Pennsylvania Department of Health
PARAMOUNT NURSING AND REHABILITATION AT FAYETTEVILLE, LLC
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

PARAMOUNT NURSING AND REHABILITATION AT FAYETTEVILLE, LLC
Inspection Results For:

There are 83 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.


PARAMOUNT NURSING AND REHABILITATION AT FAYETTEVILLE, LLC - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:

Based on a Medicare/Medicaid Recertification, State Licensure and Civil Rights survey completed on July 3, 3024, it was determined that Paramount Nursing and Rehab at Fayetteville, LLC was not in compliance with the following 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:

483.10(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 81°F; and

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

Observations:

Based on observations and staff interviews, it was determined that the facility failed to maintain a safe, clean, and home-like environment for two of 20 residents observed (Residents 35 and 54).

Findings include:

Observations of Resident 35's room on July 1, 2024, at 9:59 AM, and July 2, 2024, at 11:51 AM, revealed a pedestal fan with gray fuzzy debris on the blades and blowing from the front of the fan.

Observations of Resident 54's room on July 1, 2024, at 11:18 AM, and July 2, 2024, at 11:52 AM, revealed a small fan sitting on a nightstand with gray fuzzy debris on the blades and blowing from the front of the fan.

In an email communication received from the Nursing Home Administrator (NHA) on July 3, 2024, at 9:08 AM, the NHA revealed that the facility did not have a policy on the cleaning of fans. She further indicated that she had spoken to the housekeeping manager and that the cleaning of fans had now been added to the monthly resident room deep clean list. She also indicated that the housekeeping staff had cleaned all facility fans.

In an interview with the NHA on July 3, 2024, at 10:54 AM, the NHA indicated that housekeeping staff was wiping down the outside of the fans and confirmed that they had no process for disassembling the fans and cleaning the blades of any debris before July 2, 2024.

28 Pa. Code 201.14(a) Responsibility of licensee.
28 Pa. Code 201.18(b)(1)(3) Management.

Plan of Correction - To be completed: 08/23/2024

All fans in resident's rooms were cleaned by the housekeeping staff on 7/3/24. The Housekeeping Manager educated all housekeepers on fans being added to the deep clean monthly room list for housekeeping to dust and clean the blades by disassembling the fans and step by step instructions on how to clean a fan were provided. The housekeeping staff will clean facility fans during the monthly terminal cleaning of the resident room. This will be documented on the monthly resident room terminal log. The Housekeeping Manager will audit the terminal cleaning logs monthly for 2 months to ensure that the fans have been adequately cleaned. Any fans that the housekeeping staff can't adequately clean a Maintenance work order will be completed to have the fans cleaned by Maintenance. The results of the terminal cleaning audit of all resident room fans will be reported at the monthly QAPI meeting and reviewed by the Committee.

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

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

Observations:

Based on observations, clinical record review, and staff interviews, it was determined that the facility failed to provide care and services to promote healing and prevent worsening of pressure ulcers for one of two residents reviewed for pressure ulcers (Resident 56).

Findings include:

Review of Resident 56's clinical record revealed diagnoses that included stage 4 pressure ulcer of the right heel (wound that occurs when the skin and tissue are damaged by prolonged pressure), type 2 diabetes mellitus with foot ulcer (a metabolic disorder in which the body has high sugar levels for prolonged periods of time leading to breakdown of skin and sometimes deeper tissues), and hypertension (high blood pressure).

Review of Resident 56's physician orders revealed an order for "Heels up when in bed", with a start date of March 29, 2024.

Further review of Resident 56's physician orders revealed an order for "Offloading boot to be worn in bed to RLE" (right lower extremity), with a start date of April 2, 2024.

Review of Resident 56's weekly wound consultation notes revealed recommendations from the wound physician initiated April 8, 2024, for "Float heels while in bed, limit sitting for 60 minutes, bed cradle to keep weight of blankets off toes, elevate legs."

Further review of all weekly wound consultation notes from April 8, 2024, to present revealed "The clinical documentation for this consultation was made available to the referring physician. This documentation has also been made available for access to the appropriate personnel and placement in the medical record."

Observations of Resident 56 in her room on July 1, 2024, at 10:35 AM, 11:18 AM, and 12:22 PM, revealed both of her feet were exposed and laying directly on her mattress.

During an interview with the Director of Nursing (DON) on July 2, 2024, at 1:56 PM, the surveyor revealed the observations of Resident 56 in bed without elevated heels, no offloading boot to RLE, and no bed cradle.

During a follow-up interview with the DON on July 3, 2024, at 12:59 PM, he revealed the bed cradle was implemented that morning. He further revealed the process for communicating wound physician recommendations is the facility wound nurse will communicate any recommendations from the wound physician to the facility physician to review and order, unless he disagrees. Further, he could not find any documentation to indicate the physician disagreed with the weekly recommendation for the bed cradle, dating back to April 8, 2024.

During an interview with the Nursing Home Administrator on July 3, 2024, at 1:01 PM, she revealed she was unable to locate documentation to indicate Resident 56 had refused her heels up or offloading boot at the time of surveyor observations.

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

Plan of Correction - To be completed: 08/23/2024

Wound offloading orders clarified for Resident 56 with facility provider by DON and clarification orders received to discontinue RLE foam boot and continue heels up device. Heels up device present and verified in use by DON. Education completed by DON with resident 56 regarding importance of offloading heels to prevent further skin breakdown of bony prominence as well as residents right to refuse. Resident Foot cradle recommendations reviewed with provider, order entered per recommendation and foot cradle equipped to bed by facility staff. Education provided to wound nurse on processing wound physician recommendations. The DON completed an audit of all residents with pressure relief device orders to ensure devices in place and being utilized properly per order. The DON completed an audit of All recommendations received from Wound Physician during wound rounds on 7/8/2024 to ensure all recommendations were processed correctly. Education of ALL nursing staff regarding the importance of ensuring proper usage of ordered pressure relief devices during nursing staff meetings on 7/24 and 7/25/24. Education of ALL licensed staff on proper procedure for processing consultation orders at licensed staff meeting on 7/25/24. DON and/or designee will complete audit of proper usage of ALL residents with pressure relief devices 2 x per week on varying days for 4 weeks. DON and/or designee will complete audit of ALL wound physician recommendations weekly x 4 weeks, to ensure recommendations processed appropriately, including proper order entry. DON and/or designee will report compliance of all audits at monthly QAPI. The Quality Assurance Quality Improvement Committee will review the results of the monthly monitoring and determine if further monitoring is necessary.

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 observations, clinical record review, and staff interviews, it was determined that the facility failed to ensure a resident with limited mobility received appropriate services, equipment, and assistance to maintain or improve mobility for one of three residents reviewed (Resident 54).

Findings include:

Review of Resident 54's clinical record revealed diagnoses that included dementia (a chronic disorder of the mental processes caused by brain disease, and marked by memory disorders, personality changes, and impaired reasoning) and muscle weakness.

Review of Resident 54's physician orders revealed an order for a palm protector to the right hand due to contracture (condition of shortening and hardening of muscles, tendons, or other tissue often leading to deformity and rigidity of joints), may remove for care, dated May 21, 2024.

Observation of Resident 54 and their room on July 1, 2024, at 11:18 AM, revealed Resident 54's palm protector was lying on a chair in their room and that Resident 54 was in an activity with no palm protector in place.

Observation of Resident 54 on July 1, 2024, at 12:46 PM, revealed that they were seated in the common area near the nurse's station with no palm protector in place.

Review of Resident 54's Treatment Administration Record for May 2024, June 2024, and July 2024, failed to reveal any documentation of the application of their ordered palm protector.

In an email communication received from the Nursing Home Administrator (NHA) on July 3, 2024, at 12:19 PM, the NHA indicated that they had no documentation to provide for Resident 54's palm protector application/usage since ordered on May 21, 2024. She further indicated that the facility considers a palm protector to be a splint.

In an interview with the NHA and the Director of Nursing on July 3, 2024, at 12:50 PM, the NHA confirmed that staff should have been documenting the application and/or refusal of the palm protector.

28 Pa. Code 211.10(d) Resident Care Policies
28 Pa. Code 211.12(d)(5) Nursing Services

Plan of Correction - To be completed: 08/23/2024

Resident 54's Palm Protector discontinued per physician order on 7/3/24 per family request to promote resident comfort. Nurse entering original Palm Protector order into EHR educated on appropriate entry of splint orders, to include ensuring appropriate use schedule documentation in CNA POC by DON. The DON completed an audit of all residents with splint orders to ensure proper entry, including proper documentation in CNA POC. Education of all nursing staff regarding the importance of proper entry of splint orders, including documentation schedule for application and removal of splint on CNA POC during 7/24 and 7/25/24 nursing staff meetings. DON and/or designee will complete audit of compliance with proper entry of all new splint orders as well as compliance of application of splints for all residents ordered splints weekly x 4 weeks. DON and/or designee will report compliance of all audits at monthly QAPI. The Quality Assurance Quality Improvement Committee will review the results of the monthly monitoring and determine if further monitoring is necessary.

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, observations, clinical record review, and staff interviews, it was determined that the facility failed to monitor hydration status precisely and effectively for one of 20 residents reviewed (Resident 19).

Findings include:

Review of facility policy, titled "Fluid Restriction Policy", last revised February 12, 2022, read, in part, "Purpose: To ensure that fluid restricted residents receive adequate hydration by close monitoring...Care Plans will be updated to address interventions."

Review of Resident 19's clinical record revealed she was admitted to the facility on February 4, 2024, with diagnoses that included congestive heart failure (CHF - long-term condition that happens when your heart can't pump blood well enough to meet your body's needs), shortness of breath (uncomfortable feeling of not being able to breathe well enough), and acute upper respiratory infection.

Review of Resident 19's physician orders revealed an order: "Regular diet, Regular texture, Thin consistency (fluids), Fluid Restriction 2000ml" (milliliter- unit of measure), with a start date of February 4, 2024.

Further review of resident 19's clinical record failed to reveal notation in her care plan about her fluid restriction, or a breakdown of fluids provided between dietary and nursing each shift.

Observation in Resident 19's room on July 1, 2024, at 11:20 AM, revealed a large cup on her bedside table containing approximately 120 ml of water.

Review of Resident 19's dietary tray tickets from July 1, 2024, revealed she was provided 1560 ml of fluid from dietary throughout the day: 360 ml at breakfast, 720 ml at lunch, and 480 ml at dinner.

Review of nurse aide task, titled "Additional Fluids" on July 1, 2024, revealed Resident 19 was documented as receiving 120 ml at 5:35 AM; 480 ml at 1:02 PM; 60 ml at 6:12 PM; and 120 ml at 10:47 PM.

Review of nurse aide task, titled "Fluids" on July 1, 2024, revealed Resident 19 was documented as receiving 240 ml of fluid at 1:01 PM, 1:25 PM, 6:12 PM, and 9:59 PM.

Observation in Resident 19's room on July 2, 2024, at 10:07 AM, revealed a large cup on her bedside table containing approximately 480 ml of water.

Email correspondence with the Nursing Home Administrator on July 2, 2024, at 2:24 PM, the surveyor questioned the two different nurse tasks capturing fluids as well as how the facility is managing Resident 19's fluid restriction.

Observation in Resident 19's room on July 3, 2024, at 09:41 AM, revealed a large cup on her bedside table containing approximately 120 ml of water.

Review of nurse aide task, titled "Additional Fluids" on July 3, 2024, revealed Resident 19 was documented as receiving 480 ml at 9:56 AM by Employee 1 (Nurse Aide).

Review of nurse aide task, titled "Fluids" on July 3, 2024, revealed Resident 19 was documented as receiving 240 ml of fluid at 9:56 AM by Employee 1.

During an interview with Employee 1 on July 3, 2024, at 10:31 AM, he revealed he was unaware Resident 19 was on a fluid restriction, and that he does not provide additional fluids to Resident 19, he only documents what is provided from dietary.

During an interview with the Director of Nursing (DON) on July 3, 2024, at 10:59 AM, he revealed nurse aides document the fluids from dietary under "fluids", and fluids provided by nursing, including fluids provided during medication pass, under "additional fluids". Further, the DON stated that Employee 1 might not know about Resident 19's fluid restriction as he is a "fairly new" employee.

During a follow up interview with the DON on July 3, 2024, at 1:18 PM, the surveyor revealed the concern with the overall management and monitoring of Resident 19's fluid restriction. No further information was provided.

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

Plan of Correction - To be completed: 08/23/2024

Resident 19's care plan corrected to include Fluid restriction and breakdown of fluids by meal and nursing by shift. Employee 1 provided with education by DON on how to identify residents with ordered fluid restriction and where to locate fluid breakdown information. Facility audit of all residents on fluid restriction completed by DON to ensure all fluid restriction orders and fluid breakdown care planned appropriately. DON consulted with Dietitian and Medical Director regarding Facility Fluid Restriction policy revision on 7/9/24, to include breakdown of fluids provided by dietary and nursing with specific recommended fluid breakdown values. Specific assessment criteria for exceeding ordered daily values also added to policy. Education of All nursing staff on proper care planning of fluid restriction orders, including fluid breakdown, proper documentation of fluid intake and review of revised fluid restriction policy to be completed during scheduled Nursing staff meetings on 7/24 and 7/25/24. Review of revised facility fluid restriction policy with dietary staff to be completed during dietary staff meetings on7/19/24. Nursing supervisor will complete nightly audit of all residents on fluid restriction monitoring, utilizing 24hr hour I&O record form and perform assessment per policy. DON and/or designee will complete audit of 24hr fluid intake of at least 5 x residents per week for 4x weeks, to ensure accuracy of fluid calculation over 24hr period, track compliance with revised fluid breakdown values as well as compliance with completion of RN assessment if meeting criteria. DON and/or designee will complete audit of any new fluid restriction orders or changes to existing fluid restriction order to ensure proper care planning x 4 weeks. DON and/or designee will report compliance of all audits at monthly QAPI. The Quality Assurance Quality Improvement Committee will review the results of the monthly monitoring and determine if further monitoring is necessary.

483.25(h) REQUIREMENT Parenteral/IV Fluids:

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

Observations:

Based on policy review, observations, clinical record reviews, and resident and staff interviews, it was determined that the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice related to intravenous (IV - tube inserted into a vein, which medication is administered through) therapy for two of two residents receiving IV medications (Residents 64 and 326).

Findings Include:

Facility policy, titled "13.6 Medication Administration Guidelines: Specific", effective date October 1, 2018, stated in part, "7. Compare the MAR (medication administration record) with the medication label for accuracy and note the following: A. Incorrect label or direction change by the health care provider ...D. If the label and MAR differ for any other reason or if there are questions about the dosage or directions, do not administer the medication. Contact pharmacy provider."

Review of Resident 64's clinical record revealed diagnoses that included osteomyelitis (infection of a bone) of the lumbar (lower back) region and discitis (an infection of the intervertebral disc, a structure that separates the vertebrae in the spine).

Review of Resident 64's current physician orders revealed an order for Meropenem intravenous (IV) solution reconstituted administer one gram intravenously three times a day related to osteomyelitis of vertebra, dated June 17, 2024.

During an interview with Resident 64 on July 1, 2024, at 9:53 AM, it was observed that an empty medication solution bag of Meropenem was hanging on an IV pole, the IV tubing was not dated, and the end of the IV tubing was secured into a port on the IV tubing. Observation also revealed a sheet of IV line end caps to be present hanging on the intravenous pole near the empty medication solution bag.

During an interview with the Nursing Home Administrator (NHA) and Director of Nursing (DON) on July 3, 2024, at 10:55 AM, the DON confirmed that Resident 64's IV tubing should have been properly dated and capped.

Review of Resident 326's clinical record revealed diagnoses that included: bacteremia (bacteria in the blood) and excoriation disorder (a mental illness related to obsessive-compulsive disorder characterized by repeated picking at the skin).

Review of Resident 326's physician orders revealed an order for daptomycin 500 mg intravenously one time a day for infection.

Review of Resident 326's medication administration record for July revealed daptomycin 500 mg documented as administered at 5:00 AM on July 1, 2024.

During the initial tour of the facility on July 1, 2024 at 10:44 AM, an observation of Resident 326 was completed, which revealed an IV medication bag hanging on an IV pole at Resident 326's bedside. At the time of the observation, Resident 326 revealed that she had an infection and had received IV antibiotics earlier that morning. Further observation of the IV setup revealed an IV medication bag with a pharmacy label showing daptomycin (antibiotic medication) 500 milligrams (mg) per 100 milliliters (ml) of normal sterile saline with another resident's name on the label, the IV tubing end was connected into one of the ports on the tubing, and no date was observed on the tubing.

During a staff interview on July 1, 2024 at 10:56 AM, with Employee 3 (Licensed Practical Nurse), it was revealed that the night shift registered nurse was responsible for hanging IV medications.

During an additional staff interview on July 1, 2024 at 11:00 AM, with Employee 2 (Registered Nurse Supervisor), it was revealed that the bag of IV medication was the correct medication, but was for another resident. Employee 2 stated the IV tubing should have been dated and that the tubing should have been capped, not connected to itself. Employee 2 removed the IV medication bag and tubing from Resident 326's room.

During a staff interview on July 3, 2024, with the NHA and the DON, the DON revealed it was the expectation of the facility that residents be free from medication errors, IV tubing be dated, and IV tubing be capped when not in use.

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

Plan of Correction - To be completed: 08/23/2024

Resident 64's unlabeled IV tubing removed from use and properly disposed of by RN Supervisor 7/1/24. Resident 326's unlabeled IV tubing and mislabeled bag was removed from room and properly disposed of by RN supervisor 7/1/24. Medication error form completed per facility policy for improperly labeled IV Daptomycin. RN Supervisor responsible for IV Tubing replacement and IV antibiotic infusion of resident 326 and 64, called in to facility and education provided by DON 7/2/24. Education including review of medication rights of administration, Proper IV tubing management, including proper labeling, and capping of tubing end in between therapies. Audit completed by DON of ALL residents receiving IV therapy to ensure proper IV Tubing management including, proper labeling and proper capping of tubing end, Reviewed IV Antibiotic therapies to confirm proper label, including name and date. Education of all nursing staff on proper medication administration procedure, as well as importance of proper management of IV tubing, including labeling and utilizing proper end-caps at scheduled Nursing staff meetings on 7/25/24. RN Supervisor will complete IV Therapy Checklist prior to initiating IV therapy with nurse cosigner. IV Therapy checklist to verify proper IV Tubing management: proper labeling of tubing and proper capping of tubing end, and Reviewed IV Antibiotic therapies to confirm the correct patient, medication, time, dose, and route. DON and/or designee will review IV Therapy log for compliance weekly x 4 weeks. DON and/or designee will report compliance of all audits at monthly QAPI. The Quality Assurance Quality Improvement Committee will review the results of the monthly monitoring and determine if further monitoring is necessary.

483.25(i) REQUIREMENT Respiratory/Tracheostomy Care and Suctioning:

§ 483.25(i) Respiratory care, including tracheostomy care and tracheal suctioning.
The facility must ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals and preferences, and 483.65 of this subpart.

Observations:

Based on facility policy review, observations, clinical record review, and resident and staff interviews, it was determined that the facility failed to maintain oxygen equipment in a sanitary manner and provide respiratory care consistent will professional standards for one of 20 residents reviewed for oxygen (Resident 19).

Findings include:

Review of facility policy, titled "Oxygen Therapy Policy", last revised April 4, 2018, read, in part, "Oxygen tubing will be dated and changed bi-weekly by the 11-7 Licensed Staff."

Review of Resident 19's clinical record revealed diagnoses that included Covid-19 (respiratory virus), shortness of breath (uncomfortable feeling of not being able to breathe well enough), and muscle weakness.

Observation of Resident 19's oxygen tubing on July 1, 2024, at 11:20 AM, revealed her oxygen tubing was dated June 2, 2024.

Observation of Resident 19's oxygen tubing on July 2, 2024, at 10:07 AM, revealed her oxygen tubing was dated June 2, 2024.

Review of Resident 19's clinical record revealed she tested positive for Covid-19 infection on June 20, 2024.

During an interview with the Director of Nursing (DON) on July 2, 2024, at 10:42 AM, the surveyor revealed the observations of Resident 19's oxygen tubing dated June 2, 2024.

Follow-up interview with the DON on July 2, 2024, at 1:56 PM, he revealed the tubing was not changed bi-weekly since June 2, 2024, due to the Resident being asleep and refused when awakened. The surveyor inquired if staff reapproached at a later time or documented the refusals.

Observation of Resident 19's oxygen tubing on July 3, 2024, at 9:41 AM, revealed her oxygen tubing was dated July 1, 2024.

Interview with Resident 19 on July 3, 2024, at 9:42 AM, revealed the nursing staff came in and changed her oxygen tubing the previous afternoon.

Interview with the DON on July 3, 2024, at 10:59 AM, revealed he would expect staff to reapproach about tubing change, document refusal of the tubing change, and that they would follow-up about the wrong date on the new tubing as it was changed on July 2, 2024.

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

Plan of Correction - To be completed: 08/23/2024

Resident 19's oxygen tubing and cannula was replaced with new tubing. Tubing dated with of date of tubing replaced. Treatment error report completed per facility policy with physician and resident own responsible party aware. Licensed staff person responsible for changing oxygen tubing called into facility on 7/2/2024 and provided with education by DON the importance of following through with oxygen tubing change out, including disposing of old tubing. Audit of all residents on oxygen therapy and nebulizer therapy audited by Director of Nursing to ensure tubing labeled and stored correctly was completed. Skilled nursing staff in-service on 7/24 and 7/25/2024 including proper labeling and storage of oxygen equipment. DON and/or designee will complete audit of all residents with oxygen orders for compliance of proper labeling and storage of equipment 4 x per week for 4 weeks. DON and/or designee will report compliance of all audits at monthly QAPI. The Quality Assurance Quality Improvement Committee will review the results of the monthly monitoring and determine if further monitoring is necessary.

483.80(a)(1)(2)(4)(e)(f) REQUIREMENT Infection Prevention & Control:

§483.80 Infection Control
The facility must establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections.

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

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

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

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

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

§483.80(f) Annual review.
The facility will conduct an annual review of its IPCP and update their program, as necessary.

Observations:

Based on facility policy review, observations, and staff interviews, it was determined that the facility failed to 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 for two of four residents reviewed (Residents 52 and 326).

Findings include:

Review of facility policy, titled "Isolation Precaution Policy", with a last revised date of July 25, 2023, and a last reviewed date of January 25, 2024, revealed, in part, "1. This facility will follow CDC (Center for Disease Control) guidelines when determining what form of isolation precautions will be instituted i.e., Contact, Respiratory, or Enhanced Barrier Precautions; 2) Isolation precautions will be initiated by a physician's order and or deemed necessary by nursing judgment; and 5) A sign will be placed on the resident's door to alert staff and visitors."

Review of facility policy, titled "Shingles", with a last revised date of June 20, 2017, and a last reviewed date of January 25, 2024, defined shingles as "a painful blistering skin rash due to the varicella-zoster virus, the virus that causes chickenpox"; and that the "virus will be prevented from transmission to residents and employees within the facility."

Review of facility policy, titled "Infection Control Enhanced Barrier Precaution Paramount Skilled Nursing and Rehabilitation Facilities", last revised April 1, 2024, revealed "Policy Statement - All employees will utilize Enhanced Barrier Precaution for residents with chronic wounds or indwelling medical devices during high-contact resident care activities regardless of their multidrug-resistant organism status. Implementation 1. For Enhanced Barrier Precautions, signage should clearly indicate the high-contact resident care activities that require use of gown and gloves. 2. Make PPE (personal protective equipment), including gowns and gloves, available immediately outside of the resident room."

Review of the "Center for Disease Control 2007 Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings", with a last revised date of September 2018, revealed that Contact Precautions are intended to prevent transmission of infectious agents which are spread by direct or indirect contact with the patient or the patient's environment; that Contact Precautions also apply where the presence of excessive wound drainage, fecal incontinence, or other discharges from the body suggest an increased potential for extensive environmental contamination and risk of transmission; and that someone diagnosed with shingles should remain under contact precautions until lesions are dry and crusted.

Review of Resident 52's clinical record revealed diagnoses that included herpes zoster (shingles) and mild cognitive impairment.

Review of Resident 52's current physician orders revealed an order for Acyclovir Oral Tablet 400 MG (an antiviral medication used to treat shingles) give one tablet by mouth three times a day related to herpes zoster for 10 days, dated June 24, 2024, and end date of July 4, 2024. The physician orders failed to reveal any orders regarding contact precautions.

Further review of Resident 52's past physician orders history revealed that Resident 52 was originally ordered the Acyclovir and contact precautions on June 14, 2024, for 10 days.

Observation of Resident of Resident 52's room on July 1, 2024, at 11:56 AM, revealed the presence of a sign that said to see the nurse before entering the room. Immediate interview with a staff nurse revealed that Resident 52 had a diagnosis of shingles and that the Resident was on contact precautions.

Observation of Resident 52's room on July 1, 2024, at 12:40 PM, revealed that the aforementioned sign had been removed.

Observation of Resident 52's room on July 2, 2024, at 9:47 AM, again revealed no sign was present regarding isolation precautions.

Review of Resident 52's clinical record progress notes failed to reveal any nurse's notes between June 28, 2024, and July 2, 2024, that described Resident 52's shingles rash.

Review of nurse's note dated July 2, 2024, at 3:00 PM, indicated "Acyclovir continues for shingles rash. C/O (complaint of) pain in area with relief noted after Tylenol".

Review of order note dated July 2, 2024, at 4:33 PM, indicated Resident 52's physician had "followed up with resident at this time for evaluation of shingles as resident now has peripheral edema left upper thigh", and that a new order was given to restart contact isolation for shingles rash for 10 days.

During an interview with the Director of Nursing (DON) on July 3, 2024, at 9:44 AM, the DON indicated that the staff followed the MD order for 10 days of precautions, which was ordered on June 14, 2024; however, he confirmed that precautions should have been continued while Resident 52 was actively being treated or, at the very least, staff should have followed up with the MD for further guidance.

During a follow-up interview with the Nursing Home Administrator (NHA) and DON on July 3, 2024, at 10:55 AM, the DON indicated that Resident 52 was restarted on contact precautions on July 2, 2024, and that a new area of shingles had been identified. He again confirmed that Resident 52's contact precautions should have continued or that their physician should have been notified for guidance on precautions since they were actively being treated for ongoing shingles.

Review of Resident 326's clinical record revealed diagnoses that included bacteremia (bacteria in the blood) and excoriation disorder (a mental illness related to obsessive-compulsive disorder characterized by repeated picking at the skin).

Review of Resident 326's physician orders revealed an order dated June 30, 2024, that read this Resident is on EBP (enhanced barrier precautions), use gown and gloves for high-contact care activities, such as dressing, bathing, showering, transferring, changing linens, providing hygiene, changing briefs, or assisting with toileting, every shift.

Review of Resident 326's care plan revealed a focus area for enhanced barrier precautions: mid line IV (intravenous line) with an intervention for EBP sign on door/isolation bin outside of room.

Observations of Resident 326's room on July 1, 2024, at 10:44 AM, and July 2, 2024, at 8:24 AM, failed to reveal signage for EBP or a PPE caddy.

During a staff interview on July 3, 2024 at 10:55 AM, with the NHA and DON, it was revealed that Resident 326 should have been placed on EBP at the time of the physician's order and it is the expectation of the facility that EBP be followed.

28 Pa. Code 201.18(b)(1) Management
28 Pa. Code 211.12(d)(1)(2)(5) Nursing Services

Plan of Correction - To be completed: 08/23/2024

Contact precaution reinitiated by facility provider for resident 52 per facility policy including contact precautions signage and PPE Caddy. PPE Caddy placed outside of door and EBP door signage replaced on door of resident 326. DON completed audit of all residents on contact precautions/EBP to ensure order entered correctly and isolation setup initiated and present, including PPE caddy and door signage per facility policy. Education will be completed during Skilled nursing staff meetings on 7/24 and 7/25/2024, including proper length of contact precaution for infectious disease as well as review of facility policy and procedure for contact precaution, including proper door signage, PPE bins. DON and/or designee will complete audit of all residents on contact precaution/EBP to ensure proper equipment and procedure in place, including Signage on resident's door and PPE bin outside of door, as well as audit ALL new orders, discontinuations, or changes in duration of contact precaution/EBP Weekly for 4 weeks. DON and/or designee will report compliance of all audits at monthly QAPI. The Quality Assurance Quality Improvement Committee will review the results of the monthly monitoring and determine if further monitoring is necessary.

§ 211.12(f.1)(3) LICENSURE Nursing services. :

(3) Effective July 1, 2024, a minimum of 1 nurse aide per 10 residents during the day, 1 nurse aide per 11 residents during the evening, and 1 nurse aide per 15 residents overnight.

Observations:

Based on staffing document review and staff interview, it was determined that the facility failed to ensure a required minimum of one Nurse Aide (NA) per 10 residents on day shift, one NA per 11 residents on evening shift, and one NA per 15 residents on night shift for one of one days reviewed starting July 1, 2024 (July 1, 2024).

Findings include:

Review of facility staffing ratio and resident census information for July 1, 2024, revealed the following NA ratios which did not meet the minimum NA ratio required for the facility census of residents on those shifts:

Day shift - 86 residents and 8 NAs, which did not meet the required ratio of 8.6 NAs.
Evening shift - 86 residents and 7 NAs, which did not meet the required ratio of 7.82 NAs.
Night shift - 86 residents and 4 NAs, which did not meet the required ratio of 5.73 NAs.

During an interview with the Nursing Home Administrator on July 2, 2024, at 2:15 PM, she confirmed that the facility did not meet the required NA ratios on July 1, 2024.

Plan of Correction - To be completed: 08/23/2024

Staffing ratios cannot be corrected for 7/1/24 as this is a past occurrence and the facility needs to hire more CNA's to meet the staffing ratio regulation.
Calculations of shift CNA ratios will be completed and reviewed daily for accuracy by the scheduler, ADON and/or DON while the facility is recruiting more CNA staff to meet the ratios.
The facility continues to put forth efforts to recruit and retain new CNA staff members. This includes: Pickup shift bonuses for all staff pickups effective 6/29/24 and continue at this time, new hire incentives ongoing, such as sign-on bonus and facility added a 7 + years of experience pay rate to the current CNA wage scale. The facility is holding a CNA free training job fair on 7/17/24 to recruit staff for our upcoming CNA training class in August. Staff will be re-educated on staffing ratios and potential for mandating due to call off coverage at nurse staff meetings held on July 24th July 25th. Effective on 7/28/24 facility will be having all CNA's move to an 8 hour work day increasing from 7.5 hours.
Schedules and CNA ratios will be audited daily by the scheduler and DON/designee for 8 weeks or until substantial compliance is achieved. The results of the findings will be reported monthly at the facility Quality Assurance Performance Improvement meeting.

§ 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 staffing document review and staff interview, it was determined that the facility failed to ensure a required minimum of one Licensed Practical Nurse (LPN) per 40 residents on night shift for one of 21 days reviewed (July 1, 2024).

Findings include:

Review of facility staffing ratio and resident census information for February 1-7, 2024; May 26 - June 1, 2024; and June 25 - July 1, 2024, revealed a resident census of 86 on July 1, 2024. Further review revealed two LPNs worked during the night shift on that date, which did not meet the required minimum LPN ratio of 2.15 based on resident census during that shift.

During an interview with the Nursing Home Administrator on July 2, 2024, at 2:15 PM, she confirmed that the facility did not meet the minimum required LPN ratios for night shift on July 1, 2024.

Plan of Correction - To be completed: 08/23/2024

Staffing ratios cannot be corrected for 7/1/24 as this is past occurrence and facility will need to hire more LPN staffing to meet staffing ratio regulation.
Calculations of shift LPN ratios will be completed and reviewed daily for accuracy by the scheduler and DON to assure enough LPN coverage is scheduled to meet the ratios.
The facility continues to put forth efforts to recruit and retain new nursing staff members. This includes: Pickup shift bonuses for all staff pickups effective 6/29/24 and continue at this time, new hire incentives ongoing, such as sign-on bonus, increased LPN wage matrix effective 7/9/24. Staff will be re-educated on staffing ratios and potential for mandating due to call off coverage at nurse staffing meetings held on July 24th and 25th.
Schedules and LPN ratios will be audited daily by the scheduler and DON/designee for 8 weeks or until substantial compliance is achieved. The results of the findings will be reported monthly at the facility Quality Assurance Performance Improvement meeting.

§ 211.12(i)(2) LICENSURE Nursing services.:

(2) Effective July 1, 2024, 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 3.2 hours of direct resident care for each resident.

Observations:

Based on staffing document review and staff interview, it was determined that the facility failed to ensure the total number of nursing care hours provided in each 24 hour period be a required minimum of 3.20 hours of direct care per resident beginning July 1, 2024, for one of 21 days reviewed (July 1, 2024).

Findings include:

Review of facility staffing ratio and resident census information for February 1-7, 2024; May 26, 2024, - June 1, 2024; and June 25, 2024, - July 1, 2024, revealed that the facility provided only 2.88 hours of direct care for each resident on July 1, 2024.

During an interview with the Nursing Home Administrator on July 2, 2024, at 2:15 PM, she confirmed that the facility did not meet the required staffing ratio for July 1, 2024.

Plan of Correction - To be completed: 08/23/2024

Total staff hours cannot be corrected for 7/1/24
Calculations of PPD will be completed and reviewed daily for accuracy by the scheduler, DON to assure enough staff hours per patient day is scheduled to cover PPD of 3.2.
Pickup shift bonuses for all staff pickups effective 6/29/24 and continue at this time, new hire incentives ongoing, such as sign-on bonus and facility added a 7 + years of experience pay rate to the current CNA, LPN and RN wage scale as well as waging analysis and increased starting wages for LPN and RN staff. The facility is holding a CNA free training job fair on 7/17/24 to recruit staff for our upcoming CNA training class in August. Effective on 7/28/24 facility will be having all CNA's move to an 8 hours work day increasing from 7.5 hours. Staff will be re-educated on staffing ratios and potential for mandating due to call off coverage as nurse staff meetings held on July 24th and 25th. Schedules and CNA ratios will be audited daily by the scheduler and DON/designee for 8 weeks or until substantial compliance is achieved. The results of the findings will be reported monthly at the facility Quality Assurance Performance Improvement meeting.

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