Nursing Investigation Results -

Pennsylvania Department of Health
PREMIER ARMSTRONG REHABILITATION AND NURSING FACILITY
Patient Care Inspection Results

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
PREMIER ARMSTRONG REHABILITATION AND NURSING FACILITY
Inspection Results For:

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PREMIER ARMSTRONG REHABILITATION AND NURSING FACILITY - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:
A COVID-19 Focused Emergency Preparedness Survey was conducted by The Department of Health (DOH) on March 26, 2021. Premier Armstrong Rehabilitation and Nursing Center was in compliance with 42 CFR 483.73 related to E-0024(b)(6).






 Plan of Correction:


Initial comments:
Based on a Medicare/Medicaid Recertification Survey, Civil Rights Compliance Survey, State Licensure Survey and a Covid survey, completed on March 26, 2021, it was determined that Premier Armstrong Nursing and Rehabilitation, was not in compliance with the requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care Facilities and the 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.





 Plan of Correction:


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

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

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

Based on observations and staff interviews it was determined that the facility failed to maintain sanitary conditions in the Main Kitchen which created the potential for cross contamination. (Main Kitchen)

Findings include:

During an observation on 3/24/21, at 9:45 am it was revealed that there was water dripping through a hole in a ceiling tile located above the food preparation sink. There was a large brown wet stain mark on a ceiling tile located above the hot beverage station of the tray line indicating an active leak.

During an interview on 3/24/21, at 9:50 am the Food Service Director Employee E7 confirmed that there was water from an unknown source dripping through a hole in the ceiling tile located above the food preparation sink and the ceiling tile located above the hot beverage station contained a brown wet stain indicating an active leak and that the facility failed to maintain the sanitary conditions in the Main Kitchen.

28 Pa Code: 211.6(c)(d) Dietary services.
previously cited 3/14/19





 Plan of Correction - To be completed: 05/17/2021

Leaks in question were repaired that day.

All other areas of the kitchen were in proper working order.

Dietary Director and all other managers were inserviced on inputting information into the TELS system (facility maintenance work order system) by the NHA to assure any issues needing the attention of maintenance are addressed timely and appropriately.

NHA/designee will monitor TELS system for timely completion of all work orders with report to QA monthly X3.
483.80(a)(3) REQUIREMENT Antibiotic Stewardship Program:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
483.80(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)(3) An antibiotic stewardship program that includes antibiotic use protocols and a system to monitor antibiotic use.
Observations:

Based on review of facility policy, infection control documentation and staff interview, it was determined that the facility failed to implement an antibiotic stewardship program that included protocols for antibiotic use and the tracking/reporting of antibiotic resistance for 15 of 15 months (January 2020 to March 2021).

Findings include:

Review of the facility policy "Infection Control - Antibiotic Stewardship" dated 7/1/20, indicated that the facility would include monitoring the use of antibiotics, monitoring of resistance patterns, reports on the number of antibiotics prescribed, monitoring of antibiotic resistance patterns and pharmacy consultant reviews of antibiotic usage data.

Review of infection control documentation failed to reveal any antibiotic stewardship monitoring having been completed for 15 of 15 months (January 2020 to March 2021).

During an interview on 3/24/21, at 9:15 a.m. the Assistant Director of Nursing confirmed that the facility failed to implement an antibiotic stewardship as required.

28 Pa. Code 201.14(a) Responsibility of licensee.
28 Pa. Code 201.18(b)(1) Management.
28 Pa. Code 201.18(b)(3) Management.
28 Pa. Code 201.18(e)(1) Management.
28 Pa. Code 211.12(c) Nursing services.
28 Pa. Code 211.12(d)(3) Nursing services.







 Plan of Correction - To be completed: 05/17/2021

No resident exhibited any signs of adverse reaction from antibiotic usage.

Current usage will be monitored for proper antibiotic, proper duration and stoppage of antibiotic, and appropriate diagnosis for by the Infection Preventionist.

Infection Preventionist will be re-inserviced on regulation for F881 by the DON. The IP will obtain pharmacy usage reports on a monthly basis ongoing to assure compliance with F881. Atntibiotic Stewardship implemented in coordination with pharmacy to include all necessary steps.

IP person will monitor and report at both the Infection control meeting ongoing and the QA meeting monthly X3
483.80(d)(1)(2) REQUIREMENT Influenza and Pneumococcal Immunizations:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
483.80(d) Influenza and pneumococcal immunizations
483.80(d)(1) Influenza. The facility must develop policies and procedures to ensure that-
(i) Before offering the influenza immunization, each resident or the resident's representative receives education regarding the benefits and potential side effects of the immunization;
(ii) Each resident is offered an influenza immunization October 1 through March 31 annually, unless the immunization is medically contraindicated or the resident has already been immunized during this time period;
(iii) The resident or the resident's representative has the opportunity to refuse immunization; and
(iv)The resident's medical record includes documentation that indicates, at a minimum, the following:
(A) That the resident or resident's representative was provided education regarding the benefits and potential side effects of influenza immunization; and
(B) That the resident either received the influenza immunization or did not receive the influenza immunization due to medical contraindications or refusal.

483.80(d)(2) Pneumococcal disease. The facility must develop policies and procedures to ensure that-
(i) Before offering the pneumococcal immunization, each resident or the resident's representative receives education regarding the benefits and potential side effects of the immunization;
(ii) Each resident is offered a pneumococcal immunization, unless the immunization is medically contraindicated or the resident has already been immunized;
(iii) The resident or the resident's representative has the opportunity to refuse immunization; and
(iv)The resident's medical record includes documentation that indicates, at a minimum, the following:
(A) That the resident or resident's representative was provided education regarding the benefits and potential side effects of pneumococcal immunization; and
(B) That the resident either received the pneumococcal immunization or did not receive the pneumococcal immunization due to medical contraindication or refusal.
Observations:
Based on review of facility policy and documentation, clinical record reviews, and staff interview it was determined that the facility failed to accurately document administration, refusal, and education related to influenza vaccinations for eleven of eleven residents reviewed (Resident R17, R18, R20, R21, R22 R32, R36, R38, R41, R48 and R54).

Findings include:

A review of the facility's policy "Influenza" reviewed on 7/1/20, indicated that documentation of vaccine education and administration or refusal will be documented in the resident's medical record.

Facility record review of the line-listing of influenza vaccines given, indicated that Residents R17, R21, R32, R36, R41, and R48 received the influenza vaccine on 10/21/20 while in the facility.

Review of the medical record and progress note for Residents R17, R21, R32, R36, R41, and R48 did not indicate that vaccine education and informed consent was not given by the resident or family representative.

Review of the influenza line listing and medical record indicated that Residents R18, R20, and R54 refused the influenza vaccine.

Review of the medical record and progress note for Residents R18, R20, and R54 did not indicate that vaccine education was given and refusal of the vaccine was not signed by the resident or family representitive.

During an interview on 3/23/21, at 1:45 p.m. the Assistant Director of Nursing Employee E10 confirmed that the facility failed to accurately document administration, refusal, and education, related to influenza vaccinations provided for eleven of eleven residents.

28 Pa. Code 201.14(a) Responsibility of licensee.
28 Pa. Code 201.18(b)(1) Management.
28 Pa. Code 201.18(b)(3) Management.
28 Pa. Code 211.5(f) Clinical records.
28 Pa. Code 211.5(h) Clinical records.
28 Pa. Code 211.10(c) Resident care policies.
28 Pa. Code 211.12(c) Nursing services.
28 Pa. Code 211.12(d)(1) Nursing services.
28 Pa. Code 211.12(d)(3) Nursing services.
28 Pa. Code 211.12(d)(5) Nursing services.




 Plan of Correction - To be completed: 05/17/2021

there have been no adverse effects from anyone receiving the influenza vaccine.

Going forward consent and education will be documented in the residents chart by the ADON/IP. Audit completed to assure proper compliance on all current residents.

ADON and RN Supervisor who is the person responsible for this duty will be educated on requirements for documented consent and education by the DON/designee

Audit will be conducted randomly on 25% of the residents chart during flue season to assure compliance by the DON/designee with report QA meeting monthly X3.
483.10(a)(1)(2)(b)(1)(2) REQUIREMENT Resident Rights/Exercise of Rights: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(a) Resident Rights.
The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility, including those specified in this section.

483.10(a)(1) A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the resident.

483.10(a)(2) The facility must provide equal access to quality care regardless of diagnosis, severity of condition, or payment source. A facility must establish and maintain identical policies and practices regarding transfer, discharge, and the provision of services under the State plan for all residents regardless of payment source.

483.10(b) Exercise of Rights.
The resident has the right to exercise his or her rights as a resident of the facility and as a citizen or resident of the United States.

483.10(b)(1) The facility must ensure that the resident can exercise his or her rights without interference, coercion, discrimination, or reprisal from the facility.

483.10(b)(2) The resident has the right to be free of interference, coercion, discrimination, and reprisal from the facility in exercising his or her rights and to be supported by the facility in the exercise of his or her rights as required under this subpart.
Observations:

Based on a review of facility policies, observations and staff interviews it was determined that the facility failed to provide a dignified dining experience to four of four residents dining in the 2A dining room. ( Residents R2, R33, R51, and R216)

Findings include:

A review of facility " Feeding the Resident" policy dated 5/4/2020, indicated that residents dining in the dining room will be served one table at a time making certain that all residents have been served at a table before serving other residents.

During an observation of dining room meal service on 3/22/21, at 12:10 pm the following was observed:
- at 12:15 pm the tray delivery cart arrived on the nursing unit
- at 12:20 pm Resident R33 was seated at a table in the dining room with Resident R51 was served her meal
- at 12:25 pm Resident R2, was seated at a table in the dining room with Resident R216. Resident R2's meal tray was taken to her room and then taken to the dining room where it was served to the resident
- at 12:27 pm Resident R51 was served his meal
- at 12:36 pm Resident R216 was served her meal
There was a lapse of 16 minutes from when the first resident was served until the last resident was served which failed to provide a dignified dining experience for the residents.

During an interview on 3/22/21, at 12:40 pm the above information was addressed with Register Nurse Employee E2 and confirmed that the residents were not served at the same time in the dining room which failed to create a dignified dining experience for Resident R2, R33, R51, and R216.

28 Pa Code: 201.29(j) Resident rights.






 Plan of Correction - To be completed: 05/17/2021

Tray arrangement in dining cart was re-arranged prior to next meal.

Said issue was not found in other dining carts.

Meeting held by NHA with DON, ADON, RN Supervisor and Dietary to discuss seating and tray arrangement to assure issue does not re-occur. Staff involved with tray pass inserviced on dignified dining rights.

Dining room tray pass audit will be completed by nursing and dietary weekly, one dining unit per week, X3 months to assure compliance with report to QA monthly X3. Any issues noted will be addressed immediately
483.45(g)(h)(1)(2) REQUIREMENT Label/Store Drugs and Biologicals:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.45(g) Labeling of Drugs and Biologicals
Drugs and biologicals used in the facility must be labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable.

483.45(h) Storage of Drugs and Biologicals

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

483.45(h)(2) The facility must provide separately locked, permanently affixed compartments for storage of controlled drugs listed in Schedule II of the Comprehensive Drug Abuse Prevention and Control Act of 1976 and other drugs subject to abuse, except when the facility uses single unit package drug distribution systems in which the quantity stored is minimal and a missing dose can be readily detected.
Observations:
Based on facility policy, observation and staff interview, it was determined that the facility failed to make certain medications were properly secured for one of four Medication rooms ( 2 C nursing unit Medication room) and failed to make certain food is not stored in Medication refrigerators (3 A Medication refrigerator).

Review of the facility policy "Medication storage" last reviewed on 7/1/20, indicated that only licensed staff and pharmacy personnel are permitted access to medications. Refrigerated medications are kept in closed containers and separated from food items.

During an observation on 3/22/21, at 10:15 a.m. of the 3 A Medication refrigerator a tub of margarine was found in the medication refrigerator.

During an interview on 3/22/21, at 10:18 a.m. registered Nurse Employee E4 confirmed the tub of margarine should not be stored in the Medication refrigerator.

During an observation on 3/24/2021, at 10:00 a.m., the door to the medication storage room on the second floor Yellow Zone was unlocked and unattended.

During an interview on 3/24/21, at 10:05 a.m., Nursing Assistant (NA) Employee E16 confirmed the door to the medication storage room was unlocked and unattended.


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

28 Pa. Code: 211.12(d)(1)(2)(3)(5) Nursing services.


 Plan of Correction - To be completed: 05/17/2021

Margarine was removed immediately and the door to Med room was locked immediately.

No other med refrigerators were found out of compliance nor were any other med rooms found unsecured.

All licensed staff were re-educated on Med room storage and the securing of said Med rooms by DON/ADON.
Audit to be dome weekly X3 months by DON/designee with report to QA monthly X3. Any issues found will be corrected immediately with proper education/discipline taking place.
483.40 REQUIREMENT Behavioral Health Services: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.
483.40 Behavioral health services.
Each resident must receive and the facility must provide the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. Behavioral health encompasses a resident's whole emotional and mental well-being, which includes, but is not limited to, the prevention and treatment of mental and substance use disorders.
Observations:

Based on review of facility policy, clinical records and staff interview it was determined that the facility failed to provide a comprehensive psychiatric consultation for one of four residents with behavioral concerns (Resident R8)

Findings include:

The facility "Behavioral management/trauma informed care" policy last reviewed 7/1/2020, indicated it is the policy of this facility to provide an interdisciplinary approach for the care of residents who have a diagnosis of a mental disorder, trauma, depressive behaviors, or who exhibit behavioral symptoms which could lead to negative consequences. Residents demonstrating changes in behavior shall be evaluated to ensure that appropriate intervention are instituted. The psychiatrist shall visit the facility and evaluate the residents.

Review of Resident R8 admission record indicated she was admitted to the facility on 1/1/21 with diagnoses that included diabetes, major depressive disorder, bacteremia, and chronic obstructive pulmonary disease.

Review of Resident R8 admission MDS assessment (MDS-Minimum Data Set Assessment: periodic assessment of resident care needs) dated 1/8/21, indicated that the diagnoses remain current.

Review of Resident R8 care plan dated 1/22/21, indicated to notify the resident's physician in any changes in behavior or psychosocial status and consider psychological evaluation and treatment recommendations.

Review of Resident R8 nurse progress notes indicated changes in mood and behaviors on the following dates:
2/17/21: resident R8 confused this shift.
2/22/21: Resident R8 screaming and yelling in her room. She told staff she heard phone ring and it was time to get kids up for school.
2/26/21: Resident R8 was lying in her bed staring at the ceiling and pointing asking staff to look. She was sent to the hospital and returned the same day.
2/27/21: resident R8 refused all meals.
3/8/21: Resident R8 states she has not been eating.
3/14/21: Resident R8 refused meal.
3/17/21: Resident R8 states she should eat, but when food comes, she can't get her body to eat and doesn't know why.

Review of Resident R8 nurse progress notes and consultation documentation from 2/17/21 to 3/25/21, did not include a recommendation for a psychological consultation or psychiatric assessment.

During an interview on 3/25/21, at 10:01 a.m. the Director of Social Services Employee E11 confirmed that the facility failed to provide a comprehensive psychiatric consultation for Resident R8 as required.


28 Pa code: 211.10 (a) Resident care policies.

28 Pa Code: 211.12 (d)(1)(2)(3)(5) Nursing services.

28 Pa Code: 211.16(a) Social Services.








 Plan of Correction - To be completed: 05/17/2021

Resident R8, who is her own decision maker, has been offered psycho-social services and has stated she does not wish to receive services.

All other residents that show signs of such needs have or have been offered such services and will continue to be reviewed quarterly at least, more often if signs or symptoms occur.

Facility policy "Behavior management/trauma informed care" has been reviewed with facility Director of Social Services by NHA along with need to notify/involve physician and to offer such services to resident/responsible party.

Audit will be conducted by LNAC/designee during careplan review to assure changes in condition are noted and addressed as needed. Any acute changes will be addressed in morning stand-up meeting as needed. Audit will be reported to QA monthly X3.
483.25 REQUIREMENT Quality of Care:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.25 Quality of care
Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices.
Observations:
Based on a review of facility policies, documents, observations, and resident and staff interviews, it was determined that the facility failed to follow a physician order for one of 28 residents (Resident R33) , maintain communication documentation between a hospice agency and the facility for one of two residents receiving hospice services (Resident R1), and it was determined that the facility failed to notify a physician of a change in condition for one of four residents with high glucose levels (Resident R37).

Findings include:

A review of facility "Physician Orders" policy dated 7/1/2020, indicated that the facility will secure a physician order for care and services provided for residents.

A review of facility "Hospice" policy dated 7/1/2020, indicated that if hospice care is provided in a facility through an agreement with a hospice agency , the facility must maintain a communication process, including how the communication will be documented between the facility and the hospice provider, to ensure that the needs of the resident are addressed and met 24 hours per day.

The facility "Change in resident condition" policy last reviewed on 7/1/2020, indicated that the facility will monitor residents for change in physical or mental condition and shall notify the resident attending physician.

The facility "Blood glucose monitoring" policy last reviewed on 7/1/2020, indicated the facility will assure that residents who have a diagnosis of diabetes are being monitored according to physician orders.

During an interview on 3/23/21, at 11:40 am Resident R33 indicated that the facility's maintenance department removed the enabler bars from her bed and that she was fearful of falling.

During an observation on 3/25/21, at 11:00 am it was revealed that Resident R33's bed did not contain enabler bars.

During an interview on 3/25/21, at 11:00 am Nursing Assistant (NA) Employee E6 confirmed that Resident R33 used the bed that was positioned near the window and that the bed did not contain enabler bars.

A review of Resident R33's Admission Record indicated that the resident was was admitted to the facility on 12/1/16, with the diagnosis of high blood pressure, diabetes, abnormalities of gait and mobility, muscle weakness and history of falling.

A review of Resident R33's physician order dated 4/16/2020, indicated that the resident was ordered "grab bars bilaterally to assist with bed mobility and increase functional independence.

A review of Resident R33's "Side Rail Assessment" dated 2/3/21, indicated the following:
- weakness and pain contribute to the need for side rails
- side rails will assist in bed mobility, turning side to side and moving up and down in bed.
- side rails will assist in transfers during exiting and entering the bed safely
- side rails were evaluated for safety and would not cause entrapment or a restraint
the assessment recommendation indicated that side rails/enablers were recommended at this time.

During an interview on 3/25/21, at 11:30 am the Director of Nursing confirmed that the maintenance department removed Resident R33's enabler bars and that the facility failed to follow a physician order.

A review of Resident R1's Admission Record indicated that the resident was admitted to the facility on 1/26/19, with the diagnosis of heart failure, anxiety, acid reflux, fracture of right and left femur, pain, and abnormal mobility.

A review of of Resident R1's Interdisciplinary Plan of Care Revision/Physician Orders indicated that the resident was enrolled in hospice services on 3/25/2020.

A review of communication documentation between the hospice and the facility for Resident R1 revealed a document dated 6/20/2020, and a document inaccurately dated 7/7/21, as the last two communication documents provided by the hospice agency to the facility.

During an interview on 3/25/21, at 12:00 pm the Director of Nursing (DON) confirmed that the last two communication documents received from the hospice agency for Resident R1 were 6/20/2020, and a document inaccurately dated 7/7/21. The DON confirmed that Resident R1 was currently receiving hospice services and that the hospice agency maintain the agency's electronic records and failed to provide communication as how to the needs of the resident were being met 24 hours a day as required.

Review of Resident R37 admission record indicated she was originally admitted on 4/9/19, with diagnoses that included diabetes, hypothyroidism, chronic kidney disease, and muscle weakness.

Review of Resident R37 quarterly MDS assessment (MDS-Minimum Data Set Assessment: periodic assessment of resident care needs) dated 3/12/21, indicated that these diagnoses are current.

Review of Resident R37 care plan dated 2/13/21, indicated to monitor, document, and report signs or symptoms of hyperglycemia and hypoglycemia.

Review of Resident R37 physician orders indicated to notify of high glucose levels above 400.

Review of Resident R37 glucose levels summary documented dated 7/8/19, indicated a high glucose level of 452.

Review of Resident R37 nurse progress notes from 7/1/19 to 7/31/19, did not include a notification to the physician about the high glucose level.

During an interview on 3/25/21, at 12:00 p.m. the Director of Nursing (DON) confirmed that the facility failed to notify a physician of a change in condition for Resident R37 as required.



28 Pa Code: 201.14(a) Responsibility of licensee

28 Pa. Code: 201.29(j) Resident Rights

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

28 Pa Code: 211.12(d)(1)(2)(3) Nursing services.







 Plan of Correction - To be completed: 05/17/2021

Resident R33 has enablers as ordered. Resident R1's hospice information has been obtained and is available per regulation. Physician was made aware of Resident R37's glucose level.

All other residents with orders for enablers have them as ordered. All other residents on hospice have or will have documentation as required. Review of accucheck monitoring revealed no other missing notifications.

All licensed staff will be re-inserviced by DON/ADON on following physician orders and required notifications. Meeting to be held with hospice to co-ordinate appropriate procedures to assure required documentation is available to those who need it.

Audit to be completed randomly on 20% of all on accuchecks weekly X4 and then monthly X2 by DON/designee with report to QA monthly X3. Availability of hospice documentation will be checked on all hospice residents bi-weekly X6 by RN supervisor with report to QA monthly X3. All new orders for enablers will be audited monthly X3 by ADON/designee to assure compliance with report to QA monthly X3. Any of the above issues found out of compliance will be addressed immediately.
483.21(b)(2)(i)-(iii) REQUIREMENT Care Plan Timing and Revision:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.21(b) Comprehensive Care Plans
483.21(b)(2) A comprehensive care plan must be-
(i) Developed within 7 days after completion of the comprehensive assessment.
(ii) Prepared by an interdisciplinary team, that includes but is not limited to--
(A) The attending physician.
(B) A registered nurse with responsibility for the resident.
(C) A nurse aide with responsibility for the resident.
(D) A member of food and nutrition services staff.
(E) To the extent practicable, the participation of the resident and the resident's representative(s). An explanation must be included in a resident's medical record if the participation of the resident and their resident representative is determined not practicable for the development of the resident's care plan.
(F) Other appropriate staff or professionals in disciplines as determined by the resident's needs or as requested by the resident.
(iii)Reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments.
Observations:

Based on a review of facility policies, documents and staff interviews it was determined that the facility failed to accurately revise the resident's comprehensive person centered care plan for one of 28 residents (Resident R47).

Findings include:

A review of the facility"Care planning" policy dated 7/1/2020, indicated that the facility's interdisciplinary team will meet to develop a comprehensive person centered care plan for resident's with change in conditions.

A review of Resident R47's Admission Record indicated that the resident was admitted to the facility on 7/16/2020, with the diagnosis of failure to thrive, weight loss, acid reflux, high blood pressure, abnormal gait and mobility, and muscle weakness.

A review of Resident R47's Quarterly MDS dated 2/12/21, indicated that her diagnosis remained current.

A review of Resident R47's progress notes indicated that on 2/14/21, the resident had an X-Ray due to experiencing pain and bruising of her left leg. The X-Ray results indicated that the resident had a nondisplaced acute fracture of the distal femur adjacent to the base of the knee prosthesis. As a follow up to this injury, the facility scheduled a physician appointment with an orthopedic specialist for 2/22/21.

A review of the orthopedic specialist's office progress notes dated 2/22/21, indicated that the physician obtain additional X-Rays and determined that there was no acute femoral fracture.

A review of a letter to Resident R47 from the Orthopedic specialist dated 2/22/21, and filed with the resident's medical record indicated that the Orthopedic specialist communicated to the resident that he determined that there was no femur fracture.

A review of Resident R47's comprehensive person centered care plan revealed that the care plan was revised as follows:
-on 2/23/21, the focus area indicates that the resident is at risk for constipation due to fracture of the left distal femur.
- on 2/23/21, the focus area indicates that the resident has and activities of daily living self- care performance deficit due to a new non displaced fracture of distal left femur adjacent to the base of the knee prosthesis.
- on 2/24/21, focus area indicates that the resident has limited physical mobility due to a new non displaced fracture of distal left femur adjacent to the base of the knee prosthesis.
- on 2/24/21, focus area the resident has acute pain due to new fracture of left femur.
- on 2/24/21, focus area the resident has potential for pressure ulcer development due to decreased independent bed mobility and ambulation due to a new non displaced fracture of distal left femur adjacent to the base of the knee prosthesis.

During an interview on 3/24/21, at 1:40 pm the Director of Nursing confirmed that the facility failed to accurately revise Resident R47's comprehensive person centered care plan to reflect the Orthopedic specialist's diagnosis and findings of the follow up office visit of 2/22/21.

28 Pa Code: 211.11(a) Resident care plan.





 Plan of Correction - To be completed: 05/17/2021

Resident R47's careplan has been revised to reflect current condition.

No other careplans with change in conditions in the last 60 days were found to be out of compliance. All were found to be updated as necessary

RNAC and LNAC reviewed process of updating careplans when necessitated by timeframe for updating or change in condition which would necessitate an update as per RAI manual with the NHA. Changes in condition will be discussed at morning stand-up which RNAC/LNAC are a part of. If update is warranted it will take place immediately.

Change in condition report will be monitored and 25% of careplans related to such will be audited by DON/designee weekly X4 and then monthly X2 with a report to QA. Any found to be needing updated will be done immediately.
51.3 (g)(1-14) LICENSURE NOTIFICATION:State only Deficiency.
51.3 Notification

(g) For purposes of subsections (e)
and (f), events which seriously
compromise quality assurance and
patient safety include, but not
limited to the following:
(1) Deaths due to injuries, suicide
or unusual circumstances.
(2) Deaths due to malnutrition,
dehydration or sepsis.
(3) Deaths or serious injuries due
to a medication error.
(4) Elopements.
(5) Transfers to a hospital as a
result of injuries or accidents.
(6) Complaints of patient abuse,
whether or not confirmed by the
facility.
(7) Rape.
(8) Surgery performed on the wrong
patient or on the wrong body part.
(9) Hemolytic transfusion reaction.
(10) Infant abduction or infant
discharged to the wrong family.
(11) Significant disruption of
services due to disaster such as fire,
storm, flood or other occurrence.
(12) Notification of termination of
any services vital to continued safe
operation of the facility or the
health and safety of its patients and
personnel, including, but not limited
to, the anticipated or actual
termination of electric, gas, steam
heat, water, sewer and local exchange
of telephone service.
(13) Unlicensed practice of a
regulated profession.
(14) Receipt of a strike notice.

Observations:
Based on a review of facility policies, documents, State Agency Event Reporting records, and staff interviews, it was determined that the facility failed to report and incident with an injury or unknown origin for one of 28 residents (Resident R47) as required.

Findings include:

A review of the facility's "Incident Reports" policy dated 7/1/2020, indicated that the all accidents/incidents where there is mistreatment, neglect, abuse or injury of unknown origin will be reported to the Adminsitrator and Director of Nursing immediately for review and reporting to the State Agency.

A review of Resident R47's progress notes revealed that on 2/14/21, the resident voiced concerns of pain and bruising on her left leg. The facility contacted the physician and obtained an order for an X-Ray. The results of the X-Ray dated 2/14/21, revealed a non displaced acute fracture of the distal femur adjacent to the base of the knee prosthesis.

A review of the facility's State Agency Event Reporting records for this time period failed to provide evidence that the facility reported this incident to the State Agency as required.

During an interview of 3/24/21, at 1:40 pm the Director of Nursing confirmed that the facility failed to report an incident with an injury of unknown origin for Resident R47 to the State Agency as required.


 Plan of Correction - To be completed: 05/17/2021

Report was completed to the State Event Reporting System.

Review of other incidents in past 90 days revealed all other issues requiring reporting had been completed.

Guidelines for reportable incidents will be reviewed with all managers by NHA/DON to include qualifying incidents and timelines for reporting.

Review of all incident reports will be done ongoing by NHA/DON to assure accurate and timely reporting
201.14(a) LICENSURE Responsibility of licensee.:State only Deficiency.
(a) The licensee is responsible for meeting the minimum standards for the operation of a facility as set forth by the Department and by other State and local agencies responsible for the health and welfare of residents.
Observations:
Based on review of facility infection control policies and procedures, quality assurance surveillance, and staff interview, it was determined that the facility failed to comply with the following requirement of MCARE Act 403(a)(1), for three of four Quality Assurance/Infection Control Committee meetings (Februaury 2020 and February 2021 revealed that meeting minutes did not have all quality members

Findings include:

MCARE Act, Section 403(a)(1), 40 P.S. 1303.403(a)(1) - Infection Control Plan, states:
(a) Development and compliance - Within 120 days of the effective date of this section, a health care facility and an ambulatory surgical facility shall develop and implement an internal infection control plan that shall be established for the purpose of improving the health and safety of patients and health care workers and shall include:
(1) A multidisciplinary committee including representatives from each of the following, if applicable to the specific health care facility:
(i) Medical staff that could include the chief medical officer or the nursing home medical director.
(ii) Administration representatives that could include the chief executive officer, the chief financial officer or the nursing home administrator.
(iii) Laboratory personnel.
(iv) Nursing staff that could include a director of nursing or a nursing supervisor.
(v) Pharmacy staff that could include the chief of pharmacy.
(vi) Physical plant personnel.
(vii) A patient safety officer.
(viii) Members from the infection control team, which could include an epidemiologist.
(ix) The community, except that these representatives may not be an agent, employee or contractor of the health care facility or ambulatory surgical facility.

A review of the facility infection control surveillance (tracking of all infections within the facility in an effort to identify trends or to prevent further infections from developing) and Quality Assurance Committee meeting minutes for calendar year 2020/2021, revealed no evidence that the facility had all required members as a part of the interdisciplinary Quality Control Committee for February 24, 2020, July 31, 2020, and November 23, 2020.

During an interview on 3/23/21, at 11:40 a.m. the Director of Nursing confirmed that the quarterly review of Infection Control data completed at the Quality Assurance Committee meetings did not include all required members.


 Plan of Correction - To be completed: 05/17/2021

Facility did not have all required members due to COVID-19 restrictions.

Going forward, required members will be present if possible barring extension/continuation due to pandemic precautions. If conditions prohibit in-person meeting a conference call will be utilized and documented.

NHA/designee will monitor infection control meetings for compliance.
201.20(c) LICENSURE Staff development.:State only Deficiency.
(c) There shall be at least annual inservice training which includes at least infection prevention and control, fire prevention and safety, accident prevention, disaster preparedness, resident confidential information, resident psychosocial needs, restorative nursing techniques and resident rights, including personal property rights, privacy, preservation of dignity and the prevention and reporting of resident abuse.
Observations:
Based on review of facility policy, employee personnel record, in-service education documentation and staff interview it was determined that the facility failed to provide a comprehensive annual in-service education for one of four nurse personnel files (LPN Employee E13).

Findings include:

The facility "Staff development training program" policy last reviewed on 7/1/2020, indicated all personnel must participate in regularly scheduled in-service training classes. Mandatory in-service training includes fire safety, disaster preparedness, and behavioral health.

Review of Licensed Practical Nurse (LPN) Employee E1 personnel record indicated her date of hire as of 2/22/16.

Review of annual in-service training dated 3/2020, 9/2020, and 10/2020 did not indicate that LPN Employee E13 received fire prevention and disaster preparation training.

During an interview on 3/25/21, at 12:28 p.m. the Assistant Director of Nursing (ADON) confirmed that the facility failed to provide a comprehensive annual in-service education for LPN Employee E13 as required.



 Plan of Correction - To be completed: 05/17/2021

LPN E13 no longer is employed at the facility.

All other employees had required education/training.

Administrative secretary, who is responsible for maintaining files will be inserviced on checking and monitoring employee files for required documentation by NHA.

NHA/designee will randomly audit 10% of all employees with greater than 1 yr of service to assure compliance with annual inservice requirements
209.8(a) LICENSURE Fire Drills.:State only Deficiency.
(a) Fire drills shall be held monthly. Fire drills shall be held at least four times per year per shift at unspecified hours of the day and night.
Observations:

Based on review of facility policy, fire drill records, and staff interview it was determined that the facility failed to conduct annual fire drills for one out of three shifts (night shift-11 p.m. to 7:00 a.m.)

Findings include:

The facility "Fire drill" policy last reviewed on 7/1/2020, indicated fire drills will be performed as required once per month, per quarter, per shift.

Review of the facility fire drill documentation from January 2020 to February 2021, indicated that only one fire drill took place during the 11:00 p.m. to 7:00 a.m. shift (2/26/2020 at 5:00 a.m.).

During an interview on 3/22/21, at 1:58 p.m. the Maintenance Supervisor Employee E1 confirmed that the facility failed to provide annual fire drills per shift for four quarters in a year as required.





 Plan of Correction - To be completed: 05/17/2021

Fire drills will be conducted as required by regulation.

Review of requirements done by NHA with Maintenance Director/Safety Officer to include frequency of and documentation of fire drills.

NHA/designee will monitor fire drills ongoing to assure compliance. Any discrepancies will be addressed with Maintenance Direcot/Safety Officer immediately.
209.8(b) LICENSURE Fire Drills.:State only Deficiency.
(b) A written report shall be maintained of each fire drill which includes date, time required for evacuation or relocation, number of residents evacuated or moved to another location and number of personnel participating in a fire drill.
Observations:

Based on review of facility policy, fire drill records, and staff interview it was determined that the facility failed to document staff participation in annual fire drills for eight out of 14 months (April 2020, May 2020, June 2020, July 2020, August 2020, September 2020, October 2020, and November 2020).

Findings include:

The facility "Fire drill" policy last reviewed on 7/1/2020, indicated fire drills will be performed once per month, per quarter, per shift. When the fire alarm sounds, it is everyone's responsibility to perform expected duties. Fire drills will exercise staff response. The facility maintenance supervisor will maintain records of drills and staff response.

Review of the facility fire drills from January 2020 to February 2021 did not include documentation of staff participants for April 2020, May 2020, June 2020, July 2020, August 2020, September 2020, October 2020, and November 2020.

During an interview on 3/22/21, at 1:58 p.m. the Maintenance Supervisor Employee E1 confirmed that that the facility failed to document staff participation in annual fire drills for eight out of 14 months.





 Plan of Correction - To be completed: 05/17/2021

Fire drills will be documented as required going forward.

NHA will review said requirements with Maintenance Director/Safety Officer to assure compliance.

NHA will monitor fire drills going forward to assure proper documentation is in place. Any issues discovered will be addressed as needed.
35 P. S. 448.809b LICENSURE Photo Id Reg:State only Deficiency.
(1) The photo identification tag shall include a recent photograph of the employee, the employee's FIRST name, the employee's title and the name of the health care facility or employment agency.

(2) The title of the employee shall be as large as possible in block type and shall occupy a one-half inch tall strip as close as practicable to the bottom edge of the badge.

(3) Titles shall be as follows:
(i) A Medical Doctor shall have the title " Physician. "
(ii) A Doctor of Osteopathy shall have the title " Physician. "
(iii) A Registered Nurse shall have the title " Registered Nurse. "
(iv) A Licensed Practical Nurse shall have the title " Licensed Practical Nurse. "
(v) Abbreviated titles may be used when the title indicates licensure or certification by a Commonwealth agency.

(4)A notation, marker or indicator included on an identification badge that differentiates employees with the same first name is considered acceptable in lieu of displaying an employee's last name.


Observations:
Based on observations and staff interviews, it was determined that the facility failed to make certain that staff members properly wore a photo identification tag for two to two Nursing Assistants (NA) (NA Employee E5, and E6) and one of two Registered Nurses (RN) (RN Employee E3) as required.

Finding include:

A review of the Photo Identification Tag Regulation indicates that staff must wear a photo identification tag that shall include a recent photograph of the employee, the employee's first name, the employee's title and the name of the health care facility or employment agency.

During an observation on 3/22/21, at 12:10 pm it was observed that NA Employee E5 and NA Employee E6 were displaying on their uniform shirt a piece of masking tape with their name and title hand written on the masking tape.

During an observation on 3/24/21, at 1:00 pm it was observed that RN Employee E3 was displaying on her uniform shirt a piece of masking tape with her name and title hand written on the masking tape.

During an interview on 3/24/21, at 1:40 pm the Director of Nursing confirmed that NA Employee E5 and RN Employee E3 were staff members of an employment agency that does not provide their staff with photo identification tags and that the facility failed to make certain that NA Employee E5, NA Employee E6 and RN Employee E3 properly wore photo identification tags with the require information displayed as required.


 Plan of Correction - To be completed: 05/17/2021

All staff going forward, weather facility or agency will have and display proper identification.

Staffing co-ordinator will discuss such need with all agencies used. HR director will assure all employees have said identification.

Management staff at all times while out on the resident units will monitor staff (employees and agency) for compliance with appropriate identification. A report will be given to QA monthly X3 on compliance.

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