Pennsylvania Department of Health
MONTGOMERYVILLE SKILLED NURSING AND REHABILITATION CENTER
Patient Care Inspection Results

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

Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

MONTGOMERYVILLE SKILLED NURSING AND REHABILITATION CENTER
Inspection Results For:

There are 159 surveys for this facility. Please select a date to view the survey results.

Surveys don't appear on this website until at least 41 days have elapsed since the exit date of the survey.


MONTGOMERYVILLE SKILLED NURSING AND REHABILITATION CENTER - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:

Based on a Medicare/Medicaid Recertification survey, State Licensure survey, and a Civil Rights Compliance survey completed May 22, 2024, it was determined that Montgomeryville Skilled Nursing and Rehabilitation Center was not in compliance with the following requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care and the 28 Pa. Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.

Plan of Correction:

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

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

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

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

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

Observations:

Based on observation and interview, it was determined that the facility failed to store and serve food under sanitary conditions in the kitchen.

Findings include:

Observation of the kitchen on May 19, 2024, at 9:20 a.m., revealed the following:

On a food preparation surface with a microwave, there was an open Pepsi bottle, a staff drink cup, an apron, a mask, crumbs and debris, Styrofoam cups, and plastic lids. .

The corner of the wall at the entry way was marred and peeling. There was an accumulation of food that remained in the dish machine trap. In an interview, Dietary Aide (DA) 1 stated that the dish machine had not yet been used on that date.

On the bottom shelf of a food preparation surface, there was an accumulation of debris that included dust and crumbs on a case of corn starch. There was a rolling cart in the hot food preparation area with a ladle and an open container of powdered potatoes on the cart. In an interview, Cook 1 stated that the potatoes had not been used on that date and were left out and uncovered from the previous day. There was an accumulation of a dried, white substance that appeared to have dripped down the front of the oven doors. There was an accumulation of an unidentified substance on the bulk rice and flour bins. There was an open container of peanut butter with a spoon stored in the container.

In the walk-in refrigerator, there was a pan of packaged raw beef and pork that were not dated. There were pans of macaroni and cheese and rice that were not dated. There were open packages of hard- boiled eggs and chicken patties that were not sealed and left open to air. In the walk-in freezer, there was a box of frozen potatoes that was stored on the floor. There were open boxes of frozen bread dough and pizzas that were not sealed and left open to air. In dry storage, there was a bag of baking powder that was not sealed and left open to air.

Observation of the tray line service on May 21, 2024, at 11:31 a.m., revealed a fan on the counter at the tray line. There was an accumulation of dust on the fan which was blowing onto the plates. Cook 2 was wearing gloves and assembling resident plates on the tray line. Cook 2 left the tray line, opened and obtained items from the reach-in refrigerator, returned to tray line, and continued to assemble resident plates and handle ready to eat food, without changing gloves or performing hand hygiene.

CFR 483.60(i)(1)(2) Food Procurement Store/Prepare/Serve-Sanitary
Previously cited 6/1/23.

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

Plan of Correction - To be completed: 07/10/2024

F0812
SS=F

Personal items at the food preparation area have been removed. The corner wall at the entryway was cleaned, repaired, and painted. The dish machine was cleaned and the food accumulation was removed. The bottom shelf of the food preparation area was cleaned. The ladle was removed from the rolling cart and powdered potatoes were disposed of. The accumulation of white substance on the oven doors was cleaned. The bulk rice and flour containers were cleaned. The open container of peanut butter was disposed of. All food items that were not labeled, dated, or sealed as required were disposed of and replaced.
The Food Service Director did a sanitation and food safety audit to ensure all food in dry storage or in the refrigerator and freezer were properly sealed, labeled, and dated, and the kitchen sanitation was conducted as required.

Dietary staff will be re-educated regarding food storage, labeling, dating, and sanitation cleaning requirements.

The Dietician or designee will complete a twice a week audit for 30 days, then a once a week audit for 60 days to ensure food storage, labeling, and dating is done as required and kitchen cleaning and sanitation is done as scheduled and required.

Results of the audits will be presented to the monthly QAPI meeting for review and recommendation.

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 81°F; and

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

Observations:

Based on observations, it was determined that the facility failed to maintain the resident environment in a safe, clean and homelike manner for two of three nursing units. (Rehab and Second floor)

Findings include:

Observations on May 19, 2024, at 10:00 a.m., on the Rehab nursing unit revealed that in resident room 1, there was a piece of tile missing next to the door. In resident rooms 10, 14, and 16, there were chunks of paint missing on the wall. In resident room 27, there were two small holes in the wall where the glove rack had been hanging, but the rack was missing. In resident room 28, white splatter was observed at the bottom of the door. There were stained ceiling tiles in resident room 4 and in the hallway near Resident rooms 23, 25, and 30. The central bathing area on the Rehabilitation unit did not have soap in the dispenser by the sink and the toilet tank cover was missing.

Observations made during an environmental tour on May 19, 2024, at 10:14 a.m., revealed that the refridgerators in the pantry on the second floor nursing unit had multiple containers of food items that were not labeled or dated. There was a carton of thickened lemon flavored water that was opened and dated March 19, 2024. The manufacturer's instructions on the carton indicated that the water could be kept for up to seven days once opened in the refrigerator. The refrigerator bottom drawers were soiled with a red liquid substance. The freezer contained frozen bottles of water, a frozen milk carton, and food items that were either opened or in plastic that were not labeled or dated.

Observations on May 20, 2024, at 12:41 p.m., on the second floor nursing unit revealed that there was a small linen cart located on the B wing in the hallway. On this cart, was a bottle of shea butter lotion, a dirty glove, a soiled plastic cup, and an opened package of disposable razors.

Observations on May 21, 2024, at 12:25 p.m. revealed that the fall mat by the bed in room 214 was soiled. In addition, the wall below the handrail near the entrance of room 206 was damaged and there was a hole in the wall.

CFR 483.10(i)(1)-(7) Safe/Clean/Comfortable/Homelike environment
Previously cited 6/1/23.

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

Plan of Correction - To be completed: 07/10/2024

In resident room 1 the piece of tile missing next to the door was replaced; in resident room 10,14,16 the damaged walls were patched and repainted; in resident room 27, the two small holes were patched and painted; in resident room 28 the white splatter on the door was removed; in resident room 4 the stained ceiling tile was replaced; in the hallway by resident rooms 23, 25, and 30 the stained ceiling tiles were replaced; in the central bathroom on the Rehabilitation Unit the soap dispenser by the sink was replaced and the toilet tank cover was replaced. The wall below the handrail at the entrance to room 206 was repaired. Refrigerator in second floor pantry was cleaned and all items that were not labeled and/or dated were discarded. The items on the second floor linen cart were immediately removed and discarded. Fall Matt in 214 was cleaned and replaced.

Maintenance Staff/designee will make rounds to ensure all walls, ceiling tiles, wall penetrations, and fixtures are in place and free of damage throughout the center. Housekeeping Staff/designee will audit all refrigerators to ensure they are clean and all items are appropriately labeled and dated. If items are found that are not labeled and/or dated they will be immediately discarded. Unit Managers/designee will round units daily to ensure all personal items are labeled and stored appropriately.

Staff will be educated to identify these issues and report them utilizing the TELs Work Order System to ensure these issues are addressed timely. Staff will also be educated to ensure refrigerators are kept clean and all items put in the refrigerators are appropriately labeled and dates. Education will also be done to ensure personal items are no left on linen carts in the hallways.

Maintenance Staff/Designee will conduct audits twice a week for 30 days, then a once a week audit for 60 days to ensure these issues do not reoccur.

Results of the audits will be presented to the monthly QAPI meeting for review and recommendation.

483.25(g)(1)-(3) REQUIREMENT Nutrition/Hydration Status Maintenance:

§483.25(g) Assisted nutrition and hydration.
(Includes naso-gastric and gastrostomy tubes, both percutaneous endoscopic gastrostomy and percutaneous endoscopic jejunostomy, and enteral fluids). Based on a resident's comprehensive assessment, the facility must ensure that a resident-

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

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

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

Observations:

Based on facility policy review, clinical record review, and staff interview, it was determined that the facility failed to monitor and assess resident weights and weight changes for five of 14 reviewed residents who were at risk for weight loss. (Residents 36, 73, 84, 95, 122)

Findings include:

Review of the facility policy entitled, "Weights and Heights," last reviewed February 1, 2024, revealed that residents were to be weighed upon admission and/or re-admission, then weekly for four weeks and monthly thereafter. Additional weights may be obtained at the discretion of the interdisciplinary care team. In an interview on May 21, 2024, at 1:24 p.m., the Director of Nursing stated that reweighs should be completed the next day.

Clinical record review revealed that Resident 36 had diagnoses that included dementia and heart disease. Review of the care plan revealed that the resident had an alteration in nutritional status due to dementia and weight loss with an intervention to review monthly weights and notify the doctor of significant weight loss. Review of the documented weights revealed that on January 1, 2024, the resident's weight was 143.6 pounds (lbs) and on February 1, 2024, her weight was 120 lbs. The resident had a 23.6 pound (lb) weight loss in 30 days. There was no documented evidence that the weight loss was addressed in a timely manner. On March 8, 2024, a dietician noted that the resident had a significant weight loss.

In an interview on May 22, 2024, at 12:11 p.m., the Director of Nursing confirmed that the significant weight loss for Residents 36 had not been addressed in a timely manner.

Clinical record review revealed that Resident 73 had diagnoses that included dementia and anemia. Review of the care plan revealed the resident was at nutritional risk due to inadequate intake and significant weight loss. There was no evidence that the resident's monthly weight was obtained in January, February, March, or April 2024, per facility policy.

Clinical record review revealed that Resident 84 had diagnoses that included dysphagia and aphasia (comprehension and communication disorder). Review of the care plan revealed that the resident was at nutritional risk due to inadequate intake. On January 11, 2024, the resident weighed 198.4 lbs, and on February 1, 2023, the resident weighed 162.8 lbs, which reflected a significant weight loss of 35.6 lbs (17.9%), in less than 30 days. There was no evidence that a reweigh was obtained in 24 hours or that the significant weight loss was identified or addressed in a timely manner. On March 1, 2024, the resident weighed 159.8 lbs, which confirmed the ongoing weight loss. There was no evidence that the weight loss was addressed or that the resident was assessed until March 12, 2024.

Clinical record review revealed that Resident 95 was admitted to the facility on April 26, 2024, and had diagnoses that included hydrocephalus (water on the brain), diabetes, and depression. Review of the care plan revealed that the resident was at risk for alteration in nutrition status. The resident was weighed on April 26, 2024 and May 1, 2024. There was no documented evidence that Resident 95 was weighed weekly after admission per facility policy.

Clinical record review revealed that Resident 122 had diagnoses that included end stage renal disease with hemodialysis, legal blindness, and depression. Review of the care plan revealed that the resident was at risk for malnutrition. The resident was admitted to the facility on February 8, 2024, and weighed 143.4 lbs at that time. There was no evidence that the resident was weighed again until February 28, 2024, not weekly per facility policy.

In an interview on May 22, 2024, at 9:57 a.m., the Director of Nursing confirmed that the residents had not been weighed or assessed per facility policy.

CFR 483.25(g)(1) Maintain acceptable parameters of nutritional status.
Previously cited 12/6/23

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

Plan of Correction - To be completed: 07/10/2024

F0692
SS=E

Resident 36's weight loss has been addressed by the dietician. Resident 73's weight has been obtained and updated. Resident 84's reweight was obtained and dietician addressed the weight loss. Resident 95's weekly weights were re-initiated for four weeks. Resident 122's weekly weights were re-initiated for four weeks.

All resident weights will be reviewed by the dietician from April 1, 2024 to identify if any weekly or monthly weights were missed and any significant weight loss is appropriately addressed.

Professional Nurses will be re-educated on the importance of obtaining weekly and monthly weights and notifying the dietician regarding significant weight loss.

The Director of Nursing or designee will complete a twice a week audit for 30 days, then a once a week audit for 60 days to ensure the weekly and monthly weights are obtained and all significant weight loss is addressed timely.

Results of the audits will be presented to the monthly QAPI meeting for review and recommendation.

483.10(e)(3) REQUIREMENT Reasonable Accommodations Needs/Preferences:

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(e)(3) The right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents.

Observations:

Based on clinical record review and observation, it was determined that the facility failed to accommodate resident needs by providing access to the call bell system for one of 34 sampled residents. (Resident 124)

Findings include:

Clinical record review revealed that Resident 124 had diagnoses that included depression. Review of the care plan revealed that the resident was at risk for falls and that staff was to reinforce the need to call for assistance. On May 19, 2024, from 9:52 a.m. through 1:16 p.m., the resident was observed lying in bed. There was no call bell plugged into the system for the resident's side of the room. On May 20, 2023, at 9:53 a.m., the resident was observed lying in bed. There was no call bell plugged into the system for the resident's use. On May 21, 2024, from 9:12 a.m. through 12:08 p.m., the resident was observed lying in bed. The call bell was on the nightstand, out of reach.

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

Plan of Correction - To be completed: 07/10/2024

F0558
SS=D

Resident 124's call bell was replaced and connected to the jack. The call bell was placed in reach of the resident.

Maintenance Staff/designee will check every call bell in the center to ensure it is functioning and in reach.

Staff will be re-educated to ensure they are checking for placement and function of the call bell to ensure they operate and are within reach of the patient/resident.

The Director of Nursing or designee will complete a twice a week audit for 30 days, then a once a week audit for 60 days, to ensure call bells are functioning and within reach of the patients/residents.

Results of the audits will be presented to the monthly QAPI meeting for review and recommendation.

483.60(f)(1)-(3) REQUIREMENT Frequency of Meals/Snacks at Bedtime:

§483.60(f) Frequency of Meals
§483.60(f)(1) Each resident must receive and the facility must provide at least three meals daily, at regular times comparable to normal mealtimes in the community or in accordance with resident needs, preferences, requests, and plan of care.

§483.60(f)(2)There must be no more than 14 hours between a substantial evening meal and breakfast the following day, except when a nourishing snack is served at bedtime, up to 16 hours may elapse between a substantial evening meal and breakfast the following day if a resident group agrees to this meal span.

§483.60(f)(3) Suitable, nourishing alternative meals and snacks must be provided to residents who want to eat at non-traditional times or outside of scheduled meal service times, consistent with the resident plan of care.

Observations:

Based on facility documentation review, observation, and family, resident, and staff interview, it was determined that the facility failed to ensure that meals were served at regularly scheduled times, in a timely manner, and in accordance with the residents' needs on one of three the nursing units. (Second floor nursing unit)

Findings include:

Review of the facility meal times schedule revealed that lunch was to arrive on the nursing units between 11:30 a.m. and 1:00 p.m..

On May 19, 2024, at 12:45 p.m., confidential staff interviews on the second floor nursing unit revealed that the lunch was being served very late today and had been served late on other occasions.

In a confidential interview on May 19, 2024, at 1:09 p.m., a family member of a resident on the second floor stated that meals were frequently served late. Observation at that time revealed that the resident of this family member did not receive lunch until 1:15 p.m., 15 minutes after the latest scheduled time for the meals to arrive on the nursing units.

In an interview on May 19, 2024, at 1:00 p.m., Residents 32 and 34 stated that they were waiting for their lunches and that the meals today were very late. In addition, they both stated that they were hungry and were anxiously awaiting their meals. Residents 32 and 34 did not receive their meals until 1:40 p.m., 40 minutes past the latest scheduled time for the meals to arrive on the nursing units.

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

Plan of Correction - To be completed: 07/10/2024

F0809
SS=D

Meals are being delivered to the resident units at the scheduled time.

An audit will be conducted daily for 30 days by the Food Service Director to ensure dietary cart delivery times are in compliance with the scheduled times.

Dietary and nursing staff will be re-educated to ensure meals are prepared, delivered, and distributed to the residents timely.

The Dietician or designee will complete a twice a week audit for 30 days, then a once a week audit for 60 days to ensure residents are receiving their meal at the scheduled time.

Results of the audits will be presented to the monthly QAPI meeting for review and recommendation.

483.60(e)(1)(2) REQUIREMENT Therapeutic Diet Prescribed by Physician:

§483.60(e) Therapeutic Diets
§483.60(e)(1) Therapeutic diets must be prescribed by the attending physician.

§483.60(e)(2) The attending physician may delegate to a registered or licensed dietitian the task of prescribing a resident's diet, including a therapeutic diet, to the extent allowed by State law.

Observations:

Based on clinical record review, observation, and resident and staff interview, it was determined that the facility failed to ensure that a therapeutic diet was provided as recommended by a registered dietician to one of 14 sampled residents who were at risk for weight loss. (Resident 43)

Findings include:

Clinical record review revealed that Resident 43 had diagnoses that included rhabdomyolysis (breakdown of muscle tissue), diabetes, and anemia. The Minimum Data Set assessment dated May 3, 2024, indicated that the resident was alert and oriented, had weight loss, was not on a prescribed weight loss program, and was on a therapeutic diet.

Review of a registered dietician's note dated March 7, 2024, revealed that the resident had a weight loss, had a good appetite, and that "the resident stated he feels that breakfast portions can sometimes be too small." At that time, the dietician documented that the resident was to be provided with double portions at meals.

Review of the facility master diet guide sheet revealed that on May 20, 2024, the meal served at lunch was three ounces of baked chicken, four ounces of seasoned zucchini, and a half-cup of orzo and fruit ambrosia salad.

On May 20, 2024, Resident 43 was observed in his room and he had been served his lunch. Review of his tray card revealed that he was to receive double portions of food at his meals. At that time, he only received one portion each of the lunch items listed above. Resident stated he had a good appetite and liked to eat all of his food.

In an interview on May 22, 2024, at 9:51 a.m., the Director of Nursing stated that the resident was to receive double portions of food at his meals.

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

Plan of Correction - To be completed: 07/10/2024

F0808
SS=D

Resident 43's is receiving double portions as documented by the dietician.
An audit will be conducted to ensure all residents that the dietician documented to receive double portions are receiving the required amount of food on their tray.

Dietary staff will be re-educated regarding complying with the dieticians recommendations for double portions and the required portion sizes.

The Dietician or designee will complete a twice a week audit for 30 days, then a once a week audit for 60 days to ensure residents are receiving double portions when requested by the dietician.

Results of the audits will be presented to the monthly QAPI meeting for review and recommendation.

483.60(d)(4)(5) REQUIREMENT Resident Allergies, Preferences, Substitutes:

§483.60(d) Food and drink
Each resident receives and the facility provides-

§483.60(d)(4) Food that accommodates resident allergies, intolerances, and preferences;

§483.60(d)(5) Appealing options of similar nutritive value to residents who choose not to eat food that is initially served or who request a different meal choice;

Observations:

Based on clinical record review, review of facility documentation, observation, and resident interview, it was determined that the facility failed to ensure that a resident's preference at meal times had been accommodated for two of 34 sampled residents. (Residents 49, 126)

Findings include:

Clinical record review revealed that Resident 49 had diagnoses that included dysphagia (difficulty swallowing) and atrial fibrillation. Reivew of the Minimum Data Set (MDS) assessment dated May 2, 2023, revealed the resident had no cognitive impairment. Review of Resident 49's care plan revealed she had a nutritional risk with an intervention for staff to honor food preferences. In an interview on May 19, 2024, at 12:43 p.m., the resident stated that she often didn't receive the food that she ordered. According to the resident's meal selection sheet (a document completed weekly by the resident to select food choices) she requested spinach, egg, and cheese casserole for lunch that day. When her lunch tray was observed at 12:50 p.m., she received turkey, mashed potatoes, and carrots. The resident stated that she didn't like these items.

Clinical record review revealed that Resident 126 was admitted to the facility on February 21, 2024, with diagnoses that included hypertension (high blood pressure) and hyponatremia (low sodium levels). Review of the MDS assessment dated February 28, 2024, revealed that the resident had no cognitive impairment. Review of Resident 126's care plan revealed she had an altered nutrition status with an intervention for staff to honor food preferences. On May 20, 2024, at 12:34 p.m., Resident 126 was observed to receive fish as her meal. At that time, the resident stated she did not like fish and ordered a burger with raw onions. The resident's tray card indicated that the resident was to receive a burger with raw onions.

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

28 Pa. Code 201.18(b) Management.

Plan of Correction - To be completed: 07/10/2024

F0806
SS=D

Resident 49 and 126's meal preferences were updated and their select menu was received and reviewed by dietary staff to ensure meal preferences/selections were recorded.

Audits will be conducted by the Food Service Director or designee daily three random test trays per day for 30 days to ensure residents received the food they selected/preferred.

Dietary and Nursing staff will be re-educated regarding complying with the residents selected/preferred food choices.

The Dietician or designee will complete a twice a week audit for 30 days, then a once a week audit for 60 days to ensure residents received the food they preferred/selected.

Results of the audits will be presented to the monthly QAPI meeting for review and recommendation.

483.20(b)(1)(2)(i)(iii) REQUIREMENT Comprehensive Assessments & Timing:

§483.20 Resident Assessment
The facility must conduct initially and periodically a comprehensive, accurate, standardized reproducible assessment of each resident's functional capacity.

§483.20(b) Comprehensive Assessments
§483.20(b)(1) Resident Assessment Instrument. A facility must make a comprehensive assessment of a resident's needs, strengths, goals, life history and preferences, using the resident assessment instrument (RAI) specified by CMS. The assessment must include at least the following:
(i) Identification and demographic information
(ii) Customary routine.
(iii) Cognitive patterns.
(iv) Communication.
(v) Vision.
(vi) Mood and behavior patterns.
(vii) Psychological well-being.
(viii) Physical functioning and structural problems.
(ix) Continence.
(x) Disease diagnosis and health conditions.
(xi) Dental and nutritional status.
(xii) Skin Conditions.
(xiii) Activity pursuit.
(xiv) Medications.
(xv) Special treatments and procedures.
(xvi) Discharge planning.
(xvii) Documentation of summary information regarding the additional assessment performed on the care areas triggered by the completion of the Minimum Data Set (MDS).
(xviii) Documentation of participation in assessment. The assessment process must include direct observation and communication with the resident, as well as communication with licensed and nonlicensed direct care staff members on all shifts.

§483.20(b)(2) When required. Subject to the timeframes prescribed in §413.343(b) of this chapter, a facility must conduct a comprehensive assessment of a resident in accordance with the timeframes specified in paragraphs (b)(2)(i) through (iii) of this section. The timeframes prescribed in §413.343(b) of this chapter do not apply to CAHs.
(i) Within 14 calendar days after admission, excluding readmissions in which there is no significant change in the resident's physical or mental condition. (For purposes of this section, "readmission" means a return to the facility following a temporary absence for hospitalization or therapeutic leave.)
(iii)Not less than once every 12 months.

Observations:

Based on clinical record review, it was determined that the facility failed to complete a comprehensive assessment for two of 34 sampled residents. (Residents 106, 107)

Findings include:

Clinical record review revealed that Resident 106 was transferred to and admitted to the hospital for a change in condition on April 14, 2024. There was no Minimum Data Set (MDS) assessment completed to reflect that the resident was discharged from the facility.

In an interview on May 22, 2024, at 9:57 a.m., the Director of Nursing confirmed an MDS assessment had not been completed for Resident 106's discharge to the hospital.

Clinical record review revealed that on March 29, 2024, the physician ordered hospice services for Resident 107. Review of a recent doctor's note dated May 1, 2024, revealed that the resident continued to be on hospice services. There was no MDS assessment completed to reflect the significant change in his status.

In an interview on May 22, 2024, at 9:50 a.m., the Director of Nursing confirmed that a significant change MDS had not been completed for Resident 107 when he had been placed on hospice services.

Plan of Correction - To be completed: 07/10/2024

F0636
SS=D

The Minimum Data Set (MDS) for resident 106 for discharge from the facility to the hospital was completed. The MDS for resident 107 for significant change and placement on hospice services was completed.

All resident records going back to April 1, 2024 will be reviewed to ensure MDS assessments were completed for residents that discharge to the hospital or have been placed on hospice services.

MDS Coordinators will be re-educated on the appropriate completion of MDS assessments following a resident discharge to the hospital or being placed on hospice services.

The Director of Nursing or designee will complete a twice a week audit for 30 days, then a once a week audit for 60 days to ensure MDS assessments are completed after a resident discharge to the hospital or have been placed on hospice services.

Results of the audits will be presented to the monthly QAPI meeting for review and recommendation.

483.21(b)(1)(3) REQUIREMENT Develop/Implement Comprehensive Care Plan:

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

Observations:

Based on clinical record review and staff interview, it was determined that the facility failed to develop a comprehensive care plan to meet each resident's needs for three of 34 sampled residents. (Residents 121, 124, 296)

Findings include:

Clinical record review revealed that Resident 121 was readmitted to the facility on May 10, 2024, and had diagnoses that included acute pulmonary edema and congestive heart failure. There was no care plan developed to address Resident 121's needs.

Clinical record review revealed that Resident 124 was admitted to the facility on April 11, 2024, and had diagnoses that included bacteremia and benign prostatic hyperplasia (urinary condition). On April 25, 2024, the physician ordered for Resident 124 to have an indwelling urinary catheter. There was no evidence that interventions to address Resident 124's urinary status and catheter were included in the current care plan.

Clinical record review revealed that Resident 296 was admitted to the facility on May 4, 2024, and had diagnoses that included dependence on renal dialysis, nontraumatic ischemic infarction of the right lower leg muscle (blocked blood flow), and peripheral vascular disease. The Minimum Data Set (MDS) Care Area Assessment (CAA) summary dated May 11, 2024, noted that the resident's ADL (activities of daily living) function, urinary incontinence, pressure ulcers, and pain were to be addressed in the care plan. There was no evidence that interventions to address Resident 13's ADL function, urinary incontinence, pressure ulcers, or pain were included in the current care plan.

In an interview on May 22, 2024, at 9:54 a.m., the Director of Nursing confirmed there was no documented evidence that the care areas were addressed in the residents' current care plans.

CFR. 483.21(b)(1) Comprehensive Care Plans.
Previously cited 6/1/23

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

Plan of Correction - To be completed: 07/10/2024

F0656
SS=D

Resident 121's care plan has been reviewed and updated to address the areas of acute pulmonary edema and congestive heart failure. Resident 124's care plan was reviewed and updated to address the areas of urinary status and catheter. Resident 296's care plan was reviewed and updated to address the areas of renal dialysis, nontraumatic ischemic infarction of right lower leg muscles and peripheral vascular disease. Resident 13's care plan was reviewed and updated to address the areas of ADL function, urinary incontinence, pressure ulcers, and pain.

All residents records will be audited to ensure there are care plans in place to address the residents individual and specific needs.

Staff will be re-educated to ensure all residents have appropriate care plan interventions to address their individual and specific needs.

The Director of Nursing or designee will complete a twice a week audit for 30 days, then a once a week audit for 60 days to ensure needed resident care plans are individualized and in place as needed.

Results of the audits will be presented to the monthly QAPI meeting for review and recommendation.

Date of Compliance: 7/10/2024

483.25 REQUIREMENT Quality of Care:

§ 483.25 Quality of care
Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices.

Observations:

Based on clinical record review and staff interview, it was determined that the facility failed to follow physician orders for three of 34 sampled residents. (Residents 107, 115, 296)

Findings include:

Clinical record review revealed that Resident 107 had diagnoses that included a history of sepsis (infection of the blood) and Alzheimer's disease. The Minimum Data Set (MDS) assessment dated March 26, 2024, indicated that the resident had been on an antibiotic medication in the last seven days and that he had a primary medical condition of sepsis of an unspecified organism. On March 18, 2024, a physician ordered for staff to administer an antibiotic medication (amoxicillin) twice a day for seven days for a total of 14 doses of the medication. Review of the March 2024 Medication Administration Record (MAR), revealed that staff had not administered the first dose of the antibiotic on March 18, 2024. Review of a nursing note dated March 18, 2024, revealed that the antibiotic was not administered because it had not been available. Further review of the MAR, revealed that he received the last dose of the antibiotic on March 24, 2024. The resident only received 13 doses of the antibiotic. There was no documented evidence that the resident received the full 14 dose antibiotic treatment for the sepsis.

In an interview on May 22, 2024, at 9:49 a.m., the Director of Nursing confirmed that the resident had not received the full treatment of the antibiotic medication to treat sepsis.

Clinical record review revealed that Resident 115 had diagnoses that included a traumatic brain injury and pressure ulcers. Review of Resident 115's care plan revealed he had an alteration in skin integrity with an intervention for staff to elevate heels and use assistive devices. On March 23, 2024, the physician ordered for staff to apply pressure reducing boots while in bed. Observations on May 20, 2024, from 9:16 a.m. through 1:12 p.m., and May 21, 2024, from 9:12 a.m. through 12:08 p.m., revealed Resident 115 in bed with no pressure reducing boots in place.

Clinical record review revealed that Resident 296 was admitted to the facility on May 4, 2024, and had diagnoses that included a dependence on renal dialysis and nontraumatic ischemic infarction (blocked blood flow) of the right lower leg muscle. Review of Resident 115's hospital discharge instructions dated May 4, 2024, revealed he was to receive epoetin alpha (medication that helps your body produce red blood cells) three times a week. On May 4, 14, 17, and 20, 2024, the physician ordered for Resident 115 to receive epoetin alpha three times a week. In an interview on May 20, 2024 at 12:34 p.m., Resident 115's wife stated he had not received the epoetin at all during his stay. There was no documented evidence that Resident 115 had received epoetin alpha as ordered by the physician.

In an interview on May 22, 2024 at 9:54 a.m., the Director of Nursing confirmed that Resident 115 did not receive his ordered epoetin alpha in a timely manner.

CFR 483.25 Quality of Care.
Previously cited 2/12/24

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

Plan of Correction - To be completed: 07/10/2024

F0684
SS=D

Resident 107's missed amoxicillin dose was from 3/25/2024, physician was consulted and no new orders were given. Resident 115's pressure relieving boots were put in place and an order was put in the MAR to have nurses check placement. Resident 296's Epoetin Alpha order was put in place as ordered by the physician.

All resident records will be audited by each Nursing Unit Manager to ensure all physician orders are in place and implemented.

Staff will be educated to ensure that all physician orders are put in place and implemented.

The Director of Nursing or designee will complete a twice a week audit for 30 days, then a once a week audit for 60 days to ensure all orders are given and/or in place.

Results of the audits will be presented to the monthly QAPI meeting for review and recommendation.

483.25(c)(1)-(3) REQUIREMENT Increase/Prevent Decrease in ROM/Mobility:

§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, observation, and staff interview, it was determined that the facility failed to provide services and treatment to prevent further limitations in range of motion for one of five sampled residents who had limitations in range of motion. (Resident 41)

Findings include:

Clinical record review revealed that Resident 41 had a diagnosis of a stroke with hemiplegia, (paralysis), of the non-dominant left side. The Minimum Data Set assessment dated March 3, 2024, indicated that the resident had some memory impairment and had limitations in range of motion on one side of the lower and upper extremities. A review of the care plan revealed that the resident had an activites of daily living deficit due to physician limitations. There was a current intervention for staff to apply a left resting hand splint in the morning and to remove it at night. In addition, there was a current physician order since March 8, 2024, for staff to apply the left resting hand splint every day to prevent contractures.

Review of an occupational therapy evaluation dated May 16, 2024, revealed that the left resting hand splint was missing.

On May 19, 2020, at 11:30 a.m., 12:10 p.m., 1:21 p.m., and 1:51 p.m., the resident was observed dressed and seated in her reclining broda chair without the left resting hand splint in place.

In an interview on May 22, 2024, at 9:49 a.m., the Director of Nursing stated that the left resting hand splint was to be in place as ordered by the physician and that the splint was found to have been missing.

CFR 483.25(c)(1)-(3) Increase/Prevent Decrease in ROM/Mobility
Previously cited 6/1/23.

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

Plan of Correction - To be completed: 07/10/2024

F0688
SS=D

The order for Resident 41's resting hand splint was discontinued on 5/20/2024.

An audit will be conducted to ensure all residents that have orders for splints have them in place as ordered.

Staff will be educated regarding the need to comply with placement of splints as ordered.

The Director of Nursing or designee will complete a twice a week audit for 30 days, then a once a week audit for 60 days to ensure splints are in place as ordered.

Results of the audits will be presented to the monthly QAPI meeting for review and recommendation.

483.25(d)(1)(2) REQUIREMENT Free of Accident Hazards/Supervision/Devices:

§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 facility policy review, clinical record review, and staff interview, it was determined that the facility failed to provide adequate supervision and interventions to prevent accidents for two of five residents at risk for accidents. (Residents 2, 100).

Findings include:

Clinical record review revealed that Resident 2 had diagnoses that included traumatic brain injury and history of falls. Review of Resident 2's care plan revealed he was at risk for falls with interventions for staff to provide music or YouTube videos and to provide a laptop to watch baseball games. On May 19, 2024, at 9:15 a.m. through 10:45 a.m., and 12:08 p.m. through 12:45 p.m., Resident 2 was observed in his wheelchair in the hallway with no music, videos, or laptop. On May 20, 2024, at 10:05 a.m. through 12:35 p.m., Resident 2 was again observed in his wheelchair in the hallway with no music, videos, or laptop.

In an interview on May 22, 2024, at 12:13 p.m., the Director of Nursing confirmed that staff should have provided music, YouTube videos, or a laptop to watch baseball games to Resident 2.

Clinical record review revealed that Resident 100 had diagnoses that included hemiparesis (paralysis) to the left side, dysphagia (difficulty swallowing), and pneumonitis (inflammation of lung) due to inhalation of food. On April 6, 2023, the physician ordered for staff to provide supervision during meals for aspiration precautions (guidelines to prevent food or liquid from entering the lungs). On May 19, 2024, at 12:26 p.m. through 12:58 p.m., Resident 100 was observed in bed eating lunch without supervision from staff. On May 20, 2024, at 12:05 p.m. through 12:36 p.m., Resident 100 was again observed in bed eating lunch without supervision from staff.

In an interview on May 22, 2024, at 9:58 a.m., the Director of Nursing confirmed that staff should have provided supervision of Resident 100 during meals.

CFR 483.25(d)(2) Accidents.
Previously cited 4/3/24

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

Plan of Correction - To be completed: 07/10/2024

F0689
SS=D

Resident 2's fall prevention interventions are put in place. Resident 100's aspiration precautions were put in place.

Care plans for fall prevention and aspiration precautions will be audited for all residents to ensure they are in place.

Staff will be educated regarding fall and aspiration precautions and to ensure appropriate interventions are in place.

The Director of Nursing or designee will complete a twice a week audit for 30 days, then a once a week audit for 60 days to ensure fall prevention and aspiration precaution contained in the clinical record are in place as documented.

Results of the audits will be presented to the monthly QAPI meeting for review and recommendation.

483.25(l) REQUIREMENT Dialysis:

§483.25(l) Dialysis.
The facility must ensure that residents who require dialysis receive such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences.

Observations:

Based on policy review, clinical record review, and staff interview, it was determined that the facility failed to provide services consistent with professional standards of practice for one of two residents who received dialysis. (Resident 39)

Findings include:

A review of the facility policy entitled, "Dialysis: Hemodialysis (HD) Provided by a Certified Dialysis Facility,"
last reviewed February 1, 2024, revealed that professional standards of practice included ongoing communication and collaboration with the dialysis facility regarding HD care and services. The care of the patient who received HD reflected ongoing communication, coordination, and collaboration between the center and dialysis staff. Communication included medication administration and changes, advanced directive and code status, and changes to functional status or falls.

Clinical record review revealed that Resident 39 had diagnoses that included hypertension, heart failure, and end stage renal disease. Review of the resident's dialysis communication forms revealed that the pre-treatment report, which included code status, medications administered prior to dialysis, vital signs, falls, and relevant changes since the last treatment, was to be completed by the facility nurse. Further review of the resident's dialysis communication forms from April and May 2024, revealed that the pre-treatment report section of the communication forms was incomplete on April 1, 3, 5, 8, 10, 12, 15, 17, 19, 24, 26, and 29, 2024, and May 1, 6, 3, 8, 10, 15, and 17, 2024.

In an interview on May 22, 2024, at 12:46 p.m., the Director of Nursing confirmed that the dialysis pre-treatment report was to be completed and was incomplete on those dates.

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

Plan of Correction - To be completed: 07/10/2024

F0698
SS=D

Resident 39's dialysis communication form will have the pre-treatment report section completed as required by nursing.

An audit will be conducted to ensure all dialysis patients in the center have the pre-treatment section of the dialysis communication forms completed.

Nursing staff will be re-educated on the required and proper completion of the pre-treatment section of the dialysis communication forms.

The Director of Nursing or designee will complete a twice a week audit for 30 days, then a once a week audit for 60 days to ensure all dialysis residents have complete pre-treatment sections of the dialysis communication forms.

Results of the audits will be presented to the monthly QAPI meeting for review and recommendation.

483.25(m) REQUIREMENT Trauma Informed Care:

§483.25(m) Trauma-informed care
The facility must ensure that residents who are trauma survivors receive culturally competent, trauma-informed care in accordance with professional standards of practice and accounting for residents' experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization of the resident.

Observations:

Based on clinical record review and staff interview, it was determined that the facility failed to develop and implement a individualized, person-centered plan to render trauma informed care to a resident with a diagnosis of post-traumatic stress disorder (PTSD) for one of 34 sampled residents. (Resident 84)

Findings include:

Clinical record review revealed that Resident 84 had diagnoses that included bipolar disorder, depression, anxiety, aphasia (impaired ability to understand or form language), and PTSD. Further review of the resident's clinical record revealed that there were no resident specific interventions to meet the resident's needs for minimizing triggers or preventing re-traumatization.

In an interview on May 22, 2024, at 11:51 a.m., the Director of Nursing confirmed the resident had a diagnoses of PTSD, and no individualized care plan was developed.

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

Plan of Correction - To be completed: 07/10/2024

F0699
SS=D

Resident 84's clinical records was updated to provide resident specific interventions to address triggers and prevent re-traumatization as a result of her PTSD diagnosis.

All residents records will be reviewed to ensure that residents with PTSD have individualized care plans in place.

Social Services and Professional Nurses will be re-educated in resident specific PTSD care plans to meet the resident's needs.

The Director of Nursing or designee will complete a twice a week audit for 30 days, then a once a week audit for 60 days to ensure any care needs regarding PTSD are addressed and care plans are updated as needed.

Results of the audits will be presented to the monthly QAPI meeting for review and recommendation.

483.45(c)(1)(2)(4)(5) REQUIREMENT Drug Regimen Review, Report Irregular, Act On:

§483.45(c) Drug Regimen Review.
§483.45(c)(1) The drug regimen of each resident must be reviewed at least once a month by a licensed pharmacist.

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

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

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

Observations:

Based on facility policy review, clinical record review, and staff interview, it was determined that the facility failed to ensure that pharmacy recommendations were acted upon by the physician for one of 34 sampled residents. (Resident 111)

Findings include:

A review of the facility policy entitled, "Medication Regimen Review," last reviewed February 1, 2024, revealed that the facility was to ensure that the attending physician, Medical Director, and Director of Nursing (DON) were provided with copies of the medication regimen reviews. The attending physician should document in the resident's record that an irregularity was reviewed and what, if any, action had been taken to address it. The attending physician should have addressed the consultant pharmacist's recommendation on their next scheduled visit to the facility to assess the resident, and no later than 60 days.

Clinical record review revealed that Resident 111 had diagnoses that included dementia and insomnia. On October 31, 2023, the physician ordered for staff to administer melatonin (a hormone that assisted with sleep) three milligrams (mg) with instructions to provide one mg by mouth once a day for insomnia. On February 22, 2024, the pharmacist noted that the dose of the melatonin was to be clarified by the physician. On May 3, 2024, the pharmacist again noted that the dose of the melatonin was to be clarified by the physician. There was no evidence that Resident 111's physician acknowledged or acted upon the pharmacist's recommendation.

In an interview on May 22, 2024, at 9:57 a.m., the Director of Nursing confirmed that the physician did not address the pharmacist's recommendation from February 22, 2024.

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

Plan of Correction - To be completed: 07/10/2024

F0756
SS=D

Resident 111's order for Melatonin was clarified by the physician.

All pharmacist recommendations from May 1, 2024 will be reviewed to ensure proper and timely follow up by the physician.

Professional Nurses will be re-educated to ensure they are addressing pharmacist recommendations are addressed and responded to by the attending physician.

The Director of Nursing or designee will complete a twice a week audit for 30 days, then a once a week audit for 60 days to ensure pharmacist recommendations are responded to timely by the physicians.

Results of the audits will be presented to the monthly QAPI meeting for review and recommendation.

483.60(d)(1)(2) REQUIREMENT Nutritive Value/Appear, Palatable/Prefer Temp:

Least serious deficiency but affects more than a limited number of residents, staff, or occurrences. This deficiency has the potential for causing no more than a minor negative impact on the resident but is not found to be throughout this facility.

§483.60(d) Food and drink
Each resident receives and the facility provides-

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

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

Observations:

Based on resident interview, review of facility documentation, observation, and results of a test tray audit, it was determined that the facility failed to provide food that was palatable and at acceptable temperatures on three of three nursing units. (Rehab, First floor, and Second floor nursing units)

Findings include:

During interviews on May 19, 2024, between 10:22 a.m. and 1:10 p.m., Residents 62, 88, and 144, stated that the food was often served cold.

In a group interview conducted on May 20, 2024, at 10:00 a.m., Residents 60, 120, 126, and 134, stated that the food was often served cold.

During interviews on May 20, 2024, between 11:00 a.m. and 12:45 p.m., Residents 20 and 66 stated that the food was often served cold.

Review of the facility's "Food and Nutrition Services Test Tray Evaluation," revealed that the temperature range of hot items should be greater than 140 degrees Fahrenheit (F).

A test tray conducted on May 21, 2024, at 12:07 p.m., revealed chicken at a temperature of 120 degrees F, rice at a temperature of 119 degrees F, and corn at a temperature of 118 degrees F.

In an interview on May 21, 2024, at 12:56 p.m. the Director of Dietary confirmed that the items did not maintain acceptable temperatures at the point of service.

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

Plan of Correction - To be completed: 07/10/2024

F0804
SS=D

Residents 20, 60, 62, 66, 88, 120, 126, 134, and 144 have been receiving their food in the required temperature range. Additional Pellets were ordered to ensure the center consistently has enough for all the beds in the center.

Test trays will be conducted by the Food Service Director or designee daily, three random test trays per day for 30 days to ensure that the food is received in the required temperature range at point of service.

Dietary and Nursing staff will be re-educated regarding the required food temperatures at point of service.

The Dietician or designee will complete a twice a week audit for 30 days, then a once a week audit for 60 days to ensure food temperatures are in the correct temperature range at point of service.

Results of the audits will be presented to the monthly QAPI meeting for review and recommendation.

§ 211.12(f.1)(2) LICENSURE Nursing services. :

(2) Effective July 1, 2023, a minimum of 1 nurse aide per 12 residents during the day, 1 nurse aide per 12 residents during the evening, and 1 nurse aide per 20 residents overnight.

Observations:
Based on a review of nursing time schedules, it was determined that the facility failed to meet the minimum nurse aide (NA) to resident ratios for 17 of 21 days reviewed.

Findings include:

Review of nursing time schedules from May 1 through 21, 2024, revealed the following:

The facility failed to meet the minimum ratio of one NA for 12 residents on evening (3:00 p.m. to 11:00 p.m.) shift on May 2, 3, 4, 5, 9, 10, 12, and 21, 2024.

The facility failed to meet the minimum ratio of one NA for 20 residents on the night (11:00 p.m. to 7:00 a.m.) shift on May 2, 4, 5, 7, 8, 9, 11, 12, 14, 15, 16, 17, 19, and 20, 2024.

Plan of Correction - To be completed: 07/10/2024

P5510

To Correct and ensure that this issue does not persist, steps have been put in place to remain in compliance with the state's staffing requirements.

Daily staffing meetings between the Scheduler, DON, and NHA are taking place to ensure that the staffing ratios for nurse aides (NA) of direct care for the residents follow the state's requirements.

Random audits will be conducted weekly x4 to ensure compliance.

The Scheduler/designee will report the results of the audits to the QAPI committee monthly.

§ 211.12(f.1)(4) LICENSURE Nursing services. :

(4) Effective July 1, 2023, a minimum of 1 LPN per 25 residents during the day, 1 LPN per 30 residents during the evening, and 1 LPN per 40 residents overnight.

Observations:
Based on a review of nursing time schedules, it was determined that the facility failed to meet the minimum licensed practical nurse (LPN) to resident ratios for 17 of 21 days reviewed.

Findings include:

Review of nursing time schedules from May 1 through 21, 2024, revealed the following:

The facility failed to meet the minimum LPN to resident ratio of one LPN for 25 residents on the day (7:00 a.m. to 3:00 p.m.) shift on May 1 and 12, 2024.

The facility failed to meet the minimum LPN to resident ratio of one LPN for 30 residents on the evening (3:00 p.m. to 11:00 p.m.) shift on May 3, 4, 5, 7, 9, 10, 12, 13, 14, 17, 19, and 20, 2024.

The facility failed to meet the minimum LPN to resident ratio of one LPN for 40 residents on the night (11:00 p.m. to 7:00 a.m.) shift on May 1, 2, 4, 5, 6, 7, 8, 9, 10, 12, 14, 17, 18, and 20, 2024.

Plan of Correction - To be completed: 07/10/2024

P5530

To Correct and ensure that this issue does not persist, steps have been put in place to remain in compliance with the state's staffing requirements.

Daily staffing meetings between the Scheduler, DON, and NHA are taking place to ensure that the staffing ratios for licensed practical nurse (LPN) of direct care for the residents follow the state's requirements.

Random audits will be conducted weekly x4 to ensure compliance.

The Scheduler/designee will report the results of the audits to the QAPI committee monthly.

§ 211.12(i)(1) LICENSURE Nursing services.:

(1) Effective July 1, 2023, the total number of hours of general nursing care provided in each 24-hour period shall, when totaled for the entire facility, be a minimum of 2.87 hours of direct resident care for each resident.

Observations:
Based on a review of nursing time schedules, it was determined that the facility failed to provide a minimum of 2.87 hours of direct care for each resident for four of 21 days reviewed.

Findings include:

Review of nursing time schedules from May 1 through 21, 2024, revealed the following total nursing care hours below minimum requirements:

May 4, 2024: 2.66 care hours per resident.
May 5, 2024: 2.51 care hours per resident.
May 12, 2024: 2.38 care hours per resident.
May 19, 2024: 2.84 care hours per resident.

Plan of Correction - To be completed: 07/10/2024

P5630

To Correct and ensure that this issue does not persist, steps have been put in place to remain in compliance with the state's staffing requirements.

Daily staffing meetings between the Scheduler, DON, and NHA are taking place to ensure that the minimum hours (HPPD) of direct care for the residents follow the state's requirements.

Random audits will be conducted weekly x4 to ensure compliance.

The Scheduler/designee will report the results of the audits to the QAPI committee monthly.

Back to County Map

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

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