Nursing Investigation Results -

Pennsylvania Department of Health
JOHN J KANE REGIONAL CENTER- MCKEESPORT
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

JOHN J KANE REGIONAL CENTER- MCKEESPORT
Inspection Results For:
There are 182 surveys for this facility. Please select a date to view the survey results.

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JOHN J KANE REGIONAL CENTER- MCKEESPORT - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:
Based on a Medicare/Medicaid Recertification, State Licensure, Civil Rights Compliance, and an Abbreviated Survey in response to two complaints, completed on October 25, 2019, it was determined that John J. Kane Regional Center - McKeesport, was not in compliance with the requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care Facilities and the 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.

Plan of Correction:

483.60(i)(1)(2) REQUIREMENT Food Procurement,Store/Prepare/Serve-Sanitary:

This is a less serious (but not lowest level) deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.

�483.60(i) Food safety requirements.
The facility must -

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

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

Plan of Correction - To be completed: 12/17/2019

Deep Fryer:
-Deep fryer was cleaned out immediately
-Staff to be educated by Food Service Director protocol for cleaning deep fryers and how often, training to be documented
-Deep fryer will be monitored via Sanitation Rounds by Dining Director, RD or Kitchen Supervisor daily for one week beginning 11/10/19, then weekly x5 months.
Labeling:
-Trays in cooler #7 was labeled properly immediately
-Tray in reach in #6 was labeled properly immediately
-Cold prep refrigerator was labeled and dated immediately
-Cereal on work table was labeled and dated immediately
-Staff to be educated by Food Service Director on policy and procedure for labeling and dating all product, training to be documented
-Labeling will be monitored via Sanitation Rounds by Dining Director, RD or Kitchen Supervisor daily for one week beginning 11/10/19, then weekly x5 months.
Appropriate Handling of cups/bowls/silverware:
-Once notified employee was immediately reprimanded for placing fingers inside the bowls
-Once notified employee was immediately reprimanded for placing fingers inside of the cup
-Staff to be re-educated by Food Service Director on the importance of cross contamination and the procedure for hand washing and changing gloves, and appropriate handling of wares, training to be documented
-Bowls were immediately flipped to drain water properly
-Small bowl was immediately removed from rack
- Silverware was re-washed immediately
-Staff to be re-educated by Food Service Director on the proper procedure for drying and storing dishware, training to be documented
-Handling of clean dishes and silverware will be monitored via Sanitation Rounds by Dining Director, RD or Kitchen Supervisor daily for one week beginning 11/10/19, then weekly x5 months.
Paint in need of touch up:
- Work order was put in immediately to have the walls painted
- Staff was educated by Food Service Director on proper procedure to put in work orders
- Allegheny County Facilities Management Trades will complete painting and repair work
- Areas in kitchen will be assessed for completion of painting via Sanitation Rounds by Dining Director, RD or Kitchen Supervisor daily for one week beginning 11/10/19, then weekly x5 months.
Cleanliness of drains and grates in kitchen:
- Drain and grates were cleaned immediately
- Staff to be educated by Food Service Director on properly cleaning drains and the grate, and training to be documented
- Drains and grates will be monitored via Sanitation Rounds by Dining Director, RD or Kitchen Supervisor daily for one week beginning 11/10/19, then weekly x5 months.
Audits results will be evaluated by the Quality Commitee

483.10(j)(1)-(4) REQUIREMENT Grievances:

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(j) Grievances.
�483.10(j)(1) The resident has the right to voice grievances to the facility or other agency or entity that hears grievances without discrimination or reprisal and without fear of discrimination or reprisal. Such grievances include those with respect to care and treatment which has been furnished as well as that which has not been furnished, the behavior of staff and of other residents, and other concerns regarding their LTC facility stay.

�483.10(j)(2) The resident has the right to and the facility must make prompt efforts by the facility to resolve grievances the resident may have, in accordance with this paragraph.

�483.10(j)(3) The facility must make information on how to file a grievance or complaint available to the resident.

�483.10(j)(4) The facility must establish a grievance policy to ensure the prompt resolution of all grievances regarding the residents' rights contained in this paragraph. Upon request, the provider must give a copy of the grievance policy to the resident. The grievance policy must include:
(i) Notifying resident individually or through postings in prominent locations throughout the facility of the right to file grievances orally (meaning spoken) or in writing; the right to file grievances anonymously; the contact information of the grievance official with whom a grievance can be filed, that is, his or her name, business address (mailing and email) and business phone number; a reasonable expected time frame for completing the review of the grievance; the right to obtain a written decision regarding his or her grievance; and the contact information of independent entities with whom grievances may be filed, that is, the pertinent State agency, Quality Improvement Organization, State Survey Agency and State Long-Term Care Ombudsman program or protection and advocacy system;
(ii) Identifying a Grievance Official who is responsible for overseeing the grievance process, receiving and tracking grievances through to their conclusions; leading any necessary investigations by the facility; maintaining the confidentiality of all information associated with grievances, for example, the identity of the resident for those grievances submitted anonymously, issuing written grievance decisions to the resident; and coordinating with state and federal agencies as necessary in light of specific allegations;
(iii) As necessary, taking immediate action to prevent further potential violations of any resident right while the alleged violation is being investigated;
(iv) Consistent with �483.12(c)(1), immediately reporting all alleged violations involving neglect, abuse, including injuries of unknown source, and/or misappropriation of resident property, by anyone furnishing services on behalf of the provider, to the administrator of the provider; and as required by State law;
(v) Ensuring that all written grievance decisions include the date the grievance was received, a summary statement of the resident's grievance, the steps taken to investigate the grievance, a summary of the pertinent findings or conclusions regarding the resident's concerns(s), a statement as to whether the grievance was confirmed or not confirmed, any corrective action taken or to be taken by the facility as a result of the grievance, and the date the written decision was issued;
(vi) Taking appropriate corrective action in accordance with State law if the alleged violation of the residents' rights is confirmed by the facility or if an outside entity having jurisdiction, such as the State Survey Agency, Quality Improvement Organization, or local law enforcement agency confirms a violation for any of these residents' rights within its area of responsibility; and
(vii) Maintaining evidence demonstrating the result of all grievances for a period of no less than 3 years from the issuance of the grievance decision.

Observations:

Based on facility policy review, observations and resident and staff interviews, it was determined that the facility failed to provide an anonymous process to file a concern/grievance on one of six units (3B nursing unit) and failed to make grievance forms and a labeled receptacle available on three of three nursing floors (Second, Third and Fourth nursing floors).

Findings include:

The facility policy "Concerns/Complaints/Grievance" dated 2/7/19, indicated that the resident shall be encouraged and assisted throughout the period of stay to exercise his/her rights and voice grievances without discrimination or reprisal and without fear of discrimination or reprisal. Such grievances include those with respect to care and treatment which has been furnished as well as that which has not been furnished, the behavior of staff and ot other residents and other concerns regarding their stay. The facility maintains confidentiality of all information associated with grievances including the identity of the resident for those grievances submitted anonymously.

During an observation on 10/23/19, at 10:15 a. m. on the 3B secured nursing unit it was noted that no concern/grievance forms and a receptacle to place the concern/grievance forms anonymously was provided.

During an interview on 10/23/19, at 10:23 a. m. when Resident R31 was asked how she would file a concern/grievance with the facility, she indicated that she did not know of a process and would just tell a nurse, the social worker or the Ombudsman.

During an interview on 10/24/19, at 11:10 a. m. Nurse Aide (NA) Employee E12 indicated that concern/grievance forms are kept at the nurse's station and they give them to residents when they ask. NA Employee E12 confirmed that there are no forms or box for the forms available on the nursing unit.

During an interview on 10/24/19, at 11:36 a. m. Social Service (SS) Supervisor Employee E13 indicated that the concern/grievance receptacles are located in each floor's recreation rooms and confirmed that by residents of the secured unit needing to ask to leave the unit to go to the recreation room, SS Supervisor Employee E12 confirmed there is no anonymous process in place.

During an observation on 10/25/19, of the Second, Third and Fourth floor recreation rooms revealed no concern/grievance forms and no labeled receptacle to place an anonymous concern/grievance form.

During an interview on 10/25/19, at 10:45 a. m. SS Supervisor Employee E13 confirmed that by not labeling the receptacle and not having concern/grievance forms available, there is no comprehensive grievance process in place.

28 Pa Code: 201.29 (d) (i) (j) Resident rights.

Plan of Correction - To be completed: 12/17/2019

The Grievance officer/designee delivered a blank grievance form to each of the resident rooms on 3B
R-31 was educated by the Director of Nursing /Designee on how to file a grievance anonymously
E-12 was educated by Social Service Director/Grievance officer on where to direct residents to obtain a blank grievance forms and how to submit anonymously
E-13 was re-educated on the process of submitting a resident grievance anonymously by the Central Corporate Compliance Officer.

Resident council to be held Nov 13, 2019. The Central Corporate Compliance and Grievance officer will address resident council. The Central Corporate Compliance officer and Grievance officer will conduct a separate education on 3B as to the process of submitting a grievance anonymously as some may choose not to attend resident council. The process has been in place prior to plan of correction that the grievance officer will go throughout the facility to communicate/educate and ensure that residents have anonymous forms in their night stand drawers.
Grievance officer /designee will be responsible for delivering a blank grievance form to each resident room.
Grievance officer /designee will secure boxes on each floor including 3B and the lobby with signage providing information on submitting a grievance anonymously.
Grievance officer /designee will provide an area on each floor for residents to obtain blank grievance forms anonymously. RCC/Social Service Staff/Designee will be responsible for refilling resident drawers with blank grievance forms on a PRN basis.
The process on submitting a written grievance anonymously will be discussed with new admission on new admission orientation by the Social Service Department.

The Central Corporate Compliance Office will Educate the Director of Social Service (The grievance officer) and his staff on the process of submitting resident grievances anonymously.
ADON Educators/designee will educate the 3B staff on the submission of submitting grievance's form anonymously.

Compliance of submitting the resident grievance forms on unit 3B anonymously will be audited weekly for one month, bi-monthly X two months and monthly X two months. All results will be reviewed by the Quality committee for compliance. Grievance official will present audit results to the Quality committee for compliance

483.45(g)(h)(1)(2) REQUIREMENT Label/Store Drugs and Biologicals:

�483.45(g) Labeling of Drugs and Biologicals
Drugs and biologicals used in the facility must be labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable.

�483.45(h) Storage of Drugs and Biologicals

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

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

Observations:
Based on review of facility policy and manufacturer guidelines, observations and staff interviews, it was determined that the facility failed to dispose of expired medications in two of six medication carts (2B Team 2 and 3A Team 1 medication carts), failed to properly store medication for one of 23 residents (Resident R158), in one of three medication refrigerators (3B medication room) and in one of six medication carts (3B high hallway medication cart).

Findings include:

The facility policy "Medication Administration General Guidelines" last reviewed 2/7/19, indicated that it is the facility policy to store medications in the appropriate section of the medication cart.

The facility policy "Medication Administration General Guidelines" dated 2/7/19, indicated that medication refrigerators will be used only for those medications requiring refrigeration. The temperature of the refrigerator will be controlled at 38 to 45 degrees Fahrenheit. In the event that the temperature is noted to be outside the acceptable range, environmental services will be notified promptly and the medications will be moved promptly and stored in another refrigerator until the refrigerator is repaired and back in the temperature zone.

The facility policy "Medication Distribution System" dated 2/7/19, indicated that orally administered medications are kept separate from medications administered by other routes.

The facility policy "Medication Administration General Guidelines" last reviewed 2/7/19, indicated that it is the facility policy to safely administer medications to residents as prescribed by the physician and in accordance with current standards of practice and regulatory requirements.

The facility policy "Expiration Dates" last reviewed 2/7/19, indicated that that all pharmacy provided items have a stated expiration date on the container. This is either a manufacturer's expiration date or an expiration date determined by Pharmacy. No medication or other item provided by the Pharmacy is to be used after the earliest listed expiration date.

The manufacturer's storage and handling guidelines for Basaglar KwikPen indicate that in-use (opened) room temperature vials should be disposed of 28 days after open date.

During an observation on 10/21/19, at 11:00 a.m. there was one white round pill on Resident R158's overbed table.

During an interview on 10/21/19, at 11:00 a.m. Resident R158's reported "I have no clue where that pill came from, it is not mine."

During an interview on 10/21/19, at 11:10 a.m. Registered Nurse (RN) Employee E4 reported "I do not know where it came from or what it is and it is not her room mates because she get's hers crushed."

During an observation of the 2B Team 2 medication cart on 10/24/19, at 10:00 a.m. the following was observed:

A bottle of Maalox (antacid- used to heartburn and upset stomach) with an expiration date of 10/19/19.

During an interview on 10/24/19, at 10:15 a.m. Licensed Practical Nurse (LPN) Employee E2 confirmed that that the facility failed to properly dispose of expired medications in the 2B Team 2 medication cart.

During an observation of the 3A Team 1 medication room on 10/24/19, at 10:35 a.m. the following was observed:

One bottle of calcium with vitamin D (used to treat a calcium deficiency) with a pharmacy label that indicated expiration date of 9/5/19.

One Basaglar (Insulin) KwikPen with an open date of 9/20/19, the pharmacy label indicated discard after 28 days.

During an interview on 10/24/19 at 10:51 a.m. LPN Employee E3 confirmed that that the facility failed to dispose of expired medications in the 3A Team 1 medication cart.

During an observation of the 3B medication room refrigerator on 10/23/19, at 12:05 p. m. revealed a temperature of 32 degrees Fahrenheit. A second observation on 10/23/19, at 2:47 p. m. revealed a temperature of 32 degrees Fahrenheit. Cath Flo (biological agent used to keep intravenous catheters patent) that was in the refrigerator is not safe to be stored under 36 degrees Fahrenheit and laxative suppositories stored in the refrigerator are to be stored between 68-77 degrees Fahrenheit.

During an interview on 10/23/19, at 2:50 p. m. Registered Nurse Assessment Coordinator Employee E10 confirmed that the facility failed to properly store refrigerated medications.

During an observation of the 3B high hallway medication cart on 10/23/19, at 9:24 a. m. the following was observed:
Six pairs of slipper socks stored with oral medications.
Oral medications stored with nasal medications.
Oral medications stored with injectable medications.
Eye medications stored with oral medications.
Oral medications stored with Clorox cleaning wipes.

During an interview on 10/23/19, at 9:30 a. m. Licensed Practical Nurse Employee E11 confirmed that the facility failed to properly store medications and biologicals in the medication cart.

28 Pa. Code: 211.9 (a) (g) (h) (i) Pharmacy.

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

Plan of Correction - To be completed: 12/17/2019

1) Expired medications on 2B team 2 and 3 A team 1 medication cart were discarded, new medication was obtained from the pharmacy
R-158 medication in refrigerator was discarded and new medication obtained.
R-158 white pill on the over bed table was discarded immediately.
3B medication cart was checked for expired medications and improperly stored medication. Medications expired were discarded and replaced.
3B medication refrigerator was checked for proper temperature, 38-45 degree any medications affected were immediately discarded and new medication were obtained.
Insulin Pens and open insulin vials were checked for expiration dates if expired after being opened 28 days prior the vials and pens were discarded. New medication was obtained from the pharmacy.
Each medication cart on all units were audited for expired medications.
Any expired medication was eliminated and replaced with new medications.
Medications in each medication refrigerator on all units were checked for proper temperature, storage, and expiration dates. Any expired medications were discarded and replaced.
Each medication cart was checked for proper storage according to medication route.
Each medication refrigerator was checked for proper temperature to store medication.
3) ADON/Educator will in-service the RN/LPN staff on proper storing
Of medication both in the medication carts as well as medication refrigerators. Education will include the process of handling medication if the refrigerator is out of acceptable range. 38-45 degree.
In-service will also include. Removing expired medication and the replacement of new meds, and the storage of medication according to route, in the medication carts
Audit of the medication carts and medication refrigerators will be completed by Unit RN/RCC every week X 4 bi-monthly X 2 monthly X 2 all audits will be evaluated by the Quality committee for compliance.

483.15(c)(1)(i)(ii)(2)(i)-(iii) REQUIREMENT Transfer and Discharge Requirements:

This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.

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

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

Observations:
Based on a review of facility documents and staff interviews it was determined that the facility failed to obtain a physician order to release the body to a funeral home for one of three discharged residents (Resident CR245).

Findings include:

A review of Resident CR245's discharge summary indicated that that the resident was admitted to the facility on 8/12/14, with diagnoses that included dementia, chronic kidney disease and failure to thrive. Resident CR245 passed away on 8/14/19.

A review of the clinical record did not include a physician order to release the body of Resident CR245 to the funeral home as required.

During an interview on 10/25/19, at 11:05 a.m. the Nursing Home Administrator and Director of Nursing confirmed that clinical record did not contain a physician order to release the resident's body to the funereal home.

28 Pa Code: 201.25 Discharge policy

28 Pa. Code: 211.5 (d) Clinical records.

Plan of Correction - To be completed: 12/17/2019

Resident CR245 chart has a verbal order signed by the physician, granting permission to transfer the resident's body to the morgue and funeral home.
Residents charts who were transferred/discharged during the month of Sept and Oct were audited by Medical records for physician orders to transfers or to discharge residents who CTB.
3) ADON Educator/Designee will educate the RN/LPN staff on obtaining a physician order before transferring or discharging a resident who CTB.
4) An audit for compliance for obtaining a physician order prior to transfer or discharge of a resident who CTB will be completed by DON/Designee weekly X 4, bi-monthly X 2 monthly X2 . The results will be evaluated by the Quality Committee.

483.60(i)(4) REQUIREMENT Dispose Garbage and Refuse Properly:

�483.60(i)(4)- Dispose of garbage and refuse properly.

Observations:
Based on observation and staff interview it was determined that the facility failed to properly dispose of rubbish which created the potential for rodent infestation in the outside dumpster area (outside dumpster area).

Findings include:

During an observation of the outside dumpster area on 10/21/19, at 10:01 a.m. the following was noted:
- sitting on the ground in the area of the outside dumpsters were 30 television sets.
- a dumpster with an opened access door contained mattresses and other debris.

During an interview on 10/21/19, at 10:01 a.m. the Food Service Manager Employee E5 confirmed the improper disposal of rubbish which created the potential for rodent infestation.

28 Pa Code: 207.2(a) Administrator's responsibility.

Plan of Correction - To be completed: 12/17/2019

Materials Manager contacted the Cyber Crunch Company on 10-21-19 and asked for the TV's to be removed. Cyber Crunch Company removed TV's on 10-23-19 before survey exit
Environmental Services Manager (ESM) Contacted Republic Services on 10-21-19 concerning the broken door on the refuse dumpster. The company replaced the dumpster on 10-23-19 with a door in good working order before survey exit.
Facilities Management, Housekeeping and Materials Management Staff will be educated by ESM on the proper refuse disposal process and monitoring of proper functioning of the dumpster door.

483.25(b)(1)(i)(ii) REQUIREMENT Treatment/Svcs to Prevent/Heal Pressure Ulcer:

�483.25(b) Skin Integrity
�483.25(b)(1) Pressure ulcers.
Based on the comprehensive assessment of a resident, the facility must ensure that-
(i) A resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable; and
(ii) A resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing.

Observations:
Based on a review of facility policies, observations and staff interviews it was determined that the facility failed to provide proper wound prevention care to one of four residents (Resident R84).

Findings include:

The facility policy "Wounds" dated 2/7/19, indicated it is the policy of the facility to provide necessary care and services to attain the highest practicable well-being. Ensure that care and services are provided to promote the prevention of pressure ulcers, healing existing pressure ulcers and to prevent the development of additional pressure ulcers.

Review of the admission documentation dated 12/22/18, indicated Resident R84 was admitted to the facility on 12/6/18, with diagnoses that included paraplegia, neurogenic brain disorder, and neuropathic foot wounds.

Review of Resident R84 significant change Minimum Data Set (MDS -periodic assessment of care needs) dated 8/12/19, indicated Resident R84 these diagnoses remained current.

Review of recapitulation physician orders dated 10/15/19, indicated to float both of Resident R84 heels on pillow when in bed.

Review of the care plan dated 9/17/19, indicated to elevate Resident R84's feet while in bed.

Review of a physican order dated 7/26/19, indicated Occupational Therapy is to issue heel float boots to be worn at all times when in bed.

Review of wound tracking documentation dated 10/16/19, indicated Resident R84 had the following wounds:
Left second toe: 1cm x 1cm x 0.0 cm
Left Medial Malleolus 0.3 cm x 0.5 cm x 0.0 cm
Left lateral distal foot 1.8 cm x 2.0 cm x 0.1 cm
Right fifth toe 0.6 cm x 0.4 cm x 0.0 cm
Right lateral mid foot 1cm x 0.5 cm x 0.0 cm
Right medial foot interior 3.0 cm x 2.0 cm x 0.1 cm

During observations on 10/24/19, at 10:34 AM Resident R84 was observed in bed resting. Resident R84 was observed with both feet wrapped in bandages, his legs were contracted to the right side and both feet were not elevated. Resident R84 heel floating boots were observed in his hamper to be washed.

During an interview on 10/24/19, at 10:36 a.m. Nurse aide Employee E1 confirmed that Resident R84 feet were not floating/elevated as per the physician order.

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

28 Pa Code: 211.12(d)(1)(2)(3)(5) Nursing services.

Plan of Correction - To be completed: 12/17/2019

R-84 heel protectors were washed and placed on residents' heels.
R-84 heels are floated on pillows at night.

An audit was completed by RN/CWC of Residents with physician orders for heel protectors and floating on pillows at night for compliance. DON/designee will utilize the Braden scale to identify residents with a risk score of 15 and greater, An audit will be completed by RN/CWC to ensure the preventive pressures protocols are in place
ADON/Educator will re-educate the staff on the wound program addressing wound prevention including floating heels with in bed
An audit will be completed Unit RN/RCC for compliance weekly X4 bi-monthly X2 and monthly X2 all results will be reviewed by the Quality Committee.

483.21(b)(1) REQUIREMENT Develop/Implement Comprehensive Care Plan:

�483.21(b) Comprehensive Care Plans
�483.21(b)(1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at �483.10(c)(2) and �483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following -
(i) The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under �483.24, �483.25 or �483.40; and
(ii) Any services that would otherwise be required under �483.24, �483.25 or �483.40 but are not provided due to the resident's exercise of rights under �483.10, including the right to refuse treatment under �483.10(c)(6).
(iii) Any specialized services or specialized rehabilitative services the nursing facility will provide as a result of PASARR recommendations. If a facility disagrees with the findings of the PASARR, it must indicate its rationale in the resident's medical record.
(iv)In consultation with the resident and the resident's representative(s)-
(A) The resident's goals for admission and desired outcomes.
(B) The resident's preference and potential for future discharge. Facilities must document whether the resident's desire to return to the community was assessed and any referrals to local contact agencies and/or other appropriate entities, for this purpose.
(C) Discharge plans in the comprehensive care plan, as appropriate, in accordance with the requirements set forth in paragraph (c) of this section.

Observations:
Based on review of facility policies and clinical records, observations and staff and resident interviews it was determined that the facility failed to develop and implement a care plan for two of 40 residents (Resident R9 and R126).

Findings include:

The facility policy "Assessment-Comprehensive Person Centered Care Planning" dated 2/7/19, indicated that the facility will develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. This is to be reviewed and revised by the interdisciplinary team after each assessment.

During an observation on 10/21/19, at 11:30 a.m. it was revealed that Resident R9's bed was against the wall.

A review of Resident R9's annual Minimum Data Set (MDS - a periodic assessment of resident care needs) dated 9/24/19, indicated that the resident was admitted to the facility on 3/8/16, with diagnoses that included acid reflux, high blood pressure, heart failure, stroke and depression.

A review of Resident R9's plan of care did not include a care plan that addressed Resident R9's bed against the wall.

During an interview on 10/24/19, at 12:14 p.m. Registered Nurse Employee E17 confirmed that the plan of care failed to address Resident R9's bed against the wall.

Review of Resident R126 admission diagnostic sheet dated 8/27/19, indicated she was admitted to the facility on 8/27/19, with diagnoses that included anxiety disorder, PTSD (post-traumatic stress disorder) insomnia and history of intravenous substance abuse.

Review of clinical record documentation dated 9/29/19, revealed an altercation upon return from smoking with another resident where Resident R126 attempted to slap/punch another resident. Documentation dated 10/3/19, revealed inappropriate behavior upon returning from smoking where she demanded her medication and was yelling at staff. Documentation dated 10/21/19, revealed that she was argumentative and yelling at nurse while waiting for bedtime medication stating she was more important than the resident she was caring for.

Review of Resident R126's care plan did not reveal a plan to address the altercations with another resident and nursing staff.

During an interview on 10/24/19, at 11:36 a. m. Registered Nurse Assessment Coordinator Employee E10 confirmed that the facility failed to develop a care plan to address Resident R126's emotional and behavioral needs.

28 Pa. Code: 211.11 (a) (c) (d) Resident care plan.

Plan of Correction - To be completed: 12/17/2019

R-9 Care plan was updated to reflect the resident wishes to periodically place her bed against the wall
R-126 Care plan was updated to include resident emotional needs and behaviors that infringed on the rights of other residents.
R-126 Care plan was updated to include a behavior management plan to address inappropriate behaviors toward other residents and care givers.
Residents requesting beds against the walls were interviewed by Social Service/designee. If their request is appropriate the request will be care planed by the Interdisciplinary team.
Social Service/designee will review the care plans of residents with emotional needs or identified behaviors for appropriate goals and approaches.
ADON/Educator will re-educate the RN Nursing and Social Service Staff on addressing resident behaviors, emotional needs, and preference on placing the bed against the wall when care planning.
An audit of care plan compliance will be completed by the RNAC weekly X 4 bi-monthly X2 and Monthly X 2 the results will be evaluated by the Quality Committee.

51.3 (f) LICENSURE NOTIFICATION:

51.3 Notification

(f) If a health care facility is
aware of a situation or the occurrence
of an event at the facility which
could seriously compromise quality
assurance or patient safety, the
facility shall immediately notify the
Department in writing.
The notification shall include
sufficient detail and information to
alert the Department as to the reason
for its occurrence and the steps which
the health care facility shall take to
rectify the situation.

Observations:
Based on observations and staff interviews it was determined that the facility failed to report to the State Agency of malfunction and replacement plans for the Main Kitchen Freezer which is equipment vital to the operation of the facility as required. (Main Kitchen Freezer Replacement)

Findings include:

During an observation on 10/21/19, at 10:01 a.m. it was revealed that the facility was utilizing a freezer truck stationed at the receiving dock area to store frozen food products due to the facility's main kitchen freezer was not functioning.

During an interview on 10/21/19, at 10:15 a.m. Food Service Manager Employee E5 confirmed that the facility began utilizing the freezer truck on Monday 10/14/19, due to scheduled renovations and replacement of the main kitchen freezer that had been malfunctioning.

During an interview on 10/21/19, at 2:30 p.m. the Nursing Home Administrator confirmed that the facility failed to report to the State Agency the malfunctioning of the main kitchen freezer which is vital to the operations of the facility as required.

Plan of Correction - To be completed: 12/17/2019

Event report was completed on 10/21/19 concerning the failure of the walk-in freezer.
The facility understands that an event report must be transmitted to the State DOH when there is a failure of significant equipment.
CNO will educate Administrator on posting of events with the DOH concerning the failure of vital equipment.
Administrator/designee will post any future events concerning the failure of vital equipment upon the failure date of that equipment within the protocols of event reporting.

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