Pennsylvania Department of Health
CHURCH OF GOD HOME INC
Patient Care Inspection Results

Note: If you need to change the font size, click the "View" menu at the top of the page, place the mouse over the "Text Size" menu item, and select the desired font size.

Severity Designations

Click here for definitions Click here for definitions Click here for definitions Click here for definitions
Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
CHURCH OF GOD HOME INC
Inspection Results For:

There are  90 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.
CHURCH OF GOD HOME INC - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on a Medicare/Medicaid Recertification survey, State Licensure survey, and Civil Rights Compliance survey completed on March 21, 2024, it was determined that Church of God Home, Inc was not in compliance with the following requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care and the 28 Pa. Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations as they relate to the Health portion of the survey.


 Plan of Correction:


483.25(g)(1)-(3) REQUIREMENT Nutrition/Hydration Status Maintenance: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(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 facility policy review, clinical record review, and staff interviews, it was determined that the facility failed to ensure proper monitoring and timely implementation of interventions to maintain acceptable parameters of nutritional status for four of 17 residents reviewed (Residents 22, 23, 45, and 57), resulting in actual harm as evidenced by continued weight loss after a significant weight loss was documented for two of 17 residents reviewed (Residents 22 and 45).

Findings include:

Review of facility policy, titled "Weight Monitoring", dated October 2022, read, in part, "The facility will ensure that all residents maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the residents clinical condition demonstrates this is not possible or residents preferences indicate otherwise ...the facility will utilize a systematic approach to optimize a residents nutritional status. This process includes ...Monitoring the effectiveness of interventions and revising them as necessary ...Residents with weight loss-monitor weight weekly ...the physician should be informed of a significant change in weight and may order nutritional interventions ...The Registered Dietitian or Dietary Manager should be consulted to assist with interventions; actions are recorded in the nutrition progress notes ...the interdisciplinary plan of care communicates care instructions to staff."

Review of Resident 22's clinical record revealed diagnoses that included dementia (a chronic disorder of the mental processes caused by brain disease, marked by memory disorders, personality changes, and impaired reasoning), dysphagia (difficulty swallowing), and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest in things).

Review of Resident 22's weights revealed she weighed 127.5 pounds (lbs) on January 22, 2024; 109.8 lbs on February 2, 2024; 109.7 lbs on February 7, 2024; and 107.4 lbs on February 13, 2024. This equated to a weight loss of 17.7 pounds (-13.8%) from January 22, 2024, to February 2, 2024, and a continued weight loss of 2.4 pounds (-2%) from February 2, 2024, to February 13, 2024.

Review of Resident 22's clinical record failed to reveal that a nutritional assessment was completed for Resident 22 between the dates of August 14, 2023, and March 20, 2024; and failed to reveal that any interventions were put into place for a significant weight loss between February 2, 2024 (the date a significant weight loss was noted), and February 16, 2024 (the date the physician was notified of Resident 22's weight loss).

Review of Resident 22's progress notes revealed a note dated February 16, 2024, that stated, "[Employee 11 (Physician)] notified of resident's 20 lb weight loss over past 3 weeks. Resident is consuming 0-25% of meals consistently, has Med Pass 2.0 ordered twice daily and receives snacks between meals three times daily. Antibiotic treatment for UTI (urinary tract infection) was completed on 2/10/24. New order received for Remeron 15 mg by mouth in the evenings. POA (power of attorney) notified of new order."

Review of Resident 22's progress notes revealed a note dated February 19, 2024, that stated, "Fax placed to MD in regards to obtaining weekly weights."

Review of Resident 22's progress notes revealed a note dated February 20, 2024, that stated, "New order for weekly weights due to weight loss. POA aware."

Review of Resident 22's physician orders revealed an order for "Weekly weights x 4 every day shift every Mon for 4 Administrations", with a start date of February 26, 2024.

Review of Resident 22's MAR (Medication Administration Record - documentation for treatments/medication administered or monitored) and her clinical record failed to reveal a weekly weight was obtained on March 11, 2024, as per physician order.

Review of Resident 22's progress notes revealed a note dated February 22, 2024, that stated, "Notified by Social worker that resident's family was updated at care plan meeting about resident's weight loss and declining condition. Family will discuss hospice."

During an interview with the Nursing Home Administrator (NHA) on March 20, 2024, at 2:34 PM, the surveyor revealed the concern with Resident 22's weight loss not being assessed timely, interventions not being put into place timely and implemented per order, and continued weight loss without interventions. The NHA confirmed she would have expected nutrition assessments and interventions to be put into place timely and implemented following a significant weight change. The NHA further revealed nursing was responsible for notifying the physician of significant weight changes at that time, since the facility did not have dietitian coverage during the period of Resident 22's weight loss. She also revealed that there was a corporate Certified Dietary Manager that they should have consulted during that time, but that they failed to consult them.

The facility failed to ensure timely evaluation and implementation of new interventions to prevent further weight loss for Resident 17 following a significant weight loss of 17.7 lbs (13.8%) in less than 14 days, resulting in harm as evidenced by an additional weight loss of 2.3 lbs (2%) before interventions were put into place.

Review of Resident 23's clinical record revealed diagnoses that included dementia, hypertensive heart disease (heart condition caused by high blood pressure), and depression.

Review of Resident 23's weight records revealed that they weighed 194.8 lbs on July 18, 2023; 187 lbs on September 3, 2023; and 164.2 lbs on March 1, 2024 (a loss of 12.19%).

Review of Resident 23's Physician Services notes revealed a note dated February 27, 2024, which indicated the following: Resident 23 was being seen for a routine visit and review of their weight loss; the Resident had an 11.98% weight loss over the past six months; their weight had consistently declined month-to-month in that time; their nutritional supplement was increased in January 2024; the resident was on a regular diet with double portions and increased dessert portions; and their cause of weight loss was unknown as their caloric intake and meal consumption was high, but was likely unavoidable secondary to advanced dementia. The note further indicated that the practitioner's plan was to increase the nutritional supplement again, to have Resident 23 weighed weekly, and follow further recommendations of the dietician.

Review of Resident 23's clinical record on March 19, 2023, at 10:31 AM, revealed that they had one nutritional assessment completed by the facility dietician on July 25, 2023, at the time of their admission to the facility.

Review of Resident 23's clinical record progress notes on March 19, 2023, at 10:31 AM, revealed that the last documentation completed by a dietician was dated August 3, 2023, at which time the note indicated that they were questioning a weight that had been obtained and had requested that the resident be reweighed.

During an interview with the NHA and Employee 1 (Registered Nurse Assessment Coordinator - RNAC) on March 20, 2024, at 2:24 PM, the aforementioned information from the practitioner's note was shared, as well as concern regarding the lack of nutritional assessments or any documented follow-up by a dietician. The NHA confirmed that there were no additional nutritional assessments completed on Resident 23 since they were admitted to the facility on July 18, 2023. She indicated that the facility was without a dietician from September 15, 2023, until March 5, 2024. She indicated that during the time the facility was without a dietician, the Director of Nursing (DON) was to be reviewing resident weights and addressing weight concerns in the interim, and that there was a corporate Certified Dietary Manager that the facility could have reached out to when needed. The NHA shared that this DON was no longer an employee at the facility, and that the facility had failed to contact the corporate Certified Dietary Manager for assistance.

A follow-up review of Resident 23's clinical record on March 21, 2024, at 8:59 AM, revealed a progress note by the dietician which indicated that there was an order clarification for the weekly weight monitoring due to significant weight loss over six months. At the time of this review, there was still no documented nutritional assessment by the facility dietician.

During a final interview with the NHA on March 21, 2024, at 10:29 AM, she confirmed that she would expect a resident to have a nutritional assessment completed quarterly by a dietician, at minimum, and with any nutritional change, such as weight loss.

Review of Resident 45's clinical record revealed diagnoses that included dementia, dysphagia, and breast cancer.

Review of Resident 45's weight records revealed the following weights:
December 1, 2023, 111 lbs;
January 22, 2024, 101.5 lbs;
January 30, 2024, 101.6 lbs;
February 20, 2024, 97.5 lbs
February 21, 2024, 95.4 lbs
February 22, 2024, 96.2 lbs
February 26, 2024, 85.6 lbs
February 27, 2024, 88.7 lbs
March 1, 2024, 93.6 lbs
March 5, 2024, 93.5 lbs
This equated to a significant weight loss of 13.5 lbs (12.2%) between December 1, 2023, and February 20, 2024; an additional 11.9 lb weight loss between and February 20, 2024 and February 26, 2024; and a total weight loss of 17.5 lbs (15.7%) between December 1, 2023 and March 5, 2024.

Review of Resident 45's clinical record revealed that their last nutritional assessment was completed by a dietician on September 20, 2023, at the time of their admission to the facility.

Review of Resident 45's clinical record progress notes revealed a note by the facility dietician dated March 6, 2024, at 1:09 PM, which indicated that their weekly weights were reviewed and that their current weight on March 5, 2024, "triggers as a significant loss of 6.9% x 30 days. Resident continues to tolerate a Regular diet, regular texture, thin liqs [liquids] PO [oral] intake is not adequate to meet estimated needs at ~ [approximately] 30 % ave[rage] w[ith]/ 9 meal refusals. Resident continues to receive and accept Medpass [a nutritional supplement] 240 mL [milliliters] BID [twice a day], ~[approximately] 100% ave[rage]. Recommending to increase Medpass to 240 mL TID [three times a day] to provide additional calories and protein. Order added on (2/17) to encourage fluids. Weekly wt [weight] monitoring to continue. Care plan updated."

In addition, there was a progress note dated March 6, 2024, at 1:37 PM, which indicated that Resident 45's responsible party was notified of their weight change and new recommendations. The documentation did not indicate if Resident 45's physician was made aware of the weight loss.

Further review of Resident 45's clinical record progress notes failed to reveal any documentation regarding Resident 45's weight loss, including physician notification and responsible party notification between February 20, 2024, when the resident started triggering for weight loss, and March 6, 2024. The last documentation of Resident 45's physician being made aware of any weight loss was on December 19, 2023, during which time the resident was experiencing a COVID-19 infection and additional orders were given for nutritional supplementation.

During an interview with the NHA on March 20, 2024, at 10:24 AM, the aforementioned concerns were shared regarding Resident 45's weight loss identification, lack of dietician involvement, and lack of documentation that the physician or responsible party were notified of the weight loss that triggered on February 20, 2024, and of ongoing weight loss triggered with each weight obtained thereafter. The NHA confirmed that there were no other nutritional assessments completed for Resident 45 since they were admitted to the facility on September 12, 2023. She indicated that the facility did not have a dietician during this timeframe, and that nursing was attempting to identify and address weight concerns.

During another interview with the NHA and Employee 1 on March 20, 2024, at 2:24 PM, the aforementioned concerns were all shared again. The NHA indicated that the facility was without a dietician from September 15, 2023, until March 5, 2024. She indicated that during the time the facility was without a dietician, the DON was to be reviewing resident weights and addressing weight concerns in the interim, and that there was a corporate Certified Dietary Manager that the facility could have reached out to when needed. The NHA shared that this DON was no longer an employee at the facility and that the facility had failed to contact the corporate Certified Dietary Manager for assistance.

During an interview with the NHA on March 21, 2024, at 10:29 AM, she confirmed that she would expect a resident to have a nutritional assessment completed quarterly by a dietician, at minimum, and with any nutritional change, such as weight loss.

During a final interview with the NHA on March 21, 2024, at 1:24 PM, the NHA confirmed that Resident 45's physician and responsible party should have been notified when they began triggering for weight loss at the end of February 2024.

The facility failed to ensure timely evaluation and implementation of new interventions to prevent further weight loss for Resident 45 following a significant weight loss of 13.5 lbs. (12.2%), resulting in harm as evidenced by an additional weight loss which totaled 17.5 net pounds (15.7%) before interventions were put into place.

Review of Resident 57's clinical record revealed diagnoses that included dementia, major depressive disorder, and vitamin D deficiency.

Review of Resident 57's weight measures revealed she had a significant weight gain of 9.4 lbs. (+10.6%) from October 17, 2023, to November 3, 2023.

Review of Resident 57's clinical record on March 20, 2024, failed to reveal that a nutritional assessment was completed for Resident 57 between the dates of September 15, 2023, and present.

During an interview with the NHA on March 20, 2024, at 2:34 PM, the surveyor revealed the concern that Resident 57 did not have a nutritional assessment completed following a significant weight change. The NHA confirmed she would expect nutrition assessments to be conducted timely following a significant weight change. The NHA further revealed nursing was responsible for notifying the physician of significant weight changes at that time, as the facility did not have dietitian coverage during the period of Resident 57's weight gain. She also revealed there was a corporate Certified Dietary Manager that they should have consulted during that time, but failed to do.

28 Pa. Code 201.14(a) Responsibility of licensee.
28 Pa. Code 201.18(b)(1)(3)(e)(6) Management.
28 Pa Code 211.12(d)(1)(3)(5) Nursing Services.










 Plan of Correction - To be completed: 04/18/2024

*UPDATE 4/2/24: Education will be done by the Dietician or designee with the entire team on the requirements of a dietician and the regulations associated with their role in long term care. If the organization goes without a dietician for any amount of time, a temporary dietician will be contracted or someone from a corporate standpoint will be responsible for covering the duties of the dietician. Audits will be conducted as stated and will include 5 residents for weight notes and 5 residents for nutritional assessments.

1. Immediate action(s) taken for the resident(s) found to have been affected include:
Residents 22, 23, 45, 17, and 57 have all received comprehensive nutritional assessments.

2. Identification of other residents having the potential to be affected was accomplished by:
All residents have the potential to be affected by this deficient practice. Therefore, updated nutritional assessments of all addition residents will be completed within 30 business days.

3. Actions taken/systems put into place to reduce the risk of future occurrence include:
Registered Dietitian was hired 3/5/24. Monthly audits to be reviewed with the Interdisciplinary team at QAPI.

4. How the corrective action(s) will be monitored to ensure the practice will not recur:
The Nursing Home Administrator or designee will audit appropriate completion of weight notes and nutritional assessments 2 time/week for 4 weeks and 4 times/month for 3 mos. Random audits will be conducted thereafter until consistent substantial compliance is met.

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 facility policy review and staff interview, it was determined that the facility failed to develop a Water Management Program for the prevention, detection, and control of water-borne contaminants, such as Legionella, a bacteria that may cause Legionnaires' Disease (a serious type of pneumonia).

Findings Include:

Review of facility policy, titled "Water Management Program", dated October 23, 2022, revealed "It is the policy of this facility to establish water management plans for reducing the risk of Legionellosis and other opportunistic pathogens... A water management team has been established to develop and implement the facility's water management program... The Maintenance Director maintains documentation that describes the facility's water system... A risk assessment will be conducted by the water management team annually ..."

The facility was unable to provide an assessment to identify where Legionella and other opportunistic waterborne pathogens could grow and spread, and was unable to provide evidence of measures to prevent the growth of opportunistic waterborne pathogens and how to monitor them.

During an interview with the Nursing Home Administrator on March 19, 2024, at 10:15 AM, she confirmed that the facility has not implemented a water management program.

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


 Plan of Correction - To be completed: 04/18/2024

1. Immediate action(s) taken for the resident(s) found to have been affected include:
Contacted Special Pathogens on March 20, 2024 requesting Legionella testing kits as the company used previously was no longer providing the kits.

2. Identification of other residents having the potential to be affected was accomplished by:
All residents have the potential of being affected. No residents have had any symptoms or diagnosis of legionella.

3. Actions taken/systems put into place to reduce the risk of future occurrence include:
Education to responsible staff for conducting the samples for Legionella testing per the water management plan requirements. Nursing Home Administrator and Director of Facilities will keep all documentation and ensure testing and lab results are recorded.

4. How the corrective action(s) will be monitored to ensure the practice will not recur:
Audits of the testing will be conducted quarterly by the NHA or designee for the remainder of the year and thereafter.

483.10(e)(3) REQUIREMENT Reasonable Accommodations Needs/Preferences: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(e)(3) The right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents.
Observations:

Based on observations, clinical record reviews, and staff interviews, it was determined that the facility failed to ensure that services were provided with reasonable accommodation of resident need for one of 17 residents reviewed (Resident 6).

Findings include:

Review of Resident 6's clinical record revealed diagnoses that included dementia (a chronic disorder of the mental processes caused by brain disease, marked by memory disorders, personality changes, and impaired reasoning), legal blindness (a term to describe severe visual impairment that cannot be corrected with glasses or contact lenses), and generalized anxiety disorder (a mental disorder characterized by feelings of worry, nervousness, or unease).

Review of Resident 6's care plan revealed a focus area of "[Resident 6] has impaired visual function related to legal Blindness ...", created on February 23, 2023, with interventions for "Place foods in individual bowl except sandwiches, arrange all items on tray, by placing same arrangement on tray each time to enhance ability to feed self" created on February 23, 2023, and "The resident prefers to have their room and things arranged to promote independence. Resident prefers to have cell phone within reach while awake, staff to place on charger at bedside every evening and remove from charger and keep within reach while awake", created on April 12, 2023.

Observations of Resident 6 on March 18, 2024, at 12:09 PM; March 18, 2024, at 12:50 PM; March 19, 2024, at 9:13 AM; March 19, 2024, at 12:29 PM; and March 20, 2024, at 9:37 AM, revealed Resident 6 was awake, sitting in her recliner, and her cell phone was across the room charging on a table.

Observation of Resident 6 during her lunch meal on March 18, 2024, at 12:50 PM, revealed her food was in three separate bowls and they were all set-up on her tray in a straight line.

Observation of Resident 6 during her lunch meal on March 19, 2024, at 12:29 PM, revealed her food was in three separate bowls, her ice cream and carrots were in the front of her tray side-by-side, and her entrwas at the back of her tray.

During an interview with the Nursing Home Administrator (NHA) on March 20, 2024, at 10:37 AM, the surveyor revealed the observations of Resident 6's phone not being in reach while awake and the inconsistencies of her tray set-up during lunch.

During a follow-up interview with the NHA on March 20, 2024, at 2:56 PM, she revealed Resident 6's meal tray should be set-up with the bowls arranged in a clockwise manner, and she would expect her phone to be within reach when she's awake.

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




 Plan of Correction - To be completed: 04/18/2024

* UPDATES: In addition to the stated audits, the only other blind resident will have her set-up audited as the same intervals as Resident 6. If any new residents are admitted with special needs, they will be audited 3 times/week for their first week, 2/week for their second week and 1/week for the third week. If consistent substantial compliance is met, auditing will stop at that time. If not, random audits will continue 3 times/week until substantial compliance is met.

1. Immediate action(s) taken for the resident(s) found to have been affected include:
An in-service was conducted to re-educate dietary and nursing staff on arranging Resident 6's tray using the clockwise method. In addition, nursing staff were reminded that Resident #6 needs her cell phone placed in the drawer in her nightstand to her right. These preferences were care planned.

2. Identification of other residents having the potential to be affected was accomplished by:
One other resident in this home is legally blind. A review was conducted and that resident was interviewed by the Director of Nursing. Resident shares no concerns with how her food is arranged upon delivery. She had been care planned for the clockwise method.


3. Actions taken/systems put into place to reduce the risk of future occurrence include:
At admissions all residents will be asked whether they need assistance with vision accommodations. All admissions are reviewed daily at the clinical team meetings. Accommodations for new residents with any disability will be care planned appropriately. In addition, care plan education will be provided to the IDT team and licensed staff to ensure they are documenting accommodation of needs for all new residents and any current residents' whose needs change.

4. How the corrective action(s) will be monitored to ensure the practice will not recur:
3 audits will be conducted weekly for 4 weeks to ensure Resident 6's cell phone is placed in the drawer of her nightstand and that her food is arranged using the clockwise method. Following those 4 weeks, 3 audits will be done bi-weekly and then randomly thereafter until such time when consistent compliance has been met.

483.95(g)(1)-(4) REQUIREMENT Required In-Service Training for Nurse Aides: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.
§483.95(g) Required in-service training for nurse aides.
In-service training must-

§483.95(g)(1) Be sufficient to ensure the continuing competence of nurse aides, but must be no less than 12 hours per year.

§483.95(g)(2) Include dementia management training and resident abuse prevention training.

§483.95(g)(3) Address areas of weakness as determined in nurse aides' performance reviews and facility assessment at § 483.70(e) and may address the special needs of residents as determined by the facility staff.

§483.95(g)(4) For nurse aides providing services to individuals with cognitive impairments, also address the care of the cognitively impaired.
Observations:

Based on personnel file review and staff interviews, it was determined that the facility failed to ensure each nurse aide was provided required in-service training consisting of no less than 12 hours per year, which included dementia management and resident abuse prevention, for five of five nurse aide employee records reviewed (Employees 2, 3, 4, 5, and 6).

Findings Include:

Review of personnel information revealed Employee 2's hire date was February 14, 2022; Employee 3's hire date was May 2, 2016; Employee 4's hire date was June 21, 2022; Employee 5's hire date was September 4, 2012; and Employee 6's hire date was September 18, 2017.

Review of facility training records failed to reveal that the aforementioned Employees completed 12 hours of required annual training in the past 12 months.

Further review of facility training records failed to reveal evidence that dementia management training was completed by Employees 2, 3, 4, 5, and 6 within the past 12 months, or that abuse prevention training was completed by Employee 3 within the past 12 months.

During an interview with the Nursing Home Administrator (NHA) on March 19, 2024, at 2:55 PM, she stated that it had already been recognized that nurse aide education was a concern and that a performance improvement plan had been initiated.

On March 20, 2024, at 8:22 AM, the NHA confirmed that Employees 2, 3, 4, 5, and 6 did not have any education for the year 2023. The NHA stated that Employees 2, 4, 5, and 6 completed an education fair in February 2024, which included Resident Rights, Abuse/Neglect and Exploitation, Emergency Preparedness, Lift Training (Nursing only), Behavioral Health, QAPI, Compliance & Ethics, Communication, but could provide no documented evidence that at least 12 hours of training had been completed in the past 12 months.

28 Pa. Code 201.14(a) Responsibility of licensee
28 Pa. Code 201.19(7) Personnel policies and procedures
28 Pa. Code 201.20(a)(d) Staff development



 Plan of Correction - To be completed: 04/18/2024

1. Immediate action(s) taken for the resident(s) found to have been affected include:
All staff were added to a spreadsheet according to anniversary date. Those who have anniversary dates prior to present day will have education assigned through Paycom within the next 4 weeks and will have it completed within 2 weeks following the assignment or they will be removed from the working schedule.

2. Identification of other residents having the potential to be affected was accomplished by:
All staff are affected by this delinquent practice. The remedy is to follow the same practice as mentioned above for all staff; all staff will be assigned their annual 12 hours of education through Paycom, the electronic education platform used within the organization. All assignments will be made within the next 4 weeks and will "pop" for the staff member 30 days prior to their anniversary. They will have 2 weeks to complete the assignments. If they do not complete the assignments prior to their anniversary date, they will be removed from the schedule until their education is completed.

3. Actions taken/systems put into place to reduce the risk of future occurrence include:
Once the staff member has been put into the system, the annual education will automatically renew annually thereafter.

4. How the corrective action(s) will be monitored to ensure the practice will not recur:
According to policy, the scheduler is responsible to ensure all clinical staff are maintaining their annual requirements. The Nursing Home Administrator or designee will conduct 5 audits per month for the next 3 months to ensure all staff are completing their education according to their anniversary date. Random audits will continue until such time consistent substantial compliance is met.

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

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

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

Based on facility policy review, observations, and staff interviews, it was determined that the facility failed to store food and utilize and monitor equipment in accordance with professional standards for food service safety in the main kitchen and in two of two pantry areas.

Findings include:

Review of facility policy, titled "Date Marking for Food Safety", last revised April 15, 2023, read, in part, "Policy: The facility adheres to a date marking system to ensure the safety of ready-to-eat, time/temperature control for safety food ...refrigerated, ready-to-eat, time/temperature control for safety food (i.e. perishable food) shall be held at a temperature of 41 degrees Fahrenheit or less for a maximum of 7 days ...The food shall be clearly marked to indicate the date or day by which the food shall be consumed or discarded ...the marking system shall consist of the day/date of opening and the day/date the item must be consumed or discarded ...the department head, or designee, shall be responsible for checking the refrigerator daily for food items that are expiring and shall discard them accordingly."

Review of facility policy, titled "Unit Refrigeration", last revised August 2009, read, in part, "Purpose: To assure that refrigeration units are properly monitored for temperatures and contents storage ...Nursing team members to document on Refrigerator Temperature Log on all refrigerators on unit ...Nursing team members will maintain daily temperature logs for each refrigerator."

Observation in the dry storage area in the main kitchen on March 18, 2024, at 9:28 AM, revealed three gelatin mixes not dated; two stuffing mixes not dated; and one package of strawberry mousse mix not dated.

Observation in the main walk-in refrigerator unit on March 18, 2024, at 9:34 AM, revealed a container of sweet and sour sauce with the lid partially open; one cut zucchini and tomato wrapped together, not dated; one bucket of pickles dated April 28, 2023 that had a black substance around the lid; and four individual yogurts with a use by date of February 2, 2024.

Observation in the walk-in freezer unit on March 18, 2024, at 9:40 AM, revealed two bags of donut holes, not dated; two individual pie shells, not dated; six cupcakes in a bin labeled use by January 16, 2024; and four pumpkin pies labeled use by January 25, 2024.

Observation in the main kitchen on March 18, 2024, at 9:43 AM, revealed four individually prepped cups of brown sugar, not dated.

An interview with Employee 9 (Cook) on March 18, 2024, at 9:43 AM, revealed the brown sugar cups should have been labeled with a date.

Observation in the main kitchen on March 18, 2024, at 9:49 AM, revealed one container of cinnamon sugar labeled use by March 6, 2024; one open container of donut glaze not dated with an open date; and one open container of margarine not labeled with an open date.

An interview with Employee 9 on March 18, 2024, at 9:49 AM, revealed the open containers should have been labeled with an open date and a date when they should be discarded.

Observation of the three-compartment sink in the main kitchen on March 18, 2024, at 9:53 AM, revealed the sanitizer sink was filled with sanitizing solution and water. The surveyor requested Employee 9 test the sanitizer water with a test strip. The test strip used to test the water revealed a concentration around 100 parts per million (ppm- concentration unit of measure).

An interview with Employee 9 on March 18, 2024, at 9:54 AM, revealed he was not sure what concentration the sanitizer solution should be, and that they do not log the concentration of the sanitizer solution.

Observation of the dishwasher temperature log in the main kitchen on March 18, 2024, at 9:56 AM, revealed the AM and PM temperatures were logged for March 1 and 2, 2024, but no other dates for March 2024 were logged.

Observation during initial tour of the Faith pantry area on March 18, 2024, at 10:05 AM, revealed a bin of individual cookies, not dated.

Observation of the Refrigerator/Freezer Temperature Log in Faith Pantry Area on March 18, 2024, at 10:07 AM, revealed there were holes in the PM area of the March 2024 temperature log on March 1-6, 9-10, and 13-16, 2024.

Observation during initial tour of the Love pantry area on March 18, 2024, at 10:14 AM, revealed 12 individual cereal boxes in a bin, not dated; and nine individual cereal boxes in a cabinet, not dated.

Observation of the Refrigerator/Freezer Temperature Log in Faith Pantry Area on March 18, 2024, at 10:17 AM, revealed it was a different log than the previous unit, as it only required staff to log the refrigerator and freezer temperatures once daily, and temperatures were not recorded on March 6, 2024.

An interview with the Nursing Home Administrator (NHA) on March 20, 2024, at 10:14 AM, revealed it is the facility's expectation that food and beverages are labeled and dated, and food items and kitchen equipment are stored and utilized in accordance with professional standards.

During an interview with Employee 8 (Dietary Manager) on March 20, 2024, at 11:31 AM, the surveyor revealed the concerns of the initial tour of the kitchen and pantries on March 18, 2024, including the lack of a log for the three-compartment sink sanitizer ppm. Employee 8 confirmed he would expect labeling and dating per facility policy, and staff should be logging the ppm of the three compartment sink sanitizer water. The surveyor requested information on the required ppm of the sanitizer solution used in order for it to be effective.

Review of Safety Data Sheet (SDS) for the sanitizing solution provided by the NHA on March 20, 2024, at 12:28 PM, revealed the ppm of the sanitizing solution should be between 272 and 700 ppm to be effective.

During a follow-up interview with the NHA on March 20, 2024, at 2:28 PM, she confirmed the SDS states the ppm should be between 272 and 700 ppm, dietary staff should be recording the concentration of the sanitizing sink, the facility should not be using conflicting temperature logs in the pantries, and she expects them to use the log that requires them to log temperatures daily.

28 Pa. Code 201.18(b)(1)(3)(e)(1) Management.
28 Pa. Code 211.6(f) Dietary services



 Plan of Correction - To be completed: 04/18/2024

1. Immediate action(s) taken for the resident(s) found to have been affected include:
All items mentioned were discarded. Consistent temperature logs have been placed on both Love and Faith units so that temperatures are taken daily. The sanitizer on the three-compartment sink will be calibrated by Ecolab, the contractor that supplies the sanitizer and logs will be maintained to ensure stability of the solution.

2. Identification of other residents having the potential to be affected was accomplished by:
All residents have the potential to be affected by the deficient practice. As stated above, all items not labeled were discarded.


3. Actions taken/systems put into place to reduce the risk of future occurrence include:
New logs will be distributed to both nursing units and all old logs will be discarded. Education will be provided to all staff regarding the importance of obtaining the temperatures daily and keeping consistent logs on both units. The kitchen will be educated on the importance of keeping the logs in the kitchen for the sanitizer and ensuring the parts per million are correct at all times. All staff will be re-educated on the dating and labeling policy.

4. How the corrective action(s) will be monitored to ensure the practice will not recur:
3 audits per week for dating/labeling all foods, the temperature logs and the three-compartment sink sanitizer will occur for the next 4 weeks, bi-weekly for 4 weeks after and randomly thereafter until such time consistent substantial compliance is met.

483.60(a)(1)(2) REQUIREMENT Qualified Dietary Staff:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
§483.60(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 clinical record review and staff interviews, it was determined that the facility failed to consult qualified dietary staff to assess the nutritional needs of residents in the absence of a qualified dietitian for four of 17 residents reviewed (Residents 22, 23, 45, 57).

Findings include:

During the initial tour of the kitchen and pantries with Employee 9 (Cook) on Monday March 18, 2024, at 9:25 AM, he revealed the Dietary Manager was off that day, the Dietitian was new, and he wasn't sure about her schedule.

During an interview with the Nursing Home Administrator (NHA) on March 20, 2024, at 10:50 AM, she revealed they now have a Dietitian that recently started a little over a week ago.

During an interview with Employee 8 (Dietary Manager) on March 20, 2024, at 11:25 AM, he revealed he has been employed as the Dietary Manager at the facility since October 2023 and they have been without a Dietitian since then. He revealed nursing communicates residents' diet orders to the kitchen, and Employee 9, himself, or a dining clerk see residents upon admission, and as needed, to obtain their personal food and beverage preferences and allergies; this information is then sent to headquarters and a nutritional ticket is generated for that resident. He further revealed neither he nor Employee 9 would be able to assess residents' nutritional needs or nutritional status.

During an interview with Employee 10 (Registered Dietitian) on March 20, 2024, at 12:08 PM, she revealed she started employment with the facility on March 5, 2024. She further revealed she usually comes to the facility on Wednesdays, but she has remote access to the facility's electronic health record and checks in daily and as needed.

Review of Resident 22's clinical record revealed diagnoses that included dementia (a chronic disorder of the mental processes caused by brain disease, marked by memory disorders, personality changes, and impaired reasoning), and dysphagia (difficulty swallowing).

Review of Resident 22's clinical record failed to reveal a nutritional assessment was completed for Resident 22 between the dates of September 15, 2023, and March 20, 2024.

Review of Resident 23's clinical record revealed diagnoses that included dementia and anemia (deficiency of healthy red blood cells).

Review of Resident 23's clinical record on March 19, 2023, at 10:31 AM, revealed that they had one nutritional assessment completed by the facility Dietician on July 25, 2023, at the time of their admission to the facility.

Review of Resident 23's clinical record progress notes on March 19, 2023, at 10:31 AM, revealed that the last documentation completed by a Dietician was on August 3, 2023, at which time the note indicated that they were questioning a weight that was obtained and had requested that the resident be reweighed.

Review of Resident 45's clinical record revealed diagnoses that included dementia and dysphagia.

Review of Resident 45's clinical record failed to reveal any nutritional assessments between the dates of September 20, 2023, and March 6, 2024.

Review of Resident 57's clinical record revealed diagnoses that included dementia and vitamin D deficiency.

Review of Resident 57's clinical record on March 20, 2024, failed to reveal a nutritional assessment was completed for Resident 57 between the dates of September 15, 2023, to present.

During an interview with the NHA on March 20, 2024, at 2:29 PM, the surveyor revealed the concern with absence of qualified dietary staff to conduct nutrition assessments during the period when the facility was without Dietitian coverage, which was between September 15, 2023, and March 5, 2024. The NHA revealed they could have been consulting the corporate Certified Dietary Manager at the time, and should have, but they failed to consult them.

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





 Plan of Correction - To be completed: 04/18/2024

*UPDATE 4/2/24: Education will be done by the Dietician or designee with the entire team on the requirements of a dietician and the regulations associated with their role in long term care.

1. Immediate action(s) taken for the resident(s) found to have been affected include:
Residents 22, 23, 45, and 57 have all received comprehensive nutritional assessments.

2. Identification of other residents having the potential to be affected was accomplished by:
3. All residents have the potential to be affected by this deficient practice. Therefore, updated nutritional assessments of all addition residents will be completed within 30 business days.

4. Actions taken/systems put into place to reduce the risk of future occurrence include:
Registered Dietitian was hired 3/5/24. Monthly audits to be reviewed with the Interdisciplinary team at QAPI.

5. How the corrective action(s) will be monitored to ensure the practice will not recur:
The Nursing Home Administrator or designee will audit appropriate completion of weight notes and nutritional assessments 2 time/week for 4 weeks and 4 times/month for 3 mos. Random audits will be conducted thereafter until consistent substantial compliance is met.

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

Based on observations, facility policy review, clinical record review, and staff interviews, it was determined that the facility failed to ensure care and services were provided in accordance with professional standards of practice to meet each resident's physical, mental, and psychosocial needs for four of 19 residents reviewed (Residents 7, 22, 45, and 67).

Findings Include:

Review of facility policy, titled "Dressing Change Policy", dated January 15, 2017, revealed "Remove soiled dressing and discard in a trash bag;...Don non-sterile/sterile gloves (when appropriate) prior to cleansing wound site; Cleanse wound site per physician's order; Wash hands; Don non-sterile/sterile gloves (when appropriate) and apply topical treatment as ordered..."

Review of facility policy, titled "Pressure Injury Prevention and Management", dated October 23, 2022, revealed "Pressure Ulcer/Injury refers to localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device."

Review of Resident 7's clinical record revealed diagnoses that included Bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs) and Type 2 Diabetes Mellitus (a long-term condition in which the body has trouble controlling blood sugar and using it for energy).

Reivew of Resident 7's current physician orders revealed a treatment order for Resident 7's MASD (moisture associated skin damage), dated February 23, 2024, to cleanse sacrum with normal saline solution (NSS), pat dry, apply medical grade honey and cover with a foam border, daily, and PRN (as needed) when soiled/dislodged.

Observation of Resident 7's treatment on March 20, 2024, at 11:23 AM, revealed Employee 7 (Licensed Practical Nurse [LPN]) washed her hands and applied gloves. Resident 7 was positioned onto his side and his brief was removed. At that time, Resident 7 was observed to not have a dressing in place to remove from his sacrum. Employee 7 was asked why Resident 7 did not have a dressing in place, as ordered. Employee 7 stated that the nurse aide had just been in the room prior to the dressing change, and Resident 7 was incontinent; the dressing was soiled and removed.

Further observation of Resident 7's treatment revealed Employee 7 cleansed Resident 7's wound with NSS, patted the wound dry, and applied the medical grade honey and then the foam border. Employee 7 then removed her gloves and washed her hands. Employee 7 did not change gloves or perform hand hygiene after cleansing the wound and prior to applying the medical grade honey.

During an interview with the Nursing Home Administrator (NHA) on March 21, 2024, at 9:45 AM, she stated that Employee 7 should have followed the facility policy regarding hand hygiene and changing gloves.

Review of Resident 22's clinical record revealed diagnoses that included dementia (a chronic disorder of the mental processes caused by brain disease, marked by memory disorders, personality changes, and impaired reasoning), dysphagia (difficulty swallowing), and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest in things).

Review of Resident 22's care plan revealed a focus area of, "[Resident 22] has an alteration in musculoskeletal status related to fracture of the left forearm", last revised March 21, 2024, with an intervention to "encourage the resident with use of supportive devices (splints, braces, canes, crutches etc.) as recommended", last revised March 21, 2024.

Observations of Resident 22 on March 18, 2024, at 9:13 AM and at 12:49 AM; and March 19, 2024, at 12:33 PM failed to reveal Resident 22 wearing a splint device to her left forearm.

Email correspondence with the NHA on March 20, 2024, at 7:22 PM, revealed Resident 22 came back from the hospital with orders for a splint and it is care planned, and when therapy had her on their caseload from January 1, 2024, to January 11, 2024, she was still ordered the splint. Her family declined her appointment for her orthopedic follow-up and they had decided on comfort care. According to staff interviews, she continued to refuse the sling, but it is in her room and available and, due to lack of orthopedic follow-up, the care plan remained for her to wear when she is agreeable.

Review of Resident 22's hospital discharge summary dated December 29, 2023, revealed "Open fracture of the distal end of left radius (arm) ...Post reduction placed in sugar tong splint."

Review of Resident 22's physician orders failed to reveal an order for a splint/brace.

Email correspondence with the NHA on March 21, 2024, at 12:59 PM, revealed Resident 22 had no order for her splint in her electronic health record. The usage of the splint was from her discharge order from the hospital and a clarification order will be obtained and the care plan updated accordingly.

During a follow-up interview with the NHA on March 21, 2024, at 1:26 PM, the NHA explained she will follow-up with the physician to clarify if Resident 22 should be ordered the splint, because the family cancelled her orthopedic follow-up and she refuses the splint. She revealed the facility never ordered the splint per the directions of her hospital discharge summary, and they should have ordered it when she returned from the hospital.

Review of Resident 45's clinical record revealed diagnoses that included dementia, dysphagia, and breast cancer.

Observations of Resident 45 on March 19, 2024, at 12:42 PM, and on March 20, 2024, at 1:34 PM, revealed Resident 45's bilateral feet/toes were resting against the footboard of their bed.

Review of Resident 45's clinical record progress notes revealed a nurse's progress note dated November 7, 2023, at 9:55 PM, that indicated that Resident 45 was found to have a "dark, purple red coloration with generalized dependent edema noted at right lower shin, ankle, and foot. Noted area that presents as venous stasis issue at tip of right great toe and same at left great toe. Bilateral lower extremities are cool to touch with dependent, generalized edema noted."

Review of Resident 45's clinical record progress notes also revealed a nurse's note dated November 7, 2023, at 10:05 PM, that indicated that a consult had been faxed to Wound Healing Solutions (wound mangement consultation service) to determine etiology and treatment of areas at the tip of right great toe and tip of left great toe.

Review of Resident 45's clinical record progress notes revealed a note dated November 17, 2023, at 2:41 PM, that indicated that the resident had been seen by the wound specialist from Healing Partners (wound mangement consultation service) earlier that day at 7:41 AM, and Resident 45 had a pressure injury to their left great toe that measured 0.4 centimeters (cm) by 0.6 cm, and was classified as a deep tissue injury. A diagnosis of Pressure-induced deep tissue damage of the other site was added, treatment orders were given, and a recommendation was made for staff to ensure the resident had proper fitting footwear to prevent/minimize unwanted pressure and friction.

Review of Resident 45's clinical record progress notes revealed a note dated November 20, 2023, at 1:39 PM, that indicated their toe was assessed that morning and, at that time, "Resident's toes were noted to be hitting against footboard of bed causing possible trauma to site. Resident was repositioned to prevent sliding in bed."

Review of Resident 45's clinical record progress notes revealed a note dated November 24, 2023, that indicated the area to their left toe now measured 0.5 cm by 0.5 cm, and was documented as "a trauma area to left great toe."

Review of Resident 45's clinical record progress notes revealed a note dated December 1, 2023, at 3:07 PM, that indicated that the resident was seen by the wound specialist from Healing Partners earlier that day at 8:07 AM, and that Resident 45 had an injury to their left great toe. "Per nursing staff this is due to trauma from the patient hitting her toes on the end of the bed." The note went on to state that the primary etiology was trauma, that the wound was still classified as a deep tissue injury, and measured 0.4 cm by 0.6 cm.

Review of Resident 45's clinical record progress notes revealed a note dated December 7, 2023, that indicated the resident was seen by the wound specialist from Healing Partners earlier that day, and that the etiology of Resident 45's wound to their left great toe was "arterial" and measured 0.4 cm by 0.5 cm. This note also included the results of their November 8, 2023, arterial studies that showed "No significant PAD [Peripheral Artery Disease - condition in which narrowed arteries reduce blood flow to the arms and legs] of arteries of bilateral LE [lower extremities]. ABI [Ankle Brachial Index - test for peripheral artery disease]: normal range and satisfactory perfusion [how much pressure it takes to push blood through all the blood vessels in a specific area]."

Review of Resident 45's clinical record progress notes revealed a note dated December 15, 2023, that indicated they were seen by the wound specialist from Healing Partners earlier that day, and that the etiology of Resident 45's wound to their left great toe was "arterial" and measured 0.4 cm by 0.5 cm. This note also included the aforementioned results of their November 8, 2023, arterial studies that showed "No significant PAD of arteries of bilateral LE. ABI: normal range and satisfactory perfusion."

Review of Resident 45's clinical record progress notes revealed a note dated December 21, 2023, at 1:01 PM, that indicated "L[eft]Toe is NOT a Pressure Injury - We need to d/c [discontinue] documenting this as a Pressure injury, per DON [Director of Nursing]/WCC [wound care certified].

Review of Resident 45's clinical record progress notes revealed a note dated December 22, 2023, that indicated the resident was seen by the wound specialist from Healing Partners earlier that day, and that the etiology of Resident 45's wound to their left great toe was "arterial" and measured 0.4 cm by 0.5 cm. This note also included the aforementioned results of their November 8, 2023, arterial studies that showed "No significant PAD of arteries of bilateral LE. ABI: normal range and satisfactory perfusion."

Review of Resident 45's clinical record progress notes revealed a note dated December 29, 2023, that indicated they were seen by the wound specialist from Healing Partners earlier that day, the the etiology of Resident 45's wound to their left great toe was "arterial" and measured 0.0 centimeters by 0.0 centimeters and was resolved.

Further review of Resident 45's clinical record progress notes revealed that facility nurses continued to document on the area to the left great toe on a weekly basis.

During an interview with the NHA on March 20, 2024, at 10:37 AM, concerns were presented regarding wound documentation and classification of Resident 45's wound in the clinical record. Discussion specifically included that there were notes by the wound specialist consultant that had identified the area as pressure initially, then the wound specialist consultant documented that the wound was trauma related, and then the wound specialist consultant documented that the wound was an arterial ulcer. It was also shared that in the same note by the wound specialist consultant that indicated the wound was an arterial ulcer, it was noted that the arterial test results revealed that Resident 45 did not have any arterial blood flow blockages. Surveyor also shared that there were notes that indicated the wound was resolved and notes that indicated that the wound remained.

During an interview with the NHA and Employee 1 (RNAC - Registered Nurse Assessment Coordinator) on March 20, 2024, at 2:26 PM, Employee 1 indicated that they were reviewing everything to determine what type of wound Resident 45 had. The NHA also indicated that the Registered Nurse Supervisor was going to assess Resident 45 to determine if the wound was still present. She also indicated that she had reached out to the wound specialist consultant for additional information. The NHA indicated that she seemed to recall that there was some discussion with the former Director of Nursing (DON) and the wound specialty consultant having conflicting information regarding Resident 45's wound.

Email communication received from the NHA on March 20, 2024, at 7:30 PM, indicated that Resident 45 had a wound to their left great toe that was documented as resolved on December 29, 2023. She also indicated that, according to an interview with the Nurse Supervisor that date, staff continued to document on the resolved area "because there is still a scab."

Email communication received from the NHA on March 21, 2024, at 9:00 AM, included an email from Wound Healing Partners's wound nurse who saw Resident 45 for her left great toe wound, and indicated that the DON did not think this was pressure and did not want it listed as such. The email further indicated that was why arterial studies were ordered. The NHA also indicated that facility staff are "still treating the L[eft] great toe because there is still a scab on it. They continue to monitor and will make referral to WHP (Wound Healing Partners) if necessary."

During a final interview with the NHA on March 21, 2024, at 10:30 AM, she confirmed that she would expect clear communication to have occurred to determine the exact wound type for adequate follow-up at the time that Resident 45 developed the wound. She also indicated that the DON who was employed at the facility at the time that Resident 45 developed their wound has since been terminated, and that part of the reason they were terminated was related to wound classifications.

Review of Resident 67's clinical record revealed diagnoses that included hypertension (high blood pressure) and dementia.

Review of Resident 67's current comprehensive person-centered care plan revealed a focus area of: The Resident has a Urinary Tract Infection (UTI), with an initiation date of February 19, 2024, and a revision date of March 16, 2024, with an intervention to include: monitor vital signs every shift until March 19, 2024, with an initiation date of March 16, 2024.

Review of Resident 67's clinical record revealed vital signs were not being monitored every shift as care planned from March 12, 2024, to March 19, 2024.

During an interview with the NHA on March 21, 2024, at 1:28 PM, she revealed that Resident 67's vital signs were not consistently documented, and she would have expected them to have been if it was care planned.

28 Pa. Code 211.12(c)(d)(1)(2)(5) Nursing services



 Plan of Correction - To be completed: 04/18/2024

*UPDATE 4/2/24: Resident 7's wound was assessed by the wound consultant on 3/22 and is documented as "improving without complications." The wound consultant saw the wound again on 3/29 and was again documented as still improving. Current treatment will continue with consultant as well as clinical staff until resolved. Resident 45 was assessed by the Nurse Supervisor and the wound on her toe has been resolved; it has been removed from her care plan and is documented as resolved. Resident 67 was on his antibiotic until 3/19 at which time his vitals were switched from every shift to monthly. While the vitals were not taken every shift, Resident 67 had no further issues and the antibiotic appears to have cleared the infection. Resident's order is in the electronic medical record to continue monthly and his care plan for the infection has been resolved. In terms of hand washing during dressing changes, the policy will be reviewed and updated to be more clear about the steps required during dressing changes. Audits will be conducted by the Nursing Home Administrator, Director of Nursing and/or designee to ensure proper hand hygiene is maintained during dressing changes/wound care. These audits will happen through observations and will be done randomly 4 times/week for 4 weeks, 4 times bi-weekly for 4 weeks and randomly thereafter until such time consistent substantial compliance has been met. In order to ensure physician orders are carried out, night shift licensed staff will conduct second checks on orders for all residents, especially those returning from the emergency room, hospital or other outside care. Additionally, new order are reviewed each morning in clinical meeting. Audits will be conduced of second checks on new resident orders. This will happen on random residents 2 times/week for 4 weeks, 2 times/week bi-weekly for 4 weeks and then randomly thereafter until such time consistent substantial compliance is met. Education on wound management, documentation and the wound policies will be reviewed with licensed staff. When the consulting wound provider rounds in this facility, the Director of Nursing and/or Designee will round with the provider. Audits of all current and new wounds will be conducted by the Director of Nursing and/or designee weekly for the next 4 weeks, bi-weekly for 4 weeks following and 4 weeks randomly thereafter until such time that consistent substantial compliance is met.

1. Immediate action(s) taken for the resident(s) found to have been affected include:
The Medical Director was followed up with to determine clarification on Resident 22's plan of care.

2. Identification of other residents having the potential to be affected was accomplished by:
All residents who have wounds or new orders are potentially affected by this deficient practice.

3. Actions taken/systems put into place to reduce the risk of future occurrence include:
All clinical staff will be educated on the Dressing Change Policy, Pressure Injury Prevention and Management Policy and a review of proper hand hygiene during dressing changes will be provided. Additionally, when the contractor is present for wound rounds, the Director of Nursing or Designee will round with the wound consultant to ensure appropriate recommendations and orders are followed and clarified if needed. Education on wound management and the wound policies will be reviewed with licensed staff. Night shift licensed staff will conduct second checks on orders for all residents, especially those returning from the emergency room, hospital or other outside care.

4. How the corrective action(s) will be monitored to ensure the practice will not recur:
Audits will be conducted by the Nursing Home Administrator, Director of Nursing and/or designee to ensure proper hand hygiene is maintained during dressing changes/wound care. These audits will happen through observations and will be done randomly 4 times/week for 4 weeks, 4 times bi-weekly for 4 weeks and randomly thereafter until such time consistent substantial compliance has been met. Additionally, audits will be conduced of second checks on new resident orders. This will happen on random residents 2 times/week for 4 weeks, 2 times/week bi-weekly for 4 weeks and then randomly thereafter until such time consistent substantial compliance is met.

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 clinical record review and staff interviews, it was determined that the facility failed to ensure that the resident assessment accurately reflected the resident's status for six of 19 residents reviewed (Residents 6, 7, 8, 22, 33, and 41).

Findings Include:

Review of Resident 6's clinical record revealed diagnoses that included dementia (a chronic disorder of the mental processes caused by brain disease, marked by memory disorders, personality changes, and impaired reasoning), legal blindness (a term to describe severe visual impairment that cannot be corrected with glasses or contact lenses), and generalized anxiety disorder (a mental disorder characterized by feelings of worry, nervousness, or unease).

Review of Resident 6's Quarterly MDS (Minimum Data Set - an assessment tool to review all care areas specific to the resident such as a resident's physical, mental, or psychosocial needs) dated February 23, 2024, revealed under Section O. Special Treatments, Procedures and Programs, subsection K1. Hospice Care, Resident 6 was marked "yes", indicating she was receiving hospices services during the ARD (assessment reference date of previous 7 days).

Review of Resident 6's clinical record revealed a social services progress note on November 28, 2023, that stated Resident 6's last covered day for hospice services was December 1, 2023, and that they are not able to recertify her on hospice services.

Review of Resident 6's clinical record revealed she had a Significant Change MDS Assessment completed on December 1, 2023, due to the discontinuation of hospice services.

During an interview with Employee 1 on March 20, 2024, at 2:41 PM, the surveyor inquired about hospice being coded on Resident 6's MDS with ARD of February 23, 2024. Employee 1 (Registered Nurse Assessment Coordinator) replied "Yes, that was a mistake."

During an interview with the Nursing Home Administrator (NHA) on March 20, 2024, at 2:42 PM, she revealed she would expect Resident 6's aforementioned Quarterly MDS assessment to be coded accurately.

Review of Resident 7's clinical record revealed diagnoses that included Bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs) and Type 2 Diabetes Mellitus (a long-term condition in which the body has trouble controlling blood sugar and using it for energy).

Review of Resident 7's current physician orders revealed orders, both dated February 26, 2023, for Olanzapine (antipsychotic medication), 2.5 mg daily, and Xarelto (anticoagulant medication), 15 mg at bedtime.

Review of Resident 7's quarterly MDS assessment dated February 22, 2024, revealed that in Section N, it was marked "No", that Resident 7 was taking an antipsychotic medication or an anticoagulant medication.

Further review of Resident 7's MDS revealed that Section N0450 A, was coded "No, antipsychotics were not received."

Review of Resident 7's Medication Administration Record (MAR) dated February 2024, revealed that Resident 7 received Olanzapine and Xarelto every day in February 2024.

During an interview with the NHA on March 21, 2024, at 10:20 AM, she stated that Resident 7's MDS was marked in error.

Review of Resident 8's clinical record revealed diagnoses that included hypertension (high blood pressure) and dementia.

Review of Resident 8's quarterly MDS assessment dated January 23, 2024, revealed that Section P0100 Physical Restraints, D. Other, was marked "Used daily".

Review of Resident 8's clinical record revealed no indication of Resident 8 having a physical restraint.

Observation of Resident 8 on March 18, 2024, at 10:09 AM, revealed no observation of Resident 8 having a physical restraint.

During an interview with the NHA on March 20, 2024, at 2:21 PM, she revealed that Resident 8 does not have a physical restraint.

During an interview with the NHA on March 21, 2024, at 10:37 AM, she revealed that Resident 8's quarterly MDS dated January 23, 2024, Section P0100 D was coded incorrectly and should not have indicated Resident 8 had a physical restraint.

Review of Resident 22's clinical record revealed diagnoses that included dementia, history of falling, and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest in things).

Review of Resident 22's clinical record revealed she had an unwitnessed fall on December 24, 20213, that resulted in a fracture to her left forearm.

Review of Resident 22's care plan revealed a focus area of, "[Resident 22] has an alteration in musculoskeletal status related to fracture of the left forearm", initiated on December 29, 2023, upon her return from the hospital.

Review of Resident 22's Discharge Return Anticipated MDS dated December 24, 2023, revealed that in section J under subsection J1900, resident 22 was marked "one" for "Number of falls since Admission or Prior assessment - Injury (except major)" and "one" for "Number of falls since Admission or Prior assessment - Major injury."

During an interview with Employee 1 (RNAC - Registered Nurse Assessment Coordinator) on March 20, 2024, at 2:32 PM, she revealed Resident 22 had a fall with major injury prior to the assessment, and did not have a fall with injury (except major) that should be coded on that assessment. She revealed Resident 22 was coded incorrectly for "Number of falls since Admission or Prior assessment - Injury (except major)" and should have been coded no under that section.

During a follow-up interview with the NHA on March 20, 2024, at 2:32 PM, she revealed she would expect Resident 22's MDS assessment to be coded accurately.

Review of Resident 33's clinical record revealed diagnoses that included sleep apnea (a potentially serious sleep disorder in which breathing repeatedly stops and starts) and atrial fibrillation (A-fib - an irregular, often rapid heart rate that commonly causes poor blood flow).

Review of Resident 33's current physician orders revealed an order dated March 5, 2023, for CPAP (continuous positive airway pressure - a machine that uses mild air pressure to keep breathing airways open while you sleep) for sleep.

Review of Resident 33's quarterly MDS assessment dated February 5, 2024, revealed that in Section O, Non-Invasive Mechanical Ventilator (provides respiratory support without the use of invasive ventilation, such as CPAP) was coded as "No."

During an interview with the NHA and Employee 1 on March 20, 2024, at 2:42 PM, Employee 1 stated that the CPAP was missed being coded on Resident 33's MDS.

Review of Resident 41's clinical record revealed diagnoses that included obstructive sleep apnea (intermittent airflow blockage during sleep), unspecified heart failure (condition that develops when your heart doesn't pump enough blood for your body's needs), and depression.

Review of Resident 41's physician orders revealed an order for CPAP, continue with current settings at 8.0, dated March 9, 2023.

Review of Resident 41's Annual MDS with the assessment reference date of January 17, 2024, and Quarterly MDS with the assessment reference date of February 28, 2024, revealed in Section O. Special Procedures, Treatments, and Programs that at question G1. Non-invasive Mechanical Ventilator Resident 41 was coded as "No", therefore, disabling question G3. CPAP from being answered.

During an interview with the NHA and Employee 1 on March 20, 2024, at 2:21 PM, Employee 1 confirmed that Resident 41's MDS was coded inaccurately for their CPAP.

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







 Plan of Correction - To be completed: 04/18/2024

*UPDATE 4/2/24: Audits will review all sections of the MDS.

1. Immediate action(s) taken for the resident(s) found to have been affected include:
All residents' assessments have been corrected to reflect necessary changes.

2. Identification of other residents having the potential to be affected was accomplished by:
All residents have the potential to be affected by this deficient practice. An initial random audit of 20 residents will be conducted.


3. Actions taken/systems put into place to reduce the risk of future occurrence include:
Registered Nurse Assessment Coordinator will be re-educated on the need for completion of accurate assessments.

4. How the corrective action(s) will be monitored to ensure the practice will not recur:
RNAC or designee will review 10 random assessments in clinical meeting weekly for 4 weeks, bi-weekly for 2 additional weeks and monthly thereafter until such time as consistent substantial compliance has been met. Findings of these audits will be reported to the Quality Assurance Performance Improvement team at their monthly meetings.

483.21(b)(2)(i)-(iii) REQUIREMENT Care Plan Timing and Revision: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.
§483.21(b) Comprehensive Care Plans
§483.21(b)(2) A comprehensive care plan must be-
(i) Developed within 7 days after completion of the comprehensive assessment.
(ii) Prepared by an interdisciplinary team, that includes but is not limited to--
(A) The attending physician.
(B) A registered nurse with responsibility for the resident.
(C) A nurse aide with responsibility for the resident.
(D) A member of food and nutrition services staff.
(E) To the extent practicable, the participation of the resident and the resident's representative(s). An explanation must be included in a resident's medical record if the participation of the resident and their resident representative is determined not practicable for the development of the resident's care plan.
(F) Other appropriate staff or professionals in disciplines as determined by the resident's needs or as requested by the resident.
(iii)Reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments.
Observations:

Based on facility policy review, observations, clinical record review, and staff interviews, it was determined that the facility failed to ensure the resident's comprehensive plan of care was updated upon changes in the resident's condition for three of 17 residents reviewed (Residents 29, 53, and 60).

Findings Include:

Review of facility policy, titled "Care Plan Revisions Upon Status Change", with a last revised date of April 18, 2023, revealed "1. The comprehensive care plan will be reviewed, and revised as necessary, when a resident experiences a status change."

Review of Resident 29's clinical record revealed diagnoses that included atrial fibrillation (A-fib- an irregular, often rapid heart rate that commonly causes poor blood flow) and hypertension (elevated blood pressure).

Review of Resident 29's current care plan revealed an active care plan for a pressure ulcer, dated December 10, 2023.

Review of Resident 29's wound assessment dated February 2, 2024, revealed that Resident 29's pressure ulcer resolved as of this date.

During an interview with the Nursing Home Administrator (NHA) on March 21, 2024, at 10:19 AM, she stated that Resident 29's care plan should have been updated when the pressure ulcer resolved.

Review of Resident 53's clinical record revealed diagnoses that included vascular dementia (brain damage caused by multiple strokes which causes memory loss in older adults), anxiety disorder (mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), and atrial fibrillation.

Review of Resident 53's care plan revealed a focus area for risk of falls related to deconditioning, with an initiated and revised date of March 21, 2023. Interventions included, but were not limited to, ensuring that the resident is wearing appropriate footwear when ambulating or mobilizing in wheelchair, with a last revision date of March 10, 2024.

Observations of Resident 53 on March 19, 2024, at 8:28 AM; March 19, 2024, at 12:43 PM; and March 20, 2024, at 8:33 AM, all revealed that the resident was barefoot and sitting on the side of the bed.

During an interview with the NHA on March 20, 2024, at 10:35 AM, the aforementioned observations of Resident 53 were shared. She indicated that she would look into the concern.

Email communication received from the NHA on March 20, 2024, at 1:47 PM, indicated she had spoken to the staff on the unit where Resident 53 resides and that they said that Resident 53 often removes their socks. She further indicated that she "asked them to care plan that."

During an interview with the NHA and Employee 1 (Registered Nurse Assessment Coordinator-RNAC) on March 20, 2024, at 2:21 PM, the NHA confirmed that Resident 53's care plan prior to today should have included that they often remove their socks.

Review of Resident 60's clinical record revealed diagnoses that included dementia (a chronic disorder of the mental processes caused by brain disease, marked by memory disorders, personality changes, and impaired reasoning), dysphagia (difficulty swallowing), and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest in things).

Review of Resident 60's care plan on March 18, 2024, revealed she had an active care plan with a focus area "The resident has oxygen therapy r/t Ineffective gas exchange", with a start date of June 22, 2023, with an intervention for "Oxygen settings: O2 via nasal cannula", with a start date of June 22, 2023.

Observation in Resident 60's room on March 18, 2024, at 1:04 PM, failed to reveal oxygen equipment.

Review of Resident 60's active physician orders on March 21, 2024, failed to reveal an order for oxygen.

Review of select facility order sheet provided for Resident 60 revealed an order for "Oxygen: Obtain SPO2 as needed", with discontinued date of October 26, 2023, and a reason of "Resident is no longer in need of oxygen."

An interview with the NHA on March 21, 2024, at 1:25 PM, revealed she would expect Resident 60's oxygen care plan to be resolved.


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



 Plan of Correction - To be completed: 04/18/2024

1. Immediate action(s) taken for the resident(s) found to have been affected include:
Care plans for the Residents 29, 53 and 60 were updated immediately to match physician orders. All resolved areas were removed from the care plans. All items that needed added were added.

2. Identification of other residents having the potential to be affected was accomplished by:
An audit of 20 random care plans will be conducted by the Nursing Home Administrator or designee as all residents have the potential to be affected. Any necessary updates/changes will be made and any items needing to be resolved will be resolved.

3. Actions taken/systems put into place to reduce the risk of future occurrence include:
All team members will be re-educated on the importance of keeping care plans updated according to policy. Licensed staff and interdisciplinary care team (IDT) members will have addition education on care planning. Additionally, an IDT approach will be taken moving forward with all care plans. A system will be developed on how frequently the team will meet, how care conferences will be conducted and how/when care plans are reviewed prior to the family conference.

4. How the corrective action(s) will be monitored to ensure the practice will not recur:
Random audits of 10 residents' comprehensive care plans will be conducted for four weeks, then 5 per month for 6 months and then randomly thereafter until such time consistent substantial compliance has been met.

483.21(c)(2)(i)-(iv) REQUIREMENT Discharge Summary: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(c)(2) Discharge Summary
When the facility anticipates discharge, a resident must have a discharge summary that includes, but is not limited to, the following:
(i) A recapitulation of the resident's stay that includes, but is not limited to, diagnoses, course of illness/treatment or therapy, and pertinent lab, radiology, and consultation results.
(ii) A final summary of the resident's status to include items in paragraph (b)(1) of §483.20, at the time of the discharge that is available for release to authorized persons and agencies, with the consent of the resident or resident's representative.
(iii) Reconciliation of all pre-discharge medications with the resident's post-discharge medications (both prescribed and over-the-counter).
(iv) A post-discharge plan of care that is developed with the participation of the resident and, with the resident's consent, the resident representative(s), which will assist the resident to adjust to his or her new living environment. The post-discharge plan of care must indicate where the individual plans to reside, any arrangements that have been made for the resident's follow up care and any post-discharge medical and non-medical services.
Observations:

Based on clinical record review and staff interview, it was determined the facility failed to develop a discharge summary that anticipated resident needs and included all required information for one of two discharged residents reviewed (Resident 69).

Findings Include:

Review of Resident 69's clinical record revealed diagnoses that included chronic obstructive pulmonary disease (COPD - a group of lung diseases that block airflow and make it difficult to breathe) and anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities).

Review of Resident 69's clinical record revealed she was discharged to her home on December 23, 2023.

Continued review of Resident 69's clinical record revealed no documentation of a recapitulation of the resident's stay, a final summary of the resident's status, a reconciliation of the resident's pre-discharge and post-discharge medications, or a post-discharge plan of care, developed with resident participation, to assist Resident 69 to adjust to her living environment.

An interview with the Nursing Home Administrator on March 20, 2024, at 1:30 PM, revealed a recapitulation of Resident 69's stay, a final summary of the resident's status, and reconciliation of the resident's medications were not completed, and she would have expected them to have been completed.


28 Pa. Code 211.5(d)(f) Clinical records
28 Pa. Code 211.12(d)(1)(5) Nursing services.



 Plan of Correction - To be completed: 04/18/2024

*UPDATE 4/2/24: All discharges will be audited.

1. Immediate action(s) taken for the resident(s) found to have been affected include:
No immediate action was taken for this deficient practice. This will be discussed daily at morning meeting. Therapy will update the NHA, DON, Social Services and Dietary on their discharge date.

2. Identification of other residents having the potential to be affected was accomplished by:
All residents who discharge or transfer have the potential to be affected by this deficient practice. A random audit of 5 files for the discharges/transfers over the past 6 months will be completed to ensure all necessary regulatory pieces of a discharge were completed. This audit will be used as a teaching opportunity for the Medical Director and Interdisciplinary Team.


3. Actions taken/systems put into place to reduce the risk of future occurrence include:
Utilizing the audit completed above, the Nursing Home Administrator or Designee will re-educate team members who are deficient in their part of a discharge. A system of review will be developed and utilized during morning clinical meetings.

4. How the corrective action(s) will be monitored to ensure the practice will not recur:
The Nursing Home Administrator and/or designee will conduct weekly audits over the next 4 weeks, biweekly audits for the 4 weeks following and monthly random audits thereafter until such time consistent substantial compliance is met.

483.24(a)(2) REQUIREMENT ADL Care Provided for Dependent Residents:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
§483.24(a)(2) A resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene;
Observations:

Based on observation, facility policy review, clinical record review, and resident and staff interviews, it was determined that the facility failed to provide assistance with activities of daily living (ADL) for dependent residents for one of 19 residents reviewed (Resident 29).

Findings Include:

Review of facility policy, titled "Activities of Daily Living", dated November 26, 2016, revealed "The facility will provide care and services for the following activities of daily living: (1) Hygiene- bathing, dressing, grooming and oral care."

Review of Resident 29's clinical record revealed diagnoses that included atrial fibrillation (A-fib- an irregular, often rapid heart rate that commonly causes poor blood flow) and hypertension (elevated blood pressure).

Review of Resident 29's current ADL care plan, dated December 10, 2023, revealed that Resident 29 is a moderate 1-2 assist for dressing. Further review of Resident 29's care plan revealed no evidence that Resident 29 prefers to stay in bed or prefers to be in a gown.

Observation of Resident 29 on March 18, 2024, at 12:13 PM and 1:00 PM, revealed Resident 29 in bed, wearing a nightgown.

During an interview with Resident 29 on March 18, 2024, at 12:13 PM, Resident 29 stated she has not yet received her morning care and the gown she is wearing is what she slept in the night prior.

During an interview with the Nursing Home Administrator on March 21, 2024, at 1:23 PM, she stated that she has not had a chance to speak to the Nurse Aide who cared for Resident 29 on March 18, 2024, to determine why the resident remained in bed and a gown at that time, but stated that she would expect that residents would be dressed prior to that time, unless it would be noted as a preference on their care plan to remain in bed and/or in a gown.

28 Pa. code 211.10(d) Resident care policies
28 Pa. code 211.12(d)(1)(5) Nursing services


 Plan of Correction - To be completed: 04/18/2024

1. Immediate action(s) taken for the resident(s) found to have been affected include:
The Nursing Home Administrator and Registered Nurse Supervisor have initiated an investigation as to why Resident 29 was still in her gown at 1 p.m. when this is not her preference.

2. Identification of other residents having the potential to be affected was accomplished by:
All residents have the potential to be affected by this deficient practice. Therefore, random audits will be conducted to ensure residents' preferences are being followed according to their care plan, and that all residents are receiving appropriate care with their activities of daily living. These audits will be conducted at all shifts.


3. Actions taken/systems put into place to reduce the risk of future occurrence include:
Education on the facility policy "Activities of Daily Living" will be conducted for all clinical team members.

4. How the corrective action(s) will be monitored to ensure the practice will not recur:
The audits mentioned above will consist of observations by the Nursing Home Administrator, Director of Nursing, Registered Nurses and/or designees--10 audits per week for 4 weeks, 5 audits per week for an addition 4 weeks and then randomly thereafter until such time when consistent substantial compliance is met.

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

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

Based on observations, facility policy review, clinical record review, and staff interviews, it was determined that the facility failed to implement a fall intervention for one of six residents reviewed for falls (Resident 29).

Findings Include:

Review of facility policy, titled "Fall Prevention and Management Interventions", dated May 11, 2018, revealed "Bedside mat."

Review of Resident 29's clinical record revealed diagnoses that included atrial fibrillation (A-fib- an irregular, often rapid heart rate that commonly causes poor blood flow) and hypertension (elevated blood pressure).

Review of Resident 29's progress notes revealed a note dated January 22, 2024, stating that Resident 29 had an unwitnessed fall and a new fall intervention would be a fall mat to the left side of Resident 29's bed.

Review of Resident 29's current care plan revealed an intervention dated January 22, 2024, for a fall mat to the left side of the bed.

Review of Resident 29's current physician orders revealed an order dated February 8, 2024, for a fall mat to the left side of the bed.

Observations of Resident 29's room on March 19, 2024, at 1:21 PM, and on March 21, 2024, at 9:07 AM, revealed Resident 29 in bed, with a fall mat on the right side of the bed. Further observations revealed there was no fall mat on the left side of the bed during either observation.

On March 21, 2024, at 10:16 AM, the Nursing Home Administrator (NHA) was made aware of the observations of the fall mat not being on the left side of the bed.

In an email correspondence from the NHA on March 21, 2024, at 11:40 AM, she stated that, based on Resident 29's physician order and care plan, staff are not following the care plan by placing the fall mat to the right side of the bed.

28 Pa code 211.12(d)(1)(5) Nursing services


 Plan of Correction - To be completed: 04/18/2024

1. Immediate action(s) taken for the resident(s) found to have been affected include:
It was immediately discovered that some certified nursing assistants were uncertain as to residents' right versus left. Education was completed with all certificated nursing assistants to ensure they understand that when the care plan states "left" it refers to the resident's left as they lay in the bed; not as the staffs' left looking at the bed. Resident 29 was evaluated to determine the mat was located on the appropriate side of the bed according to their care plan and the education provided.

2. Identification of other residents having the potential to be affected was accomplished by:
The Interdisciplinary team feels all residents who are care planned for floor mats have the potential to be affected. An audit of all residents with fall mats was conducted following the education provided and all fall mats are now located on the care planned side of the bed.

3. Actions taken/systems put into place to reduce the risk of future occurrence include:
All staff will be educated on the aforementioned understanding of the left vs. right—knowing that a resident's left is their left when laying in the bed, not the team member's left when they are looking at the bed. Additionally, the Fall Prevention and Management Interventions policy will be reviewed with all staff.

4. How the corrective action(s) will be monitored to ensure the practice will not recur:
Audits will be conducted on all resident using fall mats weekly for 4 weeks, monthly for an additional 4 weeks and quarterly thereafter until such time that consistent substantial compliance is met.

483.25(i) REQUIREMENT Respiratory/Tracheostomy Care and Suctioning:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
§ 483.25(i) Respiratory care, including tracheostomy care and tracheal suctioning.
The facility must ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals and preferences, and 483.65 of this subpart.
Observations:

Based on facility policy review, observations, clinical record reviews, and staff interviews, it was determined that the facility failed to provide respiratory care/oxygen services consistent with professional standards of practice for two of two residents reviewed for respiratory care (Residents 33 and 41).

Findings Include:

Review of facility policy, titled "Noninvasive Ventilation (CPAP [in part])", with an implemented date of April 17, 2023, revealed "Definitions: CPAP, or continuous positive airway pressure, is a respiratory therapy intervention used to provide a patent airway during periods of sleep apnea [intermittent airflow blockage during sleep]. It uses air pressure generated by a machine, delivered through a tube into a mask that fits over the nose or mouth" and "13. Follow manufacturer instructions for the frequency of cleaning/replacing filters [in part]."

Review of Resident 33's clinical record revealed diagnoses that included sleep apnea (a potentially serious sleep disorder in which breathing repeatedly stops and starts) and atrial fibrillation (A-fib - an irregular, often rapid heart rate that commonly causes poor blood flow).

Review of Resident 33's current physician orders revealed an order dated March 5, 2023, for CPAP for sleep, and an order dated April 4, 2023 for CPAP mask to be placed in appropriate storage bag when not in use.

Observations of Resident 33's room on March 18, 2024, at 10:44 AM; March 19, 2024, at 1:08 PM; and March 20, 2024, at 9:38 AM, revealed Resident 33's CPAP mask was not in a storage bag and was laying on top of the CPAP machine, which was located on Resident 33's bedside dresser.

Additional observations on those dates and times also revealed a clear, gallon container of distilled water sitting near the CPAP machine. The distilled water container was not full and had no date indicating when the container was opened.

During an interview with the Nursing Home Administrator (NHA) on March 20, 2024, at 11:08 AM, she stated that Resident 33's CPAP mask should be stored in a bag when not in use and the distilled water should be dated when opened.

Review of Resident 41's clinical record revealed diagnoses that included obstructive sleep apnea (intermittent airflow blockage during sleep), unspecified heart failure (condition that develops when your heart doesn't pump enough blood for your body's needs), and depression.

Review of Resident 41's physician orders revealed the following orders: CPAP,continue with current settings at 8.0, dated March 9, 2023; Change CPAP mask and fine filter (light blue) every 14 days, dated February 28, 2023; and Resident requesting water level of CPAP to be checked at night and be refilled if needed every night shift, dated February 28, 2023.

Observations of Resident 41's room on March 19, 2024, at 8:38 AM, and March 20, 2024, at 9:41 AM, revealed their CPAP machine to be sitting on their nightstand with a clear plastic gallon container of distilled water, approximately 25 percent full, with no date indicating when the container was opened. Observation of the CPAP filter at the same times revealed a slight gray, dusty appearance along the blue plastic rim of the filter.

Review of Resident 41's March Treatment Administration Record (TAR) revealed that on March 13, 2024, their filter and tubing were scheduled to be changed, but that it was coded as "9. Other/See progress note."

Further review of the TAR revealed no other entries that the filter or tubing were changed.

Review of Resident 41's clinical record progress notes for March 13, 2024, revealed a note that indicated the order was not completed because supplies were not available and that the Registered Nurse would notify Social Services.

Further review of Resident 41's clinical record progress notes revealed no other documentation regarding obtaining the supplies and/or the filter and tubing being changed as ordered.

During an interview with the NHA on March 20, 2024, at 10:54 AM, the aforementioned observations were shared as well as the concern that the documentation indicated that Resident 41's filter and tubing were not changed as ordered because of lack of supplies. The NHA indicated that the distilled water should have been dated when opened. She further indicated that she would look into the supply concern and the changing of the filter and tubing.

In email communication received from the NHA on March 21, 2024, at 9:22 AM, she indicated: "We do not have documentation to prove that the C-PAP tubing was changed. I do know we had a supply concern that weekend but it was communicated that when the supplies arrived Monday the tubing would be changed. However, we do not have documentation that it was done."

During a follow-up interview with the NHA on March 21, 2024, at 10:27 AM, she confirmed that she would expect staff to communicate supply concerns and complete all necessary follow-up documentation of actions/communications.

28 Pa. Code 211.12(d)(1)(2)(5) Nursing Services.



 Plan of Correction - To be completed: 04/18/2024

1. Immediate action(s) taken for the resident(s) found to have been affected include:
All residents with order for oxygen or CPAP machines were assessed by the Director of Nursing and Nurse Supervisor to be sure the water was dated and their masks were stored in the storage bag when not in use.

2. Identification of other residents having the potential to be affected was accomplished by:
All residents on Oxygen or CPAP machines are potentially affected by this deficient practice.

3. Actions taken/systems put into place to reduce the risk of future occurrence include:
The Noninvasive Ventilation Policy (CPAP) and Oxygen policies will be reviewed with all licensed staff. Night shift licensed staff will be conducting checks weekly of all residents with oxygen to ensure the policies are being followed; including but not limited to non-used masks are in storage bags, water is dated with open date and expiration date, tubing is clean and changed appropriately and machines are working properly.

4. How the corrective action(s) will be monitored to ensure the practice will not recur:
Audits of the weekly checks will be conducted by the Director of Nursing or designee by observation and report checks maintained by the licensed staff for 3 residents/week for 4 weeks, 3 residents bi-weekly for 4 weeks and then randomly thereafter until such time that consistent substantial compliance is met.

483.35(a)(1)(2) REQUIREMENT Sufficient Nursing Staff:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
§483.35(a) Sufficient Staff.
The facility must have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment required at §483.70(e).

§483.35(a)(1) The facility must provide services by sufficient numbers of each of the following types of personnel on a 24-hour basis to provide nursing care to all residents in accordance with resident care plans:
(i) Except when waived under paragraph (e) of this section, licensed nurses; and
(ii) Other nursing personnel, including but not limited to nurse aides.

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

Based on observations, facility policy review, clinical record review, and resident and staff interviews, it was determined that the facility failed to ensure there was sufficient staff to ensure residents attained or maintained the highest practicable physical, mental, and psychosocial well-being for one of 19 residents reviewed (Resident 29).

Findings Include:

Review of facility policy, titled "Call Lights: Accessibility and Timely Response", dated October 23, 2022, revealed "All staff members who see or hear an activated call light are responsible for responding. If the staff member cannot provide what the resident desires, the appropriate personnel should be notified."

Review of Resident 29's clinical record revealed diagnoses that included atrial fibrillation (A-fib- an irregular, often rapid heart rate that commonly causes poor blood flow) and hypertension (elevated blood pressure).

Review of Resident 29's current care plan revealed an intervention, dated December 10, 2023, for moderate assistance with toilet use, and a care plan intervention, dated February 6, 2024, to transfer and ambulate with assist of one with rolling walker and gait belt.

During an interview with Resident 29 on March 18, 2024, at 12:13 PM, she stated that staff do not always answer her call bell timely and, if they do, they often tell her they are busy. At that time, Resident 29 was noted to be in her gown, which she stated she slept in the night prior and had not yet received morning care.

On March 18, 2024, at 12:51 PM, staff were observed passing out lunch trays. The surveyor was in the lounge right outside of Resident 29's room and, at that time, the surveyor overheard an unidentified staff member say to Resident 29 that they were "busy passing trays right now." The surveyor immediately entered Resident 29's room, but the unidentified staff member had already exited. The surveyor asked Resident 29 what she asked the staff member for and if Resident 29 knew the staff member's name. Resident 29 stated she asked to use the bathroom and she thought it was Employee 12 who told her they were passing out trays right now.

Continuous observations from 12:51 PM through 1:22 PM revealed no staff member assisting Resident 29 to the bathroom.

At 1:23 PM, Resident 29 told the surveyor she still needed to use the bathroom and put her call light on at that time. Resident 29's call light was immediately responded to and she was assisted to the bathroom, 32 minutes after she initially asked to use the bathroom.

On March 19, 2024, at 1:10 PM, the surveyor observed Resident 29's call light to be on. The call light was already on prior to the surveyor arriving to the nursing unit.

At 1:18 PM, the surveyor spoke to Resident 29 who stated she was ringing for a drink, but that her family member just went and got it for her so she didn't have to wait anymore.

At 1:27 PM, Resident 29's call light was responded to by staff, 17 minutes after the surveyor noted the call light to be on.

On March 20, 2024, at 2:45 PM, the Nursing Home Administrator (NHA) was made aware of the aforementioned observations. She stated that she would have to look at the facility policy, but it is her expectation that a call light be responded to within 15 minutes.

On March 20, 2024, at 5:15 PM, the NHA provided the call bell policy and stated "Our policy does not address timely response or how long is expected to answer a call bell."

In a follow-up interview with the NHA on March 21, 2024, at 10:18 AM, it was revealed that Employee 12 was not assigned to Resident 29's unit on March 18, 2024, so it was unable to be confirmed if that was the staff member who stated they were passing trays when Resident 29 requested to use the bathroom. At that time, the NHA again stated that it is her expectation for call bells to be responded to within 15 minutes.

28 Pa. Code 201.14 (a) Responsibility of licensee
28 Pa. Code 201.18 (b)(1)(3) Management
28 Pa. Code 211.12 (d)(1)(4)(5) Nursing services



 Plan of Correction - To be completed: 04/18/2024

*UPDATE 4/2/24: The facility staffs according to acuity, staffing ratios and typically exceeds hours per resident day. This deficient practice is reflective of how staff spend their time, separation of duties and the need for additional leadership from the licensed staff. Licensed staff will attend a leadership training specific to long term care. These sessions will be scheduled and completed over the next 3 months in order to get all the staff through the training. They will be expected to more closely monitor the team on the unit and ensure residents' bells are being answered, care is being provided in a timely manner and that division of labor is addressed when needed. 2 audits per shift will be conducted by the Director of Nursing or Designee. These audits will entail monitoring call bell response times, bathing audits, and documentation as the care is provided. 2 audits will occur per shift per day for 4 weeks, then 2 audits daily at random shifts for 4 weeks and then randomly per day until such time as consistent substantial compliance is met.

1. Immediate action(s) taken for the resident(s) found to have been affected include:
Investigation was conducted on the care preferences such as normal wake time and preferred clothing for Resident 29. It was found that she prefers to wake early and that night shift typically gets her ready for the day during their last rounds; between 6 a.m.-7 a.m. Her preference is to be dressed at that time. These preferences will be care planned and followed.

2. Identification of other residents having the potential to be affected was accomplished by:
It is the expectation of the facility for everyone to answer a call bell and for clinical staff to do regular rounding. All residents are affected by the timeliness of answered call bells. For many residents, the call bell is their most reliable means of communication.


3. Actions taken/systems put into place to reduce the risk of future occurrence include:
Education will be provided on the timeliness of answering a call bell and expectation that all call bells should be answered when they are activated; no matter what position served. Random checks will be conducted to be sure staff are answering call bells in a timely fashion.

4. How the corrective action(s) will be monitored to ensure the practice will not recur:
5 Call bell response times will be monitored weekly for 4 weeks, biweekly for 2 months and then monthly thereafter. These response times will be monitored through varies means; they will include situations where call bells will be initiated by the Nursing Home Administrator or designee to ensure the bell is answered, review of call bell response logs from the call bell system report and interviewing residents to ensure they feel the staff are answering their bells in a timely manner. Random audits will continue until which time as consistent substantial compliance is met.

483.35(d)(7) REQUIREMENT Nurse Aide Peform Review-12 hr/yr In-Service:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
§483.35(d)(7) Regular in-service education.
The facility must complete a performance review of every nurse aide at least once every 12 months, and must provide regular in-service education based on the outcome of these reviews. In-service training must comply with the requirements of §483.95(g).
Observations:

Based on facility document review and staff interview, it was determined that the facility failed to complete a performance review for nurse aide staff at least once every 12 months for one of five employees reviewed (Employee 6).

Findings Include:

Review of Employee 6's personnel record revealed a hire date of September 18, 2017, and no evidence of a recent annual performance review.

On March 20, 2024, at 8:22 AM, the Nursing Home Administrator confirmed that Employee 6 did not have a recent annual performance review completed.

28 Pa. Code 201.14(a) Responsibility of licensee.
28 Pa. Code 201.19(2) Personnel policies and procedures.



 Plan of Correction - To be completed: 04/18/2024

1. Immediate action(s) taken for the resident(s) found to have been affected include:
Evaluations for staff who have not received them to date, and whose anniversary date was between January 1st and present will receive their evaluations in the next 3 weeks.

2. Identification of other residents having the potential to be affected was accomplished by:
All staff have the potential to be affected by this deficient practice.

3. Actions taken/systems put into place to reduce the risk of future occurrence include:
The Nursing Home Administrator and/or designee will conduct an audit of all staff working in the home. A spreadsheet will be created with anniversary dates and shared with each department head. The department head will have paper evaluations to complete for their reports based on their anniversary date. After completion of the evaluation, the team member and department head will meet to have an in-person review regarding their performance. Both parties will be expected to sign the evaluation and the evaluation will be returned to he Nursing Home Administrator who will review and send to Human Resources for placement in the team member's personnel file.

4. How the corrective action(s) will be monitored to ensure the practice will not recur:
The Nursing Home Administrator and/or designee will conduct audits weekly to ensure each team member receives their evaluation according to their anniversary date and 100% compliance is maintained.

483.45(a)(b)(1)-(3) REQUIREMENT Pharmacy Srvcs/Procedures/Pharmacist/Records: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 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 clinical record review and staff interviews, it was determined that the facility failed to ensure an accurate accounting of the disposition of uncontrolled medications during the discharge process for one of two discharged residents reviewed (Resident 68).

Findings include:

Review of Resident 68's closed clinical record revealed diagnoses that included chronic obstructive pulmonary disease (COPD - a type of progressive lung disease characterized by long term respiratory symptoms and airflow limitations) and chronic diastolic congestive heart failure (heart failure that occurs when the heart does not relax properly between beats causing the heart to be unable to pump an adequate amount of blood to the body).

The review of the closed clinical record for Resident 68 on March 21, 2024, revealed that Resident 68 was admitted to the facility on December 30, 2023, and that they passed away at the facility on January 9, 2024.

Review of Resident 68's physician orders revealed that the resident had a total of 24 uncontrolled medications orders at the time of their death.

Further review of Resident 68's closed record revealed a form, titled "Medication Disposition", with an effective date of January 11, 2024, which listed three medications with doses remaining that were being returned to the pharmacy. The form was not signed/dated as being completed.

During an interview with the Nursing Home Administrator (NHA) on March 20, 2024, at 2:20 PM, the aforementioned concern was shared and additional information was requested.

Email communication received from the NHA on March 21, 2024, at 10:23 AM, confirmed that Resident 68's medication disposition was started and not completed.

During a final interview with the NHA on March 23, 2023, at 10:46 AM, the NHA confirmed that she would expect all uncontrolled medications to be accounted for on the medication disposition form at the time of a resident's discharge and that the form would be completed in it's entirety.

28 Pa. Code 211.9(j.1)(3) Pharmacy services.
28 Pa. Code 211.12(d)(1)(3)(5) Nursing services




 Plan of Correction - To be completed: 04/18/2024

*UPDATE 4/2/24: All residents who discharge will be audited.

1. Immediate action(s) taken for the resident(s) found to have been affected include:
A meeting with the Medical Director was conducted with the Nursing home Administrator reviewing the deficient practice.

2. Identification of other residents having the potential to be affected was accomplished by:
All residents who discharge or transfer have the potential to be affected by this deficient practice. A random audit of 5 files for the discharges/transfers over the past 6 months will be completed to ensure all necessary regulatory pieces of a discharge were completed. This audit will be used as a teaching opportunity for the Medical Director and Clinical Team.


3. Actions taken/systems put into place to reduce the risk of future occurrence include:
Utilizing the audit completed above, the Nursing Home Administrator or Designee will re-educate team members who are deficient in their part of a discharge. A system of review will be developed and utilized during morning clinical meetings.

The medication disposition policy will be reviewed with licensed staff and the medical director.

4. How the corrective action(s) will be monitored to ensure the practice will not recur:
The Nursing Home Administrator and/or designee will conduct weekly audits over the next 4 weeks, biweekly audits for the 4 weeks following and monthly random audits thereafter until such time consistent substantial compliance is met.

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

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

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

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

Based on facility policy review, clinical record review, and staff interview, it was determined that the facility failed to ensure that the physician reviewed and responded to pharmacy review recommendations in a timely manner for one of five residents reviewed for unnecessary medications (Resident 7).

Findings include:

Review of facility policy, titled "Medication Regimen Review", undated, revealed "At least monthly, the consultant pharmacist reports any irregularities to the attending physician, Medical Director and Director of Nursing...The findings are faxed or e-mailed within (72 hours) to the director of nursing or designee and are documented in the resident's active record. The prescriber and/or medical director is notified if needed...Recommendations are acted upon and documented by the facility staff and/or the prescriber. Prescriber accepts and acts upon suggestion or rejects and provides an explanation for disagreeing."

Review of Resident 7's clinical record revealed diagnoses that included bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs) and Type 2 Diabetes Mellitus (a long-term condition in which the body has trouble controlling blood sugar and using it for energy).

Review of Resident 7's monthly pharmacy reviews revealed that on December 27, 2023, a recommendation was made by the pharmacist.

Review of Resident 7's clinical record revealed no evidence of what the recommendation was or if the physician responded to it.

During an interview with the Nursing Home Administrator on March 20, 2024, at 11:04 AM, she stated that the pharmacist sent the recommendation to the person who was the Director of Nursing (DON) at that time, and that the DON did not forward the recommendation to the provider for a response. She further stated that she would expect the pharmacy recommendations to be forwarded to the physician and responded to timely.

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



 Plan of Correction - To be completed: 04/18/2024

1. Immediate action(s) taken for the resident(s) found to have been affected include:
The Nursing Home Administrator had a phone conversation with the consulting pharmacist about the findings of this survey, specifically this tag. The Consulting Pharmacist and Medical Director will work together to determine resident 7's plan of care.

2. Identification of other residents having the potential to be affected was accomplished by:
All residents have the potential to be affected by this deficient practice. The Nursing Home Administrator now receives the pharmacy recommendations and they will be followed up with during morning clinical meeting upon receipt until such time consistent substantial compliance is met.

3. Actions taken/systems put into place to reduce the risk of future occurrence include:
The Medication regimen Policy will be reviewed with all licensed clinical staff. The pharmacy recommendations will be reviewed when they arrive at the daily clinical meeting.

4. How the corrective action(s) will be monitored to ensure the practice will not recur:
The consulting pharmacist will prepare and review the report stating how many recommendations were made and how many were followed at the Quality Assurance Process Improvement Meeting. The Director of Nursing and/or Medical Director will provide a report for any recommendations not followed with reasoning. Additionally, the Nursing Home Administrator, Director of Nursing or Designee will audit all recommendations 1 week after the Medical Director has signed them to ensure they are being followed and there are no side-effects being documented and no additional follow-up required.

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

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

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

Based on facility policy review, review of select facility documentation, observation, completion of a test tray, and resident and staff interviews, it was determined that the facility failed to provide food and beverages that were palatable and at appetizing temperatures for one of one meals tested.

Findings include:

Review of facility policy, titled "Resident Services- Taste and Temperature Control", last revised November 2002, read, in part, "Cold foods such as milk, butter, ice cream and juices are refrigerated during service or properly iced."

Review of document, titled "Senior Living Meal Assessment", revealed hot food should be served at 130 degrees or greater, and cold beverages should be served at or below 45 degrees.

An interview with Resident 270 on March 18, 2024, at 10:54 AM, revealed the food could be better and is always served cold.

Review of facility grievance log for November 2023 revealed a grievance filed on November 15, 2023, with complaints of cold food.

Observation during the tray line meal service on March 20, 2024, at 11:50 AM, revealed the cold beverages served on the trays were stored at room temperature during service.

A test tray was completed on March 20, 2024, at 12:42 PM, utilizing a lunch tray served from tray line in the main kitchen. A test tray was served and placed in a closed food cart for approximately two minutes prior to being delivered to the Love Unit (other trays for room service were being delivered here also at this time). The test tray included: country fried steak with gravy, baked potato, green beans, strawberry cake, apple juice, and coffee. Temperatures taken by Employee 8 (Dietary Manager) revealed the country fried steak with gravy was 121 degrees, the green beans were 119 degrees (the green beans were not seasoned), and the apple juice was 60 degrees. Consequently, all items were not palatable.

During an interview with Employee 8 on March 20, 2024, at 12:50 PM, he revealed that he would expect hot food and cold beverages to be served at palatable temperatures. He further revealed that he put a new pan of green beans directly on the tray line without seasoning them first with margarine, salt, and pepper, that he should have seasoned them, and that the cold beverages served from the tray line should be kept chilled during service.

During an interview with the Nursing Home Administrator on March 20, 2024, at 2:31 PM, the surveyor revealed the concerns with the test tray. The NHA revealed she would expect food and beverages to be served at appetizing and palatable temperatures.

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




 Plan of Correction - To be completed: 04/18/2024

1. Immediate action(s) taken for the resident(s) found to have been affected include:
The Dietary Manager met with Resident 270 and reviewed preferences; likes and dislikes and interviewed her to determine how the food could better suit her needs.

2. Identification of other residents having the potential to be affected was accomplished by:
All residents have the potential to be affected. At the next scheduled resident food committee meeting, all residents present will be asked to specifically speak to whether hot foods are served hot and cold foods are served cold. Additionally, the Dietary Manager or Designee will be present in the dining room for minimally one meal/day to ensure temperatures are kept and palatability is suitable to residents.


3. Actions taken/systems put into place to reduce the risk of future occurrence include:
Daily test trays will be completed, varying meals in order to ensure temperature and palatability is maintained. The plate warmer was broken during the time of the survey and has been repaired and will continue to be utilized for all meals. Additionally, a team meeting is scheduled to re-educate nursing and dietary team members about their responsibility in timeliness of meal service.

4. How the corrective action(s) will be monitored to ensure the practice will not recur:
Audits will be conducted weekly to ensure the dietary manager covers one meal/day, the minutes from resident food committee reflect the residents' satisfaction with the food temperatures and palatability. Audits will also be completed ensuring the test trays are following food policy temperatures. Additionally, audits will ensure that any comments made during food committee are followed up and carried out. A total of 5 audits/week for 4 weeks, 5 audits bi-weekly for 4 weeks and then random thereafter will be conducted. All of the actions taken in this corrective action will be on-going until such time consistent substantial compliance has been met.

§ 201.14(a) LICENSURE Responsibility of licensee.:State only Deficiency.
(a) The licensee is responsible for meeting the minimum standards for the operation of a facility as set forth by the Department and by other Federal, State and local agencies responsible for the health and welfare of residents. This includes complying with all applicable Federal and State laws, and rules, regulations and orders issued by the Department and other Federal, State or local agencies.

Observations:

Based on review of state regulations, the facility's Infection Control meeting attendance records, and staff interview, it was determined that the facility failed to have one of the required multidisciplinary members present at the Infection Control meetings (Laboratory personnel).

Findings include:

Review of Act 52 (The Act of March 20, 2002, P.L.154, No. 13), known as the "Medical Care Availability and Reduction of Error (Mcare) Act, Chapter 4, Section 403(1) Infection Control Plan", stated, "A multidisciplinary committee including representatives from each of the following if applicable to that specific health care facility." A review of the applicable members include Medical Staff, Administration, Nursing Staff, Patient Safety Officer, Physical Plant Personnel, a Community Member, Lab Personnel, Pharmacy Staff, and Infection Control Team Members.

Review of the facility's infection control meeting attendance records dated July 28, 2023; November 27, 2023; and January 19, 2024, failed to reveal that a lab member attended.

On March 21, 2024, at 12:20 PM, the Nursing Home Administrator confirmed that the lab does not attend the infection control meetings, and stated they do not provide any reports or information for the meetings.


 Plan of Correction - To be completed: 04/18/2024

1. Immediate action(s) taken for the resident(s) found to have been affected include:
The lab was immediately notified that they need to attend the infection prevention meetings and be prepared to present any pertinent information. A calendar invite was sent to the lab representative for the remainder of 2024. Additionally, education was provided to the lab on their responsibility of serving according to the Medical Care Availability and Reduction of Error Act, Chapter 4, Section 403.

2. Identification of other residents having the potential to be affected was accomplished by:
Because all residents have the potential to be affected, education on the Medical Care Availability and Reduction of Error Act will be conducted for the Infection Preventionist, the QAPI team and all staff.

3. Actions taken/systems put into place to reduce the risk of future occurrence include:
The lab member has been invited to the remainder of the 2024 meetings and the Nursing Home Administrator will ensure the signature page is signed by the lab representative. Minutes will be kept to detail their participation.

4. How the corrective action(s) will be monitored to ensure the practice will not recur:
The Nursing Home Administrator or designee will conduct audits of the quarterly meetings' sign-in sheets to ensure the lab representative is present and has signed the signature page. Any reports that the lab shares will become part of the minutes for these meetings. These audits will take place after each meeting for the remainder of the calendar year.

§ 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 facility policy review, clinical record review, and staff interviews, it was determined that the facility failed to ensure confirmed receipt of personal property upon discharge for two of two discharged residents reviewed (Residents 68 and 69).

Findings include:

Review of facility policy, titled "Resident's Personal Belongings", with a last revision date of June 21, 2023, revealed "11. Following the discharge or death of a resident, all personal clothing and items of a customized personal nature are to be given to the designated resident representative within 30 days; and 12. Inventories of all items are to be reviewed and examined by Social Services designee and the resident's representative. Recipients of such personal items at the time of discharge or death shall sign-off with their legal signature, acknowledging receipt of all personal belongings presented."

Review of Resident 68's clinical record revealed diagnoses that included chronic obstructive pulmonary disease (COPD - a type of progressive lung disease characterized by long term respiratory symptoms and airflow limitations) and chronic diastolic congestive heart failure (heart failure that occurs when the heart does not relax properly between beats causing the heart to be unable to pump an adequate amount of blood to the body).

Review of Resident 68's clinical record revealed that the resident passed away at the facility on January 9, 2024.

Review of Resident 68's "Resident Personal Belongings Inventory" sheet, revealed that the area of the document utilized for acknowledging receipt of a resident's personal items upon discharge did not contain any signatures or date.

During an interview with the Nursing Home Administrator (NHA) on March 21, 2024, at 10:30 AM, the NHA confirmed that facility staff should have signed the personal Inventory sheet and should have ensured that it was also signed by the person receiving Resident 68's items upon discharge.

Review of Resident 69's clinical record revealed diagnoses that included chronic obstructive pulmonary disease (COPD - a group of lung diseases that block airflow and make it difficult to breathe) and anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities).

Review of Resident 69's clinical record revealed she was discharged to her home on December 23, 2023.

Review of Resident 69's clinical record revealed no indication of a personal belongings inventory sheet being completed upon discharge.

Electronic mail received from the NHA on March 21, 2024, at 1:00 PM, revealed that a personal belongings inventory sheet was not completed for Resident 69, and she would have expected an inventory sheet to have been completed.




 Plan of Correction - To be completed: 04/18/2024

1. Immediate action(s) taken for the resident(s) found to have been affected include:
Families for resident 68 and resident 69 were called to ensure they discharged with all items they brought to the home. Families reported no concerns.

2. Identification of other residents having the potential to be affected was accomplished by:
All residents who discharge from the home can be affected. Therefore, social services will conduct a random sample of 20 evaluations to determine current residents have up-to-date inventory sheets.


3. Actions taken/systems put into place to reduce the risk of future occurrence include:
A review of the policy will be performed and a new process developed around the current policy. All staff will be educated on the policy and process.

4. How the corrective action(s) will be monitored to ensure the practice will not recur:
Once the policy is reviewed and process developed, an audit of the first 10 discharges/transfers will be completed by the Nursing Home Administrator or designee to ensure the new process was followed and ultimately, the inventory sheet was signed and accepted by the resident/POA. If at that time, substantial compliance is not met, audits will continue util such time as consistent compliance is met.

§ 211.5(f)(i)-(xi) LICENSURE Medical records.:State only Deficiency.
(f) In addition to the items required under 42 CFR 483.70(i)(5) (relating to administration), a resident ' s medical record shall include at a minimum:
(i) Physicians' orders.
(ii) Observation and progress notes.
(iii) Nurses' notes.
(iv) Medical and nursing history and physical examination reports.
(v) Admission data.
(vi) Hospital diagnoses authentication.
(vii) Report from attending physician or transfer form.
(vii) Diagnostic and therapeutic orders.
(viii) Reports of treatments.
(ix) Clinical findings.
(x) Medication records.
(xi) Discharge summary, including final diagnosis and prognosis or cause of death.

Observations:

Based on clinical record review and staff interview, it was determined that the facility failed to ensure the resident's medical record included a complete discharge summary for one of two closed records reviewed (Resident 68).

Findings Include:

Review of Resident 68's clinical record revealed diagnoses that included chronic obstructive pulmonary disease (COPD - a type of progressive lung disease characterized by long term respiratory symptoms and airflow limitations) and chronic diastolic congestive heart failure (heart failure that occurs when the heart does not relax properly between beats causing the heart to be unable to pump an adequate amount of blood to the body).

Continued review of Resident 68's clinical record revealed they were admitted to the facility on December 30, 2023, and that they passed away at the facility on January 9, 2024.

Further review of Resident 68's closed clinical record revealed a document, titled "Transfer/Discharge Report", which indicated that Resident 68 was released to the funeral home on January 9, 2024, at 9:21 PM. This form was signed by Resident 68's physician, but the signature was not dated and the form did not include Resident 68's cause of death.

During an interview with the Nursing Home Administrator (NHA) on March 21, 2024, at 10:30 AM, the NHA confirmed that Resident 68's Discharge Summary did not include their final diagnosis/cause of death and that the physician did not date the document. She further indicated that she would expect a resident's discharge summary to contain all required information.



 Plan of Correction - To be completed: 04/18/2024

1. Immediate action(s) taken for the resident(s) found to have been affected include:
There was no immediate action for this deficiency for Resident 68 as the resident is deceased.

2. Identification of other residents having the potential to be affected was accomplished by:
All residents who transfer or are discharged have the potential of being affected. A random audit of 10 of the past 6 month's discharges/transfers will be completed to ensure residents had the physician summary completed and signed. In discussion with the Medical Director, it was determined that when the facility transferred from paper discharge summaries to electronic ones, the discharge summary has not been completed comsistenty.

3. Actions taken/systems put into place to reduce the risk of future occurrence include:
It was decided that after re-educating the Medical Director on the regulations and policy, the Nursing Home Administrator or designee will communicate to the Medical Director about any and all planned discharges/transfers through our Communication Board in the Electronic Medical Record System. It will be the Medical Director's responsibility to check the communication board daily to ensure all discharges/transfers are completed. An audit will be completed by the Nursing Home Administrator or designee on all discharges/transfers for the next 2 months and randomly thereafter until such time as consistent substantial compliance is met.

4. How the corrective action(s) will be monitored to ensure the practice will not recur:
The Nursing Home Administrator and/or designee will conduct weekly audits over the next 4 weeks, biweekly audits for the 4 weeks following and monthly random audits thereafter.

§ 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 document review and staff interview, it was determined that the facility failed to ensure a required minimum of one Licensed Practical Nurse (LPN) per 25 residents on the day shift for one of 21 days reviewed (December 25, 2023), and one LPN per 40 residents on the overnight shift for one of 21 days reviewed for staffing ratio (December 26, 2023).

Findings Include:

Review of facility-provided staffing ratio information for December 25, 2023, on day shift, revealed a census of 67 residents. Further review revealed a LPN ratio of two; therefore, the facility did not meet the required minimum LPN ratio for the facility census on that shift.

Review of facility-provided staffing ratio information for December 26, 2023 on night shift, revealed a census of 66 residents. Further review revealed a LPN ratio of 1.5; therefore, the facility did not meet the required minimum LPN ratio for the facility census on that shift.

During an interview with the Nursing Home Administrator on March 21, 2024, at 1:23 PM, she confirmed that the facility did not meet the LPN ratio on the aforementioned dates and shifts.


 Plan of Correction - To be completed: 04/18/2024

*UPDATE 4/2/24: Daily we complete a staffing sheet for the next day. These staffing sheets are completed by the scheduler and then reviewed and signed by the nursing home administrator daily. This practice will continue. The root cause of the deficient practice was not how many staff were scheduled, but rather the fact that there were 2 call-offs and 1 no call, no show; causing the deficiency. Reviewing and educating staff on the mandation policy and enforcing the need to utilize mandation will be completed by 4/18/24.

1. Immediate action(s) taken for the resident(s) found to have been affected include:
Review of resident incidents on identified days revealed no negative impact to residents.

2. Identification of other residents having the potential to be affected was accomplished by:
No remedy to audit past deficient practice.

3. Actions taken/systems put into place to reduce the risk of future occurrence include:
NHA or designee will Educate scheduler and RN Supervisors on LPN ratios.

4. How the corrective action(s) will be monitored to ensure the practice will not recur:
NHA or designee will monitor staffing ratios daily to ensure LPN ratios are met.


Back to County Map


  
Home : Press Releases : Administration
Health Planning and Assessment : Office of the Secretary
Health Promotion and Disease Prevention : Quality Assurance



Copyright © 2001 Commonwealth of Pennsylvania. All Rights Reserved.
Commonwealth of PA Privacy Statement

Visit the PA Power Port