Pennsylvania Department of Health
 GLEN BROOK REHABILITATION AND HEALTHCARE CENTER
Patient Care Inspection Results

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GLEN BROOK REHABILITATION AND HEALTHCARE CENTER
Inspection Results For:

There are  134 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.
GLEN BROOK REHABILITATION AND HEALTHCARE CENTER - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on a Medicare/Medicaid Recertification, State Licensure, and Civil Rights Compliance survey completed on June 7, 2024, it was determined that Glen Brook Rehabilitation and Healthcare Center was not in compliance with the following requirements of 42 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:


483.10(a)(1)(2)(b)(1)(2) REQUIREMENT Resident Rights/Exercise of Rights:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
§483.10(a) Resident Rights.
The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility, including those specified in this section.

§483.10(a)(1) A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the resident.

§483.10(a)(2) The facility must provide equal access to quality care regardless of diagnosis, severity of condition, or payment source. A facility must establish and maintain identical policies and practices regarding transfer, discharge, and the provision of services under the State plan for all residents regardless of payment source.

§483.10(b) Exercise of Rights.
The resident has the right to exercise his or her rights as a resident of the facility and as a citizen or resident of the United States.

§483.10(b)(1) The facility must ensure that the resident can exercise his or her rights without interference, coercion, discrimination, or reprisal from the facility.

§483.10(b)(2) The resident has the right to be free of interference, coercion, discrimination, and reprisal from the facility in exercising his or her rights and to be supported by the facility in the exercise of his or her rights as required under this subpart.
Observations:


Based on a review of grievances filed with the facility and the minutes from resident group meeting and resident and staff interviews, it was determined that the facility failed to provide care in a manner and environment that promotes each resident's quality of life by failing to respond timely to residents' requests for assistance, including experiences reported by three out of the 35 residents sampled (Residents 8, 50, and 161) and five out of 10 residents interviewed during a group interview (Residents 56, 141, 154, 172, and 173).

Findings include:

A review of grievances lodged with the facility revealed a grievance from a resident dated April 14, 2024, relaying that the resident had activated her call bell to request staff assistance to be changed. According to the resident's grievance, staff came in to the resident's room and told the resident she would get someone to help her and turned off her call bell but staff did not return to the resident's room to provide the needed care.

A resident grievance dated April 16, 2024, indicated that nursing staff "gave him hell" after he turned his call bell light back on after 45 minutes. The grievance indicated that the resident was told he had to wait an additional 20 minutes because staff was on break.

A resident grievance dated April 25, 2024, indicated that the resident reported that the aides left him sitting in "sh*t" for two hours. The grievance indicated that staff told the resident that she needed to collect lunch trays.

A resident grievance dated April 28, 2024, indicated that a resident stated that she rang her call bell and staff told her she would have to wait until night shift because "she was changed enough."

A grievance dated May 28, 2024, indicated that a resident rang the call bell to request staff provide the bedpan, but staff never came. The grievance indicated that the resident was incontinent with urine and waited almost three hours for care.

A review of Resident Council Meeting Minutes dated March 13, 2024 revealed that residents in attendance indicated that some licensed nursing staff are hard to find and "nurse aides are not responsive to call bells.

Resident Council Meeting Minutes dated April 9, 2024, revealed that residents in attendance voiced concerns with how long it takes for nursing staff to respond to their call bells requesting assistance or that staff turn off their call bells, then leave their rooms, but do not provide the needed care.

During an interview on June 4, 2024, at 11:13 AM, Resident 161 stated that he knows that the wait times for staff to respond to call bells are long, so even when he needs assistance, he will wait until staff are less busy before he rings his call bell for assistance. He explained that the wait times are at least 20 to 30 minutes when staff are busy. Resident 161 stated he hates to ring for assistance, but when he needs help, he has to rely on staff for care.

During an interview on June 4, 2024, at 11:51 AM, Resident 8 stated that she experiences long wait times for care. She explained that at times she waits 35 to 45 minutes for staff to respond to her call bell requests for assistance. Resident 8 stated that she is diabetic and is worried about the time it takes to get assistance from staff. She explained that she waits the longest for care on the evening and night shifts. Resident 8 stated that last week she waited from 8:00 PM until 9:20 PM before someone responded to her call bell for assistance.

During an interview on June 5, 2024, at 1:00 PM Resident 50 stated that she waits 20 minutes to an hour for staff to respond to her call bell requests for staff assistance. She explained that the wait time is even longer when the nursing shifts change or during meal times. Resident 50 stated that yesterday she came back to the facility at 3:00 PM and rang her call bell for staff assistance to return to bed. She explained that staff did not respond and help her to bed until 5:00 PM.

During a resident group interview on June 5, 2024, at 10:00 AM, five alert and oriented residents reported that they are experiencing long wait times for care after ringing their call bells for staff assistance (Residents 56, 141, 154, 172, and 173).

Resident 56 stated that he experiences wait times up to 30 minutes. He explained that lately the wait times are getting worse.

Resident 141 stated that she waits up to two hours to receive care from staff. She explained that she believes there are not enough licensed nurses in the building to provide the care the residents need. The resident stated that she has filed many grievances about how long it takes to receive care from nursing staff, but nothing has changed. She explained that she tries not to ring the call bell for staff assistance when she knows staff are busy, but sometimes she can't help it and needs their assistance.

Resident 154 stated that she experiences long wait times for staff assistance on the weekends. She explained that sometimes she waits 30 minutes for care after ringing her call bell for staff assistance.

Resident 172 stated that she waits 30 minutes for care from staff when requested.

Resident 173 stated that she experiences long wait times to receive care when requested, especially during the overnight shifts. She explained that staff will often initially respond to her call bell, turn her call light off, then leave without providing her care. She stated that she sometimes waits up to an hour before being provided care that had requested.

During an interview on June 6, 2024, at approximately 10:30 AM, the Nursing Home Administrator (NHA) and Director of Nursing (DON) verified that all residents at the facility should be treated with dignity and respect. The NHA and DON were unable to explain why residents are reporting untimely staff responses to residents' requests for assistance, which is negatively affecting their quality of life in the facility.



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

28 Pa. Code 201.29 (a) Resident Rights

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



 Plan of Correction - To be completed: 07/30/2024

F550 Resident Rights
1. Residents 8, 50, and 161,56, 141, 154, 172, and 173 were visited by social service/designee to assure that their needs were being met on 07/08/2024.
2. All residents have the potential to be affected.
3. Nursing staff will be in serviced by staff educator/designee on the importance of timely responding to call bells and meeting care needs of resident to promote quality of life.
4. Random resident interviews will be conducted by social service/designee to ensure call bells are answered timely and resident care needs are being met , any issues identified will be resolved. Audits will be done weekly x4 then monthly x2 then quarterly until compliance is achieved. Results will be presented in QAPI committee meeting.
5. Date of compliance: July 30, 2024

483.80(a)(3) REQUIREMENT Antibiotic Stewardship Program: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(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)(3) An antibiotic stewardship program that includes antibiotic use protocols and a system to monitor antibiotic use.
Observations:

Based on a review of the facility's infection control policies and procedures and clinical records, and staff interview, it was determined that the facility failed to fully implement an antibiotic stewardship program and maintain a system to effectively monitor antibiotic usage for two of 35 sampled residents (Residents 50 and 18).


Findings include:

A review of facility policy entitled "Antibiotic Stewardship Program" last reviewed April 17, 2024, revealed it is the policy of the facility to implement an antibiotic stewardship program as part of the facility's overall infection prevention and control program. The purpose of the program is to optimize the treatment of infections while reducing the adverse events associated with antibiotic use. Further it is indicated the facility will use McGeer criteria to define an infection and will us the Loeb Minimum criteria to determine whether to treat an infection with an antibiotic.

A clinical record review revealed that Resident 50 was admitted to the facility on May 13, 2014, with diagnoses that included chronic kidney disease (gradual loss of kidney function) and cerebral infarction (brain damage that results from a lack of blood).

A nursing progress note dated April 5, 2024, at 9:15 PM indicated that the physician was made aware that Resident 50 had complaints of pain, burning, and frequency with urination. The entry noted a new physician's order was received to obtain a urine analysis (UA) and culture and sensitivity (C&S- a laboratory test used to identify organisms present in the urine and determine their susceptibility to antibiotic treatment).

A physician's order dated April 5, 2024, was noted to obtain UA and C&S for Resident 50's complaints of pain, burning, and \ frequency.

However, there was no documented evidence in the resident's clinical record that nursing staff attempted to obtained urine sample to perform the diagnostic lab studies as ordered.

A nursing progress note dated April 8, 2024, at 2:18 PM indicated that the physician was notified that a urine sample was not collected because Resident 50 is incontinent of urine.

A physician's order was noted for Resident 50 to receive Doxycycline Hyclate Oral Capsule 100 mg (an antibiotic medication) with the direction to give 100 mg by mouth every 12 hours for dysuria, a possible urinary tract infection for five days.

According to the resident's April 2024 MAR Resident 50 received 10 doses of Doxycycline Hyclate Oral Capsule 100 mg.

The facility failed to obtain a urine sample to confirm the resident had a urinary tract infection and the most effective antibiotic for treatment and the necessity of the antibiotic therapy prescribed.

A clinical record review revealed that Resident 18 was admitted to the facility on January 11, 2024, with dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities).

A nursing note dated March 4, 2024, at 12:45 PM revealed that the resident was continuing to hallucinate. The resident's vital signs were stable. The resident did not have any complaints of pain or dysuria (discomfort, pain, or burning when urinating) The physician was called, and an order was obtained for a urinalysis with culture and sensitivity and to start Ciprofloxacin 500MG every 12 hours for 10 days.

The resident's clinical record revealed no further symptoms after the urine sample was obtained. A review the resident's laboratory report results, that were dated as available on March 6, 2024, at 9:34 AM revealed the urine showed multiple flora suggesting either the sample was contaminated or colonized.

A review of a nursing note dated March 6, 2024, at 4:45 PM revealed the physician was made aware of the urine sample being contaminated and he stated to continue Cipro for the 10 days.

A review of Resident 18's March 2024 Medication Administration Record revealed the resident received 20 doses of an unnecessary antibiotic.

An interview with the infection preventionist (IP) on June 6, 2024, at approximately 10:30 AM, revealed the facility was not using McGeer's criteria to identify infections as indicated in their policy. The IP stated that she puts the symptoms into the PA-PSRS system, and it will identify if it meets criteria. The IP stated she does not have any documentation, however, that the above residents' symptoms were inputted to apply any type criteria to identify if the resident's symptoms met defined criteria as an infection. Further the IP stated she was not using the Loeb Minimum criteria to determine if an infection is to be treated with an antibiotic.

At the time of the survey ending June 7, 2024, the facility failed to demonstrate appropriate actions designed to optimize the treatment of infections through improving antibiotic prescribing, administration, and management practices thus reducing inappropriate use.

An interview with the Nursing Home Administrator and Director of Nursing on June 7, 2024, at approximately 12:45 PM confirmed the facility failed to have a functioning antibiotic stewardship program.

Refer F757


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

28 Pa. Code 211.2 (d)(3)(5) Medical Director

28 Pa. Code 211.10 (a) Resident care policies



 Plan of Correction - To be completed: 07/30/2024

F0881 Antibiotic Stewardship Program
1. Residents 50 and 18 had no negative impact.
2. Residents currently on antibiotics for a urinary tract infection in the last 7 days will be reviewed by the ICP to verify that residents on antibiotics are appropriately prescribed per the antibiotic stewardship program.
3. Licensed practical nurses and the ICP will be educated by the QA Nurse/ designee on the antibiotic stewardship program and the importance of obtaining ordered urine samples for identifying infections and utilizing McGeers criteria to identify infections.
4. The ICP/ designer will audit the residents who are prescribed antibiotics to verify that antibiotics were prescribed appropriately. Audits will be done weekly x4 then monthly x2 then quarterly until compliance is achieved. Results will be presented in QAPI committee meeting.
5.Date of compliance: July 30, 2024

483.60(f)(1)-(3) REQUIREMENT Frequency of Meals/Snacks at Bedtime: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(f) Frequency of Meals
§483.60(f)(1) Each resident must receive and the facility must provide at least three meals daily, at regular times comparable to normal mealtimes in the community or in accordance with resident needs, preferences, requests, and plan of care.

§483.60(f)(2)There must be no more than 14 hours between a substantial evening meal and breakfast the following day, except when a nourishing snack is served at bedtime, up to 16 hours may elapse between a substantial evening meal and breakfast the following day if a resident group agrees to this meal span.

§483.60(f)(3) Suitable, nourishing alternative meals and snacks must be provided to residents who want to eat at non-traditional times or outside of scheduled meal service times, consistent with the resident plan of care.
Observations:

Based on a review of the minutes from Resident Council and Food Committee Meetings, scheduled facility mealtimes, select facility policy, and resident and staff interviews, it was determined that the facility failed to consistently provide snacks as desired by residents, including one out of the 35 residents sampled and experiences reported by residents during a group interview (Residents 42, 56, 141, 154, and 173).

Findings include:

A review of the facility's policy titled "Offering/Serving Bedtime Snacks," last reviewed on April 17, 2024, indicated that it is the practice of the facility to offer and serve residents with a nourishing snack in accordance with their needs, preferences, and requests at bedtime on a daily basis.

A review of the facility's scheduled mealtimes revealed that the time between dinner and breakfast the next day exceeds fourteen hours.

A review of Resident Council Meeting Minutes dated March 13, 2024, revealed that residents in attendance stated that snacks and sugar-free snacks are not always available or not distributed by staff.

A review of Food Committee Meeting Minutes dated April 8, 2024 revealed that residents in attendance stated that nursing staff report that at times there are no snacks available for the residents.

During interview with Resident 117, a cognitively intact resident, on June 4, 2024, at 11:45 AM the resident stated that she is not always offered a snack at bedtime. The resident confirmed that she would like to be asked in the evening if she would like a snack.

During a resident group interview on June 5, 2024, at 10:00 AM, five alert and oriented residents stated that they were not being offered evening snacks (Residents 42, 56, 141, 154, and 173). The residents stated that they are not regularly offered snacks in the evening, and sometimes there are no snacks available when they request an evening snack.

During an interview on June 6, 2024, at 10:30 AM, the Nursing Home Administrator (NHA) and Director of Nursing (DON) were unable to explain why Residents 42, 56, 141, 154, 173, and 117 are indicting that the facility is not offering nutritious snacks. The NHA confirmed that it is the facility's policy to offer and serve residents a nourishing snack in accordance with their needs, preferences, and requests at bedtime on a daily basis.



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



 Plan of Correction - To be completed: 07/30/2024

F 0809 Frequency of Meals/Snacks at Bedtime

1. Residents 42, 56, 141, 154, and 173 were visited by Unit Managers /designee to ensure that HS snacks are provided as desired by residents per plan of care.
2. All residents have the potential to be affected.
3. Unit Managers /designee will meet with residents to ensure that HS snacks are provided as desired by residents and per plan of care. Staff educator/designee will educate nursing staff on offering HS snacks to residents per plan of care.
4. Random resident interviews will be conducted by Unit Managers /designee to ensure that residents are being offered HS snacks. Audits will be done weekly x4 then monthly x2 then quarterly until compliance is achieved. Results will be presented in QAPI committee meeting.
5. Date of compliance: July 30, 2024

483.45(g)(h)(1)(2) REQUIREMENT Label/Store Drugs and Biologicals: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(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 observation, a review of select facility policy, and staff interview, it was determined that the facility failed to adhere to acceptable storage and use by dates for multi-dose diabetes medication on two of four medication carts observed (Spruce 400 hall, Willow 800 hall medication cart - Resident's 107, 6, 27, 147, 34, 57, and M1).

Findings include:

A review of facility policy entitled "Multi-Dose Vials" last reviewed by the facility April 17, 2024, revealing once opened and used, the vials needs to be stored in the body of the refrigerator when not in use, be dated when opened, and it expires 30 days after opening.

Observation of the Spruce 400 hall medication cart on June 4, 2024, at approximately 9:08 AM, in the presence of Employee 3, Licensed Practical Nurse (LPN), revealed the following opened multi-dose diabetes medications:

One (1) Novolin N Flex Pen opened and available for use, not dated when initially opened, Two (2) Insulin Lispro vials, both opened and available for use, the first was dated April 20, 2024, and the second not dated when initially opened, belonging to Resident 107.

One (1) Fiasp vial, opened and available for use, dated April 20, 2024, belonging to Resident 6.

One (1) Fiasp Kwik pen, and One (1) Novolog flex pen, opened and available for use, not dated when initially opened, belonging to Resident 27.

One (1) Lantus Solo Star flex pen, opened and available for use, dated April 22, 2024, and one (1) Insulin Aspart pen, opened and available for use, dated May 1, 2024, belonging to Resident 147.

One (1) Insulin Degludec pen, and one (1) Insulin Aspart pen, opened and available for use, not dated when initially opened, belonging to Resident 34.

One (1) Humalog Kwik pen, opened and available for use, not dated when initially opened, belonging to Resident 57.

Interview at that time with Employee 3, Licensed Practical Nurse (LPN), confirmed the above findings and that the medications should have been dated when initially opened.

Observation of the Willow 800 hall medication cart on June 4, 2024, at approximately 9:37 AM, in the presence of Employee 4, Licensed Practical Nurse (LPN), revealed the following opened multi-dose diabetes medications:

One (1) Humalog vial, opened and available for use, not dated when initially opened, belonging to Resident M1.

Interview at that time with Employee 4, Licensed Practical Nurse (LPN), confirmed the above finding and that the medication should have been dated when initially opened.

Interview with the Director of Nursing (DON) on June 5, 2024, at approximately 12:55 PM, confirmed the that the facility failed to date multi-dose medications when opened to assure acceptable storage times.




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

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





 Plan of Correction - To be completed: 07/30/2024

F 0761 Label/Store Drugs and Biologicals
1. Medication carts of Spruce 400 hall, Willow 800 hall (- Resident's 107, 6, 27, 147, 34, 57, and M1) with diabetic medications were reviewed to ensure proper storage and use by dates for multi-dose vials were identified.
2. Medication carts on all units were audited to ensure that diabetic medications were stored properly and used by dates for multi-dose vials were identified.
3. Staff educator/designee will educate Licensed Nursing Staff on the importance of storing and identifying Use by date on diabetic medications when opened.
4. Audits will be done by -unit managers/designees on medication carts of Diabetic meds to ensure that they are stored properly and use by dates for multi dose vials are identified. Audits will be done weekly x4 then monthly x2 then quarterly until compliance is achieved. Results will be presented in QAPI committee meeting.
5. Date of compliance: July 30, 2024

483.45(f)(2) REQUIREMENT Residents are Free of Significant Med Errors: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.
The facility must ensure that its-
§483.45(f)(2) Residents are free of any significant medication errors.
Observations:

Based on a review of resident clinical records and select facility policy and staff and resident interviews, it was revealed that the facility repeatedly failed to assure that one of the 35 residents sampled was free of significant medication errors (Resident 8).

Findings include:

A review facility policy titled "Timely Administration of Insulin," dated March 29, 2024, revealed that it is the facility policy to provide timely administration of insulin in order to meet the needs of each resident and to prevent adverse effects on a resident's condition.

A clinical record review revealed that Resident 8 was admitted to the facility on July 29, 2023, with diagnoses that included diabetes mellitus (a chronic disease that occurs either when the pancreas does not produce enough insulin or when the body cannot effectively use the insulin it produces).

A review of a comprehensive Minimum Data Set assessment (MDS - a federally mandated standardized assessment process conducted periodically to plan resident care) dated April 30, 2024 revealed that Resident 8 is cognitively intact with a BIMS score of 15 (Brief Interview for Mental Status- a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 13-15 indicates cognition is intact).

Resident 8 had a current physician order to receive Novolin subcutaneous suspension (70-30) 100 units/ml (insulin isophane and regular) with directions to inject 28 units subcutaneously in the morning and 15 units in the evening related to diabetes mellitus.

Resident 8 was scheduled to receive her morning dose of Novolin subcutaneous suspension (70-30) 100 units/ml (insulin isophane and regular) at 8:00 AM and her evening dose at 5:00 PM according to the clinical record.

A review of the resident's April 2024 medication administration record (MAR) revealed that staff did not administer the resident's AM dose of Novolin subcutaneous suspension (70-30) 100 units/ml (insulin isophane and regular) on April 30, 2024, at 8:00 AM. The document indicated the reason as "other."

The clinical record revealed no documented evidence explaining why Resident 8's insulin medication was not administered on April 30, 2024, at 8:00 AM as ordered

A review of the resident's MARs dated from May 1, 2024, through June 3, 2024 revealed that staff failed to timely administer Novolin subcutaneous suspension (70-30) 100 units/ml (insulin isophane and regular) to the resident on the following dates:

May 2, 2024, at 9:13 AM (one hour and 13 minutes late)
May 3, 2024, at 9:11 AM (one hour and 11 minutes late)
May 6, 2024, at 11:20 AM (three hours and 20 minutes late)
May 7, 2024, at 11:18 AM (three hours and 18 minutes late)
May 10, 2024, at 9:54 AM (one hour and 54 minutes late)
May 11, 2024, at 9:15 AM (one hour and 15 minutes late)
May 13, 2024, at 9:38 AM (one hour and 38 minutes late)
May 18, 2024, at 9:49 AM (one hour and 49 minutes late)
May 21, 2024, at 9:45 AM (one hour and 45 minutes late)
May 26, 2024, at 6:40 PM (one hour and 40 minutes late)
May 31, 2024, at 10:44 AM (two hours and 44 minutes late)
June 2, 2024, at 11:03 AM (three hours and 3 minutes late)
June 2, 2024, at 6:14 PM (one hour and 14 minutes late)
June 3, 2024, at 6:27 PM (one hour and 27 minutes late)

During an interview on June 4, 2024, at 11:50 AM, Resident 8 stated that she continually has concerns that her diabetic medication is administered late or at the wrong time. She explained that she could recall five times recently staff administered her diabetes medications late.

During an interview on June 6, 2024, at approximately 10:30 AM, the Director of Nursing (DON) confirmed that the facility failed to ensure that Resident 8 was free from significant medication errors. The DON was unable to explain why staff did not administer Novolin subcutaneous suspension (70-30) 100 units/ml (insulin isophane and regular) on April 30, 2024.

28 Pa. Code 211.10 (a)(c)(d)

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

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




 Plan of Correction - To be completed: 07/30/2024

0760 Residents are Free of Significant Med Errors
1. Resident 8 was not negatively affected.
2. Residents on routine orders for insulin have the potential to be affected.
3. Staff educator/designee will educate Licensed nursing staff on the 5 rights of medication administration which includes "Right Time" in order to ensure that residents are free from medication errors.
4. DON/designee will randomly audit EMAR of residents with routine insulin orders to ensure that insulins are administered timely. Audits will be done weekly x4 then monthly x2 then quarterly until compliance is achieved. Results will be presented in QAPI committee meeting.
5. Date of compliance: July 30, 2024

483.35(a)(3)(4)(c) REQUIREMENT Competent Nursing Staff: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.
§483.35 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 observation, a review of clinical records, select facility reports, and employee personnel files and interviews with staff, it was determined that the facility failed to provide nursing staff with the necessary competencies and skills to administer prescribed medications, according to professional standards of nursing practice to residents for 5 out of 35 residents residing in the facility. (Residents 83, 32, 92, 50, and 3).

Findings include:

According to the American Nurses Association the Standards of Practice describe a competent level of nursing care as demonstrated by the critical thinking model known as the nursing process. The nursing process includes the components of assessment, diagnosis, out- comes identification, planning, implementation, and evaluation. Nurses' responsibility for medication administration includes ensuring that the right medication is properly drawn up in the correct dose and administered at the right time through the right route to the right patient.

A review of clinical record revealed that Resident 83 was admitted to the facility on September 22, 2023, with diagnosis to include dementia (a condition characterized by progressive or persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often with personality change), gastro-esophageal reflux disease (GERD), and anxiety.

A quarterly Minimum Data Set assessment (MDS - a federally mandated standardized assessment process conducted at specific intervals to plan resident care) dated December 16, 2023, revealed that the resident was severely cognitively impaired.

A review of a nurses note dated March 9, 2024, at 0845 hours (8:45 AM) indicated that Resident 83 was laying in bed no complains of pain, difficulty breathing or discomfort noted. A narcotic medication error was identified during change of shift at 7 AM on that date whereas Employee 2, an agency LPN, on the 11 PM to 7 AM shift administered Tramadol (opioid pain medication) 50 milligram (mg) instead of the prescribed Oxycodone (opioid pain medication) 5 mg capsule. Employee 2, agency LPN, stated she must have been confused by same last name with another resident. Vitals are stable, Temperature 97.7 Pulse 78 Blood Pressure 148/72 Respiration 18 oxygen saturation 94%. Supervisor on call made aware, MD made aware, called family member (son), left message, will continue to monitor resident status.

A nurse's note dated March 9, 2024, at 1236 hours (12:36 PM) indicated that the resident's son was made aware of medication error, advised him that resident is stable no signs or symptoms of discomfort noted. Son verbalized understanding and he will call resident later today.

A medication error report dated March 9, 2024, revealed that at 1:43 AM, on March 9, 2-24, Employee 2, agency LPN administered Tramadol 50 mg, instead of the physician ordered Oxycodone 5 mg to Resident 83. Physician, supervisor, pharmacy, and family notified. The corrective action was an in-service (education) on the 7 rights of medications.

Employee 2 (Agency LPN)'s facility orientation, job orientation, skills check, and or medication competency evaluation was requested at the time of the survey ending June 6, 2024.

Interview with the Nursing Home Administrator (NHA) on June 6, 2024, at approximately 9:35AM, confirmed that the facility was unable to provide any of the requested orientation and competency information regarding Employee 2 (Agency LPN). According to the NHA, Employee 2 agency LPN, employment with the facility was terminated and the nurse was do not return (DNR).

During an observation of the medication administration pass on June 4, 2024, at approximately 9:45 AM, Employee 1 Licensed Practical Nurse (LPN) was working on the East E/F medication cart. As Employee 1 (LPN) opened the top drawer of the medication cart, she moved her right hand, which was holding a few medication blister cards over to the right side in an apparent attempt to cover something. When asked what was on the right side of the drawer, she moved her hand displaying stacks of several clear, plastic, disposable medication cups containing medications. The cups were not labeled with any resident names.

Interview with Employee 1, LPN, at that time, revealed that Employee 1 stated that the cups of medications observed in the top drawer of the medication cart were the medications prepared for the morning med pass. Employee 1, LPN, stated she had already pre-poured the medications (pre-pouring medications is the process of preparing medications in advance and then storing them until administering to the patient), and stated "I will probably get in trouble for this", and in questioning why the medications were pre-poured Employee 1 (LPN) stated "it is a shortcut that I do."

During continued interview with Employee 1, Licensed Practical Nurse (LPN), at that time revealed that she stated that she pre-poured medications for the following residents:

Resident 32: aspirin 81 milligram (mg), carbidopa-levodopa 25-100 mg, Lexapro 20 mg, Keppra 750 mg, lorazepam 0.5 mg, metoprolol 50 mg, potassium chloride 20 meq, and risperidone 1 mg.

Resident 92: atenolol 25 mg, metformin 500 mg, amlodipine 10 mg, omeprazole 40 mg, senna 8.6 mg, rosuvastatin 5 mg, and hydrochlorothiazide 25 mg.

Resident 50: tramadol 50 mg.

Resident 83: Xanax 0.5 mg.

Resident 3: Ativan 0.5 mg.

A review of Employee 1 (LPN) personnel file conducted on June 5, 2024, at approximately 1:40 PM, with the Director of Human Resources identified the date of hire [Employee 1 (LPN)] was May 15, 202. The facility was unable to locate - provide documented evidence of the nursing specific orientation, skills check upon hire, yearly performance evaluation, and or recent competency evaluation.

Interview with the Nursing Home Administrator (NHA) on June 6, 2024, at approximately 9:35AM, confirmed the facility was unable to locate - provide documented evidence of the nursing specific orientation, skills check list upon hire, yearly performance evaluation, and or competency evaluation. The NHA further confirmed the facility failed to provide nursing staff with the necessary competencies and skills to administer prescribed medications, according to professional standards of nursing practice.



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

28 Pa. Code 201.19 (6)(7) Personnel records






 Plan of Correction - To be completed: 07/30/2024

F0726 Competent Nursing Staff
1. Residents 83, 32, 92, 50, and 3 were not negatively affected. E2 agency nurses are no longer scheduled at the facility. Employee 1 Licensed Practical Nurse was provided education on not pre-pouring medications during a medication administration pass.
2. All Licensed nurses have the potential to be affected.
3. Staff educator/designee will provide education to licensed nursing staff on medication administration and evidence of the completed competency/skill will be noted.
4. Audits will be completed by staff educator/designee to ensure staff scheduled are educated and competencies are noted on the 5 rights of medication administration including not pre-pouring medications. Audits will be done weekly x4 then monthly x2 then quarterly until compliance is achieved. Results will be presented in QAPI committee meeting.
5. Date of compliance: July 30, 2024

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 observation, a review of clinical records, select incident/accident reports and facility policy and staff interview, it was determined that the facility failed to maintain an environment free of potential accident hazards by failing to prevent accidental ingestion of denture tablets for one resident (Resident 88) out of 35 sampled and safe storage of oxygen cylinders (tanks) on two of four nursing units (North and East Nursing Units).

Findings include:

A review of clinical record revealed that Resident 88 was admitted to the facility on May 10, 2020, with diagnoses to include diabetes, dysphagia (difficulty in swallowing), bipolar disorder (extreme mood swings), and age-related cataracts.

A quarterly Minimum Data Set assessment (MDS - a federally mandated standardized assessment process conducted at specific intervals to plan resident care) dated February 26, 2024, revealed that the resident was moderately cognitively impaired.

A review of a late entry nurses note dated March 22, 2024, at 1302 hours (1:02 PM) indicated that Resident 88 was found with a small amount of green debris on the right side of her mouth. It was noted that nursing staff found several denture cleaning tablets (denture cleaning tablets that use chemicals to remove stains caused by food) in the resident's room and removed them. Resident 88 denied that they are for cleaning dentures. The incident was reported to the physician and no new orders were received. The resident's vital signs were obtained and within normal range, 97.4, 83, 18, 112/55, 97% room air, no injuries were noted.

A nurses note dated March 22, 2024, at 1342 hours (1:42 PM) noted that staff found denture cleaning tablets in resident's room, and the resident has no dentures. A small amount green debris was coming out of the right side of the resident's mouth. The resident reported that she was eating candy. The RN was notified.

A review of a late entry nurses note dated March 22, 2024, at 1808 hours (6:08 PM) indicated that staff noted earlier this day that the resident had some green material around her mouth. It was determined to be from a denture tab that the resident thought was candy and had placed in her mouth. The denture tab was spit out and not consumed. Attempts to educate the resident that the denture tab was not food or "candy" was ineffective as she refused to believe staff. Her room was searched with her permission and the remaining two denture tablets were removed. MD and RP were made aware of all of the above and no new orders were received.

A review of a nurses note dated March 22, 2024, at 1342 hours (1:42 PM) stating the incident from March 22, 2024, discussed with Interdisciplinary Team (IDT) members. Resident does not have dentures, but her roommate (Resident 45) does, and resident is known to rummage through other resident's belongings and take things that do not belong to her. New intervention is to do a sweep of resident's room x 1 week and make sure that no denture tabs or other non-edible items are within her reach and/or removed from the room. MD and RP made aware of same.

A facility provided incident report (IR) dated March 22, 2024, at 1303 (1:03 PM) indicated that the resident had some green debris on her chin, and around the right side of her mouth. Green denture cleaning tablets (2) found in her room. Resident does not have dentures. She (Resident 88) said it was candy.

A witness statement from Employee 1, Licensed Practical Nurse (LPN), dated March 22, 2024, indicated she had last seen Resident 88 at 10:00 AM, at which time the resident was sitting on her bed.

A review of clinical record revealed that Resident 45 (Resident 88's roommate) was admitted to the facility on September 15, 2023, with diagnosis to include cerebral infarction (stroke), and hemiplegia and hemiparesis following cerebral infarction affecting right dominant side.

A quarterly Minimum Data Set assessment dated February 17, 2024, revealed that the resident was moderately cognitively impaired.

A review of Resident 45's plan of care revealed she has upper/lower dentures, but the care plan did not identify who was responsible for cleaning or storing supplies needed for the dentures in the resident's room.

Resident 45's physician orders at the time the survey ending June 7, 2024, revealed no orders that the resident may keep denture cleaning supplies in the resident's room.

Interview with the Director of Nursing (DON) on June 5, 2024, at approximately 12:55 PM, confirmed that treatments, including denture cleaning tablets were not to be left in the residents rooms, unless physician ordered and if the resident had demonstrated the ability to safely use, and safely store them.

Interview with the Nursing Home Administrator (NHA) on June 5, 2024, at approximately 1:05PM, confirmed that the facility failed to maintain the residents' environment free of potential accident hazards by leaving the denture cleaning tablets accessible to residents and potential misuse or ingestion

Review of a facility policy entitled "Oxygen Safety" last reviewed on April 17, 2024, indicated that it is the policy of the facility to provide a safe environment for residents, staff, and the public. Oxygen Storage requires that cylinders will be properly chained or supported in racks or other fastenings (i.e. sturdy portable carts, approved stands) to secure all cylinders from falling, whether connected, unconnected, full, or empty.

Observation of Resident Room 6W on the North Nursing Unit on June 4, 2024, at 11:45 AM revealed an oxygen cylinder (tank) standing upright under the windowsill. The oxygen cylinder was not secured.

Interview with Employee 5 (LPN) at this time confirmed the observation and the employee stated that all oxygen cylinders were to stored securely.

Observation of Resident Room 33W on the East Nursing Unit on June 6, 2024, at 12:30 PM revealed an oxygen cylinder standing upright in the corner of the room.

Interview with Employee 6 (RN) at this time confirmed that oxygen tanks should be stored in a secure manner

Interview with the nursing home administrator on June 6, 2024, at approximately 1:00 PM, confirmed that the oxygen tanks were to be stored securely at all times.



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

28 Pa. Code 211.10 (a) Resident care policies

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





 Plan of Correction - To be completed: 07/30/2024

F0689 Free of Accident Hazards/Supervision/Devices

1. Resident 88 was not negatively affected, and denture cleaning tablets were removed from bedside.
Room 6W and Room 33W unsecured oxygen cylinder (tanks) were removed.
2 All residents have the potential to be affected.
3 Direct care staff will be educated by the staff educator/designee on ensuring that denture cleaning supplies are not unsecured in the resident's room. Direct care staff and therapy staff will be in-serviced by staff educator/designee on safe storage of oxygen cylinders (tanks) in resident rooms.
4. Random room audits will be conducted by Unit Managers/designee to ensure that denture cleaning supplies are not unsecured in the resident's room. Random audits of resident rooms will be conducted to ensure that there is safe storage of oxygen cylinders (tanks) in resident rooms. Audits will be done weekly x4 then monthly x2 then quarterly until compliance is achieved. Results will be presented in QAPI committee meeting.
5. Date of compliance: July 30, 2024

483.15(c)(1)(i)(ii)(2)(i)-(iii) REQUIREMENT Transfer and Discharge Requirements: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.
§483.15(c) Transfer and discharge-
§483.15(c)(1) Facility requirements-
(i) The facility must permit each resident to remain in the facility, and not transfer or discharge the resident from the facility unless-
(A) The transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in the facility;
(B) The transfer or discharge is appropriate because the resident's health has improved sufficiently so the resident no longer needs the services provided by the facility;
(C) The safety of individuals in the facility is endangered due to the clinical or behavioral status of the resident;
(D) The health of individuals in the facility would otherwise be endangered;
(E) The resident has failed, after reasonable and appropriate notice, to pay for (or to have paid under Medicare or Medicaid) a stay at the facility. Nonpayment applies if the resident does not submit the necessary paperwork for third party payment or after the third party, including Medicare or Medicaid, denies the claim and the resident refuses to pay for his or her stay. For a resident who becomes eligible for Medicaid after admission to a facility, the facility may charge a resident only allowable charges under Medicaid; or
(F) The facility ceases to operate.
(ii) The facility may not transfer or discharge the resident while the appeal is pending, pursuant to § 431.230 of this chapter, when a resident exercises his or her right to appeal a transfer or discharge notice from the facility pursuant to § 431.220(a)(3) of this chapter, unless the failure to discharge or transfer would endanger the health or safety of the resident or other individuals in the facility. The facility must document the danger that failure to transfer or discharge would pose.

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

Based on a clinical record review and staff interview, it was determined that the facility failed to ensure that the necessary resident specific information was communicated to the receiving health care provider upon transfer for two out of the 35 residents sampled with facility-initiated transfers (Residents 124 and 90).

The findings include:

A review of Resident 124's clinical record revealed that the resident was transferred to the hospital on February 10, 2024, and returned to the facility on February 10, 2024.

A review of Resident 90's clinical record revealed that the resident was transferred to the hospital on February 22, 2024, and returned to the facility on February 28, 2024.

There was no documented evidence that the facility had communicated specific information to the receiving health care provider for these residents transferred and expected to return, including advance directive information, special instructions, or precautions for ongoing care, as appropriate, or comprehensive care plan goals to ensure a safe and effective transition of care.

During an interview on June 6, 2024, at approximately 10:30 AM, the Director of Nursing (DON) and Nursing Home Administrator (NHA) confirmed that there was no evidence that the necessary information was communicated to the receiving health care institution or provider upon transfer or discharge.


28 Pa. Code 201.29 (a) Resident rights

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




 Plan of Correction - To be completed: 07/30/2024

F 0622 Transfer and Discharge Requirement
1. The facility cannot retroactively correct this issue. No residents were negatively affected.
2. All residents transferred to the hospital have the potential to be affected.
3. Staff educator/designee will educate the Licensed nursing staff on ensuring that necessary information (e.g. advance directive, special instructions, or precautions, comprehensive care plan goals) are sent to the receiving health care institution or provider upon transfer or discharge to ensure a safe and effective transition of care.
4. Medical records of residents transferred or discharged to a health care institution or provider will be reviewed by DON/designee to ensure that there is evidence that necessary information was communicated to the receiving health care institution or provider upon transfer or discharge. Audits will be done weekly x4 then monthly x2 then quarterly until compliance is achieved. Results will be presented in QAPI committee meeting.
5. Date of compliance: July 30, 2024

483.20(g) REQUIREMENT Accuracy of Assessments:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
§483.20(g) Accuracy of Assessments.
The assessment must accurately reflect the resident's status.
Observations:



Based on a review of clinical records, and the Resident Assessment Instrument and resident, and staff interviews, it was determined that the facility failed to ensure the Minimum Data Set Assessments (MDS - a federally mandated standardized assessment conducted at specific intervals to plan resident care) accurately reflected the status of one resident out of 35 sampled (Resident 98).

Findings include:

A review of the clinical record revealed that Resident 98 was admitted to the facility on July 15, 2019, with diagnoses to have included cerebral infarction (stroke) and left sided hemiplegia and hemiparesis (one-sided paralysis or weakness caused by brain or spinal cord problem).

During an interview on June 4, 2024, at approximately 12:57 PM, with Resident 98, he stated he had suffered a stroke awhile back and has minimal to no use of his left side.

A review of Resident 98's Annual MDS Assessment dated November 6, 2023, and Quarterly MDS Assessment dated February 18, 2024, Section GG - Functional Abilities and Goals, question GG0115 Functional limitations in range of motion, A. upper extremity (shoulder, elbow, wrist, hand) B. lower extremity (hip, knee, ankle, foot) was coded "1" indicating impairment on one side.

A review of Resident 98's Quarterly MDS Assessment dated May 20, 2024, Section GG - Functional Abilities and Goals, question GG0115 Functional limitations in range of motion, A. upper extremity (shoulder, elbow, wrist, hand) B. lower extremity (hip, knee, ankle, foot) was coded "0" indicating no impairment.

Interview with the RNAC (registered nurse assessment coordinator) on June 6, 2024, at approximately 9:20 AM, confirmed that the resident's Quarterly MDS Assessment dated May 20, 2024, was inaccurate, with respect to completion of Section GG - Functional Abilities and Goals.

Interview with the Director of Nursing (DON) on June 6, 2024, at 10:00 AM, confirmed that Resident 98's quarterly MDS assessment was not accurate.






 Plan of Correction - To be completed: 07/30/2024

0641 Accuracy of Assessments
1. Resident 98 (MDS) was modified to accurate reflect the status of the resident on 06/14/24.
2. All residents have the potential to be affected.
3. Regional Reimbursement Consultant - will educate RNAC/LNAC on ensuring MDS Section GG - Functional Abilities and Goals reflects accurate status of residents.
4. RNACs will conduct audits of Section GG of MDS transmitted weekly to ensure that it reflects the accurate status of the resident. Audits will be done weekly x4 then monthly x2 then quarterly until compliance is achieved. Results will be presented in QAPI committee meeting.
5. Date of compliance: July 30, 2024

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 a review of clinical records and staff interview, it was determined that the facility failed to follow physician orders for a bowel protocol prescribed for one resident out of 35 sampled (Residents 15) to promote normal bowel activity to the extent possible .

Findings include:

According to the American Academy of Family Physicians primary goal of constipation management should be symptom improvement, and the secondary goal should be the passage of soft, formed stool without straining at least three times per week).

A review of the clinical record revealed that Resident 15 was admitted to the facility on September 23, 2022, with diagnoses which included Parkinson's disease (a disorder of the central nervous system that affects movement, often including tremors) and constipation.

The resident had physician orders dated September 24, 2022, for the following bowel regimen:

Milk of Magnesia (MOM) 400 MG/5 ML give 30 ml by mouth as needed for no bowel movement in 72 hours;
Dulcolax Suppository 10MG insert 1 suppository rectally as needed if no bowel movement in 4 days and no results from the MOM;
Fleet Enema 7-19 GM/118 ML insert 1 dose rectally as needed if no bowel movement for 5 days and no results from the MOM and Dulcolax.

Review of Resident 15 's report of bowel activity, the Documentation Survey Report for the month of April 2024, revealed that the resident had a bowel movement on April 4, 2024, at 8:46 PM , and did not have a bowel movement again until six days later on April 10, 2024.

Review of Resident 15's Medication Administration Record (MAR) for April 2024, revealed that the facility failed to follow the physician's order and provide the resident with MOM on April 7, 2024, the Dulcolax suppository on April 8, 2024, and the Fleets enema on April 9, 2024, to promote a bowel movement.

Review of Resident 15's report of bowel activity, the Documentation Survey Report for the month of May 2024, revealed the resident had a bowel movement on May 9, 2024, at 10:24 PM, and did not have a bowel movement again until 5 days later on May 15, 2024.

Review of Resident 15's MAR for May 2024 revealed that the facility failed to follow the physician's order and provide the resident with MOM on May 13, 2024 and the Dulcolax suppository on May 14, 2024 to promote a bowel movement.

During an interview with the Director of Nursing and Nursing Home Administrator on June 7, 2024, at approximately 12:45 PM, confirmed that the facility failed to follow physician orders for bowel protocol prescribed for Resident 15.


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

28 Pa. Code 211.5 (f) Medical records



 Plan of Correction - To be completed: 07/30/2024

F0684 Quality of Care
1. R15's physician orders for bowel protocol were reviewed along with resident's pattern of bowel movement.
2. All residents have the potential to be affected.
3. Staff educator/designee will educate Licensed nursing staff on following facility's 3-day bowel protocol and the execution of protocol with exceptions.
4. Random audits will be conducted by the Director of Nursing/designee of residents who trigger for intervention of 3-day bowel protocol and the correct implementation of protocol. Audits will be done weekly x4 then monthly x2 then quarterly until compliance is achieved. Results will be presented in QAPI committee meeting.
5. Date of compliance: July 30, 2024

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 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(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 a review of clinical records and staff interview, it was determined that the attending physician failed to act upon pharmacist identified irregularities in the medication regimen of one of 35 residents sampled (Resident 124).

Findings include:

Regulatory requirements under requires that the resident's attending physician review and act on any identified irregularities.

A review of the clinical record revealed Resident 124 was admitted to the facility on October 14, 2023, and had diagnoses that included dementia with agitation (a chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning), major depressive disorder, and generalized anxiety disorder.

A review of December 2023 monthly pharmacy reviews revealed that the consultant pharmacist identified three irregularities in Resident 124's drug regimen. The consultant pharmacist recommended that the resident's as needed (prn) Olanzapine (Zyprexa an antipsychotic medication) with severe agitation diagnosis will trigger quality indicator for inappropriate antipsychotic use. The pharmacist suggested that the physician indicate 14 days length of therapy. The pharmacist also identified that the prescribed Brexpiprazole (Rexulti and antipsychotic medication) with a dementia diagnosis will trigger quality indicator for inappropriate antipsychotic use.

At the time of the survey ending June 7, 2024, the facility was unable to provide documented evidence of the above pharmacy recommendations that were sent to the physician and failed to provide written documentation of the attending physician's response to the identified drug irregularities.

A review of a "Consultant Pharmacist Nursing Unit Inspection Report" dated March 28, 2024, revealed that the consultant pharmacist identified that Quetiapine (Seroquel and antipsychotic medication) with an anxiety disorder will trigger quality indicator for inappropriate antipsychotic use. The pharmacist requested that the physician "Please review the diagnosis."

At the time of the survey ending June 7, 2024, the resident's attending physician failed to document an appropriate response to the identified irregularity, but instead, the facility's consultant psychiatric CRNP (certified registered nurse practitioner) had responded to the pharmacy recommendation and signed off as he reviewed it.

A review of a "Consultant Pharmacist Nursing Unit Inspection Report" dated April 29, 2024, revealed the consultant pharmacist indicated Seroquel with a dementia diagnosis will trigger inappropriate use. Please review the diagnosis and usage and consider a GDR (gradual dose reduction).

Further review revealed the resident's attending physician failed to document an individualized response to the pharmacy recommendation. Instead, the facility's consultant psychiatric CRNP had responded stating "behavioral history benefits outweigh risks" to the pharmacy recommendation and signed off as he reviewed the recommendation.

In an interview with the Director of Nursing on June 7, 2024, at approximately 10:00 AM revealed that the facility was unable to locate the pharmacy recommendations for December 2023 and confirmed that consultant psychiatric CRNP was responding to the pharmacy recommendations and not the resident's attending physician as noted in the regulation.


28 Pa. Code 211.9 (k) Pharmacy services.

28 Pa. Code 211.12 (c) Nursing services.



 Plan of Correction - To be completed: 07/30/2024

F0756 Drug Regimen Review, Report Irregular, Act
1. Resident 124 pharmacy recommendation for December 2023 was reviewed and written documentation will be noted by the attending physician's response to the identified drug irregularities.
2. All residents have the potential to be affected.
3. Administrator/designee will educate physicians on timely reviewing monthly pharmacy recommendations and addressing response in writing.
4. Audits of pharmacy recommendations will be done by DON/designee to monitor if attending physicians have addressed in writing their response to recommendations. Audits will be done weekly x4 then monthly x2 then quarterly until compliance is achieved. Results will be presented in QAPI committee meeting.
5. Date of compliance: July 30, 2024

483.45(d)(1)-(6) REQUIREMENT Drug Regimen is Free from Unnecessary Drugs: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(d) Unnecessary Drugs-General.
Each resident's drug regimen must be free from unnecessary drugs. An unnecessary drug is any drug when used-

§483.45(d)(1) In excessive dose (including duplicate drug therapy); or

§483.45(d)(2) For excessive duration; or

§483.45(d)(3) Without adequate monitoring; or

§483.45(d)(4) Without adequate indications for its use; or

§483.45(d)(5) In the presence of adverse consequences which indicate the dose should be reduced or discontinued; or

§483.45(d)(6) Any combinations of the reasons stated in paragraphs (d)(1) through (5) of this section.
Observations:

Based on a review of clinical records, and staff interviews, it was determined that the facility failed to ensure that a resident's drug regimen was free of unnecessary antibiotic drugs for two out of 35 residents sampled (Residents 50 and 18).

Findings included:

A clinical record review revealed that Resident 50 was admitted to the facility on May 13, 2014, with diagnoses that included chronic kidney disease (gradual loss of kidney function) and cerebral infarction (brain damage that results from a lack of blood).

A review of a quarterly Minimum Data Set assessment (MDS - a federally mandated standardized assessment process conducted periodically to plan resident care) dated May 4, 2024, revealed that Resident 50 is cognitively intact with a BIMS score of 15 (Brief Interview for Mental Status- a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 13-15 indicates cognition is intact).

A nursing progress note dated April 5, 2024, at 9:15 PM indicated that the physician was aware that Resident 50 had complaints of pain, burning, and frequency with urination. The note indicated that a new physician's order was received for a urine analysis (U/A) and culture and sensitivity (C&S- a laboratory test used to identify organisms present in the urine and determine their susceptibility to antibiotic treatment).

A physician's order dated April 5, 2024, was noted for Resident 50 to have a U/A and C&S for complaints of pain, burning, and \ frequency.

Clinical record review conducted at the time of the survey ending June 7, 2024, revealed no documentation that staff attempted to obtain a urine sample to complete the testing.

A nursing progress note dated April 8, 2024, at 2:18 PM was noted that the physician was notified that a urine sample was not been collected because Resident 50 is incontinent.

A nursing progress note dated April 9, 2024, at 2:25 PM indicated that the physician was notified because the resident continues to complain of urinary frequency and burning with urination and a urine sample was not collected as the resident is 100% incontinent.

A physician's order was noted Resident 50 to receive Doxycycline Hyclate Oral Capsule 100 mg (an antibiotic medication) with the direction to give 100 mg by mouth every 12 hours for dysuria, a possible urinary tract infection for five days.

A Medication Administration Record (MAR) dated April 2024 revealed that Resident 50 received her first dose of Doxycycline Hyclate Oral Capsule 100 mg on April 9, 2024, at 8:00 PM.

A nursing progress note dated April 10, 2024, indicated that an order for antibiotic medication was initiated for symptoms of dysuria without a urine analysis or culture and sensitivity completed. The physician indicated that the risk of antibiotic therapy to treat bacterial infection of the urine does not outweigh the risk of complications from catheterization required to obtain a specimen.

A progress note dated April 11, 2024, at 2:12 PM indicated that Resident 50 reported that she still has \ frequency and burning progress note dated April 12, 2024, at 1:23 PM indicated that Resident 50 reported that she still has \ frequency and burning Medication Administration Record dated April 20, 2024, revealed that Resident 50 received her last ordered dose of Doxycycline Hyclate Oral Capsule 100 mg on April 14, 2024, at 8:00 AM.

A progress note dated April 15, 2024, at 1:11 PM indicated that Resident 50 reported that she still has some burning with urination.

According to the MAR dated April 2024, Resident 50 received 10 doses of Doxycycline Hyclate Oral Capsule 100 mg.

During an interview on June 5, 2024, at 13:00 PM, Resident 50 stated that she gets urinary tract infections regularly. She explained that in the past, the facility would assist her in collecting a sample of her urine. She stated that she is able to hold her urine occasionally and would be able to urinate in a container with staff assistance. She stated that during April, staff never attempted to assist her to provide a sample of her urine for the necessary lab testing.

During an interview on June 6, 2024, at approximately 10:30 AM, the Director of Nursing (DON) was unable to provide evidence that Resident 50 was free from unnecessary antibiotic medications. The DON was unable to provide evidence that staff attempted to collect a urine sample from Resident 50 prior to the administration of antibiotic medication or during the course of treatment as the resident continued to have complaints of burning and increased urinary frequency.

A clinical record review revealed that Resident 18 was admitted to the facility on January 11, 2024, with dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities).

A review of a nursing note dated March 4, 2024, at 12:45 PM revealed that the resident was continuing to hallucinate. The resident vital signs were stable. The resident did not have any complaints of pain or dysuria (discomfort, pain, or burning when urinating) The physician was called, and an order was obtained for a urinalysis with culture and sensitivity. The physician, at that time, also ordered Ciprofloxacin 500MG every 12 hours for 10 days.

Nursing documentation, dated March 5, 2024, following the collection of the urine sample, revealed that the resident did not display any other signs or symptoms of a UTI.

A review of documentation provided by the infection preventionist during the survey ending June 7, 2024, revealed the resident's only symptom of possible UTI was altered mental status and a sticky note was present, which stated "did not meet McGeer's criteria."

A review the resident's laboratory report results dated March 6, 2024, at 9:34 AM revealed the urine showed multiple flora suggesting either the sample was contaminated or colonized.

A review of a nursing note dated March 6, 2024, at 4:45 PM revealed that the physician was made aware of the urine sample being contaminated and the physician advised to continue Cipro for the 10 days.

A review of Resident 18's March 2024 Medication Administration Record revealed the resident received 20 doses of an unnecessary antibiotic, Cipro.

An interview with the Director of Nursing on June 7, 2024, at approximately 12:45 PM, confirmed that the administration of Ciprofloxacin was not clinically justified, and the resident received medication that was unnecessary.


Refer 881

28 Pa. Code 211.2(d)(3)(5) Medical Director

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

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




 Plan of Correction - To be completed: 07/30/2024

F 0757 Drug Regimen is Free from Unnecessary Drugs

1. Residents 50 and 18 were not negatively affected.
2. Residents currently on antibiotics for a urinary tract infection shall be reviewed by the ICP to verify that the antibiotic therapy is clinically justified, and that drug regimen is free from any unnecessary drugs.

3. ICP will be educated by QAPI nurse/designee on reviewing residents on antibiotics to ensure that drug regimen is free from any unnecessary drugs; Licensed nurses shall be educated by the ICP/Designee on the antibiotic stewardship program and the importance of obtaining urinary samples and ensuring the antibiotic therapy is clinically justified and that drug regimen is free from any unnecessary drugs.
4. The ICP/Designee will audit the residents who are prescribed antibiotics for urinary tract infections to ensure compliance with the regulation that drug regimen should be free from any unnecessary drugs. Audits will be done weekly x4 then monthly x2 then quarterly until compliance is achieved. Results will be presented in QAPI committee meeting.
5. Date of compliance: July 30, 2024

483.45(c)(3)(e)(1)-(5) REQUIREMENT Free from Unnec Psychotropic Meds/PRN Use:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
§483.45(e) Psychotropic Drugs.
§483.45(c)(3) A psychotropic drug is any drug that affects brain activities associated with mental processes and behavior. These drugs include, but are not limited to, drugs in the following categories:
(i) Anti-psychotic;
(ii) Anti-depressant;
(iii) Anti-anxiety; and
(iv) Hypnotic

Based on a comprehensive assessment of a resident, the facility must ensure that---

§483.45(e)(1) Residents who have not used psychotropic drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record;

§483.45(e)(2) Residents who use psychotropic drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs;

§483.45(e)(3) Residents do not receive psychotropic drugs pursuant to a PRN order unless that medication is necessary to treat a diagnosed specific condition that is documented in the clinical record; and

§483.45(e)(4) PRN orders for psychotropic drugs are limited to 14 days. Except as provided in §483.45(e)(5), if the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she should document their rationale in the resident's medical record and indicate the duration for the PRN order.

§483.45(e)(5) PRN orders for anti-psychotic drugs are limited to 14 days and cannot be renewed unless the attending physician or prescribing practitioner evaluates the resident for the appropriateness of that medication.
Observations:


Based on a review of clinical records and staff interview, it was determined that the facility failed to consistently attempt non-pharmacological interventions prior to the administration of an antipsychotic medication prescribed on an as needed basis (PRN) for one resident out of 35 reviewed (Resident 230).

Findings include:

A review of the clinical record revealed that Resident 230 had diagnoses, which included cerebral infarction with left-side hemiplegia and anxiety.

An admission Minimum Data Set assessment (MDS-standardized assessment completed at specific intervals to identify specific resident care needs) dated May 25, 2024, revealed that the resident was moderately cognitively impaired with a BIMS score of 10 (the Brief Interview for Mental Status a tool that assesses cognition; a score of 8-12 equates to being moderately cognitively impaired).

A current physician's order, initially dated May 30, 2024, was noted for Seroquel (an antipsychotic) 25 mg one tablet as needed every 24 hours for anxiety for 14 days. Non-pharmacological interventions planned included activities, redirection, repositioning, food/fluids, rest period, and quiet environment.

A review of the resident's June 2024 Medication Administration Record (MAR) revealed that staff administered the prn antipsychotic medication on June 1, 2024, at 8:46 PM and June 3, 2024, at 1:32 AM for behaviors of the resident being very restless and increased yelling out.

There was no documented evidence that the planned non-pharmacological interventions were attempted prior to administering the prescribed antipsychotic prn medication.

During an interview with the Director of Nursing (DON) on June 7, 2024, at approximately 1:00 PM failed to provide documented evidence planned non-pharmacological interventions were attempted prior to administering the prescribed prn antipsychotic medication.


28 Pa. Code 211.5(f) Medical records

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






 Plan of Correction - To be completed: 07/30/2024

F 0758 Free from Unnecessary Psychotropic Meds/PRN Use
1. Resident 230's physician orders for antipsychotic meds were reviewed to ensure that orders reflect non-pharmacological interventions attempted prior to the administration of PRN antipsychotic medication.
2. Current residents on PRN antipsychotic medications shall be reviewed by the Unit Managers/designee to verify that physician orders reflect non-pharmacological interventions attempted prior to the administration of PRN antipsychotic medication.
3. The Staff Educator/designee shall review the regulation with the licensed nursing staff as it relates to PRN antipsychotic medication orders so that NPI'S are attempted prior to the administration of the PRN antipsychotic medication.
4. The Unit Managers/designee shall review in clinical AM meeting to verify PRN antipsychotic medication have NPI 's identified and that they are attempted prior to the administration of the PRN antipsychotic mediation. Any issues identified will be addressed. Audits will be done weekly x4 then monthly x2 then quarterly until compliance is achieved. Results will be presented in QAPI committee meeting.
5. Date of compliance: July 30, 2024

483.60(i)(1)(2) REQUIREMENT Food Procurement,Store/Prepare/Serve-Sanitary: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.
§483.60(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 maintain acceptable practices for the storage and service of food to prevent the potential for contamination and microbial growth in food, which increased the risk of food-borne illness in two of four resident pantries (Spruce Nursing Unit and North Nursing Unit).

Findings include:

Food safety and inspection standards for safe food handling indicate that everything that comes in contact with food must be kept clean and food that is mishandled can lead to foodborne illness. Safe steps in food handling, cooking, and storage are essential in preventing foodborne illness. You cannot always see, smell, or taste harmful bacteria that may cause illness according to the USDA (The United States Department of Agriculture, also known as the Agriculture Department, is the U.S. federal executive department responsible for developing and executing federal laws related to food).

Observation of the resident food pantry located on the Spruce Nursing Unit on June 5, 2024, at 12:00 PM revealed that inside the refrigerator there was an opened 46-ounce container of cranberry nectar-thickened juice which was not dated when opened (manufacturer's label noted that the juice was to be used within 10 days of opening).

Observation of the resident food pantry located on the North Nursing Unit on June 5, 2024, at 12:30 PM revealed that inside the refrigerator there was an opened 46-ounce container of lemon nectar-thickened water which was dated May 23, 2024. The manufacturer's label noted to keep under refrigeration after opening for up to seven days.

Interview with the Nursing Home Administrator on June 5, 2024, at 2:00 PM confirmed that all food items in the resident pantries were to be properly dated upon opening and discarded according to manufacturer recommendations to ensure food quality and reduce the risk of food-borne illness.



28 Pa. Code 211.6 (f) Dietary services

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












 Plan of Correction - To be completed: 07/30/2024

F 0812 Food Procurement, Store/Prepare/Serve-Sanitary
1. All food Items in food pantry located on the Spruce Nursing Unit and North Nursing Unit were discarded.
2. Unit food pantry refrigerators were checked to ensure that all food items were properly dated upon opening and discarded according to manufacturer recommendations to ensure food quality and reduce the risk of food-borne illness.
3. Unit Managers /designee will educate nursing staff and food service supervisor on the need to check Unit food pantry refrigerators to ensure that all food items are properly dated upon opening and discarded according to manufacturer recommendations to ensure food quality and reduce the risk of food-borne illness.
4. Audits of unit food pantry refrigerators will be conducted by Dietary Managers/designee to ensure that all food items are properly dated upon opening and discarded according to manufacturer recommendations to ensure food quality and reduce the risk of food-borne illness. Audits will be done weekly x4 then monthly x2 then quarterly until compliance is achieved. Results will be presented in QAPI committee meeting.
5. Date of compliance: July 30, 2024

§ 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 the review of clinical records and staff interviews, it was determined that the facility failed to maintain a complete and accurate record of a resident's personal possessions upon admission and discharge for one resident out of two closed records sampled (Resident 179).

Findings included:

Clinical record review revealed that Resident 179 was admitted to the facility on March 19, 2021, and expired while at the facility on March 22, 2024.

A review of Resident 179's Inventory of Personal Belongings sheet revealed no evidence that the the resident's or resident representative's documented agreement that the inventory of his property was accurate.

During an interview on June 6, 2024, at approximately 10:30 AM, the Nursing Home Director (NHA) and Director of Nursing (DON) were unable to provide evidence that the facility attained the resident's or resident representative's agreement that the inventory of his personal property was accurate.



 Plan of Correction - To be completed: 07/30/2024

P 1210 Management
1. Resident 179 is discharged.
2. The MR Director/designee will review admissions /discharges for the last 7 days to ensure there is an accurate record of residents' personal possessions.
3. The Licensed Nursing staff, Guest services, admissions will be educated by the Staff Educator/Designee to ensure that there is an accurate record of a resident's personal possessions for admissions/discharges.
4. The MR Director shall complete a random weekly audit of the admissions and discharges to verify there is an accurate record of a resident's personal possessions. Audits will be done weekly x4 then monthly x2 then quarterly until compliance is achieved. Results will be presented in QAPI committee meeting.
5. Date of compliance: July 30, 2024

§ 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 a review of nurse staffing and staff interview, it was determined that the facility failed to ensure the minimum licensed practical nurse staff to resident ratio was provided on each shift for one shift out of 63 reviewed.

Findings include:

A review of the facility's weekly staffing records revealed that on the following dates the facility failed to provide minimum licensed practical nurse (LPN) staff of 1:40 on the night shift based on the facility's census.

May 24, 2024 - 4 LPNs on the night shift, versus the required 4.60 for a census of 184. No additional excess higher-level staff were available to compensate this deficiency.

An interview with the Nursing Home Administrator on June 7, 2024, approximately 12:45 PM, confirmed the facility had not met the required LPN to resident ratios on the above dates.




 Plan of Correction - To be completed: 07/30/2024

P 5530 Nursing services.
1. The facility cannot retroactively correct this issue. No residents were negatively affected.
2. The daily staffing sheet was reviewed on 06/15/2024 to ensure that the minimum licensed practical nurse staff to resident ratio was met.
3. The Regional HR consultant/designee will educate the staff scheduler on reviewing daily staffing schedule to ensure minimum licensed practical nurse staff to resident ratio is being met.
4. NHA/DON / designer will conduct audits of daily staffing schedules to ensure minimum licensed practical nurse staff to resident ratio are being met. Audits will be done weekly for 4 weeks then monthly for 2 months or until substantial compliance is met.
5. Date of compliance July 30, 2024


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