer exhaust area.

A second wire storage rack had debris accumulating on the bottom cover/shelf.

A clear plastic container holding various green and red lids that Employee 12, Dietary Manager, identified as clean had a dead insect in the bottom of the container.

A plastic base of a stainless-steel coffee container was broken and cracked.

A container of handled plastic adaptive cups and various other plastic cups were stained and there was debris in the bottom of the plastic container the cups were being stored in.

There were 16 bowls of various cereals that were uncovered with no noted labels or dates.

There were two slices of bread wrapped in saranwrap on the stainless-steel shelf above the steam table that were not labeled or dated.

There were nine clear, small plastic containers of a brown sugar like substance with no labels or dates on them on the stainless-steel shelf above the steam table.

The underside of the stainless-steel shelf above the steam table had an accumulation of debris.

There was a significant accumulation of dust on top of the commercial coffee machine.

Three frying pans of various sizes hanging from a rack near the middle of the kitchen had an extensive build-up of a black color, that appeared to be burnt on the cooking surface of the pans.

Multiple clear plastic containers that were stored and stacked upside down on a shelf had an extensive volume of moisture between the containers.

There were significant splash stains that were brown in color on the wall near the fire extinguisher.

There was a container of Italian dressing with no open date in a refrigerator near the main entrance to the kitchen.

There were eight cups of a milk like liquid, five cups that appeared to be orange juice, and a sealed Yoplait original container with no labels or dates in a refrigerator located near the fire extinguisher. The milk like liquid was spilled in the bottom of the container.

There were 15 lidded plastic cups of fruit being stored in the refrigerator located near the fire extinguisher. Seven of the containers had dislodged lids which left the fruit open to the air.

There was a large, lidded container of sliced American cheese in the refrigerator near the fire extinguisher. There were no labels or dates on the container.

There were six pies with no labels or dates located in the refrigerator near the fire extinguisher.

The roll-up door at the loading dock had an extensive build-up of cobwebs around the door.

The light on the ceiling at the loading dock had a build-up of debris and dead insects on the exterior of it.

The alcohol-based hand cleaner dispenser at the loading dock had a significant build-up of black-colored dust on it.

The walk-in freezer had an extensive build-up of ice on multiple food items that included various sealed meats and boxes. There was a layer of ice on the interior ceiling of the freezer especially near the cooling fans. There were multiple icicles hanging from a black conduit pipe under the cooling fans. A concurrent interview with Employee 12 revealed the door to the freezer was "bowed" and this causes a "bad ice build-up." Employee 12 further reported that maintenance uses a "heat gun" twice a week to help dethaw the freezer.

There was a build-up of cobwebs on the ceiling at the entrance from the loading dock area to the main kitchen.

There were extensive brown stains on the ceiling above the dishwasher area and there were areas of a black colored stains where the wall meets the ceiling above the dishwasher.

The above findings were reviewed with Employee 12 on June 11, 2024, at 11:35 AM and the Nursing Home Administrator and Director of Nursing on June 13, 2024, at 2:15 PM.

A review of the "Refrigerator/Freezer Temperature Log" for June 2024, for the refrigerator located as "by door," revealed a notation that indicated, "Refrigerator temperatures below 40 degrees." Review of the temperatures for "Night Shift" revealed the following dates where temperatures were above the desired 40 degrees: June 6, 2024, at 42 degrees; June 7, 2024, at 42 degrees; and June 10, 2024, at 46 degrees. There was no documented corrective action or recheck of the temperature documented on the form in the "Corrective Action" section for these dates.

The above information regarding the temperature log was reviewed with the Nursing Home Administrator on June 14, 2024, at 1:14 PM.

28 Pa. Code 201.14(a) Responsibility of licensee


 Plan of Correction - To be completed: 07/21/2024

1. All areas identified during survey were corrected. The plastic coffee container base was discarded and replaced. The ceiling tiles were replaced. The facility has ordered a new freezer door.
2. Food Service Director will conduct an audit of opened dates and general cleanliness standards of kitchen.
3. Food Service Director and dietary staff will be educated on open dates and general cleanliness standards of the kitchen.

Daily cleaning checklists for each shift will be implemented, and the supervisor will sign off after verification of cleaning.

Weekly cleaning checklists will be implemented and signed off by FSD.
4. Nursing home administrator/designee will conduct random audits of kitchen areas daily x4 days a week for two weeks and then weekly times two months. Results will be reviewed during the monthly QAPI meeting.

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

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

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

Based on clinical record review and staff interview, it was determined that the facility failed to ensure that the resident or resident representative received written notice of the facility bed hold policy at the time of transfer for six of seven residents reviewed for hospitalization concerns (Residents 3, 37, 59, 19, 34, and 60).

Findings include:

Clinical record review for Resident 3 revealed nursing documentation dated April 3, 2024, at 1:34 PM that Resident 3 was admitted to the hospital from her appointment with the wound care consultant provider. Resident 3 had a surgical procedure for a below the knee amputation.

Nursing documentation dated May 11, 2024, at 1:36 AM revealed that Resident 3 had emesis resembling coffee grounds (indicative of gastrointestinal bleeding), had abdominal discomfort, and staff called emergency transport.

An emergency room history and physical dated May 10, 2024, indicated that Resident 3 was admitted from the emergency room.

A review of a Bed Hold/Transfer/Therapeutic Leave Notification form (form the facility utilized to communicate to a resident and resident's representative that a resident transferred out of the facility) dated April 3, 2024, and May 10, 2024, included no evidence that the facility provided written notification of the state bed-hold policy to either Resident 3 or her representative at the time of Resident 3's hospitalizations.

Clinical record review for Resident 19 revealed nursing documentation dated April 15, 2024, at 12:51 PM that Resident 19 had a severe congested cough, difficulty with deep breathing, and chest pain when breathing. The physician instructed staff to send the resident to the emergency room.

A review of a Bed Hold/Transfer/Therapeutic Leave Notification form dated April 15, 2024, revealed no evidence that staff provided written notification to Resident 19's representative (daughter) of the state bed-hold policy.

Clinical record review for Resident 34 revealed nursing documentation dated April 6, 2024, at 3:21 PM that Resident 34 had an irregular heart rate (appeared to be atrial fibrillation, an irregular and often very rapid heart rhythm). Nursing documentation dated April 7, 2024, at 8:27 PM revealed that Resident 34 was holding her chest area and requested to go to the emergency room for evaluation. Staff notified the physician and arranged emergency transport to the emergency room.

Nursing documentation dated April 20, 2024, at 9:15 PM revealed that staff believed Resident 34 had blood clots from her vaginal opening. Resident 34 left the facility via emergency transport at 9:10 PM. Nursing documentation dated April 21, 2024, at 10:34 AM indicated that the hospital admitted Resident 34 with a urinary tract infection.

Review of Bed Hold/Transfer/Therapeutic Leave Notification forms dated April 7, 2024, and April 20, 2024, revealed no evidence that staff provided written notification to Resident 34's representative (sister-in-law) of the state bed-hold policy.

Clinical record review for Resident 60 revealed documentation from the certified registered nurse practitioner dated February 8, 2024, at 11:38 AM that Resident 60 had lack of feeling and movement on her right side (change from baseline). Resident 60 was sent to the emergency room for evaluation and treatment.

The facility could not provide a Bed Hold/Transfer/Therapeutic Leave Notification form for Resident 60's hospitalization on February 8, 2024.

Nursing documentation dated May 17, 2024, at 4:27 AM revealed that Resident 60 was very diaphoretic (sweating), had a low-grade temperature of 99.9 (Fahrenheit), and had a deteriorating pressure wound on her coccyx (tailbone) area that was foul-smelling. Nursing documentation dated May 17, 2024, at 7:00 AM indicated that staff made the physician aware of Resident 60's change in condition that included altered mental status, fever, skin ulcer, diaphoresis, and increased confusion. The physician responded with instructions to send Resident 60 to the emergency room for evaluation. Nursing documentation dated May 17, 2024, at 7:35 AM revealed Resident 60 left the facility via emergency transport.

Review of a Bed Hold/Transfer/Therapeutic Leave Notification form dated May 17, 2024, revealed no evidence that staff provided written notification to Resident 60's representative (son) of the state bed-hold policy.

The surveyor reviewed the above findings for Residents 3, 19, 34, and 60 during an interview with the Director of Nursing, the Nursing Home Administrator, and Employee 6, on June 13, 2024, at 2:00 PM.

Review of Resident 37's clinical record revealed that the facility transferred him to the hospital on February 27, 2024, after a fall with injuries. Resident 37 was admitted to the hospital and returned on March 6, 2024. The facility could not provide a Bed Hold/Transfer/Therapeutic Leave Notification form for Resident 37's hospitalization on February 27, 2024.

Review of Resident 59's clinical record revealed that the facility transferred her to the hospital on March 29, 2024. Resident 59 was admitted to the hospital and returned on April 3, 2024. The facility could not provide a Bed Hold/Transfer/Therapeutic Leave Notification form for Resident 59's hospitalization on March 29, 2024.

Interview with the Administrator on June 14, 2024, at 10:49 AM confirmed the above findings for Resident 37 and 59.

483.15(d) Notice of Bed Hold Policy Before/Upon Transfer
Previously cited deficiency 7/21/23

28 Pa. Code 201.14(a) Responsibility of licensee

28 Pa. Code 201.29(f) Resident rights


 Plan of Correction - To be completed: 07/21/2024

1. The facility cannot retroactively correct the missing documented evidence of bed hold policy for residents cited.

2. The facility will audit hospital transfers over the past 30 days to ensure bed hold policy was provided to the residents/resident representatives.

3. Licensed Nurses will be educated on the facility's bed hold policy and providing written notices that include required information to resident/resident representatives.

4. All hospital transfers will be reviewed in AM meeting 4x a week for 4 weeks, and weekly x2 months to ensure written BH notification was provided to resident and RR. Audits will continue until substantial compliance is achieved.

483.80(d)(3)(i)-(vii) REQUIREMENT COVID-19 Immunization:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
§483.80(d) (3) COVID-19 immunizations. The LTC facility must develop and implement policies and procedures to ensure all the following:
(i) When COVID-19 vaccine is available to the facility, each resident and staff member
is offered the COVID-19 vaccine unless the immunization is medically contraindicated or the resident or staff member has already been immunized;
(ii) Before offering COVID-19 vaccine, all staff members are provided with education
regarding the benefits and risks and potential side effects associated with the vaccine;
(iii) Before offering COVID-19 vaccine, each resident or the resident representative
receives education regarding the benefits and risks and potential side effects associated with the COVID-19 vaccine;
(iv) In situations where COVID-19 vaccination requires multiple doses, the resident,
resident representative, or staff member is provided with current information regarding those additional doses, including any changes in the benefits or risks and potential side effects associated with the COVID-19 vaccine, before requesting consent for administration of any additional doses;
(v) The resident, resident representative, or staff member has the opportunity to accept or refuse a COVID-19 vaccine, and change their decision;
(vi) The resident's medical record includes documentation that indicates, at a minimum,
the following:
(A) That the resident or resident representative was provided education regarding the
benefits and potential risks associated with COVID-19 vaccine; and
(B) Each dose of COVID-19 vaccine administered to the resident; or
(C) If the resident did not receive the COVID-19 vaccine due to medical
contraindications or refusal; and
(vii) The facility maintains documentation related to staff COVID-19 vaccination that
includes at a minimum, the following:
(A) That staff were provided education regarding the benefits and potential risks
associated with COVID-19 vaccine;
(B) Staff were offered the COVID-19 vaccine or information on obtaining COVID-19 vaccine; and
(C) The COVID-19 vaccine status of staff and related information as indicated by the Centers for Disease Control and Prevention's National Healthcare Safety Network (NHSN).
Observations:

Based on review of select facility policies and procedures, clinical record review, and staff interview, it was determined that the facility failed to offer the COVID-19 vaccine as indicated by the Centers for Disease Control (CDC) for four of five residents reviewed for immunization concerns (Residents 2, 35, 36, and 60).

Findings include:

The facility policy entitled, "Coronavirus Disease (COVID-19) - Infection Prevention and Control Measures," last reviewed without changes on August 1, 2023, revealed that the infection prevention and control measures that are implemented to address the SARS-Co V-2 are incorporated into the facility infection prevention and control plan. These measures include encouraging staff, residents, and visitors, to remain up to date with all COVID-19 vaccine doses.

The policy provided by the facility did not include education provided to residents regarding benefits and potential risks associated with the COVID-19 vaccine, or the documentation maintained regarding education provided, administration of vaccines, or recommendations implemented per the CDC.

Current CDC guidelines at https://www.cdc.gov/coronavirus/2019-ncov/vaccines/stay-up-to-date.html recommend that people aged 65 years and older who received one dose of any updated 2023-2024 COVID-19 vaccine (Pfizer-BioNTech, Moderna, or Novavax) should receive one additional dose of an updated COVID-19 vaccine at least four months after the previous updated dose. People aged 65 years and older are up to date when they have received two updated 2023-2024 COVID-19 vaccine doses. People aged 65 years and older who have not previously received any COVID-19 vaccine doses and choose to get Novavax should get two doses of updated Novavax vaccine, followed by one additional dose of any updated 2023-2024 COVID-19 vaccine to be up to date.

Clinical record review for Resident 2 revealed that the facility admitted her on December 3, 2021; and that she was 96 years old. Review of immunization information contained in her medical record revealed that her last COVID-19 immunization was on August 2, 2022. There was no evidence that the facility provided vaccine information or offered any 2023-2024, or Novavax COVID-19 immunizations to Resident 2 after 2022.

Clinical record review for Resident 35 revealed that the facility admitted her on July 31, 2020; and that she was 87 years old. Review of immunization information contained in her medical record revealed that her last COVID-19 immunization was on June 24, 2022. There was no evidence that the facility provided vaccine information or offered any 2023-2024, or Novavax COVID-19 immunizations to Resident 35 after 2022.

Clinical record review for Resident 36 revealed that the facility admitted her on December 16, 2022, and that she was 78 years old. Review of immunization information contained in her medical record revealed that her last COVID-19 immunization was on December 8, 2021. There was no evidence that the facility provided vaccine information or offered any 2023-2024, or Novavax COVID-19 immunizations to Resident 36 after 2021.

Clinical record review for Resident 60 revealed that the facility admitted her on December 30, 2023, and that she was 80 years old. Review of immunization information contained in her medical record revealed that her last COVID-19 immunization was on June 9, 2021. There was no evidence that the facility provided vaccine information or offered any 2023-2024, or Novavax COVID-19 immunizations to Resident 60.

Interview with the Director of Nursing on June 14, 2024, at 10:30 AM requested any additional evidence regarding the COVID-19 immunizations for Residents 2, 35, 36, and 60.

Interview with the Director of Nursing, the Nursing Home Administrator, and Employee 6 (clinical consultant) on June 14, 2024, at 11:45 AM confirmed that the facility had no additional information to evidence that Residents 2, 35, 36, and 60 were provided education regarding COVID 19 immunizations, or an immunization to remain up to date with the available COVID-19 vaccines.

28 Pa. Code 211.5(f) Medical records

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

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


 Plan of Correction - To be completed: 07/21/2024

1. Residents 2, 35, 36, and 60 were offered Covid-19 vaccination. Consents/declination will be uploaded to medical record after vaccination administration.
2. A whole house audit was completed to determine which resident's requested a Covid-19 vaccination/booster and which declined. Consents/declination will be uploaded to medical record after vaccination administration.
3. Infection Preventionist and DON were educated on "Coronavirus Disease (Covid-19) – Infection Prevention and Control Measures" policy, to include encouraging residents to stay up-to-date with Covid vaccines and to provide residents Covid-19 vaccination education. Residents will be given education from the CDC, with the most up-to-date information regarding COVID vaccinations.
4. Administrator/designee will audit resident requests/declination to ensure all residents that wished to receive vaccination, did. Administrator will audit all new admission requests or declination to ensure they receive vaccination or that declination was uploaded to medical record.

483.80(b)(1)-(4) REQUIREMENT Infection Preventionist Qualifications/Role:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
§483.80(b) Infection preventionist
The facility must designate one or more individual(s) as the infection preventionist(s) (IP)(s) who are responsible for the facility's IPCP. The IP must:

§483.80(b)(1) Have primary professional training in nursing, medical technology, microbiology, epidemiology, or other related field;

§483.80(b)(2) Be qualified by education, training, experience or certification;

§483.80(b)(3) Work at least part-time at the facility; and

§483.80(b)(4) Have completed specialized training in infection prevention and control.
Observations:

Based on staff interview and a review of the facility's infection control program, it was determined that the facility failed to have a designated Infection Preventionist with the necessary qualifications responsible for the facility's infection prevention and control program.

Findings include:

Interview with the Nursing Home Administrator on June 11, 2024, at 10:02 AM revealed that the facility's previous Director of Nursing from April 1, 2024, to June 2, 2024, fulfilled the position of infection preventionist until her discontinuation of employment on June 2, 2024. The interview indicated that a current licensed practical nurse employee assumed the infection preventionist position.

Interview with the Nursing Home Administrator on June 13, 2024, at 10:04 AM confirmed that no staff currently employed by the facility has completed any specialized training in infection prevention and control. The interview also confirmed that the facility could not provide any evidence of infection control committee meetings (that included the required members) since the facility's last standard survey that ended on July 21, 2023.

Interview with the Director of Nursing on June 14, 2024, at 10:30 AM indicated that she has not completed any specialized training in infection prevention and control; however, she has attempted to monitor antibiotic use and infection prevalence in the facility. The interview indicated that she could not provide a current line listing of the facility's infections or evidence of antibiotic surveillance that she has completed. The Director of Nursing also confirmed that she did not have access to the State's PA-PSRS (Pennsylvania Patient Safety Reporting System, a secure, web-based, system that permits healthcare facilities to submit reports that are defined as serious events and incidents) reporting system; she did not know who was performing that task.

Interview with the Director of Nursing, the Nursing Home Administrator, and Employee 6 (clinical consultant) on June 14, 2024, at 11:45 AM confirmed the above findings regarding the infection preventionist position.

28 Pa. Code 201.18(b)(1)e)(1)(3)(6) Management

28 Pa. Code 201.19(3) Personnel policies and procedures

28 Pa. Code 211.12(c)(d)(1)(4)(5) Nursing services


 Plan of Correction - To be completed: 07/21/2024

1. The facility cannot retroactively correct the Infection Preventionist deficiency.
Infection Control Committee meeting will be held with next monthly QAPI with all required attendee's .
2. An Infection Preventionist has been hired and has completed the PA Infection Preventionist Certification on 6/27/2024.
3. The NHA / designee will be reeducated on the requirement for Infection Preventionist.
4. A one-time audit will be conducted to ensure Infection Preventionist is in facility onsite.

483.80(a)(1)(2)(4)(e)(f) REQUIREMENT Infection Prevention & Control:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
§483.80 Infection Control
The facility must establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections.

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

§483.80(a)(1) A system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon the facility assessment conducted according to §483.70(e) and following accepted national standards;

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

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

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

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

Based on observation, clinical record review, and staff interview, it was determined that the facility failed to implement appropriate enhanced barrier transmission-based precautions for four of 13 residents reviewed (Residents 25, 49, 59, and 60).

Findings include:

Review of the memo entitled "Enhanced Barrier Precautions (EBP, gown and glove use) in Nursing Homes to Prevent the Spread of Multi-drug Resistant Organisms" released by the Center for Medicaid and Medicare Services (CMS) on March 20, 2024, with an implementation date of April 1, 2024, revealed that nursing care facilities are to use EBP for residents with chronic wounds or indwelling medical devices (i.e., indwelling urinary catheters) during high-contact resident care activities regardless of their multidrug-resistant organism status. High-contact activity would include things like dressing, transferring, changing linens, providing hygiene, changing briefs, wound care, or device care.

Interview with Employee 5, nurse aide, on June 12, 2024, at 11:18 AM revealed that the nurses usually tell the aides if someone is using EBP and if there was PPE (personal protective equipment, such as gloves, masks, and gowns) hanging on the door. Employee 5 indicated that if they are not told or if no PPE is on the door, they would have no idea if a resident was on EBP or not.

Review of Resident 25's clinical record revealed a Minimum Data Set Assessment (MDS, an assessment tool completed at specific intervals to determine care needs) dated May 28, 2024, that indicated the facility assessed Resident 25 as using an indwelling urinary catheter. There was no documented evidence in Resident 25's clinical record to indicate that the facility implemented the use of EBP. Observation of Resident 25's room on June 12, 2024, at 11:21 AM revealed no evidence that nursing staff were to use EBP when performing high-contact activity for Resident 25, such as signage or PPE.

Review of Resident 49's clinical record revealed an MDS dated May 3, 2024, that indicated the facility assessed Resident 49 as using an indwelling urinary catheter. There was no documented evidence in Resident 49's clinical record to indicate that the facility implemented the use of EBP. Observation of Resident 49's room on June 12, 2024, at 11:23 AM revealed no evidence that nursing staff were using EBP when performing high-contact activity for Resident 49, such as signage or PPE.

Review of Resident 59's clinical record revealed an MDS dated April 7, 2024, that indicated the facility assessed her as having a current unstageable pressure ulcer to her bottom. A skin assessment dated June 13, 2024, indicated that the wound consultant assessed Resident 59's wound as being a Stage 4 (full thickness skin loss exposing muscle, bone, or tendon). There was no documented evidence in Resident 59's clinical record to indicate that the facility implemented the use of EBP. Observation of Resident 59's room on June 12, 2024, at 11:25 AM revealed no evidence that nursing staff were using EBP when performing high-contact activity for Resident 59, such as signage or PPE.

Interview with the Administrator and Director of Nursing on June 12, 2024, at 2:07 PM confirmed the above findings for Residents 25, 49 and 59, and indicated that EBP should have been implemented.

Observation of Resident 60 with Employee 14 (licensed practical nurse) on June 11, 2024, at 1:43 PM revealed she was in bed with an indwelling urinary catheter collection bag stored directly on the floor on the left side of her bed. A dignity bag (material bag used to hold and obscure the urinary collection bag that may keep the surface of the bag from potentially infectious surfaces) that was secured to the right side of her bed was empty. A yellow PPE organizer was hung from Resident 60's room door. Interview with Employee 14, on the date and time of the observation, indicated that Resident 60 required EBP due to an indwelling urinary catheter and a pressure ulcer. Employee 14 confirmed that Resident 60's room did not have bins to discard PPE (e.g., gowns or linens, etc.) before leaving Resident 60's room.

Observation of Resident 60 on June 12, 2024, at 12:38 PM with Employee 14 and Employee 15 (nurse aide) revealed staff stored the urinary collection bag directly on the floor on the left side of the bed. The dignity bag also secured to the left side of Resident 60's bed was empty. Employee 15 repositioned the urinary collection bag to inside the dignity bag.

The surveyor reviewed the above infection control concerns for Resident 60 with the Director of Nursing on June 14, 2024, at 10:30 AM.

28 Pa. Code 201.18(b)(3)(d)(e)(1) Management

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


 Plan of Correction - To be completed: 07/21/2024

1. Resident 25, 49, and 59 all had Enhanced Barrier Precautions implemented. Resident 60 has been discharged from the facility.
2. Current residents were reviewed to determine if EBP required to be implemented.
3. All staff were educated on EBP and requirements. All new admissions or readmissions will be reviewed in AM meeting to determine if EBP is required.
4. Administrator/designee will audit residents on EBP's 4x a week for 4 weeks, and then weekly x2 months to ensure that EBP are in place.

483.70(n)(2)(iii)(iv)(6) REQUIREMENT Binding Arbitration Agreements: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.
§483.70(n)(2) The facility must ensure that:
(iii) The agreement provides for the selection of a neutral arbitrator agreed upon by both parties; and
(iv) The agreement provides for the selection of a venue that is convenient to both parties.

§483.70(n)( (6) When the facility and a resident resolve a dispute through arbitration, a copy of the signed agreement for binding arbitration and the arbitrator's final decision must be retained by the facility for 5 years after the resolution of that dispute on and be available for inspection upon request by CMS or its designee.
Observations:

Based on review of the facility's arbitration agreements and staff interview, it was determined that the facility's arbitration agreements failed to ensure a neutral and fair arbitration process by ensuring the selection of a neutral arbitrator for six of six residents reviewed with a signed arbitration agreement (Residents 34, 47, 16, 62, 49, and 26).

Findings include:

Review of a Mandatory Binding Arbitration Agreement (an agreement that the resident and the facility will resolve legal disputes through binding arbitration, waiving their right to a trial) signed by Resident 34 on August 22, 2022, revealed that the document stipulated that, "All Arbitrations shall be administered by (name of arbitrator services company which the facility utilized)." The document also stipulated that if, "...(name of arbitrator services company which the facility utilized), is unable or unwilling to handle the Arbitration, the parties will work in good faith to agree on an alternative neutral arbitration service, and if the parties cannot reach an agreement within thirty (30) days, the Facility will select a neutral arbitrator to resolve the arbitration..."

The agreement afforded the facility the selection of the arbitrator (third-party decision-maker contracted to resolve a dispute) initially and/or if the parties cannot reach an agreement on a neutral arbitration service within 30 days.

Review of a Mandatory Binding Arbitration Agreement signed by Resident 47 on December 29, 2022, revealed that she signed a document with the same verbiage as Resident 34 that afforded the facility the selection of the arbitrator initially and/or if the parties cannot reach an agreement on a neutral arbitration service within 30 days.

Review of an Arbitration Agreement signed by Resident 16 on October 14, 2023, revealed that the document stipulated, "To start an Arbitration, a party must submit a written request for Arbitration to the other party within the time limit required by this Arbitration Agreement. At that point the parties will work together in good faith to agree upon a neutral arbitrator to resolve the dispute. By signing this Arbitration Agreement, the parties hereby agree that if the parties cannot agree on a neutral arbitrator after thirty (30) days, then (name of arbitrator services company which the facility utilized) will serve as neutral arbitrator..."

Review of an Arbitration Agreement signed by Resident 62 on June 11, 2024, revealed that she signed a document with the same verbiage as Resident 16 that afforded the facility the selection of the arbitrator if the parties cannot reach an agreement on a neutral arbitration service within 30 days.

Resident 49's representative signed this version of an Arbitration Agreement on February 13, 2024. Resident 26's representative signed this version of an Arbitration Agreement on February 9, 2024.

Interview with Employee 13 (medical records) on June 13, 2024, at 11:08 AM and 1:17 PM confirmed that all arbitration agreements reviewed for Residents 34, 47, 16, 62, 49, and 26 afford the facility's selection of an arbitrator either initially and/or if the parties cannot reach an agreement on a neutral arbitration service within 30 days.

The surveyor confirmed the above findings pertaining to arbitration agreements for Residents 34, 47, 16, 62, 49, and 26, during an interview with the Nursing Home Administrator, the Director of Nursing, and Employee 6 (clinical consultant), on June 13, 2024, at 2:00 PM.

28 Pa. Code 201.14(a) Responsibility of licensee

28 Pa. Code 201.18(b)(2) Management.

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


 Plan of Correction - To be completed: 07/21/2024

1. Residents 34, 47, 16, 62, 49, and 26 will sign a new revised Arbitration Agreement.

2. A whole house audit was completed to identify other residents to ensure that the arbitration process is neutral and fair and a revised Arbitration Agreement will be signed.

3. The facility will implement a revised Arbitration Agreement, removing 30 day stipulation.

The facility Arbitration Agreement will be reviewed to ensure that the process is fair, neutral and in compliance with F848. The Admissions Director/designee will be educated on F848.

4. Random Audits of new admission paperwork will be completed weekly x 4 weeks and monthly x 2 months to ensure compliance with F848. Results of the audits will be presented at the Quality Assurance Performance Improvement meetings for review.

483.20(f)(5), 483.70(i)(1)-(5) REQUIREMENT Resident Records - Identifiable Information: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.
§483.20(f)(5) Resident-identifiable information.
(i) A facility may not release information that is resident-identifiable to the public.
(ii) The facility may release information that is resident-identifiable to an agent only in accordance with a contract under which the agent agrees not to use or disclose the information except to the extent the facility itself is permitted to do so.

§483.70(i) Medical records.
§483.70(i)(1) In accordance with accepted professional standards and practices, the facility must maintain medical records on each resident that are-
(i) Complete;
(ii) Accurately documented;
(iii) Readily accessible; and
(iv) Systematically organized

§483.70(i)(2) The facility must keep confidential all information contained in the resident's records,
regardless of the form or storage method of the records, except when release is-
(i) To the individual, or their resident representative where permitted by applicable law;
(ii) Required by Law;
(iii) For treatment, payment, or health care operations, as permitted by and in compliance with 45 CFR 164.506;
(iv) For public health activities, reporting of abuse, neglect, or domestic violence, health oversight activities, judicial and administrative proceedings, law enforcement purposes, organ donation purposes, research purposes, or to coroners, medical examiners, funeral directors, and to avert a serious threat to health or safety as permitted by and in compliance with 45 CFR 164.512.

§483.70(i)(3) The facility must safeguard medical record information against loss, destruction, or unauthorized use.

§483.70(i)(4) Medical records must be retained for-
(i) The period of time required by State law; or
(ii) Five years from the date of discharge when there is no requirement in State law; or
(iii) For a minor, 3 years after a resident reaches legal age under State law.

§483.70(i)(5) The medical record must contain-
(i) Sufficient information to identify the resident;
(ii) A record of the resident's assessments;
(iii) The comprehensive plan of care and services provided;
(iv) The results of any preadmission screening and resident review evaluations and determinations conducted by the State;
(v) Physician's, nurse's, and other licensed professional's progress notes; and
(vi) Laboratory, radiology and other diagnostic services reports as required under §483.50.
Observations:

Based on clinical record review and staff interview, it was determined that the facility failed to ensure accurate clinical documentation for two of 13 residents reviewed (Residents 20 and 50).

Findings include:

Clinical record review for Resident 20 revealed that the resident was discharged from hospice services on March 17, 2023.

Clinical documentation for Resident 20 dated May 16, 2024, at 2:21 PM revealed a physician's progress note that indicated under the notes section titled Care Plan to "Continue Hospice care." Under the section titled Counseling and/or Coordination of Care of the same note it indicated to "Continue skilled level of care."

Clinical documentation for Resident 20 dated May 9, 2024, at 2:20 PM revealed a physician's progress note that indicated under the notes section titled Care Plan to "Continue Hospice care." Under the section titled Counseling and/or Coordination of Care of the same note it indicated to "Continue skilled level of nursing."

Clinical documentation for Resident 20 dated April 4, 2024, at 2:06 PM revealed a physician's progress note that indicated under the notes section titled Subjective the, "Patient will continue with Hospice care." Under the section titled Care Plan the documentation noted that, "Patient is on Hospice will continue current Tx (treatment)."

Clinical documentation for Resident 20 dated March 21, 2023, at 4:56 PM revealed a physician's progress note that indicated under the notes section titled Subjective the, "Patient will continue with Hospice care." Under the note section titled Care Plan to "Continue Hospice care." Under Assessment four of the note, the documentation noted, "Patient is on hospice and will continue current Tx (treatment)."

An interview with the Nursing Home Administrator and Director of Nursing on June 13, 2024, at 2:15 PM confirmed the resident was discharged from hospice services on March 17, 2023. It was unclear why the above documentation for Resident 20 continued to mention hospice care, but believed it was related to documentation errors.

Clinical record review for Resident 50 revealed that the resident was on Gabapentin (a medication that can be used to treat seizures and nerve pain) oral capsule and give 300 milligrams (mg) by mouth three times a day for neuropathy (pain caused by nerve damage). This order was discontinued on May 1, 2024.

A review of the census information for Resident 50 revealed the resident was hospitalized from April 30, 2024, to May 7, 2024.

A Discharge Summary for Resident 50 from the hospital revealed a discharge medication list that did not include gabapentin. The gabapentin was not reordered by the facility upon return from the hospital and was not listed under the current orders for Resident 50.

Clinical documentation for Resident 50 revealed a Nurse Practitioner Progress Note dated May 30, 2024, at 3:29 PM that indicated an assessment and plan that noted pain and to continue with Tylenol (a medication used to treat pain and fever), lidocaine patch (a transdermal patch that goes on the skin that contains a medication used to treat pain), and gabapentin 300 mg by mouth three times a day as ordered.

Clinical documentation for Resident 50 revealed a Nurse Practitioner Progress Note dated June 6, 2024, at 5:03 PM that indicated an assessment and plan that noted pain and to discontinue the lidocaine patch five percent, start Aspercreme patch (a transdermal patch used to treat pain), continue Tylenol, and gabapentin 300 mg by mouth three times a day as ordered.

The above information for Resident 50 was reviewed in a meeting with the Nursing Home Administrator and Director of Nursing on June 13, 2024, at 2:15 PM.

An interview with the Director of Nursing on June 14, 2024, at 10:14 AM confirmed that the gabapentin was discontinued on May 1, 2024, by the physician and there was not a current order to administer it. It was believed that the above documentation for Resident 50 was a documentation error since there were no current orders entered in the electronic medical record to administer the gabapentin.

28 Pa. Code 211.5(i) Medical records

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


 Plan of Correction - To be completed: 07/21/2024

1. The facility cannot retroactively correct the missing documentation related clinical documentation. Resident 20 longer require hospice services and has been discontinued. Resident 50 will be evaluated by MD for appropriateness of Gabapentin for this resident and a note will be entered.

2. All residents currently on hospice were audited for appropriate care plan and doctors orders.
An audit of all residents that returned from the hospital in the last 2 weeks was completed to ensure medication reconciliation was completed.

3. All nursing staff will be educated on proper care planning for residents on hospice and medication reconciliation when returning from hospital.

4. DON/designee will audit all hospice care plans weekly for 4 weeks, and monthly for 2 months. DON/designee will audit all transfers back from the hospital to ensure proper medication is reconciled on return. Results will be reviewed during the monthly QAPI meeting.

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

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

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

§483.45(c)(5) The facility must develop and maintain policies and procedures for the monthly drug regimen review that include, but are not limited to, time frames for the different steps in the process and steps the pharmacist must take when he or she identifies an irregularity that requires urgent action to protect the resident.
Observations:

Based on clinical record review and staff interview, it was determined that the facility failed to ensure that the resident's attending physician addressed pharmacy recommendations for four of five residents reviewed (Residents 10, 22, 25, and 46).

Findings include:

Review of Resident 10's clinical record revealed that the pharmacist made recommendations on the following dates: February 25, 2024, and November 20, 2023. There was no documented evidence in Resident 10's clinical record to indicate what the recommendations were and if the recommendations were acted upon. Interview with the Director of Nursing (DON) on June 14, 2024, at 12:00 PM confirmed the recommendations could not be located for Resident 10.

Review of Resident 46's clinical record revealed that the pharmacist made recommendations on the following dates: March 28, 2024, February 25, 2024, January 28, 2024, November 20, 2023, and September 22, 2023. There was no documented evidence in Resident 46's clinical record to indicate what the recommendations were or if the recommendations were acted upon. Interview with the DON on June 14, 2024, at 12:00 PM confirmed the recommendations could not be located for Resident 46.

Review of Resident 25's clinical record revealed that the pharmacist made recommendation on the following dates: October 16, 2023, December 19, 2023, and March 28, 2024. There was no documented evidence in Resident 25's clinical record to indicate what the recommendations were or if the recommendations were acted upon.

Interview with the Administrator on June 14, 2024, at 9:46 AM confirmed the above findings for Resident 25.

Clinical record review for Resident 22 revealed documentation by the consultant pharmacist dated May 26, 2024, that indicated recommendations were made and to, "review Clinical Pharmacy Report."

Resident 22's clinical record did not contain a "Clinical Pharmacy Report," or documentation as to the details of the recommendation or if a physician acted upon the recommendation.

The surveyor requested any additional information available to resolve the above concern for Resident 22 during an interview with the Nursing Home Administrator, the Director of Nursing, and Employee 6, on June 13, 2024, at 2:22 PM; however, the facility did not provide any additional information during the onsite survey.

483.45(c)(1)(2)(4)(5) Drug Regimen Review, Report Irregular, Act On
Previously cited deficiency 7/21/23

28 Pa. Code 211.9 (d)(k) Pharmacy services

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


 Plan of Correction - To be completed: 07/21/2024

1. The facility cannot retroactively correct the missing documentation related to medication regimen reviews.
2. A whole house audit was completed for the past 30 days, to ensure all recommendations from the pharmacist have been addressed and completed.
3. DON was educated on reviewing "Clinical Pharmacy Report" and uploading into residents medical record in a timely manner.
4. Administrator/designee will audit Clinical Pharmacy Reports for 2 months to ensure that all recommendations were addressed and uploaded into the resident medical record. Results will be reviewed during the monthly QAPI meeting.

483.25(g)(1)-(3) REQUIREMENT Nutrition/Hydration Status Maintenance: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(g) Assisted nutrition and hydration.
(Includes naso-gastric and gastrostomy tubes, both percutaneous endoscopic gastrostomy and percutaneous endoscopic jejunostomy, and enteral fluids). Based on a resident's comprehensive assessment, the facility must ensure that a resident-

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

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

§483.25(g)(3) Is offered a therapeutic diet when there is a nutritional problem and the health care provider orders a therapeutic diet.
Observations:

Based on clinical record review and staff interview, it was determined that the facility failed to provide physician ordered interventions for two of six residents reviewed for nutritional risk (Residents 25 and 59).

Findings include:

Review of Resident 25's plan of care dated August 6, 2020, and last revised on December 25, 2023, indicated that the facility determined he was a nutritional risk. The facility indicated that an intervention of a nutritional supplement would benefit him and maintain his skin integrity.

A physician's order dated July 25, 2023, indicated that nursing staff were to provide 8 oz (ounces) of Boost (a nutritional supplement) twice a day.

Review of Resident 25's Medication Administration Record (MAR, a form utilized to document the administration of select physician orders) dated April 2024, indicated that nursing staff did not give him the Boost five times, documenting that it was "unavailable" or "on order." Review of Resident 25's MAR dated May 2024, indicated that nursing staff did not give him the Boost 26 times documenting that it was "unavailable, none in facility, or on order."

A dietary note dated May 28, 2024, indicated that Resident 25 prefers to follow a high protein diet and to continue using Boost, as Resident 25 has a history of skin breakdown. Nursing documentation dated June 7, 2024, at 9:51 PM indicated that nursing staff found a small open area on Resident 25's scrotum.

Review of Resident 59's clinical record revealed a dietary note dated March 26, 2024, indicating that Resident 59 had an open wound and recommended to start Boost twice a day. A physician's order dated April 4, 2024, indicated that nursing staff were to provide Boost before meals. Review of Resident 59's MAR dated April 2024 indicated that nursing staff did not give her the Boost seven times documenting that it was "unavailable." Review of Resident 59's MAR dated May 2024, indicated that nursing staff did not give her the Boost 31 times documenting that it was "unavailable."

A dietary note dated May 7, 2024, indicated that Resident 59 was now experiencing a significant weight loss of 9 percent in one month. The dietary note indicated to continue the Boost.

Interview with Employee 13, medical records and purchasing, on June 13, 2024, at 11:14 AM confirmed that the facility does not always receive the supply of Boost that is initially ordered.

Interview with the Administrator and Director of Nursing on June 13, 2024, at 2:00 PM acknowledged the above findings for Residents 25 and 59.

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


 Plan of Correction - To be completed: 07/21/2024

1. The facility cannot retroactively correct the deficiency relating to physician ordered interventions for residents 25 and 59.

2. Administrator/designee completed an audit of all residents who received nutritional supplements in the last 30 days and was documented as "unavailable, on order, none in facility."

3. Nursing staff will be educated on proper notification and process if nutritional supplements are not available. Central Supply will be educated on ordering enough nutritional supplements for par level. Nutritional supplements will be stored in med room, easily accessible to nursing staff.

4. Administrator/designee will audit 4x a week for 4 weeks, then weekly for 2 months to residents that require nutritional supplements are receiving them. Results will be reviewed during the monthly QAPI meeting.

483.25(b)(1)(i)(ii) REQUIREMENT Treatment/Svcs to Prevent/Heal Pressure Ulcer:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
§483.25(b) Skin Integrity
§483.25(b)(1) Pressure ulcers.
Based on the comprehensive assessment of a resident, the facility must ensure that-
(i) A resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable; and
(ii) A resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing.
Observations:

Based on observation, clinical record review, and staff interview, it was determined that the facility failed to provide treatment and services to promote healing and prevent infections regarding pressure ulcers for two of seven residents reviewed (Residents 58 and 59).

Findings include:

Review of Resident 58's clinical record revealed a physician's order dated March 16, 2024, indicating that nursing staff were to perform wound care to Resident 58's coccyx (sacral area) wound twice a day by packing the wound with half strength betadine-soaked gauze and a dry dressing.

Review of Resident 58's Treatment Administration Record (TAR, a form utilized to document the completion of treatments) dated March 2024, revealed that nursing staff did not complete the treatments on the evening of March 16, 2024, and March 18, 2024, the morning of March 19, 2024, and March 21, 2024. There was no additional documented evidence to indicate that nursing staff completed Resident 58's wound care as ordered by her physician.

Review of Resident 58's weekly wound assessments revealed that the wound consultant assessed her sacral pressure ulcer on March 25, 2024, as being a Stage 4 (full thickness tissue loss with exposed bone, muscle, or tendon) measuring 10 cm (centimeter) by 8 cm by 1 cm. There was no documented evidence that the facility assessed or measured Resident 58's sacral pressure area until the wound consultant completed it on April 23, 2024. There was no documented evidence to indicate that the facility assessed and measured Resident 58's coccyx wound the week of April 1, April 8, or April 15, 2024.

Review of Resident 59's clinical record revealed a physician's order dated March 19, 2024, that indicated nursing staff were to cleanse her sacral wound with normal saline, apply betadine, and a border lite dressing twice a day. Review of Resident 59's TAR dated March 2024, revealed that nursing staff did not complete the treatments on the evening of March 22, 2024, and the morning of March 27, 2024.

A physician's order dated April 4, 2024, indicated that nursing staff were to change Resident 59's sacral wound dressing twice a day by packing it with betadine and saline gauze and cover with a dry dressing. Review of Resident 59's TAR dated April 2024, revealed that nursing staff did not complete the treatment on the evenings of April 23, 2024, and April 24, 2024. Review of Resident 59's TAR dated May 2024, revealed that nursing staff did not complete the treatment on the evenings of May 1, 2, 8, and 14, 2024.

Observation on June 13, 2024, at 10:10 AM revealed Employee 1, licensed practical nurse, performing wound care for Resident 59's sacral wound. Employee 1 gathered all the dressing care supplies with gloved hands. Employee 1 placed supplies on top of Resident 59's bed side table, while preparing a field on top of Resident 59's bed. Employee 1 used the same gloved hands to open dressing supplies, and placed gauze into a betadine solution. Employee 1 used the same gloved hands to clean Resident 59's wound and placed the betadine-soaked gauze into her wound. Interview with Employee 1 at this time revealed that she should have changed her gloves and washed her hands between gathering supplies and before applying a clean dressing to Resident 59's wound.

Interview with the Director of Nursing on June 14, 2024, at 10:20 AM confirmed the above findings for Residents 58 and 59.

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


 Plan of Correction - To be completed: 07/21/2024

1. Resident 58 was seen by wound care consultant. A comprehensive assessment of the wound was completed and documented, and a treatment was ordered.
Employee number 1 was educated on proper infection control procedures relating to wound care and treatment.

2. A facility wide skin assessment was conducted for current residents with skin impairments and were documented. Current residents orders were audited to ensure wound care consults recommendations were completed timely.

3. Licensed Nursing staff will be educated on the Skin Integrity Policy including comprehensive wound assessment documentation, implementation of interventions and timely follow up on consultation orders. Licensed nursing staff will also be educated on proper infection control procedures relating to wound care and treatment.

4. DON/Designee will conduct random weekly audits for three weeks then monthly for three months of skin assessments to ensure a comprehensive wound assessment is documented and interventions are put into place. An audit of the TAR's of residents with skin impairments will be completed 4x a week for 4 weeks, and then weekly x2 months to ensure completion and documentation of ordered treatments. A random audit will be completed weekly to observe licensed nursing staff completing dressing changes.

DON/Designee will conduct random weekly audit for three weeks then monthly for three months of wound consult orders to ensure timely completion of consultation. Results will be reviewed during the monthly QAPI meeting.

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 observation and staff interview, it was determined that the facility failed to provide adequate housekeeping and maintenance services to ensure a clean, safe, and comfortable environment on one of two nursing units (Ivy Nursing Unit) and a facility dining room.

Findings include:

Observation of the facility's dining room located adjacent to the main kitchen on June 12, 2024, at 11:41 AM and June 13, 2024, at 10:40 AM revealed the following: various stains on the floor, the overhead lights had various debris in the protective covers, there were two stained ceiling tiles and one tile had a large crack in it near the middle of the room above where the residents were sitting for lunch service, debris and dust on the windowsills, and multiple dried splash stains on the glass of the windows.

Observation of the shower room on June 12, 2024, at 12:26 PM revealed the following: a scratched and marred commode seat, dried and brown colored stains on the commode seat, the area behind the toilet paper roll had chipped paint, dead insects in the protective covering over the ceiling light near the commode, a significant build-up of debris under the blue cushion of the shower gurney, an opening in the brick wall behind the "jet tub" with an accumulation of cobwebs, various linens discarded on the sink, and a significant build-up of debris in the shower drain.

Observation of the shower room on June 13, 2024, at 10:31 AM revealed the same findings as above in addition to the following: different linens on the sink that included seven folded towels and a washcloth and two wash cloths on the rails in the shower room.

The above information was reviewed in a meeting with the Nursing Home Administrator and Director of Nursing on June 13, 2024, at 2:15 PM.

28 Pa. Code 201.18(b)(3)(e)(2.1) Management


 Plan of Correction - To be completed: 07/21/2024

1. All identified areas of concern were addressed at the time of the survey.

2. A whole house environmental assessment was completed to identify any other areas of concern.

3. Housekeeping staff will be educated to ensure the dining room is safe, clean, comfortable and homelike. Nursing staff will be educated that the shower room will be maintained in a clean and sanitary way. Environmental audits will be conducted of the dining room and shower room, daily 4x a week, weekly for 4 weeks and monthly x2 by the Administrator/designee to ensure compliance.

4. Results of the audits will be presented at the Quality Assurance Performance Improvement meetings for review and changes will be made as needed until substantial compliance is attained.

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 observation and staff interview, it was determined that the facility failed to ensure that essential equipment was in safe operating condition for the facility's main kitchen.

Findings include:

Observation and concurrent interview with Employee 12, Dietary Manager, of the walk-in freezer on June 11, 2024, at 11:00 AM revealed the emergency release on the interior of the freezer was broken and introduced an entrapment risk if the door would close and lock with a staff member inside of the freezer. It was unknown how long the emergency release was not functional. Employee 12 further noted that two staff members are supposed to be present when using the walk-in freezer so one staff member can stay outside to prevent the door from fully closing. Employee 12 indicated that maintenance is aware of the issue, but it has not been fixed.

The Nursing Home Administrator was made aware of the issue on June 11, 2024, at 12:17 PM and again at 2:00 PM.

The above was also reviewed in a meeting with the Nursing Home Administrator and Director of Nursing on June 13, 2024, at 2:15 PM.

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


 Plan of Correction - To be completed: 07/21/2024

1. The facility cannot retroactively fix the freezer door.
2. Quote was approved for freezer door replacement, lead time on door is approximately 8-10 weeks.
3. Maintenance will be educated on the requirement for Essential Equipment being in safe and operating condition.
4. Administrator/designee will audit freezer door functionality after replacement weekly for 4 weeks and then monthly for 2 months. Results will be reviewed during the monthly QAPI meeting.

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

Based on review of active nurse aides and staff interview, it was determined that the facility failed to complete a performance evaluation of every nurse aide at least once every 12 months for three of three nurse aides reviewed (Employees 3, 4, and 5).

Findings Include:

Review of the facility's list of active nurse aide staff revealed Employee 3 with a hire date in 2022; Employee 4 with hire date in 2022; and Employee 5 with a hire date in 2022.

Requests to review Employees 3, 4, and 5's performance evaluations revealed no documented evidence that the facility is completing the evaluations at least once every 12 months.

Interview with Employee 6, clinical consultant, on June 14, 2024, at 12:13 PM confirmed the above findings and indicated that no performance evaluations can be provided on any current nurse aide working in the facility.

28 Pa. Code 201.19 Personnel policies and procedures


 Plan of Correction - To be completed: 07/21/2024

1. Employees 3,4, and 5 had performance reviews completed.
2. A whole house audit was completed for nurse's aides with 12 or more consecutive months worked. Any performance reviews not completed were done.
3. HR was educated on keeping track of nurse's aides that are due for performance reviews. HR will inform DON of any performance reviews that need to be completed via AM Meeting and send a back up email communication. DON was educated on completing the nurse aide performance evaluations in a timely manner, once every 12 months.
4. An audit will be completed by Administrator/designee weekly for 4 weeks, and monthly for 2 months for any employee due for a performance evaluation and ensure completion. Results will be reviewed during the monthly QAPI meeting.

483.35(a)(3)(4)(c) REQUIREMENT Competent Nursing Staff: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.
§483.35 Nursing Services
The facility must have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment required at §483.70(e).

§483.35(a)(3) The facility must ensure that licensed nurses have the specific competencies and skill sets necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care.

§483.35(a)(4) Providing care includes but is not limited to assessing, evaluating, planning and implementing resident care plans and responding to resident's needs.

§483.35(c) Proficiency of nurse aides.
The facility must ensure that nurse aides are able to demonstrate competency in skills and techniques necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care.
Observations:

Based on staff interview, it was determined that the facility failed to ensure that nursing staff possessed the appropriate competencies and skill sets related to wound care (Employees 1 and 2).

Findings include:

A review of the facility's current resident population documentation revealed that the facility had four residents who had skin concerns and/or wounds.

A request for nursing staff competencies for wound care revealed the facility was unable to provide any. Interview with Employee 6, clinical consultant, on June 14, 2024, at 12:15 PM revealed that the facility does not have any competencies on Employee 1 or Employee 2 (both licensed practical nurses).

The findings were reviewed with the Administrator and Director of Nursing on June 14, 2024, at 12:30 PM.

28 Pa Code 201.20(a) Staff development


 Plan of Correction - To be completed: 07/21/2024

1. Employee 1 and 2 had competencies completed relating to wounds.
2. An audit of all Nursing Staff was completed to ensure competencies relating to wounds was completed.
3. DON was educated on completing competencies with new licensed professional staff. After completion, DON will give to HR to file in personnel file. HR will be educated that new employee competencies must be completed timely. New employee names will be brought to AM meeting.
4. An audit will be completed by Administrator/designee weekly for 4 weeks, and monthly for 2 months for new employee competencies. Results will be reviewed during the monthly QAPI meeting.

483.25(n)(1)-(4) REQUIREMENT Bedrails: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(n) Bed Rails.
The facility must attempt to use appropriate alternatives prior to installing a side or bed rail. If a bed or side rail is used, the facility must ensure correct installation, use, and maintenance of bed rails, including but not limited to the following elements.

§483.25(n)(1) Assess the resident for risk of entrapment from bed rails prior to installation.

§483.25(n)(2) Review the risks and benefits of bed rails with the resident or resident representative and obtain informed consent prior to installation.

§483.25(n)(3) Ensure that the bed's dimensions are appropriate for the resident's size and weight.

§483.25(n)(4) Follow the manufacturers' recommendations and specifications for installing and maintaining bed rails.
Observations:

Based on review of select facility policies and procedures, clinical record review, observation, and staff interview, it was determined that the facility failed to properly assess and obtain informed consent or provide the resident and/or responsible party with the risks and benefits for the use of side rails for two of 11 residents reviewed (Residents 10 and 34).

Findings include:

The policy entitled "Use of Bed Rails," last reviewed without changes on August 1, 2023, revealed the purpose of the guidelines is to "ensure the safe use of bed rails as resident mobility aids and to prohibit the use of bed rails as restraints unless necessary to treat a resident's medical symptoms."

Further review of the policy included a section titled, "General Guidelines," which noted that an assessment will be made to determine the resident's symptoms, risk of entrapment, and reason for using the bed rails. When used for mobility or transfer, an assessment will include review of the resident's bed mobility, ability to change positions, transfer to and from bed or chair, to stand and toilet, potential risks with the use of bed rails, and that the bed's dimensions are appropriate for the resident's size and weight. The policy noted that consent for using restrictive devices will be obtained from the resident or legal representative per facility protocol. When bed rail use is appropriate, the facility will assess the space between the mattress and bed rails to reduce the risk of entrapment (the amount of space may vary depending on the type of bed and mattress being used).

Observation of Resident 10 on June 11, 2024, at 12:58 PM revealed the resident's bed had a right sided enabler bar (halo type) on it. The other side of the bed was against the wall and did not have an observed enabler bar or side rail.

Observation of Resident 10 on June 14, 2024, at 10:30 AM revealed the resident was in bed. The enabler bar was again noted on the resident's right side of the bed. The other side of the bed remained against the wall.

Clinical record review for Resident 10 revealed an MDS assessment (Minimum Data Set, an assessment tool completed at specific intervals to determine resident care needs) dated May 2, 2024, that revealed the resident had severely impaired cognitive skills with a BIMS (Brief Interview for Mental Status) score of two indicating severe cognitive impairment.

The current care plan for Resident 10 revealed the resident had an activities of daily living (ADL) self-care performance deficit related to a history of a cerebrovascular accident (CVA, stroke). An intervention noted the resident required one staff to reposition and turn in bed for bed mobility.

Facility documentation titled, "Communication Memo," for Resident 10 and dated March 20, 2023, revealed the resident "needs bed rails" and had a written "B" circled indicating bilateral bed rails. A handwritten notation indicated "Done 3/21/23." The room for Resident 10 was a different room than the current room the resident was observed in by the surveyor.

A Bed Rail Evaluation dated March 21, 2023, revealed the resident had the following checked under recommendations: Bed rails or grab bars are indicated and serve as an enabler to promote independence with bed mobility and positioning.

Facility documentation titled, "Bed System Measurement Device Test Results Worksheet," dated March 21, 2023, noted a Bed ID of "69." The bed make was written as "DS Panacea" and a model "1500." Entrapment zones were assessed for bilateral bed rails per the documentation.

An interview with Employee 10, Maintenance Director, on June 14, 2024, at 10:48 AM revealed that maintenance usually installs the bed rails and assesses the entrapment zones with a device they have. Employee 10 confirmed the document for Resident 10 titled, "Bed System Measurement Device Test Results Worksheet," indicated that bilateral bed rails were assessed.

Observation of Resident 10's bed with Employee 10 on June 14, 2024, at 10:52 AM revealed that the current bed is different than what was assessed on the documentation provided by the facility. The resident was currently in a "Hill-Rom" bed, which is a different bed than what was originally assessed. The enabler bars are also different than what was originally assessed per Employee 10. Employee 10 further noted there was no "maintenance order" to reassess the bed when the resident changed rooms.

A review of the census documentation for Resident 10 revealed the resident was admitted to the facility on March 16, 2023. The census indicated the resident changed rooms on April 10, 2023, June 22, 2023, March 14, 2024, and April 28, 2024, (where the resident currently resides).

Further clinical record review revealed no documentation that Resident 10's enabler bar(s) and bed was reassessed or transferred with the resident to the different rooms. There was also no evidence of any type of informed consent explaining the risks and benefits of the enabler bar(s). The facility could provide no further documentation regarding Resident 10's enabler bar.

An interview on June 14, 2024, at 11:07 AM revealed that the Nursing Home Administrator was aware of the above information for Resident 10. Further interview on June 14, 2024, at 12:58 PM with the Nursing Home Administrator and Employee 6, registered nurse clinical consultant, revealed there was no further evidence to indicate that the resident or responsible party was informed of the risks and benefits of enabler bars.

Observation of Resident 34's room on June 11, 2024, at 2:04 PM revealed assistive devices mounted bilaterally to Resident 34's bed.

The surveyor requested documentation regarding Resident 34's assessed need for assistive devices on her bed, consent for their use, and assessments pertaining to entrapment risks during an interview with the Nursing Home Administrator, Director of Nursing, and Employee 6 (clinical consultant) on June 12, 2024, at 2:00 PM.

Clinical record review for Resident 34 revealed occupational therapy documentation dated August 24, 2022, that Resident 34 had enabler (Halo) bars installed and tested on the right side of her bed.

A Bed System Measurement Device Test Results Worksheet dated August 25, 2022, indicated that potential zones of entrapment were evaluated on the right side of Resident 34's bed. There were no zones assessed on the left side of Resident 34's bed. Handwritten documentation on this form that were undated and unsigned noted that Resident 34 moved rooms twice and had an, "R," and an, "L," circled.

Resident 34's clinical record contained no evidence that the facility completed a bed rail evaluation since August 22, 2022, even though Resident 34 moved to a different room twice and the intervention was revised from one side to bilaterally. The facility did not provide evidence that Resident 34 or her responsible party signed a consent for the use of the enabler devices.

The surveyor confirmed the above concerns regarding Resident 34's assistive devices during an interview with the Nursing Home Administrator, the Director of Nursing, and Employee 6 on June 13, 2024.

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


 Plan of Correction - To be completed: 07/21/2024

1. Resident 10 and 34 had consent for use, measurements, assessment and careplan update completed following survey.

2. A whole house audit was conducted for every resident currently using bed rails/enabler bars and appropriateness for use. Each resident that currently utilizes bed rails/enabler bars has a consent, measurement sheet, assessment, and doctor order for use. Care plans were also updated appropriately for enabler bar usage.

3. The DOR will be educated on obtaining bed rail/enabler bar consents, and ensuring careplan and doctors order is present on medical chart.

4. Administrator/designee will audit weekly for 4 weeks, monthly for 2 months for any new orders for enabler bars to ensure proper consents and additional paperwork was completed. Results will be reviewed during the monthly QAPI meeting.

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 review and staff interview, it was determined that the facility failed to provide the coordination of dialysis services and administration of physician ordered medications for one of one resident reviewed (Resident 28).

Findings include:

Review of Resident 28's clinical record revealed that she received kidney dialysis (a procedure to remove waste products and excess fluid from the blood when the kidneys stop working properly) on Tuesdays, Thursdays, and Saturdays at an outside provider. Resident 28 leaves the facility to go to dialysis prior to breakfast being served around 6:45 AM.

Review of Resident 28's current physician orders revealed that nursing staff are to administer the following medications in the morning:

Miralax (stool softener) 17 grams, one scoop at 8:00 AM
Protonix (treats acid reflux) 40 mg (milligrams) at 8:00 AM
Eliquis (a blood thinner) 2.5 mg at 8:00 AM
Simethicone (relives symptoms of extra gas) 125 mg at 7:00 AM

Review of Resident 28's Medication Administration Record (MAR, a form utilized to document the administration of medications) dated June 2024, revealed that there were several days when nursing staff did not administer the above medications in the morning due to Resident 28 being at dialysis. There was no documented evidence in Resident 28's clinical record to indicate that the facility coordinated care with dialysis or her physician to determine if the medications were to be given at a different time or if they were appropriate to be skipped on dialysis days.

Interview with the Director of Nursing on June 14, 2024, at 10:30 AM confirmed the above findings for Resident 28.

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


 Plan of Correction - To be completed: 07/21/2024

1. Resident 28 medication was reviewed with the MD/dialysis to determine appropriate administration times. A "dialysis communication binder" was created to travel with resident to and from dialysis.

2. All other current dialysis residents will have medication lists reviewed by MD/dialysis to determine appropriate administration times. A "dialysis communication binder" was created to travel with all other resident to and from dialysis.

3. Licensed nursing staff will be educated on ensuring medication administration times are appropriate for dialysis residents.

A "dialysis communication binder" was created to travel with all other resident to and from dialysis.

MD will approve administration times of all medications for residents that receive dialysis.

4. Administrator/designee will audit "dialysis communication binder" 3x a week for 4 weeks, and then weekly for 2 months to ensure all communication forms are present and completed. Administrator/designee will audit medication times on any newly ordered medications or new resident that admit on dialysis.

483.25 REQUIREMENT Quality of Care:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
§ 483.25 Quality of care
Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices.
Observations:

Based on clinical record review, observation, and staff interview, it was determined that the facility failed to provide the highest practicable care related to intravenous access and an implanted pacemaker for one of 13 residents reviewed (Resident 22).

Findings include:

The surveyor requested the facility's policy or procedure regarding care and services for the use of a PICC
(PICC, long, thin, tube that is inserted through a vein in the arm and passed through to a larger vein near the heart. The line requires careful care and monitoring for complications including bleeding, infection, and blood clots) line during an interview with the Nursing Home Administrator, Director of Nursing, and Employee 6 (clinical consultant) on June 12, 2024, at 2:15 PM, and June 13, 2024, at 2:00 PM.

The facility did not provide a policy pertaining to the use of a PICC line during the onsite survey.

Information regarding PICC line care available from the Mayo clinic (https://www.mayoclinic.org/tests-procedures/picc-line/about/pac-20468748) instruct that the arm used for the PICC line should be protected (i.e., do not lift heavy objects, do not have blood pressure readings taken from that arm, and avoid submerging the PICC line in water). Risks associated with PICC line use include a blocked or broken PICC line and bleeding.

Clinical record review for Resident 22 revealed documentation by the physician dated May 23, 2024, at 11:39 AM that Resident 22 was admitted to the facility with a diagnosis of bacteremia (infection in the blood) and would receive intravenous antibiotics for six weeks. The documentation also included Resident 22's surgical history, which included a pacemaker implantation (small device implanted into the chest used to control and/or monitor the heartbeat).

Documentation by the physician dated May 24, 2024, at 2:26 PM included that a PICC site to Resident 22's right upper extremity was clean and dry.

Observation of Resident 22 on June 11, 2024, at 12:56 PM revealed a PICC line access site on the inside of his right bicep. Observation of Resident 22 and Resident 22's room revealed no indication of any restrictions preventing use of his right arm for blood pressures or venipunctures (blood draws). There was no emergency equipment readily visible in Resident 22's room in the event of complications from the PICC line access (such as clamps or compression dressing kit in the event of bleeding).

Interview with Employee 11 (licensed practical nurse) on June 11, 2024, at 1:02 PM confirmed that there was no signage or information readily visible for caregiving staff to deter the use of Resident 22's right arm. Employee 11 also confirmed that there were no supplies for staff to use in an emergency should a potential complication occur with the PICC line.

Clinical record review for Resident 22 revealed no care plan developed by the facility to address Resident 22's diagnosis of bacteremia, intravenous antibiotic administration, PICC line use, or implanted pacemaker care.

The surveyor reviewed the above concerns regarding Resident 22's PICC line and implanted pacemaker during an interview with the Nursing Home Administrator, the Director of Nursing, and Employee 6 (clinical consultant) on June 13, 2024, at 2:13 PM.

Physician orders obtained following the surveyor's questioning (dated June 13, 2024) instructed staff to measure the PICC line catheter length on admission and with each dressing change, change needleless connector weekly and as needed, change intermittent tubing every 24 hours, and keep a bag of emergency supplies in Resident 22's room for the PICC line. New physician orders dated June 13, 2024, also instructed staff to arrange a cardiology consult for Resident 22.

A plan of care pertaining to Resident 22's implanted pacemaker initiated by the facility on June 13, 2024 (following the surveyor's questioning) included:
Resident 22 has a Merlin pacemaker related to dysrhythmias (an abnormal or irregular heartbeat that can be harmless or serious)
Resident 22 has a Merlin transmitter that must be connected at all times; placed on a nightstand or table close to the bed
The Merlin home transmitter front needs to be facing the resident for it to properly read the device
"Scheduled sessions and device checks occur automatically if requested by your doctor or clinic. How often the Merlin@home transmitter collects data from your implanted device is determined by your doctor or clinic. Commonly, the information transfer occurs sometime during the night while you sleep"

Observation of Resident 22's room on June 14, 2024, at 9:43 AM revealed a machine on the bedside table with the name, "Merlin," on it. Interview with Resident 22 on the date and time of the observation indicated that staff questioned him the previous day about his pacemaker monitoring; and he told them that he had a monitoring machine at home. Resident 22 stated that staff put the machine in his room the day before (June 13, 2024).

Interview with the Director of Nursing on June 14, 2024, at 10:28 AM confirmed that she interviewed the resident and determined that he had a monitoring machine at his home. Facility staff contacted Resident 22's wife and arranged for facility staff to pick up the monitoring machine from Resident 22's house; and staff brought the machine to the facility on June 13, 2024.

483.25 Quality of Care
Previously cited deficiency 2/7/24

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

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


 Plan of Correction - To be completed: 07/21/2024

1. Resident # 22 has had their care plan reviewed and has been updated to reflect the presence of and care for the implantable pacemaker and picc or IV line.

2. The DON/designee shall review residents with pacers/iv access to verify that their orders and care plan reflects the presence and care for the implantable pacemaker/iv access devices.

A emergency supply bag was placed above the bed for residents currently utilizing IV Access.

A sign was placed above bed with information readily visible to staff.

3. The Licensed Nursing staff shall be educated by DON / designee on development of comprehensive care plans to include goals and interventions for resident with implantable cardiac pacemakers, and IV access devices .

4. The DON /Designee will complete audits of any newly admitted resident or current resident with new pacemaker devices/iv access to ensure the plan of care includes pacemaker device or IV access. An audit will be completed for emergency supply bags and signs with readily visible information for residents utilizing IV access.

Audits will be conducted weekly for four weeks, then monthly for two months or until compliance is sustained. The DON/Designee shall review any concerns during the monthly QAPI meeting.


483.24(a)(1)(b)(1)-(5)(i)-(iii) REQUIREMENT Activities Daily Living (ADLs)/Mntn Abilities: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.
§483.24(a) Based on the comprehensive assessment of a resident and consistent with the resident's needs and choices, the facility must provide the necessary care and services to ensure that a resident's abilities in activities of daily living do not diminish unless circumstances of the individual's clinical condition demonstrate that such diminution was unavoidable. This includes the facility ensuring that:

§483.24(a)(1) A resident is given the appropriate treatment and services to maintain or improve his or her ability to carry out the activities of daily living, including those specified in paragraph (b) of this section ...

§483.24(b) Activities of daily living.
The facility must provide care and services in accordance with paragraph (a) for the following activities of daily living:

§483.24(b)(1) Hygiene -bathing, dressing, grooming, and oral care,

§483.24(b)(2) Mobility-transfer and ambulation, including walking,

§483.24(b)(3) Elimination-toileting,

§483.24(b)(4) Dining-eating, including meals and snacks,

§483.24(b)(5) Communication, including
(i) Speech,
(ii) Language,
(iii) Other functional communication systems.
Observations:

Based on clinical record review and staff interview, it was determined that the facility failed to complete a restorative nursing program for one of three residents reviewed for activities of daily living concerns (Resident 18).

Findings include:

Clinical record review for Resident 18 revealed a diagnoses list that included the following: osteoarthritis (a degenerative joint disease) of the knee, abnormalities of gait and mobility, and muscle weakness.

Review of the current care plan for Resident 18 revealed the resident requires assistance with walking and transferring. An intervention included one-assist with a rolling walker for mobility.

Further review of the current care plan for Resident 18 revealed a restorative nursing program that noted a goal that the resident will ambulate up to 70 feet with a rolling walker, one-assist daily, and a wheelchair to follow for safety. The target date was noted as June 24, 2024. Interventions included the following: allow rest breaks as needed, encourage the resident to ambulate at her own pace, and the resident will ambulate up to 70 feet with a rolling walker/ one-assist daily/ wheelchair to follow for safety.

Review of the Physical Therapy Discharge Summary for Resident 18 dated March 22, 2024, at 3:58 PM revealed the discharge recommendation of a restorative nursing program. The restorative program noted the resident will ambulate 70 feet with a rolling walker, one-assist daily, and a wheelchair to follow for safety. The resident's prognosis was noted as "Good with consistent staff follow-through."

A review of the current tasks for Resident 18 revealed the following nursing restorative task: Resident will ambulate up to 70 feet with rolling walker, one-assist daily, wheelchair to follow for safety.

Review of the restorative nursing program documentation for the last 30 days revealed the following:
May 16, 22, 25, 2024, no documentation noted to indicate the task was completed as recommended.
June 1, 7, 2024, no documentation noted to indicate the task was completed as recommended.
The following days were marked by various staff as Not Applicable: May 15, 17, 19, 20, 21, 23, 26, 29, 30, 2024; June 6, 8, 9, 11, 2024.

An interview with Employee 7, Director of Therapy, on June 13, 2024, at 11:00 AM revealed that the resident was discharged to the restorative program. Employee 7 was unsure what the documentation of "Not Applicable" meant and reported that the nurse aides do the restorative program with the residents.

An interview with Employee 8, nurse aide, on June 13, 2024, at 11:16 AM revealed that she had documented not applicable on several days because it meant she did not see Resident 18 complete the program during the shift so marked not applicable.

The facility failed to complete the restorative nursing program for Resident 18 as recommended by therapy upon discharge from physical therapy.

The above information for Resident 18 was reviewed in a meeting with the Nursing Home Administrator and Director of Nursing on June 13, 2024, at 2:15 PM.

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


 Plan of Correction - To be completed: 07/21/2024

1. The facility cannot retroactively correct the improper documentation relating to restorative nursing programming. Resident 18 is currently on a restorative nursing program for walking.

2. The facility will audit new restorative nursing programming for the past 30 days to ensure proper responses are documented in the medical record.

3. Nurse aides will be educated on proper response documentation to the restorative nursing program.

4. The Administrator/Designee will complete an audit of all residents on restorative nursing program 4x a week for 4 weeks and then weekly for 2 months to ensure all proper responses are documented and restorative nursing program is being completed. Results will be reviewed during the monthly QAPI meeting.

483.15(c)(3)-(6)(8) REQUIREMENT Notice Requirements Before Transfer/Discharge: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.
§483.15(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(l).
Observations:

Based on clinical record review and staff interview, it was determined that the facility failed to provide a written notice of transfer that included all the written components to the resident and/or the resident's responsible party and failed to notify the Office of the State Long-Term Care Ombudsman upon transfer to the hospital for six of seven residents reviewed (Resident 37, 59, 3, 19, 34, and 60).

Findings include:

Review of Resident 37's clinical record revealed that the facility transferred him to the hospital on February 27, 2024. There was no documented evidence that that the facility provided Resident 37 and/or his responsible party with a transfer notice that included all the required contents: State long term care appeal agency or contact and address information for the Office of the State Long-Term Care Ombudsman including email address. There was also no documented evidence that the facility notified the Office of the State Long-Term Care Ombudsman regarding Resident 37's transfer to the hospital on February 27, 2024.

Review of Resident 59's clinical record revealed that the facility transferred her to the hospital on March 29, 2024. There was no documented evidence that the facility provided Resident 59 and/or her responsible party with a transfer notice that included all the above components, including notification to the Office of the State Long-Term Care Ombudsman.

Interview with the Administrator on June 14, 2024, at 10:49 AM confirmed the above findings for Resident 37 and 59.

Clinical record review for Resident 3 revealed nursing documentation dated April 3, 2024, at 1:34 PM that Resident 3 was admitted to the hospital from her appointment with the wound care consultant provider. Resident 3 had a surgical procedure for a below the knee amputation.

Nursing documentation dated May 11, 2024, at 1:36 AM revealed that Resident 3 had emesis resembling coffee grounds (indicative of gastrointestinal bleeding), had abdominal discomfort, and staff called emergency transport.

An emergency room history and physical dated May 10, 2024, indicated that Resident 3 was admitted from the emergency room.

A review of a Bed Hold/Transfer/Therapeutic Leave Notification form (form the facility utilized to communicate to a resident and resident's representative that a resident transferred out of the facility) dated April 3, 2024, and May 10, 2024, included no evidence that the facility provided the State long term care appeal agency or contact and address information for the Office of the State Long-Term Care Ombudsman (including email address) to Resident 3 or her responsible party. There was also no documented evidence that the facility notified the Office of the State Long-Term Care Ombudsman regarding Resident 3's hospitalizations.

Clinical record review for Resident 19 revealed nursing documentation dated April 15, 2024, at 12:51 PM that Resident 19 had a severe congested cough, difficulty with deep breathing, and chest pain when breathing. The physician instructed staff to send the resident to the emergency room.

A review of a Bed Hold/Transfer/Therapeutic Leave Notification form dated April 15, 2024, revealed no evidence that staff provided written notification of the transfer to Resident 19 or Resident 19's representative (daughter) that contained all the required components (e.g., the State long term care appeal agency or contact information for the Office of the State Long-Term Care Ombudsman). There was also no documented evidence that the facility notified the Office of the State Long-Term Care Ombudsman regarding Resident 19's hospitalization.

Clinical record review for Resident 34 revealed nursing documentation dated April 6, 2024, at 3:21 PM that Resident 34 had an irregular heart rate (appeared to be atrial fibrillation, an irregular and often very rapid heart rhythm). Nursing documentation dated April 7, 2024, at 8:27 PM revealed that Resident 34 was holding her chest area and requested to go to the emergency room for evaluation. Staff notified the physician and arranged emergency transport to the emergency room.

Nursing documentation dated April 20, 2024, at 9:15 PM revealed that staff believed Resident 34 had blood clots from her vaginal opening. Resident 34 left the facility via emergency transport at 9:10 PM. Nursing documentation dated April 21, 2024, at 10:34 AM indicated that the hospital admitted Resident 34 with a urinary tract infection.

Review of Bed Hold/Transfer/Therapeutic Leave Notification forms dated April 7, 2024, and April 20, 2024, revealed no evidence that staff provided written notification of Resident 34's transfers to Resident 34 or her responsible party that contained all the required components.

Clinical record review for Resident 60 revealed documentation from the certified registered nurse practitioner dated February 8, 2024, at 11:38 AM that Resident 60 had lack of feeling and movement on her right side (change from baseline). Resident 60 was sent to the emergency room for evaluation and treatment.

The facility could not provide a Bed Hold/Transfer/Therapeutic Leave Notification form for Resident 60's hospitalization on February 8, 2024, that contained all the required components.

Nursing documentation dated May 17, 2024, at 4:27 AM revealed that Resident 60 was very diaphoretic (sweating), had a low-grade temperature of 99.9 (Fahrenheit), and had a deteriorating pressure wound on her coccyx (tailbone) area that was foul-smelling. Nursing documentation dated May 17, 2024, at 7:00 AM indicated that staff made the physician aware of Resident 60's change in condition that included altered mental status, fever, skin ulcer, diaphoresis, and increased confusion. The physician responded with instructions to send Resident 60 to the emergency room for evaluation. Nursing documentation dated May 17, 2024, at 7:35 AM revealed Resident 60 left the facility via emergency transport.

Review of a Bed Hold/Transfer/Therapeutic Leave Notification form dated May 17, 2024, revealed no evidence that staff provided written notification of the transfer to Resident 60 or Resident 60's representative (son) that contained all the required components. There was also no documented evidence that the facility notified the Office of the State Long-Term Care Ombudsman regarding Resident 60's hospitalizations on February 8, 2024, or May 17, 2024.

The surveyor confirmed the above findings for Residents 3, 19, 34, and 60 during an interview with the Director of Nursing, the Nursing Home Administrator, and Employee 6, on June 13, 2024, at 2:00 PM.

483.15(c)(3) Notice before Transfer
Previously cited 7/21/23

28 Pa. Code 201.14(a) Responsibility of license

28 Pa. Code 201.29(a) Resident rights


 Plan of Correction - To be completed: 07/21/2024

1. The State Long Term Care Ombudsman will be notified via email of the transfers of Resident 37, 59, 3, 19, 34, and 60.

2. NHA/designee will audit the facility-initiated transfers or discharges for the last 30 days to ensure that written notification of transfer was provided to resident or resident's representative and Office of the State Long-Term Care Ombudsman.

3. Social Service Director/designee will maintain a log of residents transferred or discharged from the facility. Monthly, the NHA/designee will audit the log to ensure compliance and SSD will submit the log to the Office of the State Long-Term Care Ombudsman. The date of notification will be recorded on the audit form.

4. All hospital transfers will be reviewed in AM meeting 4x a week for 4 weeks, and weekly x2 months to ensure written notification was provided to resident and/or RR. Results of the audits will be presented at the Quality Assurance Performance Improvement meetings for review and changes will be made as needed until substantial compliance is attained.

483.20(g) REQUIREMENT Accuracy of Assessments:Least serious deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency has the potential for causing no more than a minor negative impact on the resident.
§483.20(g) Accuracy of Assessments.
The assessment must accurately reflect the resident's status.
Observations:

Based on clinical record review and staff interview, it was determined that the facility failed to ensure the accuracy of an MDS assessment for one of 13 residents reviewed (Resident 57).

Findings include:

Closed clinical record review for Resident 57 revealed social services documentation dated April 29, 2024, at 2:01 PM that Resident 57 was discharging from the facility to home with home health services. The facility provided a written notice to Resident 57 that stipulated that she did not have to discharge but chose to discharge home.

A discharge (return not anticipated) MDS (Minimum Data Set, an assessment tool completed at specific intervals to determine resident care needs) dated April 29, 2024, indicated that Resident 57 discharged to an acute care hospital.

Interview with Employee 9 (registered nurse assessment coordinator) on June 13, 2024, at 1:19 PM confirmed that staff coded Resident 57's discharge MDS assessment incorrectly. Employee 9 indicated that the facility submitted a modification to the assessment following the surveyor's questioning.

28 Pa. Code 211.5(f)(ix) Medical records

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



 Plan of Correction - To be completed: 07/21/2024

I hereby acknowledge the CMS 2567-A, issued to ATHENS NURSING AND REHABILITATION CENTER for the survey ending 06/14/2024, AND attest that all deficiencies listed on the form will be corrected in a timely manner.
§ 201.14(a) LICENSURE Responsibility of licensee.:State only Deficiency.
(a) The licensee is responsible for meeting the minimum standards for the operation of a facility as set forth by the Department and by other Federal, State and local agencies responsible for the health and welfare of residents. This includes complying with all applicable Federal and State laws, and rules, regulations and orders issued by the Department and other Federal, State or local agencies.

Observations:

Based on staff interview and review of facility documentation, it was determined that the facility did not comply with the multidisciplinary committee requirements or the nursing home infection reporting to PA-PSRS requirements of the Act 52 Infection Control Plan.

Findings include:

Act 52 Infection Control Plan, states that a health care facility should develop and implement an internal infection control plan that should be established for the purpose of improving the health and safety of residents and health care workers and should include a multidisciplinary committee including a representative from each of the following, if applicable to the specific health care facility:

(i) Medical staff that could include the chief medical officer or the nursing home medical director
(ii) Administration representatives that could include the chief executive officer, the chief financial officer, or the nursing home administrator
(iii) Laboratory personnel
(iv) Nursing staff that could include a director of nursing or a nursing supervisor
(v) Pharmacy staff that could include the chief of pharmacy
(vi) Physical plant personnel
(vii) A patient safety officer
(viii) Members from the infection control team, which could include an epidemiologist.
(ix) The community, except that these representatives may not be an agent, employee, or contractor of the health care facility.

Act 52 Infection Control Plan also requires that the facility have a minimum of one staff member who has continuous access to the PA-PSRS system.

The surveyor requested infection control committee meeting attendance during an interview with the Nursing Home Administrator on June 11, 2024, at 10:15 AM.

The surveyor reiterated the request for infection control committee attendance during an interview with the Nursing Home Administrator on June 12, 2024, at 3:10 PM. The Nursing Home Administrator indicated that attendance at quality assurance meetings should be used for infection control committee attendance.

Review of provided quality assurance meeting attendance dated since the facility's most recent standard recertification and relicensure survey that ended July 21, 2023, revealed that the facility had meetings on September 19, 2023, October 24, 2023, November 28, 2023, December 28, 2023, January 24, 2024, and February 28, 2024.

There was no evidence that a community member, pharmacy staff, or laboratory personnel attended any of the meetings.

Interview with the Nursing Home Administrator on June 13, 2024, at 10:04 AM confirmed the absence of required members at infection control committee meetings.

Interview with the Director of Nursing on June 14, 2024, at 10:30 AM indicated that she would be the only staff responsible for the infection preventionist duties until the facility identified a qualified staff member to assume the role. The Director of Nursing could not provide a current line listing of the facility's infections, or evidence of antibiotic surveillance, that she has completed. The Director of Nursing also confirmed that she did not have access to the State's PA-PSRS (Pennsylvania Patient Safety Reporting System, a secure, web-based, system that permits healthcare facilities to submit reports that are defined as serious events and incidents) reporting system; she did not know who was performing that task.

Interview with the Director of Nursing, the Nursing Home Administrator, and Employee 6 (clinical consultant) on June 14, 2024, at 11:45 AM confirmed the above findings regarding the members of the infection control committee. The interview also confirmed that no staff currently employed at the facility had both access and training to submit required PA-PSRS reports.


 Plan of Correction - To be completed: 07/21/2024

1. Infection Control Committee meeting will be held immediately following the next QAPI meeting with all required attendees. DON received access to PA-PSRS system on 6/26/2024.
2. All PA-PSRS reporting for June will be submitted in the required time frame.

Infection Control Committee meeting will be held immediately following the next QAPI meeting to include a community member, pharmacy or lab personnel attending the meetings.

3. Infection Preventionist will be educated on Act 52 Infection Control Plan and the requirement of having an Infection Control Committee. DON will be educated on the requirement of having continuous access to the PA-PSRS system.

4. Administrator/designee will audit IC Committee meetings for 3 months to ensure all required attendees were present. Administrator/designee will audit monthly PA-PSRS reporting to ensure all required reporting was completed. Results will be reviewed during the monthly QAPI meeting.

§ 201.18(b)(2) LICENSURE Management.:State only Deficiency.
(2) Protection of personal and property rights of the residents, while in the facility, and upon discharge or after death, including the return of any personal property remaining at the facility within 30 days after discharge or death.
Observations:

Based on clinical record review and staff interview, it was determined that the facility failed to ensure accurate documentation regarding the disposition of a resident's personal belongings following discharge from the facility for two of three closed records reviewed (Residents 55 and 57).

Findings include:

Closed clinical record review for Resident 55 revealed discharge documentation dated April 11, 2024, at 9:22 AM that noted the resident's transport arrived to be transported to another facility. The documentation indicated that "All property was packed and placed into vehicle when resident was loaded into van for transportation."

A review of the closed clinical record and facility documentation for Resident 55 revealed no evidence that a personal inventory of belongings was completed upon admission or discharge to another facility.

An interview with Employee 6, registered nurse clinical consultant, on June 14, 2024, at 12:00 PM revealed that the facility could not find a personal inventory of belongings for Resident 55. Employee 6 further noted the resident should have one started upon admission even if the resident did not come with belongings.

The facility was unable to provide documentation to indicate the disposition of Resident 55's belongings within 30 days of the resident's discharge.

Closed clinical record review for Resident 57 revealed nursing documentation dated April 29, 2024, at 2:17 PM that Resident 57 discharged to home. The nurse indicated that Resident 57 left with all her belongings.

The surveyor requested Resident 57's closed clinical record documentation during interviews with the Nursing Home Administrator, the Director of Nursing, and Employee 6 on June 12, 2024, at 2:00 PM, and June 13, 2024, at 2:00 PM.

The facility failed to provide documentation of an inventory of Resident 57's personal property to ensure that all Resident 57's personal property was returned to her within 30 days of her discharge.


 Plan of Correction - To be completed: 07/21/2024

1. The facility cannot retroactively correct the lack of personal inventory sheet for resident 55 and 57.
2. An audit of all admissions and discharges in the past 30 days was completed to ensure all personal inventory sheet was completed and present in medical chart.
3. Medical Records was educated on ensuring a personal inventory sheet with disposition of belongings is included in the closed resident chart.
4. Administrator/designee will audit discharges 4x a week for 4 weeks, and then weekly x2 months to ensure all closed resident charts have a personal inventory sheet with disposition of belongings included in chart. Results will be reviewed during the monthly QAPI meeting.

§ 211.9(j.1) (1) - (5) LICENSURE Pharmacy services.:State only Deficiency.
(j.1) The facility shall have written policies and procedures for the disposition of medications that address all of the following:
(1) Timely and safe identification and removal of medications for disposition.
(2) Identification of storage methods for medications awaiting final disposition.
(3) Control and accountability of medications awaiting final disposition consistent with standards of practice.
(4) Documentation of actual disposition of medications to include the name of the individual disposing of the medication, the name of the resident, the name of the medication, the strength of the medication, the prescription number if applicable, the quantity of medication and the date of disposition.
(5) A method of disposition to prevent diversion or accidental exposure consistent with applicable Federal and State requirements, local ordinances and standards of practice.

Observations:

Based on closed clinical record review and staff interview, it was determined that the facility failed to document the actual disposition of medications for one of three discharged residents reviewed (Resident 57).

Findings include:

Closed clinical record review for Resident 57 revealed nursing documentation dated April 29, 2024, at 2:17 PM that Resident 57 discharged to home. The nurse indicated that Resident 57 left with all her belongings; however, the documentation did not address the disposition of Resident 57's medications.

The surveyor requested Resident 57's closed clinical record documentation during interviews with the Nursing Home Administrator, the Director of Nursing, and Employee 6 on June 12, 2024, at 2:00 PM, and June 13, 2024, at 2:00 PM.

Review of Resident 57's medication administration record dated April 2024 revealed that Resident 57 received medications that included the following at the time she discharged from the facility:

Atorvastatin Calcium (medication used to lower blood cholesterol)
Colchicine (medication used to decrease uric blood uric acid to treat gout)
Lidocaine patches (adhesive medicated patches applied to areas on the body to reduce pain)
Valsartan (medication used to lower blood pressure)
Furosemide (medication used to increase urination and remove excess fluid from the body)
Methocarbamol (muscle relaxer, reduces pain sensations that are sent to the brain)
Metoprolol (medication used to lower blood pressure)
Cefazolin sodium (antibiotic to treat bacterial infection)

The facility failed to provide documentation of the disposition of Resident 57's medications that would include the quantity and method of disposition.


 Plan of Correction - To be completed: 07/21/2024

1. The facility cannot retroactively correct the medication disposition sheet for resident 57.
2. An audit of all discharges in the past 30 days was completed to ensure a medication disposition sheet was completed, including the name, quantity and method of disposition.
3. DON was educated on ensuring a medication disposition sheet was completed on discharge, including the name, quantity and method of disposition.
4. Administrator/designee will audit discharges 4x a week for 4 weeks, and then weekly x2 months to ensure a medication disposition sheet is included in chart. Results will be reviewed during the monthly QAPI meeting.

§ 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 staffing hours and staff interview, it was determined that the facility failed to ensure a minimum of one licensed practical nurse (LPN) per 25 residents during the day shift on one of 15 days reviewed.

Findings include:

Interview with Employee 16 (LPN) on June 14, 2024, at 9:50 AM revealed that there were two LPNs in the facility for a resident census of 55.

Interview with the Director of Nursing on June 14, 2024, at 9:57 AM confirmed that another scheduled LPN called off and the facility had 54 residents in-house and one additional bed hold resident; therefore, there were two LPNs for a resident census of 54.

Day shift (requires one LPN per 25 residents):

June 14, 2024, 2.0 LPNs for a census of 54, requires 2.16 LPNs

Interview with Employee 17 (human resources/scheduler) in the presence of the Director of Nursing on June 14, 2024, at 10:07 AM confirmed that there were only two LPNs in the building for a resident census of 54, which did not meet the regulatory LPN-to-resident ratio.


 Plan of Correction - To be completed: 07/21/2024

1. Facility is unable to correct past deficiency.
2. The facility has an active recruitment/retention plan to fill open positions which includes supplemental staffing bonuses to cover vacancies and contract with Staffing Agencies.
3. Staff Scheduler and DON will be educated on the importance of meeting LPN ratios, and that the facility is actively recruiting LPNs.
Agency will be utilized for open shifts as needed and available. Bonus are offered when needed.
Calculation of daily shift ratios will be completed and reviewed daily during Daily Labor Meeting for accuracy by the scheduler and DON. All efforts will be made to meet the staffing ratio. 
If call offs occur, all efforts will be made to attempt to fill that position with LPN's that are working in ancillary departments.
4.The DON or designee will conduct an audit of the LPN ratios to ensure ratios are being met weekly x4 weeks then monthly x 2 months. The results will be submitted to the QAPI Committee for review and re-evaluation.

§ 211.12(f.1)(5) LICENSURE Nursing services. :State only Deficiency.
(5) Effective July 1, 2023, a minimum of 1 RN per 250 residents during all shifts.
Observations:

Based on review of nursing staffing hours and staff interview, it was determined that the facility failed to ensure, in addition to the director of nursing services, a minimum of one registered nurse (RN) per 250 residents during all shifts on two of 15 days reviewed.

Findings include:

Interview with the Director of Nursing on June 14, 2024, at 9:57 AM revealed that the Director of Nursing was the only RN in the facility during the day shift on June 12 and 13, 2024. The Director of Nursing indicated that there was a staff call off on June 12, 2024; however, the schedule anticipated her filling the role of RN on the day shift on June 13, 2024.

Interview with Employee 17 (human resources/scheduler) in the presence of the Director of Nursing on June 14, 2024, at 10:07 AM confirmed that the Director of Nursing was the only RN in the facility during day shift on June 12 and 13, 2024. The interview confirmed that the Director of Nursing attended meetings and obtained information for the onsite Department of Health survey staff on those days due to the annual relicensure/recertification survey in progress on those dates. Employee 17 and the Director of Nursing were not able to provide a record of tasks performed for the given days (to include the amount of time spent performing those tasks) as proof of the hours worked as the RN.


 Plan of Correction - To be completed: 07/21/2024

1. Facility is unable to correct past deficiency.
2. The facility has an active recruitment/retention plan to fill open positions which includes supplemental staffing bonuses to cover vacancies and contract with Staffing Agencies.
3. Staff Scheduler and DON will be educated on the importance of meeting RN ratios, and that the DON hours can not be counted toward both DON hours and staffing ratio hours.
Calculation of daily shift ratios will be completed and reviewed daily during Daily Labor Meeting for accuracy by the scheduler and DON. All efforts will be made to meet the staffing ratio. 
If call offs occur, all efforts will be made to attempt to fill that position with RN's that are working in ancillary departments.
4.The DON or designee will conduct an audit of the RN ratios to ensure ratios are being met weekly x4 weeks then monthly x 2 months. The results will be submitted to the QAPI Committee for review and re-evaluation.


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