Pennsylvania Department of Health
HERITAGE RIDGE SENIOR LIVING AT JOHNSTOWN
Patient Care Inspection Results

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
HERITAGE RIDGE SENIOR LIVING AT JOHNSTOWN
Inspection Results For:

There are  103 surveys for this facility. Please select a date to view the survey results.

Surveys don't appear on this website until at least 41 days have elapsed since the exit date of the survey.
HERITAGE RIDGE SENIOR LIVING AT JOHNSTOWN - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on a Medicare/Medicaid Recertification survey, State Licensure survey, and a Civil Rights Compliance survey completed on February 28, 2024, it was determined that Heritage Ridge Senoir Living at Johnstown was not in compliance with the following requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care Facilities and the 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.


 Plan of Correction:


483.25(d)(1)(2) REQUIREMENT Free of Accident Hazards/Supervision/Devices: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(d) Accidents.
The facility must ensure that -
483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and

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


Based on clinical record reviews, observations, and staff interviews, it was determined that the facility failed to complete safety assessments to ensure that the use of air mattresses did not create safety hazards for four of 25 residents reviewed (Residents 22, 25, 31, 33).

Findings include:

A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 22, dated January 10, 2024, revealed that the resident was cognitively intact and that he had skin breakdown. Physician's order for Resident 22, dated October 4, 2023, included an order for the resident to have a specialty air mattress. Resident 22's care plan, dated December 14, 2023, indicated that the resident was to have a specialty air mattress.

Observations of Resident 22 on February 26, 2024, at 8:56 a.m. revealed that the resident was in bed and lying on an air mattress.

There was no documented evidence that the use of an air mattress was assessed for potential safety hazards prior to the air mattress being placed on Resident 22's bed.


A significant change MDS assessment for Resident 25, dated January 2, 2024, revealed that the resident was cognitively impaired, required assistance for daily care needs, received oxygen therapy, had a Stage 3 pressure ulcer, and had diagnoses that included a stroke, dementia, high blood pressure, and heart failure. Physician's orders for Resident 25, dated December 27, 2023, included an order for the resident to have a specialty air mattress.

Observation of Resident 25 on February 26, 2024, at 9:45 a.m. revealed that the resident was in bed and lying on an air mattress.

There was no documented evidence that the use of an air mattress was assessed for potential safety hazards prior to the air mattress being placed on Resident 25's bed.


An admission MDS assessment for Resident 31, dated December 25, 2023, revealed that the resident was cognitively impaired, required assistance for daily care needs, and had diagnoses that included a hip fracture and dementia. Physician's orders for Resident 31, dated December 26, 2023, included an order for the resident to have a specialty air mattress.

Observation of Resident 31 on February 26, 2024, at 10:15 a.m. revealed that the resident was in bed and lying on an air mattress.

There was no documented evidence that the use of an air mattress was assessed for potential safety hazards prior to the air mattress being placed on Resident 31's bed.


A quarterly MDS assessment for Resident 33, dated February 6, 2024, revealed that the resident was cognitively intact, required assistance for daily care needs, and had diagnoses that included diabetes mellitus, anxiety, and depression. Physician's orders for Resident 33, dated November 21, 2023, included an order for the resident to have a specialty air mattress.

Observation on of Resident 33 on February 26, 2024, at 9:36 a.m. revealed that the resident was in bed and lying on an air mattress.

There was no documented evidence that the use of an air mattress was assessed for potential safety hazards prior to the air mattress being placed on Resident 33's bed.

Interview with the Director of Nursing on February 27, 2024, at 1:31 p.m. confirmed that an assessment for potential safety hazards was not completed prior to the air mattress being placed on any of the residents' beds.

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



 Plan of Correction - To be completed: 04/29/2024

Full house audit to be completed by 3/22/24 on all residents.

Mattress safety assessment to be completed on all residents with air mattresses by 3/22/24.

Staff training by 3/29/24.

DON, or designee to audit

2x weekly x2 weeks 3/24/24-4/6/24

1x weekly x3 weeks 4/7/24-4/27/24

Results of audits will be presented to the Administrator by the Director of Nursing at monthly quality assurance and performance improvement meeting for a period of 3 months.
483.75(c)(d)(e)(g)(2)(i)(ii) REQUIREMENT QAPI/QAA Improvement Activities:This is a less serious (but not lowest level) deficiency and 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.
483.75(c) Program feedback, data systems and monitoring.
A facility must establish and implement written policies and procedures for feedback, data collections systems, and monitoring, including adverse event monitoring. The policies and procedures must include, at a minimum, the following:

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

483.75(c)(2) Facility maintenance of effective systems to identify, collect, and use data and information from all departments, including but not limited to the facility assessment required at 483.70(e) and including how such information will be used to develop and monitor performance indicators.

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

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

483.75(d) Program systematic analysis and systemic action.

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

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

483.75(e) Program activities.

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

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

483.75(e)(3) As part of their performance improvement activities, the facility must conduct distinct performance improvement projects. The number and frequency of improvement projects conducted by the facility must reflect the scope and complexity of the facility's services and available resources, as reflected in the facility assessment required at 483.70(e). Improvement projects must include at least annually a project that focuses on high risk or problem-prone areas identified through the data collection and analysis described in paragraphs (c) and (d) of this section.

483.75(g) Quality assessment and assurance.

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

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


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

Findings include:

The facility's deficiencies and plans of corrections for a State Survey and Certification (Department of Health) survey ending March 2, 2023, revealed that the facility developed plans of correction that included quality assurance systems to ensure that the facility maintained compliance with cited nursing home regulations. The results of the current survey, ending February 28, 2024, identified repeated deficiencies related to development of comprehensive care plans, revision of residents' care plans, quality of care, safe environment free of accident hazards, proper nutrition and hydration, accountability of controlled substances, labeling of medications, and food stored, prepared and served in a sanitary manner.

The facility's plan of corrections for deficiencies regarding developing/implementing comprehensive care plans, cited during the survey ending March 2, 2023, revealed that the facility would complete audits and report the results of the audits to the QAPI committee for review. The results of the current survey, cited under F656, revealed that the facility's QAPI committee failed to successfully implement their plan to ensure ongoing compliance with regulations regarding developing comprehensive care plans.

The facility's plan of correction for a deficiency regarding revising residents' care plans, cited during the survey ending March 2, 2023, revealed that audits of care plans would be completed, and the results would be reported to the QAPI committee for review. The results of the current survey, cited under F657, revealed that the QAPI committee was ineffective in maintaining compliance with the regulation regarding revising residents' care plans.

The facility's plan of correction for a deficiency regarding quality of care cited during the survey ending March 2, 2023, revealed that quality of care would be monitored by QAPI. The results of the current survey, cited under F684, revealed that the QAPI committee was ineffective in maintaining compliance with regulation regarding quality of care.

The facility's plans of correction for deficiencies regarding providing a safe environment free of accident hazards, cited during the survey ending March 2, 2023, revealed that the facility developed plans of correction that included completing audits and reporting the results of the audits to the QAPI committee for review. The results of the current survey, cited under F689, revealed that the facility's QAPI committee failed to maintain compliance with the regulation regarding safety and accident-free environment.

The facility's plans of correction for deficiencies regarding nutrition and hydration, cited during the survey ending on March 2, 2023, revealed that audits would be conducted and the results of the audits would be brought before the QAPI committee for further monitoring. The results of the current survey, cited under F692, revealed that the QAPI committee was ineffective in maintaining compliance with the regulation regarding nutrition and hydration.

The facility's plan of corrections for deficiencies regarding accountability of controlled substances, cited during the survey ending March 2, 2023, revealed that the facility would complete audits and report the results of the audits to the QAPI committee for review. The results of the current survey, cited under F755, revealed that the facility's QAPI committee failed to successfully implement their plan to ensure ongoing compliance with regulations regarding accountability of controlled substances.

The facility's plan of corrections for deficiencies regarding the storage/labeling/disposal of medications, cited during the survey ending March 2, 2023, revealed that the facility would complete audits and report the results of the audits to the QAPI committee for review. The results of the current survey, cited under F761, revealed that the facility's QAPI committee failed to successfully implement their plan to ensure ongoing compliance with the labeling/storage/disposal of medications.

The facility's plan of correction for a deficiency regarding food procurement, store/prepare/serve-sanitary cited during the survey ending March 2, 2023, revealed that food procurement, store/prepare/serve-sanitary would be monitored by QAPI. The results of the current survey, cited under F812, revealed that the QAPI committee was ineffective in maintaining compliance with regulation food procurement, store/prepare/serve-sanitary.

Refer to F656, F657, F684, F689, F692, F755, F761, and F812.

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

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




 Plan of Correction - To be completed: 04/29/2024

Quapi team to meet weekly x4 weeks to ensure POC being followed and to review audits.

Quapi team to resume monthly meetings after initial 4 weeks if issues not identified during weekly meetings.
483.60(i)(1)(2) REQUIREMENT Food Procurement,Store/Prepare/Serve-Sanitary:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
483.60(i) Food safety requirements.
The facility must -

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

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


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

Findings include:

The facility's policy regarding food storage, dated November 30, 2023, revealed that any food that has been opened must be labeled, dated and secured in such a way that the food item is air tight.

Observations in the kitchen's freezer on February 27, 2024, at 9:30 a.m. revealed approximately 30 chicken patties, one-third of a bag of French fries, three-quarters of a bag of Tater tots, 25 egg omelets, and 20 sausage patties that were opened and not labeled, dated or secured.

Observations in the kitchen's walk-in dry storage on February 27, 2024, at 11:31 a.m. revealed that there was one opened box with approximately two pounds of loose lasagna noodles and one opened box of approximately five pounds of spaghetti noodles that were not labeled, dated or secured.

The facility's policy regarding hair coverings, dated November 30, 2023, revealed that the purpose of the policy was to ensure sanitary practices during food preparation in the kitchen. Hair restraints were to be worn in a manner to cover all hair.

Observations in the kitchen on February 27, 2024, at 11:35 a.m. revealed that Cook 2 was plating food that included, barbecue chicken, macaroni and cheese, spinach and carrots. The cook wore a hairnet that revealed approximately five inches of hair tendrils on the right side of her head and two inches on the back of her neck. Dietary Aide 3 was receiving the plated food and adding food to the plate. She wore a hairnet and approximately seven inches of hair on the right side of her head was not covered. Dietary Aide 4 was carrying and working with trays of uncovered food. She wore a hairnet and approximately six inches of hair on the left side of her face was not covered.

Observations inside the pantry microwave on February 27, 2024, at 12:57 p.m. revealed the following exposed, worn and/or rusty areas: a two-inch area on the bottom (in the back), a one-inch area on the top right, and a five to six-inch area on the top left.

Interview with the Dietary Manager on February 27, 2024, at 1:01 p.m. confirmed that all food items in the kitchen should be labeled, dated and secured, that staff should wear hairnets that cover all of their hair, and that the inside of the pantry microwave should not have areas where the paint is worn off.

28 Pa. Code 211.6(f) Dietary Services.



 Plan of Correction - To be completed: 04/29/2024

1. All undated, unlabeled, unsecured items were labeled when dates were known, discarded if they weren't known. In-service held on 2/28/2024.
2. All residents receiving meals have the potential to be affected.
3. Manager will continuously monitor labeling, dating, and product security. Manager or designee will take immediate action to correct occurrences found to be out of compliance.
4. Manager will document each occurrence of non-compliance and review with administrator weekly. Manager will submit summary report to QAPI monthly until committee determines that deficiency is resolved for 6 consecutive months.

483.60(d)(1)(2) REQUIREMENT Nutritive Value/Appear, Palatable/Prefer Temp:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
483.60(d) Food and drink
Each resident receives and the facility provides-

483.60(d)(1) Food prepared by methods that conserve nutritive value, flavor, and appearance;

483.60(d)(2) Food and drink that is palatable, attractive, and at a safe and appetizing temperature.
Observations:


Based on observations, as well as resident and staff interviews, it was determined that the facility failed to serve food items that were palatable.

Findings include:

Interview with Resident 10 on February 26, 2024, at 9:47 a.m. revealed that she does not like the taste of the food.

Interview with Resident 23 on February 16, 2024, at 11:24 a.m. revealed that the food can be hard and the meals are sometimes cold.

Interview with Resident 33 on February 26, 2024, at 9:36 a.m. revealed that the food is not very warm.

Observations in the kitchen for the lunch meal service on February 27, 2024, at 12:21 a.m. revealed that a test tray left the kitchen and arrived on the Rose Room dining area at 12:22 p.m., where one tray was removed from the food cart and at 12:25 p.m. the cart was then transported to the B hall nursing unit and arrived at 12:27 p.m. The lunch meal on February 27, 2024, consisted of barbecue chicken breast, spinach, carrots, macaroni and cheese, mandarin oranges, milk and coffee. Trays were passed to the residents in their rooms and the last resident was served and eating at 12:39 a.m. The test tray on February 27, 2024, at 12:40 p.m. revealed that the chicken was 105.2 degrees Fahrenheit (F), the temperature of the spinach was 104 degrees F, the temperature of the macaroni and cheese was 119 degrees F, the mandarin slices were 57 degrees F, the milk was 50 degrees F, and the coffee was 150 degrees F. The chicken, spinach, and macaroni and cheese were cool and unappetizing.

Interview with the Food Service Director on February 27, 2024, at 12:49 p.m. confirmed that foods should be served to residents at proper temperatures.





 Plan of Correction - To be completed: 04/29/2024

1. Resident 10, 23, and 33 were visited to obtain more specific information of items that didn't taste good and which items weren't warm enough. In-service was conducted on 2/28/2024 reviewing practice of verifying that heat support equipment is working prior to each meal, taking and recording temperature of each food item prior to the beginning of service.
2. All residents receiving meals have the potential to be affected.
3. Manager or designee will conduct meal rounds covering all resident once a week. When residents respond that everything is fine, ask "If you could change one thing about your food or service, what would it be?" - record responses. Test trays will be conducted at least 3 times per week 1 breakfast, 1 lunch, 1 dinner. Manager will verify by observation and tasting that recipes are being followed.
4. Manager will complete summary report of meal rounds each week and review results and actions taken with the administrator. Manager will compile a summary report of test tray results each week and review results with the administrator. Results will be reported to QAPI monthly until committee agrees that deficiency is resolved for 6 consecutive months.

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

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

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

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

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

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


Based on review of facility policy and clinical records, as well as staff interviews, it was determined that the facility failed to maintain accountability for controlled medications (drugs with the potential to be abused) for three of 25 residents reviewed (Residents 22, 31, 33).

Findings include:

The policy for narcotic destruction, dated November 30, 2023, revealed that there must be one nurse to destroy a narcotic and one nurse to witness the destruction.

A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 22, dated January 10, 2024, revealed that the resident was cognitively intact and that he had pain.

Physician's orders for Resident 22, dated November 17, 2023, included an order for the resident to receive a 5 micrograms (mcg) per hour Buprenorphine patch (narcotic pain medication) and to change the patch weekly.

Review of the controlled drug record (a form that accounts for each tablet/pill/dose of a controlled drug) for Resident 22 for November and December 2023, as well as January and February 2024, indicated that a Buprenorphine patch was removed from the resident on November 24, 2023; December 1, 8, 15, 22, 29, 2023; January 5, 19, 26, 2024; and February 9, 2024, prior to placing a new patch on him at that time.

There was no documented evidence that two nurse's witnessed the destruction of the Buprenorphine patch on any of the dates listed.

Interview with the Director of Nursing on February 28, 2024, at 10:12 a.m. confirmed that there was no documented evidence in Resident 22's clinical records to indicate that there were two nurses to destroy the Buprenorphine patches and that there should have been.

An admission MDS assessment for Resident 31, dated December 25, 2023, revealed that the resident was cognitively impaired, required assistance for daily care needs, and had diagnoses that included hip fracture.

Physician's orders for Resident 31, dated January 2, 2024, included an order for the resident to receive 5 mg (milligram) of Oxycodone (narcotic pain medication) every six hours for pain as needed.

Review of the controlled drug record for Resident 31 for December 2023 and January 2024 indicated that one 10 mg tablet of Oxycodone was signed-out for administration to the resident on December 31, 2023, and January 12, 2024. However, the resident's clinical record, including the Medication Administration Record (MAR) and nursing notes, contained no documented evidence that the signed-out tablet of Oxycodone was administered to the resident on these dates.

Interview with the Director of Nursing on February 27, 2024, at 12:12 p.m. confirmed that there was no documented evidence on the resident's electronic health record that staff administered the controlled drug to Resident 31 on the dates mentioned above.

A quarterly MDS assessment for Resident 33, dated February 6, 2024, revealed that the resident was cognitively intact, required assistance for daily care needs, and had diagnoses that included diabetes mellitus, anxiety, and depression.

Physician's orders for Resident 33, dated August 21, 2023, included an order for the resident to receive 10 mg (milligram) of Oxycodone (narcotic pain medication) every four hours for pain.

Review of the controlled drug record for Resident 33 for September and October 2023 indicated that one 10 mg tablet of Oxycodone was signed-out for administration to the resident on September 8 and 25, 2023, and October 6, 23 and 29, 2023. However, the resident's clinical record, including the MAR and nursing notes, contained no documented evidence that the signed-out tablet of Oxycodone was administered to the resident on these dates.

Interview with the Director of Nursing on February 28, 2024, at 12:20 p.m. confirmed that there was no documented evidence on the resident's electronic health record that staff administered the controlled drug to Resident 33 on the dates mentioned above.

28 Pa. Code 211.9(h) Pharmacy Services.

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



 Plan of Correction - To be completed: 04/29/2024

Entire house audit of all patients with controlled patches to be completed by 3/22/24.

Destroying old patch with witness added to orders for all controlled patches.

Batch orders updated to include two nurses to destroy all controlled patches.

Staff retraining by 3/29/24.

DON or designee to audit

5x weekly x1 week 3/24/24-3/30/24

3x weekly x2 weeks 3/31/24-4/13/24

1x weekly x2 weeks 4/14/24-4/27/24
Results of audits will be presented to the Administrator by the Director of Nursing at monthly quality assurance and performance improvement meeting for a period of 3 months.

Whole house audit on PRN narcotics completed by 3/22/24. Medications unsigned in PCC corrected and education provided to any nurse in violation.

Staff to be retrained by 3/29/24.

DON or designee to audit

5x weekly x1 week 3/24/24-3/30/24

3x weekly x2 weeks 3/31/24-4/13/24

1x weekly x2 weeks 4/14/24-4/27/24

Results of audits will be presented to the Administrator by the Director of Nursing at monthly quality assurance and performance improvement meeting for a period of 3 months.

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


Based on review of facility contracts and clinical records, and staff interview, it was determined that the facility failed to maintain records relating to dialysis communication and collaboration for one of one residents reviewed for dialysis (Resident 37).

Findings include:

A Quarterly MDS assessment (a mandated assessment of a resident's abilities and care needs) for Resident 37, dated December 21, 2023, revealed that the resident was cognitively intact, required minimal assistance for daily care needs, and was receiving dialysis (a procedure to remove waste products and excess fluid from the blood when the kidneys stop working properly).

Review of the dialysis contract, dated August, 2022, revealed that "the center shall maintain reports of all services rendered by Center in accordance with its usual medical records procedures."

Review of Resident 37's clinical record revealed an admission date of November 28, 2023, with diagnoses that included end-stage renal disease (a disease that causes the kidneys not to function properly), diabetes, and hypercholesterolemia (high cholesterol).

Current physician's orders for Resident 37 revealed orders that included dialysis every Monday, Wednesday, and Friday at 7:00 a.m.

Review of Resident 37's clinical record revealed no evidence of communication between the facility and dialysis clinic.

Interview with the Director of Nursing on February 27, 2024, at 12:25 p.m. confirmed that there was no evidence of ongoing communication and collaboration between the facility and dialysis clinic, and also confirmed that communication should be done with every dialysis treatment.

28 Pa. Code 211.5(f)(viii) Medical Records.

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




 Plan of Correction - To be completed: 04/29/2024

DON, or designee, to do full house audit for patients on dialysis by 3/22/24.

Added to patient orders for night shift (10p-6a) to sign acknowledgement paper was prepared and sent with patient. Added for day shift (6a-2p) to sign acknowledgement paper was prepared and sent back to facility with patient.

Call placed to dialysis, followed up in email with DON contact information and fax number. To please advise if papers were not being sent from the facility and fax information in the event dialysis would not return with resident for any reason.

Staff to be retrained by 3/29/24.

DON or designee to audit

3x weekly x2 weeks 3/24/24-4/6/24

2x weekly x2 weeks 4/7/24-4/20/24

1x weekly x1 week 4/21/23-4/27/24

Results of audits will be presented to the Administrator by the Director of Nursing at monthly quality assurance and performance improvement meeting for a period of 3 months.

483.25(g)(4)(5) REQUIREMENT Tube Feeding Mgmt/Restore Eating Skills: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)(4)-(5) Enteral Nutrition
(Includes naso-gastric and gastrostomy tubes, both percutaneous endoscopic gastrostomy and percutaneous endoscopic jejunostomy, and enteral fluids). Based on a resident's comprehensive assessment, the facility must ensure that a resident-

483.25(g)(4) A resident who has been able to eat enough alone or with assistance is not fed by enteral methods unless the resident's clinical condition demonstrates that enteral feeding was clinically indicated and consented to by the resident; and

483.25(g)(5) A resident who is fed by enteral means receives the appropriate treatment and services to restore, if possible, oral eating skills and to prevent complications of enteral feeding including but not limited to aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, and nasal-pharyngeal ulcers.
Observations:


Based on a review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that a tube feeding was documented in accordance with the facility's policy and the resident's care plan for one of 25 residents reviewed (Resident 13).

Findings include:

The facility's policy regarding enteral feeding (nutritional formula provided via a tube inserted into the stomach), dated November 30, 2022, indicated that nursing staff will monitor for signs and symptoms of aspiration and/or feeding intolerance.

An annual Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 13, dated February 2, 2024, indicated that the resident was cognitively intact, required assistance from staff for all daily care needs, and had a feeding tube (a tube surgically implanted into the stomach for feeding). Resident 13's current care plan, dated September 26, 2023, revealed that staff should check for tube placement and gastric contents/residual volume per the facility's protocol.

Physician's orders for Resident 13, dated September 25, 2023, included an order to check tube placement before starting feedings and medications. Check the residual at least once each shift and record it. Physician's orders for the resident, dated February 23, 2024, included orders for the resident to receive 79 cc per hour of Jevity 1.2 (type of enteral nutrition) for 20 hours and 25 cc per hour of free water flush for 20 hours for a total of 500 cc a day.

Review of Resident 13's clinical record for September 2023 through February 28, 2024, revealed that there was no documented evidence that gastric residuals or tube placement was checked per physician's orders.

Interview with the Director of Nursing on February 28, 2024, at 8:26 a.m. confirmed that there was no documented evidence that gastric residual or tube placement was checked per physician's orders.

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




 Plan of Correction - To be completed: 04/29/2024

Full house audit on tube feeding; staff to monitor for s/s aspiration/feeding intolerance by 3/22/24. All corrections to be made.

Full house audit check placement and residual q shift by 3/22/24. All corrections to be made.

Staff monitor for s/s aspiration/feeding intolerance and check placement and residual orders added to admission batch orders.

All staff to be retrained by 3/29/24.

Will review at weekly dietary/weight meetings with IDT team.

DON or designee to audit

2x weekly x2 weeks 3/24/24-4/6/24

1x weekly x3 weeks 4/7/24-4/27/24
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 reviews and staff interviews, it was determined that the facility failed to initiate nutritional interventions to prevent weight loss for one of 25 residents reviewed (Resident 11).

Findings include:

A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 11, dated November 16, 2023, revealed that the resident was cognitively intact, was able to make himself understood, could understand others, and did not require staff assistance with meals.

A dietician's note for Resident 11, dated January 22, 2024, revealed that the resident experienced a 7.5 percent unplanned weight loss in three months.

A physician's order for Resident 11, dated January 27, 2024, revealed that the resident was to have a house supplement twice a day due to weight loss.

There was no documented evidence that Resident 11 received the ordered house supplement twice a day from January 27, 2024, to February 1, 2024.

Interview with the Dietitian on February 28, 2024, at 8:38 a.m. confirmed that there was no documented evidence that Resident 11 received the house supplement on the above dates as ordered.

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



 Plan of Correction - To be completed: 04/29/2024

Full house audit to ensure percentages are selected for documentation by 3/22/24.

Staff retraining by 3/29/24.

Will review at weekly dietary/weight meetings with IDT team.

DON or designee to audit

2x weekly x2 weeks 3/24/24-4/6/24

1x weekly x3 weeks 4/7/24-4/27/24
483.10(g)(17)(18)(i)-(v) REQUIREMENT Medicaid/Medicare Coverage/Liability Notice: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(g)(17) The facility must--
(i) Inform each Medicaid-eligible resident, in writing, at the time of admission to the nursing facility and when the resident becomes eligible for Medicaid of-
(A) The items and services that are included in nursing facility services under the State plan and for which the resident may not be charged;
(B) Those other items and services that the facility offers and for which the resident may be charged, and the amount of charges for those services; and
(ii) Inform each Medicaid-eligible resident when changes are made to the items and services specified in 483.10(g)(17)(i)(A) and (B) of this section.

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


Based on clinical record reviews and staff interviews, it was determined that the facility failed to provide the required notice to the resident or the resident's representative following the end of their Medicare coverage for three of three residents reviewed (Residents 10, 39, 146) who remained in the facility for long-term care.

Findings include:

A Skilled Nursing Facility (SNF) Beneficiary Protection Notification Review form, completed by the facility and dated January 19, 2024, revealed that Medicare coverage for Resident 10 started on December 5, 2023, and that her last covered day was January 21, 2024. The form indicated that the facility initiated discontinuation from Medicare Part A coverage and that the resident's benefit days were not exhausted.

A Skilled Nursing Facility (SNF) Beneficiary Protection Notification Review form, completed by the facility and dated October 10, 2023, revealed that Medicare coverage for Resident 39 started on August 29, 2023, and that her last covered day was October 5, 2023 The form indicated that the facility initiated discontinuation from Medicare Part A coverage and that the resident's benefit days were not exhausted.

A Skilled Nursing Facility (SNF) Beneficiary Protection Notification Review form, completed by the facility and dated January 17, 2024, revealed that Medicare coverage for Resident 146 started on December 27, 2023, and that her last covered day was January 17, 2024. The form indicated that the facility initiated discontinuation from Medicare Part A coverage and that the resident's benefit days were not exhausted.

There was no documented evidence that Resident's 10, 39 and 146 were provided with an Advance Beneficiary Notice of Noncoverage (ABN - a notice given to Medicare beneficiaries to convey that Medicare is not likely to provide coverage in a specific case).

Interview with the Nursing Home Administrator and Director of Social Services on February 27, 2024, at 9:07 a.m. revealed that the ABN's were not issued because there was no staff doing that, and that they will be doing it going forward.

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




 Plan of Correction - To be completed: 04/29/2024

Social worker, MDS coordinator and admissions director will receive training on the following: purpose of a SNFABN, what information must be included on the SNFABN, the disposition of the completed and signed SNFABN and how to properly document why or why not the SNFABN was issued. Training to be completed 3/29/24.

SW will keep a list of all Medicare Part A admissions, all residents who receive skilled services under Medicare Part A, the final discharge disposition and if SNFABN was issues.

List to be reviewed weekly during rehab meeting 3/24/24-4/27/24

Results of audits will be presented to the Administrator by the Director of Nursing at monthly quality assurance and performance improvement meeting for a period of 3 months.

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


Based on clinical record reviews and staff interviews, it was determined that the facility failed to ensure that resident-centered care plans were developed and implemented for two of 25 residents reviewed (Residents 13, 25).

Findings include:

The facility's policy regarding care plans, dated November 30, 2023, indicated that the facility would develop a written plan of care that was individualized for each resident's daily care routines and would be reviewed and revised as necessary and when a resident experiences a status change.

An annual Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 13, dated February 2, 2024, revealed that the resident was cognitively intact, required assistance from staff for his daily care needs, required oxygen therapy. and had diagnoses that included Parkinson's, heart failure, and dementia.

Physician's orders for Resident 13, dated November 21, 2023, included an order for oxygen 3 liters via nasal cannula.

There was no documented evidence that a care plan was developed to address Resident 13's individual care and treatment needs related to his use of oxygen.

Interview with the Director of Nursing on February 28, 2024, at 8:26 a.m. confirmed that there was no care plan developed for Resident 13's care and treatment needs related to his use of oxygen.


A significant change MDS assessment for Resident 25, dated January 2, 2024, revealed that the resident was cognitively impaired, required assistance for daily care needs, received oxygen therapy, had a Stage 3 pressure ulcer (involves full thickness of the skin and underlying subcutaneous tissue), and had diagnoses that included a stroke, dementia, high blood pressure, and heart failure.

Physician's orders for Resident 25, dated January 9, 2024, included an order for oxygen 1-6 liters via nasal cannula. Physician's orders for Resident 25, dated February 26, 2024, included an order for one-half strength Dakin's Solution and calcium alginate (treatments used to treat wounds), apply to sacral wound topically and cover with bordered gauze one time a day.

There was no documented evidence that a care plan was developed to address Resident 25's care needs related to the use of oxygen or a Stage 3 pressure injury.

Interview with the Director of Nursing on February 27, 2024, at 3:28 p.m. confirmed that Resident 25's care plan did not address his care needs related to his use of oxygen or the Stage 3 pressure injury and should have.

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



 Plan of Correction - To be completed: 04/29/2024

All licensed staff retraining by 3/29/24

Baseline care plan instructions added to admission packet.

Clinical to review all orders and care plans for completeness and correct

5x weekly x2 weeks 3/24/24-4/6/24

3x weekly x2 weeks 4/7/24-4/20/24

2x weekly x1 weeks 4/21/24-4/27/24

Results of audits will be presented to the Administrator by the Director of Nursing at monthly quality assurance and performance improvement meeting for a period of 3 months.

483.21(b)(2)(i)-(iii) REQUIREMENT Care Plan Timing and Revision:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.21(b) Comprehensive Care Plans
483.21(b)(2) A comprehensive care plan must be-
(i) Developed within 7 days after completion of the comprehensive assessment.
(ii) Prepared by an interdisciplinary team, that includes but is not limited to--
(A) The attending physician.
(B) A registered nurse with responsibility for the resident.
(C) A nurse aide with responsibility for the resident.
(D) A member of food and nutrition services staff.
(E) To the extent practicable, the participation of the resident and the resident's representative(s). An explanation must be included in a resident's medical record if the participation of the resident and their resident representative is determined not practicable for the development of the resident's care plan.
(F) Other appropriate staff or professionals in disciplines as determined by the resident's needs or as requested by the resident.
(iii)Reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments.
Observations:


Based on clinical record reviews and staff interviews, it was determined that the facility failed to review and revise care plans for one of 25 residents reviewed (Resident 25).

Findings include:

A significant change Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 25, dated January 2, 2024, revealed that the resident was cognitively impaired, required assistance for daily care needs, received oxygen therapy, had a Stage 3 pressure ulcer (involves the full thickness of the skin and underlying subcutaneous tissue), and had diagnoses that included a stroke, dementia, high blood pressure, and heart failure. A care plan, dated December 17, 2023, indicated the resident's Foley catheter (a tube inserted into the bladder) was an 18 French, 10 cc catheter (size of the catheter).

Physician's orders for Resident 25, dated December 27, 2023, included an order for an indwelling Foley catheter, size 16 French 10 cc.

Observation of Resident 25 on February 28, 2024, at 9:28 a.m. with the Licensed Practical Nurse Assessment Coordinator confirmed that the resident had a 16 French 10 cc catheter inserted.

There was no documented evidence that Resident 25's care plan was updated to reflect the physician's orders for the size of the Foley catheter.

Interview with the Director of Nursing on February 28, 2024, at 1:30 p.m. confirmed that Resident 25's care plan should have been updated to reflect the change in physician's orders for the size of the Foley catheter.

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




 Plan of Correction - To be completed: 04/29/2024

All catheter care plans to be audited and updated by 3/22/24

All licensed staff retraining by 3/29/24

Baseline care plan instructions added to admission packet.

Clinical to review all orders and care plans for completeness and correctness

5x weekly x2 weeks 3/24/24-4/6/24

3x weekly x2 weeks 4/7/24-4/20/24

2x weekly x1 weeks 4/21/24-4/27/24

Results of audits will be presented to the Administrator by the Director of Nursing at monthly quality assurance and performance improvement meeting for a period of 3 months.

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 reviews and staff interviews, it was determined that the facility failed to ensure that physician's orders were followed regarding a resident's enteral feeding (feeding through a tube inserted directly into the stomach) and calorie count for one of 25 residents reviewed (Resident 22) and failed to obtain and document a pain level every shift for one of 25 residents reviewed (Resident 33).

Findings include:

A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 22, dated January 10, 2024, revealed that the resident was cognitively intact and that he had a feeding tube. Resident 22's care plan, dated January 6, 2024, indicated that the resident should receive enteral nutrition as ordered.

Physician's orders for Resident 22, dated September 28, 2023, and January 13, 2024, included an order for the resident to received Osmolite 1.5 (a type of liquid feed for a feeding tube) at 55 milliliters (mL) per hour for 20 hours per day.

A nursing note for Resident 22, dated January 19, 2024, revealed that the physician ordered a calorie count for the resident.

A physician's note, dated February 1, 2024, indicated that the calorie count had not been done and that the physician was still asking for one to be done. He stated that Resident 22 appeared to be getting excess calories with the enteral feeding and the regular food the resident was consuming.

A nutritional note, dated January 26, 2024, revealed that Resident 22's feeding was to be decreased from 55 mL per hour to 45 mL per hour and to run for only 16 hours per day. There was no documented evidence that Resident 22's enteral feed was changed at that time.

Physician's note, dated Feburary 8, 2024, regarding Resident 22 revealed that staff told the physician that Resident 22's feeding had been decreased since he was ingesting a lot of calories by mouth.

A nutritional note, dated Feburary 9, 2024, for Resident 22 indicated that his enteral feeding was to be decreased to 45 mL per hour for 18 hours. There was no documented evidence that Resident 22's enteral feeding was changed at that time.

Observations of Resident 22 on February 26, 2024, at 9:38 a.m. revealed that his enteral feed was Osmolite 1.5 and it was infusing at 55 mL per hour.

Observations of Resident 22 on February 27, 2024, at 10:11 a.m. revealed that his feeding was infusing at 45 mL per hour.

Interview with the Director of Nursing on February 28, 2024, at 10:12 a.m. revealed that there was a miscommunication between the physician and the dietician and that they were not aware of what the other one wanted, that was why there was a delay in changing the rate of the feeding tube infusion for Resident 22, and also a delay in getting the calorie count done.


An admission MDS assessment for Resident 31, dated December 25, 2023, indicated that the resident was cognitively impaired, required staff assistance for daily care needs, and had a diagnosis of a hip fracture.

Physician's orders for Resident 31, dated December 19, 2023, included an order to document the resident's pain level every shift.

A review of Resident 31's Medication Administration Record for December 2023 and January 2024 revealed no evidence that a numeric pain level was obtained and documented every shift as ordered from December 19, 2023, to January 8, 2024.

Interview with the Director of Nursing on February 27, 2024, at 12:12 p.m. confirmed that the pain level should have been obtained every shift and documented as ordered.

28 Pa. Code 211.5(f) Clinical Records.

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






 Plan of Correction - To be completed: 04/29/2024

Staff to be retrained by 3/29/24.

Dietician to use physician order sheet for all new orders/recommendations beginning 3/22/24.

Licensed staff to review with MD and implement new orders in PCC.

Orders to be redlined daily.

Will review at weekly dietary/weight meetings with IDT team.

DON or designee to audit

2x weekly x2 weeks 3/24/24-4/6/24

1x weekly x 2 weeks 4/7/24-4/27/24

All patients, in house, to be audited for pain score by 3/22/24. And corrected if no pain score.

Staff to be retrained by 3/29/24 on admission batch orders.

DON or designee to audit

3x weekly x2 weeks 3/24/24-4/6/24

2x weekly x2 weeks 4/7/24-4/20/24

1x weekly x1 weeks 4/21/24-4/27/24

Results of audits will be presented to the Administrator by the Director of Nursing at monthly quality assurance and performance improvement meeting for a period of 3 months.
483.45(f)(1) REQUIREMENT Free of Medication Error Rts 5 Prcnt or More:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.45(f) Medication Errors.
The facility must ensure that its-

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


Based on review of clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that the medication error rate was less than five percent.

Findings include:

Observations during medication administration on February 26, 2024, at 3:59 p.m. revealed that three medication administration errors were made during 29 opportunities for error, resulting in an error rate of 10.34 percent.

Physician's orders for Resident 20, dated November 3, 2023, included an order for the resident to receive 850 milligrams (mg) of Metformin (a medicine used to treat high blood sugar) twice a day. A review of the pill card (a way of packaging medications that are grouped by the time and day of taking them) for Resident 20's Metformin revealed that the pharmacy had placed several additional labels (stickers) on the pill card related to the medication. One label advised that the resident was to receive Metformin with food.

Observations during A hall medication pass on February 26, 2024, at 4:13 p.m. revealed that Licensed Practical Nurse 1 administered Resident 20's Metformin with water but no food as per the pharmacy label on the pill card.

Physician's orders for Resident 28, dated October 6, 2023, included an order for the resident to receive 25 mg of Metoprolol (a medicine used to treat heart failure) twice a day. A review of the pill card for Resident 28's Metoprolol revealed that the pharmacy had placed several additional labels (stickers) on the pill card related to the medication. One label advised that the resident was to receive Metoprolol with or immediately after a meal.

Observations during A hall medication pass on February 26, 2024, at 4:21 p.m. revealed that Licensed Practical Nurse 1 administered Resident 28's Metoprolol with water only and no food, and not immediately after a meal, as the resident had not eaten her dinner meal yet.

Physician's orders for Resident 33, dated September 28, 2023, included orders for the resident to receive 1000 mg of Metformin twice a day. A review of the pill card for Resident 33's Metformin revealed that the pharmacy had placed several additional labels (stickers) on the pill cards related to the medications. One label advised that the resident was to receive Metformin with food.

Observations during A hall medication pass on February 26, 2024, at 4:03 p.m. revealed that Licensed Practical Nurse 1 administered Resident 28's Metformin with water only and no food, as per the pharmacy label.

Interview with Licensed Practical Nurse 1 on February 26, 2024, at 4:44 p.m. revealed that she did not notice the pharmacy labels (stickers) on the pill cards for Residents 20, 28 or 33 advising to either give the medications with food or immediately after a meal. She further revealed that the electronic medication administration record did not indicate that these medications were to be given specifically with food or immediately after meals.

Interview with the Nursing Home Administrator on February 27, 2024, at 12:25 p.m. confirmed that the facility failed to ensure that physicians orders, pharmacy recommendations, and the electronic medication administration record all matched for Resident 20's Metformin, Resident 28's Metoprolol, and Resident 33's Metformin.

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





 Plan of Correction - To be completed: 04/29/2024

Medical director made aware metoprolol to be given with or immediately following meals. Per medical director, Dr. Craig Fockler metoprolol to be given in morning and bedtime. "Patients are more likely to have an episode overnight if given at 8am and 5pm. Spoke with other attending physician, Balkissoon Maharajh, who was in agreement.

Spoke with pharmacy consultant Mike Plaska. Updated to remove warning labels from metoprolol 3/4/24.

All warning labels removed from existing metoprolol cards by DON by 3/4/24.

All antidiabetic medications to be given with meals per manufacture instructions 100% audit to be completed by 3/22/24. With meals added to all orders applicable.

Update to admission batch orders.

All staff to be retrained by 3/29/24.

DON or designee to audit antidiabetic medications and warning labels

5x weekly x1 week 3/24/24-3/30/24

3x weekly x2 weeks 3/31/24-4/13/24

1x weekly x2 weeks 4/14/24-4/27/24

Results of audits will be presented to the Administrator by the Director of Nursing at monthly quality assurance and performance improvement meeting for a period of 3 months.


483.45(g)(h)(1)(2) REQUIREMENT Label/Store Drugs and Biologicals:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.45(g) Labeling of Drugs and Biologicals
Drugs and biologicals used in the facility must be labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable.

483.45(h) Storage of Drugs and Biologicals

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

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


Based on observations and staff interviews, it was determined that the facility failed to ensure that labeling of medication matched physician's orders for three of 25 residents reviewed (Residents 20, 28, 33).

Findings include:

Physician's orders for Resident 20, dated November 3, 2023, included an order for the resident to receive 850 milligrams (mg) of Metformin (a medicine used to treat high blood sugar ) twice a day. A review of the pill card (a way of packaging medications that are grouped by the time and day of taking them) for Resident 20's Metformin revealed that the pharmacy had placed several additional labels (stickers) on the pill card related to the medication. One label advised that the resident was to receive Metformin with food.

Observations during A hall medication pass on February 26, 2024, at 4:13 p.m. revealed that Licensed Practical Nurse 1 administered Resident 20's Metformin with water but no food as per the pharmacy label on the pill card.

Physician's orders for Resident 28, dated October 6, 2023, included an order for the resident to receive 25 mg of Metoprolol (a medicine used to treat heart failure) twice a day. A review of the pill card for Resident 28's Metoprolol revealed that the pharmacy had placed several additional labels (stickers) on the pill card related to the medication. One label advised that the resident was to receive Metoprolol with or immediately after a meal.

Observations during A hall medication pass on February 26, 2024, at 4:21 p.m. revealed that Licensed Practical Nurse 1 administered Resident 28's Metoprolol with water only and no food, and not immediately after a meal, as the resident had not eaten her dinner meal yet.

Physician's orders for Resident 33, dated September 28, 2023, included orders for the resident to receive 1000 mg of Metformin twice a day. A review of the pill card for Resident 33's Metformin revealed that the pharmacy had placed several additional labels (stickers) on the pill cards related to the medications. One label advised that the resident was to receive Metformin with food.

Observations during A hall medication pass on February 26, 2024, at 4:03 p.m. revealed that Licensed Practical Nurse 1 administered Resident 28's Metformin with water only and no food, as per the pharmacy label.

Interview with Licensed Practical Nurse 1 on February 26, 2024, at 4:44 p.m. revealed that she did not notice the pharmacy labels (stickers) on the pill cards for Residents 20, 28 or 33 advising to either give the medications with food or immediately after a meal. She further revealed that the electronic medication administration record did not indicate that these medications were to be given specifically with food or immediately after meals.

Interview with the Nursing Home Administrator on February 27, 2024, at 12:25 p.m. confirmed that the facility failed to ensure that physicians orders, pharmacy recommendations, and the electronic medication administration record all matched for Resident 20's Metformin, Resident 28's Metoprolol, and Resident 33's Metformin.

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




 Plan of Correction - To be completed: 04/29/2024

Audit completed on 100% of medication cards by 3/4/24.

Non-applicable warning labels removed.

Meeting with Mike Plaska, pharmacy representative 3/4/24 to have warning labels not applicable to be removed for all cards moving forward.

All staff to be retrained by 3/29/24.

Licensed staff to review warning labels on drugs received and notify DON of any labels that still need to be removed. DON to notify pharmacy.

DON or designee to audit warning label to ensure match MD orders

5x weekly x1 week 3/24/24-3/30/24

3x weekly x2 weeks 3/31/24-4/13/24

1x weekly x2 weeks 4/14/24-4/27/24

Results of audits will be presented to the Administrator by the Director of Nursing at monthly quality assurance and performance improvement meeting for a period of 3 months.

201.14(d) LICENSURE Responsibility of licensee.:State only Deficiency.
[Reserved]
Observations:


Based on a review of clinical records, as well as staff interviews, it was determined that the facility failed to notify the Department of Health of an incident that had the potential for serious harm to a resident.

Findings include:

A Quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 43, dated October 11, 2023, revealed that the resident was cognitively intact and required assistance from staff for his daily care needs.

A nurse's note for Resident 43, dated November 28, 2023, at 1:40 p.m., revealed that the resident had an unwitnessed fall on November 28, 2023. The resident began to complain of rib pain at 3:56 p.m. on November 28, 2023.

A nurse's note for Resident 43, dated November 28, 2023, at 10:10 a.m., revealed that the resident left by ambulance for the hospital for evaluation due to rib pain.

A nurse's note for Resident 43, dated November 29, 2023, at 9:58 p.m., revealed that the resident was being admitted to the hospital with a diagnosis of rib fracture.

A physician's order for Resident 43, dated November 28, 2023, for an x-ray of the ribs was completed on November 28, 2023, and was reviewed by the physician on November 28, 2023, at 7:18 p.m.

There was no documented evidence to indicate that this fall with fracture was reported to the Department of Health.

Interview with the Director of Nursing on February 28, 2024, at 11:25 a.m. confirmed that the Department of Health was not notified of this incident.

Chapter 51.3(f) Notification.




 Plan of Correction - To be completed: 04/29/2024

DON and administrator retaining by Rosemarie Tierney, Chief Nursing Officer 3/18/24.

DON/administrator to send all reportable incidents and questions to administrator, chief nursing officer and COO for review.
211.10(d) LICENSURE Resident care policies.:State only Deficiency.
(d) The policies shall be designed and implemented to ensure that the resident receives proper care to prevent pressure sores and deformities; that the resident is kept comfortable, clean and well-groomed; that the resident is protected from accident, injury and infection; and that the resident is encouraged, assisted and trained in self-care and group activities.

Observations:


Based on clinical record reviews and staff interviews, it was determined that the facility failed to develop policies related to completing safety assessments prior to the use of air mattresses on residents' beds.

Findings include:

Physician's order for Resident 22, dated October 4, 2023, included an order for the resident to have a specialty air mattress.

Physician's orders for Resident 25, dated December 27, 2023, included an order for the resident to have a specialty air mattress.

Physician's orders for Resident 33, dated November 21, 2023, included an order for the resident to have a specialty air mattress.

Review of the facility's care policies, most recently reviewed by the facility on November 30, 2023, revealed that there was no policy in place to ensure that air mattress safety assessments were completed.

Interview with the Nursing Home Administrator on February 28, 2024, at 1:36 p.m. confirmed that there were no assessments for potential safety hazards prior to the air mattress being placed on Resident 22's, Resident 25's and Resident 33's beds and that a policy regarding completing the assessments was not developed yet.





 Plan of Correction - To be completed: 04/29/2024

Full house audit to be completed by 3/22/24 on all residents.

Mattress safety assessment to be completed on all residents with air mattresses by 3/22/24.

Staff training by 3/29/24.

DON, or designee to audit

2x weekly x2 weeks 3/24/24-4/6/24

1x weekly x3 weeks 4/7/24-4/27/24
211.12(f.1)(4) LICENSURE Nursing services. :State only Deficiency.
(4) Effective July 1, 2023, a minimum of 1 LPN per 25 residents during the day, 1 LPN per 30 residents during the evening, and 1 LPN per 40 residents overnight.
Observations:


Based on review of nursing schedules, review of staffing information furnished by the facility, and staff interviews, it was determined that the facility failed to ensure a minimum of one licensed practical nurse (LPN) per 30 residents during the evening on the evening shift for eight of 21 days (24-hour periods) reviewed.

Findings Include:

Review of facility census data indicated that on February 7, 2024, the facility census was 46, which required 1.53 LPNs during the evening shift.

Review of the nursing time schedules revealed 1.07 LPNs worked on the evening shift on February 7, 2024. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on February 8, 2024, the facility census was 44, which required 1.47 LPN's during the evening shift.

Review of the nursing time schedules revealed 1.00 LPNs worked on the evening shift on February 8, 2024. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on February 9, 2024, the facility census was 44, which required 1.47 LPNs during the evening shift.

Review of the nursing time schedules revealed 1.03 LPNs worked on the evening shift on February 9, 2024. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on February 12, 2024, the facility census was 42, which required 1.40 LPNs during the evening shift.

Review of the nursing time schedules revealed 1.00 LPNs worked on the evening shift on February 12, 2024. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on February 13, 2024, the facility census was 41, which required 1.37 LPNs during the evening shift.

Review of the nursing time schedules revealed 1.00 LPNs worked on the evening shift on February 13, 2024. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on February 14, 2024, the facility census was 43, which required 1.43 LPNs during the evening shift.

Review of the nursing time schedules revealed 1.03 LPNs worked on the evening shift on February 14, 2024. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on February 15, 2024, the facility census was 46, which required 1.53 LPNs during the evening shift.

Review of the nursing time schedules revealed 1.10 LPNs worked on the evening shift on February 15, 2024. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on February 20, 2024, the facility census was 45, which required 1.50 LPNs during the evening shift.

Review of the nursing time schedules revealed 1.07 LPNs worked on the evening shift on February 20, 2024. No additional excess higher-level staff were available to compensate this deficiency.

Interview with the Nursing Home Administrator on February 28, 2024, at 1:28 p.m. confirmed that the facility did not meet the required LPN-to-resident staffing ratios for the days listed above.



 Plan of Correction - To be completed: 04/29/2024

Retraining of staffing coordinator 3/1/24

Staffing to be reviewed by staffing coordinator and nursing home administrator, or designee, daily to ensure appropriate staffing.

Staffing coordinator to send daily staffing email to corporate leadership team daily for review.

DON, or designee to audit

5x weekly x2 weeks

3x weekly x2 weeks

1x weekly x2 weeks

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