Pennsylvania Department of Health
EMBASSY OF TUNKHANNOCK
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

EMBASSY OF TUNKHANNOCK
Inspection Results For:

There are 110 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.


EMBASSY OF TUNKHANNOCK - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:

Based on a Medicare/Medicaid Recertification, State Licensure, Civil Rights Compliance and Abbreviated Complaint survey completed on May 21,2024, it was determined that Embassy of Tunkhannock was in not 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:

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

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

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

Plan of Correction - To be completed: 07/18/2024

1. The facility cannot retroactively correct the deficient practice that caused resident 23's mucosal membrane pressure injury. The blister on resident 23's thigh resolved on 12/24/2023.
2. The facility will review current residents with foley catheters and suprapubic catheters to ensure no injury. The facility will review current wounds to ensure size, color, the surrounding tissue's appearance, and potential causative factor(s) are indicated.
3. Licensed nursing staff will be educated on proper placement of foley catheters and suprapubic catheters to prevent further occurrences. Licensed nursing staff will be educated in documenting size, color, the surrounding tissue's appearance, and potential causative factors upon initial discovery of wounds to prevent recurrence of missing documentation.
4. The DON/designee will audit residents with foley catheters and suprapubic catheters for mechanical injuries weekly X 4 then monthly X 3. Audits for residents with newly identified wounds will be completed for the same duration. These audits will include size, color, the surrounding tissue's appearance and potential causative factors.
5. July 18, 2024

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

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

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

Observations:

Based on a review of clinical records, select incident reports and facility policy, and staff interview it was determined that the facility failed to provide necessary supervision of a resident with known unsafe behaviors to prevent a fall resulting in serious injuries, a fracture left humeral head and fracture of the left nasal bone, for one out of 20 sampled residents (Resident 12).

Findings include:

A review of a facility policy entitled "Falls Management System" that was provided by the facility on May 21, 2024, indicated that each resident is assisted in attaining or maintaining their highest practicable level of function through providing the resident adequate supervision, assistive devices, and functional programs, as appropriate, to prevent accidents. It is the policy of this center to provide each resident with appropriate evaluation and interventions to prevent falls and minimize complications if a fall occurs.

A review of Resident 12's clinical record revealed that the resident was admitted to the facility on March 4, 2024, with diagnoses that included vascular dementia [is a condition caused by the lack of blood that carries oxygen and nutrient to a part of the brain that causes problems with reasoning, planning, judgment, and memory], cognitive communication deficit [are problems with communication caused by impaired cognitive processes, such as attention, memory, perception, and language], symbolic dysfunction [refers to the breakdown in communication that occurs when symbols, such as words, gestures, or facial expressions, are misinterpreted or misunderstood], anxiety [fear characterized by behavioral disturbances], and dysphasia (difficulty swallowing).

An admission "Nursing Assessment - Section 6. Fall Risk" dated March 4, 2024, at 1:21 p.m., revealed that Resident 12 was assessed as a high fall risk. Nursing documentation in the resident's clinical record following the resident's admission on March 4, 2024, revealed that the resident required assistance of one staff with activities of daily living and assist of two with transfers out of bed to the wheelchair daily daily. Employee 1, LPN noted that the resident was oriented to self but had confusion to location and situation. The resident was able to resident able to make needs known to staff but was non-compliant with alarms. Staff had observed the resident ambulating around room and pushing her bed side table and stated to this author \ "I went to college, how much money do you make?" Safety device in place and functioning and will continue to monitor, call bell within reach.

Additionally, a nurse progress behavior note completed by Employee 1, a LPN, dated March 8, 2024, at 10:58 a.m., revealed that the resident was continuously standing up from her wheelchair and was non-compliant with safety devices. Resident was standing up in lobby and attempting to walk around during activities and stated, "I want to go home, I need to go home to my mother for supper. what do you want me to do, do you want me to hit you or slap it out of you. You just need to leave me alone, goodbye." The resident continued standing up out of chair, post therapy and one-to-one, fluids, toileting, and activities were ineffective, and the resident was grabbing at other people's hand as they walked by and yelled "Diane." Safety devices were in place and functioning and will monitor.

A Minimum Data Set assessment (MDS - a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated March 11, 2024, revealed that the resident had severe cognitive impairment, physical behavioral symptoms directed toward others (e.g., hitting, kicking, pushing, scratching, grabbing, abusing others sexually), and other behavioral symptoms not directed toward others (e.g., physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes, or verbal/vocal symptoms like screaming or disruptive sounds) behavior of this type occurred 1 to 3 days.
The MDS noted that the resident's behaviors significantly put the resident at risk for physical illness or injury and the resident used daily bed and chair alarm [any physical or electronic device that monitors resident movement and alerts the staff when movement is detected].

Resident 12's care plan revised March 15, 2024, identified that the resident was at risk for falls with prevention interventions to anticipate and meet the resident's needs, be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed and provide a prompt response to all requests for assistance, ensure that the resident is wearing appropriate footwear such as nonskid sock when ambulating or mobilizing in wheelchair, and use chair/bed electronic alarm and ensure the device is in place as needed.

Progress notes dated March 11, 2024, through March 20, 2024, revealed that the resident displayed behaviors such as combativeness and non-compliance with care, punching, and slapping at staff, crying/weeping, was difficult to console or redirect, and continued to exhibit unsafe behaviors.

A review of a SBAR (Situation Background Assessment Recommendation - a communicate tool) completed by Employee 2, a Licensed Practical Nurse (LPN), dated March 20, 2024, at 8:09 p.m., revealed that the resident had a change in condition related to a fall. Vitals were as follows: pulse: 107, respiration rate: 24, temperature: 98.4, pulse oximetry: O2 98.0 % room air, and had pain. Employee 2 noted that she heard crying and found the resident lying on the floor \ with a small amount blood noted from resident's nose. Supervisor \ called to room and assessment was performed and the resident's Primary Care Provider responded to send resident to ER (emergency department) for evaluation.

An incident report completed by Employee 3, a Registered Nurse (RN), dated March 20, 2024, at 8:38 p.m., revealed that at 7: 45 p.m., Resident 12 was found lying on her back, on the floor in her room, in front of the door. Resident noted to have scant amount of sanguineous (bloody) drainage under her nose and was awake and alert with confusion per norm. This nurse \ attempted to ask resident what happened, resident started to say that she got out of bed and then became emotional with incomprehensible speech. Emotional support given. Vitals obtained and as charted. Resident stated that her head hurt and attempted to reposition herself and proceeded to cry out when she moved her left shoulder. Able to move right arm without difficulty. Legs equal in length and no external foot rotation noted with plus two pitting edema (swelling) noted to bilateral lower extremities. Skin was intact. While trying to safely reposition the resident, she became lethargic and less responsive to verbal stimuli than baseline. Noted predisposing situation factors \ included ambulating without assistance, bare feet or inappropriate footwear, non-compliance with safety instructions, incident during unassisted self-transfer from bed, bed in lowest position, and safety mat(s) at side of the bed. The on-call physician was contacted and ordered to send resident to the ER (emergency room) and the responsible party (RP) was notified with 911 called.

Resident 21's clinical record revealed that she returned to the facility on March 21, 2024, at 6:56 am, with diagnoses of minimally displaced fracture (broken) left humeral head (bone in the upper arm) and a minimally displaced fracture of the left nasal (nose) bone.

The facility was aware of the resident's confusion to location and situation, unsafe behaviors, and non-compliance with safety measures, including alarms, but failed to provide the resident with the necessary supervision, at the level and frequency required, to prevent this fall during which the resident sustained multiple fractures.

During an interview with the Director of Nursing (DON) on May 21, 2024, at 12:00 p.m., confirmed that the facility failed to provide adequate supervision of a resident (Resident 12) with known unsafe behaviors to prevent falls and from sustaining major injuries, fractures to the left humeral head and left nasal bone.

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

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

Plan of Correction - To be completed: 07/18/2024

1. The facility cannot retroactively correct the deficient practice of not providing resident 12, who was noted to have unsafe behaviors, with the necessary supervision to prevent a fall with injuries.
2. Residents with unsafe behaviors will be reviewed by IDT, to ensure that residents receive adequate supervision, at the level and frequency required and assistive devices to prevent accidents.
3. IDT will review residents noted with unsafe behaviors and the need for increased supervision during daily clinical meetings. Nursing staff will be educated on the need for increased supervision, at the level and frequency required, and assistive devices to prevent recurrence.
4. The DON/designee will audit residents with increased need for supervision and residents with unsafe behaviors daily x 4 weeks then monthly x 3 to ensure residents are provided necessary supervision, at the level and frequency required. Results will be sent to the QA committee for review and compliance.
5. July 18, 2024

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 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 and two of three resident pantries.

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).

Review of a facility policy titled "Food Storage" that was provided by the facility on May 20, 2024, indicated that food storage areas shall be maintained in a clean, safe, and sanitary manner. Guidelines for food storage included the following:

Food storage areas shall be clean at all times.
All packaged food, canned foods, or food items stored shall be kept clean and dry at all times.
All foods stored in walk-in refrigerators and freezers shall be stored above the floor on the shelves, racks, dollies, or other surfaces that facilitates thorough cleaning. All food will be dated at time of receipt and be inventoried using the FIFO (first in, first out) method.
Bulk items such as flour, sugar, oatmeal, etc. shall be stored in covered plastic bins. These should be labeled and dated clearly and appropriately.

The initial tour of the kitchen was conducted on May 18, 2024, at 8:38 AM, that revealed the following unsanitary practices with the potential to introduce contaminants into food and increase the potential for food-borne illness:

Observed a rack of clear plastic beverage pitchers that had an accumulation of a white substance coating the surfaces.

Above the beverage station, observed a ceiling tile that had tan colored circular staining and the top of the coffee maker had an accumulation of dust adhered to the surface. Also, behind the coffee maker and on the molding of the stainless-steel table there was an accumulation of debris and dust.

Observations of another food/beverage preparation station revealed that the shelving had debris present and stained serving trays with dishes on the tray and were not covered. The trays that had thermal cups that were on a tray that was stained.

Observations of the walk-in freezer revealed that the door latch was broken and did not make contact with the latch to secure the door closed. Upon entry, the air curtain was ill-fitting, covered in frost, and had icicles hanging off the plastic strips and dripping on to the floor. The entry way floor was covered in a thick coating of ice that was slippery.

Additionally, observed that the cases of frozen food were encased in ice crystals and observed three cases of frozen food left in direct contact with the floor.

Observed that there was a free-standing black colored fan that was pointed at the walk-in freezer door that was covered with debris and dust.

The ceiling tiles near the tray line area were splattered with a brown-colored substance and the ceiling light covers had several dead bugs accumulated on the inside.

Further observations of revealed that there was a dirty broom leaning between the wall and kitchen preparation equipment.

Observed that microwave, near the tray line, had food splattered on the handle.

Additionally, there were two plastic containers of serving utensils placed inside with the handles at the bottom of the container and left uncovered.

The cook's sink had a green cutting board that was placed between the wall and faucet and was observed with deep knife marks and worn.

In the cook's area, observed a black mobile cart with two eight-quart clear plastic storage containers with cereal inside and were not labeled or dated.

Observed that the wall exiting the cook's area was peeling and the tile baseboard behind was crumbling that left a gap between the wall and tile.

Observed that ceiling tiles in the dish room area had a tannish-brown colored substance splattered on them.

An observation conducted on May 18, 2022, at 9:11 AM, of the green unit resident pantry revealed that the there was a ceiling tile near a vent that had brown circular stains. The top of the refrigerator had debris and dust, an uncovered thermometer, and a blue basket with food remnants.

Additionally, observed that the blue unit resident pantry had reddish colored stains on the floor around the perimeter of the refrigerator.

During an interview with the Nursing Home Administrator on May 20, 2024, at 10:39 a.m., confirmed the above observations and that dietary department, and dietary equipment, and resident pantry areas should be maintained in a sanitary manner to prevent opportunities for foodborne illness.

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

28 Pa. Code 211.6 (f) Dietary Services

Plan of Correction - To be completed: 07/18/2024

1. Ceiling tiles are scheduled to be replaced once materials become available. Unclean areas were cleaned during the annual survey. Walk in freezer – vendors scheduled to assess door, latch and extensive ice buildup to be assessed to determine root cause. Wall and tiles assessed by maintenance director and materials ordered to complete repairs. Dinettes on blue and green wings assessed and cleaned.
2. Comprehensive assessment of environmental completed in dietary and dinettes to ensure sanitary conditions to prevent opportunities for foodborne illness.
3. Education to be provided to dietary staff on areas identified in the citation. Cleaning lists reviewed to ensure a complete cleaning guide available to dietary staff. Nursing and housekeeping staff to be educated on proper cleaning procedures for unit dinettes.
4. Areas indicated in citation will be audited weekly X 4 weeks and then monthly X 3 months to ensure continued sanitary conditions are present and that staff education is conclusive with staff responsibilities. Audits to be sent to QA Committee to ensure compliance.
5. July 18, 2024

483.90(d)(2) REQUIREMENT Essential Equipment, Safe Operating Condition:

§483.90(d)(2) Maintain all mechanical, electrical, and patient care equipment in safe operating condition.

Observations:

Based on observations, and staff interview, it was determined the facility failed to ensure that essential equipment was in safe operating condition in the facility's kitchen.

Findings include:

Observation of the dietary department on May 18, 2024, at 8:38 a.m., revealed that the door latch to the facility's walk-in freezer was broken and did not make contact with the latch on the door jamb to secure it closed and left a gap around the perimeter of the door. Additionally, observed that the seal around the freezer door was ill-fitting.

Upon entering the walk-in freezer, observed that the air curtain was ill-fitting, covered in frost, and had icicles hanging off the plastic strips and dripping on to the floor. The freezer entry way floor was covered in a thick coating of ice and was slippery.

Additionally, observed that the cases of frozen food were encased in ice crystals and the wire metal shelves were encased in ice.

At the time of the survey ending May 21, 2024, the Nursing Home Administrator (NHA) could not provide documented evidence that that the facility had acted upon the on-going issues with the walk-in freezer to maintain resident food in a safe and sanitary manner.

Refer F812

28 Pa. Code 201.18 (e)(2)(3)(4) Management

Plan of Correction - To be completed: 07/18/2024

1. Facility cannot retroactively correct deficiency related to the walk-in freezer.
2. Walk in freezer was identified during the 2023 annual DOH survey as having ice buildup on food boxes, and unsafe ice buildup on floor and door of walk-in. A vendor was hired to repair issues in 2023. Vendor did make corrections to walk-in freezer at that time. Walk-in freezer was assessed by the regional vice president of facility maintenance June 2024. Areas of concerns and root cause analysis on-going.
3. Vendor of refrigeration to be scheduled to assess walk-in freezer and make necessary corrections to equipment to prevent excessive ice build-up on surfaces of freezer and boxes of food to ensure a safe environment for employees and to prevent any possibility of food borne illness.
4. Post vendor assessment and corrective action maintenance director/designee will monitor the walk-in freezer daily X 4 weeks to ensure excessive ice buildup does not occur while maintaining proper temperatures of walk-in. After 4 weeks of daily audits, audits will continue monthly X 3 months with results to the QA Committee to ensure compliance with regulations.
5. July 18, 2024

483.75(g)(1)(i)-(iii)(2)(i); 483.80(c) REQUIREMENT QAA Committee:

§483.75(g) Quality assessment and assurance.
§483.75(g) Quality assessment and assurance.
§483.75(g)(1) A facility must maintain a quality assessment and assurance committee consisting at a minimum of:
(i) The director of nursing services;
(ii) The Medical Director or his/her designee;
(iii) At least three other members of the facility's staff, at least one of who must be the administrator, owner, a board member or other individual in a leadership role; and
(iv) The infection preventionist.

§483.75(g)(2) The quality assessment and assurance committee reports to the facility's governing body, or designated person(s) functioning as a governing body regarding its activities, including implementation of the QAPI program required under paragraphs (a) through (e) of this section. The committee must:
(i) Meet at least quarterly and as needed to coordinate and evaluate activities under the QAPI program, such as identifying issues with respect to which quality assessment and assurance activities, including performance improvement projects required under the QAPI program, are necessary.

§483.80(c) Infection preventionist participation on quality assessment and assurance committee.
The individual designated as the IP, or at least one of the individuals if there is more than one IP, must be a member of the facility's quality assessment and assurance committee and report to the committee on the IPCP on a regular basis.

Observations:

Based on review of facility documents and staff interviews, it was determined that the facility failed to maintain a Quality Assurance Process Improvement (QAPI) Committee.

Findings include:

During review of QAPI committee on May 21, 2024, the Nursing Home Administrator was unable to provide evidence of any staff, administration, or Medical Director attendance to meetings.

The NHA failed to provide evidence of QAPI Committee meeting sign-in sheets for the period of April 2023 through April 2024.

Interview with the NHA on May 21, 2024, at 10:36 AM confirmed that the facility failed to maintain a QAPI committee.

28 Pa. Code 211.2(d)(5)(6)(7)(8)(10) Medical director

28 Pa. Code 201.18 (e)(2)(3)(4) Management.

Plan of Correction - To be completed: 07/18/2024

1. Facility cannot retroactively correct findings of citation. NHA indicated to DOH surveyor that corrective actions to address gaps in system processes and effectiveness of those actions were completed, however not documented in a standard QA format. NHA indicated that investigation, analysis and prevention of adverse events are discussed during IDT meetings daily, however not documented in a standard manner as indicated in the regulation.
2. QA committee members will be re-identified and required attendance will be documented at scheduled meetings. NHA educated on regulatory composition of QA committee minutes/metrics.
3. NHA/designee will complete quality assurance committee meetings monthly to ensure all regulatory compliance requirements are met per federal guidelines. NHA/designee to ensure all requirements are documented in a standardized format to meet regulatory compliance. Education provided to NHA by Regional Vice President of Operations on QA Committee requirements. NHA/designee will ensure all QA Committee meeting minutes and attendance sheets are completed.
4. Operations VP will review QA Committee documentation monthly to ensure complete compliance with regulatory requirements X 3 months with results reviewed with QA committee members by RVP/designee.
5. July 18, 2024

483.75(c)(d)(e)(g)(2)(i)(ii) REQUIREMENT QAPI/QAA Improvement Activities:

§483.75(c) Program feedback, data systems and monitoring.
A facility must establish and implement written policies and procedures for feedback, data collections systems, and monitoring, including adverse event monitoring. The policies and procedures must include, at a minimum, the following:

§483.75(c)(1) Facility maintenance of effective systems to obtain and use of feedback and input from direct care staff, other staff, residents, and resident representatives, including how such information will be used to identify problems that are high risk, high volume, or problem-prone, and opportunities for improvement.

§483.75(c)(2) Facility maintenance of effective systems to identify, collect, and use data and information from all departments, including but not limited to the facility assessment required at §483.70(e) and including how such information will be used to develop and monitor performance indicators.

§483.75(c)(3) Facility development, monitoring, and evaluation of performance indicators, including the methodology and frequency for such development, monitoring, and evaluation.

§483.75(c)(4) Facility adverse event monitoring, including the methods by which the facility will systematically identify, report, track, investigate, analyze and use data and information relating to adverse events in the facility, including how the facility will use the data to develop activities to prevent adverse events.

§483.75(d) Program systematic analysis and systemic action.

§483.75(d)(1) The facility must take actions aimed at performance improvement and, after implementing those actions, measure its success, and track performance to ensure that improvements are realized and sustained.

§483.75(d)(2) The facility will develop and implement policies addressing:
(i) How they will use a systematic approach to determine underlying causes of problems impacting larger systems;
(ii) How they will develop corrective actions that will be designed to effect change at the systems level to prevent quality of care, quality of life, or safety problems; and
(iii) How the facility will monitor the effectiveness of its performance improvement activities to ensure that improvements are sustained.

§483.75(e) Program activities.

§483.75(e)(1) The facility must set priorities for its performance improvement activities that focus on high-risk, high-volume, or problem-prone areas; consider the incidence, prevalence, and severity of problems in those areas; and affect health outcomes, resident safety, resident autonomy, resident choice, and quality of care.

§483.75(e)(2) Performance improvement activities must track medical errors and adverse resident events, analyze their causes, and implement preventive actions and mechanisms that include feedback and learning throughout the facility.

§483.75(e)(3) As part of their performance improvement activities, the facility must conduct distinct performance improvement projects. The number and frequency of improvement projects conducted by the facility must reflect the scope and complexity of the facility's services and available resources, as reflected in the facility assessment required at §483.70(e). Improvement projects must include at least annually a project that focuses on high risk or problem-prone areas identified through the data collection and analysis described in paragraphs (c) and (d) of this section.

§483.75(g) Quality assessment and assurance.

§483.75(g)(2) The quality assessment and assurance committee reports to the facility's governing body, or designated person(s) functioning as a governing body regarding its activities, including implementation of the QAPI program required under paragraphs (a) through (e) of this section. The committee must:

(ii) Develop and implement appropriate plans of action to correct identified quality deficiencies;
(iii) Regularly review and analyze data, including data collected under the QAPI program and data resulting from drug regimen reviews, and act on available data to make improvements.

Observations:

Based on information provided by the facility, and staff interview it was determined that the facility failed to implement a quality assurance program to identify problems that are opportunities for improvement.

Findings include:

According to federal regulatory requirements at 42 CFR (g)(2) the QAPI committee must:

(g)(2)(ii) Develop and implement appropriate plans of action to correct identified quality deficiencies;

(g)(2)(iii) Regularly review and analyze data, including data collected under the QAPI program and data resulting from drug regimen reviews, and act on available data to make improvements.

Interview with the Nursing Home Administrator on May 21, 2024, at 10:36 AM revealed there was no evidence the facility had taken actions aimed at performance improvement since last annual survey completed April 21, 2023.

28 Pa. Code 201.18 (b)(1)(3)(e)(1)(2)(4) Management

Plan of Correction - To be completed: 07/18/2024

1. Facility cannot retroactively correct findings of citation. NHA indicated to DOH surveyor that corrective actions to address gaps in system processes and effectiveness of those actions were completed, however not documented in a standard QA format. NHA indicated that investigation, analysis and prevention of adverse events are discussed during IDT meetings daily, however not documented in a standard manner as indicated in the regulation.
2. NA
3. NHA/designee will complete quality assurance committee meetings monthly to ensure all regulatory compliance requirements are met per federal guidelines. NHA/designee to ensure all requirements are documented in a standardized format to meet regulatory compliance. Education provided to NHA by Regional Vice President of Operations on QA Committee requirements.
4. Operations VP will review QA Committee documentation monthly to ensure complete compliance with regulatory requirements X 3 months.
5. July 18, 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 facility policies and staff interview, it was determined that the facility failed to maintain documentation and demonstrate evidence of its ongoing QAPI (Quality Assurance Performance Improvement - a framework utilized to guide an organization's performance improvement efforts) program.

Findings include:

Review of the facility policy entitled "Quality Assurance and Performance Improvement" last revised August 29, 2022, revealed, the company is committed to developing, implementing, and maintaining an effective, comprehensive, data-driven QAPI program that focuses on indicators of the outcomes of care and quality of life.

The facility will:
1.Maintain documentation and demonstrate evidence of its ongoing QAPI program which may include but is not limited to:
a.systems and reports demonstrating systematic identification, reporting, investigation, analysis, and prevention of adverse events; and
b.documentation demonstrating the development, implementation, and evaluation of corrective actions or performance improvement activities;
2. Present its QAPI plan to the State Survey Agency as requested;
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
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.

Interview with the Nursing Home Administrator on May 21, 2024, at 10:36 AM revealed that the facility had not conducted a QAPI meeting. The NHA could not provide evidence of when the last QAPI meeting had been conducted. According to the NHA, he "has had other things to worry about".

There was no evidence at the time of the survey ending on May 21, 2024, that the facility had developed, implemented, or maintained an effective QAPI program.

28 Pa. Code 201.14(a) Responsibility of licensee

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

Plan of Correction - To be completed: 07/18/2024

1. Facility cannot retroactively correct findings of citation. NHA indicated to DOH surveyor that corrective actions to address gaps in system processes and effectiveness of those actions were completed, however not documented in a standard QA format. NHA indicated that investigation, analysis and prevention of adverse events are discussed during IDT meetings daily, however not documented in a standard manner as indicated in the regulation.
2. NA
3. NHA/designee will complete quality assurance committee meetings monthly to ensure all regulatory compliance requirements are met per federal guidelines. NHA/designee to ensure all requirements are documented in a standardized format to meet regulatory compliance. Education provided to NHA by Regional Vice President of Operations on QA Committee requirements.
4. Operations VP will review QA Committee documentation monthly to ensure complete compliance with regulatory requirements X 3 months.
5. July 18, 2024

483.70(e)(1)-(3) REQUIREMENT Facility Assessment:

§483.70(e) Facility assessment.
The facility must conduct and document a facility-wide assessment to determine what resources are necessary to care for its residents competently during both day-to-day operations and emergencies. The facility must review and update that assessment, as necessary, and at least annually. The facility must also review and update this assessment whenever there is, or the facility plans for, any change that would require a substantial modification to any part of this assessment. The facility assessment must address or include:

§483.70(e)(1) The facility's resident population, including, but not limited to,
(i) Both the number of residents and the facility's resident capacity;
(ii) The care required by the resident population considering the types of diseases, conditions, physical and cognitive disabilities, overall acuity, and other pertinent facts that are present within that population;
(iii) The staff competencies that are necessary to provide the level and types of care needed for the resident population;
(iv) The physical environment, equipment, services, and other physical plant considerations that are necessary to care for this population; and
(v) Any ethnic, cultural, or religious factors that may potentially affect the care provided by the facility, including, but not limited to, activities and food and nutrition services.

§483.70(e)(2) The facility's resources, including but not limited to,
(i) All buildings and/or other physical structures and vehicles;
(ii) Equipment (medical and non- medical);
(iii) Services provided, such as physical therapy, pharmacy, and specific rehabilitation therapies;
(iv) All personnel, including managers, staff (both employees and those who provide services under contract), and volunteers, as well as their education and/or training and any competencies related to resident care;
(v) Contracts, memorandums of understanding, or other agreements with third parties to provide services or equipment to the facility during both normal operations and emergencies; and
(vi) Health information technology resources, such as systems for electronically managing patient records and electronically sharing information with other organizations.

§483.70(e)(3) A facility-based and community-based risk assessment, utilizing an all-hazards approach.

Observations:
Based on staff interviews, it was determined that the facility failed to conduct a facility wide assessment that reflected the personnel and specific resources presently available and to identify those that are necessary to care for its current resident population.

Findings include:

At the time of the survey ending May 21, 2024, the facility failed to provide evidence that a facility assessment to determine the specific and unique needs of its resident population and the available and accessible resources to meet these needs on a daily basis and during emergent situations had been developed.

During an interview with the Nursing Home Administrator on May 19, 2024, at 1:00 PM, the NHA had indicated that the facility assessment was provided in the "survey readiness" binder.

Additional interview with the NHA on May 21, 2024, at 1 PM indicated that the facility assessment had recently been updated yet failed to provide the survey team with the required document.

There was no facility assessment presented to the survey team by survey ending May 21, 2024.

28 Pa. Code 201.14(a) Responsibility of licensee

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

Plan of Correction - To be completed: 07/18/2024

Facility cannot retroactively correct deficient practice identified. Facility assessment was provided to survey team lead when requested. The facility assessment was dated March 2024 and is updated quarterly to indicate needs of residents and accessible resources to meet those needs on a daily basis and during emergent situations.
2. Facility assessment will continued to be updated on a quarterly basis or as needed if resources change or the resident population needs exist.
3. NHA reviewed regulations on facility assessment to ensure compliance with federally mandated requirements.
4. Facility assessment will be reviewed by the QA Committee quarterly to ensure compliance with regulatory requirements.
5. May 21, 2024

483.10(c)(2)(3) REQUIREMENT Right to Participate in Planning Care:

This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.

§483.10(c)(2) The right to participate in the development and implementation of his or her person-centered plan of care, including but not limited to:
(i) The right to participate in the planning process, including the right to identify individuals or roles to be included in the planning process, the right to request meetings and the right to request revisions to the person-centered plan of care.
(ii) The right to participate in establishing the expected goals and outcomes of care, the type, amount, frequency, and duration of care, and any other factors related to the effectiveness of the plan of care.
(iii) The right to be informed, in advance, of changes to the plan of care.
(iv) The right to receive the services and/or items included in the plan of care.
(v) The right to see the care plan, including the right to sign after significant changes to the plan of care.

§483.10(c)(3) The facility shall inform the resident of the right to participate in his or her treatment and shall support the resident in this right. The planning process must-
(i) Facilitate the inclusion of the resident and/or resident representative.
(ii) Include an assessment of the resident's strengths and needs.
(iii) Incorporate the resident's personal and cultural preferences in developing goals of care.

Plan of Correction - To be completed: 07/18/2024

1. Facility investigated citation on residents involved. Residents 19, 37, 61 and 73 had evidence located in the multidisciplinary care plan form that they had been invited and refused to participate in their care plan meetings. Resident 30 was asked to participate in a non-scheduled care plan review. Resident refused to participate.
2. Resident audit completed to determine any residents who did not participate in their care plan meetings.
3. Invitations to resident care plans will be sent to all resident representatives for residents who are not their own RP. Residents who are their own RP will receive letters of notification within the facility. Date of notification and response to invitations will be documented on the multidisciplinary care conference note.
4. Random audits by the NHA/designee weekly X 4 weeks and then monthly X 3 months with results of audits sent to the QA Committee for interpretation and compliance reporting.
5. July 18, 2024

483.60(f)(1)-(3) REQUIREMENT Frequency of Meals/Snacks at Bedtime:

§483.60(f) Frequency of Meals
§483.60(f)(1) Each resident must receive and the facility must provide at least three meals daily, at regular times comparable to normal mealtimes in the community or in accordance with resident needs, preferences, requests, and plan of care.

§483.60(f)(2)There must be no more than 14 hours between a substantial evening meal and breakfast the following day, except when a nourishing snack is served at bedtime, up to 16 hours may elapse between a substantial evening meal and breakfast the following day if a resident group agrees to this meal span.

§483.60(f)(3) Suitable, nourishing alternative meals and snacks must be provided to residents who want to eat at non-traditional times or outside of scheduled meal service times, consistent with the resident plan of care.

Observations:

Based on review of the minutes from Resident Council Meetings, scheduled facility mealtimes, and select facility policy, and resident and staff interviews, it was determined that the facility failed to consistently provide snacks as desired by residents including 3 out of the 20 residents sampled (19, 30, and 37) and experiences reported by residents during a group interview (Residents 61 and 73).

Findings include:

A review of the facility's policy titled "Policy: Frequency of Meals," last reviewed in July 2023, indicated that nourishing snacks will be available for residents who need or desire additional food between meals. The policy indicates that residents will be offered nourishing snacks if the time span between the evening meal and the next day's breakfast exceeds fourteen hours.

A review of the facility's scheduled mealtimes revealed that the time between dinner and breakfast the next day exceeds fourteen hours.

A review of resident council meeting minutes dated April 12, 2024, revealed that all residents in attendance indicated that they were not receiving snacks. The meeting minutes indicated that a grievance was filed on behalf of the residents in attendance.

The facility provided daily water and snack pass forms to be completed and signed by a nurse aide and licensed nurse to indicate that water and snacks were passed. Six of the 13 forms had no signature indicating that water or snacks were passed on the 2:00 PM to 10:00 PM shift (evening shift). Six of the 13 forms reviewed had no date to confirm when the task was completed.

During the resident group interview on May 20, 2024, at 10:00 AM, all residents in attendance (Residents 19, 30, 37, 61, and 73) indicated that they were not being offered evening snacks. The residents explained that about once or twice a month they are offered snacks, but the majority of the time they have to ask staff for assistance or get their own snack. The residents indicated that the facility runs out of snacks, and on several occasions, no snacks were available when requested by residents. The residents explained that the facility is aware of this concern; however, the problem has not been resolved. The residents indicated that the facility is often short on nurse staffing and that there may not be enough staff to offer snacks to the residents every evening.

During an interview on May 21, 2024, at 10:30 AM, the Nursing Home Administrator (NHA) was unable to explain why Residents 19, 30, 37, 61, and 73 are indicting that the facility is not offering nutritious snacks. The NHA stated that the facility does not evaluate snack inventory level to ensure snacks are consistently available to meet residents needs.

Refer F565

28 Pa. Code 211.12 (d)(3)(5) Nursing Services

Plan of Correction - To be completed: 07/18/2024

The facility cannot retroactively correct the deficient practice of not providing evening snacks to residents 19, 30, 37, 61 and 73.
2) An audit will be conducted of current residents who desire/need additional food between meals.
3) During resident counsel, residents will be asked if they are having issues with receiving evening snacks. Concerns identified will be placed on a grievance form and given to NHA for review and follow up. Care providers will mark in the task section of the medical chart whether residents accepted or refused snack pass.
4) NHA/designee will audit resident medical charts weekly x 4 weeks then monthly x 3 months. The Dietician/designee will audit snack inventory level to ensure snacks are available to meet the residents needs weekly x 4 then monthly x 3 with results sent to the QA Committee for review and compliance.
5) July 18, 2024

483.10(f)(5)(i)-(iv)(6)(7) REQUIREMENT Resident/Family Group and Response:

§483.10(f)(5) The resident has a right to organize and participate in resident groups in the facility.
(i) The facility must provide a resident or family group, if one exists, with private space; and take reasonable steps, with the approval of the group, to make residents and family members aware of upcoming meetings in a timely manner.
(ii) Staff, visitors, or other guests may attend resident group or family group meetings only at the respective group's invitation.
(iii) The facility must provide a designated staff person who is approved by the resident or family group and the facility and who is responsible for providing assistance and responding to written requests that result from group meetings.
(iv) The facility must consider the views of a resident or family group and act promptly upon the grievances and recommendations of such groups concerning issues of resident care and life in the facility.
(A) The facility must be able to demonstrate their response and rationale for such response.
(B) This should not be construed to mean that the facility must implement as recommended every request of the resident or family group.

§483.10(f)(6) The resident has a right to participate in family groups.

§483.10(f)(7) The resident has a right to have family member(s) or other resident representative(s) meet in the facility with the families or resident representative(s) of other residents in the facility.

Observations:

Based on a review of select facility policy, the minutes from resident council meetings, grievance logs, and resident and staff interviews, it was determined that the facility failed to demonstrate timely action to resolve resident grievances raised at resident group meetings and keep the residents apprised of the status of the facility's decisions and efforts toward grievance resolution, including concerns expressed by five of the five residents interviewed during a resident council group interview (Residents 19, 30, 37, 61, and 73).

Findings include:

A review of facility policy titled "Grievance Policy and Guidelines," last reviewed by the facility in July 2023, indicated that all employees are responsible for ensuring customer satisfaction. The policy indicates that when concerns arise, a grievance system is in place to resolve the issues to the satisfaction of all parties involved. The policy also indicates that response to the grievance should be as soon as possible, but within ten working days of receipt of the grievance form.

A review of resident council meeting minutes dated February 16, 2024, revealed residents in attendance had concerns indicating that their food and coffee were not being served hot. The residents in attendance suggested snack flyer postings so residents would know what snacks are available and suggested more filling snacks. The meeting minutes indicated that a grievance was filed on behalf of the residents regarding cold food and coffee temperatures.

A review of grievances filed revealed no grievance form or actions taken to resolve the grievance. The concern was recorded on a February 2024 grievance log and indicated that all residents at the resident council had concerns that the temperature of the food and coffee was not hot. The log did not indicate actions taken by the facility to resolve the residents' concern.

A review of resident council meeting minutes dated March 15, 2024 revealed that the grievance regarding the temperatures of the hot food and coffee was resolved. The meeting minutes indicated that a resident in attendance indicated that the coffee was "hotter than usual."

A review of resident council meeting minutes dated April 12, 2024, revealed that all residents in attendance indicated that their snacks were not being offered. The meeting minutes indicated a grievance was filed regarding the resident's concern.

A review of grievances filed with the facility failed to reveal a grievance was filed on behalf of residents' regarding snacks offered. The facility grievance log dated April 2024 did not include any information regarding residents' concerns about not being offered snacks.

During the resident group interview on May 20, 2024, at 10:00 AM, all residents in attendance (Residents 19, 30, 37, 61, and 73) indicated that they have concerns that snacks are not being offered, that the facility sometimes runs out of snacks, and that the temperature of food and coffee is cold. Residents 19, 37, 61, and 73 stated that they often wait 15 minutes for staff to respond to their call bell rings for assistance. The residents stated that if they need care, then the wait is even longer because the nursing staff will turn off the bell and then not come back for another 10 or 15 minutes to provide the care that's needed, on top of the 15 minutes they already waited. All residents in attendance stated that the facility does not have enough staff, which affects how quickly they can pass out meals and respond to residents calls for care or assistance. The residents in attendance stated that the facility has not resolved their concerns they have brought up regarding food temperatures, snacks, or call bell wait times. The residents in attendance confirmed that they continuously bring up these issues with facility staff and during resident council meetings.

During the resident group interview on May 20, 2024, at 10:00 AM, the residents explained that the food trays are delivered hot, but the food often sits in the hall for 30 minutes or longer because there is not enough staff to distribute the meals and provide care that residents need.

During an interview on May 21, 2024, at approximately 10:00 AM, the Nursing Home Administrator (NHA) confirmed that it is the facility's policy to demonstrate timely action to resolve resident grievances raised at resident group meetings and keep the residents apprised of the status of the facility's decisions and efforts toward grievance resolution. The NHA was not able to provide evidence that the facility made efforts to identify and address the cause of the resident's grievances. NHA was not able to explain why all residents interviewed during the resident group interview (Residents 19, 30, 37, 61, and 73) indicated that the facility has not addressed their concerns brought up at resident group meetings regarding food and coffee temperatures, snacks, and call bell wait times over the last few months.

Refer F809

28 Pa. Code: 201.18 (e)(1)(4) Management.

28 Pa. Code: 201.29 (a) Resident Rights.

Plan of Correction - To be completed: 07/18/2024

1. Facility investigated citation on residents involved. Residents 19, 30, 37, 61, and 73 were interviewed by social services director and provided education on facility plans for audits to address concerns over cold food, snack pass and quantity, and call bell responding. Audits include call bell audits, snack audits, tray pass audit and temperature audits. Data will be compiled and reviewed by department supervisors and solutions derived. Education on grievances and on identified issues will be presented by the NHA/designee at the next resident council meeting.
2. Random resident interviews conducted on the issues identified by the citation. No further areas of concern were identified.
3. Facility staff will be educated regarding grievance policy and the system in place resolve the issues to the satisfaction of all parties involved.
4. SS/designee will audit all grievances weekly X 4 then monthly X 3 to ensure timely action of resident grievances and to keep them informed of the status of the facilities decision and efforts toward grievance resolution. The dietician/designee will randomly audit temperatures of food and beverages weekly X 4 and monthly X 3 to ensure that food/beverages is at proper temperature.
5. July 18, 2024

483.10(i)(1)-(7) REQUIREMENT Safe/Clean/Comfortable/Homelike Environment:

§483.10(i) Safe Environment.
The resident has a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

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

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

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

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

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

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

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

Observations:

Based on observation, clinical record review, and resident and staff interviews, it was determined that the facility failed to provide housekeeping and maintenance services to maintain a clean and safe resident environment on two of two occupied resident care units.

Findings include:

An observation on May 18, 2024, at 11:10 AM in resident room #107 revealed a ceiling block with a large brown and tan stain above the resident's mirror. In the resident's bathroom, cracks in the floor were observed extending around the edge of the floor. The bathroom wall to the left of the sink, revealed multiple areas of scraped paint, gray and black scuff marks, and exposed drywall.

An observation on May 18, 2024, at 11:14 AM in the Nursing Green Hall shower room revealed that the sink faucet continuously flowed water when in the off position. The shower room vent was observed to have a thick layer of gray dust. A gray bucket under a shower chair was observed to contain a brown and black substance. A toilet with cardboard covering the tank and a missing tank lid. The resident shower stall was observed to have brown and black discoloration stains along the shower floor grout.

An observation on May 18, 2024, at 9:36 AM in resident room #104 revealed a wall to the right of the resident's bathroom with a four-foot by one-foot area of scrapped wall exposing white plaster. Black scuffs were observed across the floor molding and bathroom door.

Observation of resident room 112 on May 19, 2024, at 9:31 AM revealed that the top right dresser drawer was missing, and the top dresser drawer on the left side was unable to be opened/closed properly.

Observation of resident room 113 on May 19, 2024, at 9:37 AM revealed that the second drawer on the resident's dresser was broken. The drawer was unable to be opened/closed properly. The ceiling tile around the vent in the resident bathroom was stained brown.

Observation of resident room 114 on May 19, 2024, at 9:37 AM revealed that the second drawer on the right-hand side of the dresser was broken and would not open/close properly.

Observation of resident room 116 on May 19, 2024, at 9:42 AM revealed the dresser was heavily soiled with food and dried liquid.

Observation of the medication/treatment supply room on the Green Wing on May 20, 2024, at 9:34 AM revealed the sink was heavily soiled and stained with a greenish-blue substance. There was thick brown sludge-like substance coating the faucet and each water turn on knob. The base of the sink was coated with the same brown/black sludge-like substance.

Beneath the sink there was a pink plastic wash basin setting beneath the sink pipe. The basin was coated with a thick layer of brown/black substance. The cabinet frame was heavily soiled with a brown/tan substance.

Ceiling tiles above where the medication cart is stored when not in use were heavily water stained.

An observation on May 20, 2024, at 9:41 AM revealed the medication/treatment supply room on the Blue Wing had a large hole in the wall next to the heating/ac unit that was covered with plastic and secured with blue painter's tape. The cabinet beneath the sink was heavily stained/soiled with a rust-colored substance, dirt, and debris.

Interview with Employee 6, licensed practical nurse, revealed that there were dead animals in the wall that had to be removed. At the time of the observation, the air conditioning was set on "high", and there were air fresheners placed on the air conditioning unit.

Observation of the Blue Wing resident care unit on May 20, 2024, at 9:49 AM revealed multiple water-stained ceiling tiles outside the resident kitchenette and resident shower room. Ceiling tiles next to the vents in the same area were heavily soiled with black dust/lint.

Interview with NHA on May 20, 2024, at approximately 10 AM, confirmed that there were dead squirrels in the wall that needed to be removed. According to the NHA, the facility was waiting on supplies to repair the hole. The NHA further stated that purchase orders were submitted for new drawers/dressers for the resident rooms yet was unable to provide evidence to surveyors that replacement items were on order or that the need for repairs had been identified and/or addressed prior to survey.

An observation on May 20, 2024, at 11:08 AM in the Nursing Blue Hall resident laundry room revealed a sink with multiple rust spots and a faucet that continued to run when in the off position.

Repeat observation of the Blue Wing medication/ treatment supply room at 1:20 PM, revealed that the hole in the wall was repaired. The plastic had been removed and was replaced with an electrical outlet and outlet cover.

Interview with the Nursing Home Administrator on May 21, 2024, at approximately 2 PM confirmed that the residents' environment was to be maintained in a clean and sanitary manner.

Refer F867

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

Plan of Correction - To be completed: 07/18/2024

1. Facility unable to retroactively address citations listed. All areas of concern in the citation will be reviewed and planned for repair or replacement.
2. Resident care areas assessed for repairs and sanitary conditions. Discrepancies were identified and reported to maintenance personnel.
3. Maintenance director/designee will review ceiling tiles routinely and replace stained/broken tiles. Resident laundry area, and all medication rooms will be assessed by maintenance weekly to ensure appropriate cleanliness and assets are in proper working condition. Resident rooms will be rounded on by department heads daily to ensure work orders are submitted in a timely manner. NHA/designee will follow up with maintenance director to ensure work orders are completed as needed.
4. NHA/designee will conduct audits for sanitary conditions, operational resources and home like conditions in all facility areas once a week X 4 weeks, followed by monthly X 3 months. Results will be conveyed to the QA Committee for continued compliance.
5. July 18, 2024

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 observation, review of select facility policy and staff interview, it was determined that the facility failed to ensure that medication was stored at the appropriate temperature according to manufacturer's directions in one of three medication storage rooms reviewed. (Blue Wing)

Findings include:

Observation of the facility's medication storage refrigerator on May 20, 2024, at 9:41 AM in the presence of Employee 6, Licensed Practical Nurse (LPN) revealed that the thermometer read 26 degrees Fahrenheit (6 degrees below freezing).

Observation revealed the following medications stored in the medication refrigerator: Lorazepam Intensol 2mg/mL (oral concentrate), Promethazine 25mg suppositories, and the following insulins; Lantus Solostar 100 units/mL (3 mL) pen, Novolog Flexpen 100 units/mL (3 mL) pen, Victoza 18 mg/3 mL (3 mL) pen, Humalog Kwikpen 100 units/mL (3 mL), and Ozempic.

Review of the medication room refrigerator temperature log dated May 2024, revealed that "refrigerator temp. must be between 36 and 46 degrees" Fahrenheit. The staff are to report any malfunctions/fluctuations.

According to the refrigerator temperature log, the refrigerator was 36 degrees on May 20, 2024, on the off-going shift (10 PM to 6 AM).

Interview with the Director of Nursing confirmed that the medication refrigerator was not at the correct temperature and made pharmacy aware that medications were stored below the instructed 36 degrees Fahrenheit.

Review of manufacturer instructions for each insulin revealed that each unopened insulin medication needs to be refrigerated at temperatures between 36 degrees Fahrenheit and 46 degrees Fahrenheit. Further review of manufacturer instructions for insulin revealed that if the medication has been frozen it is not to be used and needs to be discarded.

Review of manufacturer instructions for Lorazepam Intensol 2mg/mL revealed that the medication is to be refrigerated at temperatures between 36 degrees Fahrenheit and 46 degrees Fahrenheit.

Interview with the Director of Nursing on May 21, 2024, at approximately 1:30 PM confirmed that medications were to be stored at proper temperatures according to manufacturer's directions to maintain integrity of the medication.

28 Pa. Code 211.9 (a)(1) Pharmacy services

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

Plan of Correction - To be completed: 07/18/2024

1. The facility cannot retroactively correct the temperatures of medical room refrigerators on blue wing.
2. An audit will be conducted 2 X daily X 1 week by DON to ensure accuracy of temperatures in facility medication room refrigerators.
3. Licensed nursing staff will be educated on the required daily temperature range and use of the daily temperature log, disposal of insulin, and reporting of malfunctions/fluctuations to DON and maintenance.
4. DON/designee will be completed 2 X day audit X 1 week, followed by weekly X 4 weeks then monthly X 3 with results to the QA committee to ensure compliance.
5. July 18, 2024

483.60(d)(4)(5) REQUIREMENT Resident Allergies, Preferences, Substitutes:

§483.60(d) Food and drink
Each resident receives and the facility provides-

§483.60(d)(4) Food that accommodates resident allergies, intolerances, and preferences;

§483.60(d)(5) Appealing options of similar nutritive value to residents who choose not to eat food that is initially served or who request a different meal choice;

Observations:

Based on observations, a review of facility's planned meal tickets, and resident and staff interviews it was determined that the facility failed to accommodate residents' food preferences, and provide foods planned for oral gratification for one resident of 20 residents reviewed (Resident 32).

Findings included:

A review of resident 32's clinical record indicated she was most recently admitted to the facility on June 30, 2023, with diagnoses to include chronic obstructive pulmonary disease (COPD), diabetes, and gastroparesis (a condition which affects the stomach muscles and prevents proper stomach emptying).

The resident's care plan, dated August 15, 2016, included a focus area of Nutrition, revealing the resident is dependent on tube feeding related to duodenal stricture, gastroparesis with a planned included that the resident is NPO (nothing by mouth, ice chips, clear Gatorade, coffee, and lemon Italian ice allowed) see orders section of medical chart, date revised December 13, 2022. The resident's care plan, also included the problem/need of socialization, date-initiated July 7, 2023, with an intervention that staff is to offer resident lemon Italian ice or coffee during social as alternative due to dietary restrictions, initiated April 26, 2024.

A review of current physician orders dated June 30, 2023, revealed that the resident was to receive an enteral tube feeding every shift, give 45 ml/hr of Isosource 1.5 for 20 hrs. via J tube document amount administered each shift and document.

Observation of the lunch meal on May 18, 2024, at approximately 12:20 PM, revealed that Resident 32's tray card [is a menu-based document that provides essential information about a resident ' s meal such as diet order, preferences, food allergies, dislikes, dining location, supplements, and adaptive equipment (if required) and helps staff accurately prepare and serve meals to residents based on their individual needs and preferences] indicated that her lunch items were to include 2 lemon ice, and hot coffee, (may have ice chips or Italian ice). During this observation the surveyor observed that the resident's lunch tray revealed that the resident was not served lemon ice, or Italian ice. Interview with the the alert and oriented, cognitively intact resident at that time the resident stated she "never gets it" (referring to the lemon or Italian ice) According to the resident she is "exhausted asking for it", and that staff is "well aware" of her continued requests/complaints of not receiving it on her meal tray

A second observation of the lunch meal on May 19, 2024, at approximately 12:15 PM, revealed that Resident 32's tray card indicated that her lunch items were to include 2 lemon ice, and hot coffee, (may have ice chips or Italian ice). During this second observation the surveyor observed that the resident was again not served lemon ice, or Italian ice on her lunch tray.

During an interview with the Nursing Home Administrator (NHA) on May 19, 2024, at approximately 1:45 PM, the NHA stated that the facility's policy requires Resident 32 to purchase her own Italian lemon ice. The meal ticket for the resident's lunch time indicated that 2 Lemon ice are to be served, and that the resident's care plan indicated staff is to offer lemon Italian ice in activities. The NHA stated that staff are to offer the "lemon Italian ice during activities." The surveyor requested the facility policy that indicated the resident is to purchase her own lemon Italian Ice, the NHA replied, "it is my policy."

28 Pa. Code 201.29 (a) Resident rights

28 Pa. Code 211.6 (a) Dietary services

Plan of Correction - To be completed: 07/18/2024

Resident 32's preference for oral gratification as ordered by the MD will be honored and the facility cannot retroactively correct the deficient practice. The facility provided 2 lemon ice or Italian ice and hot coffee as per resident's meal ticket.
2. Residents will be reviewed to identify those with orders for oral gratification to ensure all residents are receiving timely items.
3. New admissions will be audited by the IDT for food planned for oral gratification. Residents with oral gratification orders will be reviewed by dietary monthly to ensure items are ordered and available for use.
4. Dietician/designee will audit resident 32's meal tickets and tray pass weekly X 4 weeks then monthly X 3 with results to the QA committee to ensure compliance.
5. July 18, 2024

483.70(o)(1)-(4) REQUIREMENT Hospice Services:

§483.70(o) Hospice services.
§483.70(o)(1) A long-term care (LTC) facility may do either of the following:
(i) Arrange for the provision of hospice services through an agreement with one or more Medicare-certified hospices.
(ii) Not arrange for the provision of hospice services at the facility through an agreement with a Medicare-certified hospice and assist the resident in transferring to a facility that will arrange for the provision of hospice services when a resident requests a transfer.

§483.70(o)(2) If hospice care is furnished in an LTC facility through an agreement as specified in paragraph (o)(1)(i) of this section with a hospice, the LTC facility must meet the following requirements:
(i) Ensure that the hospice services meet professional standards and principles that apply to individuals providing services in the facility, and to the timeliness of the services.
(ii) Have a written agreement with the hospice that is signed by an authorized representative of the hospice and an authorized representative of the LTC facility before hospice care is furnished to any resident. The written agreement must set out at least the following:
(A) The services the hospice will provide.
(B) The hospice's responsibilities for determining the appropriate hospice plan of care as specified in §418.112 (d) of this chapter.
(C) The services the LTC facility will continue to provide based on each resident's plan of care.
(D) A communication process, including how the communication will be documented between the LTC facility and the hospice provider, to ensure that the needs of the resident are addressed and met 24 hours per day.
(E) A provision that the LTC facility immediately notifies the hospice about the following:
(1) A significant change in the resident's physical, mental, social, or emotional status.
(2) Clinical complications that suggest a need to alter the plan of care.
(3) A need to transfer the resident from the facility for any condition.
(4) The resident's death.
(F) A provision stating that the hospice assumes responsibility for determining the appropriate course of hospice care, including the determination to change the level of services provided.
(G) An agreement that it is the LTC facility's responsibility to furnish 24-hour room and board care, meet the resident's personal care and nursing needs in coordination with the hospice representative, and ensure that the level of care provided is appropriately based on the individual resident's needs.
(H) A delineation of the hospice's responsibilities, including but not limited to, providing medical direction and management of the patient; nursing; counseling (including spiritual, dietary, and bereavement); social work; providing medical supplies, durable medical equipment, and drugs necessary for the palliation of pain and symptoms associated with the terminal illness and related conditions; and all other hospice services that are necessary for the care of the resident's terminal illness and related conditions.
(I) A provision that when the LTC facility personnel are responsible for the administration of prescribed therapies, including those therapies determined appropriate by the hospice and delineated in the hospice plan of care, the LTC facility personnel may administer the therapies where permitted by State law and as specified by the LTC facility.
(J) A provision stating that the LTC facility must report all alleged violations involving mistreatment, neglect, or verbal, mental, sexual, and physical abuse, including injuries of unknown source, and misappropriation of patient property by hospice personnel, to the hospice administrator immediately when the LTC facility becomes aware of the alleged violation.
(K) A delineation of the responsibilities of the hospice and the LTC facility to provide bereavement services to LTC facility staff.

§483.70(o)(3) Each LTC facility arranging for the provision of hospice care under a written agreement must designate a member of the facility's interdisciplinary team who is responsible for working with hospice representatives to coordinate care to the resident provided by the LTC facility staff and hospice staff. The interdisciplinary team member must have a clinical background, function within their State scope of practice act, and have the ability to assess the resident or have access to someone that has the skills and capabilities to assess the resident.
The designated interdisciplinary team member is responsible for the following:
(i) Collaborating with hospice representatives and coordinating LTC facility staff participation in the hospice care planning process for those residents receiving these services.
(ii) Communicating with hospice representatives and other healthcare providers participating in the provision of care for the terminal illness, related conditions, and other conditions, to ensure quality of care for the patient and family.
(iii) Ensuring that the LTC facility communicates with the hospice medical director, the patient's attending physician, and other practitioners participating in the provision of care to the patient as needed to coordinate the hospice care with the medical care provided by other physicians.
(iv) Obtaining the following information from the hospice:
(A) The most recent hospice plan of care specific to each patient.
(B) Hospice election form.
(C) Physician certification and recertification of the terminal illness specific to each patient.
(D) Names and contact information for hospice personnel involved in hospice care of each patient.
(E) Instructions on how to access the hospice's 24-hour on-call system.
(F) Hospice medication information specific to each patient.
(G) Hospice physician and attending physician (if any) orders specific to each patient.
(v) Ensuring that the LTC facility staff provides orientation in the policies and procedures of the facility, including patient rights, appropriate forms, and record keeping requirements, to hospice staff furnishing care to LTC residents.

§483.70(o)(4) Each LTC facility providing hospice care under a written agreement must ensure that each resident's written plan of care includes both the most recent hospice plan of care and a description of the services furnished by the LTC facility to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, as required at §483.24.

Observations:

Based on observation, clinical record review, and staff interview, it was determined that the facility failed to ensure the coordination of hospice services with facility services to meet the resident's needs on a daily basis for one out of 20 residents sampled (Resident 5).

Findings include:

A clinical record review revealed that Resident 5 was admitted to the facility on January 6, 2017, with diagnoses that included multiple sclerosis (an immune-inflammatory disease that attacks and damages cells in the central nervous system and causes neurological impairment).
Further review of the clinical record revealed a physician's order for Resident 5 to be admitted to hospice services related to a malignant neoplasm of the colon initiated on April 26, 2024.

A clinical record review revealed a significant change in status comprehensive Minimum Data Set assessment (MDS - a federally mandated standardized assessment process conducted periodically to plan resident care) for Resident 5 dated May 4, 2024.

According to the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual User's, Chapter 2: Section 03 Significant Change in Status Assessments (SCSA) dated October 2023, the Care Area Assessment (CAA) completion date must be no later than 14 days after the determination that the criteria for a significant change in status occurred. The care plan completion date must be no later than 7 calendar days after the CAA completion date.

The criteria for a significant change of status occurred when Resident 5 was admitted to hospice care on April 26, 2024.

The required completion date for Resident 5's CAAs was May 10, 2024.

Resident 5's care plan completion date with revisions after assessment and admission to hospice services was May 17, 2024.

A clinical record review revealed no evidence that the facility updated Resident 5's care plan to include hospice care. The resident's care plan did not identify measures planned to assure that nursing facility staff coordinate and monitor the delivery of resident care in conjunction with the hospice provider's services to meet the resident's needs.

Further review of the clinical record and facility hospice communication documents failed to reveal that a schedule was developed and/or available to the resident, resident's representative, or facility to ensure coordination of resident care.

During an interview on May 21, 2024, at 10:30 AM, the Nursing Home Administrator (NHA) confirmed that the facility failed to ensure that the implementation of hospice services was included in Resident 5's plan of care. The NHA was unable to provide evidence that a schedule for Resident 5's hospice care was developed to ensure the coordination of hospice services with facility services to meet the resident's needs on a daily basis. At the time the survey concluded on May 21, 2024, the care plan was not updated to include hospice services (5 days overdue).

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

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

Plan of Correction - To be completed: 07/18/2024

Facility cannot retroactively correct the findings for resident 5 as indicated in the citation. Care plan for hospice was developed and a schedule of services received from hospice service immediately after exit of DOH survey team on 5/21/2024.
2. Facility has no further residents on hospice to evaluate if care plan was provided and a scheduled service schedule was presented to facility, resident or resident representative at time of correction. A review of 5 hospice residents medical charts identified that care plans were in place at time of service.
3. Education provided to social services director and DON for hospice care planning per regulation. Education provided to hospice vendor to provide a schedule service calendar weekly to facility and to forward that calendar to the resident and resident representative during service.
4. DON/designee to audit hospice orders to include care plans weekly X 4 weeks and then monthly X 3 months to ensure care planning is completed as well as service calendars are distributed accordingly by the hospice vendor. Results of audits to be reviewed by QA Committee to ensure compliance with the regulation.
5. July 18, 2024

§ 201.18(d.2) LICENSURE Management.:

(d.2) The administrator's anticipated biweekly work schedule shall be publicly posted in the facility. The anticipated work schedule shall be updated within 24 hours of a change.

Observations:

Based on observation and staff interview, it was determined that the facility failed to publicly post the nursing home administrator's (NHA) anticipated biweekly work schedule in the facility or provide updates within 24 hours of a change.

Findings included:

Upon entrance into the facility on May 18, 2024, at 8:30 AM, the NHA was not available.

Observation of information bulletin boards hung in the lobby failed to show evidence of the NHA's anticipated biweekly work schedule being publicly posted.

During interview on May 18, 2024, at approximately 11:30 AM the NHA confirmed that he was employed full-time at the facility for 40 hours per week.

The NHA's biweekly work schedule was not publicly posted as required by state regulation.

Plan of Correction - To be completed: 07/18/2024

1. NHA cannot retroactively correct deficiency related to NHA schedule requirements.
2. 2-week schedule of NHA availability to be posted by NHA office door for visibility to residents, guests and staff. Schedule to be updated biweekly, or as needed.
3. Education provided to NHA from regional vice president of operations regarding state regulation on NHA schedule posting.
4. Vice president of operations to ensure NHA schedule is posted per regulatory compliance bi-weekly. QA Committee to track compliance X 3 month.
5. July 18, 2024

§ 211.5(d) LICENSURE Medical records.:

(d) Records of discharged residents shall be completed within 30 days of discharge. Medical information pertaining to a resident ' s stay shall be centralized in the resident ' s record.

Observations:

Based on a clinical record review and staff interview, it was determined that one of the three closed records reviewed did not include a completed discharge summary within 30 days of the resident's discharge (Residents 79).

Findings include:

A clinical record review revealed that Resident 79 was admitted to the facility on March 20, 2022, and expired on April 14, 2024.

A review of the resident's clinical records revealed no documented evidence that a discharge summary was completed.

During an interview on May 21, 2024, at approximately 10:30 AM, the Director of Nursing (DON) confirmed that these closed clinical records did not include a discharge summary completed within 30 days of discharge.

Plan of Correction - To be completed: 07/18/2024

Facility cannot retroactively correct deficiency related to discharge summary on resident 79.
2. Facility audit of last 15 discharges indicated that 2 medical charts did not have discharge summaries as required by the state regulation.
3. Education to medical director and physician extender providers on discharge summary requirements of all residents regardless of type of discharge or reason for discharge.
4. Medical records clerk/designee will audit discharged resident medical charts to determine if a discharge summary is completed. Discrepancies will be reported to the NHA for discussion with medical director and corrective action.
5. July 18, 2024

§ 211.10(b) LICENSURE Resident care policies.:

(b) The policies shall be reviewed at least annually and updated as necessary.

Observations:
Based on review of facility policies and staff interview, it was determined that the facility failed to make certain that the Disaster Plan, Operational Policy and Procedure, and Clinical Policy and Procedure Manuals were reviewed on an annual basis.

Findings include:

During an interview on with the Nursing Home Administrator on May 21, 2024, at approximately 10:30 AM, there was no evidence provided that the Disaster Plan, Operational Policy and Procedure, and Clinical Policy and Procedure Manual had been reviewed since January 2023, or more than one year previous.

Plan of Correction - To be completed: 07/18/2024

Facility cannot retroactively correct deficiency. Facility survey readiness book presented to the team lead surveyor during survey contained the facility form with signatures indicating that operational and clinical policies and procedures were reviewed and updated by the QA committee members in January 2024.
2. NA
3. NHA was educated by regional vice president of operation on state regulation regarding policy and procedures review at least annually and as needed.
4. NHA/designee will ensure policies and procedure reviews are completed as scheduled. QA committee will track yearly requirement.
5. 5/21/2024

§ 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: 07/18/2024

Facility cannot retroactively correct past CNA to resident ratios.
2. Facility is focusing on retention of existing nursing assistants and recruitment of new nursing assistants, through efforts of the Human Resources Manager and Nursing Administration. A third-party recruitment agency has been contracted to assist with candidates.
3. The scheduler has been re-educated regarding the CNA ratio regulatory requirements. Calculation of the daily CNA ratios will be completed and reviewed for accuracy by the scheduler/designee.
4. Daily ratios will be audited weekly X 4 weeks then monthly X 2 months. Audits will be reviewed at QAPI for compliance.

§ 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: 07/18/2024

Facility cannot retroactively correct past LPN to resident ratios.
2. Facility is focusing on retention of existing LPNs and recruitment of new LPNs, through efforts of the Human Resources Manager and Nursing Administration. A third-party recruitment agency has been contracted to assist with candidates.
3. The scheduler has been re-educated regarding the LPN ratio regulatory requirements. Calculation of the daily LPN ratios will be completed and reviewed for accuracy by the scheduler/designee.
4. Daily ratios will be audited weekly X 4 weeks then monthly X 3 months. Audits will be reviewed at QAPI for compliance.
5. 07/18/2024

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

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

Plan of Correction - To be completed: 07/18/2024

Facility cannot retroactively correct past nursing hours.
2. Facility is focusing on retaining current nursing staff and recruitment using in-house recruitment resources and a third-party recruitment firm dedicated to only nursing applicants to correct nursing hours.
3. Facility is implementing staff incentives for current and new staff as well as reinforcing the facility call off policy to deter unnecessary call offs. NHA or designee will educate staff on incentives and call off policy.
4. NHA/designee will audit nursing hours weekly for three weeks then monthly X 3 months. Audits will be reviewed by QA monthly X 3 months to ensure compliance with POC.
5. 07/18/2024

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