Nursing Investigation Results -

Pennsylvania Department of Health
JUNIPER VILLAGE AT BROOKLINE-REHABILITATION AND SKILLED CARE
Patient Care Inspection Results

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JUNIPER VILLAGE AT BROOKLINE-REHABILITATION AND SKILLED CARE
Inspection Results For:

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JUNIPER VILLAGE AT BROOKLINE-REHABILITATION AND SKILLED CARE - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on a Medicare Recertification Survey, State Licensure Survey, Civil Rights Compliance Survey, and Complaint Investigation, completed on June 10, 2022, it was determined that Juniper Village at Brookline-Rehabilitation and Skilled Care was not in compliance with the following requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care and the 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.


 Plan of Correction:


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

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

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

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

Findings include:

A tour of the facility's main kitchen with Employee 6 (Dietary Manager) on June 7, 2022, at 9:50 AM revealed the following:

Dried splash stains on the walls above two blue garbage cans in one corner of the kitchen adjacent to the kitchen office.

A storage rack contained the following items that were opened with no open dates noted on the items: ground cinnamon, cocoa powder, imitation vanilla, apple cider vinegar, cooking wine, and confectioner's powder.

A tiled wall in the center of the kitchen contained unidentified debris and dust build-up with noted dried splashes. Some areas of the wall were sticky to touch.

A covered meat slicer had crumbs and unidentifiable debris build-up on the stand where the slicer was stored and the shelf underneath.

A stainless-steel cabinet that was located on an outside perimeter wall had two doors and three drawers. The front of the cabinet had multiple areas where dried splashes were noted.

A storage rack in the center of the kitchen had two plastic totes with yellow lids. There was a build-up of dust and debris on top of the lids.

There was an obvious accumulation of debris and dust on the top of the automatic dishwashing machine. There was also an accumulation of large white unidentified flakes on the back perimeter of the dishwashing machine just above the area where the cleaned plates are expelled after washing and rinsing.

A wire storage rack attached to a perimeter wall had a significant accumulation of dust on the racks and the rails where the rack attaches to the wall. The rack stored clean water pitchers.

A plastic storage/shelving unit next to the tray line had a significant build-up of debris and obvious crumbs on all shelving units. There was an open container of plastic lids with at least two lids that had come out of the package and were lying on one of the shelves. A plastic, portable storage tote held several packets of peanut butter crackers and sugar packets. There was an obvious build-up of crumbs an debris in the divided storage areas. One of the sugar packets and two of the observed peanut butter cracker packets were covered in a brown and sticky unidentified substance.

A broken blue plate was found in a plate warmer adjacent to the tray line. Employee 6 reported this plate warmer was in service and would be used for the upcoming lunch service.

An appliance identified as the "steamer" had an accumulation of spashes on the sides of the unit and there was an obvious accumulation of debris and dust on the top of the unit. Some areas were sticky to touch.

An in-floor grated drain was noted in front of the stove and other appliances. The drain had an obvious accumulation of wet debris including what appeared to be food items and paper items. The dietary manager reported it was expected to be cleaned daily and "it was obviously not cleaned last night."

The wall behind the stove and other appliances had an accumulation of dust and debris on the wall including dust build-up on a pipe that spanned the area.

A garbage can lid on the outer perimeter had a build-up of debris and obvious stains.

The dry storage area had a tray holding several boxes of Cream of Wheat. The tray holding the Cream of Wheat boxes had a significant accumulation of an unidentified white and powdery substance.

The walk-in cooler had several food items with a use by date labeled June 7th. The dietary manager reported these items should have been discarded based on the date. The items were labeled as sliced turkey, ham, and chicken noodle soup.

A tray holder in the walk-in cooler held a tray marked with a use by date of June 7th. It held nine containers/bowls with plastic disposable lids that were labeled strawberries.

On June 8, 2022, a review of the cool-down logs labeled, "Cooling Temperature Log," revealed the following instructions: record the temperatures every hour during the cooling cycle; staff are instructed that the food must be cooled down to 70 degrees Fahrenheit within two hours and then cooled to 41 degrees Fahrenheit in the next two hours; if both of these parameters are not met then the corrective action would be to dispose of the food.

HACCP (Hazard Analysis and Critical Control Points) Cooling Procedures for Hot Food: Hot food must be cooled from 140 degrees Fahrenheit to 70 degrees Fahrenheit within 2 hours and then to 40 degrees Fahrenheit below within an additional 4 hours total cooling time 6 hours. The more rapid the cooling process the better for food safety and quality. Place food in pre-chilled, shallow stainless steel pans

The "Cooling Temperature Log" revealed the following:

No timestamps were noted on the log for the following dates:

January 6, 19, and 20, 2022
February 22, 2022
March 29, 2022 (second entry); and March 30, 2022

A questionable date written in a black marker, appeared to be January 27, 2022. At least three of the temperatures were illegible and another was scribbled out.

April 4, 2022: the times and associated temperatures for the cooling of "navy bean soup" were noted as 12:30 (does not specify AM or PM) at 180 degrees, 2:00 at 90 degrees, 3:15 at 65 degrees, and 4:00 at 38 degrees. The log indicated that the temperatures were not clearly documented at the two hour mark to ensure the food had cooled to within 70 degrees per HACCP cooling procedures for hot food.

April 18, 2022: the times and associated temperatures for the cooling of "sloppy joe" were noted as 10:00 AM at 190 degrees, 12:00 PM at 97 degrees, 2:00 PM at 70 degrees, and 4 PM at 40 degrees. The log indicated that the food was not cooled to within 70 degrees Farenheit wihtin 2 hours per the HACCP cooling procedures for hot food. There was no documentation on the log to indicate that corrective actions were taken.

June 3, 2022: the times and associated temperatures for the cooling of "BBQ sauce" were noted as 12:30 (does not specify AM or PM) at 176 degrees, 1:30 at 146 degrees, 2:35 at 87 degrees, and 3:45 at 53 degrees. The log indicated that the food was not cooled to within 70 degrees Fahrenheit within 2 hours per the HACCP cooling procedures for hot food. There was no documentation on the log to indicate that corrective actions were taken.

June 7, 2022: the times and associated temperatures for the cooling of "pulled pork" were noted as 1:00 PM at 169 degrees, 1:35 PM at 150 degrees, 4:00 PM at 66 degrees, and 6:00 PM at 39 degrees. The log indicated that the temperatures were not monitored at the two hour mark to ensure the food had cooled to within 70 degrees Fahrenheit per HACCP cooling procedures for hot food. There was no documentation on the log to indicate that corrective actions were taken.

June 7, 2022: the times and associated temperatures for the cooling of "chicken noodle" were noted as 1:00 PM at 176 degrees, 2:00 PM at 136 degrees, 4:00 PM at 67 degrees, and 6:00 PM at 37 degrees. The log indicated that the temperatures were not monitored at the two hour mark to ensure the food had cooled to within 70 degrees Fahrenheit per HACCP cooling procedures for hot food.

The above findings were discussed in a meeting with the Nursing Home Administrator and Director of Nursing on June 9, 2022, at 2:00 PM.

483.60 (i) Food, Store and Serve -Sanitary
Previously cited deficiency 6/29/2021

28 Pa. Code 211.6 (c) Dietary services


 Plan of Correction - To be completed: 07/28/2022

No residents were harmed based on this deficit practice. Ground cinnamon, cocoa powder, imitation vanilla, apple cider vinegar, cooking wine, and confectioner's powder was thrown away at the time it was discovered an open date was not present. Broken plate, sugar packets, and peanut butter packets were discarded when found during surveyor walk through of the kitchen. Sliced turkey, ham, chicken noodle soup, and strawberries with discard date of 07/07/2022 were thrown out on 07/07/2022. Education to all dining associates will be completed by 07/07/2022 on new HACCP logs that include space for item, date, time, temperature, required timing intervals and needed corrective actions as applicable. All areas noted were cleaned and will be added to weekly cleaning task list. Audit of completion of weekly task list will occur weekly for 4 weeks, then monthly until two consecutive months of 100% compliance are met. Audit of proper labeling and disposing of foods based on labeling will be conducted weekly for 4 weeks, then monthly until two consecutive months of 100% compliance are met. Findings of audits will be presented at monthly QAPI meeting.
483.24(c)(2)(i)(ii)(A)-(D) REQUIREMENT Qualifications of Activity Professional: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.
483.24(c)(2) The activities program must be directed by a qualified professional who is a qualified therapeutic recreation specialist or an activities professional who-
(i) Is licensed or registered, if applicable, by the State in which practicing; and
(ii) Is:
(A) Eligible for certification as a therapeutic recreation specialist or as an activities professional by a recognized accrediting body on or after October 1, 1990; or
(B) Has 2 years of experience in a social or recreational program within the last 5 years, one of which was full-time in a therapeutic activities program; or
(C) Is a qualified occupational therapist or occupational therapy assistant; or
(D) Has completed a training course approved by the State.
Observations:
Based on staff interviews, it was determined that the facility failed to ensure that the activities program was directed by a qualified professional who was a qualified therapeutic recreational specialist or an activity professional (Employee 2).

Findings include:

Interview with Employee 2, Connections Director (activity director), on June 10, 2022, at 10:10 AM revealed that she was new to the facility, was not licensed as an activity director, and was not eligible for certification as a therapeutic recreation specialist (professional qualified to utilize recreation and other activity-based interventions to address the assessed needs of individuals with illnesses and/or disabling conditions, to psychological and physical health, recovery, and well-being) or as an activities professional by a recognized accrediting body on or after October 1, 1990. Employee 2 did not have two years of experience in a social or recreational program within the last five years, one of which was full-time in a therapeutic activities program, or a qualified occupational therapist, or occupational therapy assistant, or has completed a training course approved by the state.

Review of Employee 2's personnel record revealed her hire date was September 3, 2021.

Interview with the Nursing Home Administrator on June 10, 2022, at 10:59 AM confirmed that Employee 2 has not completed the training course and does not meet the experience requirements.

28 Pa Code: 201.3 (i)(ii) Resident activities coordinator

28 Pa. Code 201.18(b)(3)(e)(2)(6) Management

28 Pa. Code 201.19 Personnel policies and procedure


 Plan of Correction - To be completed: 07/28/2022

No resident was harmed based on this deficit practice. Activities director will complete CTRS or activities professional certification by a recognized accrediting body. Until CTRS or activities professional certification is received, department will be directed by associate who is ACC (activity consultant certified) through NCCAP. Updates on progression of course will be discussed at monthly QAPI meetings.
483.80(b)(1)-(4)(c) REQUIREMENT Infection Preventionist Qualifications/Role:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
483.80(b) Infection preventionist
The facility must designate one or more individual(s) as the infection preventionist(s) (IP)(s) who are responsible for the facility's IPCP. The IP must:

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

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

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

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

483.80 (c) IP participation on quality assessment and assurance committee.
The individual designated as the IP, or at least one of the individuals if there is more than one IP, must be a member of the facility's quality assessment and assurance committee and report to the committee on the IPCP on a regular basis.
Observations:

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

Findings include:

During the entrance conference interview with the Nursing Home Administrator on June 7, 2022, at 10:30 AM she stated that the facility's infection control surveillance program was the responsibility of the Director of Nursing. The Nursing Home Administrator named the Director of Nursing as the Infection Preventionist.

Interview with the Director of Nursing on June 10, 2022, at 9:30 AM indicated that although she was a registered nurse, she had no specialized training or certification in infection prevention and control. The interview indicated that she receives consultation from the facility's former Director of Nursing as needed; however, the facility's former Director of Nursing is present in the facility less than five hours a week.

Review of the infection control committee meeting attendance records confirmed that the Director of Nursing assumed the position as the instructor for the two meetings held in 2022 (February and April). The facility's former Director of Nursing did not attend either infection control committee meeting in 2022.

The facility failed to designate an infection preventionist, at the facility at least part-time, who was qualified by specialized training or certification.

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


 Plan of Correction - To be completed: 07/28/2022

No resident was harmed based on this deficit practice. Director of Nursing to complete specialized training in infection control to meet the qualifications of an Infection Preventionist. Training to be completed by 07/28/2022.
483.80(a)(1)(2)(4)(e)(f) REQUIREMENT Infection Prevention & Control:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
483.80 Infection Control
The facility must establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections.

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

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

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

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

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

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

Based on review of select facility policies and procedures, observation, clinical record review, and staff interview, it was determined that the facility failed to ensure an environment free from the potential spread of infection and failed to properly implement interventions to prevent the potential spread of COVID-19 for five of nine residents reviewed for infection control concerns (Residents 13, 17, 27, 30, and 47) and two of five staff reviewed for COVID-19 mitigation requirements (Employees 3 and 4).

Findings include:

Centers for Disease Control (CDC) Interim Guidance for Managing Healthcare Personnel (HCP) with SARS-CoV-2 (COVID-19) Infection or Exposure, Work Restrictions for HCP with COVID-19 infection, updated January 21, 2022, stipulated that regardless of vaccination status, staff diagnosed with COVID-19 infection could return to work in seven days with a negative test, or 10 days without testing, with the improvement of symptoms.

The PAHAN 516 (Pennsylvania Department of Health Alert Network Notice) dated July 18, 2020, stipulated that facilities operating under critical staffing shortages (described at https://www.cdc.gov/coronavirus/2019-ncov/hcp/mitigating-staff-shortages.html) might choose to allow health care personnel (HCP) to return to work earlier than CDC return-to-work criteria. If there are no longer enough staff to provide safe patient care, and other contingency capacity strategies have been exhausted (see CDC strategies, https://www.cdc.gov/coronavirus/2019-ncov/hcp/mitigating-staff-shortages.html ), healthcare facilities and employers may need to implement crisis capacity strategies to continue to provide patient care. The decision to follow contingency or crisis standards belongs to the healthcare facility, but these decisions and actions must be detailed in and consistent with their emergency preparedness plan.

The facility's current policy entitled, "COVID-19 Return to Work," revised January 1, 2022, permitted HCP with laboratory-confirmed COVID-19 who have not had any symptoms to return to work after five days passed since the date of the positive COVID-19 diagnostic test. The policy did not require a negative COVID-19 diagnostic test or that the facility implement contingency or crisis staffing measures first.

Interview with the Nursing Home Administrator and the Director of Nursing on June 10, 2022, at 9:30 AM confirmed that the facility could not provide a CDC standard that permitted staff to return to work before seven days under conventional staffing conditions.

Review of Employee 4's (nurse aide) COVID-19 testing revealed a positive test from a sample collected on February 19, 2022. Review of Employee 4's timecard history revealed that regular work hours in the facility resumed on February 25, 2022 (six days later).

The surveyor requested evidence of the facility's pre-shift COVID-19 symptom screening for Employee 4 for February 12 - 29, 2022, during an interview with the Nursing Home Administrator and the Director of Nursing on June 8, 2022, at 2:00 PM. An interview with the Nursing Home Administrator and the Director of Nursing on June 10, 2022, at 9:30 AM confirmed that the facility was unable to provide evidence of symptom surveillance before Employee 4 began her shift in the facility on the dates requested.

Interview with the Nursing Home Administrator and the Director of Nursing on June 10, 2022, at 9:30 AM confirmed that the facility did not implement any measures to indicate a contingency staffing plan was in place in February 2022 that warranted Employee 4's return to work before the CDC return-to-work guidance. The interview also confirmed that the facility had no evidence of a negative COVID-19 test for Employee 4 before her return to work.

Review of Employee 3's (licensed practical nurse) COVID-19 testing revealed a positive test from a sample collected on September 16, 2021. The surveyor requested evidence of the facility's pre-shift COVID-19 symptom screening for Employee 3 for September 9 through 26, 2021 (Employee 3's timecard indicated regular hours worked on September 13, 16, and 26). Interview with the Nursing Home Administrator on June 9, 2022, at 9:44 AM revealed that the facility was continuing to try and obtain the pre-shift symptom screening information. Interview with the Nursing Home Administrator and the Director of Nursing on June 10, 2022, at 9:30 AM revealed that the facility was unable to provide evidence of the pre-shift symptom screening information requested.

The facility policy entitled, "Health Safety and Wellness Manual Infection Control Section - Introduction, Hand Hygiene," last reviewed without changes on June 27, 2022, stipulated that staff are to wash their hands with soap and water vigorously for at least 15 seconds, rinse hands with water, dry thoroughly with a disposable towel, and turn off the faucet on the sink with the disposable paper towel.

Observation of Resident 27's right foot wound treatment with Employee 5 (licensed practical nurse) on June 8, 2022, at 2:58 PM revealed that after Employee 5 removed the soiled dressings from Resident 27's right foot, she entered Resident 27's bathroom to wash her hands. Employee 5 washed her hands with soap and water; however, used her clean hand to turn off the sink faucet before drying her hands with a disposable towel. After Employee 5 applied the new dressing treatment to Resident 27's right foot, she utilized the soiled ace wrap (known to have at least a dime-sized soiled area from wound drainage on it) over the clean dressings.

Interview with Employee 5 on June 8, 2022, at 3:29 PM confirmed that she put the soiled ace wrap, with known drainage soiling, over Resident 27's clean dressings because she could not locate another ace wrap in Resident 27's room.

Observation of Resident 47 with Employee 5 on June 8, 2022, at 3:13 PM revealed that his indwelling catheter (tube inserted into the urethra to the bladder to drain urine) collection bag hung from his bed frame. The collection bag was not in a dignity bag. The collection bag spout used to drain the contents of the bag as needed was not secured on the bag; but was hanging from the bag and in direct contact with the bottom frame of Resident 47's overbed table. Employee 5 did not clean the spout but positioned it back in the slot of the collection bag. Following an observation of Resident 47's heel wound treatment on June 8, 2022, at 3:13 PM Employee 5 discarded the soiled garbage in the nursing unit's main shower room. Employee 5 utilized the sink in the shower room to wash her hands. Employee 5 washed her hands with soap and water; however, used her clean hand to turn off the sink faucet before drying her hands with a disposable towel.

Interview with Employee 5 on June 8, 2022, at 3:29 PM confirmed that she did not utilize a disposable towel to turn off the faucet during the observed handwashing procedures.

Clinical record review for select residents (Residents 13, 17, 27, and 30) for the infection control symptom surveillance, revealed no evidence that the facility was conducting symptom surveillance of each resident to include monitoring for a fever, respiratory illness, or other signs and symptoms of COVID-19 at least daily.

Interview of the Nursing Home Administrator on June 10, 2022, at 10:10 AM revealed that the facility is unable to provide evidence that they are conducting daily symptom surveillance related to COVID-19 for Residents 13, 17, 27 and 30.

483.80(a)(1)(2)(4)(e)(f) Infection Prevention and Control
Previously cited deficiency 6/29/21

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

28 Pa. Code 211.10(d) Resident care policies

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


 Plan of Correction - To be completed: 07/28/2022

No residents were harmed based on this deficient practice. Batch order will be placed in each resident record for surveillance of fever, respiratory illness, or other signs and symptoms of COVID-19. All associates who are returning from work from a positive COVID-19 diagnostic test must follow CDC guidelines for safe return to work, which is a minimum of seven days. A list of associates who test positive for COVID-19 will be kept by the administrator or designee and will list their first return to work date (a minimum of seven days.) This list will be brought to QAPI monthly. Hand hygiene competency will be done for all staff by 07/14/2022. Audit of watching hand hygiene preformed will occur of 5% of all associates weekly for four weeks, then monthly until two consecutive months of 100% compliance are met. Education to LPN's and RN's will be completed by 07/07/2022 on ace bandage use. Rt 27 did receive new ace bandage on 6/8/2022 following being informed of soiled bandage. Rt 27 and all residents who are currently using ace wraps received an order placed in chart to change ace weekly and PRN if soiled. Resident 47 did receive additional dignity bag for indwelling catheter. Nursing staff will receive education about use of dignity bags and proper cleaning of bag spout by 07/07/2022. Weekly audits of dignity bag use will occur for four weeks, then monthly until at least two consecutive months of 100% compliance are met. Audits will be presented at monthly QAPI meeting. NHA or designee will print all associate pre-shift symptom screening information monthly and keep in NHA office, as current electronic system does not keep more than 90 days of information within the program. Will keep printed associate pre-screening records for no less than 12 months.
483.10(c)(1)(4)(5) REQUIREMENT Right to be Informed/Make Treatment Decisions: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(c) Planning and Implementing Care.
The resident has the right to be informed of, and participate in, his or her treatment, including:

483.10(c)(1) The right to be fully informed in language that he or she can understand of his or her total health status, including but not limited to, his or her medical condition.

483.10(c)(4) The right to be informed, in advance, of the care to be furnished and the type of care giver or professional that will furnish care.

483.10(c)(5) The right to be informed in advance, by the physician or other practitioner or professional, of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options and to choose the alternative or option he or she prefers.
Observations:

Based on clinical record review, review of facility documentation, and staff interview, it was determined that the facility failed to allow a responsible party to make informed choices related to a resident's medical treatment for one of 24 residents reviewed (Resident 4).

Findings Include:

Clinical record review for Resident 4 revealed a physician's order dated February 8, 2022, for an X-ray of the right wrist due to pain and swelling. Further review of physician orders for the above date, revealed orders for Prednisone (steroidal medication to reduce inflammation) 20 milligrams by mouth, three tablets for three days, then give two tablets one time a day for three days, and then give one tablet one time a day for three days.

Review of a grievance dated March 3, 2022, revealed the responsible party never approved an x-ray and prednisone. The responsible party indicated that the resident had an old injury and would never have approved the treatment.

During an interview with the Director of Nursing on June 9, 2022, at 9:50 AM it was confirmed that the responsible party was not informed in advance of the proposed treatment or provided an opportunity to make a choice about the treatment.

28 Pa. Code 201.29 (a) Resident rights

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


 Plan of Correction - To be completed: 07/28/2022

No resident was harmed based on this deficit practice. Education to all LPNs and RNs on notification to responsible party and corresponding documentation in progress notes to occur by 07/07/2022. Audit will be done weekly of 10% of new orders for 4 weeks, then monthly until 2 consecutive months at 100% compliance. Results of audits will be presented at monthly QAPI meeting.
483.10(f)(11)(i)-(iii) REQUIREMENT Limitations on Charges to Personal Funds: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(f)(11) The facility must not impose a charge against the personal funds of a resident for any item or service for which payment is made under Medicaid or Medicare (except for applicable deductible and coinsurance amounts).
The facility may charge the resident for requested services that are more expensive than or in excess of covered services in accordance with 489.32 of this chapter. (This does not affect the prohibition on facility charges for items and services for which Medicaid has paid. See 447.15 of this chapter, which limits participation in the Medicaid program to providers who accept, as payment in full, Medicaid payment plus any deductible, coinsurance, or copayment required by the plan to be paid by the individual.)
(i) Services included in Medicare or Medicaid payment. During the course of a covered Medicare or Medicaid stay, facilities must not charge a resident for the following categories of items and services:
(A) Nursing services as required at 483.35.
(B) Food and Nutrition services as required at 483.60.
(C) An activities program as required at 483.24(c).
(D) Room/bed maintenance services.
(E) Routine personal hygiene items and services as required to meet the needs of residents, including, but not limited to, hair hygiene supplies, comb, brush, bath soap, disinfecting soaps or specialized cleansing agents when indicated to treat special skin problems or to fight infection, razor, shaving cream, toothbrush, toothpaste, denture adhesive, denture cleaner, dental floss, moisturizing lotion, tissues, cotton balls, cotton swabs, deodorant, incontinence care and supplies, sanitary napkins and related supplies, towels, washcloths, hospital gowns, over the counter drugs, hair and nail hygiene services, bathing assistance, and basic personal laundry.
(F) Medically-related social services as required at 483.40(d).
(G) Hospice services elected by the resident and paid for under the Medicare Hospice Benefit or paid for by Medicaid under a state plan.
(ii) Items and services that may be charged to residents' funds. Paragraphs (f)(11)(ii)(A) through (L) of this section are general categories and examples of items and services that the facility may charge to residents' funds if they are requested by a resident, if they are not required to achieve the goals stated in the resident's care plan, if the facility informs the resident that there will be a charge, and if payment is not made by Medicare or Medicaid:
(A) Telephone, including a cellular phone.
(B) Television/radio, personal computer or other electronic device for personal use.
(C) Personal comfort items, including smoking materials, notions and novelties, and confections.
(D) Cosmetic and grooming items and services in excess of those for which payment is made under Medicaid or Medicare.
(E) Personal clothing.
(F) Personal reading matter.
(F) Gifts purchased on behalf of a resident.
(H) Flowers and plants.
(I) Cost to participate in social events and entertainment outside the scope of the activities program, provided under 483.24(c).
(J) Non-covered special care services such as privately hired nurses or aides.
(K) Private room, except when therapeutically required (for example, isolation for infection control).
(L) Except as provided in (e)(11)(ii)(L)(1) and (2) of this section, specially prepared or alternative food requested instead of the food and meals generally prepared by the facility, as required by 483.60.
(1) The facility may not charge for special foods and meals, including medically prescribed dietary supplements, ordered by the resident's physician, physician assistant, nurse practitioner, or clinical nurse specialist, as these are included per 483.60.
(2) In accordance with 483.60(c) through (f), when preparing foods and meals, a facility must take into consideration residents' needs and preferences and the overall cultural and religious make-up of the facility's population.
(iii) Requests for items and services.
(A) The facility can only charge a resident for any non-covered item or service if such item or service is specifically requested by the resident.
(B) The facility must not require a resident to request any item or service as a condition of admission or continued stay.
(C) The facility must inform, orally and in writing, the resident requesting an item or service for which a charge will be made that there will be a charge for the item or service and what the charge will be.
Observations:
Based on review of select billing statements and staff interview, it was determined that the facility charged a resident for items that were not utilized by the resident for one of four residents reviewed (Resident 4).

Findings include:

Review of Resident 4's billing statement for April 1, 2022, revealed the resident was charged for the following items:

6 Elastic bandages 4 x 5 yards at $1.85 each
1 Abdominal pad 5 x 9 at $0.26 each
1 tape at $1.75 each
1 bandage 4x4 at $0.97 each

Clinical record review for Resident 4's progress notes, medication administration records, and treatment administration records revealed no evidence the resident needed the above items.

During a telephone interview with Employee 7, business office manager, on June 9, 2022, at 12:40 PM, the billing process was explained. Staff are to remove a sticker from the item and place it on a form that has the resident's name. The form is entitled "Patient Scan Sheet." The resident is then charged for the items on the page. Employee 7 does not recall any billing concerns with Resident 4.

During an interview with Director of Nursing on June 9, 2022, at 12:30 PM a copy of Resident 4's Patient Scan Sheet for March 2022, was provided. Review of the Patient Scan sheet included charges for the April billing. There were no stickers matching the above nine items on the Patient Scan Sheet. The Director of Nursing confirmed that Resident 4 was charged for items not provided.

28 Pa. Code 201.29 (a) Resident rights

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


 Plan of Correction - To be completed: 07/28/2022

No resident was harmed based on this deficit practice. Resident 4 was credited the total amount of the items listed (6 elastic bandages 4x5 yards, 1 abdominal pad, 1 tape, 1 bandage.) All charge sheets will now be kept for a minimum of 12 months. Bills will have notation of "if you have questions about charges, please call Traci Martz at 814-235-2002." Monthly, all charge sheets will be verified for date and initials before charges are entered onto resident accounts. Audit will be done monthly of 10% of all residents for appropriate charges for three months, then quarterly until 2 consecutive quarters at 100% compliance are met. Results of audits will be presented at monthly QAPI meeting.
483.15(c)(3)-(6)(8) REQUIREMENT Notice Requirements Before Transfer/Discharge: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)(3) Notice before transfer.
Before a facility transfers or discharges a resident, the facility must-
(i) Notify the resident and the resident's representative(s) of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand. The facility must send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman.
(ii) Record the reasons for the transfer or discharge in the resident's medical record in accordance with paragraph (c)(2) of this section; and
(iii) Include in the notice the items described in paragraph (c)(5) of this section.

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

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

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

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

Based on clinical record review and staff interview, it was determined that the facility failed to notify the ombudsman of a resident's transfer to the hospital for one of three residents reviewed (Resident 8).

Findings include:

Review of Resident 8's clinical review revealed that Resident 8 was transferred to the emergency room and admitted to the hospital on March 23, 2022. A notice of transfer was provided to the responsible party with the required information on March 24, 2022. There was no documented evidence that the facility provided a copy of the written notice of transfer to the Office of the State Long-Term Care Ombudsman.

Further clinical review revealed that Resident 8 was transferred to the emergency room and admitted to the hospital on June 6, 2022. A written notice of transfer was provided to the responsible party with the required information on June 6, 2022. There was no documented evidence that the facility provided a copy of the written notice of transfer to the Office of the State Long-Term Care Ombudsman.

Interview with the Nursing Home Administrator on June 10, 2022, at 11:19 AM confirmed the above information that the facility failed to provide the Office of the State Long-Term Care Ombudsman with a copy of Resident 8's written notice of transfer.

28 Pa. Code 201.14(a) Responsibility of license

28 Pa. Code 201.29(a) Resident rights


 Plan of Correction - To be completed: 07/28/2022

No resident was harmed based on this deficit practice. Resident 8's notice of transfer was faxed to the Office of the State Long-term Ombudsman. All resident's transferred to the hospital will have their notice of transfer or discharge form faxed to the Office of the State Long-term Ombudsman. Social Services Department will document in the progress notes of resident's medical record the completion of the notice of transfer or discharge form
and that the form was faxed to the Office of the State Long-term Ombudsman. Social Services Department will create a binder to be kept in the Social Services Office with copies of notice of transfer or discharge forms and confirmation that form was faxed to the Office of the State Long-term Ombudsman. This binder will be organized by month. Social Services Department will audit 2 charts a month of resident's transferred to the hospital to ensure the completion of the notice of transfer or discharge form and that the form was faxed to the Office of the State Long-term Ombudsman. This audit will continue until there is 100% compliance for 3 months in a row. Results of audits will be presented at monthly QAPI meeting.

483.24(c)(1) REQUIREMENT Activities Meet Interest/Needs Each Resident:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.24(c) Activities.
483.24(c)(1) The facility must provide, based on the comprehensive assessment and care plan and the preferences of each resident, an ongoing program to support residents in their choice of activities, both facility-sponsored group and individual activities and independent activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community.
Observations:

Based on clinical record review and staff interview, it was determined that the facility failed to provide an ongoing program of activities designed to meet the individual needs and interests for one of two residents reviewed (Resident 6).

Findings include:

Clinical record review for Resident 6 revealed a care plan dated September 24, 2021, that identified the resident at risk for elopement and the intervention was to provide a program of activities to minimize the potential for wandering while meeting the resident's needs for social and cognitive (thinking skills) stimulation.

Resident 6's care plan dated September 25, 2021, revealed the resident is dependent upon staff for activities, cognitive stimulation, social interactions related to cognitive deficits, and physical limitations. The resident was to receive four to five in-room one on one visits and/or group programs per week. The resident's preferred activities were listening to opera, classical music, music of native language, choirs and patriotic music, and videos of the beach and nature.

A significant change MDS (Minimum Data Set, an assessment tool completed at specific intervals to determine resident care needs) assessment dated December 20, 2021, revealed the resident is rarely or never understood and the family or significant other was not available for interview on the resident's preferences for daily and activity preferences.

Record review for Resident 6 revealed activity attendance records dated May and June 2022, which indicated the resident was not offered activities four to five times a week on the following weeks:

May 8 to 15, activity offered x 2
May 16 to 22, activity offered x 2
May 23 to 31, activity offered x 3
June 1 to 10, activity offered x 1

During an interview with Employee 2, activity director, on June 10, 2022, at 10:10 AM it was confirmed that it was unknown as to why the responsible party was not contacted to conduct the activity assessment on the MDS as the responsible party is actively involved in the resident's care and can be reached. Employee 2 also confirmed there was no documentation of music offered, and that the resident was not offered four to five activities each week.

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

28 Pa. Code 211.10(d) Resident care policies


 Plan of Correction - To be completed: 07/28/2022

No resident was harmed based on this deficit practice. An audit of all resident care plans will be conducted by 07/28/2022 to make sure care plans reflect resident choice of group and individual activities. Monthly activity calendars will reflect scheduled 1:1 times. Audits will occur weekly for 4 weeks, then monthly until 2 consecutive months at 100% show resident participation levels in both group and 1:1 groups are met based on their care plan goals.
483.25 REQUIREMENT Quality of Care:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.25 Quality of care
Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices.
Observations:

Based on clinical record review and staff interview, it was determined that the facility failed to provide the highest practicable care regarding the administration of physician ordered medication for one of 24 residents reviewed (Resident 4).

Findings include:

Clinical record review for Resident 4 revealed a physician order dated December 9, 2021, for the administration of Cardizem CD extended release (medication to treat high blood pressure, chest pain, or irregular heartbeat) 180 mg (milligram) capsule by mouth in the morning.

Record review for Resident 4 revealed a medication administration record dated May 13 through May 17, 2022, at 8:00 AM that the Cardizem CD was not administered at the scheduled time and to see nurse's notes.

An LPN (licensed practical nurse) progress note dated May 13, 2022, at 7:27 AM indicated that the above medication was ordered two days ago and was not available from the pharmacy and the pharmacy was called again on May 12, 2022.

Nursing documentation dated May 14, 2022, at 10:14 AM revealed that the above medication was not available, and the nurse spoke to pharmacy, and it was to be sent out that day.

Record review for Resident 4 revealed an LPN progress note dated May 15 and 16, 2022, at 7:52 AM and 8:09 AM, respectively, that the above medication was on order.

Record review for Resident 4 revealed an LPN progress note dated May 17, 2022, at 3:13 PM that the above medication was not there and "unable to get from pharmacy."

Record review for Resident 4 revealed an RN (registered nurse) progress note dated May 17, 2022, at 6:21 PM that the resident had not received the Cardizem extended release 180 mg for five days. The resident was unaware. The resident was assessed, especially for cardiac (heart) responses of irregular heartbeat, palpitations (heart flutter, racing, or pounding), vertigo (a spinning sensation), headache, or shortness of breath. "BP's (blood pressures) have been taken and recorded daily. Lying, sitting, and standing blood pressures were done. The physician assistant was made aware. The medication missed was due to insurance issues with pharmacy."

Review of an email dated May 19, 2022, at 10:29 AM to Resident 4's responsible party from the facility, revealed that the nurse ordered the above medication from the incorrect pharmacy and the facility's response to prevent further recurrence was for the facility to assume financial responsibility.

Record review for Resident 4 revealed no evidence in the progress notes, medication administration record, or vital sign record that blood pressures were monitored, or the resident was monitored for the above potential concerns outlined in the RN progress note written on May 17, 2022. In addition, there was no documented evidence that the physician or RN was notified prior to May 17, 2022, that medication was not available.

During an interview with the Director of Nursing on June 9, 2022, at 10:45 AM the above medication omission and lack of documentation for Resident 4 was confirmed.

483.25 Quality of Care
Previously cited 6/29/21

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

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



 Plan of Correction - To be completed: 07/28/2022

Resident 4 does have adequate Cardizem CD stock at this time. RN's and LPN's will be educated by 07/07/2022 regarding medication being pulled or ordered from the on-site Omnicell if outside pharmacy cannot provide. Any resident not receiving medication from facility contracted pharmacy, Omnicare, will be recorded on paper in the from of the medication binder on the corresponding med cart. An EMAR order will be placed in each resident record and checked weekly to make sure a minimum of a seven day supply is present. An EMAR order will be placed to sign off every shift to notify RN if medication is not available from outside pharmacy. Audit will be done weekly for 4 weeks then monthly for 2 months. Findings from audit will be presented at monthly QAPI meeting.
483.25(i) REQUIREMENT Respiratory/Tracheostomy Care and Suctioning: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(i) Respiratory care, including tracheostomy care and tracheal suctioning.
The facility must ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals and preferences, and 483.65 of this subpart.
Observations:

Based on review of select facility policies and procedures, clinical record review, observation, and visitor and staff interview, it was determined that the facility failed to administer supplemental oxygen consistent with professional standards of practice for one of one resident reviewed for oxygen concerns (Resident 25).

Findings include:

The facility policy entitled, "Oxygen Administration," last reviewed without changes on January 27, 2022, revealed that the first procedural step instructs the user to review the physician's order for liter flow, method of administration, frequency of oxygen saturation monitoring, and desired titration percentages. The procedure instructs the user to set the flow meter to the rate ordered by the physician. Care Plan Documentation Guidelines include to identify the appropriate problem under which to list oxygen administration as an approach; list measurable goal(s) to be accomplished (i.e., control or resolution of signs or symptoms that indicate the need for oxygen therapy); and list instructions unique to the resident in the approaches.

Observation of Resident 25 on June 7, 2022, at 1:33 PM revealed supplemental oxygen in place via a nasal canula (flexible tubing with a two-pronged end superficially inserted into the nose to administer supplemental oxygen) that was connected to a room concentrator (machine used to concentrate the oxygen from room air to supply oxygen-enriched air back to the resident). The rate set on the flow meter was less than one liter per minute. Interview with the paid care giver present in Resident 25's room on the date and time of the observation revealed that she believed Resident 25's oxygenation saturations have been running in the low to middle 90s. She stated that Resident 25 is not on supplemental oxygen all the time; just as needed.

Clinical record review for Resident 25 revealed a physician's order active since January 21, 2022, to administer supplemental oxygen at two liters per minute via a nasal cannula as needed to keep oxygen saturations greater than or equal to 90 percent. The active order did not include instructions for staff to titrate the oxygen below two liters per minute.

Nursing documentation dated February 20, 2022, at 6:51 AM revealed that the registered nurse assessed Resident 25 who was desaturating (percentages lower than 90 percent when staff used a medical device placed over the tip of one finger to assess the oxygen saturation in capillary blood) and congested. The documentation indicated that the assessment of Resident 25's oxygen saturation was 84 percent on supplemental oxygen set at four liters per minute; and staff increased the flow rate to five liters per minute. Staff assessed abnormal sounds (crackles and wheezing) when they listened to Resident 25's lungs with a stethoscope.

The clinical record did not contain evidence that the staff contacted Resident 25's physician to obtain an order to titrate Resident 25's oxygen above two liters per minute.

Nursing documentation dated April 16, 2022, at 2:17 PM revealed that Resident 25 was noted to be short of breath and wheezing at approximately 5:00 AM that day. Staff assessed Resident 25's oxygen saturation as 73 percent on room air and applied supplemental oxygen at two liters per minute. Resident 25 showed no improvement and staff documented that after a nebulizer (medicated breathing) treatment was given, the registered nurse increased the supplemental oxygen "at small intervals" while monitoring Resident 25's oxygen saturation. The documentation indicated that Resident 25's oxygen saturation was 90 percent while on five liters per minute. Staff assisted Resident 25 to her wheelchair for breakfast that morning and assessed her saturation as 95 percent while continuing on supplemental oxygen at five liters per minute. Staff then decreased the liter flow slowly to two liters per minute.

The clinical record did not contain evidence that the staff contacted Resident 25's physician to obtain an order to titrate Resident 25's oxygen above two liters per minute on April 16, 2022.

A quarterly MDS (Minimum Data Set, an assessment tool completed at specific intervals to determine resident care needs) assessment dated April 20, 2022, errantly indicated that Resident 25 did not use supplemental oxygen in the previous 14 days (despite the above nursing documentation dated April 16, 2022, confirmed Resident 25's use of supplemental oxygen).

Review of plans of care developed by the facility for Resident 25 revealed no approaches that included the use of supplemental oxygen.

The surveyor reviewed the above findings pertaining to Resident 25's supplemental oxygen use during an interview with the Nursing Home Administrator and the Director of Nursing on June 9, 2022, at 3:45 PM.

483.25(i) Respiratory/tracheostomy Care and Suctioning
Previously cited deficiency 6/29/21

28 Pa. Code 211.11(d) Resident care plan

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


 Plan of Correction - To be completed: 07/28/2022

No resident was harmed based on this deficit practice. Education to all LPN's and RN staff to check that oxygen orders matches liter flow rate for oxygen, if SPO2 indicates resident needs a higher level of oxygen then staff must notify MD and document in resident record will occur by 07/07/2022. Audits on all oxygen orders will be conducted weekly for 4 weeks then monthly until two consecutive months are at 100% compliance. Findings from audits will be presented at monthly QAPI meeting.
483.35(a)(1)(2) REQUIREMENT Sufficient Nursing Staff:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.35(a) Sufficient Staff.
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)(1) The facility must provide services by sufficient numbers of each of the following types of personnel on a 24-hour basis to provide nursing care to all residents in accordance with resident care plans:
(i) Except when waived under paragraph (e) of this section, licensed nurses; and
(ii) Other nursing personnel, including but not limited to nurse aides.

483.35(a)(2) Except when waived under paragraph (e) of this section, the facility must designate a licensed nurse to serve as a charge nurse on each tour of duty.
Observations:

Based on review of select facility policies and procedures, observation, and resident and staff interview, it was determined that the facility failed to have sufficient nursing staff to meet a resident's needs for one of two residents reviewed for sufficient staffing (Resident 27).

Findings include:

The facility policy entitled, "Call Light, Use Of," last reviewed without changes on January 27, 2022, revealed that it is the purpose of the policy to have staff respond promptly to a resident's call for assistance. The procedure reiterated the instruction to answer all call lights in a timely manner. The policy did not include a quantitative measurement (e.g., number of minutes) that the facility deemed acceptable or outside acceptable parameters regarding call bell response times.

Observation of Resident 27 on June 8, 2022, at 10:21 AM revealed she was still in bed dressed in a hospital gown. Interview with Resident 27 on the date and time of the observation revealed that she was still in bed because no one had helped her get out of bed. Resident 27 stated that it was not her preference to still be in bed at that hour of the morning; and she stated that she has missed an occasional therapy session because of the lack of help. Resident 27 stated that it, "...seems like I'm the last one (to receive help with morning care)." Resident 27 confirmed that she ate her breakfast while in bed. During the ongoing interview with Resident 27 on June 8, 2022, at 10:27 AM, she stated that she receives, "water pills (diuretic medication that increases the frequency and urgency of urination)," and that she tries, "...to hold it (her urine) but sometimes they take a while." Resident 27 stated that her wait could be one-half to one hour long.

Review of Resident 27's call bell report dated May 8, 2022, to June 8, 2022, revealed the following examples of call bell wait times 25 minutes or more during the hours between 7:00 AM and 10:48 AM:

May 8, 2022, 26.4 minutes, from 8:52 AM to 9:19 AM
May 11, 2022, 31.5 minutes, from 8:04 AM to 8:36 AM
May 14, 2022, 33.1 minutes, from 10:15 AM to 10:48 AM
May 19, 2022, 36.7 minutes, from 9:09 AM to 9:46 AM
May 21, 2022, 52.2 minutes, from 7:00 AM to 7:52 AM
May 26, 2022, 26.5 minutes, from 7:11 AM to 7:38 AM
May 30, 2022, 48.5 minutes, from 7:25 AM to 8:13 AM
May 31, 2022, 29.9 minutes, from 8:23 AM to 8:53 AM
June 3, 2022, 25 minutes, from 7:14 AM to 7:39 AM
June 4, 2022, 60 minutes, from 7:59 AM to 8:59 AM

The surveyor reviewed the above findings during an interview with the Nursing Home Administrator and the Director of Nursing on June 9, 2022, at 2:00 PM. The Nursing Home Administrator stated that it is the facility's expectation that staff respond to resident call bells in approximately 15 minutes.

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

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


 Plan of Correction - To be completed: 07/28/2022

No residents were harmed based on this deficit practice. Education to all associates on the importance of any associate being able to respond to a call bell, will be completed on 07/07/2022. Call bell audits for all call bells greater than 25 minutes will be completed weekly for 4 weeks and root cause analyze will be completed for each of these call bells. Then audits will continue every two weeks until less than five call bells a week are greater than 25 minutes for two consecutive weeks. Findings from audits will be presented at monthly QAPI meetings.
483.80(i)(1)-(3)(i)-(x) REQUIREMENT COVID-19 Vaccination of Facility Staff:Least serious deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents. This deficiency has the potential for causing no more than a minor negative impact on the resident.
483.80(i)
COVID-19 Vaccination of facility staff. The facility must develop and implement policies and procedures to ensure that all staff are fully vaccinated for COVID-19. For purposes of this section, staff are considered fully vaccinated if it has been 2 weeks or more since they completed a primary vaccination series for COVID-19. The completion of a primary vaccination series for COVID-19 is defined here as the administration of a single-dose vaccine, or the administration of all required doses of a multi-dose vaccine.

483.80(i)(1) Regardless of clinical responsibility or resident contact, the policies and procedures must apply to the following facility staff, who provide any care, treatment, or other services for the facility and/or its residents:
(i) Facility employees;
(ii) Licensed practitioners;
(iii) Students, trainees, and volunteers; and
(iv) Individuals who provide care, treatment, or other services for the facility and/or its residents, under contract or by other arrangement.

483.80(i)(2) The policies and procedures of this section do not apply to the following facility staff:
(i) Staff who exclusively provide telehealth or telemedicine services outside of the facility setting and who do not have any direct contact with residents and other staff specified in paragraph (i)(1) of this section; and
(ii) Staff who provide support services for the facility that are performed exclusively outside of the facility setting and who do not have any direct contact with residents and other staff specified in paragraph (i)(1) of this section.

483.80(i)(3) The policies and procedures must include, at a minimum, the following components:
(i) A process for ensuring all staff specified in paragraph (i)(1) of this section (except for those staff who have pending requests for, or who have been granted, exemptions to the vaccination requirements of this section, or those staff for whom COVID-19 vaccination must be temporarily delayed, as recommended by the CDC, due to clinical precautions and considerations) have received, at a minimum, a single-dose COVID-19 vaccine, or the first dose of the primary vaccination series for a multi-dose COVID-19 vaccine prior to staff providing any care, treatment, or other services for the facility and/or its residents;
(iii) A process for ensuring the implementation of additional precautions, intended to mitigate the transmission and spread of COVID-19, for all staff who are not fully vaccinated for COVID-19;
(iv) A process for tracking and securely documenting the COVID-19 vaccination status of all staff specified in paragraph (i)(1) of this section;
(v) A process for tracking and securely documenting the COVID-19 vaccination status of any staff who have obtained any booster doses as recommended by the CDC;
(vi) A process by which staff may request an exemption from the staff COVID-19 vaccination requirements based on an applicable Federal law;
(vii) A process for tracking and securely documenting information provided by those staff who have requested, and for whom the facility has granted, an exemption from the staff COVID-19 vaccination requirements;
(viii) A process for ensuring that all documentation, which confirms recognized clinical contraindications to COVID-19 vaccines and which supports staff requests for medical exemptions from vaccination, has been signed and dated by a licensed practitioner, who is not the individual requesting the exemption, and who is acting within their respective scope of practice as defined by, and in accordance with, all applicable State and local laws, and for further ensuring that such documentation contains:
(A) All information specifying which of the authorized COVID-19 vaccines are clinically contraindicated for the staff member to receive and the recognized clinical reasons for the contraindications; and
(B) A statement by the authenticating practitioner recommending that the staff member be exempted from the facility's COVID-19 vaccination requirements for staff based on the recognized clinical contraindications;
(ix) A process for ensuring the tracking and secure documentation of the vaccination status of staff for whom COVID-19 vaccination must be temporarily delayed, as recommended by the CDC, due to clinical precautions and considerations, including, but not limited to, individuals with acute illness secondary to COVID-19, and individuals who received monoclonal antibodies or convalescent plasma for COVID-19 treatment; and
(x) Contingency plans for staff who are not fully vaccinated for COVID-19.

Effective 60 Days After Publication:
483.80(i)(3)(ii) A process for ensuring that all staff specified in paragraph (i)(1) of this section are fully vaccinated for COVID-19, except for those staff who have been granted exemptions to the vaccination requirements of this section, or those staff for whom COVID-19 vaccination must be temporarily delayed, as recommended by the CDC, due to clinical precautions and considerations;
Observations:

Based on review of select facility policies and procedures, review of employee vaccination information, and staff interview, it was determined that the facility failed to implement a process to ensure that all documentation that supports staff requests for medical exemption included which of the authorized COVID-19 vaccines are clinically contraindicated for the staff member to receive and the recognized clinical reasons for the contraindications for one of one staff reviewed for medical exemptions (Employee 1).

Findings include:

The facility policy entitled, "COVID-19, Vaccinations - Associates and Ancillary Providers and Compassionate Caregivers," last reviewed without changes on January 27, 2022, revealed that only associates and ancillary providers meeting the approved medical exemptions will be exempt from COVID-19 vaccination. Contraindications are limited to specific medical circumstances that include a history of severe allergic reaction (e.g., anaphylaxis) to previous COVID-19 vaccine or other vaccine or an injectable therapy.

Current CDC (Centers for Disease Control) contraindications and precautions (found at https://www.cdc.gov/vaccines/covid-19/clinical-considerations/covid-19-vaccines-us.html) include a history of a severe allergic reaction (e.g., anaphylaxis) after a previous dose or to a component of the COVID-19 vaccine, history of a known diagnosed allergy to a component of the COVID-19 vaccine, Guillain-Barrsyndrome (GBS, rare condition in which your immune system attacks your nerves, leading to muscle weakness and even paralysis), and myocarditis or pericarditis (inflammation of or around the heart). The reference lists that the vaccinations are not necessarily contraindicated for those who have had an immediate allergic reaction to other vaccines (non-COVID-19) or injectable therapies; but that special precautions are recommended such as a 30-minute observation period following the immunization or an additional risk assessment. The resource stipulated that the benefit of vaccination outweighs the risks for most people.

Review of the facility's COVID-19 employee vaccination status information revealed that Employee 1 (registered nurse assessment coordinator) was not fully vaccinated; but was granted a medical exemption.

Interview with Employee 1 on June 8, 2022, at 3:32 PM confirmed that she had not received any COVID-19 immunizations due to a history of an allergic reaction to other substances.

Review of Employee 1's medical accommodation information provided by the facility, dated December 29, 2020, noted only, "Please excuse (Employee 1) from getting the COVID-19 vaccine at this time."

A Medical Exemption Statement for COVID-19 Vaccine Declination Associate form dated by the medical practitioner on January 25, 2021, noted the medical contraindication to the COVID-19 vaccine was a history of severe allergic reaction (e.g., anaphylaxis) to an injectable therapy.

The information provided by the facility did not stipulate which of the available COVID-19 vaccines were contraindicated for Employee 1. The information also did not indicate what injected therapy resulted in a reaction; or any current CDC medical contraindications diagnosed for Employee 1.

Interview with the Nursing Home Administrator on June 9, 2022, at 9:44 AM confirmed that the medical exemption documentation does not include which COVID-19 vaccinations are contraindicated; and is unclear as to what "injectable therapy" Employee 1 had a history of an allergic reaction to.

28 Pa. Code 201.14(a) Responsibility of Licensee

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



 Plan of Correction - To be completed: 07/28/2022

No resident was harmed based on this deficit practice. Facility will update their medical exemption form to include current CDC contraindications and precautions. Employee 1 to meet with medical practitioner to review new exemption form. Updated information will be placed in Employee 1 personal file. Updated medical exemption form will be used moving forward for all new associates who request a medical exemption for the COVID-19 vaccine. Audit will be completed quarterly for two quarters or until 100% compliance is met consecutively for two audits, on all associates who have a medical exemption to confirm proper documentation in place. Results of audits will be presented at monthly QAPI.
201.14(a) LICENSURE Responsibility of licensee.:State only Deficiency.
(a) The licensee is responsible for meeting the minimum standards for the operation of a facility as set forth by the Department and by other State and local agencies responsible for the health and welfare of residents.
Observations:

Based on staff interview and review of select facility policies, it was determined that the facility did not comply with the requirements of the Act 52 Infection Control Plan.

Findings include:

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

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

Review of the facility's infection control committee meeting attendance records since the last standard survey of June 2021, revealed no evidence that a physical plant or patient safety officer attended any of the four meetings held.

Interview with the Nursing Home Administrator and the Director of Nursing on June 10, 2022, at 9:30 AM confirmed that the facility conducts infection control committee meetings quarterly (attendance provided for July 8, 2021, October 14, 2021, February 10, 2022, and April 14, 2022). The Director of Nursing confirmed that the facility had no attendance records that included evidence that a physical plant/safety officer attended any meetings since the facility's last standard survey in June 2021.

The Healthcare-Associated Infection Prevention Reporting Guide for Nursing Homes, Written Notification (Serious Event Reporting), requires written notification to a patient or available family member or designee of the occurrence of a healthcare-associated infection. The resident/family member/responsible party must receive written notification within seven days of confirmation of the infection.

Interview with the Director of Nursing on June 10, 2022, at 9:30 AM, confirmed that the facility has no system to notify, and document the notification of the resident/family member/responsible party of a healthcare-associated infection.


 Plan of Correction - To be completed: 07/28/2022

No residents were harmed by this deficient practice. All quarterly infection control meetings will have the following attendees: medical staff, administration representative, laboratory personnel, nursing staff, pharmacy staff, physical plant personnel, patient safety officer, members of the infection control team, and community representative. Written notification will be given to the resident or family member or designee of a healthcare-associated infection. Quarterly audits will occur for 4 quarters on attendees at the infection control meetings. Monthly audits will occur for three months on healthcare-associated infection notification to the resident or family member or designee. Findings will be presented at monthly QAPI meeting.
211.5(d) LICENSURE Clinical records.:State only Deficiency.
(d) Records of discharged residents shall be completed within 30 days of discharge. Clinical information pertaining to a resident's stay shall be centralized in the resident's record.
Observations:

Based on a review of two closed clinical records and staff interview, it was determined that the facility failed to complete a discharge summary for one resident (Resident 55).

Findings include:

A review of the closed clinical record revealed that the facility admitted Resident 55 on February 23, 2021. Resident 55 ceased to breath on March 19, 2022. There was no documented evidence in the clinical record that the physician completed a discharge summary for Resident 55.

An interview with the Nursing Home Administrator on June 10, 2022, at 10:17 AM confirmed that there was no discharge summary completed by Resident 55's physician within 30 days of her death.

The facility failed to complete a discharge summary for Resident 55.











 Plan of Correction - To be completed: 07/28/2022

No resident was harmed by this deficient practice. MD will be educated by 06/18/2022 of the need to write a discharge summer on residents who cease to breathe, that includes a summary of care provided while at the facility. Monthly audit of 10% of discharges will occur for 4 months or until two consecutive months of 100% compliance are met, whichever is longer. Findings will be presented at monthly QAPI meeting.
211.9(j) LICENSURE Pharmacy services.:State only Deficiency.
(j) Disposition of discontinued and unused medications and medications of discharged or deceased residents shall be handled by facility policy which shall be developed in cooperation with the consultant pharmacist. The method of disposition and quantity of the drugs shall be documented on the respective resident's chart. The disposition procedures shall be done at least quarterly under Commonwealth and Federal statutes.
Observations:

Based on review of two closed resident records and staff interview, it was determined that the facility failed to account for the disposition of medications upon discharge for one closed record (Resident 55).

Findings include:

Review of Resident 55's closed clinical record revealed that she expired on March 19, 2022. There was no documented evidence that the facility accounted for the disposition or quantity of the following medications prescribed to Resident 55:

Amlodipine Besylate (a medication used to treat high blood pressure) 5 mg (milligrams)
Cyanocobalamin Tablet (a form of vitamin B12) 100 mcg (microgram)
Diltiazem HCl (a medication used to treat high blood pressure) 30 mg
Famotidine tab (used to treat stomach ulcers) 20 mg
Folic Acid (used to treat certain types of anemia) 400 mcg
Lasix (used to reduce extra fluid in the body) 20 mg
Metoprolol Tartrate (used to treat high blood pressure) 12.5 mg
Sertraline (used for the treatment of depression)100 mg.

Interview with the Nursing Home Administrator on June 10, 2022, 11:18 AM confirmed these findings.


 Plan of Correction - To be completed: 07/28/2022

No resident was harmed by this deficient practice. LPN's and RN's will be educated by 07/07/2022 that any discontinuation or destroyed medications must be documented in resident medical records including how many and how it was destroyed. Monthly audit of 10% of discontinued medications will be done weekly for 4 weeks, then monthly until two consecutive months at 100% compliance of proper documentation. Audit findings will be presented at monthly QAPI meeting.

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