Nursing Investigation Results -

Pennsylvania Department of Health
PREMIER AT SUSQUEHANNA FOR NURSING AND REHABILITATION, LLC
Patient Care Inspection Results

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
PREMIER AT SUSQUEHANNA FOR NURSING AND REHABILITATION, LLC
Inspection Results For:

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PREMIER AT SUSQUEHANNA FOR NURSING AND REHABILITATION, LLC - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Representatives of the Harrisburg Field Office, Division of Nursing Care Facilities conducted a Medicare/Medicaid Recertification, State Licensure and Civil Rights Compliance survey, completed on December 11, 2019, and it was determined that Premier at Susquehanna for Nursing and Rehabilitation 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 affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
483.10(i) Safe Environment.
The resident has a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

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

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

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

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

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

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

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


Based on observations, facility policy review and resident and staff interviews, it was determined that facility failed to ensure a clean, comfortable, home-like environment for two of 167 residents residing in the facility (Residents 68 and 121) and failed to ensure to maintain comfortable temperature levels in two of eight resident corridors (Hall 700 and Hall 800).

Findings included:

On December 9, 2019, at 9:45 AM, Resident 68 was asked about the cleanliness of her room. At that time, Resident 68 pointed to a cobweb at the top of the window in her room. Surveyor also observed the cobweb.

On December 10, 2019, at 11:35 AM the Director of Nursing was made aware of the cobweb in Resident 68's room. On December 10, 2019, at 2:06 PM the Nursing Home Administrator (NHA) stated the cobweb was taken care of.

Review of facility policy " Quality of Life-Dignity" revised in 10/2019 revealed each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect and individuality.

Observations on December 8, 2019 at approximately 9:30 a.m. a white sheet was laying on the floor at the bottom of the bed of Resident 121.

Interview with Director of Nursing on December 9, 2019 at approximately 2:30 p.m. revealed that any clothes or sheets should not be on the floor in resident rooms.

Interview with the NHA on December 11, 2019, at approximately 2:30 p.m. revealed that the NHA concurred with the Director of Nursing and linens should not be laying on the floor.

During initial observations of the 800 hallway on December 8, 2019 at approximately 9:15 AM, the resident corridor was found to be cold. Observations of Nurse Aide (NA) 4 on the unit revealed NA 4 was wearing a light jacket. During a staff interview on December 8, 2019, at approximately 10:03 AM, NA 4 was asked if the hallway seemed cold to NA 4; NA 4 responded, "It's colder than it usually is. I don't know why it's so cold." NA 4 was asked if the cooler temperature was reported to the charge nurse to which NA 4 replied, "Yes, but I don't know if they contacted maintenance..."

On December 8, 2019 at approximately 10:25 AM the Director of Maintenance was observed at the far end the 800 unit. During a staff interview at that time, the Director of Maintenance stated that, "Someone turned the thermostat down. I usually have it set for 72 to 74 [degrees]." When asked what the the thermostat was found to be set at, Director of Maintenance stated, "70." The Director of Maintenance then proceeded to the beginning of the hall (closest to the nurses station) and used a facility tool to evaluate the ambient air temperature of the 800 unit. Temperatures displayed at approximately 10:29 AM ranged between 67.8 to 68.4 degrees Fahrenheit. During a staff interview the Maintenance Director revealed that the hand-held instrument that is normally used to monitor temperatures in the building was not functioning and that he was using a multimeter (electronic device that can perform a range of functions). The Maintenance Director stated that he was going to be purchasing a thermometer directly. At approximately 10:32 AM, Maintenance Director left the unit.

During observations of the 700 hallway, on December 8, 2019 at approximately 11:00 AM, Resident 41 was observed standing in the doorway of Resident 41's room as the Maintenance Director evaluated the 700 Hallway temperatures. At this time, Resident 41 stated, "Are you going to fix that [ventilation in the ceiling being reviewed with a laser thermometer by the Maintenance Director]? It's been cold; past couple of days. I walk down the hallway and get blasted with cold air..."

Observation of the ventilation grate revealed cold air could be felt flowing from the ventilation into the hallway. Temperature readings with a laser thermometer, utilized by Maintenance Director revealed temperature readings that fluctuated between 56.8 and 58.2 F. The Maintenance Director stated that, "I'll have to look. Sometimes there's a door on the unit that is open and that can cause that [cold air to flow into the hallway]."

During a staff interview on December 11, 2019 at approximately 10:40 AM, the Director of Maintenance revealed that a filter had been placed into the grate of the 700 hallway which stopped the flow of cold air into the 700 hall unit.

During a staff interview on December 11, 2019 at approximately 12:00 PM, the NHA revealed it was the facility's policy for temperatures to range between 71 and 81 degrees F.

28 Pa code 201.18(b)(1)(3) Management

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


 Plan of Correction - To be completed: 01/14/2020

1. The cobweb in the corner blind of Res 68s room was removed. The sheet on the floor at the base of Res 121s bed was removed. The temperatures in the far end of the 800 hall and near the ventilation grate in the 700 hall were corrected to be in regulatory compliance during the survey.
2. Maintenance department staff will measure and monitor temperatures in common areas 5x per week for 4 weeks, to insure compliance.
3. Maintenance staff will receive in-service education on temperature requirements of the facility in common areas. Housekeeping staff will receive in-service education on 5 and 7 step cleaning process, including dusting.
4. Five resident interviews will be conducted weekly for 4 weeks to assess satisfaction with clean comfortable environment, with reporting monthly to the QAPI Committee.
5. Date of correction is January 14, 2020.

483.60(i)(1)(2) REQUIREMENT Food Procurement,Store/Prepare/Serve-Sanitary: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.
483.60(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, review of facility policy and interview with staff, it was determined that the facility failed to store food in accordance with professional standards for food service safety in the main kitchen area.

Findings included:

Review of facility policy " Food Storage" revised October, 2019, revealed all open food or those not labeled with an expiration date will be discarded according to guidelines.

Observations on December 8, 2019, at approximately 9:10 a.m. revealed there was a cell phone and a navy blue hoodie jacket laying on the prep table beside the mixer.
In the kitchen was a metal cart which had a metal tray with approximately 25 small glass dishes with vanilla pudding uncovered.
The dry storage area had an opened bag of Roset Noodles approximately 1/4 full not dated with open date or labeled.
The refrigerator had a plastic container with approximately 2 cups of shredded lettuce with a green lid that was partially opened.
There was a container of mashed potatoes, a container of cooked rice, and a container of meat patties that were not dated or labeled.

An interview with the Food Service Manager on December 9, 2019, at approximately 11:00 a.m. revealed that food should be labeled and dated when opened. Non food items, such as the cell phone and jacket should not be on any food preparation areas.

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

28 Pa. Code: 201.18(b)(1)Management.

28 Pa. Code: 211.6(f) Dietary services



 Plan of Correction - To be completed: 01/14/2020

Facility will continue to store food in accordance with professional standards for food service safety in the main kitchen area.

1. The items identified during the survey were immediately corrected.
2. Food service manager or designee will verify that all food will be stored properly daily, and that staff personal items are also properly stored away in a proper area.
3. Education will be provided to dietary staff on proper food storage guidelines and personal item storage. The opening storage checklist has been modified to comply with requirements.
4. The Food service manager or designee will monitor the opening storage checklist 5x per week for 4 weeks, then weekly for an additional 60 days, to insure ongoing compliance.
5. Date of correction is January 14, 2020.

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 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.
483.35(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 personnel file review and staff interview, it was determined that the facility failed to ensure that nurse aide performance evaluations were completed at least annually for three of five nurse aides reviewed (Nurse Aides 1, 2 and 3).

Findings Include:

Review of Nurse Aide (NA) 1's most recent performance evaluation revealed that NA 1 was hired on March 1, 2018 but NA 1's annual performance evaluation was not completed until December 9, 2019.

Review of NA 2's most recent performance evaluation revealed that NA 2 was hired on March 1, 2018 but NA 2's annual performance evaluation was not completed until December 9, 2019.

Review of NA 3's most recent performance evaluation revealed that NA 3 was hired on May 24, 2018 but NA 3's annual performance evaluation was not completed until December 9, 2019.

During an interview on December 10, 2019, at 12:10 PM the Director of Nursing stated that the evaluations for NAs 1, 2 and 3 had to be reprinted because the NAs never completed them and handed them back in. She stated she keeps a spreadsheet of when the evaluations are due. Review of the spreadsheet revealed that the evaluations for NA 1 and NA 2 were due in March 2019 and the evaluation for NA 3 was due in May 2019.


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

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












 Plan of Correction - To be completed: 01/14/2020

1. Evals completed 12/9/19
2. Audit of CNA evals, any overdue will be reissued for completion
3. Education to HR to reissue if eval not returned in 2 weeks
4. Audit of 5 CNA evals weekly x 4 then monthly x 2 for timeliness of completion by HR or designee
5. 1/14/20

483.25 REQUIREMENT Quality of Care:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
483.25 Quality of care
Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices.
Observations:

Based on observations, clinical record review and staff interviews, it was determined that the facility failed to ensure that care and services were provided to attain or maintain the resident's highest level of well-being for two of 33 residents reviewed (Residents 13 and 271).

Findings include:

Review of Resident 13's clinical record revealed diagnoses that included dysphagia (difficulty swallowing), abnormal posture, lack of coordination, and dementia (significant loss of intellectual abilities, such as memory capacity, that is severe enough to interfere with social or occupational functioning; dementia criteria include; impairment of attention, orientation, memory, judgment, language, motor and spatial skills, and function).

Review of Resident 13's physician's orders, active as of December 9, 2019, revealed the order "Regular diet Puree texture, Thin consistency" with a noted start date of December 5, 2018.

Review of Resident 13's current active Care Plan, last reviewed December 19, 2019, revealed the care Focus Area of "The resident has an ADL (Activities of Daily Living) Self Care Performance Deficit r/t (due to) dementia inability to perform, impaired mobility. Total assist of 1-2 (staff persons) for all areas of ADL's. upper dentures, own lower teeth." Further review of this identified Focus Area revealed it was initiated on November 30, 2018, with revision on September 17, 2019.
Review of associated Interventions for this Focus area revealed "EATING: The resident requires staff assistance to eat" with an indicated initiation date of November 30, 2018, and a revision date of January 2, 2019.

Observation was made in Resident 13's room on December 8, 2019, at 12:28 PM, of Nursing Aide (NA) 5 setting up and initiating to feed Resident 13. NA 5 revealed that it was difficult to get into a good position to feed the resident as she (NA) was right handed and due to the bed being relatively close to the wall, she needed to feed the resident on the resident's left side. It was observed that upon NA 5 initiating feeding Resident 13, that the head of the bed was not elevated much. This was addressed with NA 5 and she raised the bed a little higher, appearing at approximately 20 to 30 degrees incline and proceeded to feed the resident.

Observation was made on December 9, 2019, at 12:22 PM of Nursing Aide (NA) 6 delivering, setting up, and attempting to feed a lunch meal tray to Resident 13. It was observed that the head of the resident's bed was not flat, however that the resident was not upright and the bed appeared to be inclined at approximatley 50 degrees. NA 6 revealed that the head of the bed "was as far as it would go." NA 6 also revealed that the head of the bed was "probably at 70 degrees, not 90." NA 6 made another attempt to use the remote to raise the head of bed, but was unable to get it to change. NA 6 attempted to put another pillow behind Resident 13's head to raise her further up and this movement caused the bed to roll forward despite the bed locks being engaged. NA 6 then proceeded to feed the resident.

Review of facility policy "Preparing the Resident for a Meal" revealed under Preparation on line 7. "Unless otherwise indicated, residents whose meals are served in bed should be properly positioned in a nearly upright position. (Note: Having the resident in the sitting position, with the head slightly forward will lessen the possibility of choking)."

Review of Speech Therapy Discharge Summary signed by Speech Language Pathologist (SLP) 1 on May 8, 2019, revealed under "Skilled Interventions" "Skilled interventions provided: skilled treatment interventions focused on education and training patient and caregivers in safe swallow strategies and environmental modifications in order to increase safety and success with pureed/thin diet level and maximize intake for adequate nutrition and hydration." Review of Strategies under Discharge Recommendations revealed "Strategies/Positions: Upright at 90 degrees, small bite/sip size..." Further review of "D/C (discharge) Recs (Recommendations)" revealed "Discharge Recommendations: Continued implementation of trained safe swallow strategies." Review of Functional Maintenance revealed "Dining/Swallowing Program Established/ Trained : SLP trained family/CGs (caregivers) in use of safe swallow strategies in order to maximize intake and decrease s/s (signs/symptoms) dysphagia. Patient requires full assist for all intake).

Facility provided documentation that NA 5 was educated December 10, 2019, on "Preparing the Resident for a Meal."

During an interview with the Director of Nursing (DON) on December 11, 2019, at 11:35 AM, the DON revealed the expectation that Resident 13 would be positioned upright for assisted feeding.

Review of the clinical record for Resident 271 revealed diagnoses of cerebral infarction (damage to tissues in the brain due to a loss of oxygen to the area) and atrial fibrillation (irregular heartbeat).

Review of the current physician orders for Resident 271 revealed an order for a palm roll and edema glove to the right hand, on with morning care and off with evening care.

Observation on December 9, 2019, at 9:48 AM, revealed Resident 271 up to a chair. The palm roll and edema glove were not applied to the resident. On December 10, 2019, at 12:38 PM the palm roll and edema glove were applied.

During an interview with the Director of Nursing on December 11, 2019, at 11:39 AM she stated that it was put in the system incorrectly and was not showing up on the treatment record. She confirmed that the palm roll and edema glove should have been in place.



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









 Plan of Correction - To be completed: 01/14/2020

1. Res 13 bed replaced during survey to ensure elevation during meals. Res 271 had palm guard and edema glove properly scheduled in PCC during survey
2. Review of facility beds to ensure HOB elevates adequately completed. Review of orders for palm guards and edema gloves to ensure scheduled in PCC completed.
3. Education to nursing on preparing positioning for meals. Education to licensed staff and therapy on scheduling orders in PCC. Beds to be evaluated quarterly by maintenance for proper HOB function.
4. Random audits of 10 residents for positioning with meals wkly x 4 then monthly x 2, and random audits of 5 residents with palm guards or edema gloves for placement weekly x 4 then monthly x 2 by DON or designee
5. DOC 1/14/20

483.10(c)(7) REQUIREMENT Resident Self-Admin Meds-Clinically Approp: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(c)(7) The right to self-administer medications if the interdisciplinary team, as defined by 483.21(b)(2)(ii), has determined that this practice is clinically appropriate.
Observations:


Based on observation, clinical record review, facility document review, and staff interview, it was determined that the facility failed to ensure one of 33 residents reviewed was assessed and determined clinically appropriate for self-administration of medications (Resident 65).

Findings include:

Review of facility policy titled, "Self-Administration of Medications," last revised December 2016, revealed it's stated policy was, "Residents have the right to self-administer medications if the interdisciplinary team has determined that it is clinically appropriate and safe for the resident to do so."

Review of Resident 65's clinical record on December 10, 2019 at approximately 12:20 PM revealed diagnoses including anxiety disorder (mental health disorder characterized by excessive fear and/or worry), and hypertension (elevated/high blood pressure).

During medication observations on December 10, 2019, at approximately 10:10 AM, two inhalers (devices utilized to deliver a drug which is designed to be inhaled) were observed on Resident 65's bedside table.

Upon exiting Resident 65's room, Licensed Practical Nurse (LPN) 1 was asked if it was known to LPN 1 that there were inhalers on a bedside table in Resident 65's room. LPN 1 returned to the room and retrieved the two inhalers. During an interview on December 10, 2019, at approximately 10:20 AM, LPN 1 revealed that LPN 1 was not sure if Resident 65 had been assessed to be capable of self-administering medications. Review of the inhalers revealed one was an albuterol inhaler (short acting medication to alleviate breathing difficulties) and one was a Flovent inhaler (long-acting medication used to treat breathing difficulties). LPN 1 placed the inhalers in boxes labled for Resident 65 within the medicine cart.

Review of Resident 65's clinical record on December 10, 2019, at approximately 12:20 PM revealed that Resident 65 did not have an assessment for self-administration of medications, Resident 65 did not have a physician's order for the self-administration of medications, nor a care plan developed to address the self-administration of medications.

During a staff interview on December 11, 2019, at approximately 12:00 PM, the Director of Nursing revealed it is the facility's expectation that residents are assessed for safety prior to having medications for self-administration.

28 PA code 211.12(D)(1)(3)(5) Nursing services





 Plan of Correction - To be completed: 01/14/2020

1. Self med evaluation completed for Res 65 during survey
2. Interviews with alert and oriented residents for desire to self med conducted, rooms audited for any meds at bedside.
3. Education on self med process to licensed nurses
4. Audits of new alert and oriented admissions conducted weekly x 4 then monthly x 2 by DON or designee. New admissions will be audited to determine their desire to self medicate, and those capable of self medication will be reviewed quarterly to ensure they remain capable.
5. DOC 1/14/20

483.20(g) REQUIREMENT Accuracy of Assessments: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.
483.20(g) Accuracy of Assessments.
The assessment must accurately reflect the resident's status.
Observations:



Based on clinical record review and staff interview, it was determined that the facility failed to ensure the resident assessment accurately reflected the resident status for one of 33 resident records reviewed (Resident 149).

Findings include:

Review of Resident 149's clinical record on December 9, 2019 at approximately 1:00 PM, revealed diagnoses including hypothyroidism (decrease production of hormones by the thyroid gland) and Alzheimer's disease (progressive, irreversible degenerative disease of the brain that results in decreased contact with reality and ability to function on a daily basis).

Review of Resident 149's clinical record on December 9, 2019, at approximately 1:00 PM, revealed that, on November 19, 2019, Resident 149 was identified as suffering a deep tissue injury (injury to the layers of tissue under the skin) of the left heel.

Review of the clinical record reviewed staff assessed the left heel area as a Stage II pressure injury (injury which involves partial loss of the skin due to pressure over a bony prominence).

Review of a quarterly Minimum Data Set assessment (MDS - assessment tool utilized to identify a residents' physical, mental, and psychosocial needs), dated November 25, 2019 revealed section M - Skin Conditions was not coded to reflect the Stage II pressure injury to the left heel of Resident 149.

During a staff interview on December 11, 2019 at approximately 12:00 PM, Director of Nursing revealed the Resident 149's quarterly MDS should have been coded to include the Stage II pressure injury and further, that a corrected version of the MDS assessment had been completed on December 10, 2019 after being informed that the Stage II pressure injury had not been coded..

28 PA code 211.12(D)(1)(3)(5) Nursing services






 Plan of Correction - To be completed: 01/14/2020

1. Modification completed during survey for Res 149
2. Review of section M completed for residents existing pressure areas for accuracy
3. Education will be provided to Reimbursement staff (RNAC and LPNACs) on coding of section M of the MDS. RNACs and LPNACs are responsible for coding the MDS.
4. Random audits of Section M of 5 MDS's wkly x 4 then monthly x 2 by DON or designee
5. DOC 1/14/20

483.25(i) REQUIREMENT Respiratory/Tracheostomy Care and Suctioning:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.25(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 surveyor observation, clinical record review and staff interview, it was determined the facility failed to provide respiratory care consistent with professional standards of practice, for one of 9 residents observed with oxygen concentrators (Resident 33).

Findings Include:

Review of Resident 33's clinical record revealed diagnoses that included Chronic Obstructive Pulmonary Disease (COPD- a group of lung diseases that block airflow and make it difficult to breathe) and hypertension (elevated blood pressure).

Observation on December 8, 2019, at 11:56 AM revealed the resident wearing supplemental oxygen at 4 Liters via nasal cannula. The nasal cannula tubing was dated November 25.

Review of Resident 33's current physician orders revealed an order dated September 14, 2019, to change the filter and the tubing weekly, every night shift every Sunday. Review of Resident 33's current care plan revealed an intervention, with an initiation date of September 13, 2019, to "Provide oxygen as ordered. Change tubing and clean filter as ordered."

Review of Resident 33's Treatment Administration Record (TAR) dated November 2019, revealed that the tubing was signed off as being changed on the nightshift of November 24, 2019, into November 25, 2019. Review of Resident 33's TAR dated December 2019, revealed that the tubing was signed off as being changed on the nightshift of December 1 into December 2, 2019, but as of December 8, 2019, the tubing was still dated for November 25.

During an interview with the Director of Nursing on December 10, 2019, at 2:08 PM she stated that she was unsure why the tubing was dated for November 25.


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










 Plan of Correction - To be completed: 01/14/2020

1. O2 tubing for Res 33 changed on 12/8/19
2. Audit of residents receiving O2 to ensure O2 dated timely
3. Education to licensed staff on required weekly change of O2 tubing signed and dated in TAR
4. Audits of residents with O2 in use for timely tubing change weekly x 4 then monthly x 2 by DON or designee
5. DOC 1/14/20

483.60(d)(1)(2) REQUIREMENT Nutritive Value/Appear, Palatable/Prefer Temp: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.
483.60(d) Food and drink
Each resident receives and the facility provides-

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

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


Based on observations, and interviews with residents and staff, it was determined that the facility failed to serve foods that were palatable and at safe and appetizing temperatures for one of one test tray completed.

Findings included:

Based on resident interviews during the initial pool phase of the survey, it was revealed that three residents stated dissatisfaction with the taste and/or temperature of the food served during mealtime at the facility.
Review of the grievance tracking log on 11/10/2019 a visitor of Resident 3 indicated that the resident's food was cold.

Review of the facility's Tray Assessment Form revealed, the satisfactory temperature range for hot foods and beverages should be greater than 150 degrees Fahrenheit (F) (unit of measure), and the satisfactory temperature for all cold food and beverages should be less than 45 degrees F.

A test tray was completed on December 20, 2019, on unit 100 at 7:46 a.m. in the presence of the Food Service Manager. The food cart was assembled in the kitchen at 6:50 a.m., left the kitchen at 7:26 a.m., arrived on 100 unit at 7:28 a.m. and staff began passing trays to the residents at 7:31 a.m. Temperatures were taken by the Food Service Manager at 7:46 a.m.

The following temperatures were obtained:
Regular Diet:
Scrambled Eggs with Cheese 115 degrees F.
Coffee 128 degrees F.
Milk 50 degrees F.
Pureed Diet:
Pureed Scrambled Eggs with Cheese 115 degrees F.
Coffee 128 degrees F.
Milk 48 degrees F.

The surveyor and the Food Service Manager both tasted the test tray and the eggs and the milk on both trays were not palatable for temperatures.

Interview on December 10, 2019 at 7:50 a.m. with the Food Service Manager revealed that the food items and the beverages should be within the appropriate temperature ranges indicated on the Tray Assessment Form.

Interview on December 11, 2019 at approximately 2:50 p.m. with the Nursing Home Administrator revealed the food temperatures should be within the satisfied temperature guideline on the Tray Assessment Form and comply with the federal regulations.

28 Pa. Code: 211.6 (c) Dietary services
Previously cited 11/29/2018

28 Pa. Code: 201.18(b)(1)(3)(e)(1) Management
Previously cited 11/29/2018



 Plan of Correction - To be completed: 01/14/2020

The facility will continue to serve foods that are palatable and at safe and appetizing temperatures.

1. Temperatures of the plate warmers were modified to enhance ability of tray to hold proper food temperatures.

2. Food Service Manager or designee will continue to monitor food temperatures via test tray(s) at point of service daily for 10 days, then 3 trays per week to ensure they meet regulatory guidelines.

3. Education will be provided to dietary staff regarding food temperature requirements and systems designed to ensure same.

4. Daily test trays will be conducted for 10 days, then on an ongoing basis, 3 test trays per week will occur to insure ongoing compliance. Results will be reviewed monthly at QAPI meeting.

5. Date of correction is January 14, 2020.

483.80(a)(1)(2)(4)(e)(f) REQUIREMENT Infection Prevention & Control:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.80 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 observations, clinical record, and staff interview, it was determined that the facility failed to ensure implementation of infection control practices for one of four residents observed during medication administration (Resident 37) and one of four residents on isolation precautions (Resident 38).

Findings include:

Review of Resident 37's clinical record on December 10, 2019, at approximately 11:00 AM, revealed diagnoses including hypertension (elevated/high blood pressure) and cerebral vascular accident (CVA, sudden loss of blood flow to a part of the brain and/or bleeding within the brain which causes physical and psychological deficits and can lead to death; also referred to as a "stroke").

During medication observations on December 10, 2019, at approximately 10:10 AM, upon entering the room for medication administration, Resident 37 was in the bathroom. LPN 1 assisted Resident 37 with toileting via locating a brief and helping to transfer Resident 37 into a wheelchair. LPN 1 performed hand hygiene appropriately after Resident 37 was transferred to a wheel chair. LPN 1 proceeded to Resident 37's bed side table and placed a tissue on Resident 37's bedside table. LPN 1 then emptied a medicine cup, containing oral medications for Resident 37, into LPN 1's ungloved, left hand. LPN 1 then used her ungloved, right hand to pick up the medications, individually, and laid them out in a resident preferred order on the tissue. Resident 37 then took each pill orally.

During a staff interview on December 12, 2019, at approximately 12:45 PM, Director of Nursing revealed it was the facility's expectation that staff do not handle resident's medications with their ungloved hands.

Review of the current Infection Control policy stated that the purpose of the facility Infection Prevention and Control Program is to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of communicable diseases and infections, and to improve antibiotic use. Further review of the policy states that transmission based precautions should be followed and hand hygiene procedures should be followed by staff involved in direct resident contact.

Review of the clinical record for Resident 38 revealed diagnoses that included hypertension (elevated blood pressure) and cerebral infarction (damage to tissues in the brain due to a loss of oxygen to the area).

On December 6, 2019, the physician ordered testing to rule out respiratory syncytial virus (RSV - a contagious virus infecting the respiratory tract). There was also a new order on December 6, 2019, for contact precautions while ruling out RSV.

Observation on December 8, 2019, at 11:00 AM revealed Nurse Aide (NA) 7 entered Resident 38's room. She exited the room with Resident 38's water pitcher and filled the pitcher with ice water. She then entered the room and delivered the water pitcher. No gloves were worn and no hand hygiene was performed.

During an interview with the Director of Nursing on December 10, 2019, at 2:35 PM, she stated that she would have expected NA 7 to perform hand hygiene.

On December 10, 2019, the facility provided education that NA 7 received about hand hygiene and cross contamination with contact precaution/isolation rooms.

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







 Plan of Correction - To be completed: 01/14/2020

1. Education provided to involved staff during survey
2. Audits of staff for hand hygiene with contact with residents on precautions to be completed by DON or designee for the first three days post admission for two months then reviewed by QAPI for ongoing need. Med pass audits for licensed staff assigned to Res 37 to be completed
3. Education to nursing staff on hand hygiene with precautions and education to licensed staff on use of gloves while handling medication completed
4. Random med pass audits of 3 licensed nurses weekly x 4 then monthly x 2, random hand hygiene audits of 5 nursing staff weekly x 4 then monthly x 2 by DON or designee
5. DOC 1/14/20


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