Pennsylvania Department of Health
SMITH HEALTH CARE, LTD.
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

There are 62 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.


SMITH HEALTH CARE, LTD. - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:

Based on a Medicare/Medicaid Recertification, State Licensure and Civil Rights Compliance Survey completed on June 28, 2024, it was determined that Smith Healthcare, Ltd 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:

483.60(a)(1)(2) REQUIREMENT Qualified Dietary Staff:

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(a) Staffing
The facility must employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, taking into consideration resident assessments, individual plans of care and the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment required at §483.70(e)

This includes:
§483.60(a)(1) A qualified dietitian or other clinically qualified nutrition professional either full-time, part-time, or on a consultant basis. A qualified dietitian or other clinically qualified nutrition professional is one who-
(i) Holds a bachelor's or higher degree granted by a regionally accredited college or university in the United States (or an equivalent foreign degree) with completion of the academic requirements of a program in nutrition or dietetics accredited by an appropriate national accreditation organization recognized for this purpose.
(ii) Has completed at least 900 hours of supervised dietetics practice under the supervision of a registered dietitian or nutrition professional.
(iii) Is licensed or certified as a dietitian or nutrition professional by the State in which the services are performed. In a State that does not provide for licensure or certification, the individual will be deemed to have met this requirement if he or she is recognized as a "registered dietitian" by the Commission on Dietetic Registration or its successor organization, or meets the requirements of paragraphs (a)(1)(i) and (ii) of this section.
(iv) For dietitians hired or contracted with prior to November 28, 2016, meets these requirements no later than 5 years after November 28, 2016 or as required by state law.

§483.60(a)(2) If a qualified dietitian or other clinically qualified nutrition professional is not employed full-time, the facility must designate a person to serve as the director of food and nutrition services.
(i) The director of food and nutrition services must at a minimum meet one of the following qualifications-
(A) A certified dietary manager; or
(B) A certified food service manager; or
(C) Has similar national certification for food service management and safety from a national certifying body; or
D) Has an associate's or higher degree in food service management or in hospitality, if the course study includes food service or restaurant management, from an accredited institution of higher learning; or
(E) Has 2 or more years of experience in the position of director of food and nutrition services in a nursing facility setting and has completed a course of study in food safety and management, by no later than October 1, 2023, that includes topics integral to managing dietary operations including, but not limited to, foodborne illness, sanitation procedures, and food purchasing/receiving; and
(ii) In States that have established standards for food service managers or dietary managers, meets State requirements for food service managers or dietary managers, and
(iii) Receives frequently scheduled consultations from a qualified dietitian or other clinically qualified nutrition professional.

Observations:

Based on staff interview and a review of personnel files and employee credentials, it was determined that the facility failed to employ a full-time qualified dietary services supervisor in the absence of a full-time qualified dietitian.

Findings include:

Prior to beginning the initial tour of the food and nutrition services on June 25, 2024, at 9:00 AM the interim director of nursing stated that the facility did not currently have a full-time qualified dietary services supervisor or a full-time qualified dietitian.

During initial tour of the food and nutrition services department on June 25, 2024, at 9:00 AM Employee 3 (cook/assistant food services supervisor) confirmed that the facility did not currently have a full-time qualified dietary services supervisor. Employee 3 (cook/assistant food services supervisor) stated that the full-time qualified dietary services supervisor had recently resigned. Employee 3 (cook/assistant food services supervisor) stated that in the absence of the full-time qualified dietary supervisor her responsibilities included oversight of food preparation, service, and storage of food. Employee 3 (cook/assistant food services supervisor) stated that the qualified dietitian provided oversight, but was not employed full-time at the facility.

Interview with the interim director of nursing (DON) on June 27, 2024, at 11:00 AM confirmed the facility has been without a full-time qualified dietary services supervisor in the absence of a full- time qualified dietitian since June 5, 2024.

28 Pa Code 201.18(e)(1)(6) Management.

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

1. The facility is actively interviewing FSS candidates to hire and meet regulatory requirements.
2. Same as above
3. The RD will continue with frequent visits to oversee dietary department and assure compliance being met.
4. DON will update NHA weekly on outcomes of interviews and hiring of CDM\FSS.
5. To be Completed by 8/23/2024

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 review of select facility policies and the facility's infection control tracking log, and staff interview, it was determined that the facility failed to maintain and implement a comprehensive program to monitor and prevent infections in the facility, including protocols and provisions for Enhanced barrier precautions and their implementation.

Findings include:

A review of the facility's current infection control policy dated as reviewed by the facility January 2024, revealed that it is the policy of this facility to maintain an infection control program designed to provide a safe environment and to help prevent the development and transmission of infections within the residential population.

The procedure to include: All infections will be identified, monitored and tracked be the appointed infection control nurse on a needs basis utilizing an infection control report flow sheet that clearly states the residents name, diagnosis, treatment modalities, signs and symptoms, isolation precautions and organism( when applicable).

A review of MEMO FROM THE Center for Clinical Standards and Quality/Quality, Safety & Oversight Group, Ref: QSO-24-08-NH, CDC, Centers for disease control, dated March 20, 2024 regarding, "Enhanced Barrier Precautions in Nursing Homes to Prevent Spread of disease" revealed, CMS is issuing new guidance for State Survey Agencies and long term care (LTC) facilities on the use of enhanced barrier precautions (EBP) to align with nationally accepted standards. EBP recommendations now include use of EBP for residents with chronic wounds or indwelling medical devices during high-contact resident care activities regardless of their multidrug-resistant organism status.

" Enhanced Barrier Precautions " (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities.
EBP are used in conjunction with standard precautions and expand the use of PPE to donning of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing.

A review of the facility's infection control data provided at the time of the survey ending June 28, 2024, revealed that the facility's infection control program failed to reflect an operational system to monitor and investigate causes of infection and manner of spread. There was no evidence of a functional system, which enabled the facility to analyze clusters, changes in prevalent organisms, or increases in the rate of infection in a timely manner.

A review of infection control logs revealed the following:
- January 2024
Urinary Tract Infections (UTI)-3
eye infections-1
Sepsis-1
-February 2024
UTI, 6
-eye infections, 3
sepsis, 2
-March 2024
UTI, 7
eye infections, 4
-April 2024
UTI, 7
eye infections. 4
-May 2024
UTI, 6
eye infections, 2

A review of facility infection control logs for June 2024, as of June 14, 2024, revealed that the facility had not yet started tracking infections for the month of June as of the time of the survey ending June 28, 2024.

There was no documentation of any staff or resident education provided in response to the continued urinary and eye infections in the facility noted on the line listings. There was no documentation of any evaluation or interventions designed to prevent the spread of the infections in response to the continued infections that occurred.

There was also no documented evidence that the facility tracked and trended these infections to identify the potential need for intervention with staff and residents to deter similar infections.

There was no indication that the limited data that was compiled was then evaluated to determine what could be done to prevent the spread or recurrence of infection.

Clinical record review revealed that there were 5 residents with indwelling urinary catheters, 2 residents with enteral feeding tubes and 5 residents with wounds.

Observations during the initial environmental tour June 25, 2024 at 9 A.M and again June 26, and June 27, 2024, at 10 AM there was no evidence of EBP for any of the above noted residents in the facility.

Interview with the interim Director of nursing on June 27, 2024, at 1 PM confirmed that the facility infection control tracking logs were incomplete and that the facility was unable to demonstrate a fully functioning comprehensive program to monitor and prevent infections. She further confirmed that there were no EBP implemented for any resident in the facility at the time of the survey despite meeting the above criteria.

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

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

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

1. The facility has initiated EBP for residents with chronic wounds and indwelling medical devices during high contact resident care activities.
2. Same as above
3. The facility will develop an EBP policy and educate all nursing staff. The Infection Control Preventionist will revise the Infection control program to include monitoring and investigating causes of infection and manner of spread. The ICP will analyze clusters, changes on prevalent organisms or increases in the rate of infection in a timely manner.
4. The ICP will submit monthly reports to the infection control quarterly meetings.
5. To be Completed by 8/23/2024

483.20(k)(1)-(3) REQUIREMENT PASARR Screening for MD & ID:

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.

§483.20(k) Preadmission Screening for individuals with a mental disorder and individuals with intellectual disability.

§483.20(k)(1) A nursing facility must not admit, on or after January 1, 1989, any new residents with:
(i) Mental disorder as defined in paragraph (k)(3)(i) of this section, unless the State mental health authority has determined, based on an independent physical and mental evaluation performed by a person or entity other than the State mental health authority, prior to admission,
(A) That, because of the physical and mental condition of the individual, the individual requires the level of services provided by a nursing facility; and
(B) If the individual requires such level of services, whether the individual requires specialized services; or
(ii) Intellectual disability, as defined in paragraph (k)(3)(ii) of this section, unless the State intellectual disability or developmental disability authority has determined prior to admission-
(A) That, because of the physical and mental condition of the individual, the individual requires the level of services provided by a nursing facility; and
(B) If the individual requires such level of services, whether the individual requires specialized services for intellectual disability.

§483.20(k)(2) Exceptions. For purposes of this section-
(i)The preadmission screening program under paragraph(k)(1) of this section need not provide for determinations in the case of the readmission to a nursing facility of an individual who, after being admitted to the nursing facility, was transferred for care in a hospital.
(ii) The State may choose not to apply the preadmission screening program under paragraph (k)(1) of this section to the admission to a nursing facility of an individual-
(A) Who is admitted to the facility directly from a hospital after receiving acute inpatient care at the hospital,
(B) Who requires nursing facility services for the condition for which the individual received care in the hospital, and
(C) Whose attending physician has certified, before admission to the facility that the individual is likely to require less than 30 days of nursing facility services.

§483.20(k)(3) Definition. For purposes of this section-
(i) An individual is considered to have a mental disorder if the individual has a serious mental disorder defined in 483.102(b)(1).
(ii) An individual is considered to have an intellectual disability if the individual has an intellectual disability as defined in §483.102(b)(3) or is a person with a related condition as described in 435.1010 of this chapter.

Observations:

Based on clinical record review and staff interview, it was determined that the facility failed to accurately complete the PASRR (Preadmission Screening and Resident Review) for one of 12 residents reviewed related to PASRR assessments (Resident 89).

Findings include:

The Pennsylvania Department of Human Service Office of the Long-Term Living Bulletin issued March 1, 2024, and effective March 1, 2024, issued a revised Pennsylvania Preadmission Screening Resident Review (PASRR) Level I identification form (PASRR Level I). The revised PASRR Level I form (MA 376 3/24) replaces the PASRR Level I Form (MA 376 11/18).

Beginning March 1, 2024 the revised PASRR Level I form must be completed, prior to or no later than the day of admission, for individuals seeking admission to an MA certified nursing facility, regardless of the individual's payment source. If the applicant/resident is unable to answer the questions, another person who is knowledgeable about the applicant's/resident's medical condition and history (for example: family member, legal representative, or member of the health care team) may help to complete the form. Nursing facilities are responsible for assuring the accuracy of information reported on the PASRR Level I form. For a new resident entering the nursing facility, the nursing facility must make corrections to the PASRR Level I form on the resident's chart when new or missed information becomes
available (for example, information provided by the family or doctor). Do not complete a new PASRR Level I for residents readmitted from a short-term acute care hospital stay that were in the nursing facility prior to the hospital stay. For these individuals, just update the PASRR Level I that was used in the nursing facility prior to the hospital stay. If the individual has a change in condition that affects program office criteria as found on the PASRR Level I form, a PASRR Level II evaluation form will need to be completed. Nursing facilities will communicate the need to have a PASRR Level II form done by notifying the department's Office of Long-Term Living, Division of Nursing Facility Field Operations Team via the MA 408 form. Nursing facilities are to advise applicants/residents regarding their rights to know how the PASRR process will be used, how to obtain a copy of this form, and the procedure to appeal the results of a decision by the departments program office. If the applicant meets program office criteria and is not an Exceptional Admission, as defined on page 6 of the PASRR Level I form, the individual's PASRR Level I form, along with other required documents, must be forwarded to Aging Well, who will complete a PASRR Level II evaluation and will also determine the level of care the individual needs prior to an individual's admission to the nursing facility. Failure to complete the most current version of the PASRR Level I and, when applicable, the PASRR Level II, prior to admission or on the day of admission will result in forfeiture of MA reimbursement to the nursing facility during the period of noncompliance in accordance with Federal PASRR Regulations at 42 CFR 483.122.

The revised PASRR Level I form (MA 376 3/24) will be required for admissions on March 1, 2024 and thereafter. Previous versions of the PASRR Level I form are not acceptable for new admissions on March 1, 2024, and thereafter.

Review of the clinical record revealed that Resident 89 was admitted to the facility on June 8, 2024, with diagnoses which included COPD (chronic obstructive pulmonary disease- a group of lung diseases that block airflow and make it difficult to breathe).

Review of Resident 89's Level I PASRR dated June 8, 2024, indicated the review was completed using the PASRR Identification Form dated September 1, 2018 (MA 376 11/18).

Interview with the social services consultant on June 27, 2024, at approximately 11:00 AM confirmed that the facility was not yet using the revised PASRR Level I form (MA 376 3/24).

Interview with the administrator on June 27, 2024, at 11:30 AM confirmed that the facility failed to timely implement the revised PASRR Level I form (MA 376 3/24).

28 Pa. Code 201.14 (a) Responsibility of Licensee

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

1. The facility implemented the PASRR level 1 form immediately on 6\27\2024.
2. Same as above
3. The facility implemented the revised PASRR level 1 form (ma 376 3\24) as of 6\27\2024.
4. Social Service will review all PASRR on admission to assure the revised PASRR level 1 form (ma 376 3\24) is being used with the findings submitted to QA quarterly.
5. To be Completed by 8/23/2024

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

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

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

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

Observations:

Based on observation and staff interview, it was determined that the facility failed to maintain acceptable practices for the storage and service of food to prevent the potential for contamination and microbial growth in food, which increased the risk of food-borne illness in the food and nutrition services department.

Findings include:

Food safety and inspection standards for safe food handling indicate that everything that comes in contact with food must be kept clean and food that is mishandled can lead to foodborne illness. Safe steps in food handling, cooking, and storage are essential in preventing foodborne illness. You cannot always see, smell, or taste harmful bacteria that may cause illness according to the USDA (The United States Department of Agriculture, also known as the Agriculture Department, is the U.S. federal executive department responsible for developing and executing federal laws related to food).

Initial tour of the food and nutrition services department in the presence of Employee 3 (cook/assistant food services supervisor) on June 25, 2024, at 9:00 AM revealed the following sanitation concerns with the potential to introduce contaminants into food and increase the potential for food-borne illness:

Observation of the spice storage shelf revealed a 24-ounce container of dried basil which was opened but not dated when opened.

Observation of the janitor closet located in the food and nutrition services department revealed a garbage can which was filled with empty #10 fruit and vegetable cans. There was no lid on the garbage can and four fruit flies were flying above the garbage can.

There was a mop being stored in direct contact with the floor basin of the janitor closet.

The floor in the janitor closet was visibly soiled.

Observation of the lunch meal on June 25, 2024, at approximately 12:00 PM revealed staff passing trays for residents who resided in rooms 10 through 19 who desired to eat lunch in their rooms. The food cart was placed in the hall outside Resident Room 10. Further observation revealed that the dessert (cake) on the residents' trays were not covered when distributed to resident rooms throughout the hall.

Interview with Employee 3 (cook/assistant food services supervisor) on June 28, 2024, at 11:30 AM confirmed that acceptable practices for food storage were to be followed and all food storage areas were to be maintained in a sanitary manner.

28 Pa. Code 211.6 (f) Dietary services.

28 Pa. Code 201.18 (e)(2.1) Management

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

1. The facility will provide dates on all spices and foods when opened per regulation. All food will be covered on resident meal trays per regulation. The janitor closet in dietary will be cleaned and maintained to prevent the potential for contamination and microbial growth of food.
2. Same as above
3. The facility will review the food procurement\storage\prepare\serve and sanitation policy and educate the dietary and nursing staff on regulatory requirements to prevent contamination and microbial growth of food.
4. The RD will do random audits on food procurement, storage, preparation, serving and sanitation monthly with reports to QA quarterly.
5. To be Completed by 8/23/2024

483.30(b)(1)-(3) REQUIREMENT Physician Visits - Review Care/Notes/Order:

§483.30(b) Physician Visits
The physician must-

§483.30(b)(1) Review the resident's total program of care, including medications and treatments, at each visit required by paragraph (c) of this section;

§483.30(b)(2) Write, sign, and date progress notes at each visit; and

§483.30(b)(3) Sign and date all orders with the exception of influenza and pneumococcal vaccines, which may be administered per physician-approved facility policy after an assessment for contraindications.

Observations:

Based on clinical record review and staff interview, it was determined that the facility failed to ensure the physician wrote a progress note with each visit and that rubber stamp physician signature authorization is maintained by the facility for four of 12 sampled residents (Residents 14, 29, 9, and 15).

Findings include:

According to regulatory guidance at 483.30 (b) the physician must write, sign, and date progress notes at each visit and when rubber stamp signatures are authorized by the facility's management, the individual whose signature the stamp represents shall place in the administrative offices of the facility a signed statement to the effect that he/she is the only one who has the stamp and uses it. A list of computer codes, identification numbers and/or written signatures must be readily available and maintained under adequate safeguards. Adequate safeguards may include, but are not limited to, locked in a drawer; locked in a location that is accessible only by appropriate staff as defined by the facility; or available on a protected electronic site accessible by appropriate staff as defined by the facility.

Clinical record review revealed that Resident 14 was admitted to the facility on September 13, 2022, with a diagnosis of Parkinson's disease.

Resident 14's clinical record revealed that on February 28, 2024, and March 29, 2024,the physician examined the resident and wrote a corresponding progress note. Employee 1 (physician) documentation dated February 28, 2024, and March 29, 2024, were stamped with "rubber stamp" signature.

Nurses notes dated April 29, 2024, May 29, 2024 and June 19, 2024 indicated that the attending physician "was in to see the resident", no new orders noted. However, there were no physician progress notes in the resident's clinical record to correspond with the noted physician visits on these dates.

Resident 29 was admitted to the facility on October 18, 2023, with diagnoses of atrial fibrillation (irregular and often very rapid heart rhythm).

Clinical record revealed physicians progress notes written for Resident 29 dated October 30, 2023, November 29, 2023, December 27, 2023, January 29, 2024, and February 28, 2024 which indicated that the Physician examined the resident and wrote a corresponding progress note .Employee 1 (physician) progress notes dated October 30, 2023, November 29, 2023, December 27, 2023, January 29, 2024, and February 28, 2024, were stamped with a a "rubber stamp" signature.

Nurses notes dated April 29, 2024, and June 19, 2024 indicated that the attending physician "was in to see the resident" but there were no physician progress notes in the resident's clinical record corresponding to April 29, 2024, and June 19, 2024, visits.

Clinical record review revealed that Resident 9 was admitted to the facility on February 7, 2023, with diagnosis to include dementia (a chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders personality changes, and impaired reasoning).

Physician documentation in Resident 9's clinical record dated June 22, 2023, August 30, 2023, October 23, 2023, and December 27, 2023, indicated that the physician examined the resident and wrote a corresponding progress note. Employee 1 (physician)'s progress notes dated June 22, 2023, August 30, 2023, October 23, 2023, and December 27, 2023, were stamped with a "rubber stamp" signature.

Nurses notes dated February 28, 2024, April 29, 2024, and June 19, 2024 indicated that the attending physician "was in to see the resident" but there were no physician progress notes in the resident's clinical record corresponding to visits on February 28, 2024, April 29, 2024, and June 19, 2024.

Clinical record review revealed that Resident 15 was admitted to the facility on April 19, 2024, with diagnosis to include heart failure.

Nurses notes dated April 29, 2024, May 29, 2024, and June 19, 2024, indicated that the attending Physician "was in to see the resident" but there were no physician progress notes in the resident's clinical record corresponding to April 29, 2024, May 29, 2024, and June 19, 2024, physician visits.

There was no evidence at the time of the survey ending June 28, 2024, that the facility maintained safeguards regarding rubber stamped signatures.

During an interview June 27, 2024, at 2:00 PM the interim Director of Nursing confirmed that a physician progress note was not written at each visit for Residents 14, 29, 9, and 15 and that rubber stamp signature safeguards were not in place at the time of the survey.

28 Pa. Code 211.2 (d)(8) Medical director

28 Pa. Code 211.5(f) Clinical records.

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

1. Physician progress notes were placed on resident chart for Residents 14, 29, 9 and 15 with electronic signature provided by physician. The facility has no access to any physician signatures.
2. The facility will assure all physician progress notes are on resident charts according to regulations with electronic signatures provided by the physician.
3. The facility will review and revise as necessary the physician visit policy and in-service attending physicians on regulatory requirements.
4. The facility designee will do random chart audits focusing on physician visit requirements and submit findings to QA quarterly
5. To be Completed by 8/23/2024

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

This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.

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

Observations:

Based on clinical record review, observation, and staff and resident interviews, it was determined that the facility failed to reasonably accommodate a resident's need and preferences for comfortable seating for one resident (Resident 26) out of 12 residents sampled.

Findings incudes:

Clinical record review revealed that Resident 26 was admitted to the facility on November 8, 2022, with diagnoses to include, cerebral infarction (stroke) with left sided hemiplegia/hemiparesis (inability to move one side of the body) and mild dementia.

A review of a quarterly minimum data set assessment (MDS - a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated November 18, 2023, revealed that the resident had a BIMS score of 11, indicating that the resident was moderately cognitively impaired. The resident required maximum staff assistance for activities of daily living including ambulation, transfers and toileting.

According to the resident's clinical records, the resident had a fall from her power recliner chair (in her room) during which the resident sustained a fractured ankle on January 19, 2024. She was hospitalized and returned to the facility on January 24, 2024. The resident received therapy services upon the resident's return to the facility after her hospitalization. The therapy discharge summary dated March 27, 2024, revealed that Resident 26 was without complaints of pain. A Cam boot (A controlled ankle motion walking boot, is an orthopedic device prescribed for the treatment and stabilization of severe sprains,[1] fractures, and tendon or ligament tears in the ankle or foot) was in place. Therapy noted that "Emphasis today on safety with the use of the power recliner chair and reacher in place to retrieve items while seated. Resident demonstrated safety with precautions prevent future falls from the recliner chair. She verbalized movement related safety plan with active participation in strategy to prevent future falls."

During an interview conducted on June 25, 2024 at 1 PM Resident 26 stated that after her fall in January the facility staff will no longer assist her to sit in the recliner chair. She stated that staff get her up in the morning and put her in her wheelchair. She goes to breakfast, activities and lunch seated in the wheelchair. Staff puts her back to bed in the afternoon after lunch and she is not allowed to sit in the recliner, which she prefers. She stated that her left ankle still hurts and if she could recline and elevate her legs it would help. She stated that nursing staff will not put her in the recliner, even though she wants to sit in the recliner chair. She stated that she knows how to operate the chair safely and received therapy after the fall.

An interview June 26, 2024 at approximately 1:30 P.M., with the director of therapy revealed that Resident 26 received therapy services after her fall with fracture and confirmed that the resident was assessed for the use of the power recliner chair and there was no reason that she could not utilize the recliner chair for her seating comfort.

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

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

1. Resident 26 will be reassessed by therapy again for safety in the recliner chair. Social Service will perform another BIMS assessment and interview resident regarding reasonable accommodations needs\preferences. Nursing will review findings with resident and son to develop a plan of care that is safe and reasonable in meeting resident accommodations needs.
2. Social Service will interview residents and families to assure that reasonable accommodations needs\preferences are being met of each individual resident.
3. Social service will evaluate residents quarterly and PRN for reasonable accommodation needs and preferences with outcomes reported to nursing to therefore address needs not met.
4. Social service will review residents reasonable accommodation needs and preferences at quarterly care plan meeting with the IDT and submit findings to QA quarterly.
5. To be Completed by 8/23/2024

483.75(a)(1)-(4)(b)(1)-(4)(f)(1)-(6)(h)(i) REQUIREMENT QAPI Prgm/Plan, Disclosure/Good Faith Attmpt:

§483.75(a) Quality assurance and performance improvement (QAPI) program.
Each LTC facility, including a facility that is part of a multiunit chain, must develop, implement, and maintain an effective, comprehensive, data-driven QAPI program that focuses on indicators of the outcomes of care and quality of life. The facility must:

§483.75(a)(1) Maintain documentation and demonstrate evidence of its ongoing QAPI program that meets the requirements of this section. This may include but is not limited to systems and reports demonstrating systematic identification, reporting, investigation, analysis, and prevention of adverse events; and documentation demonstrating the development, implementation, and evaluation of corrective actions or performance improvement activities;

§483.75(a)(2) Present its QAPI plan to the State Survey Agency no later than 1 year after the promulgation of this regulation;

§483.75(a)(3) Present its QAPI plan to a State Survey Agency or Federal surveyor at each annual recertification survey and upon request during any other survey and to CMS upon request; and

§483.75(a)(4) Present documentation and evidence of its ongoing QAPI program's implementation and the facility's compliance with requirements to a State Survey Agency, Federal surveyor or CMS upon request.

§483.75(b) Program design and scope.
A facility must design its QAPI program to be ongoing, comprehensive, and to address the full range of care and services provided by the facility. It must:

§483.75(b)(1) Address all systems of care and management practices;

§483.75(b)(2) Include clinical care, quality of life, and resident choice;

§483.75(b)(3) Utilize the best available evidence to define and measure indicators of quality and facility goals that reflect processes of care and facility operations that have been shown to be predictive of desired outcomes for residents of a SNF or NF.

§483.75(b) (4) Reflect the complexities, unique care, and services that the facility provides.

§483.75(f) Governance and leadership.
The governing body and/or executive leadership (or organized group or individual who assumes full legal authority and responsibility for operation of the facility) is responsible and accountable for ensuring that:

§483.75(f)(1) An ongoing QAPI program is defined, implemented, and maintained and addresses identified priorities.

§483.75(f)(2) The QAPI program is sustained during transitions in leadership and staffing;
§483.75(f)(3) The QAPI program is adequately resourced, including ensuring staff time, equipment, and technical training as needed;

§483.75(f)(4) The QAPI program identifies and prioritizes problems and opportunities that reflect organizational process, functions, and services provided to residents based on performance indicator data, and resident and staff input, and other information.

§483.75(f)(5) Corrective actions address gaps in systems, and are evaluated for effectiveness; and

§483.75(f)(6) Clear expectations are set around safety, quality, rights, choice, and respect.

§483.75(h) Disclosure of information.
A State or the Secretary may not require disclosure of the records of such committee except in so far as such disclosure is related to the compliance of such committee with the requirements of this section.

§483.75(i) Sanctions.
Good faith attempts by the committee to identify and correct quality deficiencies will not be used as a basis for sanctions.

Observations:

Based on review of select facility policy, clinical records, documentation, and staff interviews, it was determined that the facility failed to demonstrate the implementation of ongoing QAPI programs, to include the use of systems for investigating and analyzing the root cause of adverse events as evidenced by one resident out of 12 sampled (Resident 26).

Findings include:

Review of the facility policy entitled "QAPI plan for the facility" last reviewed January , 2024 revealed, the purpose of QAPI in our organization is to take a proactive approach to constantly work at improving the way we care for and engage with our residents.

The objectives of the QAPI program are to:

- Our organization will use quality assurance and performance improvement to make decisions and guide our day to day operations.
-Our organization makes decisions based on data, which includes the input and experience of caregivers, residents, healthcare practioners, families and other stakeholders.
-Our staff will utilize data from current industry based clinical guidelines and evidenced practices to benchmark performance improvement, whenever possible, to achieve high quality care.

The facility owner leadership and QAPI steering committee have the responsibility for planning, designing, implementing and coordinating consumer care and service and selecting QAPI activities to meet the needs of residents and families.

Compliance will be monitored formally through incident reports and staff satisfaction and informally through discussions, staff meetings, brainstorming activities and PDSA (plan-do-study-act) cycles.

The facility will use data at every QAPI steering committee meeting to ensure performance measures are meeting QAPI goals. Root cause analysis will be completed in response to any unintended consequences identified through data sources.

Clinical record review revealed that Resident 26 was admitted to the facility on November 8, 2022, with diagnoses to include, cerebral infarction (stroke) with left sided hemiplegia/hemiparesis (inability to move one side of the body) and mild dementia.

A review of a quarterly minimum data set assessment (MDS - a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated November 18, 2023, revealed that the resident had a BIMS score of 11, indicating that the resident was moderately cognitively impaired. The resident required maximum staff assistance for activities of daily living including ambulation, transfers and toileting.

The resident's care plan, initiated November 8, 2022, revealed that Resident 26 had left sided hemiplegia and memory deficit following her stroke impaired cognitive function related to cerebral Infarction (stroke) with moderate, cognitive function. According to the resident's care plan the resident was at risk for falls related to her stroke.

The resident had a history of falls to including on December 16, 2022, the resident had an unwitnessed fall. She was found on the floor in her room in front of her recliner chair. The care plan indicated that the recliner chair was noted to be in the highest position.

A review of nursing documentation and a facility investigation report dated January 19, 2024 at 4:30 P.M., revealed that Resident 26 was seated in her recliner chair in her room. A nurse aide responded to the call bell and found the resident on the floor in front of her recliner chair. The recliner chair was noted to be in the elevated upright position. The resident was complaining of left ankle pain. The nurse aide called for the RN. The RN assessed the resident and Resident 26's left foot had an open fracture with bloody drainage. The resident was awake and oriented at that time. She denied hitting her head. The physician was contacted and the resident was sent to the hospital for evaluation and treatment.

A review of hospital documentation revealed the resident had a CT scan of the left ankle. A displaced and comminuted Weber C distal fibular, medial, and posterior malleolus fracture. Lateral shift of the Talus at the tibiotalar joint. The resident was admitted to the hospital and had surgical repair of the fractures on January 20, 2024. She was readmitted to the facility on January 24, 2024.

Further review of the facility investigation revealed the description of the event as "full slide out of the recliner."
Investigation of immediate environment at the time of the incident: "recliner chair upright."
Potential contributing factors: CVA(stroke) with left sided weakness
Review of concerns related to statements written from staff. (attach written statements):
-Resident dropped TV remote control- reached down to get it and her arm rested on the recliner remote, raising the chair. When the resident realized, it was too late and the resident slid out of the chair.
Tentative conclusion: Isolated incident-Resident aware of incident
Changes/corrective actions: will reassess on readmission to the facility.

However, the only witness statement available at the time of the survey was written by the Director of Nursing, who was noted to have been called to the resident's room after the incident to assess the resident. The statement was dated January 19, 2024 at 4:30 P.M., noting that the "Nurse aide walked in the resident's room. Resident 26 was on the floor in front of her recliner. This RN was called and assessed the resident. Fracture of the left lower extremity. The Physician was contacted."

An additional summary of the event dated January 19, 2024 at 4:30 P.M. indicated that, Resident 26 was in her recliner in her room. Nurse aide responded to call bell and found Resident 26 on the floor in front of the recliner chair. The recliner chair was noted to be in the elevated, upright position. The resident complained of left ankle pain. The nurse aide called the RN. The physician and emergency transport were called. The resident was medicated with Tramadol ( a narcotic pain medication), sent to the hospital and admitted for treatment.

The noted "follow-up" was that Resident 26 is alert and oriented and was able to recall the event. Stated she dropped her TV remote control and was trying to pick it up. She was inadvertently hitting the "up" button on her recliner when bending down and came out of the chair. She was able to reach her call bell to call for help.

There was no date or time for this "summary of event" when reviewed during the survey ending June 28, 2024. There were no employee witness statement or resident witness statement noted with the investigation. No identification of the nurse aide involved noted in the summary.

An interview June 25, 2024, at 12 PM, Resident 26 was awake and alert. She stated that she still had pain in her left ankle area. She stated that prior to the fall on January 19, 2024, she was seated in her recliner chair. She stated that she dropped her TV remote on the floor. She stated that she did not know where her call bell was at that time and she was "impatient" at the time, wanting her TV remote so she took the chair controller out of the seat pocket and raised the chair "a little." She stated that she did not put the controller back into the seat pocket, but dropped it into the seat. As she was lifted up in the chair, the weight of her body pressed on the controller with the chair ending in the upright position and her falling to the floor. She again stated that she could not find her call bell to alert staff to her needs.

During an interview June 27, 2024 at approximately 2 P.M., the interim DON stated that there were no witness statements available at the time of the survey to demonstrate that the facility had fully investigated this adverse event that resulted in serious injury to the resident to identify the potential root cause, and if the resident did have ready availability of her call bell.

At the time of the survey ending June 28, 2024, the facility had not fully investigated this adverse event, and Resident 26's fall with major injury. There was no evidence that the facility had identified the underlying cause or contributing factors to this incident and was able to provide the surveyor with a factual and accurate representation of the events surrounding Resident 26's fall with change in condition necessitating hospital transfer.

There was no evidence at the time of the survey that the facility demonstrated an effective QAPI program to include outcomes of quality of care and quality of life by investigating alleged incidents and thorough documentation to support their analysis of the data collected and any corrective actions developed and implemented.

28 Pa. Code 201.18 (b)(1)(3)(e)(1)(4) Management

28 Pa. Code 211.12 (c) Nursing Services

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

1. The facility will do further investigation of resident #26 accident\injury report to identify root cause of injury. The facility will analyze previous falls to identify any pattern or contributing factors that could aid in preventing future accidents\injury.
2. The facility will thoroughly investigate future accident\injury reports of all residents to identify root cause and contributing factors, using staff and resident input along with performance indicator data and other information.
3. The NHA and DON will review the QAPI program to ensure the objectives of developing, implementing and maintaining an effective data driven program that focuses on indicators of the outcomes of care and quality of life.
4. The DON will review and submit accident\injury reports to QAPI meetings quarterly.
5. To be Completed by 8/23/2024

483.45(a)(b)(1)-(3) REQUIREMENT Pharmacy Srvcs/Procedures/Pharmacist/Records:

§483.45 Pharmacy Services
The facility must provide routine and emergency drugs and biologicals to its residents, or obtain them under an agreement described in §483.70(g). The facility may permit unlicensed personnel to administer drugs if State law permits, but only under the general supervision of a licensed nurse.

§483.45(a) Procedures. A facility must provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident.

§483.45(b) Service Consultation. The facility must employ or obtain the services of a licensed pharmacist who-

§483.45(b)(1) Provides consultation on all aspects of the provision of pharmacy services in the facility.

§483.45(b)(2) Establishes a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation; and

§483.45(b)(3) Determines that drug records are in order and that an account of all controlled drugs is maintained and periodically reconciled.

Observations:

Based on observations, review of select facility policy and clinical records, and staff interview, it was determined that the facility failed to implement a system to assure timely disposition of resident medications (the process of returning and/or destroying unused medications) to prevent loss and potential drug diversion and failed to periodically review pharmacy procedures for continued appropriateness, effectiveness and compatability with current regulatory requirements for drugs awaiting final disposition (Resident 37).

Finding include:

Review of facility policy entitled, "Disposal of Medications and Medication Related Supplies", date revised January 25, 2002, revealed that when medications are discontinued by physician order, a resident transferred, or discharged and does not take medications with him/her, or in the event of resident's death, the medications are marked as discontinued, or if the packages are unopened, returned to the issuing pharmacy. Medications awaiting disposal or return, are stored in a locked, secure area designed for that purpose until destroyed or picked up by pharmacy.

During an observation of the facility's medication room on June 25, 2024, at approximately 9 AM accompanied by the interim Director of Nursing (DON) an unopened box of single use ampules of Albuterol nebulizer solution 0.83% with the pharmacy label indicating that they had been dispensed for Resident 37. Resident 37 had a physician order dated March 12, 2024, for Albuterol Nebulizer solution 0.83% 1 ampule via nebulizer 4 times a day as needed for shortness of breath/wheezing

In the medication refrigerator there was an open, unlabeled, multiple dose vial, of the antibiotic Ceftazidime, 1 gram vial. There was no open date. There were 3 unopened boxes containing a single dose of flu vaccine with an expiration date of May 22, 2024.

An interview with the interim DON on June 25, 2024, at approximately 9:30 AM, revealed that all the discontinued medications should have been picked up by pharmacy or destroyed per the facility policy and not stockpiled in the nursing medication room. She further confirmed the facility failed to implement procedures to promote the timely disposition of resident medications and failed to timely revise their pharmacy policies and procedures.

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

28 Pa Code 211.9 (a)(1)(d)(j.1)(1)(2)(3)(4)(5)(k) Pharmacy services

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

1. The facility immediately disposed of the medication of resident #37, expired flu vaccines and open vial of antibiotic ceftazidime.
2. The facility assessed all medications in med room to assure compliance with the required pharmacy services\procedure\pharmacist\records regulations
3. The facility will require 11p-7a nursing staff to do daily audits of the medication room to include medications in the refrigerator, cupboards and on counter to ensure regulatory compliance of medication. Treatment room and medication cart will also be included in the daily audit. 11p-7a nursing staff will document findings daily with the DON reviewing daily documentation.
4. DON will review daily documentation of med room audit and will perform weekly audits with reports to QA quarterly.
5. To be Completed by 8/23/2024

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

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

Observations:

Based on observation, review of clinical records, and staff interview, it was determined that the facility failed to maintain and store oxygen in a safe and sanitary manner and failed to provide supplemental oxygen administration as ordered for one of 12 residents reviewed (Resident 15).

Findings include:

An observation June 25, 2024, at 8:45 A.M and again at 1:30 P.M., revealed a partially full oxygen tank on the floor at the nurses station. The tank was free standing and not secured.

An interview June 25, 2024, at 1:30 P.M., the interim Director of Nursing confirmed that oxygen should be secured and stored in an appropriate location.

A review of Resident 15's clinical record revealed the resident was admitted to the facility on April 19, 2024, with diagnoses which included heart failure.

A physician order dated April 19, 2024 noted an order for oxygen at 3 liters per minute continuous via nasal cannula for a diagnosis of shortness of breath.

An observation on June 26, 2024, at 8:45 AM revealed the filter on the back of the concentrator was dust covered.

An observation on June 28, 2024, at 10:20 AM revealed the filter on the back of the concentrator was dust covered. The oxygen was set at 2 liters per minute and not the 3 liters per minute ordered by the physician.

Interview with employee 2 (LPN) at this confirmed that the filter was dusty and in need of cleaning. Employee 2 (LPN) confirmed that the oxygen was to be set at 3 liters per minute as per physician order.

An interview with the interim director of nursing on June 28, 2024, at 11:30 AM confirmed the facility failed to provide Resident 15's supplemental oxygen as ordered by the physician. The interim director of nursing confirmed that oxygen concentrator filters were to be cleaned weekly and as needed and that oxygen equipment was to be maintained in a sanitary manner.

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

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

1. a) The facility has all oxygen tanks stored securely in the oxygen room.
b)The facility has provided clean filters in all concentrators at this time
c) The facility corrected resident #15 oxygen flow rate per orders immediately.
2. a) Same as above
b) Same as above
c) Same as above
3. a) The facility will review and revise as necessary the oxygen storage policy. The facility will in-service all nursing staff on the proper storage of oxygen tanks.
b) The facility will review and revise as necessary the oxygen concentrator policy and in-service staff on required maintenance of concentrators.
c) The facility will in-service nursing staff on monitoring administration of oxygen.
4. a) The facility designee will do a weekly walk through of the facility and oxygen storage room to assure proper storage of oxygen tanks with reports submitted to weekly to DON and quarterly to QA.
b) The facility designee will do monthly audits of oxygen concentrators to assure proper maintenance with reports to QA quarterly.
c) The facility designee will do weekly audits on residents with oxygen to assure correct oxygen liters is being administered with reports to DON weekly and submitted to QA quarterly.
5. To be Completed by 8/23/2024

483.15(c)(3)-(6)(8) REQUIREMENT Notice Requirements Before Transfer/Discharge:

Least serious 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 has the potential for causing no more than a minor negative impact on the resident.

§483.15(c)(3) Notice before transfer.
Before a facility transfers or discharges a resident, the facility must-
(i) Notify the resident and the resident's representative(s) of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand. The facility must send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman.
(ii) Record the reasons for the transfer or discharge in the resident's medical record in accordance with paragraph (c)(2) of this section; and
(iii) Include in the notice the items described in paragraph (c)(5) of this section.

§483.15(c)(4) Timing of the notice.
(i) Except as specified in paragraphs (c)(4)(ii) and (c)(8) of this section, the notice of transfer or discharge required under this section must be made by the facility at least 30 days before the resident is transferred or discharged.
(ii) Notice must be made as soon as practicable before transfer or discharge when-
(A) The safety of individuals in the facility would be endangered under paragraph (c)(1)(i)(C) of this section;
(B) The health of individuals in the facility would be endangered, under paragraph (c)(1)(i)(D) of this section;
(C) The resident's health improves sufficiently to allow a more immediate transfer or discharge, under paragraph (c)(1)(i)(B) of this section;
(D) An immediate transfer or discharge is required by the resident's urgent medical needs, under paragraph (c)(1)(i)(A) of this section; or
(E) A resident has not resided in the facility for 30 days.

§483.15(c)(5) Contents of the notice. The written notice specified in paragraph (c)(3) of this section must include the following:
(i) The reason for transfer or discharge;
(ii) The effective date of transfer or discharge;
(iii) The location to which the resident is transferred or discharged;
(iv) A statement of the resident's appeal rights, including the name, address (mailing and email), and telephone number of the entity which receives such requests; and information on how to obtain an appeal form and assistance in completing the form and submitting the appeal hearing request;
(v) The name, address (mailing and email) and telephone number of the Office of the State Long-Term Care Ombudsman;
(vi) For nursing facility residents with intellectual and developmental disabilities or related disabilities, the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with developmental disabilities established under Part C of the Developmental Disabilities Assistance and Bill of Rights Act of 2000 (Pub. L. 106-402, codified at 42 U.S.C. 15001 et seq.); and
(vii) For nursing facility residents with a mental disorder or related disabilities, the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with a mental disorder established under the Protection and Advocacy for Mentally Ill Individuals Act.

§483.15(c)(6) Changes to the notice.
If the information in the notice changes prior to effecting the transfer or discharge, the facility must update the recipients of the notice as soon as practicable once the updated information becomes available.

§483.15(c)(8) Notice in advance of facility closure
In the case of facility closure, the individual who is the administrator of the facility must provide written notification prior to the impending closure to the State Survey Agency, the Office of the State Long-Term Care Ombudsman, residents of the facility, and the resident representatives, as well as the plan for the transfer and adequate relocation of the residents, as required at § 483.70(l).

Observations:

Based on review of clinical records and facility-initiated transfer notices and a staff interview, it was determined that the facility failed to failed to provide copies of written notices of facility-initiated hospital transfers of residents to a representative of the Office of the State Ombudsman for three out of 12 residents reviewed (Residents 9, 15, and 32).

Findings include:

Regulatory requirements indicate that before a facility transfers or discharges a resident, the facility must notify the resident and the resident's representative(s) of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand. The facility must send a copy of the notice to the resident and/or resident's representative and to a representative of the Office of the State Long-Term Care Ombudsman.

A review of the clinical record revealed that Resident 9 was transferred to the hospital on August 3, 2023, and returned to the facility on August 4, 2023.

A review of the clinical record revealed that Resident 15 was transferred to the hospital on May 17, 2024, and was readmitted to the facility on May 21, 2024.

A review of the clinical record revealed that Resident 32 was transferred to the hospital on May 3, 2024, and was readmitted to the facility on May 6, 2024.

Although written notices were provided to the residents and resident representatives of the facility-initiated transfers, there was no documented evidence the facility sent copies of written notices of these facility-initiated transfers to the representative of the Office of the State Long-Term Care Ombudsman.

An interview with the Nursing Home Administrator (NHA) on June 27, 2023, at approximately 1:00 PM, failed to provide documented evidence that copies of the facility-initiated transfers were sent to a representative of the Office of the State Long-Term Care Ombudsman. The NHA further confirmed that there was no evidence that copies were sent to a representative of the Office of the State Long-Term Care Ombudsman since March 15, 2023.

28 Pa. Code 201.14(a) Responsibility of Licensee

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

1. The facility will review all discharges and hospital transfers from the facility since June 1, 2024 and send notice to the office of the State Ombudsman by July 15, 2024.
2. Same as above
3. The facility will review and revise as necessary the transfer\discharge policy. Educate Social Service on the regulatory requirements for transfer\discharge of residents to the office of the State Ombudsman.
4. Social service will submit all transfer\discharge notices to NHA monthly with documented evidence that the Office of the State Ombudsman was given monthly written notice no later than the 15th the following month. All reports will be submitted to QA quarterly.
5. To be Completed by 8/23/2024

§ 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: 08/23/2024

1. The facility makes all possible attempts to meet CNA staffing requirements. There is continual paid advertisements on online platforms with competitive salaries. The facility has created their own in house contract rate schedule to entice employment. The facility has multiple contracts with staffing agencies and utilizes agency continually. The facility continues to spend at minimum $2500.00\month on nursing employment advertisement. The facility works with 2 CNA programs as a clinical site, in hopes of gaining employees. The facility offers employees a paid 8 hour day, if no call offs in a quarter. The facility does maintain overall regulated PPD nursing hours in a 24 hour period.
2. Same as above
3. The facility will review the staffing policy and make attempts to meet regulatory requirements.
4. The CNA staff to resident ratio will be reviewed weekly with reports submitted to NHA weekly. All reports will be submitted to QA quarterly.
5. Date to be completed: 08/23/2024

§ 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: 08/23/2024

1. The facility is making all attempts to meet regulatory staffing ratio requirements. The facility continues to face challenges with hiring staff. The facility is using paid advertisement and continues to spend a minimum of $2500 monthly. The facility has multiple contracts with staffing agencies, attends colleges to speak with future nurses and offer positions. The facility also advertises "in house" contracts that offer a higher salary. The facility maintains the overall required PPD hours in 24 hour period. The facility will continue to make all attempts to meet regulatory staffing ratio requirements.
2. Same as above
3. The facility will review and revise staffing policies and continue to make all attempts to meet regulatory requirements.
4. RN\LPN staff to resident ratio will be reviewed weekly with reports submitted to NHA. All reports will be submitted to QA quarterly.
5. Date to be completed: 08/23/2024

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