Nursing Investigation Results -

Pennsylvania Department of Health
OAKMONT CENTER FOR NURSING & REHABILITATION
Patient Care Inspection Results

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
OAKMONT CENTER FOR NURSING & REHABILITATION
Inspection Results For:

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OAKMONT CENTER FOR NURSING & REHABILITATION - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:
Based on a Medicare/Medicaid Recertification Survey, Civil Rights Compliance Survey, State Licensure Survey and an Abbreviated survey in response to a complaint, completed on November 27,2019, it was determined that Oakmont Center for Nursing and Rehabilitation, was not in compliance with the requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care Facilities and the 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.


 Plan of Correction:


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

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

483.60(i)(2) - Store, prepare, distribute and serve food in accordance with professional standards for food service safety.
Observations:
Based on observations and staff interview, it was determined that the facility failed to perform hand washing between tasks to prevent the potential for cross contamination and failed to restrain hair in the main kitchen.

Findings include:

During an observation of the main kitchen on 11/26/19, from 11:30 a.m. through 12:10 p.m. the following was observed:

Dietary Aides Employee E4 and E5 did not have hair restrained and were walking throughout the kitchen area.

Cook Employee E6's hair restraint was only covering the back her head.

Certified Dietary Manager(CDM) Employee E7 entered the kitchen from the dining room, walked through the kitchen past the tray line service to get a hair restraint.

Cook Employee E8 was pulling bread from bag with gloved hands and placing it into baggies with the same gloved hands without hand washing and glove change.

Two facility staff entered the kitchen area throughout tray line service to get items from kitchen staff with no hair restraints.

During an interview on 11/26/19, at 12:15 p.m. CDM Employee E7 confirmed that the facility food service staff failed to perform hand washing and glove change and failed to restrain hair in the main kitchen causing the potential for cross contamination.

28 Pa. Code: 211.6(c)(d)(f) Dietary services.


 Plan of Correction - To be completed: 01/16/2020

Employees immediately donned hair restraints. The bread was disposed of and a fresh loaf was obtained.

Hair restraints were made available at each entry to the kitchen. Hand-washing competencies were completed on dietary staff.

Dietary staff were re-educated by the CDM on hair sanitation and hand-washing.

The CDM/designee will perform audits of the use of hair restraints and random hand-washing opportunities weekly X 4 weeks then monthly X 2 months with results reviewed at the monthly facility QAPI meeting. Any discrepancies will be corrected immediately.
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 review of facility policy, observation, and staff interview, it was determined that the facility failed to maintain proper infection control practices in the laundry room.

Findings include:

Review of the facility policy "Linens" last reviewed on 5/15/19, indicated that the facility staff should place all contaminated laundry in bags or containers to prevent contaminated items from touching clothes.

During an observation of the laundry facilities on 11/25/19, at 9:36 a.m. two large bins of soiled personal items and four large piles of soiled linens observed on the floor.

During an interview on 11/25/19, at 9:26 a.m. Housekeeper Employee E1 confirmed that linens should not be on the floor and that the facility failed to maintain infection control practices in the laundry room.

28 Pa. Code: 205.26(a)(b)(c)(d) Laundry.

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


 Plan of Correction - To be completed: 01/16/2020

The laundry was removed from the floor and placed in bins.

Bins are made available in the dirty utility rooms for soiled linens to be placed in.

Laundry staff will be re-educated on the linens policy and infection control practices for soiled linens by the administrator/designee.

Audits monitoring infection control practices will be completed by the laundry manager/designee weekly x 4 weeks then monthly x 2 months with results reviewed at the monthly facility QAPI meeting. Any discrepancies will be corrected immediately.
483.10(f)(5)(i)-(iv)(6)(7) REQUIREMENT Resident/Family Group and Response: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(f)(5) The resident has a right to organize and participate in resident groups in the facility.
(i) The facility must provide a resident or family group, if one exists, with private space; and take reasonable steps, with the approval of the group, to make residents and family members aware of upcoming meetings in a timely manner.
(ii) Staff, visitors, or other guests may attend resident group or family group meetings only at the respective group's invitation.
(iii) The facility must provide a designated staff person who is approved by the resident or family group and the facility and who is responsible for providing assistance and responding to written requests that result from group meetings.
(iv) The facility must consider the views of a resident or family group and act promptly upon the grievances and recommendations of such groups concerning issues of resident care and life in the facility.
(A) The facility must be able to demonstrate their response and rationale for such response.
(B) This should not be construed to mean that the facility must implement as recommended every request of the resident or family group.

483.10(f)(6) The resident has a right to participate in family groups.

483.10(f)(7) The resident has a right to have family member(s) or other resident representative(s) meet in the facility with the families or resident representative(s) of other residents in the facility.
Observations:
Based on a review of resident council meeting minutes and resident and staff interview, it was determined that the facility failed to demonstrate a response to grievances for resident council for 6 of 12 months (May 2019, June 2019, July 2019, August 2019, September 2019, and October 2019).

Findings include:

Review of the facility Resient Council Minutes dated May 2019 through October 2019, resident concerns related to staff answering call bells and telling residents "I'm not your aide", staff not getting resident's out of bed in time for morning activities, staff use of cell phones while providing care, personal clothes not available for residents, and staff having "attitudes", did not include a resolution of the above concerns by the facility.

During an interview on 11/27/19, at 2:30 p.m. the Nursing Home Administrator confirmed that the facility failed to follow up with Resident Council concerns and respond to their grievances timely.

28 Pa. Code: 201.18(e)(4) Management.


 Plan of Correction - To be completed: 01/16/2020

The facility has reviewed the identified months and reviewed and addressed all concerns. A follow-up discussion with the residents will occur at the next scheduled resident council meeting.

The Facility has scheduled a resident council meeting to specifically review the follow-up procedure and concerns with the attending residents on 12/30/2019.

The department managers responsible for resolving resident concerns will be re-educated by the administrator/designee on the process with resolution expected within 5 days of receipt. The NHA will sign off on completed grievances. A copy of all resident concerns will be provided to the Social Services Director immediately following each resident council meeting.

The Social Services Director or designee will perform auditing of all complaint resolutions weekly X 4 weeks then monthly X 2 months with results of the auditing presented in the facility QAPI monthly meeting. Any noted discrepancies will be corrected immediately.
483.10(h)(1)-(3)(i)(ii) REQUIREMENT Personal Privacy/Confidentiality of Records:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.10(h) Privacy and Confidentiality.
The resident has a right to personal privacy and confidentiality of his or her personal and medical records.

483.10(h)(l) Personal privacy includes accommodations, medical treatment, written and telephone communications, personal care, visits, and meetings of family and resident groups, but this does not require the facility to provide a private room for each resident.

483.10(h)(2) The facility must respect the residents right to personal privacy, including the right to privacy in his or her oral (that is, spoken), written, and electronic communications, including the right to send and promptly receive unopened mail and other letters, packages and other materials delivered to the facility for the resident, including those delivered through a means other than a postal service.

483.10(h)(3) The resident has a right to secure and confidential personal and medical records.
(i) The resident has the right to refuse the release of personal and medical records except as provided at 483.70(i)(2) or other applicable federal or state laws.
(ii) The facility must allow representatives of the Office of the State Long-Term Care Ombudsman to examine a resident's medical, social, and administrative records in accordance with State law.
Observations:
Based on observation and staff interview, it was determined that the facility failed to maintain the personal privacy of one of two residents (Resident R20).

Findings include:

During an observation on 11/25/19, at 9:22 a.m. Resident R20 was observed in the dining area with an uncovered foley bag in view of any passerby.

During an interview on 11/25/19, at 9:22 a.m. Nurse Aide Employee E9 confirmed that the resident's personal privacy was not maintained.

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


 Plan of Correction - To be completed: 01/16/2020

Residents requiring indwelling or suprapubic catheters were audited and provided with dignity covers for their collection bags if identified as not having one.

New orders are reviewed during enhanced start-up. Orders for indwelling or suprapubic catheters will be noted and supervisor will ensure the dignity bag has been provided.

Clinical staff will be re-educated on dignity and the process for keeping collection bags covered by the Director of Staff Development/designee.

The DON/designee will complete an audit of collection bags weekly x 4 then monthly x 2 to ensure compliance with results presented at the facility monthly QAPI meeting. Any discrepancies will be corrected immediately.

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

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

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

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

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

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

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

483.10(i)(7) For the maintenance of comfortable sound levels.
Observations:
Based on observations and a staff interview, it was determined that the facility failed to maintain a homelike environment on one of two nursing units (First floor nursing unit).

Findings include:

During an observation on 11/25/19, at 11:08 a.m. the first floor nursing unit flooring had areas of uneven flooring tiles and gouges in the flooring. Resident room 112 had clear tape covering the edges of the window in an attempt to keep cold air out, and the wall and ceiling in the spa room had bubbled paint that was chipping.

During an interview on 11/27/19, at 9:37 a.m. Maintenance Director Employee E2 confirmed that the floor needing repair and the window had tape covering the edges and that the spa room wall and ceiling was in need of repair.

28 Pa. Code: 207.1(a) Administrator's responsibility.



 Plan of Correction - To be completed: 01/16/2020

The observed Floors, ceilings and windows were evaluated for needed repairs and identified needs were corrected. The tape on the window was removed. The remainder of the facility windows were checked with corrections made where necessary.

The facility will include the condition of the ceilings, floors, and windows in the non-clinical round process, which is completed by the department managers.

The maintenance director and assistant will be educated on the policy for floor, ceiling, and window repair by the administrator/designee.

Audits will be completed by the administrator designee of needed repairs and their timely completion weekly x 4 weeks and monthly x 2 months with results presented at the facility monthly QAPI meeting. Any discrepancies will be corrected immediately.
483.21(a)(1)-(3) REQUIREMENT Baseline Care Plan:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.21 Comprehensive Person-Centered Care Planning
483.21(a) Baseline Care Plans
483.21(a)(1) The facility must develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. The baseline care plan must-
(i) Be developed within 48 hours of a resident's admission.
(ii) Include the minimum healthcare information necessary to properly care for a resident including, but not limited to-
(A) Initial goals based on admission orders.
(B) Physician orders.
(C) Dietary orders.
(D) Therapy services.
(E) Social services.
(F) PASARR recommendation, if applicable.

483.21(a)(2) The facility may develop a comprehensive care plan in place of the baseline care plan if the comprehensive care plan-
(i) Is developed within 48 hours of the resident's admission.
(ii) Meets the requirements set forth in paragraph (b) of this section (excepting paragraph (b)(2)(i) of this section).

483.21(a)(3) The facility must provide the resident and their representative with a summary of the baseline care plan that includes but is not limited to:
(i) The initial goals of the resident.
(ii) A summary of the resident's medications and dietary instructions.
(iii) Any services and treatments to be administered by the facility and personnel acting on behalf of the facility.
(iv) Any updated information based on the details of the comprehensive care plan, as necessary.
Observations:
Based on review of facility policy, clinical record review and staff interviews, it was determined that the facility failed to develop an initial baseline care plan that included instructions to provide person centered care for two of 24 residents (Resident R41 and R215).

Findings include:

Review of the facility policy "Care Plans - Preliminary" dated 5/15/19, indicated that the a plan of care to meet the resident's immediate needs will be developed within 24 hours of admission.

Review of the admission record indicated Resident R41 was readmitted to the facility on 10/29/19, with diagnoses that included chronic respiratory failure, high blood pressure, diabetes, and heart failure.

Review of wound documentation dated 10/30/19, indicated that Resident R41 had Stage II pressure ulcer (involve partial thickness skin loss) on her coccyx (final segment of the spinal column, tailbone).

Review of the clinical record failed to reveal a baseline care plan updated for Resident R41's readmission.

Review of the admission record indicated Resident R215 was admitted to the facility on 11/19/19, with diagnoses that included infected amputation of left lower stump, diabetes, and high blood pressure.

During an observation on 11/25/19, at 9:27 a.m. Resient R215 was noted to have a PICC (a form of intravenous access that can be used for a prolonged period of time) and a foley catheter.

Review of the clinical record failed to reveal a baseline care plan was developed for any needs.

During an interview on 11/27/19, at 12:45 p.m. the Director of Nursing confirmed the facility failed to complete an updated 48 hour baseline care plan for Resident R41's readmission, and failed to complete a base line care plan for Resident R215.

28 Pa. Code 211.11(d) Resident care plan.


 Plan of Correction - To be completed: 01/16/2020

The residents identified currently have a comprehensive care plan and completion of a baseline care plan is not currently indicated.

New admissions will be reviewed at enhanced start-up and the baseline care plan will be checked for completion.

Licensed nursing staff will be re-educated on the process of initiating baseline care plans by the DON/designee.

Audits of baseline care plan completion will be performed by the DON/designee to ensure compliance weekly x 4 weeks then monthly x 2 months with results reviewed at the monthly facility QAPI meeting. Any discrepancies will be corrected immediately.
483.21(b)(1) REQUIREMENT Develop/Implement Comprehensive Care Plan:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.21(b) Comprehensive Care Plans
483.21(b)(1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at 483.10(c)(2) and 483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following -
(i) The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under 483.24, 483.25 or 483.40; and
(ii) Any services that would otherwise be required under 483.24, 483.25 or 483.40 but are not provided due to the resident's exercise of rights under 483.10, including the right to refuse treatment under 483.10(c)(6).
(iii) Any specialized services or specialized rehabilitative services the nursing facility will provide as a result of PASARR recommendations. If a facility disagrees with the findings of the PASARR, it must indicate its rationale in the resident's medical record.
(iv)In consultation with the resident and the resident's representative(s)-
(A) The resident's goals for admission and desired outcomes.
(B) The resident's preference and potential for future discharge. Facilities must document whether the resident's desire to return to the community was assessed and any referrals to local contact agencies and/or other appropriate entities, for this purpose.
(C) Discharge plans in the comprehensive care plan, as appropriate, in accordance with the requirements set forth in paragraph (c) of this section.
Observations:
Based on review of facility policies and clinical records and staff interviews, it was determined that the facility failed to develop a comprehensive care plan for one of 24 residents (Resident R46).

Findings include:

Review of the facility policy "Care Plan - Comprehensive" dated 5/15/19, indicated that a care plan that will include measurable objectives and timetables to meet the resident's medical, nursing, mental and psychosocial needs is developed for each resident.

The clinical record indicated that Resident R46 was admitted to the facility 7/15/19, with diagnoses that included atrial fibrillation (a type of heart rhythm disorder), Parkinson's disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movement), muscle weakness, and difficulty walking.

Review of the facility document "Braden Scale for Predicting Pressure Ulcer", dated 7/15/19, indicated that Resident R46 was at high risk for the development of pressure ulcers.

Review of the facility provided pressure ulcer list on 11/15/19, indicated that Resident R46 developed a left ischial (left, lower and back part of the hip bone) pressure ulcer on 10/28/19.

Review of Resident R46's plan of care revealed no care plan was developed to address Resident R46's pressure ulcer.

During an interview on 11/27/19, at 1:42 p.m. the DON confirmed that facility staff failed to develop care plans for Resident R46's pressure ulcer.

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


 Plan of Correction - To be completed: 01/16/2020

Resident R46 had a care plan initiated for the care of his acquired pressure ulcer, as well as an updated Braden assessment.

A house audit of comprehensive care plans will be completed with corrections made where indicated. New orders will be reviewed at enhanced start-up with care plans checked for accuracy.

Licensed nursing staff will be re- educated on the process of identifying resident problems, identifying appropriate interventions, and incorporating the identified interventions into the care plan by the DON/designee.

The DON/designee will complete auditing of new orders and the required interventions the resident may require weekly x 4 weeks then monthly x 2 months to ensure compliance with results reviewed at the monthly facility QAPI meeting. Any discrepancies will be corrected immediately.
483.35(d)(7) REQUIREMENT Nurse Aide Peform Review-12 hr/yr In-Service:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.35(d)(7) Regular in-service education.
The facility must complete a performance review of every nurse aide at least once every 12 months, and must provide regular in-service education based on the outcome of these reviews. In-service training must comply with the requirements of 483.95(g).
Observations:
Based on review of staff education records and staff interviews, it was determined that the facility failed to conduct at least 12 hours of in-service education, within 12 months of their hire date anniversary for nurse aides as required for five of five nurse aides (Employee E14, E15, E16, E17, and E18).

Finding include:

Review of Nurse Aide (NA) Employees E14, E15, E16, E17, and E18's education records with hire date greater than 12 months revealed the following:

NA Employee E14 had a hire date of 11/7/12, with 5.75 hours in-service education between 11/7/18, and 11/7/19.

NA Employee E15 had a hire date of 11/9/15, with 3.25 hours in-service education between 11/9/18, and 11/9/19.

NA Employee E16 had a hire date of 11/9/15, with 6.50 hours in-service education between 11/9/18, and 11/9/19.

NA Employee E17 had a hire date of 10/11/16, with 4.50 hours in-service education between 10/11/18, and 10/11/19.

NA Employee E18 had a hire date of 6/8/17, with 2.50 hours in-service education between 6/8/18, and 6/8/19.

During an interview on 11/25/19, at 1:41 p.m. the Director of Staff Development Employee E19 confirmed that the facility failed to provide the required 12 hours annual in-service education within 12 months of their hire date anniversary for NA Employee E14, E15, E16, E17, and E18.

28 Pa. Code: 201.14(a) Responsibility of Licensee.

28 Pa. Code: 201.20(c) Staff Development.


 Plan of Correction - To be completed: 01/16/2020

Nurse aide educational files were reviewed to identify the completed hours of education for this year, with additional education provided to those who received less than 12 hours. Baseline performance reviews will be completed on the employees.

Employees will receive an annual performance review during the month of their hire date anniversary and tracked by the Director of Staff Development/designee. Annual in-service training will be completed at the time of the review. In addition, mandatory monthly in-service training will be provided by the Director of Staff Development/designee with options for make-up dates for those who do not attend.

Re-Education on the required education elements for nurse aides will be provided to the Director of Staff Development by the DON/designee.

The Director of Nursing/designee will perform audits of the performance reviews and required education weekly x 4 then monthly x 2 to ensure compliance with results reviewed at the monthly facility QAPI meeting. Any discrepancies will be corrected immediately.


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

483.45(h) Storage of Drugs and Biologicals

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

483.45(h)(2) The facility must provide separately locked, permanently affixed compartments for storage of controlled drugs listed in Schedule II of the Comprehensive Drug Abuse Prevention and Control Act of 1976 and other drugs subject to abuse, except when the facility uses single unit package drug distribution systems in which the quantity stored is minimal and a missing dose can be readily detected.
Observations:
Based on review of facility policy, observation and staff interviews, it was determined that the facility failed to date all opened multi-dose vials and failed to return outdated medication to the pharmacy in one of three medication rooms (First floor medication room) and one of four medication carts (Wing C Medication Cart).

Findings include:

Review of the facility policy "Storage of Medications" dated 5/15/19, indicated that the facility shall not use discontinued, outdated, or deteriorated drugs or biologicals. They are to be returned to the pharmacy or destroyed.

During an observation on 11/25/19, at 10:00 a.m. of the first floor medication room, a vial of Tuberculin (injectable solution used to test for TB for residents and employees) had a inaccurate expiration date of 11/20 and a tube of Lidocaine cream indicated the name of a discharged resident with an expired date of 8/22/18.

During an interview on 11/25/19, at 10:07 a.m. Registered Nurse Employee E3 confirmed that the facility failed to date opened TB solution.

During an observation on 11/26/19, at 8:57 a.m., of the Wing C medication cart, one vial of Alphagan anti-glaucoma eye drops with an open date of 10/09/19, and use by date of 11/06/19, and one via or Timolol anti-glaucoma eye drops with an open date of the 10/09/19, and a use by date of 11/07/19, for Resident 56, remained in the cart.

During an interview on 11/26/19, at 9:03 a.m., Licensed Practical Nurse Employee E22, confirmed that the facility failed to dispose of the eye drop medications timely.

28 Pa. Code: 211.9(a)(1)(2)(g)(h)(k) Pharmacy services.


 Plan of Correction - To be completed: 01/16/2020

The facility immediately removed the identified medication upon notification from the supply and replaced where appropriate.

The facility conducted an audit of the facility medication carts and medication storage areas to ensure the appropriate labeling/dating of opened medication. Any identified discrepancies were corrected.

Licensed nurses were re-educated on the facility policy for labeling/storage of medication by the DON/designee.

The DON/designee will perform audits of the facility medication carts and medication storage areas for proper labeling/storage of medications weekly X 4 weeks then monthly X 2 months with results reviewed at the monthly facility QAPI meeting. Any discrepancies will be corrected immediately.
201.19 LICENSURE Personnel policies and procedures.:State only Deficiency.
Personnel records shall be kept current and available for each employe and contain sufficient information to support placement in the position to which assigned.
Observations:
Based on review of employee personnel records it was determined that the facility failed to maintain required information of a start date, criminal background check, signed job description, proof of current abuse training, verification of employee health, and orientation to the facility for four of five records (Employee E10, E11, E12, and E13).

Findings include:

Review of the personnel record indicated that Employee E10 began work at the facility on 6/9/19. Employee E10's personnel record did not include a signed job description or an orientation to the facility.

Review of the personnel record indicated that Employee E11 began work at the facility on 6/28/19. Employee E11's personnel record did not include a signed job description, proof of current abuse training, or current verification of employee health status signed by a physician or qualified practitioner.

Review of the personnel record indicated that Employee E12 began work at the facility on 9/18/19. Employee E12's personnel record did not include a signed job description or proof of current abuse training.

The facility was unable to provide a personnel record for Employee E13 that included a start date, criminal background check, signed job description, proof of current abuse training, verification of employee health, or orientation to the facility.

During an interview on 11/27/19, at 12:30 p.m. the Director of Human Resources Employee E20 confirmed that the facility failed to maintain required information for Employee E10, E11, E12, and E13.


 Plan of Correction - To be completed: 01/16/2020

Employee files were reviewed for missing information and education with corrections completed where indicated.

An employee file checklist will be instituted and employee files will be presented to the administrator/designee prior to an employee entering the onboarding process for review and approval.

HR Director will be re-educated by the administrator/designee on the employee file requirements and double check process.

Audits of new employee files will be completed on new hires by the administrator/designee weekly x 4 weeks then monthly x 2 months with results reviewed at the monthly facility QAPI meeting. Any discrepancies will be corrected immediately.
201.20(c) LICENSURE Staff development.:State only Deficiency.
(c) There shall be at least annual inservice training which includes at least infection prevention and control, fire prevention and safety, accident prevention, disaster preparedness, resident confidential information, resident psychosocial needs, restorative nursing techniques and resident rights, including personal property rights, privacy, preservation of dignity and the prevention and reporting of resident abuse.
Observations:
Based on review of staff education records and staff interviews, it was determined that the facility failed to conduct required areas of in-service education, within 12 months of their hire date anniversary, for nurse aides as required for five of five nurse aides (Employees E14, E15, E16, E17, and E18.).

Finding include:

Review of Nurse Aide (NA) Employees E14, E15, E16, E17, and E18's education records with hire date greater than 12 months revealed the following:

NA Employee E14 had a hire date of 11/7/12, did not receive annual training in infection control, fire safety, accident prevention, disaster preparedness, abuse and neglect, psychosocial needs, and resident rights, during the period of 11/7/18, through 11/7/19.

NA Employee E15 had a hire date of 11/9/15, did not receive annual training in infection control, fire safety, accident prevention, disaster preparedness, resident confidentiality, restorative nursing techniques, psychosocial needs, and resident rights, during the period of 11/9/18, through 11/9/19.

NA Employee E16 had a hire date of 11/9/15, did not receive annual training in infection control, fire safety, accident prevention, disaster preparedness, psychosocial needs, and resident rights, during the period of of 11/9/18, through 11/9/19.

NA Employee E17 had a hire date of 10/11/16, did not receive annual training in infection control, fire safety, accident prevention, disaster preparedness, abuse and neglect, psychosocial needs, restorative nursing techniques, and resident rights, during the period of 10/11/18, through 10/11/19.

NA Employee E18 had a hire date of 6/8/17, did not receive annual training in infection control, fire safety, accident prevention, abuse and neglect, resident confidentiality, psychosocial needs, restorative nursing techniques, and resident rights, during the period of of 6/8/18, through 6/8/19.

During an interview on 11/25/19, at 1:41 p.m. the Director of Staff Development Employee E19 confirmed that the facility failed to provide the required annual in-service education for NA Employee E14, E15, E16, E17, and E18.


 Plan of Correction - To be completed: 01/16/2020

Employee files were reviewed and missing education was completed.

Employees will complete annual in-service training during the month of their anniversary date as well as monthly mandatory in-service training to total a minimum of 12 additional hours of education annually with make-up dates provided to those unable to attend. This will be tracked by the Director of Staff Development.

The Director of Staff Development will be re-educated by the DON/designee on the state requirements for mandatory nurse aide training.

Audits of employee annual training will be completed by the DON/designee weekly x 4 weeks then monthly x 2 months with results reviewed at the monthly facility QAPI meeting. Any discrepancies will be corrected immediately.
201.22(j) LICENSURE Prevention, control and surveillance of TB.:State only Deficiency.
(j) New employes shall have the 2-step intradermal skin test before beginning employment unless there is documentation of a previous positive skin reaction. Test results shall be made available prior to assumption of job responsibilities. CDC guidelines shall be followed with regard to repeat periodic testing of all employes.
Observations:
Based on a review of facility records and staff interview, it was determined that the facility failed to make certain that new employees had a two step tuberculin skin test (a test conducted for surveillance of tuberculosis) before beginning of employment for three of five new employees (Employee E11, E12, and E13).

Findings include:

Review of the employee record for Licensed Practical Nurse Employee E11 with a start date of 6/28/19, did not include documentation that a two step tuberculin skin test was completed.

Review of the employee record for Environmental Services Worker Employee E12 with a start date of 9/18/19, did not include documentation that a two step tuberculin skin test was completed.

The facility was unable to provide an employee personnel file that included a tuberculin skin test for Employee E13.

During an interview on 11/27/19, at 12:30 p.m. the Director of Human Resources Employee E20 that the facility failed to perform two step intradermal skin testing for Employee E11, E12, and E13 before beginning employment.


 Plan of Correction - To be completed: 01/16/2020

Employee files were reviewed for missing PPD records and corrected. None of the employees were missing the PPD testing.

Employees will be required to have 2-step PPD testing completed and documented in their file prior to beginning the onboarding process. This testing will be included on the employee file checklist.

The Human Resources Director will be re- educated on the state requirement for PPD testing of new employees by the administrator/designee.

Audits of new employee PPD testing will be completed by the administrator/designee weekly x 4 weeks then monthly x 2 months with results reviewed at the monthly facility QAPI meeting. Any discrepancies will be corrected immediately.
209.8(b) LICENSURE Fire Drills.:State only Deficiency.
(b) A written report shall be maintained of each fire drill which includes date, time required for evacuation or relocation, number of residents evacuated or moved to another location and number of personnel participating in a fire drill.
Observations:
Based on review of facility records and staff interview, it was determined that the facility failed to maintain a written record of fire drills as required for the number of residents relocated for ten of twelve months, and the time required for relocation for ten of twelve months (January 2019 through October 2019).

Findings include:

A review of the facility monthly fire drills dated 1/26/19, 2/6/19, 3/16/19, 4/23/19, 5/22/19, 6/10/19, 7/17/19, 8/2/19 9/4/19, 10/14/19 did not reveal documentation of the number of residents moved to another location and the required time for evacuation or relocation.

During an interview on 11/27/19 at 9:33 a.m., the Maintenance Director Employee E2 confirmed that facility failed to maintain written reports of fire drills as required, including the number of residents relocated and the time needed for relocation for ten of twelve months.


 Plan of Correction - To be completed: 01/16/2020

The written records of fire drills are now closed and filed as they stand.

Future fire drills will contain documentation of the number of residents moved to another location as well as the length of time to complete the drill.

The Maintenance Director and assistant will be re- educated on the state fire drill documentation requirements by the administrator/designee.

Audits of fire drill records will be completed by the administrator/designee each month for 3 months with results reviewed at the monthly facility QAPI meeting. Any discrepancies will be corrected immediately.

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