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

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

SOUTHWESTERN NURSING AND REHABILITATION CENTER
Inspection Results For:

There are 226 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.


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

Initial comments:
Based on an Abbreviated Survey in response to five complaints completed on June 13, 2024, it was determined that Southwestern Nursing and Rehabilitation Center 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 related to the health portion of the survey process.

Plan of Correction:

483.25 REQUIREMENT Quality of Care:

This is a more serious deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency results in a negative outcome that has negatively affected 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.

Plan of Correction - To be completed: 08/06/2024

1. Resident R28 is having normal bowel movements, physician and RP aware, orders have been reviewed and verified on the EMAR. Resident R4's wound dressing is being changed per MD orders, physician and RP aware, orders have been verified on the ETAR. Resident R11's right breast surgical site is healed, and no dressing is needed currently, resident is her own RP and is aware. Resident R12 is no longer in the facility. Resident R29's wound care is administered per MD orders, physician and RP notified, orders have been verified on the ETAR.
2. The policy for bowel protocol has been reviewed and updated. Daily review of bowel movements are completed to ensure timely interventions. Current residents will have their bowel documentation reviewed to ensure residents are having timely bowel movements. Current Wound Nurse Practitioner wound notes will be reviewed to ensure requested treatment orders have been reviewed with the attending physician after weekly wound rounds by the RN wound nurse.
3. The licensed staff will have directed in servicing conducted by Affinity Health Services on July 24th and July 25th, 2024 on F684 Quality of Care. Facility has hired a dedicated registered nurse to complete wound care on June 24, 2024. The bowel movement documentation will be reviewed in the clinical meeting by the DON or designee to ensure timely bowel movements for residents. The PCC documentation for the electronic treatment administration will be reviewed by the DON or designee during the clinical meeting to ensure documentation is completed for treatments in a timely manner. Weekly wound round documentation will be reviewed by the DON or designee to ensure treatment orders are reviewed and obtained timely.
4. The DON or designee will complete 5 resident audits on the bowel protocol documentation weekly x4 weeks. The DON or designee will complete 5 audits of the wound nurse practitioner documentation to ensure wound orders are obtained timely weekly x4 weeks. The DON or designee will review PCC eTAR documentation is completed timely weekly x4 weeks. The DON or designee will complete 5 treatment observations to ensure treatment is completed and dated weekly x4 weeks. The audits will be reviewed by the QAPI committee, and the committee will determine the need for further audits.

483.12(a)(1) REQUIREMENT Free from Abuse and Neglect:

This is a more serious deficiency but is isolated to the fewest number of residents, staff, or occurrences. This deficiency results in a negative outcome that has negatively affected the resident's ability to achieve his/her highest functional status.

§483.12 Freedom from Abuse, Neglect, and Exploitation
The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms.

§483.12(a) The facility must-

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

Observations:

Based on review of facility policies and documents, clinical records and documentation, and staff interviews, it was determined that the facility failed to protect residents from neglect for one of four residents (Resident R2), that resulted in actual harm of a low leg skin tear.

Findings include:

Review of the United States Code of Federal Regulations (CFR), 42 CFR Freedom from Abuse, Neglect, and Exploitation defined neglect as "the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress."

Review of facility policy "Abuse, Neglect, Exploitation and Misappropriation Prevention Program" dated 11/30/23, indicated that residents have the right to be free from abuse and neglect.

Review of facility policy "Activities of Daily Living (ADL), Supporting" dated 11/30/23, indicated appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance.

Review of the facility provided "Certified Nurse Aide (nurse aide)" job description indicated that nurse aides would provide daily nursing care and services in accordance with the resident's assesment and care plan.

Review of Resident R2's admission record indicated she was admitted to the facility on 10/22/18.

Review of Resident R2's Minimum Data Set (MDS-periodic assessment of a resident's abilities and care needs) dated 3/27/24, included diagnoses of macular degeneration (vision loss in the center of the field of vision) and dementia (a group of symptoms that affects memory, thinking and interferes with daily life). Section G: Functional Abilities and Goals revealed that for Chair/bed-to-chair transfer (the ability to transfer to and from a bed to a chair or wheelchair) and for Lower body dressing (the ability to dress and undress below the waist, including fasteners) Resident R2 was "Dependent" on staff (meaning that the helper does all of the effort. Resident does none of the effort to complete the activity, or the assistance of two or more helpers is required for the resident to complete the activity).

Review of a physician's order dated 10/4/22, and remains current, indicated "Transfer status: Transfer assist of 1 with wheeled walker. Assist of 2 with care."

Review of Resident R2's plan of care for "ADL Self Care Performance Deficit related to Dementia" active on 5/28/24, failed to include in the interventions what level of staff assistance Resident R2 required for transferring to bed from her wheelchair and for dressing/undressing. The care plan was not updated to reflect the physician's order for transfer and assistance.

Review of Resident R2's plan of care for "ADL Self Care Performance Deficit related to dementia" updated on 6/2/24, indicated "TRANSFER: resident requires total assistance with transfers." Further review of the updated care plan failed to include interventions related to what level of staff assistance Resident R2 required for dressing/undressing.

Review of Resident R2's Kardex (document that outlines the patients' ADLs, continence levels, and behaviors, as well as physician, advanced directives, diet, and allergies) utilized by nurse aide staff dated as of 5/27/24, indicated "ADL - Transferring assist times 1 with wheeled walker; Assist of 2 with care."

Review of a progress note written by Registered Nurse (RN) Employee E2 dated 5/28/24, at 10:52 p.m. indicated "RN supervisor notified by LPN (licensed practical nurse) that resident sustained a skin tear to left shin during care. Per LPN the CNA (nurse aide) providing care for the resident reported that the resident sustained a skin tear to her left shin, and RN supervisor was contacted. Upon entering the room, the resident was observed lying on her bed turned slightly on her right side. Resident did not appear to be in any distress. Resident alert and disoriented at baseline. Resident assessed and wound care provided. Wound measured 6.5 centimeters (cm) x 5.5 cm x 0.3 cm. Resident tolerated wound care well. RN assessment, skin tear measured, cleansed with wound cleanser, patted dry, wound approximated and steri-strips (wound closure strips) applied, in area wound could not be approximated Xeroform (fine mesh gauze) was applied to the wound bed, wound covered with ABD pad (highly absorbent dressing that provides padding and protection for large wounds) and wrapped with Kerlix (absorbent rolled bandage), secured with tape. Notification made to [medical provider], [hospice provider], and resident's daughter. CNA staff reeducated on ensuring safety of resident, disengaging from resident during period of agitation, allowing for resident to have a cool down period prior to reapproaching or having someone else attempt to approach, and reporting of behaviors to nurse for documentation and appropriate treatment of behaviors."

Review of a written statement by Nurse Aide (NA) Employee E2 dated 5/28/24, indicated, "I was getting her in bed and she was fighting me. I went to pull her pants down and she was trying to kick at me and in the process, she got a skin tear to her lower left leg. Nurse [LPN Employee E4] aware."

During an interview on 6/2/24, at 3:32 p.m. NA Employee E10 stated she reviews the resident Kardex to learn the transfer and care status.

During an interview on 6/2/24, at 3:34 p.m. NA Employee E11 stated she reviews the resident chart, point of care documentation system, Kardex, or ask the charge nurse to learn the transfer and care status.

During a follow-up interview on 6/4/24, at 7:15 p.m. NA Employee E2 confirmed that she provided care alone to Resident R2." When asked why she provided care alone when Resident R2 is ordered two people for care, NA Employee E2 confirmed she was aware Resident R2 was ordered two person for care, and stated that Resident R2 is "usually not combative."

During an interview on 6/14/24, at approximately 11:30 a.m. the Nursing Home Administrator confirmed that the facility failed to protect residents from neglect for one of four residents, that resulted in actual harm of a low leg skin tear.

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

28 Pa. Code 201.18(b)(1)(3) Management.

28 Pa. Code 201.29(a)(c)(d)(j) Resident rights.

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

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

Plan of Correction - To be completed: 08/06/2024

Preparation and/or execution of this plan of correction does not constitute an admission or agreement by the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of Federal and State Law. The plan of correction represents the facility's credible allegation of compliance.

1. Resident R2 no longer resides in the facility.
2. Current residents in house will have a skin observation completed to ensure treatment orders are in place and completed per physician orders. Current residents will be evaluated by the therapy department to identify current bed mobility and transfer status. Risk management reports for the last 14 days will be reviewed to ensure allegations of abuse or neglect are investigated and reported to the appropriate agencies.
3. Facility staff will have directed in-service conducted by Affinity Health Services on F600 Freedom From Abuse/Neglect and Exploitation on Wednesday July 24th, 2024 and July 25th, 2024. Nursing staff will be in serviced on how to identify the transfer status and mobility status of residents by the DON or designee. New skin alterations will be reviewed by the ICP team to rule out abuse or neglect in the clinical meeting.
4. The DON or designee will complete 5 transfer and bed mobility audits with nursing assistants to ensure care is provided per MD orders weekly x 4weeks. The ADMIN or designee will review risk management reports during the clinical meeting to ensure complete investigations for allegations of abuse or neglect weekly x4 weeks. The audits will be reviewed by the QAPI committee and the QAPI committee will determine the need for further audits.

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.

Plan of Correction - To be completed: 08/06/2024

1. Resident R1 continues with the PRAFO boot to the left heel and licensed nursing staff remove the boot every shift and inspect skin under the boot. Resident R1 is receiving his protein drink on a daily basis. R1's wounds are being followed closely by the wound care practitioner and vascular surgeon due to ongoing, non-healing wounds and new wounds especially with increased inflammatory markers on recent labs. Resident R12 no longer resides in the facility. Resident 13 no longer resides in the facility. Resident R14 is being followed for reoccurring unavoidable wounds to left foot by wound care practitioner. Current treatment and interventions are in place.
2. Current Wound Nurse Practitioner wound notes will be reviewed to ensure requested treatment orders have been reviewed with the attending physician. Current residents in house will have a skin observation completed to ensure treatment orders are in place and completed per physician orders
3. Nursing staff will have directed in servicing conducted by Affinity Health Services on July 24th and 25th, 2024 on F686 Pressure Ulcers. DON or designee will in-service licensed nursing staff on the policy and procedure on wound care. Wound rounds will be completed weekly with the Wound Nurse Practitioner and facility nursing team. Treatment orders will be reviewed and implemented timely by nursing staff to ensure care and services of pressure ulcers. The PCC documentation for the electronic treatment administration will be reviewed by the DON or designee during the clinical meeting to ensure documentation is completed for medications and treatments in a timely manner. Physician orders will be reviewed during clinical meetings to identify new orders for heel boots to ensure orders for removal for skin observations by DON designee.
4. 5 resident wound treatment dressing observations will be conducted by the DON or designee to ensure wound treatments are completed timely weekly x4 weeks. The DON or designee will review PCC eTAR documentation is completed timely weekly x4 weeks. 5 MD orders will be reviewed by the DON or designee during the clinical meeting to ensure skin checks are in place for heel boots weekly x4 weeks. The audits will be reviewed by the QAPI committee, and the committee will determine the need for further audits.

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

§483.25(d) Accidents.
The facility must ensure that -
§483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and

§483.25(d)(2)Each resident receives adequate supervision and assistance devices to prevent accidents.

Observations:
Based on review of facility policy, facility documentation, and staff interviews, it was determined that the facility failed to protect residents from injury that resulted in actual harm of a lower leg skin tear for two of four residents (Resident R2 and R10).

Findings include:

Review of facility policy "Safety and Supervision of Residents" date d 11/30/23, indicated that, "resident safety and supervision and assistance to prevent accidents are facility-wide priorities."

Review of facility policy "Activities of Daily Living (ADL), Supporting" dated 11/30/23, indicated appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance.

Review of Resident R2's admission record indicated she was admitted to the facility on 10/22/18.

Review of Resident R2's Minimum Data Set (MDS-periodic assessment of a resident's abilities and care needs) dated 3/27/24, included diagnoses of macular degeneration (vision loss in the center of the field of vision) and dementia (a group of symptoms that affects memory, thinking and interferes with daily life). Section G: Functional Abilities and Goals revealed that for Chair/bed-to-chair transfer (the ability to transfer to and from a bed to a chair or wheelchair) and for Lower body dressing (the ability to dress and undress below the waist, including fasteners) Resident R2 was "Dependent" on staff (meaning that the helper does all of the effort. Resident does none of the effort to complete the activity, or the assistance of two or more helpers is required for the resident to complete the activity).

Review of a physician's order dated 10/4/22, indicated "Transfer status: Transfer assist of 1 with wheeled walker. Assist of 2 with care."

Review of Resident R2's plan of care for "ADL Self Care Performance Deficit related to dementia" active on 5/28/24, failed to include in the interventions what level of staff assistance Resident R2 required for transferring to bed from her wheelchair and for dressing/undressing.

Review of Resident R2's plan of care for "ADL Self Care Performance Deficit related to dementia" updated on 6/2/24, indicated "TRANSFER: resident requires total assistance with transfers." Further review of the updated care plan failed to include interventions related to what level of staff assistance Resident R2 required for dressing/undressing.

Review of Resident R2's Kardex (document that outlines the patients' ADLs, continence levels, and behaviors, as well as physician, advanced directives, diet, and allergies) utilized by nurse aide staff dated as of 5/27/24, indicated "ADL - Transferring assist times 1 with wheeled walker; Assist of 2 with care."

Review of a progress note written by Registered Nurse (RN) Employee E2 dated 5/28/24, at 10:52 p.m. indicated "RN supervisor notified by LPN (licensed practical nurse) that resident sustained a skin tear to left shin during care. Per LPN the CNA (nurse aide) providing care for the resident reported that the resident sustained a skin tear to her left shin, and RN supervisor was contacted. Upon entering the room, the resident was observed lying on her bed turned slightly on her right side. Resident did not appear to be in any distress. Resident alert and disoriented at baseline. Resident assessed and wound care provided. Wound measured 6.5cm x 5.5cm x 0.3cm. Resident tolerated wound care well. RN assessment, skin tear measured, cleansed with wound cleanser, patted dry, wound approximated and steri-strips (wound closure strips) applied, in area wound could not be approximated Xeroform (fine mesh gauze) was applied to the wound bed, wound covered with ABD pad (highly absorbent dressing that provides padding and protection for large wounds) and wrapped with Kerlix (absorbent rolled bandage), secured with tape. Notification made to [medical provider], [hospice provider], and resident's daughter. CNA staff reeducated on ensuring safety of resident, disengaging from resident during period of agitation, allowing for resident to have a cool down period prior to reapproaching or having someone else attempt to approach, and reporting of behaviors to nurse for documentation and appropriate treatment of behaviors."

Review of a written statement by Nurse Aide (NA) Employee E2 dated 5/28/24, indicated, "I was getting her in bed and she was fighting me. I went to pull her pants down and she was trying to kick at me and in the process, she got a skin tear to her lower left leg. Nurse [LPN Employee E4] aware."

During a follow-up interview on 6/4/24, at 7:15 p.m. NA Employee E2 confirmed that she provided care alone to Resident R2. "When asked why she provided care alone when Resident R2 is ordered two people for care, NA Employee E2 stated that Resident R2 is "usually not combative."

Review of Resident R10's admission record indicated she was admitted to the facility on 10/14/23.

Review of Resident R10's MDS dated 4/15/24, included diagnoses of heart failure (a progressive heart disease that affects pumping action of the heart muscles) and dementia (a group of symptoms that affects memory, thinking and interferes with daily life). Section G: Functional Abilities and Goals revealed that for Chair/bed-to-chair transfer Resident R10 required "Substantial/maximal assistance" meaning that the helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."

Review of a progress note dated 5/15/24, at 10:56 a.m. indicated, "CNA alerted this nurse that resident obtained a skin tear to her left shin while transferring resident OOB (out of bed) into w/c (wheelchair). It was reported that resident was resistant during transfer and was not following simple commands. Resident remains in stable condition and VS WNL (vital signs within normal limits).

Review of a facility provided incident report dated 5/15/24, indicated CNA (nurse aide) alerted nurse that resident obtained a skin tear to left shin while transferring OOB into w/c. The "Resident Description" section indcated, "Unable to give accurate accout, resident is a poor historian."

During a follow-up interview on 6/14/24, at 10:48 a.m. NA Employee E17 stated that Resident R10 is confused, and was initially holding onto the wheelchair tightly. Confirmed that she was nervous, but eventually did comply with requests to let go of the wheelchair.

During an interview on 6/14/24, at approximately 11:30 a.m., the Nursing Home Administrator confirmed that the facility failed to protect residents from injury that resulted in actual harm of a lower leg skin tear for two of four residents.

28 Pa. Code 201.14(a) Responsibility of Licensee.
28 Pa. Code 201.18(b)(1)(3) Management.
28 Pa. Code 201.29(a)(c)(d)(j) Resident Rights
28 Pa. Code 211.10(c)(d) Resident Care Policies.
28 Pa. Code 211.12(d)(1)(3) Nursing services.

Plan of Correction - To be completed: 08/06/2024

1. Resident R2's skin tear is healing, and the resident continues to be seen by the Wound Care Nurse Practitioner. Resident R2 remains an assist of 2 with care. Resident R10's skin tear is now healed.
2. Current residents in house will have a skin observation completed to ensure treatment orders are in place and completed per physician orders. Current residents will be evaluated by the therapy department to identify current bed mobility and transfer status.
3. Facility staff will have directed Inservice conducted by Affinity Health Services on July 24th an d25th, 2024 on F689 Supervision to Prevent Accidents. Nursing staff will be in serviced on how to identify the transfer status and mobility status of residents by DON or designee. Risk management reports for the last 14 days will be reviewed to ensure accidents are investigated and reported to the appropriate agencies as applicable by the ADMIN or designee.
4. The DON or designee will complete 5 transfer and bed mobility audits to ensure care is provided per MD orders weekly x 4weeks. The ADMIN or designee will review risk management reports during the clinical meeting to ensure complete investigations for accidents at least weekly x4 weeks. The audits will be reviewed by the QAPI committee and the QAPI committee will determine the need for further audits.

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.

Plan of Correction - To be completed: 08/06/2024

1. First and second floor nursing unit nutrition room refrigerators have been cleaned. Outdated food has been removed. Resident food has been labeled and dated. The temperature logs are current.
2. The current nursing unit nutrition room refrigerators have been cleaned. Outdated food has been removed. Resident food has been labeled and dated. The temperature logs are current.
3. Housekeeping and nursing staff will be serviced by the DON or designee to ensure nursing unit nutrition room refrigerators are clean and food is labeled and dated, and temperature logs are completed timely.
4. Certified Dietary Manager or designee will complete 5 observations audits of the nursing unit nutrition room refrigerators to ensure food is labeled and dated and refrigerators are clean and temperature logs are completed weekly x4 weeks. The audits will be reviewed by the QAPI committee, and the committee will determine the need for further audits.

483.35(a)(1)(2) REQUIREMENT Sufficient Nursing Staff:

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(a) Sufficient Staff.
The facility must have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment required at §483.70(e).

§483.35(a)(1) The facility must provide services by sufficient numbers of each of the following types of personnel on a 24-hour basis to provide nursing care to all residents in accordance with resident care plans:
(i) Except when waived under paragraph (e) of this section, licensed nurses; and
(ii) Other nursing personnel, including but not limited to nurse aides.

§483.35(a)(2) Except when waived under paragraph (e) of this section, the facility must designate a licensed nurse to serve as a charge nurse on each tour of duty.

Plan of Correction - To be completed: 08/06/2024

1. R1, R4, R5, R6, R7, R8, R9, R13, R14, R15, R16, R17, R18, R19, R20, R21, R22, R23, R24, R25, R26 and R27 call lights are being answered timely and concern forms have been followed up on. Resident R14 has had a shave and fingernails cut. R1's orders for treatments have been reviewed by CRNP or wound practitioner and are completed per order.R4's orders for treatments have been reviewed by CRNP or wound practitioner and are completed per order.
2. Current residents in house will have a skin observation completed to ensure treatment orders are in place and completed per physician orders. Current residents will be observed for facial hair and long nails and care will be provided if needed.
3. The nursing staff will be in serviced by the DON or designee on complete PCC/POC documentation and the distribution of meal trays. The PCC documentation for the treatment administration will be reviewed by the DON or designee during clinical meetings to ensure documentation is completed for treatments in a timely manner. The nursing staff will be in-serviced on phone and ear bud use during working hours by the HRD or designee. Concern Forms will be reviewed during the clinical meeting to ensure follow up of concerns.
4. 5 resident wound treatment dressing observations will be conducted by the DON or designee to ensure wound treatments are completed timely weekly x4 weeks. The DON or designee will review PCC eTAR documentation is completed timely weekly x4 weeks. The ADMIN or designee will complete 5 call bell audits, at least 1 per shift to ensure call bells are being answered timely to ensure needs are met weekly x4 weeks, monthly x 3 months. HR director or designee will conduct rounds randomly on all shifts to ensure staff are not using phones or ear buds during working hours at least 10 observations weekly x4 weeks. The ADMIN or designee will review concern forms on a weekly basis x4 weeks to ensure follow up. The RN supervisor or designee will audit meal carts to ensure meals have been distributed to residents at least weekly x4 weeks. The audits will be reviewed by the QAPI committee and the QAPI committee will determine the need for further audits

483.95 REQUIREMENT Training Requirements:

§483.95 Training Requirements
A facility must develop, implement, and maintain an effective training program for all new and existing staff; individuals providing services under a contractual arrangement; and volunteers, consistent with their expected roles. A facility must determine the amount and types of training necessary based on a facility assessment as specified at § 483.70(e). Training topics must include but are not limited to-

Observations:

Based on review of facility documentation and staff interviews, it was determined that the facility failed to develop, implement, and maintain an effective training program, including additional training topics based on the resident population, outcome of the facility assessment, or non-common procedures for three of six staff members sampled (RN Employee E12, LPN Employee E15 and E16).

Findings include:

Review of the "Facility Assessment" dated 11/30/23, indicated the facility included under the section, "Acuity - Frequency of Potentially High-Risk Treatments" that surgical drains are a type of care provided. Within the subsequent section, "Acuity - Care requirements" the assessment indicated staff competencies were required. No further information was available describing what type of education would be provided.

Review of physicians' orders dated from 6/1/23, through 5/31/24, revealed two residents had orders provided for the care of a Jackson-Pratt drain (JP drain, a surgical suction drain that gently draws fluid from a wound to help the resident recover after surgery).

Review of a progress note written by LPN Employee E16, dated 3/29/24, at 12:20 a.m. indicated, "Resident has had no output from J-Tube (jejunostomy tube is a soft, plastic tube placed through the skin of the abdomen into the midsection of the small intestine) in the last 24 hours. Denies pain or discomfort at this time. Will continue to monitor for pain and or output." (Resident in this note did not have a J-tube, Resident had a JP drain).

Review of a progress note dated 4/2/24, at 2:34 a.m. indicted, "Resident continues to have no output in J-tube." (Resident in this note did not have a J-tube, Resident had a JP drain).

During interviews with licensed practical nurse (LPN) Employee E8 (5/31/24, at 10:59 a.m.), LPN Employee E5 (5/31/24, 11:13 a.m.), and LPN Employee E4 (6/2/24, 342 p.m.), when asked to describe the procedure for care and emptying of a JP drain, each was able to do so successfully.

During an interview on 5/31/24, at 11:10 a.m. LPN Employee E15, when asked to describe the procedure for care and emptying of a JP drain, stated that you open the bottom and let the fluid drain out and re-close it. When prompted if the bulb should be compressed before closing the valve, LPN Employee E15 stated, "I think so."

During an interview on 6/2/24, at 3:37 p.m. Registered Nurse Supervisor Employee E12, when asked to describe the procedure for care and emptying of a JP drain, stated that after draining the fluid from the bulb, she allows it to re-inflate prior to closing the valve.

During an interview on 6/2/24, at approximately 1:00 p.m. when asked what type of education was provided to staff for the care of a JP drain, the Director of Nursing (DON) stated that a paper was put on the medication cart. The DON further confirmed that no evaluation for competency was completed with the nursing staff to ensure understanding of the care of a JP drain.

During an interview on 6/14/24, at approximately 11:30 a.m. the Nursing Home Administrator confirmed the care of a JP drain was not a common requirement in the facility, confirmed that the facility did not evaluate staff to ensure competency of the care of a JP drain, and further confirmed that the facility failed to develop, implement, and maintain an effective training program, including additional training topics based on the resident population, outcome of the facility assessment, or non-common procedures for four of six staff members sampled.

28 Pa. Code 201.19(7) Personnel policies and procedures.
28 Pa. Code 201.20(a) Staff development.

Plan of Correction - To be completed: 08/06/2024

1. Employee E12, E15 and E16 have been educated and competencies completed on JP drains.
2. Current licensed staff will be in serviced and a competency will be completed on JP drains.
3. The DON or designee will Inservice licensed staff on the JP drain policy and procedures. The DON or designee will review MD orders during the clinic meeting for orders for JP drains and will ensure nursing staff are competent to care for the drain.
4. The DON or designee will conduct 5 JP drain observations to ensure nursing competency weekly x4 weeks. The audits will be reviewed by the QAPI committee, and the committee will determine the need for further audits.

483.35(a)(3)(4)(c) REQUIREMENT Competent Nursing Staff:

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 Nursing Services
The facility must have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment required at §483.70(e).

§483.35(a)(3) The facility must ensure that licensed nurses have the specific competencies and skill sets necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care.

§483.35(a)(4) Providing care includes but is not limited to assessing, evaluating, planning and implementing resident care plans and responding to resident's needs.

§483.35(c) Proficiency of nurse aides.
The facility must ensure that nurse aides are able to demonstrate competency in skills and techniques necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care.

Observations:

Based on a review of nursing job descriptions, facility documents, clinical record, and staff interviews, it was determined that the facility failed to assure that licensed nurses displayed the appropriate competencies and skills sets to provide nursing services for one of two residents (Resident R11).

Findings include:

Review of the facility provided Registered Nurse (RN) job description titled, "Staff Nurse (RN)" indicated the RN nurse is responsible for competent administration of care and treatments according to physician orders and facility policy and procedure.

Review of the facility provided Licensed Practical Nurse (LPN) job description titled, "LPN Supervisor" indicated the LPN must demonstrate knowledgeable of nursing and medical practices and procedures.

Review of the "Facility Assessment" dated 11/30/23, indicated surgical drains as a type of care provided by the facility.

Review of the Lippincott "The Art and Science of Person-Centered Care, 9th edition" dated 11/9/18, included in the steps for care for a Jackson-Pratt drain (JP drain, a surgical suction drain that gently draws fluid from a wound to help the resident recover after surgery):
- Place the graduated collection container under the drain outlet. Without contaminating the outlet valve, pull off the cap. The chamber will expand completely as it draws in air. Empty the chamber's contents completely into the container. Use the gauze pad to wipe the outlet. Fully compress the chamber with one hand and replace the cap with your other hand."

Review of the clinical record indicated Resident R11 was admitted to the facility on 11/7/17.

Review of the Minimum Data Set (MDS, mandated assessment of a resident's abilities and care needs) for Resident R11 dated 3/30/24, included diagnoses of hemiplegia (paralysis on one side of the body), Alzheimer's disease (a type of brain disorder that causes problems with memory, thinking and behavior), and aftercare following surgery for neoplasm (a new and abnormal growth of tissue in some part of the body, especially as a characteristic of cancer). Review of Section C: Cognitive Patterns, Questions C0500 "BIMS Summary Score" revealed Resident R11's score to be "15."

Review of a physician's order dated 3/27/24, indicated for staff to "Empty JP drain every shift. Strip the tubing to keep it clear of clots that may form. Record amount of drainage every shift."

Review of a progress note dated 3/29/24, at 12:20 a.m. indicated, "Resident has had no output from J-Tube (jejunostomy tube (J-tube) is a soft, plastic tube placed through the skin of the abdomen into the midsection of the small intestine. Resident R11 did not have a J-tube). in the last 24 hours. Denies pain or discomfort at this time. Will continue to monitor for pain and or output."

Review of a progress note dated 3/29/24, at 10:49 a.m. indicated, "[Provider's] office called. Informed on no output in JP drain. Instructed to attempt to strip tubing with fingers. There is no build up in external tubing to be strip at this time. Instructed to call back office by 2pm today to give up date.

Review of a progress note dated 3/29/24, at 1:52 p.m. indicated, "Approx 2.5 cc (cubic centimeters, equal to milliliters) of drainage in bulb. Tubing with minimal scant drainage in tubing."

Review of a telephone encounter note dated, 3/29/24, indicated , "I spoke to RN Employee E19, supervisor at the facility. She states the drain had 130 cc's of output since surgery, bu no output over the last 2 shifts. She will go attempt to strip the drain, because she is unsure if anyone has tried that."

Review of a surgical provider note dated 4/22/24, indicated, "Palpable seroma (buildup of fluid in a place on the body where tissue has been removed) with clot in drain tubing stopping output. Tubing was stripped allowing movement of clot and release of fluid. Fluid accumulated to about 180 mL (milliliters) of SS fluid (serosanguinous fluid, combination of serous fluid and blood).

Review of a progress note dated 4/2/24, at 2:34 a.m. indicted, "Resident continues to have no output in J-tube (Resident R11 did not have a J-tube)."

Review of the "After Visit Summary" of Resident R11 post-operative surgical visit dated 4/3/24, revealed, "Apparently the drain has not put significant fluid out for the last 3-4 days although it is difficult to get an accurate assessment from the patient and even more difficult to get input from the nursing home."

Under the "Exam" section of this document, it was noted, "drain was not compressed. It was flushed and we were able to get proximally 400 cc between the drain and aspiration. It appears functioning at this time."

During interviews with LPN Employee E8 (5/31/24, at 10:59 a.m.), LPN Employee E5 (5/31/24, 11:13 a.m.), and LPN Employee E4 (6/2/24, 342 p.m.) when asked to describe the procedure for care and emptying of a JP drain, each was able to do so successfully.

During an interview on 5/31/24, at 11:10 a.m. LPN Employee E15 when asked to describe the procedure for care and emptying of a JP drain, stated that you open the bottom and let the fluid drain out and re-close it. When prompted if the bulb should be compressed before closing the valve, LPN Employee E15 stated, "I think so."

During an interview on 6/2/24, at 3:37 p.m. RN Employee E12 when asked to describe the procedure for care and emptying of a JP drain, stated that after draining the fluid from the bulb, she allows it to re-inflate prior to closing the valve.

During an interview on 6/3/24, at 10:17 a.m. with the oncology nurse, she stated, "There was do much drainage built up, it looked like she had another breast on her chest." When asked about how much of the fluid collected was from the JP drain and how much was aspirated, the nurse stated that the majority was from the drain, and the aspiration needle was used not to withdraw fluid, but to clear the blockage that most likely developed from the tubing not being properly stripped, allowed it to coagulate."

During an interview on 6/14/24, at approximately 11:30 a.m. the Nursing Home Administrator confirmed that the facility failed to assure that licensed nurses displayed the appropriate competencies and skills sets to provide nursing services for one of two residents.

28 Pa. Code: 201.14(1) Responsibility of licensee.

28 Pa. Code: 201.18(a)(3) Management.

Plan of Correction - To be completed: 08/06/2024

1. Resident R11no longer has a JP drain in place.
2. Current residents with JP drains will be reviewed to ensure appropriate MD orders are in place.
3. Licensed nursing staff will in serviced and competencies completed on JP drains by the DON or designee. Licensed nursing staff will be educated and competencies completed on any new special procedures and treatments that are not identified on the facility assessment.
4. 5 residents with JP drain observations will be completed by the DON or designee to ensure care and services weekly x4 weeks. The audits will be reviewed by the QAPI committee, and the committee will determine the need for further audits.

483.40(b)(3) REQUIREMENT Treatment/Service for Dementia:

§483.40(b)(3) A resident who displays or is diagnosed with dementia, receives the appropriate treatment and services to attain or maintain his or her highest practicable physical, mental, and psychosocial well-being.

Observations:

Based on facility documents, clinical record review, and staff interview, it was determined that the facility failed to provide the necessary services and failed to make certain appropriate treatment, and services for dementia were provided to one of four residents (Resident R2).

Findings include:

Review of the National Library of Medicine document, "Sundowning in Dementia" dated 12/27/16, defined sundowning as the emergence or worsening of neuropsychiatric symptoms (NPS) in the late afternoon or early evening. It represents a common manifestation among persons with dementia and is associated with several adverse outcomes (such as institutionalization, faster cognitive worsening, and greater caregiver burden).

Review of the facility policy, "Dementia - Clinical Protocol" dated 11/30/23, indicated for the individual with confirmed dementia, the IDT (interdisciplinary care team will identify a resident-centered care plan to maximize remaining function and quality of life. Nursing assistants will receive initial training in the care of residents with dementia and related behaviors. Direct care staff will support the resident in initiating and completing activities of daily living.

Review of facility policy "Activities of Daily Living (ADL), Supporting" dated 11/30/23, indicated appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident.

Review of the Resident Assessment Instrument 3.0 User's Manual effective October 2023, indicated that a Brief Interview for Mental Status (BIMS) is a screening test that aides in detecting cognitive impairment. The BIMS total score suggests the following distributions:
13-15: cognitively intact
8-12: moderately impaired
0-7: severe impairment

Review of Resident R2's admission record indicated she was admitted to the facility on 10/22/18.

Review of Resident R2's Minimum Data Set (MDS-periodic assessment of a resident's abilities and care needs) dated 3/27/24, included diagnoses of macular degeneration (vision loss in the center of the field of vision) and dementia (a group of symptoms that affects memory, thinking and interferes with daily life). Review of Section C: Cognitive Patterns, Questions C0500 "BIMS Summary Score" revealed Resident R2's score to be 0 .

Review of Resident R2's plan of care for "Potential to demonstrate physical behaviors combativeness such as kicking related to dementia, impaired decision making," active on 5/28/24, included only one intervention: "Assess and anticipate resident's need for food, thirst, toileting needs, comfort level, body positioning, pain, etc."

Review of Resident R2's plan of care for "Impaired cognitive function/dementia or impaired thought processes related to dementia, impaired decision making," active on 5/28/24, failed to include interventions behavioral disturbances.

Review of Resident R2's plan of care for "ADL Self Care Performance Deficit related to dementia" active on 5/28/24, failed to include in the interventions to address behavioral concerns related to ADL care.

Review of Resident R2's Kardex (document that outlines the patients' ADLs, continence levels, and behaviors, as well as physician, advanced directives, diet, and allergies) utilized by nurse aide staff dated as of 5/27/24, failed to include direction to the nurse aides related to behavioral disturbances."

Review of Resident R2's progress notes from May 2023, through May 2024, failed to include any notes documenting a behavioral disturbance.

Review of the clinical record failed to include any behavior charting completed by licensed or non-licensed nursing staff.

Review of a progress note written by Registered Nurse (RN) Employee E2 dated 5/28/24, at 10:52 p.m. indicated "RN supervisor notified by LPN (licensed practical nurse) that resident sustained a skin tear to left shin during care. Per LPN the CNA (nurse aide) providing care for the resident reported that the resident sustained a skin tear to her left shin, and RN supervisor was contacted. Upon entering the room, the resident was observed lying on her bed turned slightly on her right side. Resident did not appear to be in any distress. Resident alert and disoriented at baseline. Resident assessed and wound care provided. Wound measured 6.5 cm x 5.5 cm x 0.3 cm. Resident tolerated wound care well. RN assessment, skin tear measured, cleansed with wound cleanser, patted dry, wound approximated and steri-strips (wound closure strips) applied, in area wound could not be approximated Xeroform (fine mesh gauze) was applied to the wound bed, wound covered with ABD pad (highly absorbent dressing that provides padding and protection for large wounds) and wrapped with Kerlix (absorbent rolled bandage), secured with tape. Notification made to [medical provider], [hospice provider], and resident's daughter. CNA staff reeducated on ensuring safety of resident, disengaging from resident during period of agitation, allowing for resident to have a cool down period prior to reapproaching or having someone else attempt to approach, and reporting of behaviors to nurse for documentation and appropriate treatment of behaviors."

Review of a written statement by Nurse Aide (NA) Employee E2 dated 5/28/24, indicated, "I was getting her in bed and she was fighting me. I went to pull her pants down and she was trying to kick at me and in the process, she got a skin tear to her lower left leg. Nurse [LPN Employee E4] aware."

During a follow-up interview on 6/4/24, at 7:15 p.m. NA Employee E2 stated that she was able to place Resident R2 into bed, with Resident R2 not being combative at that time. NA Employee E2 stated that when she was going to remove Resident R2's pants, "she shot back up, like sitting up. I tried to pull her pants down and she tried to kick at me a little bit, and I guess I pulled the pant leg down to fast." NA Employee E2 confirmed that Resident R2 does become combative at times and confirmed that she provided care alone to Resident R2. "When asked why she provided care alone when Resident R2 is ordered two people for care, NA Employee E2 stated that Resident R2 is "usually not combative."

During an interview on 6/14/24, at approximately 11:30 a.m. the Nursing Home Administrator confirmed that facility staff failed to provide the necessary services and failed to make certain appropriate treatment, and services for dementia for one of four residents (Resident R2).

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

28 Pa. Code 211.10(d) Resident care policies.
.
28 Pa. Code: 201.29(a)(b)(c)(i)(n) Resident rights.

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

Plan of Correction - To be completed: 08/06/2024

1. R2's no longer resides in the facility.
2. Current residents will be reviewed for behaviors and behavior charting will be added to ensure behavioral documentation and plan of care will be reviewed and updated if indicated. Current residents in house will have a skin observation completed to ensure treatment orders are in place and completed per physician orders. Therapy staff screened current residents for appropriate transfer status and bed mobility and updated status was compared to nurse aide task list and task list was updated if indicated.
3. Nursing staff will be in serviced by the DON or designee on how to identify the transfer status and mobility status of residents. Nursing staff will be in serviced by the DON or designee on behavior monitoring and documentation. The Social Service Director will review progress notes and identify resident behaviors during the clinical meeting to ensure behavior documentation and plan of care are in place.
4. The DON or designee will complete 5 transfer and bed mobility audits to ensure care is provided per MD orders weekly x 4weeks. The DON or designee will complete 5 behavior audits to ensure documentation is completed in POC/PCC weekly x4 weeks. The Social Service director or designee will complete 5 progress note review to ensure behavior documentation is in place weekly x4 weeks. The audits will be reviewed by the QAPI committee, and the committee will determine the need for further audits.

483.40(d) REQUIREMENT Provision of Medically Related Social Service:

§483.40(d) The facility must provide medically-related social services to attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident.

Observations:

Based on review of the clinical record, physician records, documents, and staff interviews, it was determined that the facility failed to schedule ordered appointments and failed to provide transportation for one of three residents (Resident R11), which resulted in the actual harm of a delay in cancer treatment.

Findings include:

Review of the Resident Assessment Instrument 3.0 User's Manual effective October 2023, indicated that a Brief Interview for Mental Status (BIMS) is a screening test that aides in detecting cognitive impairment. The BIMS total score suggests the following distributions:
13-15: cognitively intact
8-12: moderately impaired
0-7: severe impairment

Review of information provided by the U.S. National Institutes of Health; National Cancer Institute indicated a port (commonly referred to as a port-a-cath) is a "device that is usually placed under the skin in the right side of the chest. It is attached to a catheter (a thin, flexible tube) that is threaded into a large vein above the right side of the heart. A port-a-cath is used to give intravenous fluids, blood transfusions, chemotherapy, and other drugs. It is also used for taking blood samples. A port-a-cath may stay in place for a long time and helps reduce the need for repeated needle sticks."

Review of the clinical record indicated Resident R11 was admitted to the facility on 11/7/17.

Review of the Minimum Data Set (MDS, mandated assessment of a resident's abilities and care needs) for Resident R11 dated 3/30/24, included diagnoses of hemiplegia (paralysis on one side of the body), Alzheimer's disease (a type of brain disorder that causes problems with memory, thinking and behavior), and aftercare following surgery for neoplasm (a new and abnormal growth of tissue in some part of the body, especially as a characteristic of cancer). Review of Section C: Cognitive Patterns, Questions C0500 "BIMS Summary Score" revealed Resident R11's score to be "15."

Review of a progress note written by Registered Nurse (RN) Employee E18 dated 1/26/24, at 5:36 p.m. "Returned from appt. No new orders. Follow-up appt needs to be scheduled."

Review of the physician appointment after visit summary dated 1/26/24, included referrals for:
-NM (nuclear medicine) PET/CT (PET, positron emission tomography, an imaging test that uses a radioactive substance to look for disease in the body). Skull-thigh-Initial (First imaging test done, from the skull through mid-thigh).
-Echocardiogram (ultrasound test that checks the structure and function of the heart).
Paper orders for these tests were included with the discharge paperwork, with directions highlighted at the top, with the phone number to schedule the tests.

Review of physician appointment after visit summary dated 1/31/24, included in the "Instructions" section, handwritten in large letters, "2/16/24 Port Insertion Surgery." A paper orders for the PET scan was again included, with directions circled at the top with the phone number to schedule the tests.

Review of a progress note dated 2/15/24, at 10:16 a.m. indicated Resident R11's port placement surgery was confirmed with the facility for the following day.

Review of a progress note dated 2/15/24, at 12:01 p.m. indicated the port placement appointment was cancelled due to the PET scan and echocardiogram not being done.

Review of a progress note dated 2/15/24, at 12:20 p.m. revealed the PET scan now scheduled for 2/22/24.

Review of a progress note dated 2/15/24, at 2:09 p.m. revealed the echocardiogram now scheduled for 2/21/24.

Review of a surgical provider note dated 2/28/24, indicated, "We have struggled significantly in the past 6 weeks to get her to return for testing. She was scheduled and did not show up for her CT PET scan on at least two occasions and then finally had the test completed last week. She has also failed to show up for blood work and it has been very difficult to have a reliable input from the nursing facility that she resides. After discussing with the medical oncologist, it was felt that proceeding directly to surgery and then making a decision about adjuvant treatment options after she has recovered would be more appropriate rather than having ongoing delays as well as perhaps even multiple missed appointments."

Further in this note, "I did discuss the concerns about reliable follow-up and maintaining multiple appointments for neoadjuvant chemotherapy (chemotherapy provided to shrink a tumor prior to surgical removal) but also if we were to consider breast conservation which was the original plan to make a daily appointments for radiation and the difficulty with transportation from her facility. Given these problems I had recommended we reconsider a mastectomy and then we can address adjuvant treatment options once she is recovered. We also discussed the role of genetic testing again and although this has been ordered and set up she failed to make that appointment as well."

Review of a facility appointment sheet dated 4/15/24, indicated that Resident R11 will need port placement.

Review of a surgical provider note dated 4/22/24, indicated, "Patient is 3 weeks and 6 days post op. Patient missed her appointment last week." "Medical oncology is planning to attempt adjuvant chemotherapy and therefore we will place port next week."

Review of a surgical provider note dated 5/6/24, indicated, "Patient was evaluated by Medical Oncology postoperatively and they recommended adjuvant chemotherapy. We again scheduled her for an Infuse-A-Port (type of port, often used for chemotherapy) of which she did not show up at the time of her surgery. I discussed this with Medical Oncology about concerns of putting her through an additional surgical procedure only not to have completed therapy therefore we decided to initiate her chemotherapy without the Infuse-A-Port." "Major obstacles has been compliance and working with the nursing home to make appointments and schedule surgery."

Review of a physician's note dated 5/21/24, indicated that Resident R11 is scheduled to infuse-a-port.

During an interview on 6/3/24, at 10:44 a.m. the Oncology Nurse from physician's office confirmed that the care team for Resident R11 is made up of two sides, the surgical team, and the oncology team that is treating the cancer. the Oncology Nurse confirmed that while the pre-op testing is not required for the port placement by the surgical team, the oncology providers were unwilling for the port placement to occur, due to the PET scan and echocardiogram not being done, to allow them to develop a treatment plan and decide if chemotherapy was necessary. The Oncology Nurse definitively stated that the port placement was canceled solely due to the PET scan and echocardiogram not being completed. The Oncology Nurse stated that Resident R11 was not transported to multiple appointments ("no-shows"), that she was not able to be provided a person at the facility to was responsible for coordinating care, and stated that she informed the facility that they are delaying care of Resident R11's breast cancer.

During this interview the Oncology Nurse further confirmed that the original plan was for Resident R11 to have the port placed in February (2024), to be able to provide chemotherapy to be given to shrink Resident R11's tumor, prior to the surgery. The Oncology Nurse stated that due to the missed appointments and testing, the plan was changed from an attempt to conserve Resident R11's breast, to a mastectomy, as the surgical and oncology team did not think Resident R11 would be consistently transported for daily radiation that breast conservation would require.

Review of a progress note dated 6/12/24, at 3:16 a.m. indicated that Resident R11 returned from port insertion.

During an interview on6/14/24, at approximately 11:30 a.m. the Nursing Home Administrator was made aware of the concerns related to the facility's failure to schedule ordered appointments and failure to provide transportation for one of three residents, which resulted in the actual harm of a delay in cancer treatment.

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

28 Pa. Code 201.18 (b)(1))(3)(e)(1) Management.

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

28 Pa. Code 211.2 (a) Physician services.

28 Pa. Code 211.16 (a) Social services.

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

Plan of Correction - To be completed: 08/06/2024

1. Resident R11's was provided transportation to the port placement appointment. Resident R11's follow up appointments have been scheduled and transportation has been scheduled.
2. The DON or designee will review current residents with future appointments to ensure transportation and follow-up has been arranged.
3. Licensed nursing staff will be in serviced on obtaining transportation for appointments by the DON or designee. The DON or designee will review MD orders and consult follow up during the clinic meeting to ensure transportation and appointments have been obtained.
4. The DON or designee will complete 5 consult audits weekly x4 weeks to ensure appointments, recommendations and transportation has been arranged. The audits will be reviewed by the QAPI committee, and the committee will determine the need for further audits.

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, observation, and staff interview, it was determined that the facility failed to maintain infection control practices to prevent the potential of infection and/or reinfection occurring for one of four residents (Resident R1).

Findings include:

Review of the facility policy, "Infection Prevention and Control Program" dated 11/30/23, indicated the facility maintains an Infection Prevention and Control Program to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable dieases and infections.

Review of the clinical record revealed Resident R1 was admitted to the facility on 8/4/23.

Review of the Minimum Data Set (MDS, periodic assessment of resident care needs) dated 5/20/24, included diagnoses of osteomyelitis (inflammation of bone or bone marrow, usually due to infection), peripheral vascular disease (PVD, circulatory condition in which narrowed blood vessels reduce blood flow to the limbs), and diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time).

Review of a physician's order dated 8/24/23, indicated "Wound Care: Every two hours, t/r (turn and reposition) in bed; Elevate heels with bunny boots (cushioned, heel protector booties)."

Review of the wound nurse practitioner's report dated 5/29/24, indicated Resident R1 had a Stage IV pressure wound (full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer) on his right heel. The wound was noted to have a moderate amount of sanguineous exudate (leakage of fresh blood from an open wound).

During an observation on 5/31/24, at 1:21 p.m. Resident R1's bunny boot and dressing were observed. When the boot was removed for Registered Nurse (RN) Employee E1 to complete the dressing change on Resident R1's right heel, the boot was noted to be very soiled with wound drainage. Large, crusted areas of wound drainage were present, and areas where the drainage had dried into the boot were visible.

During an interview on 5/31/24, at 1:23 p.m. RN Employee E1 confirmed that the boot was extremely soiled, and should have been changed to prevent possible infection from developing.

During an interview on 5/31/24, at 3:00 p.m. the Nursing Home Administrator confirmed the failed to maintain infection control practices to prevent the potential of infection and/or reinfection occurring for one of four residents.

28 Pa. Code: 201.14(a) Responsibility of licensee.
28 Pa. Code: 201.18(b)(1)(e)(1) Management.
28 Pa. Code: 201.20(c) Staff development.
28 Pa. Code: 211.10(d) Resident care policies.
28 Pa. Code: 211.12(d)(1)(2)(3)(5) Nursing services.

Plan of Correction - To be completed: 08/06/2024

1. Resident R1's heel boots have been replaced.
2. DON or designee with review current residents with heel boots to ensure heel boots are clean and in good repair.
3. DON or designee will in-service nursing staff on replacing heel boots if soiled.
4. The DON or designee will complete 5 residents with heel boot audits weekly x4 weeks to ensure heel boots are clean and in good repair. The audits will be reviewed by the QAPI committee, and the committee will determine the need for further audits.

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

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

Plan of Correction - To be completed: 08/06/2024

1. The facility is unable to retroactively correct the staffing ratio for days: 5/12/24, 5/17/24, 5/18/24, 5/19/24, 5/20/24, 5/21/24, 5/22/24, 5/23/24, 5/24/24, 5/26/24, 5/27/24, 5/29/24, 5/30/24, 5/31/24, and 6/1/24.
2. The facility will schedule CNA's to state ratio. Call outs will be monitored by NHA/DON and/or designee. Facility staff as well as staffing agencies will be utilized to facilitate replacement/procurement of staff.
3. The staffing ratio will be monitored weekly x4 weeks.
4. Findings will be summarized and brought to the quality assurance and performance improvement committee and reviewed for any further monitoring or changes needed.

§ 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.

Plan of Correction - To be completed: 08/06/2024

1. The facility is unable to retroactively correct the staffing ratio for days: 5/12/24, 5/17/24, 5/18/24, 5/19/24, 5/20/24, 5/21/24, 5/22/24, 5/23/24, 5/24/24, 5/26/24, 5/27/24, 5/29/24, 5/30/24, 5/31/24, and 6/1/24.
2. The facility will schedule LPNs to state ratio of 1 to 25 for day shifts, 1 to 30 for afternoon shifts and 1 to 40 for midnight shifts. Call outs will be monitored by NHA/DON and/or designee. Facility staff as well as staffing agencies will be utilized to facilitate replacement/procurement of staff.
3. NHA or designee will educate the scheduling coordinator on the requirements of LPN ratios of 1 to 25 for day shifts, 1 to 30 for afternoon shifts and 1 to 40 for midnight shifts. The staffing ratio will be monitored weekly x4 weeks.
4. Findings will be summarized and brought to the quality assurance and performance improvement committee and reviewed for any further monitoring or changes needed.

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

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

Observations:

Based on review of facility documents and nursing time schedules and staff interviews it was determined that the facility administrative staff failed to provide the minimum number of general nursing hours to each resident in a 24 hour period on two of 21 days (5/12/24, and 6/1/24).

Findings include:

Review of the "Facility Assessment" updated 2/6/24, indicated, "The facility follows state and federal regulations and guidelines on sufficiency of daily staffing."

Review of the nursing schedules and census information for 5/12/24, through 6/1/24, revealed that the facility failed to maintain 2.87 hours of general nursing care to each resident in a 24-hour period on the following dates:

-5/12/24, Census 99. PPD 2.56.
-6/01/24, Census 97. PPD 2.79.

During an interview on 6/14/24, at approximately 11:30 a.m., the Nursing Home Administrator confirmed that the facility failed to provide the minimum number of general nursing hours to each resident in a 24-hour period on two of 21 days.

Plan of Correction - To be completed: 08/06/2024

1. The facility is unable to retroactively correct the state general nursing hours for days: 5/12/24, 5/17/24, 5/18/24, 5/19/24, 5/20/24, 5/21/24, 5/22/24, 5/23/24, 5/24/24, 5/26/24, 5/27/24, 5/29/24, 5/30/24, 5/31/24, and 6/1/24.
2. The facility will schedule CNA's, LPNs, and RNs to meet state general nursing hours. Call outs will be monitored by NHA/DON and/or designee. Facility staff as well as staffing agencies will be utilized to facilitate replacement/procurement of staff.
3. NHA or designee will educate the scheduling coordinator on the state general nursing hour requirements. The daily general staffing hours will be monitored weekly x4 weeks.
4. Findings will be summarized and brought to the quality assurance and performance improvement committee and reviewed for any further monitoring or changes needed.

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