Pennsylvania Department of Health
GARDENS AT ORANGEVILLE, THE
Patient Care Inspection Results

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GARDENS AT ORANGEVILLE, THE
Inspection Results For:

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GARDENS AT ORANGEVILLE, THE - 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 Abbreviated Complaint Survey completed on February 2, 2024, it was determined that The Gardens at Orangeville was not in compliance with the follow requirements of 42 CFR Part 483 Subpart B Requirements for Long Term Care and the 28 PA Code Commonwealth of Pennsylvania Long Term Care Licensure Regulations.



 Plan of Correction:


483.60(a)(1)(2) REQUIREMENT Qualified Dietary Staff:This is a less serious (but not lowest level) deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents.  This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.60(a) Staffing
The facility must employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, taking into consideration resident assessments, individual plans of care and the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment required at 483.70(e)

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

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

Findings include:

Current regulatory guidance requires that 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. 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 receives frequently scheduled consultations from a qualified dietitian or other clinically qualified nutrition professional.

An interview with the food service director (FSD) on January 31, 2024, at 9:30 AM revealed that she has been employed as the facility food service director since September 2021, and completed an online course to become a certified dietary manager (CDM). The FSD stated that she would be taking the exam to become a CDM within the next few months. Review of the FSD's certificate for the completion of the course noted that the course was completed on December 5, 2023, which was after the required regulatory completion date of October 1, 2023.

Further interview with the FSD revealed that the facility has two part-time dietitians. One part-time dietitian worked onsite approximately eight hours per week and the other part-time dietitian worked remotely with varied hours.

The U.S. Department of Labor, Bureau of Statistics defines 34 or fewer hours a week as part-time work.

Interview with the nursing home administrator (NHA) on February 1, 2024, at 9:00 AM failed to provide documented evidence that the facility employed a full-time qualified director of food service in the absence of a full-time qualified dietitian.

Refer F812

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





 Plan of Correction - To be completed: 03/13/2024

Full time qualified director of food service will be employed. The facility will have a full time qualified food service director by 3/13/24
Facility will continue to utilize Registered Dietitian part time in addition to having the FSD qualified.
NHA to audit weekly x4 then monthly x2 the SFD is qualified. Results to QAPI for review and recommendations.

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

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

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

Based on observation and staff interview, it was determined that the facility failed to maintain acceptable practices for the storage and service of food to prevent the potential for contamination and microbial growth in food, which increased the risk of food-borne illness.

Findings include:

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

Review of a facility General Food Preparation and Handling Policy last reviewed July 1, 2023, indicated that meats, fish, and poultry are defrosted under safe thawing practices: in the refrigerator in a drip proof container, and in a manner that prevents cross-contamination; in the microwave if foods are cooked and served immediately after defrosting; in the sink, submerging the item under cold water (less than 70 degrees Fahrenheit) that is running fast enough to agitate and float off loose ice particles; or thawing as part of a continuous cooking process.

Observation during the initial tour of the food and nutrition services department conducted on January 30, 2024, at 9:00 AM, revealed the following unsanitary practices with the potential to introduce contaminants into food and increase the potential for food-borne illness:

An apron was hanging on the faucet of the handwashing sink.

The interior surface of the garbage can near the handwashing sink was visibly soiled and needed cleaning.

There was a pan with nine hot dogs soaking in water on the stove top. All burners on the stove were off at this time.

The oven door handle and knobs were sticky to touch.

There was an open case of thawed 6-ounce orange flavored nutritional beverages and two cases of thawed 4-ounce nutritional shakes on the shelf in the reach-in refrigerator which were not dated with a thaw or discard date. The manufacturer label noted the beverages/shakes were to be used within 14 days of thawing.

Observation of the food and nutrition services department on February 1, 2024, at 11:30 AM revealed a thick layer of dust on the fins of the air conditioner located in the window near the trayline.

Observation at this time also revealed a build-up of dirt and debris on two chemical holding racks located under the dishwasher.

Interview with the foods service director (FSD) at this time confirmed that food and beverages were to be stored and thawed according to acceptable practices. The FSD confirmed the dietary department was to be maintained in a sanitary manner.

28 Pa Code 211.6(f) Dietary services








 Plan of Correction - To be completed: 03/13/2024

The apron was removed from the faucet of the handwashing sink. The interior surface of the garbage can was cleaned. The oven door handle and knobs were cleaned. The open care of thawed nutritional beverages were disposed of. The dust fins on the air conditioner were cleaned. The 2 chemical holding racks were cleaned.
Cleaning schedules updated to include air conditioning, chemical racks, oven handle and knobs and garbage can.
Dietary staff re-educated by the food service director on policy for cleaning and sanitation procedures and policy for General Food preparation and handling.
Food service director will audit kitchen cleanliness and appropriate food preparation weekly x4, then monthly x2. NHA/designee will do random audits in the kitchen to ensure cleanliness and appropriate food preparation is followed Results to QAPI for review and recommendations.

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

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

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

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

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

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

Based on a review of clinical records, the minutes from resident group meeting and grievances filed with the facility, and resident and staff interviews, it was determined that the facility failed to provide care in a manner and environment that promotes each resident's quality of life by failing to respond timely to residents' requests for assistance, including experiences reported by four alert and oriented residents out of four interviewed during a group meeting (Residents 7, 26, 47, and 48), grievances filed by residents (Residents 32, 44, and 72) and two out of 20 residents sampled (Residents 30 and 44).

Findings include:

A review of grievances filed with the facility dated September 26, 2023, revealed that Resident 44 reported that it takes"a while" for the nurse aides to respond to her call bell when she rings it for assistance.

A review of the minutes from the Residents' Council meeting dated November 21, 2023, revealed that residents in attendance raised concerns that staff are not answering their call bells in a timely manner and meeting their needs for assistance. A grievance was filed on behalf of the resident group regarding these concerns.

A grievance dated December 26, 2023, indicated that Residents 32 and 44 stated that it takes nursing staff too long to respond to call bells on the 1st shift of nursing duty.

A grievance dated January 25, 2024, indicated that Resident 72 rang his call bell, and it was activated for a long time and no one answered, so he took himself to the bathroom.

A clinical record review revealed that Resident 30 was admitted to the facility on October 1, 2014. A review of the quarterly Minimum Data Set assessment (MDS - a federally mandated standardized assessment process conducted periodically to plan resident care) dated December 15, 2023, revealed that Resident 30 is cognitively intact with a BIMS score of 15 (Brief Interview for Mental Status- a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 13-15 indicates cognition is intact).

During an interview on January 30, 2024, at 12:10 PM, Resident 30 stated that he has waited two hours for staff to respond after ringing his call bell for assistance.

Clinical record review revealed that Resident 44 had diagnoses which included diabetes and anxiety. A review of the quarterly MDS assesment dated December 21, 2023, indicated that Resident 44 is cognitively intact with a BIMS score of 15.

During interview on January 30, 2024, at 1:00 PM Resident 44 stated that she is mostly independent in her room and tries to avoid ringing the call bell because of the amount of time it takes staff to respond to a call bell and provide assistance. Resident 44 stated that she has recently waited 40 minutes for staff to respond. The resident explained that call bell response time is worse on first and second shift. Resident 44 further relayed that she has filed grievances with the facility about call bells not being answered timely, but that facility solutions have only been temporary and not sustained fixes.

During a resident group meeting with residents on January 31, 2024, at 10:00 AM, four out of the four alert and oriented residents in attendance (Residents 7, 26, 47, and 48) stated that they experienced long wait times for staff to answer their call bell rings and provide assistance. The residents in attendance stated that they have brought this issue up to the facility in the past, but it has not been resolved.

During the resident group meeting on January 31, 2024, at 10:00 AM, Resident 7 stated she waits from 15 minutes to 30 minutes for staff to respond to her call bell rings when she for assistance.

During the resident group interview on January 31, 2024, at 10:00 AM, Resident 26 stated that when the facility is low on staff, it takes about 30 minutes for staff to respond to her call bell rings for assistance. She stated that the facility is often low on staff. Resident 26 explained that she once needed assistance with changing her soiled brief. She recalled that when staff did not respond timely to her requests for assistance, she left her room to look for help and felt embarrassed that people could see her wet pants.

During the resident group interview on January 31, 2024, at 10:00 AM, Resident 47 stated that when only one nurse aide is assigned to her hallway, it takes about 20 minutes for staff to respond to her call bells for assistance. Resident 47 explained that sometimes she cannot wait 20 minutes to use the bathroom and has soiled herself waiting for assistance.

During the resident group interview on January 31, 2024, at 10:00 AM, Resident 48 stated that the facility is often short on staff. He explained that when the facility is short staffed, he waits about 20 minutes for staff to respond to his call bell rings, and his needs not being met timely.

During an interview on February 1, 2024, at approximately 1:00 PM, the Director of Nursing (DON) and Nursing Home Administrator (NHA) verified that all residents at the facility should be treated with dignity and respect. The DON and NHA were unable to explain why residents are reporting untimely staff responses to residents' requests for assistance, which is negatively affecting their quality of life in the facility.




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

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

















 Plan of Correction - To be completed: 03/13/2024

Facility cannot retroactively correct this deficiency.
Grievances for the last 14 days will be reviewed for any concerns with call bell response time.
All staff will be re-educated on resident rights to provide care in a manner and environment that promotes resident's quality of life. NHA/DON/designee will review grievances to ensure any concerns voiced with call bell response time are addressed. Through observations and interviews weekly by the NHA/designee will be able to evaluate for any trends or patterns.
NHA/designee will observe 5 call bells weekly to ensure timely response.
10% of residents will be interviewed to determine if resident requests for assistance are being addressed timely weekly x4, then monthly x2. Results to QAPI for review and recommendations.

483.80(a)(1)(2)(4)(e)(f) REQUIREMENT Infection Prevention & Control:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
483.80 Infection Control
The facility must establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections.

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

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

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

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

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

483.80(f) Annual review.
The facility will conduct an annual review of its IPCP and update their program, as necessary.
Observations:
Based on a review of clinical records, PAHAN (Pennsylvania Health Alert Network) infection control guidance, select facility policies, and staff interview, it was determined that the facility failed to initiate necessary infection control precautions for cohorting a resident positive for COVID-19 to prevent the spread of the SARS-CoV-2 virus to uninfected resident. This failure placed the uninfected resident at risk to their health due to the likelihood of contracting the virus by continuing to reside in the same room as the infected resident and resulted in 1 resident out of three sampled being infected with COVID-19 (Resident 58) while residing with COVID positive roommate (Resident 20), and failed to maintain infection control practices related to reduce the potential for infections for one (Resident 8) out of four sampled residents with an indwelling urinary Foley catheter (flexible tube which is placed in the bladder to drain urine) and failed to ensure that infection control practices were implemented to reduce the potential spread of infection for one of two sampled residents with an infection (Resident 8).

Findings include:

According to information provided by the Pennsylvania Department of Health 2023-PAHAN-694 dated May 11, 2023, placement of residents with suspected or confirmed SARS-CoV-2 infection: ideally, residents should be placed in a single-person room. If limited single rooms are available, or if numerous residents are simultaneously identified to have known SARS-CoV-2 exposures or symptoms concerning for COVID-19, residents should remain in their current location. However, quarantined patients and those with suspected infection should NOT be cohorted with patients with confirmed SARS-CoV-2 infection unless they are confirmed to have SARS-CoV-2 infection through testing.

The facility has a licensed and certified bed capacity of 119 beds. At the time of September 23, 2023, the facility's census was 75 residents, and on September 24, 2023, the facility census was 74.

A review of Resident 20's clinical record revealed he was most recently admitted to the facility on June 8, 2023, with diagnoses to include atrial fibrillation (a irregular and often very rapid heart rhythm), diabetes, and chronic pulmonary embolism (a blood clot in the lungs).

A further review of a nurses note dated September 23, 2023, at 2:22 PM revealed a temperature of 101.5, pulse, 86, respirations 18, pulse ox 94% on room air. Tylenol given at 9:54 AM. Rechecked temperature 99.1, nasal congestion noted. Tested positive for COVID. Registered Nurse (RN), supervisors notified.

Review of resident 20's clinical record revealed on September 23, 2023, he resided in room East 105 bed 2.
A review of Resident 58's clinical record revealed he was admitted to the facility on December 3, 2021, with diagnoses to include Alzheimer's Disease (the most common cause of Dementia, a gradual decline in memory, thinking, behavior and social skills, affecting a person's ability to function), Crohn's disease (swelling of the tissue in your digestive tract which can lead to abdominal pain, severe diarrhea, fatigue, weight loss and malnutrition), and chronic kidney disease.

A review of a nurses note dated September 20, 2023, at 4:17 AM revealed the resident was observed sleeping. Respirations easy and unlabored. Appears in no distress.

A review of a respiratory note dated September 23, 2023, at 1:26 PM revealed a COVID test, point of care (POC) result negative. MD made aware, no new orders received (N.N.O.R).

A further review of a nurses note dated September 24, 2023, at 1:41 PM revealed resident 58 had slight cough, temperature - 99.1, pulse -103, respirations -18, pulse ox -98% on room air (RA). No complaints of pain. Good appetite. Lungs clear to auscultation (LCA).

A continued review of a nurses note dated September 25, 2023, at 8:35 AM, stated the resident resting in bed with congested cough, lungs diminished, skin warm flushed. temperature 99.8, pulse ox 91% room air, pulse 98, Blood Pressure 140/88, respirations 18. COVID test, SARS CO-V2 with positive results. RN and Director of Nursing (DON) aware of same.

Review of resident 58's clinical record revealed on September 23, 2023, he resided in room East 105 bed 1.
The facility failed to promptly isolate Resident 20, a resident with a symptomatic COVID-19 infection, to prevent potential transmission to Resident 58 according to current infection control guidance and facility policy.

Interview on January 31, 2024, at approximately 12:15 PM, with Employee 1, Registered Nurse (RN), the facility's Infection Preventionist (IP), confirmed that resident 20 had been symptomatic and tested positive for COVID 19, on September 23, 2023, and his roommate, resident 58 had tested negative for COVID 19, on September 23, 2023, and was without symptoms. Employee 1 further confirmed that both resident 20, and 58 had resided in room East 105, and that the facility did have rooms available to isolate residents that tested positive for COVID-19.

Interview with the Nursing Home Administrator on February 1, 2024, at approximately 9:45 AM, confirmed that the facility failed to implement infection control practices for cohorting and isolating COVID positive residents, to prevent the potential spread of COVID-19.

Review of facility policy titled "Isolation-Initiating Transmission-Based Precautions", reviewed by the facility on July 1, 2023, indicated that Transmission- Based Precautions (TBP) will be initiated when there is reason to believe that a resident has a communicable infectious disease. Transmission-Based Precautions may include Contact Precautions, Droplet Precautions, or Airborne Precautions. When TBP are implemented, the Infection Preventionist shall:
A.Ensure that protective equipment (i.e., gloves, gowns, mask, etc.) is maintained near the resident's room so that everyone entering the room can access what they need;
B.Post the appropriate notice on the room entrance door and on the front of the resident's chart so that all personnel will be aware of precautions, or be aware that they must first see a nurse to obtain additional information about the situation before entering the room;
C.Ensure that an appropriate linen barrel/hamper and waste container, with appropriate liner, are placed in or near the resident's room;
D.Place necessary equipment and supplies in the room that will be needed during the period of TBP;
E.Be sure that an adequate supply of antiseptic soap and paper towels is maintained in the room during the isolation period; and
F.Explain to the resident (or representative) the reason(s) for the precautions.

A review of clinical records revealed Resident 8 was admitted to the facility on December 28, 2023, with diagnoses to include sepsis (a condition in which the immune system has a dangerous reaction to an infection), urinary tract infection, and ESBL (Extended Spectrum Beta Lactamase, a bacteria resistant to most antibiotics) in the urine.

On December 28, 2023, the physician ordered that the resident be placed on contact precautions related to ESBL in the urine.

Observation on January 30, 2024, at 11:18 AM revealed that Resident 8's room, Room 307, did not have any posting on the entrance door to notify staff or visitors of any contact precautions, or instruct visitors to first see a nurse to obtain additional information about the situation before entering the room. There was no PPE (personal protective equipment) maintained near the resident's room so that everyone entering the room had access to what they needed. There was no appropriate linen barrel/hamper and waste container, with appropriate liner, placed in or near the resident's room.

Review of facility policy titled "Catheter Care, Urinary", last reviewed by the facility on July 1, 2023, indicated that the purpose is to prevent catheter-associated urinary tract infections. An aseptic technique and sterile equipment are used for catheter insertion, and the staff are to maintain a closed drainage system for indwelling catheter. Staff are to maintain a clean technique when handling or manipulating the catheter, and staff are to be sure the catheter tubing and drainage bag are kept off the floor.

Observation on January 30, 2024, at 11:18 AM revealed the Resident 8 was resting in bed. The urine collection bag from the resident's indwelling Foley catheter was laying on its side, directly on the floor.

Observation on January 31, 2024, at 9:25 AM revealed Resident 8 resting in bed. The urine collection bag was directly in contact with the floor.

Interview with Employee 1 (Infection Preventionist) on January 31, 2024, at 12:35 PM, confirmed that the facility failed to implement the facility's Infection Control Policies for Transmission-Based Precautions for Resident 8 by not posting signage on the entrance to her room, not ensuring that the appropriate PPE was readily available and not providing the appropriate linen/trash containers. Employee 1 also confirmed that the facility failed to maintain Resident 8's Foley catheter in a manner to prevent the potential for urinary tract infection and maintain infection control techniques for a resident with a Foley catheter.



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

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



 Plan of Correction - To be completed: 03/13/2024

Unable to retroactively correct the deficiency for residents 58 and 20. Resident 8 urinary catheter bag was changed and removed from the floor and signage for transmission based precautions and PPE placed on door to residents room.
Review of residents positive for COVD 19 will be reviewed to ensure single room placement is implemented. Residents medical records will be reviewed to ensure if transmission based precautions are needed and PPE and signage is on entrance to room as ordered. Will audit all residents with urinary catheter bags to ensure they are not touching the floor.
Licensed staff re-educated on PA HAN 694, Policy for "Isolation-Initiating Transmission Based Precautions", and the policy for "Catheter Care, Urinary". New admissions and new infections will be reviewed at IDT meeting to determine need for isolation.
DON/designee will audit residents positive for COVID 19 to ensure single patient room in is use. Will audit residents with urinary catheter bags to ensure they are not touching the floor and will audit 10% of residents with isolation needs to ensure signage and PPE is correctly placed on the entrance to the residents room weekly x4, then monthly x2. Results to QAPI for review and recommendations.

483.25(e)(1)-(3) REQUIREMENT Bowel/Bladder Incontinence, Catheter, UTI: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(e) Incontinence.
483.25(e)(1) The facility must ensure that resident who is continent of bladder and bowel on admission receives services and assistance to maintain continence unless his or her clinical condition is or becomes such that continence is not possible to maintain.

483.25(e)(2)For a resident with urinary incontinence, based on the resident's comprehensive assessment, the facility must ensure that-
(i) A resident who enters the facility without an indwelling catheter is not catheterized unless the resident's clinical condition demonstrates that catheterization was necessary;
(ii) A resident who enters the facility with an indwelling catheter or subsequently receives one is assessed for removal of the catheter as soon as possible unless the resident's clinical condition demonstrates that catheterization is necessary; and
(iii) A resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible.

483.25(e)(3) For a resident with fecal incontinence, based on the resident's comprehensive assessment, the facility must ensure that a resident who is incontinent of bowel receives appropriate treatment and services to restore as much normal bowel function as possible.
Observations:

Based on observations, clinical record reviews, and staff interviews, it was determined that the facility failed to ensure that residents received appropriate treatment and services to prevent potential complications for residents with indwelling catheters for two out of the 20 residents sampled (Residents 11 and 30).

Findings include:

Department of Health & Human Services, USA. Centers for Disease Control and Prevention, Guideline for Prevention of Catheter-Associated Urinary Tract Infections 2009, last updated June 6, 2019, III Proper Techniques for Urinary Catheter Maintenance, B. Maintain unobstructed urine flow. 2. Keep the collecting bag below the level of the bladder at all times. Do not rest the bag on the floor.

A review of facility policy titled Urinary Catheter Care, reviewed by the facility on July 1, 2023, revealed that it is the facility's policy to prevent catheter-associated urinary tract infections. The policy indicates that if breaks in aseptic technique, disconnection, or leakage occur, replace the catheter and collection system using aseptic technique and sterile equipment as ordered. The policy also indicates that catheter drainage bags are to be kept off the floor.

A clinical record review revealed that Resident 30 was admitted to the facility on October 1, 2014, with diagnoses to include dementia and benign prostatic hyperplasia (an enlarged prostate). A review of the quarterly Minimum Data Set assessment (MDS - a federally mandated standardized assessment process conducted periodically to plan resident care) dated December 15, 2023, Section H0100. Appliances revealed that Resident 30 has an indwelling catheter.

Physician orders dated February 3, 2023, indicate that Resident 30 requires a 16-FR Foley catheter with a 10-cc balloon related to obstructive and reflux uropathy (urine is not able to drain through the urinary tract).

An observation on January 30, 2024, at 10:23 AM in Resident 30's bathroom revealed an unlabeled urine graduate on the top of the toilet. An unlabeled urinary leg catheter drainage bag, containing urine, was observed draped over the wall-mounted assist grab bar.

An observation on January 30, 2024, at 10:30 AM revealed Resident 30 in his room. His urinary catheter drainage bag was observed on the floor. During an interview at the time of the observation, Employee 7, a Licensed Practical Nurse (LPN), indicated that the urinary drainage bag should not be on the floor but hanging from the bed. Employee 7, LPN, was not able to explain why a used urinary catheter drainage leg bag was draped over the wall-mounted assist grab bar in the resident's bathroom.

During an interview on January 30, 2024, at 10:32 AM, Employee 8, Nursing Aide (NA), indicated that the urinary drainage catheter leg bags should not be draped over the wall-mounted assist grab bar in resident bathrooms. Employee 8, NA, explained that the leg catheter drainage bags are cleaned with soap and water, then stored in plastic bags with the resident's name labeled on the bag.

A clinical record review revealed that Resident 11 was admitted to the facility on January 3, 2023, with diagnoses to include dementia and obstructive and reflux uropathy (urine is not able to drain through the urinary tract).

A review of the annual comprehensive Minimum Data Set assessment (MDS - a federally mandated standardized assessment process conducted periodically to plan resident care) dated January 3, 2024, Section H0100. Appliances revealed that Resident 11 has an indwelling catheter.

Physician orders dated February 8, 2023, indicate that Resident 11 requires an 18-Cloude Foley catheter with a 10 cc balloon related to obstructive and reflux uropathy.

An observation on January 30, 2024, at 10:45 AM in Resident 11's bathroom revealed three unlabeled urinary drainage catheter leg bags, two of which contained urine, were draped over the wall-mounted assist grab bar near the resident toilet. During an interview at the time of the observation, Employee 1, Registered Nurse (RN) confirmed that the leg catheter drainage bags should not be draped over the wall-mounted assist grab bar in resident bathrooms. Employee 1, RN, explained that those drainage bags are for single use, and facility staff should dispose of the bags when they are removed from the residents.

An observation on January 31, 2024, at 1:15 PM of the urinary drainage catheter leg bag's manufacturer's label revealed instructions to "do not re-use" and "do not re-sterilize." The manufacturer's label reads, "CAUTIONS: Reuse may result in infections and allergic reactions."

During an interview on January 31, 2024, at 1:30 PM, Employee 3, the LPN indicated that urinary drainage catheter leg bags are re-used. Employee 3 explained that the drainage bags are to be rinsed out, put into plastic bags, and stored in the resident's bedside cabinet. At the time of the interview, Employee 3 revealed the storage location for Resident 30's used urinary catheter bags in the cabinet next to his bed.

During an interview on January 31, 2024, at 1:35 PM, Employee 10, nurse aide, indicated that urinary drainage catheter leg bags are re-used. Employee 10 stated that the drainage bags are emptied of urine, cleaned, put into a clean plastic bag, and then stored in the resident's bedside cabinet.

During an interview on February 2, 2024, at approximately 12:30 PM, the Director of Nursing (DON) and Nursing Home Administrator (NHA) confirmed that the facility failed to ensure that appropriate treatment and services were consistently provided to residents to prevent potential complications for residents with indwelling catheters.



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

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



 Plan of Correction - To be completed: 03/13/2024

Resident 30 had his urine graduate cylinder labeled and placed in the appropriate location and the leg catheter bags were disposed of. Resident 11 catheter leg bags were disposed of.
Residents with urinary catheters will be reviewed to ensure all graduated cylinders are labeled and placed in the appropriate location. Will audit bathrooms of residents with catheters to ensure catheter bags are not hanging on the grab rail. Will audit all residents with urinary catheters to ensure catheter bags are not touching the floor.
Licensed staff will be re-educated to the policy for Catheter Care and following the manufacturers instructions for the leg catheter bags to be one-time use.
DON/designee will audit residents with urinary catheters to ensure graduates are labeled and stored appropriately, catheter leg bags are not re-used and hung in the bathrooms and catheter bags are not resting on the floor weekly x4, then monthly x2 with results to QAPI for review and recommendations.

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 a review of select facility policy/protocol and clinical records and staff interview it was determined that the facility failed to provide nursing services consistent with professional standards of practice by failing to follow physician orders for bowel protocol to promote normal bowel activity for one resident (Resident 18) and for the consistent application of prescribed therapeutic devices and preventative measures, skin sleeves and legs rests with foot buddy, for one resident out of 20 sampled (Resident 62).

Findings include:

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

The facility policy titled "Bowel Protocol", last reviewed by the facility, July 1, 2023, indicated the objective is that the residents should move bowels at least once every 3 days. If the resident does not move bowels in 3 days, the nurse will provide the following:

1.Abdominal assessment.
2.The nurse will initiate bowel protocol as follows:

a. administer Milk of Magnesia (MOM) as ordered at bedtime on day 3, and continue to evaluate effectiveness X 24 hours.
b. if no bowel movement (BM), the nurse will administer on day 4, Dulcolax Suppository as ordered at bedtime and continue to evaluate effectiveness X 24 hours.
c. if no BM, the nurse will administer on day 5, Fleets Enema on the 7-3 shift, and continue to evaluate.
d. If no BM after 8 hours of Fleets Enema, nurse perform abdominal assessment including bowels sounds, palpation of abdomen, and signs/symptoms of pain, and notify the medical doctor MD.

A review of the clinical record revealed that Resident 18 was most recently admitted to the facility on August 2, 2023, with diagnoses to include, chronic obstructive pulmonary disease (COPD), protein-calorie malnutrition, and gastro-esophageal reflux disease (GERD).

The resident had physician orders dated August 3, 2023, for the following bowel regimen:

Dulcolax Suppository 10 mg, insert 1 suppository rectally as needed for constipation, give 1 suppository rectally on day 4 for no BM. After MOM is administered.

Fleet Enema 7-19 gm/118 ml, insert 1 application rectally as needed for constipation. Give 1 applicatorful rectally in AM day 5 for no BM, after MOM and suppository have been administered without results.

Review of Resident 18's report of bowel activity from the Documentation Survey Report v2 for October - November 2023, revealed that the resident did not have a bowel movement October 31, November 1, 2, 3, 4, 2023, (5 consecutive days).

Review of Resident 18's Medication Administration Record (MAR) for November 2023, revealed no documented evidence that nursing administered the prescribed bowel protocol during the time period without a bowel movement to promote bowel activity.

Review of Resident 18's report of bowel activity from the Documentation Survey Report v2 for December 2023, revealed that the resident did not have a bowel movement December 11, 12, 13, 14, 15, 16, 2023, (6 consecutive days).

Review of Resident 18's Medication Administration Record (MAR) for December 2023, revealed no documented evidence that nursing administered the prescribed bowel protocol during the time period without a bowel movement to promote bowel activity.

Review of Resident 18's report of bowel activity from the Documentation Survey Report v2 for January 2024, revealed that the resident did not have a bowel movement January 21, 22, 23, 24, 2024, (4 consecutive days).

Review of Resident 18's Medication Administration Record (MAR) for January 2024, revealed no documented evidence that nursing administered the prescribed bowel protocol during the time period without a bowel movement to promote bowel activity.

During an interview with the Director of Nursing (DON) on January 31, 2024, at approximately 1:20 PM, confirmed that Resident 18's had no current physician orders for the administration of Milk of Magnesia (MOM) on day 3.

During an interview with the Nursing Home Administrator (NHA) on February 1, 2024, at 9:45 AM, the NHA confirmed the facility failed to provide nursing services consistent with professional standards, and was unable to provide evidence that physician ordered bowel protocol was followed for Resident 18.

A review of Resident 62's clinical record revealed that the resident was admitted to the facility on August 19, 2022, with diagnosis to include cerebral infarction (brain damage that results from a lack of blood), congestive heart failure (weakness of the heart that leads to build-up of fluid in the lungs and surrounding body tissues) and chronic kidney disease stage 3B (moderate to severe loss of kidney function).

A review of a physician's order dated October 29, 2023, revealed an order for skin sleeves (fabric material, often lightly padded, to protect thin/fragile skin from skin tears, abrasions and light bruising) at all times. May remove for hygiene.

A review of Resident 62's care plan, in effect at the time of the survey ending February 2, 2024, indicated that the resident was to wear skin sleeves on his bilateral upper extremities (arms) at all times and remove for hygiene.

A review of a physician's order dated January 23, 2023, revealed an order for the resident to be out of bed in a Broda chair (specialty seating system with tilt-in-space positioning) with built in positioning devices including bilateral lower extremity (legs) elevating leg rests with a foot buddy (padded calf and foot panel that prevents the feet from slipping off the wheelchair footrests).

A review of Resident 62's care plan indicated that Resident 62 was to have his feet elevated when sitting up in his chair to prevent dependent edema (swelling). It further indicated that he was to have bilateral lower extremity elevating leg rests with a foot buddy while out of bed in his Broda chair.

Observation of Resident 62 sitting in his Broda chair in his room on January 30, 2024 , at 11:30 AM and 1:30 PM and January 31, 2024, at 9:30 AM revealed that Resident 62 did not have skin sleeves applied to his bilateral arms as ordered by the physician to protect his skin.

Further observation revealed that the resident did not have legs rests, or the foot buddy, applied to his Broda chair as ordered by the physician to prevent edema.

Interview with Employee 4 (licensed practical nurse) on January 31, 2024, at 9:30 AM confirmed that staff had not followed the physician's orders for the application the skin sleeves and placement of the Broda chair elevating leg rests with foot buddy.


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

28 Pa. Code 211.5(f) Medical records



 Plan of Correction - To be completed: 03/13/2024

Resident 18 bowel protocol order was updated as per the physician. Cannot retroactively correct no documentation evidence that the prescribed bowel protocol was administered. Resident 62 had his bilateral skin sleeves applied to his arms. The leg rests with foot buddy were applied.
Bowel activity of current residents will be reviewed for bowel activity and implementation of the Bowel Protocol as needed. Residents with physician orders for skin sleeves and seating devices will be reviewed and ensure they are in place as ordered.
Licensed staff re-educated on the policy for Bowel Protocol and "Using the Care Plan" policy. Clinical staff to review in morning meeting residents requiring bowel protocol and ensuring the orders are followed as per MD. Nursing assistants to apply devices as per MD orders and Licensed staff to ensure placement of skin sleeves and setting devices are completed. Random auditing of %10 residents of skin sleeves and seating devices will be done weekly by NHA/designee ongoing.
DON/designee will audit 10% weekly of residents requiring the bowel protocol and ensuring the orders are followed. DON/designee will audit 10% weekly of residents utilizing prescribed therapeutic devices and preventative measures to ensure they are in place.

483.10(i)(1)-(7) REQUIREMENT Safe/Clean/Comfortable/Homelike Environment:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
483.10(i) Safe Environment.
The resident has a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

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

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

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

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

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

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

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

Based on a review of grievances filed with the facility (Residents 26, 44, 45, and 228) and the minutes from resident group meeting, observations, and resident and staff interview, it was determined that the facility failed to provide housekeeping services and maintenance services to maintain a clean and comfortable environment on three of the three nursing units (Units 100, 200, and 300).

Findings include:

A review of grievances filed with the facility revealed a grievance dated September 19, 2023, indicating that Resident 45's room was not cleaned. The resident's family raised concerns on behalf of the resident regarding the presence of cobwebs with spiders in the resident's closet, dirty window screens, and dirt in the corners of the resident's room.

A grievance dated September 26, 2023, revealed that Residents 26 and 44 expressed concerns with garbage cans in their bedrooms and bathrooms not being emptied.

A review of the minutes from the Residents Council meeting dated October 26, 2023, revealed residents in attendance raised concerns that facility staff are not cleaning rooms thoroughly, not picking trash up off of floors, and not mopping floors without sweeping. The facility indicated that grievances were filed to address the residents ' concerns.

A review of the minutes from Residents Council meeting dated November 21, 2023, revealed that the residents in attendance raised concerns that only one side of resident rooms are being cleaned and the floors in their are constantly sticky. The facility indicated that grievances were filed to address the residents' concerns raised at this meeting.

A grievance dated December 20, 2023, revealed that Resident 228 expressed concerns regarding her room not being cleaned during her stay at the facility. The resident stated that the housekeeper dry-mopped the floor only once, and the dry mop was very dirty. She stated that the floor in her room needs to be cleaned thoroughly.

During an environmental tour of the facility on January 30, 2024, at approximately 10:40 AM in East 100 Hall, the following was observed:

An accumulation of splattered food debris, paper debris, brown and black smears, red stains, a plastic medication cup, and a rubber band was observed on the floors of the nursing unit.

A long black streak was observed on the floor extending from the 100 hall unit shower room into resident room 113, and a pervasive urine-like odor permeated the entire unit.

In resident rooms 101, 102, 105, 111, and 112, paper debris and dark scuff marks were observed on the floor.

In resident room 111, a bed blanket was placed on the length of the windowsill, the screen on the right side of the window was not securely positioned in the window, and the window had a fogged appearance which prevented a clear view through the window.

In resident room 103, dark scuff marks, paper debris, washcloths, red stains, and food debris were observed on the floor.

In resident room 107, tan and sticky opaque stains were observed on the floor.

In resident rooms 108 and 110, there was a dark-colored stain, with paper debris observed on the floor.

In resident room 113, a bed blanket was placed on the length of the windowsill. The wall under the window was visibly soiled and scuffed.

In resident room 114, a bed blanket was placed on the length of the windowsill.

An observation on January 30, 2024, at 10:20 AM in resident room 216 revealed several pieces of red, yellow, and white plastic wrappers on the floor and under the residents' beds. A dusty, dirty buildup and discoloration was observed on the floor in the corner and wall opposite the resident beds. A gray stain trail extending several feet, leading from the resident bathroom to the furthest resident bed was observed on the floor. A strong urine smell was detected in the resident bathroom and stained and discolored flooring. Gray and tan stains
were observed on the walls in the bathroom and the bathroom door.

An observation on January 30, 2024, at 10:23 AM in resident room 217 revealed stained and discolored floors in the resident bathroom. Black speckled stains, tan and gray scuff marks were observed on the toilet seat and in the toilet basin. A red and tan stain was observed on the floor surrounding the toilet base. An unlabeled urine graduate was observed on the top of the toilet. An unlabeled urinary leg catheter bag containing urine was observed draped over the wall-mounted assist grab. Both sides of the bathroom doors were observed with black and gray scuff marks, scratches, and areas of chipped paint. A white powder residue was visible on the bathroom floor.

An observation on January 30, 2024, at 10:45 AM in resident room 301 revealed three unlabeled urinary catheter bags containing urine draped over the wall-mounted assist grab bar near the toilet in the resident bathroom. A small brown stain was observed on the bottom of the raised toilet seat. Both sides of the bathroom doors were observed with black and gray scuff marks, scratches, and areas of chipped paint. A blue liquid stain was observed on the wall behind the toilet. An unlabeled urine graduate was observed on the top of the toilet.

During interview on January 31, 2024, at 1:25 PM Resident 36 stated that today was the "first day" that her room was cleaned in the past week. Resident 36 stated that housekeeping empties the trash daily but does not sweep or mop the floor daily.

Observation on February 2, 2024, at 9:00 in resident room 201 revealed that the surface of the baseboard behind the bed was deeply gouged. There was an accumulation of dirt under the bed.

During an interview on February 2, 2024, at approximately 11:10 AM, the Nursing Home Administrator (NHA) confirmed the resident environment was to be maintained in a clean, safe, and orderly manner. The NHA confirmed that a strong urine smell persists in resident bathrooms. The NHA confirmed that bed blankets were being placed on the windowsills to reduce drafts of cold air coming into the residents' rooms.



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







 Plan of Correction - To be completed: 03/13/2024

F 584 Safe/Clean Comfortable environment
Residents grievances with housekeeping concerns were addressed at the time it was reported. The nursing unit floors were cleaned. The shower room on the 100 hall was cleaned. Rooms 101,102, 103,105, 107, 108, 110, 111, 112, 201, 216, 217, 301 were cleaned. Room 111, 113, 114 had the bed blankets removed from the windowsill and the screen on the right side of the window 214 was secured and the window was corrected to ensure a clear view. Room 217 and 301 the urine graduate and urinary leg bag were discarded. Chipped paint and scuffs were fixed in rooms 113, 201217 and 301. Resident 36's room was cleaned, trash was emptied, floor swept and mopped. Room 201 the surface of the baseboard behind the bed was fixed.
Housekeeping, maintenance and nursing staff will be re-educated on the ongoing process for maintaining the environment in a clean and sanitary manner.
Environmental rounds will be conducted weekly by NHA, Director of Housekeeping and Director of Maintenance with areas of concerns corrected accordingly.
Random weekly audits by IDT will be performed throughout the facility to ensure the environment is maintained in a clean and satisfactory manner weekly x4, then monthly x2. Results to QAPI for review and recommendations.

483.10(g)(14)(i)-(iv)(15) REQUIREMENT Notify of Changes (Injury/Decline/Room, etc.):This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.10(g)(14) Notification of Changes.
(i) A facility must immediately inform the resident; consult with the resident's physician; and notify, consistent with his or her authority, the resident representative(s) when there is-
(A) An accident involving the resident which results in injury and has the potential for requiring physician intervention;
(B) A significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications);
(C) A need to alter treatment significantly (that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment); or
(D) A decision to transfer or discharge the resident from the facility as specified in 483.15(c)(1)(ii).
(ii) When making notification under paragraph (g)(14)(i) of this section, the facility must ensure that all pertinent information specified in 483.15(c)(2) is available and provided upon request to the physician.
(iii) The facility must also promptly notify the resident and the resident representative, if any, when there is-
(A) A change in room or roommate assignment as specified in 483.10(e)(6); or
(B) A change in resident rights under Federal or State law or regulations as specified in paragraph (e)(10) of this section.
(iv) The facility must record and periodically update the address (mailing and email) and phone number of the resident
representative(s).

483.10(g)(15)
Admission to a composite distinct part. A facility that is a composite distinct part (as defined in 483.5) must disclose in its admission agreement its physical configuration, including the various locations that comprise the composite distinct part, and must specify the policies that apply to room changes between its different locations under 483.15(c)(9).
Observations:


Based on review of select facility policy and clinical records, and staff interview, it was determined that the facility failed to timely consult with the physician and notify the resident's interested representative of a change in condition for one resident out of 20 sampled (Resident 64).

Findings include:

A review of the facility's policy "Change in a Resident's Condition or Status" last reviewed by the facility July 1, 2023, indicated that the facility shall promptly notify the resident, his or her attending physician, and representative (sponsor) of changes in the resident's medical/mental condition and /or status.

A review of the clinical record revealed Resident 64 was admitted to the facility on October 30, 2023, with diagnoses that included Alzheimer's disease, muscle weakness, history of falling, and dementia. The resident's clinical record identified a resident representative.

A review of an admission BIMS (brief interview for mental status - a tool to assess cognitive status) report dated October 31, 2023, indicated that the resident was severely cognitively impaired with a BIMS score of 0.

An activities note dated January 23, 2024, at 12:47 PM revealed that the resident refused to go to the West Side Dining Room for lunch, stating that she did not feel well. The aide delivered the resident's meal tray to her room.

A nurse's note dated January 25, 2024, at 11:07 AM revealed that the resident was tested for COVID and it was negative.

NURISNG noted on January 25, 2024, at 11:35 AM that the resident stated that she just didn't feel up to things today. An assessment performed revealed no respiratory symptoms were noted. The resident pointed to bed and said "I spend all my time in there."

On January 26, 2024, at 4:23 PM, the resident displayed cold symptoms, a slight cough, and confusion were noted. Temperature 97.5.

A nurses note dated January 27, 2024, at 6:40 AM revealed that the resident continued with cold symptoms, runny nose, non - productive cough. Lungs diminish in bases.

On January 27, 2024, at 3:49 PM nursing noted that the resident continued with cold signs and symptoms. Temperature 97.6.

On January 28, 2024, at 11:54 AM nursing noted that the resident continues with runny nose and nonproductive cough. Lungs diminished upon auscultation of same.

A nurses note dated January 28, 2024, at 3:20 PM revealed that the resident continued with cold signs and symptoms, temperature was now elevated at 98.2 Farenheit.

Nursing documentation dated January 29, 2024, at 11:44 AM revealed that the resident continue with a runny nose and nasal congestion. Occasional non - productive dry cough persists.

This entry dated January 29, 2024, at 11:44 AM, indicated that the Certified Registered Nurse Practitioner (CRNP) was made aware and a respiratory panel obtained. Physician orders dated January 29, 2024, were noted for droplet precautions until respiratory panel received.

A review of a nurses note dated January 30, 2024, at 12:47 PM revealed CRNP made aware of respiratory panel results, influenza A positive. New Order for Tamiflu 75 mg twice daily (BID) for 5 days. RP made aware of same.

Interview on January 31, 2024, at approximately 12:15 PM, with Employee 1, Registered Nurse (RN), the facility's Infection Preventionist (IP), confirmed that Resident 64 had displayed signs and symptoms of illness on January 26, 2024, and that there was no documented evidence that the physician, or RP was notified for four days (January 26 - 29, 2024), despite the resident's continued signs and symptoms of a change in condition.

There was no indication the physician nor RP was timely notified of the above change in condition, potentially requiring treatment and precautions, which was confirmed during interview with the Nursing Home Administrator (NHA) on February 1, 2024, at approximately 9:45 AM

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





 Plan of Correction - To be completed: 03/13/2024

Resident 64 has since received appropriate treatment.
Nurses notes for the last 14 days will be reviewed to ensure any change in condition noted has had timely physician and family notification.
Licensed staff re-education on the change in condition policy and procedure. DON/designee will review 24 hour reports to ensure change in conditions are reported to the physician and family timely.
10% of residents medical records will be reviewed to ensure change in conditions have been reported accordingly to the physician and family timely weekly x4, then monthly x2. Results to QAPI for review and recommendations.

483.12(a)(1) REQUIREMENT Free from Abuse and Neglect:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.12 Freedom from Abuse, Neglect, and Exploitation
The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms.

483.12(a) The facility must-

483.12(a)(1) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion;
Observations:

Based on review of the facility's abuse policy, select investigative reports and clinical records, and resident and staff interview, it was determined that the facility failed to ensure that three residents were free from verbal abuse out of 20 residents sampled (Resident 67, Resident CR1, and Resident CR2)

Findings include:

Review of facility policy titled "Abuse Policy" that was last reviewed by the facility July 1, 2023, revealed that the resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. The facility must not use verbal, mental, sexual, or physical abuse, corporal punishment or involuntary seclusion. Residents must not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff or other agencies serving the resident, family members or legal guardians, friends or other individuals. The facility defined abuse as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish.

A review of Resident 67's clinical record revealed that the resident was admitted to the facility on December 6, 2022, with diagnoses to include pyogenic arthritis (inflammation of the joints caused by an infection), muscle weakness and difficulty walking.

A review of Resident 67's Quarterly Minimum Data Set Assessment (MDS - a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated May 2, 2023, revealed the Brief Interview for Mental Status (BIMS section of the MDS which assesses cognition, a tool to assess the resident's attention, orientation, and ability to register and recall new information, a score of 13-15 equates to being Cognitively Intact) that the resident scored a 15, which indicated that he was cognitively intact.

A review of Resident CR1's clinical record revealed that the resident was admitted to the facility on April 10, 2022, with diagnoses to include heart failure (a chronic, progressive condition in which the heart muscle is unable to pump enough blood to meet the body's needs for blood and oxygen), Post Traumatic Stress Disorder and muscle weakness.

A review of Resident CR1's Quarterly Minimum Data Set Assessment dated May 5, 2023, revealed the BIMS score to be a 15, which indicated that she was cognitively intact.

A review of Resident CR2's clinical record revealed that the resident was admitted to the facility on September 9, 2019, with diagnoses to include atrial fibrillation (the heart's upper chambers (atria) beat out of coordination with the lower chambers (ventricles), causing an irregular heart rate), and muscle weakness.

A review of Resident CR2's Quarterly Minimum Data Set Assessment dated May 9, 2023, revealed the BIMS score to be a 14, which indicated that she was cognitively intact.

A review of Resident 27's clinical record revealed that the resident was admitted to the facility on December 16, 2022, with diagnoses to include Schizophreniform Disorder (type of mental illness that is characterized by psychosis such as delusions, hallucinations, disorganized thinking and speech, and odd or strange behavior), mild intellectual disabilities and muscle weakness.

A review of Resident 27's Quarterly Minimum Data Set Assessment dated May 20, 2023, indicated that the resident was severely cognitively impaired with a BIMS score of 3 (0-7 represents severe cognitive impairment).

A review of progress notes dated from April 2, 2023, until May 19, 2023, revealed that Resident 27 displayed behaviors of pacing the hallways, episodes of mood swings, verbal aggression with staff and other residents, threatening remarks to staff, quick to anger, easily agitated and restless.

A review of a facility investigation report dated May 20, 2023, at 10:45 AM revealed Resident 27 was heard coming up the hallway yelling loudly "they can all f**k off, they want to kiss a** well I am not, and that dumb crippled one in the wheelchair can just die, it's nothing but bulls**t." The Activity Aide came to the nurse stating that Resident 27 "had a meltdown", yelling in other residents' faces and pulling his hand up as to appear to hit a resident. The Activity Aide immediately intervened and asked Resident 27 to exit the activity room. When a nurse attempted to talk to Resident 27, he began shouting "f**k off and I am not going to calm down until I f**king want to, you can all go to hell" while slamming his bedroom door shut. The investigation revealed that Resident 27 was interviewed and admitted that he did get into an argument with other residents and did get in their faces and threaten them. Physician, responsible parties, local police and Area of Aging were notified. Resident 27 sent to the ER for evaluation and treatment.

Review of facility investigation report, dated May 20, 2023, at 10:45 AM revealed Resident 67 stated "Resident 27 came up to me yelling and swearing at me you are a f**king cripple in your wheelchair. When I asked him to get out of my face, he began calling me an a**hole. I backed up so he was not close to me. I believe he should not be able to go to the activity room for a while, he scared a lot of people."

During an interview on February 2, 2024, at 10:10 AM, Resident 67 stated that he recalled that he was in the activities room when Resident 27 "went berserk" and started yelling and screaming at the residents in the room. Resident 67 explained that he did not remember what Resident 27 said but recalled "his eyes bulging and his face looking scary." Resident 67 stated that he was afraid of what Resident 27 was going to do. Resident 67 stated that he wanted to help calm Resident 27 down but was too afraid.

Review of facility investigation report dated May 20, 2023, at 10:45 AM revealed Resident CR1 was visibly upset and shaken by the incident in the activity room. Resident CR1's description of the incident was noted as follows: "There was a couple of us sitting in the activity room having coffee and talking when I went over and asked Resident 27 if he knew how to turn the radio off and he said 'no.' So, I asked him if I could, and he nodded his head. So, I turned the radio off so we could hear each other talk. That is when he yelling and cursing, calling us bitches and a**holes. He got right up in my face yelling and had his hand up like he was going to hit me. I really though I was in trouble. I was so scared. I asked him to back up and he cornered me in my wheelchair so I could not get away. Employee 5 came over and was able to get between us and had him leave. We could hear cursing as he left."

Review of facility investigation report dated May 20, 2023, at 4:50 PM revealed Resident CR2 reported "well he called me a bitch and I said, no, you're a bastard and he yelled back again and, you know me, I don't back down from anyone."

A review of Resident 27's comprehensive care plan in effect prior to Resident 27's verbal abuse and threats of intimidation directed towards other residents on May 20, 2023, failed to identify the known and witnessed aggressive, threatening and hostile behaviors displayed by Resident 27 documented during April 2023 and May 2023. There were no interventions developed for direct care and the interdisciplinary team to employ to address and attempt to reduce those behaviors to prevent abuse of other residents.

The facility failed to ensure that Residents 62, CR1, and CR2 were free from verbal abuse, threats and intimidation perpetrated by Resident 27.

Interview with the Director of Nursing on February 1, 2023, at approximately 2:40 PM confirmed that the facility substantiated the verbal abuse of Residents 62, CR1, and CR2 by Resident 27.


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

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

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







 Plan of Correction - To be completed: 03/13/2024

Resident 27 had interventions developed for direct care and the interdisciplinary team to employ to address and attempt to reduce those behaviors to prevent abuse.
Residents with aggression, threatening or hostile behaviors will have their plan of care reviewed and interventions implemented for direct care staff and interdisciplinary staff.
Direct care staff and interdisciplinary team will be re-educated on ensuring any residents with aggression, threatening behaviors or hostile behaviors will have interventions implemented for the interdisciplinary staff and direct care staff. Staff will be re-educated on the Abuse policy.
Social services will audit 10% of residents medical records for any aggressive behaviors have been added to the plan of care and are designated for the direct care staff and the interdisciplinary team weekly x4, then monthly x2. Results to QAPI for review and recommendation.

483.25(c)(1)-(3) REQUIREMENT Increase/Prevent Decrease in ROM/Mobility: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(c) Mobility.
483.25(c)(1) The facility must ensure that a resident who enters the facility without limited range of motion does not experience reduction in range of motion unless the resident's clinical condition demonstrates that a reduction in range of motion is unavoidable; and

483.25(c)(2) A resident with limited range of motion receives appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion.

483.25(c)(3) A resident with limited mobility receives appropriate services, equipment, and assistance to maintain or improve mobility with the maximum practicable independence unless a reduction in mobility is demonstrably unavoidable.
Observations:

Based on clinical record review and staff interview, it was determined that the facility failed to provide restorative nursing services planned to maintain mobility and functional abilities of one of 11 residents sampled (Resident 10).

Findings included:

A review of the clinical record of Resident 10 revealed admission to the facility on January 12, 2023, with diagnoses to include congestive heart failure (weakness of the heart that leads to build-up of fluid in the lungs and surrounding body tissues), unsteadiness on feet and difficulty walking.

A review of Resident 10's Physical Therapy Discharge Summary dated December 22, 2023, indicated that the resident was to receive Restorative Nursing Program (RNP) for ambulation. The discharge summary indicated that the ambulation program was established, and staff trained for the resident to ambulate 100 feet with rolling walker with assist of one person.

A review of the physician's order dated December 27, 2023, revealed an order for RNP ambulation 100 feet with rolling walker with assist of one person and wheelchair to follow.

A review of the Documentation Survey Report v2 for December 2023 and January 2024, revealed that Resident 10's RNP for ambulation was not implemented until January 22, 2024, twenty-five (25) days after the RNP was prescribed by the physician.

Interview with the Director of Nursing on January 31, 2024, at 1:15 PM failed to provide documented evidence that Resident 10 was provided with the physician prescribed RNP program during the timeframe from December 27, 2023, until January 21, 2024.



28 Pa. Code: 211.5(f) Clinical records

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







 Plan of Correction - To be completed: 03/13/2024


Resident 10 's RNP ambulation order was updated in tasks
Residents receiving restorative nursing programs will be reviewed to ensure the program is scheduled as recommended.
Licensed staff will be re-educated on the scheduling in tasks of the Restorative nursing programs
DON/designee will review any new RNP orders at daily meetings to ensure scheduling is accurate in tasks as recommended weekly x4, then monthly x2. Results to QA for review and recommendations.

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 observation, a review of clinical records, investigative reports, and information provided by the facility, and staff interview it was determined that the facility failed to use safe technique while positioning a resident and assure the presence of planned and prescribed preventative measures to prevent minor injury to one resident out of 13 sampled (Resident 1) and maintain an environment free of potential accident hazards.

Findings include:

A review of Resident 1's clinical record revealed that the resident had diagnoses to include cerebral infarction (stroke), right sided hemiplegia and hemiparesis (weakness or paralysis), gastro-esophageal reflux disease (GERD), and osteoporosis (bone softening, weakening).

A quarterly Minimum Data Set assessment (MDS - a federally mandated standardized assessment process conducted at specific intervals to plan resident care) dated December 6, 2023, indicated that the resident was severely cognitively impaired with a BIMS (brief interview to assess cognitive status) score of 3 (0 - 7 represents severe cognitive impairment) and has impairment on one side of her upper extremity (shoulder, elbow, wrist, hand), and required substantial/maximal assistance for upper body dressing.

Resident 1's care plan revised Janaury 21, 20214, revealed that the resident had a self care deficit related to hemiplegia, impaired mobility, and lack of coordination with planned interventions planned to provide 2 assist with dressing as needed, initiated January 17, 2018. The resident's care plan also identified a problem of skin integrity, monitor for actual/potential impairment related to immobility, CVA (stroke), with a history of skin tears, date revised October 13, 2023, with planned interventions for Geri skin sleeves to bilateral arms at all times, remove for hygiene care, initiated February 20, 2023.

A current physician order was noted February 20, 2023, for Geri/Glen sleeves to bilateral arms at all times. Remove for hygiene.

An incident report and nursing note dated January 9, 2024, at 5:55 PM, revealed that staff found a 2.0 centimeter (cm) x 3.0 cm bruise/hematoma to resident's right forearm. Per Employee 2, a nurse aide, the resident's arm was hanging over the side of Broda chair, in between the arm and tilt back of chair. When Employee 2, tilted the chair forward, the resident's arm was pinched. Employee 2, stated that the resident was not wearing the geri-sleeves as planned and ordered at the time of the injury. The Geri-sleeves were applied. The physician was notified with no new orders at this time. Education was given to staff about being mindful of resident's extremities for safe moving/repositioning of residents.

A review of facility provided document entitled "staff education record", dated January 9, 2024, at 7:00 PM, indicated a verbal/written education was provided to Employee 2 regarding when moving or repositioning a resident, be mindful of surroundings and residents extremities in order to avoid unwanted injuries.

Observation on February 2, 2024, at approximately 9:30 AM, in the presence of Employee 3, Licensed Practical Nurse (LPN), revealed Resident 1 was resting in bed. The resident's right forearm displayed a fading bruise, unraised - flat, with a small, dark, scabbing circular area.

During an interview on February 2, 2024, at approximately 10:15 AM, the Director of Nursing (DON) confirmed that the facility failed to address the necessary application of the resident's geri-sleeves in the education provided to the staff, along with the safe positioning, to ensure consistent application of the planned and prescribed preventative measure to protect the resident's skin. .

Observation on January 30, 2024, at 11:00 AM and January 30, 2024, at 1:15 PM revealed a jar of Triamcinolone Acetonide Cream (a steroid based cream) on the bedside dresser of Resident 14. Interview with employee 3 (LPN) on January 30, 2024, at 1:15 PM confirmed that the cream should not have been left accessible to residents in the resident's room, as the product could be potentially hazardous if mishandled or consumed by residents. .


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

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




 Plan of Correction - To be completed: 03/13/2024

Resident 1 had geri- sleeves placed to bilateral arms. Employee 2 educated on ensuring residents preventative skin measures are in place as ordered. Residents 14 steroid cream was removed from the bedside.
Residents with geri -sleeves will be reviewed and ensure placement of preventative sleeves. Rooms will be audited to ensure any products that are potentially hazardous are not at the bedside.
Licensed staff and direct care staff re-educated on the necessary application of the residents geri-sleeves and safe positioning to ensure consistent application of the planned and prescribed preventative measures to protect the residents skin. Licensed staff will be re-educated on ensuring potentially hazardous products are not left at the bedside. DON/ADON educated on ensuring to address with education to staff when preventative measures are not in place.
DON/designee to audit 10% of residents with ger-sleeves to ensure placement and will observe safe technique while positioning residents weekly x4, then monthly x2. Room audits will be done by designees weekly x4, then monthly x2 to ensure no potentially hazardous items are left at the bedside. Results to QAPI for review and recommendations.

483.25(h) REQUIREMENT Parenteral/IV Fluids: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(h) Parenteral Fluids.
Parenteral fluids must be administered consistent with professional standards of practice and in accordance with physician orders, the comprehensive person-centered care plan, and the resident's goals and preferences.
Observations:

Based on observations, review of clinical records and staff interviews it was determined that the facility failed to provide person-centered care as prescribed to meet the current clinical needs, failed to ensure the ready availability of prescribed emergency supplies, and failed to follow physician orders for management of a PICC line [(Percutaneously Inserted Central Catheter) for one resident out of 20 sampled residents (Resident 8).

Findings include:

A review of clinical records revealed Resident 8 was admitted to the facility on December 28, 2023, with diagnoses to include sepsis (a condition in which the immune system has a dangerous reaction to an infection), and urinary tract infection, and ESBL (Extended Spectrum Beta Lactamase, a bacteria resistant to most antibiotics) in the urine.

Review of Resident 8's hospital record, Procedure Note for Interventional Radiology, dated December 18, 2023, revealed that the resident underwent a procedure for a single lumen PICC placement in her right arm . Catheter total length was 35 cm with external catheter length 0 cm.
A review of physician's order, dated December 28, 2023, revealed an order to measure the PICC line catheter length on admission and with each dressing change thereafter, every Tuesday during day shift.

Review of Resident 8's Nursing Admission Evaluation dated December 28, 2023, the Medication Administration Record for December 2023, and January 2024, and nursing notes from December 28, 2023, to February 1, 2024, revealed no documented evidence that nursing had measured and recorded the PICC line catheter length on admission and every Tuesday as prescribed by the physician.

Interview with the Director of Nursing on February 1, 2024, at approximately 2:35 PM confirmed there was no documented evidence that the physician's order was followed for measuring and recording the PICC line catheter length.

A review of physician orders dated December 28, 2023, revealed an order to keep a bag of emergency supplies in the resident's room for the PICC line - check every shift for the presence of the emergency supplies, and replace if needed; if PICC becomes dislodged, apply pressure with gauze, raise arm. If unable to stop bleed call 911.

Observation conducted on January 30, 2024, 11:18 AM revealed no emergency supplies available in the resident's room.

Interview with Employee 4 (licensed practical nurse) on January 30, 2024, at 11:22 AM confirmed that Resident 8 had a physician's order for PICC line emergency supplies and confirmed that there were no emergency supplies available in Resident 8's room.


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





 Plan of Correction - To be completed: 03/13/2024

Resident 8 has been discharged from the facility to home.
Residents with PICC lines will have a review of orders for emergency supplies and weekly measuring of external length and will ensure documentation is completed for the last week to included external length measured and emergency supplies are in place.
Licensed staff will be re-educated on following physician orders to ensure the ready availability of prescribed emergency supplies are in place and to follow the order to measure external length of PICC line weekly with dressing changes.
Residents with PICC lines will be monitored for appropriate documentation of external catheter length and the presence of the emergency supplies at the bedside weekly x4, then monthly x2 with results to QAPI for review and recommendations.

483.40(b)(3) REQUIREMENT Treatment/Service for Dementia: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.
483.40(b)(3) A resident who displays or is diagnosed with dementia, receives the appropriate treatment and services to attain or maintain his or her highest practicable physical, mental, and psychosocial well-being.
Observations:


Based on a review of clinical records and staff interviews it was determined that the facility failed to develop and implement an interdisciplinary plan and approaches for direct care staff to use in managing dementia related behaviors for one resident out of five sampled residents (Resident 64).

Findings include:

A review of the clinical record revealed Resident 64 was admitted to the facility on October 30, 2023, with diagnoses that included Alzheimer's disease, muscle weakness, history of falling, and dementia.

A review of an admission BIMS (brief interview for mental status - a tool to assess cognitive status) report dated October 31, 2023, indicated that the resident was severely cognitively impaired with a BIMS score of 0.

Resident 64's care plan initiated October 31, 2023, revealed that the resident had a progressive decline in intellectual functioning characterized by deficit in memory, judgment, decision making and thought process related to Alzheimer's and Dementia. The resident's goal was that the resident will make simple needs known thru next review, target date of February 15, 2024. Planned interventions were to administer medications as ordered, allow adequate time for response, ask questions which can be answered yes, no, offer break activities into manageable subtasks. Give one instruction at a time to resident, cue and prompt resident with simple direct verbal cues and reminders to ensure resident makes attempts at own care before offering assistance, demonstrate tasks, encourage family visits, encourage small group activities, ensure access to clock/ calendar, ensure staff introduce themselves and are wearing name tags at initiation of each, establish daily routine with resident, explain each activity/ care procedure prior to beginning it, face to face communication, repeat if necessary, give resident two choices when presenting decisions, have resident echo back to ensure understanding, notify physician with change in mental status observe and report changes in cognitive status, place call bell within reach and encourage to call for assistance, provide emotional support to resident and family, provide reality orientation, peak of topics of interest to keep resident's attention, initiated October 31, 2023.

The resident's care plan dated December 19, 2023, indicated that the resident had problematic manner in which resident acts characterized by inappropriate behavior, resistive to treatment/care related to cognitive impairment, Alzheimer's Disease, major depression, constantly apologizing, stating, "I'm Sorry", with a noted goal that the she will comply with care routine/medical regime thru next review period with a target date of February 15, 2024. Planned interventions were to administer medication (Tylenol) 30 mins before attempt at activities of daily living (ADL) as per MD orders, allow for flexibility in ADL routine to accommodate resident's mood, discuss with resident implications of not complying with therapeutic regime, document care being resisted. If resident refuses care, leave resident and return in 5-10 minutes. Inform resident of ADL that is required ahead of time and give two options of times to be done, give resident choice and allow for flexibility in routines. Praise, reward resident for demonstrating consistent desired/acceptable behavior and try to redirect undesirable behavior - refusal of medications, care, treatments, initiated December 19, 2023.

A review of nurses note dated December 5, 2023, at 6:18 PM, indicated that the resident displayed continual self-transfers/ambulating without device throughout day. Nursing noted that the resident ambulated out of room carrying the roommate's tray to meal cart, was fixing roommates pillows, ambulated to nurses' station for water for roommate. Despite the resident's severe cognitive impairment, nursing noted that education was provided to the resident regarding the same. Resident "promises" she won't get up again. When this nurse left room to go for an alarm resident up again "helping her roommate."

Nursing noted on December 5, 2023, at 10:43 PM, that the resident's alarm was sounding. Staff entered room to find the resident standing up at roommate;s bed with bed controller in her hand and had put roommates bed up as high as it would go. Nursing explained to the cognitively impaired resident that she cannot put her roommates bed in the air due to safety. Staff assisted the resident back to bed, then several minutes later se attempting to crawl out of bed to get to her roommates bed to adjust her pillow.

Nursing noted on December 7, 2023, at 8:27 AM, that the resident was up unassisted walking around room to "fix roommates pillow." Staff Encouraged the severely cognitively impaired resident to ring for assistance. A personal body alarm was on and activated.

A nurse's note dated December 7, 2023, at 9:35 AM, revealed that Resident 64 was standing at roommates bed, removing her pillow from top of bed and putting it at foot of her bed. She was also observed going through a bag that was on her nightstand and had her roommates bed controller in her hand. Resident states, "sorry, sorry."

On January 22, 2024, at 9:31 PM, nursing noted that Resident 64 was helping her roommate get to the bathroom and assisting her to get dressed. She also was going through roommates closet and drawers.

On January 27, 2024, at 7:30 PM, nursing observed Resident 64 assisting her roommate onto the toilet.

During interview with the The Director of Nursing (DON) on January 31, 2024, at approximately 10:45 AM, the DON was unable to provide evidence that the facility had identified the resident's specific dementia-related behaviors regarding involvement with her roommate's care, on the resident's care plan and developed specific behavior-management or modification plans for staff to employ when the resident displays these behaviors to maintain the residents safety and the safety of her roommate. Interview with the Nursing Home Administrator (NHA) on February 1, 2024, at approximately 9:45 AM, confirmed that the facility failed to develop individualized interventions related to the resident's dementia-related behaviors and review and revise care plans that have not been effective.



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






 Plan of Correction - To be completed: 03/13/2024

Resident 64 no longer has a roommate. Care plan interventions updated to include dementia related behaviors regarding her involvement with other residents care.
Residents with dementia related behaviors plans of cares will be reviewed to ensure they are individualized.
Re-education will be provided to licensed staff and IDT by the Regional Social Service Director/designee to ensure a plan of care is individualized to dementia related behaviors. Will review behaviors in morning meeting and ensure individualized care plan is in place.
Random care plan audits will be completed by SS/designee on residents with dementia related behaviors weekly x4, then monthly x2. Results to QAPI for review and recommendations.

483.45(d)(1)-(6) REQUIREMENT Drug Regimen is Free from Unnecessary Drugs:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.45(d) Unnecessary Drugs-General.
Each resident's drug regimen must be free from unnecessary drugs. An unnecessary drug is any drug when used-

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

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

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

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

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

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


Based on a review of clinical records and a staff interview, it was determined that the facility failed to ensure that the resident's drug regimen was free of unnecessary antibiotic drugs for one out of 20 residents sampled (Resident 11).

Findings included:

A clinical record review revealed that Resident 11 was admitted to the facility on January 3, 2023, with diagnoses to include dementia and obstructive and reflux uropathy (urine is not able to drain through the urinary tract).

A nursing progress note dated September 28, 2023, at 12:50 PM revealed that the certified nurse practitioner was made aware of the resident's increased confusion, suprapubic pain, and exit-seeking behaviors. The note indicated that the nurse practitioner ordered lab work, blood cultures, and urinalysis.

A physician order dated September 28, 2023, at 3:00 PM for Resident 11 to have a urinalysis and culture and sensitivity (a test to determine the type of organisms in the urinary tract and antibiotic treatments that are effective to treat specific infections).

A progress note dated September 30, 2023, at 7:12 AM indicating that Resident 11 is stable, waiting for cultures to come back to determine treatment.

A physician progress note dated October 2, 2023, at 10:15 AM indicating that Resident 11 has increased confusion. The urinalysis results were contaminated. The CBC (complete blood count) results were unremarkable. Awaiting blood cultures.

A nursing progress note dated October 2, 2023, at 12:50 PM indicating a new order for urinalysis and culture and sensitivity tests.

A physician's order dated October 4, 2023, at 2:42 PM indicated that the urinalysis was reviewed by the nurse practitioner. A new order is noted for Resident 11 to receive Sulfamethoxazole-Trimethoprim (a combination antibiotic medication).

A physician's order was initiated on October 4, 2023, at 9:00 PM for Sulfamethoxazole-Trimethoprim Tablet 800-160 MG, 1 tablet every 12 hours, for urinary tract infection for seven days.

A review of the Medication Administration Record for October 2023 revealed that Resident 11 received 10 doses of Sulfamethoxazole-Trimethoprim Tablet 800-160 MG between October 4, 2023, and October 9, 2023.

A clinical record review revealed a urine culture lab results report for Resident 11 with a reported date of October 7, 2023, at 1:41 PM. The report indicated that the organisms identified in Resident 11's culture report were resistant to Sulfamethoxazole-Trimethoprim antiboitic medication.

A physician note dated October 9, 2023, at 11:39 AM regarding Resident 11's urinary tract infection with new orders to discontinue Sulfamethoxazole-Trimethoprim Tablet 800-160 MG and initiate Augmentin 875 mg/125 mg.

A clinical record review failed to reveal physician or certified registered nurse practitioner documentation to indicate the clinical necessity of initiating antibiotic treatment with Sulfamethoxazole-Trimethoprim to treat the resident's suspected urinary tract infection prior to receiving the results of the culture and sensitivity tests.

An interview with Employee 1, Infection Preventionist, on February 1, 2024, at approximately 12:15 PM confirmed that the administration of Sulfamethoxazole-Trimethoprim was not clinically justified for the treatment of Resident 11's urinary tract infection.





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

28 Pa. Code 211.5 (f) Clinical records

28 Pa. Code 211.9 (k) Pharmacy Services





 Plan of Correction - To be completed: 03/13/2024

Facility cannot retroactively correct this deficiency.
Residents receiving antibiotic therapy will be reviewed to ensure documentation to indicate the clinical necessity of initiation of medication is present.
Re-education by the Infection Control nurse/designee on policy for Antibiotic Stewardship will be completed with physicians, CRNP and licensed staff to ensure prior to start of antibiotic therapy there is documentation present to indicate the clinical necessity of initiating medication. New antibiotic orders will be reviewed in morning meeting to ensure the criteria is met with the initiation of the antibiotic.
DON/designee will audit residents receiving antibiotic therapy to ensure documentation of clinical necessity is present prior to initiating antibiotic therapy. Results to QAPI for review and recommendations.

483.80(d)(1)(2) REQUIREMENT Influenza and Pneumococcal Immunizations: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.
483.80(d) Influenza and pneumococcal immunizations
483.80(d)(1) Influenza. The facility must develop policies and procedures to ensure that-
(i) Before offering the influenza immunization, each resident or the resident's representative receives education regarding the benefits and potential side effects of the immunization;
(ii) Each resident is offered an influenza immunization October 1 through March 31 annually, unless the immunization is medically contraindicated or the resident has already been immunized during this time period;
(iii) The resident or the resident's representative has the opportunity to refuse immunization; and
(iv)The resident's medical record includes documentation that indicates, at a minimum, the following:
(A) That the resident or resident's representative was provided education regarding the benefits and potential side effects of influenza immunization; and
(B) That the resident either received the influenza immunization or did not receive the influenza immunization due to medical contraindications or refusal.

483.80(d)(2) Pneumococcal disease. The facility must develop policies and procedures to ensure that-
(i) Before offering the pneumococcal immunization, each resident or the resident's representative receives education regarding the benefits and potential side effects of the immunization;
(ii) Each resident is offered a pneumococcal immunization, unless the immunization is medically contraindicated or the resident has already been immunized;
(iii) The resident or the resident's representative has the opportunity to refuse immunization; and
(iv)The resident's medical record includes documentation that indicates, at a minimum, the following:
(A) That the resident or resident's representative was provided education regarding the benefits and potential side effects of pneumococcal immunization; and
(B) That the resident either received the pneumococcal immunization or did not receive the pneumococcal immunization due to medical contraindication or refusal.
Observations:

Based on a review of select facility policy, clinical records, and a staff interview, it was determined that the facility failed to offer and/or provide pneumococcal immunization for residents including one of the five residents sampled for immunizations (Resident 61).

Findings include:

A review of facility policy titled Pneumococcal Vaccine, reviewed by the facility on July 1, 2023, revealed that it is the facility's policy to offer pneumococcal vaccines to aid in preventing pneumonia or pneumococcal infections. The policy indicates that the administration of pneumococcal vaccines or re-vaccinations will be made in accordance with current Centers for Disease Control and Prevention (CDC) recommendations at the time of vaccination.

A review of the CDC's Pneumococcal Vaccination: Summary of Who and When to Vaccinate, September 22, 2023, indicates for adults 65 years of age or older who only received PCV13 and don't have an immunocompromising condition, cochlear implant, or cerebrospinal fluid leak: Give 1 dose of PCV20 or PPSV23 at least 1 year after PCV13. Regardless of the vaccine used, their vaccines are then complete. For older adults who have an immunocompromising condition, cochlear implant, or cerebrospinal fluid leak, give 1 dose of PCV20 or PPSV23. Regardless of the vaccine used, their vaccines are then complete. The PCV20 dose should be given at least 1 year after PCV13. The PPSV23 dose should be given at least 8 weeks after PCV13.

A clinical record review revealed Resident 61 was first admitted to the facility on June 2, 2021, with diagnoses to include unspecified psychosis (a condition of the mind that results in difficulty determining what is real and not real) and dementia.

A clinical record review revealed a document dated March 3, 2023, indicating that Resident 61 is incapacitated and has been legally assigned a guardian to act as a health care agent to give consent for and withhold medical treatment.

A clinical record review revealed that Resident 61 is 74 years old, and according to facility records, he received Prevenar 13 (PVC13) on November 3, 2015.

A clinical record review failed to reveal that Resident 61 or Resident 61's guardian was offered any additional pneumococcal vaccines in accordance with current CDC guidelines.

During an interview on February 2, 2024, at approximately 12:30 PM, the Director of Nursing (DON) could not provide evidence that Resident 61 or Resident 61's guardian was offered pneumococcal vaccination or educated about pneumococcal immunization in accordance with current CDC guidelines for pneumococcal immunization.


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

28 Pa code 211.12 (d)(3)(5) Nursing Services



 Plan of Correction - To be completed: 03/13/2024

Resident 61 has been offered pneumococcal immunization.
Residents will be reviewed to ensure all have been offered or educated on the pneumococcal vaccine and consents will be obtained if needed.
Licensed staff, DON and infection control staff will be re-educated on the Policy of Pneumococcal Vaccine. Immunization report will be ran monthly to ensure any resident due for pneumonia vaccine has consent or declination.
DON/ADON will audit new admissions and 10% of resident records to ensure the pneumococcal vaccine is offered as per the CDC schedule weekly x4, then monthly x2. Results to QAPI for review and recommendations.


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