Pennsylvania Department of Health
KADIMA REHABILITATION & NURSING AT LUZERNE
Patient Care Inspection Results

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KADIMA REHABILITATION & NURSING AT LUZERNE
Inspection Results For:

There are  79 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.
KADIMA REHABILITATION & NURSING AT LUZERNE - 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 February 29, 2024, it was determined that Kadima Rehabilitation & Nursing at Luzerne was not in compliance with the following requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care Facilities and the 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.




 Plan of Correction:


483.25(b)(1)(i)(ii) REQUIREMENT Treatment/Svcs to Prevent/Heal Pressure Ulcer:This is a more serious deficiency but is isolated to the fewest number of residents, staff, or occurrences. This deficiency results in a negative outcome that has negatively affected the resident's ability to achieve his/her highest functional status.
483.25(b) Skin Integrity
483.25(b)(1) Pressure ulcers.
Based on the comprehensive assessment of a resident, the facility must ensure that-
(i) A resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable; and
(ii) A resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing.
Observations:

Based on a review of clinical records, select facility policy, and investigation reports, and observation, and staff and resident interviews, it was determined that the facility failed to provide timely and consistent care, according to professional standards of practice, to prevent multiple facility acquired, unstageable pressure sores for one out of the 13 residents sampled (Resident 10).

Findings include:

A clinical record review revealed that Resident 10 was admitted to the facility on March 31, 2023, with diagnoses that included Parkinson's disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination) and schizophrenia (a chronic mental health disorder that involves problems with cognition, behavior, and emotions).

The resident's care plan, dated March 31, 2023, indicated that Resident 10 has potential for impairment to skin integrity with deceased mobility and bowel incontinence with interventions for encouraging good nutrition and hydration, keeping skin dry and clean, monitoring skin every shift and reporting findings to the nurse, and providing pressure mattress as ordered.

A physician's order for a pressure-reducing mattress was initiated on March 31, 2023.

A review of a quarterly Minimum Data Set assessment (MDS - a federally mandated standardized assessment process conducted periodically to plan resident care) dated December 23, 2023, revealed that the resident required maximum staff assistance for dressing and undressing his lower body and required partial or moderate assistance from staff to maintain perineal hygiene. The resident required partial or moderate assistance from staff to roll from lying on the back to the left and right sides in bed and partial or moderate assistance from staff to move from a lying position to a sitting position when in bed.

A Braden Scale for Predicting Pressure Sore Risk assessment dated January 2, 2024, indicated that Resident 10 was at mild risk of developing pressure injuries.

A review of Resident 10's Treatment Administration Record (TAR) for January 2024 revealed that skin inspection occurred on January 3, 10, and 17, 2024. A weekly skin review dated January 17, 2024, indicated that Resident 10's skin was intact. A review of a documentation survey report revealed that Resident 10 received a shower on January 17, 2024, at 7:51 PM.

A review of a documentation survey report revealed no evidence that Resident 10 was provided preventative skin care or turning and repositioning on January 20, 2024, during the night shift (11:00 PM through 7:00 AM).

A review of a documentation survey report revealed that Resident 10 was utilizing a low-air-loss mattress (an alternating pressure with low air loss system mattress designed to prevent and treat pressure injuries) during the months of December 2023 and January 2024 prior to pressure sore development. However, the Nursing Home Administrator stated during interview on February 29, 2024, at 11 AM that the resident was not utilizing a low-air-loss mattress, but a regular standard mattress during those months, until January 21, 2024.

A facility investigation report dated January 21, 2024, indicated that Employees B3, Nurse Aide, and Employee B4, Nurse Aide, identified that the resident had skin impairments on January 21, 2024 at 11:05 AM

Nursing notes dated January 21, 2024, at 7:29 PM indicated that Resident 10 presented with deep purple discoloration to his right buttock, right hip, and sacral area; the skin was intact. No drainage and no tenderness were noted. The resident denied pain or discomfort. The on-call physician was notified and the resident was immediately placed on an air mattress and referred to a wound consultant for evaluation and treatment.

There was no documented evidence of a treatment ordered at the time of discovery of the pressure sores, but referred to the outside wound consultant for evaluation and treatment during their next visit.

A witness statement dated January 21, 2024, provided by Employee B4, Nurse Aide, indicated that while doing care on she spotted \ and went to the RN right away. Employee B4 indicated that she did not notice the \ the day before.

A review of a facility investigation report dated January 26, 2024 revealed that Employee B4, NA, later admitted to not providing care to Resident 10 during her shift \ from 7:00 AM until 11:00 AM. The report indicated that Employee B4 was terminated.

A witness statement dated January 21, 2024, provided by Employee B2, registered nurse, revealed that she "assessed the resident and observed redness with darkened areas to the residents right and left buttocks and sacral area. A new mattress was immediately placed on the resident's bed."

A witness statement dated January 21, 2024, provided by Employee B5, Nurse Aide, indicated that on January 20, 2024, Employee B5 provided care for Employee B5 indicated that she did not notice any discoloration on the resident's buttocks, but the resident did not want to be repositioned, and the charge nurse was notified (Employee B6).

A witness statement dated January 21, 2024, provided by Employee B6, a Licensed Practical Nurse, indicated that on January 20, 2024, she was not notified of any areas or any refusals in care or repositioning. Employee B6 indicated that she did not see any \ on January 20, 2024, at 7:00 PM through January 21, 2024, at 7:00 AM.

An external provider wound evaluation and management summary dated January 22, 2024 revealed Resident 10 presented with (Site 1) an unstageable deep tissue injury (DTI) wound on the resident's sacrum measuring 3.0 cm x 3.0 cm described as having intact skin with purple/maroon discoloration and no exudate. (Site 2) An unstageable DTI wound on the resident's right hip measuring 4.0 cm x 10.0 cm described as having intact skin with purple/maroon discoloration and no exudate. (Site 3) An unstageable DTI wound on the resident's right ischium measuring 6.0 cm x 7.0 cm described as having intact skin with purple/maroon discoloration and no exudate. The evaluation indicated that "distribution and appearance of wounds to appear to be pressure." The external provider recommended a full panel of labs to work out possible causes of skin decline.

The National Pressure Ulcer Advisory Panel defines a deep tissue injury as "A pressure-related injury to subcutaneous tissues under intact skin. Initially, these lesions have the appearance of a deep bruise. These lesions may herald the subsequent development of a Stage III-IV pressure ulcers.

Three days after the pressure areas were identified, a physician's order was initiated on January 24, 2024, for skin prep wipes to "apply to right hip area topically every shift for wound house barrier to periwound."

A physician's order was also initiated on January 25, 2024, to reposition the resident every hour and document any refusals every shift.

A progress note dated January 29, 2024, at 7:08 AM indicated that Resident 10's right heel was pink, skin intact, and blanchable. The inner aspect of the left heel presented with a quarter-sized red area, skin intact and blanchable. Skin prep is applied to both heels and heels elevated off the surface with a pillow.

A progress note dated January 29, 2024, at 1:56 PM indicated that the physician was in to see the resident. Areas to the right hip, right ischium, and right buttock noted improvement. Ischial area debrided. Bilateral heel lifts were ordered at this time.

A physician's order was initiated on January 29, 2024, to apply skin prep to bilateral heels every shift for redness.

A hematology consultation report dated February 2, 2024, indicated findings of mild lymphopenia-likely medication-related and sequela (a pathological condition resulting from a prior disease, injury, or attack) of prior COVID infection, not neutropenic
(a condition where you have too few neutrophils, a type of white blood cell that fights infections by destroying germs). The consult noted the diagnosis of pressure-related injury.

An external provider wound evaluation and management summary dated February 5, 2024, revealed that the stage II sacrum pressure injury (site 1) had been resolved. An unstageable DTI wound (site 2) on the resident's right hip measuring 5.0 cm x 1.0 cm described as having intact skin with purple/maroon discoloration and no exudate. An unstageable (due to necrosis) pressure injury (site 3) on the resident's right ischium measured 5.0 cm x 5.0 cm x 0.2 cm described as having light serous exudate and 100% slough. The note indicated that the wound was stable with an insignificant amount of necrotic tissue and no signs of infection. An unstageable DTI wound (site 4) on the resident's left heel was indicated as resolved.

An external provider wound evaluation and management summary dated February 12, 2024, revealed that the unstageable DTI wound (site 2) of the resident's right hip had resolved. A full thickness stage III pressure injury (site 3) on the resident's right ischium measuring 3.5 cm x 4.0 cm x 0.2 cm was described as improving and as having a light serous exudate with 100% slough.

An external wound provider communication document indicated that the February 19, 2024, wound management appointment was rescheduled.

A clinical record review revealed that Resident 10 developed the following in-house acquired pressure sores from January 21, 2024, through February 26, 2024:

(site 1) unstageable deep tissue injury (DTI) sacrum measuring 3.0 cm x 3.0 cm.
(site 2) unstageable deep tissue injury (DTI) right hip measuring 4.0 cm x 10.0 cm.
(site 3) unstageable deep tissue injury (DTI) right ischium measuring 6.0 cm x 7.0 cm.
(site 4) unstageable deep tissue injury (DTI) resident's left heel
(site 6) partial thickness stage II pressure injury resident's left buttocks 0.5 cm x 1.0 cm x 0.1 cm

An external provider wound evaluation and management summary dated February 26, 2024, revealed a full thickness stage III pressure injury (site 3) on the resident's right ischium measuring 3.5 cm x 3.0 cm x 0.2 cm. The wound was described as improving with light serous exudate, 60% slough, and 40% granulation tissue. A new partial thickness stage II pressure injury (site 6) on the resident's left buttock measuring 0.5 cm x 1.0 cm x 0.1 cm was described as having no exudate and having open areas with exposed dermis.

An observation on February 29, 2024, at 8:50 AM revealed a superficial wound on Resident 10's left buttocks. The wound was measured by Employee 1, Licensed Practical Nurse, as 1.0 cm x 1.0 cm. The resident's buttocks wound was red in color with no drainage. Another wound on the resident's right ischium was measured by Employee 1 as 4.0 cm x 3.2 cm. The wound was pink in color with a thin, whitish film. After Employee 1 wiped the resident's ischium wound, a faint yellow liquid was visible on the white wipe. Resident 10 stated that he was not in pain during the wound treatment.

The facility failed to demonstrate the timely implementation of measures necessary to prevent skin breakdown, including pressure relief, turning and repositioning, and preventative care prior to the identification of the multiple facility acquired deep tissue injuries.

During an interview on February 29, 2024, at approximately 11:15 PM, the Director of Nursing and Nursing Home Administrator (NHA) confirmed that Resident 10 was using a regular standard mattress, not an alternating air mattress, prior to January 21, 2024. The DON stated during interview on February 29, 2024, at 11:30 AM indicated that the facility determined that Employee B4 failed to provide care for Resident 10 on January 21, 2024, from 7:00 AM through 11:00 AM as a contributing factor to the resident's skin breakdown.

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





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

1. Resident 10 has a consult for wound care. Resident 10's care plan has been reviewed by the IDT and updated with interventions. Resident 10 is being seen by in-house wound specialist.
2. An audit was completed on residents with pressure ulcers to ensure they have wound care consulted, a treatment order and their care plan contains interventions to heal and prevent pressure ulcers, such as turn and repositioning schedule and type of pressure reducing mattress. A facility wide Braden Scale audit was performed and reviewed by IDT to ensure residents were receiving the appropriate treatment.
3. Licensed nurses and non-licensed nursing staff were re-educated on prevention of pressure ulcers which includes the importance of a turn and repo schedule and importance of timely implementation of interventions by DON. DON will review wound care weekly to ensure timely and consistent care is being provided to residents.
4. The DON/designee will audit residents with newly developed pressure ulcers weekly x 4 then monthly x 2 to ensure there are timely implementation of interventions to prevent pressure ulcers. The results of the audit will be reviewed by the QAPI Committee for review and analysis of need for ongoing review.

483.60(a)(1)(2) REQUIREMENT Qualified Dietary Staff: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(a) Staffing
The facility must employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, taking into consideration resident assessments, individual plans of care and the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment required at 483.70(e)

This includes:
483.60(a)(1) A qualified dietitian or other clinically qualified nutrition professional either full-time, part-time, or on a consultant basis. A qualified dietitian or other clinically qualified nutrition professional is one who-
(i) Holds a bachelor's or higher degree granted by a regionally accredited college or university in the United States (or an equivalent foreign degree) with completion of the academic requirements of a program in nutrition or dietetics accredited by an appropriate national accreditation organization recognized for this purpose.
(ii) Has completed at least 900 hours of supervised dietetics practice under the supervision of a registered dietitian or nutrition professional.
(iii) Is licensed or certified as a dietitian or nutrition professional by the State in which the services are performed. In a State that does not provide for licensure or certification, the individual will be deemed to have met this requirement if he or she is recognized as a "registered dietitian" by the Commission on Dietetic Registration or its successor organization, or meets the requirements of paragraphs (a)(1)(i) and (ii) of this section.
(iv) For dietitians hired or contracted with prior to November 28, 2016, meets these requirements no later than 5 years after November 28, 2016 or as required by state law.

483.60(a)(2) If a qualified dietitian or other clinically qualified nutrition professional is not employed full-time, the facility must designate a person to serve as the director of food and nutrition services.
(i) The director of food and nutrition services must at a minimum meet one of the following qualifications-
(A) A certified dietary manager; or
(B) A certified food service manager; or
(C) Has similar national certification for food service management and safety from a national certifying body; or
D) Has an associate's or higher degree in food service management or in hospitality, if the course study includes food service or restaurant management, from an accredited institution of higher learning; or
(E) Has 2 or more years of experience in the position of director of food and nutrition services in a nursing facility setting and has completed a course of study in food safety and management, by no later than October 1, 2023, that includes topics integral to managing dietary operations including, but not limited to, foodborne illness, sanitation procedures, and food purchasing/receiving; and
(ii) In States that have established standards for food service managers or dietary managers, meets State requirements for food service managers or dietary managers, and
(iii) Receives frequently scheduled consultations from a qualified dietitian or other clinically qualified nutrition professional.
Observations:

Based on review of clinical records and staff interview it was determined that the facility failed to provide sufficient staff with the necessary skill set and competencies to ensure appropriate nutritional oversight for residents in the facility and nutritional assessment for one (Resident 2) out of 13 residents reviewed.

Findings include:

During an interview conducted on February 27, 2024, at 9:15 AM the foodservice director confirmed that she worked full-time and was a certified dietary manager (CDM). The CDM stated that the facility no longer employed a qualified dietitian on a full-time, part-time, or consultant basis.

Interview with the nursing home administrator on February 27, 2024, at 10:00 AM confirmed that the facility's qualified dietitian resigned on January 3, 2024.

A review of the Certifying Board for Dietary managers (the credentialing agency for the Association of Nutrition and Food Service professionals) scope of practice for certified dietary managers, these individuals were able to conduct routine nutritional screening including food/fluid intake information, calculate nutrient intake, implement diet plans and orders, utilize standard nutrition nutrition care procedures, document nutritional care screening data in the medical record and complete forms, review meal intakes, complete meal rounds, document food intake, participate in care conferences and review the effectiveness of nutritional care. Basic diet information could be provided using evidence based education materials.

Their scope of practice did not include the clinical assessment and evaluation of residents for medically related nutritional therapy or to make recommendations regarding medications or supplementation.

The facility's food service director had limited scope of practice and lacked necessary credentials/qualifications to provide the operational and nutritional oversight of a Registered Dietitian or clinically qualified nutrition professional.

According to review of Resident 2's clinical record the resident was admitted to the facility on February 8, 2024, with diagnoses which included diabetes, esophagitis, dysphagia (difficulty swallowing), and depression. Review of the clinical record revealed no documented evidence that a nutritional assessment was completed by a qualified dietitian to evaluate the nutritional needs and nutritional risk for Resident 2 who was admitted to the facility on February 8, 2024.

Interview with the administrator on February 28, 2024, at approximately 11:00 AM confirmed that the facility had not yet hired a qualified dietitian or clinically qualified nutrition professional.

Refer F692

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







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

1. Resident 2 no longer resides in the facility. A consultant Registered Dietician has been hired.
2. A facility wide audit was performed to ensure other residents were not missing nutritional assessments. A one-time audit was performed to ensure that a qualified RD was hired for the facility.
3. The RNAC and The Onboarding Specialist will be re-educated on the requirement to employee a Registered Dietician for the facility and importance of conducting nutritional assessments for residents. The Registered Dietician will audit resident records monthly to ensure each resident has a timely and accurate nutritional assessment completed.
4. The Dietician/designee will randomly audit nutritional assessments for residents weekly x 4 then monthly x 2. The results of the audit will be reviewed by the QAPI Committee for review and analysis of the need for ongoing monitoring.

483.80(b)(1)-(4) REQUIREMENT Infection Preventionist Qualifications/Role: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.
483.80(b) Infection preventionist
The facility must designate one or more individual(s) as the infection preventionist(s) (IP)(s) who are responsible for the facility's IPCP. The IP must:

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

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

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

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


Based on a review of select facility policy and staff interview, it was determined that the facility did not have one or more individuals serving as the Infection Preventionist (IP) responsible for the facility's infection prevention plan.

Findings included:

A review of the facility's infection control policy, last reviewed October 20, 2023, provided by the facility during the survey of February 29, 2024, revealed that the facility will maintain an infection control program designed to provide a safe, sanitary, comfortable environment and to help prevent the development and transmission of disease and infection. The facility assures that there is an infection control program that is effective for investigation, controlling and preventing infections. This facility will assign an infection control coordinator to collect data, monitor and analyze and make recommendations. This data will be submitted to the Quality Assurance Performance Improvement (QAPI) committee.

Interview with the nursing home administrator (NHA) on February 27, 2024, at approximately 8:45 AM, revealed that the facility had been without an Infection Preventionist (IP) since the previous IP left on January 22, 2024. The NHA confirmed that the facility does not currently have an infection Preventionist performing the regulatory required duties, and that current ongoing infection prevention and control program (IPCP) was not being completed as expected.

Refer F880

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

28 Pa. Code 211.10(a) Resident care policies

28 Pa. Code 211.12 (d)(4) Nursing services









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

1. The facility hired an Infection Preventionist.
2. A one-time audit will be performed to ensure that a qualified individual is hired for the Infection Preventionist position.
3. DON and Onboarding Specialist re-educated on importance of employing an Infection Preventionist to ensure we are meeting the requirement of employing an IP who is responsible for the facility's Infection Control plan. DON, CDM, and NHA obtained Infection Control training as a backup.
4. DON/designee will conduct random audits of infections weekly x4 then monthly x2. The results of the audit will be reviewed by the QAPI Committee for review and analysis of need for ongoing review.

483.80(a)(1)(2)(4)(e)(f) REQUIREMENT Infection Prevention & Control: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.
483.80 Infection Control
The facility must establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections.

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

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

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

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

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

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

Based on observation, review of the facility's infection control tracking logs and policy, and staff interviews it was determined that the facility failed to maintain a comprehensive program to monitor the development and spread of infections within the facility and plan preventative measures accordingly and failed to ensure the consistent implementation of infection control procedures designed to prevent the potential for the spread of infection during the medication administration for two out of two medication carts (North and South).

Findings include:

A review of the facility's infection control policy, last reviewed October 20, 2023, provided by the facility during the survey of February 29, 2024, revealed that the facility will maintain an infection control program designed to provide a safe, sanitary, comfortable environment and to help prevent the development and transmission of disease and infection. The facility assures that there is an infection control program that is effective for investigation, controlling and preventing infections. This facility will assign an infection control coordinator to collect data, monitor and analyze and make recommendations. This data will be submitted to the Quality Assurance Performance Improvement (QAPI) committee. Ongoing monitoring for occurrence of infections for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon the facility assessment. Implementation of Control Measures and Precautions include basics such as cleaning and hand hygiene, as well as Standard and Transmission Based Precautions.

At the time of review of the facility's infection control program on February 29, 2024, at 11:00 AM the facility was unable to provide the facility's infection control tracking for prior months and the current month. There was no documented evidence of facility infection control data and infection control tracking which reflected a current functioning tracking system to monitor and investigate causes of infection and manner of spread. There was no documented evidence of a system, which enabled the facility to analyze clusters, changes in prevalent organisms, or increases in the rate of infection in a timely manner.

There was no documented evidence of detailed data collection that could be used by the facility to track infections and to identify any potential trends contained in the tracking data. There was no documented evidence at the time of the survey that based on the available tracking data that the facility had identified any possible trends to implement specific interventions to prevent the spread of any of the infections.

It could not be determined if the facility determined which infections required the implementation of isolation protocols, required treatment, the specific room location, location acquired, infectious organism or antibiotic therapy.

There was no indication that the facility was compiling data and evaluating the data to determine what could be done to prevent the spread or recurrence of infection. The facility failed to include the necessary details to conduct routine, ongoing, and systematic collection, analysis, interpretation, and dissemination of surveillance data to identify infections [i.e., healthcare associated infection (HAI) and community-acquired), infection risks, communicable disease outbreaks, and to maintain or improve resident health status and to track staff for adherence to infection control policies and procedures and the potential need for corrective action.

Interview with the director of nursing (DON) and administrator (NHA) on February 29, 2024, at 11:00 AM revealed that they were both newly hired at the facility and the facility did not currently employ an infection preventionist. The administrator confirmed that the facility did not have an infection preventionist (IP) since January 22, 2024, and were unable to locate the infection surveillance and tracking records maintained by the previous IP.

Observation of medication administration pass, on February 27, 2024, at approximately 8:26 AM, revealed Employee 1, Licensed Practical Nurse (LPN), on the North medication cart. A cell phone was observed laying on the top of the medication cart, towards the back, beneath the computer screen.

Interview with Employee 1, LPN, on February 27, 2024, at approximately 8:27 AM, confirmed the observation, and stated it was her own personal cell phone, and verified that she had not adhered to infection control procedures during this medication pass.

A continued observation of medication administration pass on February 27, 2024, at approximately 8:53 AM, revealed Employee 2, (LPN) on the South Medication cart. Employee 2, LPN, used hand sanitizer, which was located on the top of the medication cart. After sanitizing her hands, Employee 2 then used the computer mouse, rearranged various items on the top of the medication cart, opened the medication cart drawer, in preparation to administer medications to Resident 25. Employee 2 (LPN) did not wash or sanitize her hands after these tasks and prior to preparing medications. Employee 2 (LPN) removed a plastic sleeve of pills which included Potassium, and Levetiracetam. After tearing the sleeve open, and reading the packet, the 2 pills, (Potassium, and Levetiracetam) fell out onto the top of the medication cart. Employee 2 (LPN) proceeded to pick each pill up using her bare hands, one at a time, and placing them into the medication cup.

Employee 2 (LPN) then removed plastic pill bottles which included guaifenesin, thiamine, and aspirin. She removed the medications out of the bottles and placed each medication (guaifenesin, thiamine, and aspirin) one at a time, in her bare hands. Employee 2 then placed each medication, one at a time, touching each medication, in a medication cup for administration to Resident 25. Employee 2 (LPN) then administered the medications to Resident 25.

Interview with Employee 2, LPN, on February 27, 2024, at approximately 9:13 AM, confirmed that she touched the resident's medications with bare hands, and she had not adhered to infection control procedures during this medication pass.

Interview with the Director of Nursing (DON), on February 28, 2024, at approximately 12:00 PM, confirmed the facility had not adhered to infection control procedures during this medication pass.

Refer F882

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

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


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

1. Facility cannot retroactively implement a Infection Prevention and Control program.
2. Employee's 1 & 2 were counseled by DON on infection control practices while administering medications.
3. Licensed and non-licensed staff were re-educated by the DON on infection prevention and control practices. Licensed nurses were re-education by DON on infection control and prevention practices during medication administration. The facility has hired an Infection Preventionist to assist in providing a safe, sanitary, and comfortable environment and will monitor and track causes of infections and the need for isolation if required to ensure the facility adheres to proper infection control and prevention practices.
4. The DON/ designee will audit medication administration passes to ensure infection prevention practices are being followed, weekly x 4 then monthly x 2. The results of the audit will be reviewed by the QAPI Committee for review and analysis of need for ongoing review.

483.60(i)(4) REQUIREMENT Dispose Garbage and Refuse Properly: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)(4)- Dispose of garbage and refuse properly.
Observations:


Based on observation and staff interview, it was determined that the facility failed to properly maintain garbage and refuse containers in garbage storage area in a sanitary manner.

Findings include:

Observation on February 27, 2024, at 8:15 AM revealed the dumpster lid was not closed and two bags of garbage were placed on the ground next to the dumpster. There was scattered debris including paper wrappers, a slice of bread, and empty plastic beverage bottles on the ground surrounding the dumpster.

Observation on February 28, 2024, at 2:30 PM revealed two bags of garbage on the ground next to the dumpster.

Interview with the foodservice director (FSD) on February 29, 2024, at 11:45 AM confirmed that both dietary and housekeeping used the dumpsters. The FSD garbage was to be placed in the facility's dumpster and dumpster lids were to be kept closed. The FSD confirmed that the area surrounding the dumpster was to be maintained in a sanitary manner.


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







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

1. The Maintenance Director immediately threw bags of trash away and properly secured the lid of the dumpster. NHA and The Maintenance Director contacted trash removal company to re-verify trash pick up days are Monday, Wednesday, and Friday weekly and recycling pick up is every Tuesday, and as needed.
2. There is only one dumpster location.
3. Facility employees were re-educated on importance of disposing of trash into the dumpster and making sure the lid is properly secured when finished. The Maintenance Director will complete daily rounding of the facility and check to make sure the dumpster lid is closed.
4. NHA will conduct facility audits weekly x4 and then monthly x2 months to ensure that the trash is being properly disposed of and the dumpster lid is properly secured. The results of the audit will be reviewed by the QAPI Committee for review and analysis of need for ongoing monitoring.

483.10(c)(6)(8)(g)(12)(i)-(v) REQUIREMENT Request/Refuse/Dscntnue Trmnt;Formlte Adv Dir: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(c)(6) The right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.

483.10(c)(8) Nothing in this paragraph should be construed as the right of the resident to receive the provision of medical treatment or medical services deemed medically unnecessary or inappropriate.

483.10(g)(12) The facility must comply with the requirements specified in 42 CFR part 489, subpart I (Advance Directives).
(i) These requirements include provisions to inform and provide written information to all adult residents concerning the right to accept or refuse medical or surgical treatment and, at the resident's option, formulate an advance directive.
(ii) This includes a written description of the facility's policies to implement advance directives and applicable State law.
(iii) Facilities are permitted to contract with other entities to furnish this information but are still legally responsible for ensuring that the requirements of this section are met.
(iv) If an adult individual is incapacitated at the time of admission and is unable to receive information or articulate whether or not he or she has executed an advance directive, the facility may give advance directive information to the individual's resident representative in accordance with State law.
(v) The facility is not relieved of its obligation to provide this information to the individual once he or she is able to receive such information. Follow-up procedures must be in place to provide the information to the individual directly at the appropriate time.
Observations:

Based on a review of clinical records and select facility policy and staff interview, it was determined that the facility failed to demonstrate that it had ascertained if a resident had an advance directive upon admission and whether the resident would like information to formulate an advance directive for three of 13 sampled residents (Residents 2, 13, and 21).

The findings include:

Review of facility's Advance Directives policy last reviewed by the facility October 20, 2023, indicated that an advance directive is a written instruction such as a living will or durable power of attorney for healthcare, recognized under state law, relating to the provision of health care when the individual is incapacitated. The document expresses wishes about treatment preferences and the designation of a surrogate if the patient is incapacitated. The facility process includes that the social worker will meet with the resident/family upon admission, quarterly, annually, and as needed to review (advance directives).

A review of Pennsylvania Statute Title 20: Chapter 54: Healthcare revealed that an advance health care directive is a health care power of attorney, a living will, or a written combination of a health care power of attorney and a living will.

A review of the clinical record revealed that Resident 2 was admitted to the facility on February 8, 2024, with diagnoses which included diabetes and depression.

Review of Resident 2's admission Minimum Data Set (MDS- a federally mandated standardized assessment process completed periodically to plan resident care) dated February 16, 2024, revealed that the resident was moderately cognitively impaired with a BIMS (brief interview mental screening tool used to screen and identify cognitive impairment) score of 12 (8 to 12 indicates moderate cognitive impairment).

Resident 2's clinical record revealed a "Pennsylvania Physician Orders for Life-Sustaining Treatment" (POLST- The POLST is not intended to replace an advance health care directive document or other medical orders. The POLST process and health care decision-making works best when the person has appointed a health care agent to speak for them when they become unable to speak for themselves. A health care agent can only be appointed through an advance health care directive or a health care power of attorney), but no documented evidence of an Advance Directive or if the facility asked the resident if he would like information to formulate an advance directive.

Further review of Resident 2's clinical record revealed an Admission Agreement packet dated February 8, 2024, indicated that Advance Directives information was provided but did not indicate if the facility asked the resident if he would like to formulate an advance directive. There was no documented evidence that the facility determined if the resident had or did not have an Advance Directive or Healthcare Power of Attorney.

A review of the clinical record revealed that Resident 13 was admitted to the facility on May 8, 2023, with diagnoses which included seizures and dysphagia (difficulty swallowing).

Review of Resident 13's quarterly Minimum Data Set (MDS- a federally mandated standardized assessment process completed periodically to plan resident care) dated February 6, 2024, revealed that the resident was moderately cognitively impaired with a BIMS (brief interview mental screening tool used to screen and identify cognitive impairment) score of 12 (8 to 12 indicates moderate cognitive impairment).

Resident 13's clinical record revealed a "Pennsylvania Physician Orders for Life-Sustaining Treatment" but no documented evidence of an Advance Directive or if the facility asked the resident if he would like information to formulate an advance directive.

Further review of Resident 13's clinical record revealed an Admission Agreement packet dated June 1, 2023, indicated that Advance Directives information was provided but did not indicate if the facility asked the resident if he would like to formulate an advance directive. There was no documented evidence that the facility determined if the resident had or did not have an Advance Directive or Healthcare Power of Attorney.

A review of the clinical record revealed Resident 21 was admitted to the facility on December 23, 2021, with diagnoses to include major depressive disorder (a mood disorder that causes pervasive feelings of hopelessness, sadness, and loss of interest in activities that were once pleasurable) and congestive heart failure (a condition that develops when the heart doesn't pump enough blood to meet the body's needs).

A review of a quarterly Minimum Data Set assessment (MDS - a federally mandated standardized assessment process conducted periodically to plan resident care) dated January 26, 2024 revealed that Resident 21 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).

Further review of Resident 21's clinical record revealed an admission notice packet dated December 23, 2021, indicating that advance directive information was provided but did not indicate if the facility asked the resident if he would like to formulate an advance directive.

A clinical record review failed to reveal evidence of an advance directive or if the facility asked the resident if he would like information to formulate an advance directive. There was no documented evidence that the facility determined if the resident had or did not have an advance directive or durable healthcare power of attorney.

An interview with the social services director (SSD) on February 28, 2024, at 1:00 PM confirmed there was no documented evidence to indicate that the facility had determined if Residents 2, 13, and 21 had or did not have an advance directive upon admission to the facility. The SSD confirmed there was no documented evidence that Residents 2, 13, and 21 were made aware of the right to formulate an advance directive and that information to formulate an advance directive could be requested and provided by the facility.




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




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

1. The facility could not retroactively give resident 2 the opportunity to formulate an advanced directive upon admission.
2. Social Worker performed a 30 day lookback to ensure no other residents were missing advanced directive information.
3. Social Worker was re-educated on the Advanced Directive policy by NHA and the importance of offering each resident the opportunity to formulate an advanced directive upon admission/re-admission, and quarterly with MDS/care plan review to ensure residents have the information and opportunity to formulate an advanced directive.
4. NHA will conduct facility audits weekly x4 and then monthly x2 months to ensure that advanced directive information is being discussed upon admission with each resident. The results of the audit will be reviewed by the QAPI Committee for review and analysis of need for ongoing review.

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

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

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

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

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

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


Based on review of select facility policy and controlled drug records and observation and staff interview, it was determined that the facility failed to implement pharmacy procedures to promote accurate administration, and records accounting for controlled drugs for five of eight residents sampled (Resident 13, 7, 24, 19, and 8), and reconciliation of controlled drugs on one of two medication carts (North).

Finding include:

A review of the facility policy "Medication ordering, receiving, and storage" (Controlled Substance), and "Medication Storage in the facility" (ID3: Controlled medication storage) last reviewed by the facility October 20, 2023, stated nursing staff must count controlled medications at the end of each shift. The nurse coming on duty and the nurse going off duty will make the count together. They must document and report any discrepancies to the director of nursing services. The director or designee investigates and makes every reasonable effort to reconcile all reported discrepancies. If a major discrepancy, or a pattern of discrepancies occur, or if there is apparent criminal activity, the director of nursing notifies the administrator, medical director, and pharmacy immediately.

During the observation of the medication administration pass, on February 27, 2024, at approximately 8:26 AM, revealed Employee 1, Licensed Practical Nurse (LPN), on the North medication cart. A review of the shift-to-shift accountability form, as identified by Employee 1 (LPN), untitled, for February 2024, for the North Hall, revealed that the on-coming nurse and/or off-going nurse failed to sign the sheets during shift change on the following date to verify that nursing staff counted the controlled drugs in the respective medication cart: February 20, and 21, 2024.

A review of Resident 13's clinical record revealed he was admitted to the facility on May 10, 2023, with diagnoses to include pain. A physician order dated May 17, 2023, was noted for Tramadol (an opioid pain medication) 50 milligram (mg), give 0.5 tablet (25 mg) by mouth every 12 hours for chronic pain.

The "controlled substance record", accounting for Resident 13's supply of Tramadol 50 mg, 0.5 tablet, (25 mg) revealed that on February 23, 2024, at 2100 (9:00 PM), dose given 1, amount remaining 26. However, a closer look revealed the nurse failed to sign the sheet.

Interview with Employee 1, LPN, on February 27, 2024, at approximately 8:30 AM, confirmed the above observations of the shift to shift, and the controlled substance record was not signed and that the expectation is that it should have been signed.

A continued observation of medication administration pass on February 27, 2024, at approximately 8:53 AM, revealed Employee 2, (LPN) on the South Medication cart. A review of Resident 7's clinical record revealed she was most recently admitted to the facility on January 1, 2024, with diagnoses to include anxiety, and pain.

A physician order dated January 25, 2024, was noted for Hydrocodone-Acetaminophen (an opioid pain medication) 10-325 mg, give 1 tablet by mouth every 4 hours for chronic pain.

The "controlled substance record", accounting for Resident 7's supply of Hydrocodone-Acetaminophen 10-325 mg revealed that on February 22, 2024, at 0400 (4:00 AM), dose given 1, amount remaining 59, February 23, 2024, at 0800 (8:00 AM), dose given 1, amount remaining 58, February 23, 2024, at 1200 (12:00 PM), dose given 1, amount remaining 57, February 23, 2024, at 1600 (4:00 PM), dose given 1, amount remaining 56, February 23, 2024, at 2000 (8:00 PM), dose given 1, amount remaining 55, and February 24, 2024, at 0000 (12:00 AM), dose given 1, amount remaining 54. (The dose given on February 22, 2024, at 0400 [4:00 AM] was incorrectly dated the 22nd, the correct date should have been February 23, 2024).

A physician order dated January 1, 2024, was noted for Lorazepam (antianxiety medication) 1 mg, give 1 tablet by mouth two times a day related to anxiety.

The "controlled substance record", accounting for Resident 7's supply of Lorazepam 1 mg, revealed that on February 17, 2024, at 1620 (4:20 PM), dose given 1, amount remaining 28, February 18, 2024, at 0500 (5:00 AM), dose given 1, amount remaining 27, February 18, 2024, at 1615 (4:15 PM), dose given 1, amount remaining 26, February 18, 2024, at 0500 (5:00 AM). (The previous dose given on February 18, 2024, at 0500 [5:00 AM] was incorrectly dated February 18, the correct date should have been February 19, 2024). February 21, 2024, at 1610 (4:10 PM), dose given 1, amount remaining 20, February 22, 2024, at 0500 (5:00 AM), dose given 1, amount remaining 19, February 22, 2024, at 1550 (3:50 PM), dose given 1, amount remaining 18, and February 22, 2024, at 0500 (5:00 AM), dose given 1, amount remaining 17. (The previous dose given on February 22, 2024, at 0500 [5:00 AM] was incorrectly dated February 22, the correct date should have been February 23, 2024).

A review of Resident 24's clinical record revealed he was most recently admitted to the facility on November 24, 2023, with diagnoses to include cerebral infarction (stroke), dementia (group of symptoms affecting memory, thinking and social abilities), and right sided hemiplegia and hemiparesis (weakness on one side of the body).

A physician order dated September 22, 2023, was noted for Lorazepam (antianxiety medication) 0.5 mg, give 1 tablet via G-tube (feeding tube) every 8 hours with agitation, related to dementia.

The "controlled substance record", accounting for Resident 24's supply of Lorazepam 0.5 mg, revealed that on February 19, 2024, at 0000 (12:00 AM), dose given 1, amount remaining 36, February 19, 2024, at 0900 (9:00 AM), dose given 1, amount remaining 35, February 19, 2024, at 1642 (4:42 PM), dose given 1, amount remaining 34, and February 19, 2024, at 12 AM, dose given 1, amount remaining 33. (The previous dose given on February 19, 2024, at 12 AM was incorrectly dated February 19, the correct date should have been February 20, 2024).
And on February 22, 2024, at 0000 (12:00 AM), dose given 1, amount remaining 28, February 22, 2024, at 0900 (9:00 AM), dose given 1, amount remaining 27, February 22, 2024, at 1707 (5:07 PM), dose given 1, amount remaining 26, and on February 22, 2024, at 0000 (12:00 AM), dose given 1, amount remaining 25. (The previous dose given on February 22, 2024, at 0000 (12:00 AM), was incorrectly dated February 22, the correct date should have been February 23, 2024).

A review of Resident 19's clinical record revealed she was most recently admitted to the facility on July 15, 2023, with diagnoses to include anxiety.

A physician order dated March 22, 2023, was noted for clonazepam (antianxiety medication) 1 mg, give 1 tablet by mouth every 12 hours for anxiety.

The "controlled substance record", accounting for Resident 19's supply of clonazepam 1 mg, revealed that on February 10, 2024, at 0915 (9:15 AM), dose given 1, amount remaining 53, February 10, 2024, at 2132 (9:32 PM), dose given 1, amount remaining 52, and on February 10, 2024, at 0930 (9:30 AM), dose given 1, amount remaining 51. (The previous dose given on February 10, 2024, at 0930 (9:30 AM), was incorrectly dated February 10, the correct date should have been February 11, 2024).

A review of Resident 8's clinical record revealed she was admitted to the facility on May 11, 2023, with diagnoses to include chronic pain, anxiety, conversion disorder with seizures or convulsions.

A review of current physician orders dated November 28, 2023, was noted for Pregabalin (a controlled anticonvulsant) capsule 75 mg, give 2 capsules by mouth 1 time a day for restless leg syndrome.

A continued review of current physician orders dated December 13, 2023, revealed Pregabalin capsule 75 mg, give 1 capsule by mouth 1 time a day for chronic pain.

A review of February 2024, Medication Administration Record (MAR), revealed Lyrica (Pregabalin), oral capsule 75 mg, give 1 capsule by mouth one time a day for chronic pain, 0900 (9:00 AM), and Pregabalin oral capsule 75 mg, give 2 capsule by mouth one time a day for restless leg syndrome, 2100 (9:00 PM).

The "controlled substance record", accounting for Resident 8's Pregabalin, stated, Pregabalin (Lyrica) capsule 75 mg, take 1 capsule by mouth once daily and take 2 capsules (150 mg) by mouth at bedtime. Handwritten, in three (3) different locations on the controlled substance record was the words "PM dose", "PM", and "P.M." A closer look revealed that on February 21, 2024, at 2020 (8:20 PM), dose given 1, amount remaining 16, February 21, 2024, at 2008 (8:08 PM), dose given 1, amount remaining 15, (The previous dose given on February 21, 2024, at 2008 (8:08 PM), was incorrectly dated February 21, the correct date should have been February 22, 2024).

The facility failed to identify the discrepancies between the resident's controlled substance records, and the shift-to-shift accountability forms, failing to implement procedures to promote accuracy in administration, and accounting of controlled drugs and decrease the potential for drug diversion.

During an interview with the Director of Nursing (DON) on February 28, 2024, at approximately 12:00 PM, confirmed the above findings, and stated that her expectation is that the controlled substance record accurately reflect the medication accounting/use and administration to the resident, and that at change of shift to demonstrate that they completed the count of the controlled drugs to identify potential discrepancies and that the facility failed to implement procedures reconciliation and accurate controlled drug medication records.

Refer F761

28 Pa. Code 211.19(a)(1)(k) Pharmacy services

28 Pa. Code 211.5 (f) Medical records

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



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

1. Medication Reports were completed for the discrepancies noted on the controlled substance records for resident 13, resident 7, resident 24, resident 19 and resident 8.
2. An audit was completed on the controlled substance records for individual residents and the shift-to-shift accountability form to ensure accurate and complete documentation for the past 30 days.
3. Licensed nurses were re-educated on "Medication ordering, receiving and storage/ controlled substances" policy by DON. DON will randomly audit weekly controlled substance records and shift-to-shift accountability forms to ensure that there are no discrepancies.
4. The DON/Designee will audit the Shift-to-Shift Accountability Forms and the Residents' Controlled Medication record for complete and accurate documentation weekly x 4 then monthly x 2. The results of the audit will be reviewed by the QAPI Committee for review and analysis of need for ongoing review.

483.20(g) REQUIREMENT Accuracy of Assessments:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
483.20(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 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 three residents out of 13 sampled (Residents 3, 22, and 12).

Findings include:

According to the RAI User's Manual dated October 2023, Section A 1500 Preadmission Screening and Resident Review (PASRR) is to be completed if the type of assessment is an admission assessment, significant change or annual assessment.

The annual MDS Assessment of Resident 3 dated December 8, 2023, revealed Section A 1500 was coded as "0" indicating that the resident was not considered by the State to require a Level II PASRR process, to have serious mental illness, and/or intellectual disability or mental retardation or a related condition.

A review of Resident 3's clinical record revealed a Level I PASRR was completed on July 27, 2021, by the transferring facility, which indicated that the resident met the criteria for a Level II PASRR.

A further review of the resident's clinical record, revealed a letter of determination dated June 24, 2021, indicating the resident met the criteria for specialized services.

A review of the clinical record revealed that Resident 22 was admitted to the facility on February 26, 2023.

According to the RAI User's Manual, Section N, "Medications", items in this section assesses, a resident received medications during the seven-day look back period.

A review of Resident 22's Quarterly MDS Assessment dated December 23, 2023, revealed Section N0415 indicated the resident received anticoagulant medications during the look back period.

A review of Resident 22's clinical record from December 2023 revealed that the resident did not receive anticoagulant medication during the look back period.

Telephone interview with the registered nurse assessment coordinator (RNAC) on February 27, 2024, at approximately 1:35 PM, confirmed that Resident 3's annual MDS Assessment dated December 8, 2023, was inaccurate, with respect to completion of Section A 1500 related to the PASRR, and Resident 22's quarterly MDS dated December 23, 2023, with respect to completion of Section N 0415 related to anticoagulant usage, was inaccurate.

A review of the clinical record revealed that Resident 12 was admitted to the facility on May 30, 2021.

A review of Resident 12's Quarterly MDS Assessment dated February 23, 2024, revealed Section N0415 indicated the resident received anticoagulant medications during the look back period.

A review of Resident 12's clinical record from February 2024 revealed that the resident did not receive anticoagulant medication during the look back period.

Interview with the director of nursing on February 28, 2024, confirmed that Resident 12's quarterly MDS dated February 23, 2024, with respect to completion of Section N 0415 related to anticoagulant usage, was inaccurate.










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

1. Residents 3, 22 and 12 have had corrections completed on their assessments.
2. An audit of the assessments completed in the last 14 days to ensure the information submitted was complete and accurate.
3. RNAC and Social Services were re-educated on the importance of ensuring the information on the assessments is accurate. A Clinical Reimbursement Coordinator was hired to audit MDS assessments.
4. The DON/Designee will randomly audit 10% of MDS assessments for accuracy, weekly x 4 then monthly x 2. The results of the audit will be reviewed by the QAPI Committee for review and analysis of need for ongoing monitoring.

483.10(i)(1)-(7) REQUIREMENT Safe/Clean/Comfortable/Homelike Environment: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(i) Safe Environment.
The resident has a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

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

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

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

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

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

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

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

Based on observations, a review of facility policy, and resident and staff interviews, it was determined that the facility failed to provide housekeeping and maintenance services necessary to maintain a clean and homelike resident environment on two of two nursing units (North and South nursing units) and failed to ensure comfortable water temperatures including three residents out of the 13 sampled (Residents 13, 21, and 25), and three out of the six residents interviewed during a resident group interview (Residents 5, 23, and 28).

Findings Include:

An observation of resident room #19 on February 27, 2024, at 8:45 AM revealed the white window blinds were bent and missing fins. A dirt buildup was visible on the window sill between the window and the screen.

During an interview on February 27, 2024, at 8:52 AM, Resident 21 stated that he gets a draft in his room through drill holes that are utilized to hold the air-conditioning unit in place during the summer months. Resident 21 explained that he was provided a piece of duct tape to put over the holes to stop the draft. An observation of resident room #22, Resident 21's room, at the time of the interview, revealed multiple 0.5 cm holes in the window frame and a strip of black duct tape to the left of the resident's window. Resident 21 also stated that the shower water temperature is "cold a lot of the time." He explained that he doesn't shower in the morning because the "water temperature in the morning is often cold."

An observation of resident room #21 on February 27, 2024, at 10:46 AM revealed the white window blinds were cracked and missing fins. A dirt buildup was visible on the window sill between the window and the screen.

During an interview on February 27, 2024, at 12:30 PM, Resident 25 stated that when he takes a shower, "the water is hot for about a minute, but then it turns very cold." He explained that he never gets to take a warm shower.

During a resident group interview on February 28, 2024, at 10:00 AM, three residents in attendance (Residents 5, 23, and 28) voiced concerns about cold water temperatures during showers. Resident 5 explained that the shower water temperatures are often cold. Resident 23 stated that he arranged his shower schedule to avoid the times of day when the shower water temperatures are very cold. Resident 23 explained that there is not enough hot water in the mid-morning through early afternoon for an enjoyable shower, so he showers early in the morning or in the evening if possible. Resident 28 stated that she takes her shower early in the morning so she has enough hot water for her shower.

An observation of the shower on the North Nursing Unit on February 29, 2024, at 9:40 AM revealed a buildup of hair and debris in the shower drain.

A review of the facility Shower/Bathing Policy, last reviewed by the facility on October 20, 2023, revealed that staff were to adjust the temperature of the water before placing residents under the shower . Check temperature. Water should be per the resident's preference and not exceed state or federal guidelines specific to water temperature.

According to PA State Regulations: 205.63 (c) The facility shall ensure that water for baths and showers is at a safe and comfortable temperature before the resident is bathed. 205.63 (c) Hot water outlets accessible to residents shall be controlled so that the water temperature of the outlets does not exceed 110an interview with Resident 13 on February 27, 2024, at approximately 10:15 AM, revealed that the resident stated that at times when he receives a shower, "the water feels cold." Resident 13 also stated that for a bed bath or hygiene in his room, the water is also cold at times.

During observation of the resident's private bathroom at this time, the hot water was turned on at the sink by the surveyor and allowed to run but did not feel warm to touch.

An interview with employee 3 (nurse aide) on February 28, 2024, at approximately 1:00 PM confirmed that at times, before giving a resident a shower, the water must run for a few minutes for the water to warm up.

An interview with employee 4 (nurse aide) on February 29, 2024, at approximately 9:50 AM confirmed that the water does not always warm up enough to give a shower, and the resident's shower will have to be rescheduled.

During an interview with the maintenance director on February 29, 2024, at 10:00 AM, it was revealed that water temperatures in the facility are monitored three times weekly and failed to identify any concerns with water temperatures not being at a comfortable temperature (98.6 to 110 degrees Fahrenheit).

During an interview on February 29, 2024, at 10:45 AM, the director of nursing and administrator confirmed that comfortable water temperatures should be maintained during the resident's shower or bed bath and residents' environment was to be maintained in a clean and comfortable manner.



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

28 Pa Code 205.37 (e) Equipment for bathrooms.

28 Pa Code 205.63 (b) Plumbing and piping systems required for existing construction.












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

1. Maintenance Director filled holes in window with silicon to prevent draft from entering resident 21's room. Maintenance Director scheduled the facilities contracted hot water service to assess the temperature of the hot water for the facility. Assessment showed that water temperature's for facility were within adequate limits.
2. Maintenance Director performed a 1x facility audit of each resident room to assess for cleanliness, broken blinds, and holes near windowsill. Maintenance Director ordered blinds for each room that was identified to have broken blinds. EVS staff cleaned each resident windowsill that was identified as dirty, and all holes near window were filled with silicon.
3.Maintenance Director were re-educated on importance of auditing rooms for cleanliness and maintaining a homelike environment for the residents. CNA's were re-educated on performing water temperature checks when showering residents. NHA and Maintenance Director will perform routine rounding of resident's rooms to ensure a homelike environment is maintained.
4.NHA will conduct facility audits weekly x4 and then monthly x2 months to ensure that notifications regarding discharged resident's personal belongings are issued timely. The results of the audit will be reviewed by the QAPI Committee for review and analysis of need for ongoing review.

483.12 REQUIREMENT Free from Misappropriation/Exploitation: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.
483.12
The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms.
Observations:

Based on a review of the facility's abuse policy, select facility investigation reports, and clinical records, and staff interview, it was determined that the facility failed to ensure one resident out of 13 sampled was free from misappropriation of resident property, medication (Resident 13).

Findings included:

A review of the facility Abuse Protection Policy last reviewed October 20, 2023, revealed that the residents have the right to be free from verbal, physical and mental abuse, corporal punishment, involuntary seclusion, neglect, and misappropriation of property. abuse, neglect, misappropriation of resident property, and exploitation. Further it is indicated misappropriation is the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's permission.

A review of the clinical record review revealed that Resident 13 was admitted to the facility on December 23, 2021, with diagnoses which include congestive heart failure and depression.

The resident had a physician order initially dated April 12, 2023, for Oxycodone HCL (opioid pain medication) 5 mg one tablet daily for chronic pain.

A review of a facility investigation report dated February 22, 2024, at approximately 9:00 AM revealed that employee 1 (LPN) reported to the director of nursing that she was "popping" an Oxycodone 5 mg (pill number 14 on blister card) for Resident 13 when she noticed that pill number 13 looked like it was tampered with. Employee 1 (LPN) then looked at the medication more closely and noted that pill number 14 and pill number 13 was Claritin (as per Google search and facility inventory). The house stock (of Claritin) is the same pill that was in the blister pack for pill number 14 and pill number 13. Resident 13 was administered the correct medication. Employee 1 (LPN) administered Oxycodone 5 mg pill number 12 from the blister pack under the director of nursing's direction. The state agency, local area agency on aging, and the police were notified of the incident.

Interview with employee 1 (LPN) on February 28, 2024, at 10:00 AM revealed that on the day of the incident (February 22, 2024) she "popped" Resident 13's Oxycodone 5 mg from the blister pack and noticed that the next pill looked tampered with. Employee 1 (LPN) did a Google search of the pill that she popped and the one that looked tampered with by the number on the pill and found that it was Claritin. The incident was then reported to the director of nursing. Employee 1 stated that Resident 13 did receive his medication with the director of nursing approval to ensure an accurate count of the resident's remaining Oxycodone 5 mg medication.

An interview with the director of nursing (DON) on February 27, 2024, at approximately 1:00 PM confirmed the facility failed to ensure Resident 21 was free from misappropriation of resident property, the resident's medication.


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

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

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











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

1. Resident 13 received the correct medication that was ordered. No negative impact on resident.
2. An audit of controlled medications was completed to ensure that the medication blister packets were free of tampering.
3. All licensed nursing staff were re-educated on the Abuse/Neglect and Misappropriation Policy in regards to misappropriation of resident medication. DON will randomly audit medication carts weekly to ensure medications have not been tampered with.
4. The DON/designee will randomly audit the controlled medications in both medication carts and the emergency box for signs of tampering weekly x 4 then monthly x 2. The results of the audit will be reviewed by the QAPI Committee for review and analysis of need for ongoing monitoring.

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

483.45(h) Storage of Drugs and Biologicals

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

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


Based on review of select facility policy and clinical records, observation and staff interview, it was determined that the facility failed to ensure that medications were labeled according to accepted labeling requirements for one of five residents sampled (Resident 8).

Findings include:

A review of the facility's policy "Disposition of Medications" last reviewed by the facility October 20, 2023, indicated it is the policy to establish guidance for the disposition of medications to implement safe and responsible disposition practices of discontinues medications in order to protect residents and staff from improper diversion or accidental exposure. Medications discontinues by prescriber order, are destroyed onsite with disposition being reported on a paper form which is then scanned into the electronic medical record. Medications are removed from the medication cart immediately upon receipt of an order to discontinue in an effort to avoid inadvertent administration.

A review of Resident 8's clinical record revealed she was admitted to the facility on May 11, 2023, with diagnoses to include chronic pain, anxiety, conversion disorder with seizures or convulsions.

A current physician order dated November 28, 2023, was noted for Pregabalin (a controlled anticonvulsant) capsule 75 milligram (mg), give 2 capsules by mouth 1 time a day for restless leg syndrome, and an order dated December 13, 2023, for Pregabalin capsule 75 mg, give 1 capsule by mouth 1 time a day for chronic pain.

A review of February 2024, Medication Administration Record (MAR), revealed Lyrica (Pregabalin), oral capsule 75 mg, give 1 capsule by mouth once daily for chronic pain, 0900 (9:00 AM), and Pregabalin oral capsule 75 mg, give 2 capsule by mouth once daily for restless leg syndrome, 2100 (9:00 PM).

An observation of medication administration pass on February 27, 2024, at approximately 8:53 AM, revealed Employee 2, (LPN) on the South Medication cart. The "controlled substance record", accounting for Resident 8's Pregabalin, revealed Pregabalin (Lyrica) capsule 75 mg, take 1 capsule by mouth once daily and take 2 capsules (150 mg) by mouth at bedtime. Handwritten, in three (3) different locations on the controlled substance record was the words "AM dose", "AM", and "A.M.".

A second "controlled substance record", accounting for Resident 8's Pregabalin, revealed Pregabalin (Lyrica) capsule 75 mg, take 1 capsule by mouth once daily and take 2 capsules (150 mg) by mouth at bedtime. Handwritten, in three (3) different locations on the controlled substance record was the words "PM dose", "PM", and "P.M.".

However a closer observation of the second controlled substance record for Resident 8's Pregabalin, "PM dose", revealed on February 21, 2024, at 2020 (8:20 PM), dose given 1, amount remaining 16, and February 21, 2024, at 2008 (8:08 PM), dose given 1, amount remaining 15, (The previous dose given on February 21, 2024, at 2008 (8:08 PM), was incorrectly dated February 21, the correct date should have been February 22, 2024), which was confirmed during interview with Employee 2, LPN, on February 27, 2024, at approximately 9:15 AM.

In the presence of Employee 2, (LPN), the surveyor requested to view the medication card (blister pack) of the Pregabalin (Lyrica). Located within the medication cart, was a locked drawer containing two (2) blister cards for the Pregabalin (Lyrica). The first, 1 of 2, was labeled Pregabalin (Lyrica) capsule 75 mg, take 1 capsule by mouth once daily and take 2 capsules (150 mg) by mouth at bedtime, date filled February 10, 2024. Handwritten on the blister card, in two (2) different locations were the words "AM dose", "AM".

The second, 2 of 2, blister back was labeled Pregabalin (Lyrica) capsule 75 mg, take 1 capsule by mouth once daily and take 2 capsules (150 mg) by mouth at bedtime, date filled February 10, 2024. Handwritten on the blister card, in two (2) different locations were the words "PM dose", "PM".

Employee 2, LPN, on February 27, 2024, at approximately 9:15 AM, confirmed there was no additional medication blister packs of medication Pregabalin (Lyrica) for Resident 8 and that the two blister packs were labeled the same with the notation added for the AM dose and PM dose.

A review of physician orders dated June 28, 2023, was noted for Tramadol (an opioid pain medication) 50 mg, give 1 tablet by mouth every 12 hours for chronic pain. Discontinued November 24, 2023, an order dated November 24, 2023, for Tramadol 50 mg, give 1 tablet by mouth every 12 hours as needed for severe pain 8-10, discontinued December 1, 2023, an order dated December 1, 2023, for Tramadol 50 mg, give 1 tablet by mouth every 12 hours as needed for moderate to severe pain 4-10, discontinued December 12, 2023, an order dated December 12, 2023, was noted for Tramadol 50 mg, give 1 tablet by mouth every 8 hours as needed for moderate to severe pain 4-10, discontinued January 1, 2024, and an order dated January 1, 2024, for Tramadol 50 mg, give 1 tablet by mouth every 8 hours as needed for severe pain 8-10

A review of the resident's February 2024, Medication Administration Record (MAR), revealed
Tramadol oral tablet, 50 mg, give 1 tablet by mouth every 8 hours as needed for severe pain 8-10. The "controlled substance record", accounting for Resident 8's Tramadol oral tablet, 50 mg, give 1 tablet by mouth every 8 hours as needed for severe pain, was labeled "take 1 tablet by mouth every 12 hours", date filled November 28, 2023.

In the presence of Employee 2, (LPN), the surveyor requested to view the medication cards of Tramadol oral tablet, 50 mg. Located within the medication cart, was a locked drawer containing one blister card of Tramadol 50 mg tablets. The medication blister card was labeled "take 1 tablet by mouth every 12 hours", date filled November 28, 2023.

Employee 2, LPN, on February 27, 2024, at approximately 9:15 AM,confirmed that the labels on the Tramadol 50 mg, controlled substance record, and medication blister pack, was not correct, and did not match the current physician orders.

Interview with the Director of Nursing (DON), on February 28, 2024, at approximately 12:00 PM, confirmed that pregabalin (Lyrica) should have been labeled with individual labels for the administration times of (AM, PM) and the label on the medication blister pack containing the Tramadol 50 mg, and controlled substance record, did not presently match the current physician order.

Refer F 755

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

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




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

1. Resident no longer resides in facility.
2. Facility wide audit was completed of controlled medications to ensure the medication labels match the current physician orders.
3. Licensed nurses were re-educated on the facility Disposition of Medications policy and the Controlled Substance policy and the importance of controlled medications matching the physician orders by DON. DON will randomly audit medications weekly to ensure proper labeling of medications that matches the current physician orders.
4. The DON/ designee will randomly audit the controlled medication labels to ensure they reflect the current physician orders, weekly x 4 then monthly x 2. The results of the audit will be reviewed by the QAPI Committee for review and analysis of need for ongoing review.

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

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

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

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

Based on clinical record and select facility policy review, and staff interview it was revealed that the facility failed to monitor weight and evaluate nutritional and hydration requirements to ensure acceptable parameters of nutritional status are maintained to the extent possible for one resident out of 13 sampled (Resident 2).

Findings include:

Review of the facility "Resident Weights" policy last reviewed October 20, 2023, indicated that weights must be obtained routinely to monitor the parameters of nutrition over time, and identify residents at risk for significant weight change. Upon admission/readmission, the resident will be weighed each day for two days. The first weight will be within 24 hours of admission or readmission. After admission weights are obtained, the individual will be weighed weekly for four weeks. After the first 4 weeks, the interdisciplinary team will determine the need for continuation of weekly weights or a change to monthly weights. All weights will be transcribed (including weekly and any reweigh) in the resident's electronic medical record.

Review of the facility "Nutrition Management" policy last reviewed October 20, 2023, indicated that based on a resident's comprehensive assessment, the facility will ensure that a resident: maintains acceptable parameters of nutritional status, such as body weight and protein levels, unless the resident's clinical condition demonstrates that this is not possible; receives a therapeutic diet when there is a nutritional problem. In evaluating weight loss, the dietitian will consider the resident's usual weight through adult life, and the potential for weight loss related to any medical conditions. It should be noted if the resident was on a calorie-restricted diet prior to admission. Location and degree of any present edema should be noted.

A review of the clinical record revealed that Resident 2 was admitted to the facility on February 8, 2024, with diagnoses, which included diabetes, esophagitis, dysphagia (difficulty swallowing), and depression.

Further review of the clinical record revealed no documented evidence that a weight was obtained upon admission on February 8, 2024, or weekly (weeks of February 15 or February 22, 2024) as per facility policy. As of the survey on February 28, 2024, the facility had not yet obtained the resident's weight.

Further review of the clinical record at the time of the survey ending February 29, 2024, revealed no documented evidence that a complete nutritional assessment was completed by the registered dietitian to evaluate the nutritional and hydration needs and nutritional risk for Resident 2 who was admitted to the facility on February 8, 2024.

Interview with the director of nursing (DON) on February 28, 2024, at 10:00 AM confirmed that Resident 2's weight was not obtained as per facility policy. The DON confirmed that a nutritional assessment was not completed by the dietitian to evaluate the resident's nutritional and hydration needs and establish nutritional interventions to meet the resident's nutritional and hydration requirements to the extent possible. The DON confirmed that the facility did not currently employ a dietitian.

Refer F801

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: 04/29/2024

1. Resident 2 no longer resides at the facility. The facility has hired a consultant registered dietician.
2. An audit was conducted on current residents to ensure a current weight has been obtained and documented. If any weight concerns are found, they will be immediately addressed.
3. CDM and nursing staff were re-educated on the facility weight policy and nutrition management policy by the consultant registered dietician to ensure that residents weights are being monitored and that residents are receiving proper nutrition and hydration according to their assessment. CQI meeting has been implemented where weekly weights will be discussed. This meeting will include members of the IDT and consultant Registered Dietician.
4. The DON/ designee will audit 10% of residents to ensure weights are obtained per facility policy weekly x 4 then monthly x 2. The results of the audit will be reviewed by the QAPI Committee for review and analysis of need for ongoing review.

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

Based on a review of clinical records and select facility investigations, and staff interviews, it was determined that the facility failed to timely develop a person-centered care plan to address a resident's high risk for falls and meet the safety needs of one resident out of 13 sampled (Resident 10).

Findings include:


A clinical record review revealed that Resident 10 was admitted to the facility on March 31, 2023, with diagnoses that included Parkinson's disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination) and schizophrenia (a chronic mental health disorder that involves problems with cognition, behavior, and emotions).

A review of an annual comprehensive Minimum Data Set assessment (MDS - a federally mandated standardized assessment process conducted periodically to plan resident care) dated April 7, 2023, revealed a care area assessment (CAA- process provides guidance on how to focus on key issues identified during a comprehensive MDS assessment and directs facility staff and health professionals to evaluate triggered care areas) for Resent 10's potential problem with falls related to his difficulty maintaining sitting balance and impaired balance during transitions. The care area assessment worksheet dated April 7, 2023, indicated a care plan will be developed and implemented to address the resident's functional status.

A clinical record review revealed a care plan dated April 13, 2023, which did not include Resident 10's potential problems with falls related to his difficulty maintaining sitting balance and impaired balance during transitions.

A review of the clinical record of Resident 10 revealed fall risk evaluation forms dated July 2, 2023, and October 2, 2023, which indicated that Resident 10 was at high risk for falls.

A review of the resident care plan in effect from July 2, 2023, through the January 24, 2024, revealed that the facility failed to address the resident's risk for falls and safety needs on the plan of care.

A review of a quarterly MDS assessment, dated December 23, 2023, revealed that Resident 10 has moderate cognitive impairment with a BIMS score of 10 (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 8 - 12 indicates moderate cognitive impairment).

A review of Resident 10's MDS, Section GG0170 Mobility, dated December 23, 2023, revealed that he required partial or moderate assistance from staff to move from a seated position to a standing position, transferring from chair to chair, or ambulating 10 feet.

A physical therapy discharge summary dated January 6, 2024, revealed that Resident 10 was not assessed for his ability to pick up objects due to safety concerns. The summary indicated that Resident 10 received physical therapy services from December 9, 2023, through January 6, 2024. He was discharged because he reached his maximum potential with skilled therapy services.

A progress note dated January 24, 2024, at 11:15 AM revealed that Resident 10 was found on the floor in front of his wheelchair with the tray table pushed away. The wheelchair brakes were locked. The resident was wearing non-skid footwear.

A clinical record review revealed that following Resident 10's fall on January 24, 2024, a plan of care focus was developed relating to the resident's potential for falls related to cognitive impairment, dated January 24, 2024. Interventions developed included a call bell reminder sign on the wall, 15-minute safety checks, keeping the bed in the lowest position, keeping the call bell within reach, offering the resident to get out of bed during confusion periods, and reminding the resident to use the call ball.

During an interview on February 29, 2024, at approximately 12:00 PM, the Director of Nursing (DON) and Nursing Home Administrator (NHA) confirmed that the facility failed to timely develop and implement a plan of care to address Resident 10's risk of falling until after he fell on January 24, 2024. The DON and NHA confirmed that Resident 10 was evaluated as a high risk for falls in July 2023 and October 2023, which was not addressed on the resident's care plan.


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




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

1. Resident 10's care plan has been reviewed by IDT and revised to ensure that it reflects his high risk for falls.
2. An audit was completed on residents that triggered as a high fall risk via the fall evaluation to ensure care plans have been developed and interventions are in place to meet the safety needs of the resident.
3. Licensed nursing staff and non-licensed staff were re-educated on the Fall Prevention policy and safety needs of residents by DON. Licensed Nurses and IDT were re-educated on accurately care planning to meet the safety needs of the residents. The facility hired a Clinical Reimbursement Coordinator to audit care plans to ensure accuracy and that proper interventions are in place for each resident monthly.
4. The DON/ designee will randomly audit 25% care plans to ensure that the care plan has been developed or revised for residents that triggered as a high. The results of the audit will be reviewed by the QAPI Committee for review and analysis of need for ongoing monitoring.

483.10(g)(17)(18)(i)-(v) REQUIREMENT Medicaid/Medicare Coverage/Liability Notice:Least serious deficiency but affects more than a limited number of residents, staff, or occurrences. This deficiency has the potential for causing no more than a minor negative impact on the resident but is not found to be throughout this facility.
483.10(g)(17) The facility must--
(i) Inform each Medicaid-eligible resident, in writing, at the time of admission to the nursing facility and when the resident becomes eligible for Medicaid of-
(A) The items and services that are included in nursing facility services under the State plan and for which the resident may not be charged;
(B) Those other items and services that the facility offers and for which the resident may be charged, and the amount of charges for those services; and
(ii) Inform each Medicaid-eligible resident when changes are made to the items and services specified in 483.10(g)(17)(i)(A) and (B) of this section.

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


Based on a review of clinical records and facility documentation, and an interview with staff, it was determined that the facility failed to provide the required advance notice, through a Notice of Medicare Non-Coverage (CMS 10123-NOMNC), regarding the termination of Medicare services for one of the three residents sampled (Resident 26).

Findings include:

A review of the Centers for Medicare and Medicaid Services Form Instructions for the Notice of Medicare Non-Coverage (NOMNC) CMS-10123 revealed that the NOMNC must be delivered at least two calendar days before Medicare-covered services end or on the second to last day of service if care is not being provided daily.

A clinical record review revealed Resident 26 was admitted to the facility on October 5, 2023.

A clinical record review revealed that the facility provided Resident 26's representative with a Notice of Medicare Non-Coverage (CMS 10123-NOMNC) letter dated November 9, 2023. The notice indicated that Medicare would likely not pay for the resident's skilled services after November 9, 2023.

Further clinical record review failed to find evidence that Resident 26 or Resident 26's representative were provided at least a two-day notice before Medicare-covered services ended.

A clinical record review revealed a social services progress note dated November 9, 2023, at 12:54 PM indicating NOMNC verbal consent with A certified letter was sent for signature.

During an interview on February 28, 2024, at approximately 1:00 PM, the Director of Social Services confirmed that the facility failed to provide the required advance notice to Resident 26 or Resident 26's representitive through a Notice of Medicare Non-Coverage (CMS 10123-NOMNC), regarding non-coverage of Medicare services.



28 Pa. Code 201.29(a) Resident rights.



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

1.The facility could not retroactively issue a NOMNC timely for resident 26.
2.A 24-hour lookback was performed to ensure there were no other outstanding NOMNC's needing to be issued.
3.Social Worker and Business Office Manager were re-educated on ensuring a NOMNC is issued 48 hours prior to last covered day of Medicare A services. Last covered days will be reviewed in UR meetings weekly to ensure NOMNC's are being issued timely.
4.NHA will conduct facility audits weekly x4 and then monthly x2 months to ensure that NOMNC's are being issued 48 hours prior to last covered day. The results of the audit will be reviewed by the QAPI Committee for review and analysis of need for ongoing review.

483.15(c)(3)-(6)(8) REQUIREMENT Notice Requirements Before Transfer/Discharge:Least serious deficiency but affects more than a limited number of residents, staff, or occurrences. This deficiency has the potential for causing no more than a minor negative impact on the resident but is not found to be throughout this facility.
483.15(c)(3) Notice before transfer.
Before a facility transfers or discharges a resident, the facility must-
(i) Notify the resident and the resident's representative(s) of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand. The facility must send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman.
(ii) Record the reasons for the transfer or discharge in the resident's medical record in accordance with paragraph (c)(2) of this section; and
(iii) Include in the notice the items described in paragraph (c)(5) of this section.

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

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

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

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

Based on a review of clinical records and written transfer notices, and staff interview, it was determined that the facility failed to ensure that a written notice of a facility initiated hospital transfer of the resident was provided to the resident and the resident's representative for one resident out of five residents sampled (Resident 12).

The findings include:

Regulatory requirements indicate that before a facility transfers or discharges a resident, the facility must notify the resident and the resident's representative of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand.

A review of Resident 12's clinical record revealed that the resident was transferred to the hospital on November 15, 2023, and returned to the facility on November 20, 2023.

Clinical record review revealed no evidence that a written notice was provided to Resident 12 and the resident representative regarding the resident's transfer to the hospital on November 15, 2023, which included the required the reason for the transfer, contact and address information for the Office of the State Long-Term Care Ombudsman, and if applicable, information for the agency responsible for the protection and advocacy of individuals with developmental disabilities.

Interview with the Nursing Home Administrator (NHA) on February 29, 2024, at approximately 10:30 AM, confirmed that there was no documented evidence that a written notification of transfer was provided to the resident and the resident's representative.



28 Pa. Code 201.29 (c) Resident rights
















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

1. The facility is unable to retroactively provide resident 12 with a transfer/bed hold notification timely.
2. A 24 hour look back was completed to ensure no other outstanding transfer/bed hold notifications needed to be issued.
3. Business Office Manager was re-educated on the importance of sending transfer/bed hold notifications to residents and responsible parties timely. Transfers and discharges will be reviewed daily at morning meeting to ensure proper notifications are send timely. Business Office will perform random audits of discharged residents to ensure notifications were sent timely.
4. NHA will conduct facility audits weekly x4 and then monthly x2 months to ensure that transfers and bed hold notifications are being issued timely. The results of the audit will be reviewed by the QAPI Committee for review and analysis of need for ongoing monitoring.

483.90(e)(1)(ii) REQUIREMENT Bedrooms Measure at Least 80 Sq Ft/Resident:Least serious deficiency but affects more than a limited number of residents, staff, or occurrences. This deficiency has the potential for causing no more than a minor negative impact on the resident but is not found to be throughout this facility.
483.90(e)(1)(ii) Measure at least 80 square feet per resident in multiple resident bedrooms, and at least 100 square feet in single resident rooms;
Observations:


Based on observations and space measurements provided by the facility, it was determined that the facility failed to provide the regulatory required minimum square footage in nine of 21 resident rooms.

Findings include:

Observations made on February 27, 2024, 9:00 AM, revealed square footage was not adequate in the following resident rooms:

Room 22 is a single-bedded resident room, which requires a minimum of 100 square feet. The square footage of this room measured 85 square feet.

Resident rooms 15, 16, 17, 18, 19, 20, 21, and 23 are two- bedded resident rooms with square footage measurements of only 143 square feet.

These multi-bed rooms failed to provide the minimum square footage requirement of 80 square feet per bed, or a total of 160 square feet in a semi-private room.

CFR 483.70(d)(1)(ii) Bedrooms

28 Pa. Code: 205.20 (d)(f) Resident bedrooms











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

1. This situation poses no threat to the safety or well-being of the residents in these rooms; therefore, the facility has requested a waiver continuation of 42CFR 428.70 (d) (1) (ii) by previously submitted letter. Please note that facility meets the variation in square footage requirements adopted by the Commonwealth of Pennsylvania at 28 PA Code section 205.20 and 205.30 (g).
2. The facility is selective in room placement and considers resident's needs and safety when assigning rooms. This facility remains committed to assuring the special needs of the residents in these rooms are met to ensure that their health and safety are not adversely affected.
3. If a resident or family member requests a room change, the facility make every effort to place the resident in a different room.
4. NHA or designee will discuss room change requests at the Interdisciplinary Team meeting. NHA or designee will audit resident Council meeting minutes to ensure concerns regarding room placement are addressed monthly x 6 months. The results of the audit will be reviewed by the QAPI Committee for review and analysis of need for ongoing monitoring.

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 interview it was determined that the facility failed to maintain a complete and accurate record of a residents' personal possessions upon admission and discharge for two residents out of two sampled (Residents 32, and 33)

Findings included:

A review of the clinical record of Resident 32 revealed that the resident was admitted to the facility on January 27, 2020, and discharged (expired) on December 1, 2023.

The inventory list upon admission for Resident 32 revealed that fifty-three (53) personal items were noted on the forms. Resident 32's inventory list on discharge (expired) did not have a resident or responsible party signature present, and or a staff member's signature.

Clinical record review revealed that Resident 33 was admitted to the facility on December 20, 2023, and discharged to the hospital December 22, 2023.

There was no documented evidence of a written record of Resident 33's personal belongings completed upon admission or discharge from the facility.

Interview with the Director of Nursing (DON) on February 29, 2024, at approximately 10:30 A.M., confirmed that the facility was unable to provide an complete and accurate record of a residents' personal possessions of Resident 32, and or 33's personal belongings upon admission and discharge.



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

1. The facility is unable to retroactively provide notice to return the property of resident 32 and 33 timely, within 30 days.
2. DON conducted a 30 day lookback to ensure that there were no outstanding notifications to RP's regarding discharged residents personal belongings. NHA and DON organized all personal belongings that were still in the facility from past residents and contacted their RP's via letter to pick up personal belongings.
3. Social Worker and nursing staff were re-educated by DON on importance of keeping accurate record of residents personal belongings upon admission and issuing notices to residents and/or RP's regarding personal belongings in reference to the Personal Belongings policy. Discharges and admissions will be discussed daily at morning meeting to ensure that notifications are sent timely for each resident who discharge. A discharge checklist has been implemented to include resident property to ensure an inventory is being taken and notices are being send the appropriate party.
4. NHA will conduct facility audits weekly x4 and then monthly x2 months to ensure that notifications regarding discharged resident's personal belongings are issued timely. The results of the audit will be reviewed by the QAPI Committee for review and analysis of need for ongoing review and monitoring.

201.22(b) LICENSURE Prevention, control and surveillance of tuber:State only Deficiency.
(b) Recommendations of the Centers for Disease Control and Prevention (CDC), United States Department of Health and Human Services (HHS) shall be followed in screening, testing and surveillance for TB and in treating and managing persons with confirmed or suspected TB.

Observations:

Based on a review of employee personnel files and select facility policy, and a staff interview, the facility failed to follow CDC (Centers for Disease Control) guidelines for administration and reading of a tuberculin skin test for two of the five new employee files sampled (Employees B2 and B8).

Findings include:

A review of facility policy titled "Employee Screening for Tuberculosis," indicated as last reviewed by the facility on October 20, 2023, revealed that "all employees shall be screened for tuberculosis (TB) infection and disease, using a two-step tuberculin skin test (TST) or blood assay for Mycobacterium tuberculosis (BAMT) and symptom screening, prior to beginning employment. The policy indicates that an initial TB testing will be a two-step TST performed by injecting 0.1 ml (5 tuberculin units) of Purified Protection Derivative (PPD) intradermally. The employee will return within 48-72 hours for skin test readings.

According to the most recent CDC guidelines (Core Curriculum on Tuberculosis: What the Clinician Should Know-Seventh Edition 2021) for TB skin testing, the TB test was to be read within 48 to 72 hours after the administration of the PPD injection in order to determine latent or active TB. If the reaction to the first TST is classified as negative, a second TST should be repeated 1 to 3 weeks later.

A review of Employee B2's personnel file revealed a PPD Skin Testing Information & Employee Consent Form that indicated Employee B2, Registered Nurse, was administered her second PPD skin test on July 19, 2023, and the test was read the same day on July 19, 2023.

A review of Employee B8's personnel file revealed a Pre-Employment Physical Examination and PPD form that indicated Employee B8's, Nursing Aide, first PPD result was read on October 4, 2023. Her second PPD (step 2) was administered on October 9, 2023, only five days later. The form indicates that the Step 2 PPD should be given within 7-21 days after the initial test is read.

During an interview on February 29, 2024, at approximately 10:45 AM, the Nursing Home Administrator (NHA) confirmed that Employee B2's second PPD skin test was not read 48-72 hours after administration. Also, the NHA confirmed that Employee B8's second PPD (step 2) test was not administered within 7-21 days after the initial PPD was read.



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

1. Employee B2 and B8 were able to provide facility with documentation of Tuberculosis screening.
2. An audit was completed of new hires within the last 30 days to ensure that TB screening was completed and documented accurately.
3. The Onboarding Specialist and licensed nurses were re-educated on screening process for TB upon hire of new employees. The Onboarding Specialist will audit employee files to ensure documentation of TB screening is accurate and complete. Nursing supervisor will review each PPD reading to ensure accuracy of administration and reading before giving it to the Onboarding Specialist.
4. The DON will audit new hire files weekly x 4 then monthly x 2, to ensure that the new employee has received TB screening and the form is completed accurately. The results of the audit will be reviewed by the QAPI Committee for review and analysis of need for ongoing review and monitoring.

211.5(d) LICENSURE Medical records.:State only Deficiency.
(d) Records of discharged residents shall be completed within 30 days of discharge. Medical information pertaining to a resident ' s stay shall be centralized in the resident ' s record.

Observations:

Based on clinical record review and staff interview it was determined that two of two closed records reviewed did not include a completed discharge summary within 30 days of the residents' discharge. (Residents 32 and 33)

Findings include:

A review of the clinical record of Resident 32 revealed that the resident was admitted to the facility on January 27, 2020, and expired on December 1, 2023.

Clinical record review revealed that Resident 33 was admitted to the facility on December 20, 2023, and discharged to the hospital December 22, 2023.

A review of the residents' clinical records revealed no discharge summary was completed within 30 days of discharge.

Interview with the Director of Nursing (DON) on February 29, 2024, at approximately 10:30 A.M., confirmed that these closed clinical records did not include a discharge summary completed within 30 days of discharge.





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

1. Facility was not able to retroactively provide resident 32 and 33 with a timely discharge summary.
2. A 24-hour look back was performed to ensure there were no other outstanding discharge summaries for other residents.
3. License nursing staff and IDT were re-educated by NHA on the importance of writing timely discharge summaries for any resident that discharges. A Clinical Reimbursement Coordinator was hired to audit resident medical charts monthly to ensure discharge summaries are completed. IDT will discuss discharges during morning meeting to ensure discharge summaries are completed on each discharged resident.
4. NHA or designee will audit medical records of discharged residents to ensure a discharge summary was completed weekly x4 and then monthly x2. The results of the audit will be reviewed by the QAPI Committee for review and analysis of need for ongoing monitoring.
211.9(j.1) (1) - (5) LICENSURE Pharmacy services.:State only Deficiency.
(j.1) The facility shall have written policies and procedures for the disposition of medications that address all of the following:
(1) Timely and safe identification and removal of medications for disposition.
(2) Identification of storage methods for medications awaiting final disposition.
(3) Control and accountability of medications awaiting final disposition consistent with standards of practice.
(4) Documentation of actual disposition of medications to include the name of the individual disposing of the medication, the name of the resident, the name of the medication, the strength of the medication, the prescription number if applicable, the quantity of medication and the date of disposition.
(5) A method of disposition to prevent diversion or accidental exposure consistent with applicable Federal and State requirements, local ordinances and standards of practice.

Observations:
Based on clinical record review and staff interview, it was determined that the facility failed to document the accounting and disposition of residents' medications in the clinical record upon discharge of one of two sampled residents (Resident 33).

Findings include:

Clinical record review revealed that Resident 33 was admitted to the facility on December 20, 2023, and discharged to the hospital December 22, 2023.

There was no documented evidence in the resident's clinical record of an accounting of the resident's medications upon discharge.

Interview with the Director of Nursing (DON) on February 29, 2024, at approximately 10:30 A.M., confirmed that the quantity and disposition of medications upon residents' discharge from the facility was not documented on the residents' records.


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

1. The facility is unable to retroactively complete a disposition of medications for resident 33, who was discharged December 23, 2023.
2. An audit of discharge records in the last 30 days was conducted to ensure that a disposition of medications was completed.
3. Licensed nurses re-educated on the Disposition of Medication Policy. IDT will discuss disposition records on discharged residents during daily meeting. DON will audit disposition of medications during monthly meeting with pharmacy consultant to ensure medications are being disposed of properly upon discharge.
4. Medical Records/DON will audit charts of discharged residents, weekly x 4 then monthly x 2 to ensure that a disposition of medications was completed, and documentation completed. The results of the audit will be reviewed by the QAPI Committee for review and analysis of need for ongoing review.

211.12(f.1)(2) LICENSURE Nursing services. :State only Deficiency.
(2) Effective July 1, 2023, a minimum of 1 nurse aide per 12 residents during the day, 1 nurse aide per 12 residents during the evening, and 1 nurse aide per 20 residents overnight.

Observations:

Based on a review of nurse staffing and staff interview, it was determined that the facility failed to ensure the minimum nurse aide staff to resident ratio was provided on each shift for 19 shifts 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 nurse aide staff of 1:12 on the day and evening shift and 1:10 on the night shift based on the facility's census.

February 4, 2024- 2 nurse aides on the day shift, versus the required 2.5 for a census of 30.
February 4, 2024- 1 nurse aides on the night shift, versus the required 1.5 for a census of 30.
February 5, 2024- 2 nurse aides on the evening shift, versus the required 2.5 for a census of 30.
February 9, 2024- 2.53 nurse aides on the day shift, versus the required 2.75 for a census of 33.
February 9, 2024- 2.53 nurse aides on the evening shift, versus the required 2.75 for a census of 33.
February 12, 2024- 2.67 nurse aides on the day shift, versus the required 2.75 for a census of 33.
February 12, 2024- 2.67 nurse aides on the evening shift, versus the required 2.75 for a census of 33.
February 13, 2024- 2.67 nurse aides on the day shift, versus the required 2.75 for a census of 33.
February 13, 2024- 1.07 nurse aides on the night shift, versus the required 1.65 for a census of 33.
February 14, 2024- 2.67 nurse aides on the day shift, versus the required 2.75 for a census of 33.
February 14, 2024- 1.07 nurse aides on the night shift, versus the required 1.65 for a census of 33.
February 15, 2024- 2.67 nurse aides on the day shift, versus the required 2.75 for a census of 33.
February 15, 2024- 2.53 nurse aides on the evening shift, versus the required 2.75 for a census of 33.
February 16, 2024- 2 nurse aides on the day shift, versus the required 2.67 for a census of 32.
February 22, 2024- 2 nurse aides on the day shift, versus the required 2.67 for a census of 32.
February 22, 2024- 2.53 nurse aides on the evening shift, versus the required 2.67 for a census of 32.
February 26, 2024- 2.53 nurse aides on the day shift, versus the required 2.58 for a census of 31.
February 27, 2024- 2 nurse aides on the evening shift, versus the required 2.58 for a census of 31.
February 28, 2024- 2.53 nurse aides on the evening shift, versus the required 2.58 for a census of 31.

An interview with the Nursing Home Administrator on February 29, 2024, at approximately 12:00 PM, confirmed the facility had not met the required nurse aide to resident ratios on the above dates.















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

1. The facility is unable to retroactively provide minimum nurse aide ratio for cited dates.
2.A facility wide audit was completed to ensure ratios were met. Recruitment increased, CNA sign on bonuses, and wages are competitive with surrounding areas.
3.The DON and scheduler were re-educated on ensuring that the nursing care ratios are provided, and that the facility is actively recruiting CNAs. DON will review census and schedule daily to ensure we have adequate staffing levels of CNA's daily.
4.The DON or designee will conduct an audit of the nursing care ratios to ensure it is provided weekly x4 weeks then monthly x 2 months. The results will be submitted to the QAPI Committee for review and analysis of need of ongoing monitoring.

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 schedules, provided nursing time, 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 32 shifts out of the 63 shifts reviewed.

Findings include:

A review of the facility's weekly staffing records revealed that the facility failed to provide minimum licensed practical nurse (LPN) staff of 1:25 during the day shift, 1:30 during the evening shift, and 1:40 during the night shift as per the facility's census.

February 3, 2024 - 1.07 LPNs during the day shift, versus the required 1.2 for a census of 30 residents.
February 4, 2024 - 1.07 LPNs during the day shift, versus the required 1.2 for a census of 30 residents.
February 4, 2024 - 0.80 LPNs during the night shift, versus the required 1 for a census of 30 residents.
February 5, 2024 - 1.07 LPNs during the day shift, versus the required 1.2 for a census of 30 residents.
February 6, 2024 - 1.07 LPNs during the day shift, versus the required 1.2 for a census of 30 residents.
February 7, 2024 - 1.07 LPNs during the day shift, versus the required 1.32 for a census of 31 residents.
February 7, 2024 - 1.07 LPNs during the evening shift, versus the required 1.10 for a census of 31 residents.
February 8, 2024 - 1.07 LPNs during the day shift, versus the required 1.37 for a census of 32 residents.
February 9, 2024 - 1.07 LPNs during the day shift, versus the required 1.41 for a census of 33 residents.
February 9, 2024 - 1.07 LPNs during the evening shift, versus the required 1.17 for a census of 33 residents.
February 10, 2024 - 1.07 LPNs during the day shift, versus the required 1.41 for a census of 33 residents.
February 10, 2024 - 1.07 LPNs during the evening shift, versus the required 1.17 for a census of 33 residents.
February 11, 2024 - 1.07 LPNs during the day shift, versus the required 1.41 for a census of 33 residents.
February 11, 2024 - 1.07 LPNs during the evening shift, versus the required 1.17 for a census of 33 residents.
February 12, 2024 - 1.07 LPNs during the day shift, versus the required 1.41 for a census of 33 residents.
February 13, 2024 - 1.07 LPNs during the day shift, versus the required 1.41 for a census of 33 residents.
February 14, 2024 - 1.07 LPNs during the day shift, versus the required 1.41 for a census of 33 residents.
February 14, 2024 - 1.07 LPNs during the evening shift, versus the required 1.17 for a census of 33 residents.
February 15, 2024 - 1.07 LPNs during the day shift, versus the required 1.41 for a census of 33 residents.
February 15, 2024 - 1.07 LPNs during the evening shift, versus the required 1.17 for a census of 33 residents.
February 16, 2024 - 1.07 LPNs during the day shift, versus the required 1.37 for a census of 32 residents.
February 22, 2024 - 1.07 LPNs during the day shift, versus the required 1.37 for a census of 32 residents.
February 23, 2024 - 1.07 LPNs during the day shift, versus the required 1.32 for a census of 31 residents.
February 23, 2024 - 1.07 LPNs during the evening shift, versus the required 1.10 for a census of 31 residents.
February 24, 2024 - 1.07 LPNs during the day shift, versus the required 1.32 for a census of 31 residents.
February 24, 2024 - 1.07 LPNs during the evening shift, versus the required 1.10 for a census of 31 residents.
February 25, 2024 - 1.07 LPNs during the day shift, versus the required 1.32 for a census of 31 residents.
February 25, 2024 - 1.07 LPNs during the evening shift, versus the required 1.10 for a census of 31 residents.
February 26, 2024 - 1.07 LPNs during the day shift, versus the required 1.32 for a census of 31 residents.
February 26, 2024 - 1.07 LPNs during the evening shift, versus the required 1.10 for a census of 31 residents.
February 27, 2024 - 1.07 LPNs during the evening shift, versus the required 1.10 for a census of 31 residents.
February 28, 2024 - 1.07 LPNs during the evening shift, versus the required 1.10 for a census of 31 residents.

An interview with the Nursing Home Administrator on February 29, 2024, at approximately 12:00 PM, confirmed the facility had not met the required LPN to resident ratios on the above dates.





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

1. The facility is unable to retroactively provide a minimum LPN ratio for cited dates.
2. A facility wide audit was completed to ensure ratios were met. Recruitment initiatives were increased, LPN sign on bonuses, and wages are competitive with surrounding areas.
3. The DON and Recruitment were re-educated on ensuring that the nursing care ratios are provided, and that the facility is actively recruiting LPNs. The DON will review census and schedule daily to ensure adequate staffing of LPN's.
4. The DON or designee will conduct an audit of the nursing care ratios to ensure it is provided weekly x4 weeks then monthly x 2 months. The results will be submitted to the QAPI Committee for review and analysis of need of ongoing monitoring.

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

Based on a review of nurse staffing schedules, provided nursing time, and resident census, it was determined that the facility failed to ensure the minimum registered nurse staff to resident ratio was provided on each shift for 23 shifts out of 63 reviewed.

Findings include:

A review of the facility's weekly staffing records and punch detail reports provided by the facility revealed that on the following dates the facility failed to provide minimum registered nurse (RN) staff on the day shift based on the facility's census.

February 27, 2024 - 0 RN on the day shift, versus the required one for a census of 31
February 28, 2024 - 0 RN on the day shift, versus the required one for a census of 31

Further review revealed the facility failed to provide a minimum of one registered nurse on the night shift as required based on facility resident census.

A review of the facility's staffing records revealed that on the night shift for the weeks of February 3 through February 9, 2024; February 10 through February 16, 2024, and February 22 through February 28, 2024, the facility failed to provide minimum registered nurse (RN) staff of 1:250 and based on the facility census of 59 or less failed to substitute a licensed practical nurse for a registered nurse on the night (overnight) shift if an RN is on call and located within a 30-minute drive of the facility.

An interview with the Director of Nursing (DON) on February 29, 2024, at approximately 12:00 PM, confirmed that the facility had not met the required RN to resident ratios on the above shifts.






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

1. The facility is unable to retroactively provide minimum registered nurse ratio for cited dates.
2.A facility wide audit was completed to ensure ratios were met. Recruitment increased, RN sign on bonuses, and wages are competitive with surrounding areas.
3.The DON was re-educated on ensuring that the nursing care ratios are provided, and that the facility is actively recruiting RNs. The DON will review census and schedule daily to ensure adequate staffing of RN's each day.
4.The DON or designee will conduct an audit of the registered nurse ratios to ensure it is provided weekly x4 weeks then monthly x 2 months. The results will be submitted to the QAPI Committee for review and analysis of need of ongoing monitoring.

211.12(i)(1) LICENSURE Nursing services.:State only Deficiency.
(1) Effective July 1, 2023, the total number of hours of general nursing care provided in each 24-hour period shall, when totaled for the entire facility, be a minimum of 2.87 hours of direct resident care for each resident.

Observations:

Based on a review of nurse staffing schedules and the daily resident census it was determined that the facility failed to consistently provide minimum general nursing care hours to each resident daily.

Findings include:

A review of the facility's weekly staffing records for the weeks of February 3 through February 9, 2024, February 10 through February 16, 2024, and February 22 through February 28, 2024, revealed that on the following dates the facility failed to provide minimum nurse staffing of 2.87 hours of general nursing care to each resident:

February 9, 2024- 2.82 nursing hours per resident per 24 hours
February 14, 2024- 2.50 nursing hours per resident per 24 hours
February 15, 2024- 2.85 nursing hours per resident per 24 hours
February 25, 2024- 2.42 nursing hours per resident per 24 hours.

On the above noted dates, the facility failed to provide the minimum of 2.87 hours of direct nursing care daily for each resident.










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

1. The facility is unable to retroactively correct PPD for dates cited.
2. A facility wide audit was completed to ensure the minimum PPD of 2.87 hours are met daily for each resident.
3. The DON /designee were re-educated on the total number of hours of general nursing care provided in each 24-hour period be a minimum of 2.87 hours. The DON will review the census daily to ensure 2.87 hours of nursing care are being provided within a 24-hour period. If staffing levels are not being met, DON will instruct the scheduler to make adjustments to the schedule by filling any gaps with per diem staff. The facility continues recruit licensed and non-licensed nursing staff.
4. The DON / designee will conduct an audit of daily staffing sheets weekly x 4 weeks, then monthly x 2 to ensure facility meets the minimum daily 2.87 nursing hours for each resident. The results will be submitted to the QAPI Committee for review and analysis of need of ongoing monitoring.

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