Nursing Investigation Results -

Pennsylvania Department of Health
GRANDVIEW NURSING AND REHABILITATION
Patient Care Inspection Results

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GRANDVIEW NURSING AND REHABILITATION
Inspection Results For:

There are  100 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.
GRANDVIEW NURSING AND REHABILITATION - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on a Medicare/Medicaid Recertification, State Licensure, and Civil Rights Compliance survey completed on November 5, 2021, it was determined that Grandview Nursing and Rehabilitation was not in compliance with the following requirements of 42 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.
Observations:

Based on a review of select facility policy and clinical records, observations and staff and resident and family interviews it was determined that the facility failed to accurately assess, consistently provide planned and prescribed care and services, consistent with professional standards of practice, to prevent pressure sore development, promote healing and prevent worsening of pressure sores for four out of 30 sampled residents (Resident 52, Resident 123, Resident 53 and Resident 254).

Findings included:

According to the US Department of Health and Human Services, Agency for Healthcare Research & Quality, the pressure ulcer best practice bundle incorporates three critical components in preventing pressure ulcers: Comprehensive skin assessment, Standardized pressure ulcer risk assessment and care planning and implementation to address the areas of risk.

The American College of Physicians (ACP) is a national organization of internists, who specialize in the diagnosis, treatment, and care of adults. The largest medical-specialty organization and second-largest physician group in the United States) Clinical Practice Guidelines indicate that the treatment of pressure ulcers should involve multiple tactics aimed at alleviating the conditions contributing to ulcer development (i.e. support surfaces, repositioning and nutritional support); protecting the wound from contamination and creating and maintaining a clean wound environment; promoting tissue healing via local wound applications, debridement and wound cleansing; using adjunctive therapies; and considering possible surgical repair.

A review of facility policy entitled: Pressure Ulcer and Skin Management Treatment Guidelines with a policy review date of January 20, 2021 indicates:
"All residents are assessed for risk factors upon admission and a complete skin assessment is completed by the LPN/RN (licensed practical nurse/ registered nurse)
"A computerized weekly/ongoing skin condition form (WSCNA) is completed in Point Click Care for the weekly/ongoing skin condition form.
"Care plans are implemented for all residents with pressure ulcers or deemed to be at risk for developing a pressure ulcer
"Wound measurements are completed for all wounds and skin tears on presentation of wound. Weekly measurements are done on the TAR (treatment administration record) and WSCNA form by the charge nurse for skin tear, pressure, surgical, diabetic, arterial, and vascular.
"All residents with skin integrity issues are assessed by the Registered Dietitian or Dietary Tech for any additional nutritional support.

Review of Resident 52's clinical record revealed that the resident was admitted to the facility on November 25, 2020, with diagnoses that included quadriplegia [paralysis caused by illness or injury that results in the partial or total loss of use of all four limbs and torso], diabetes, and had a large chronic stage 4 sacral pressure ulcer [involve full-thickness skin loss potentially extending into the subcutaneous tissue layer, exposing underlying muscle, tendon, cartilage or bone].

A physician order dated August 6, 2021, was noted for Adaptec [a non-adhering dressing to minimize wound adherence] and ABD pads [used for large wounds or for wounds requiring high absorbency] to the resident's sacral and lower back open area every shift for pressure area.

A physician order dated August 13, 2021, was noted for weekly wound measurements of the resident's sacral wound on Fridays, during the dayshift.

Review of Resident 52's "Weekly/Ongoing Skin Condition Form" dated August 13, 2021, revealed that the pressure ulcer to the back/sacrum was a Stage IV that measured 37 centimeters (cm) in length by 18 centimeters (cm) in width by 1.8 centimeters (cm) in depth. The appearance of the wound bed was described as macerated [softening and breaking down of skin resulting from prolonged exposure to moisture] with 100% granulation [new connective tissue and microscopic blood vessels that form on the surfaces of a wound during the healing process] and bloody drainage.

Review of Resident 52's "Treatment Administration Record (TAR)" for August 2021 revealed that wound measurements were not obtained weekly, as ordered by the physician. The facility failed to measure the resident's sacral wound on August 20, 2021 or on August 27, 2021. Physician ordered wound treatments were not completed on four of 25 occassions as ordered on day shift, not completed on four occassions out of 26 times on evening shifts, and staff documented that the resident refused the treatment on 19 ocassions out of 26 opportunities to perform the treatment on the night shift.

Further review of TAR for September 2021 revealed that weekly wound measurements were not obtained on September 3, 2021 or on September 24, 2021.

Review of wound care specialist "Wound Outpatient Follow-Up Note" dated September 7, 2021, revealed that resident's sacral wound measured 51.5 cm x 20.0 cm x 2.0 cm in depth, indicating that the resident's wound had increased in size and depth since last measured on August 13, 2021.

Resident 52's sacral pressure sore increased in size and depth from August 2021 to September 2021. The facility failed to consistently provide physician prescribed wound treatments and obtain weekly wound measurements to consistently monitor and timely identify declines in wound appearance, and as a result, was unable to demonstrate that the decline in the resident's pressure sore was unavoidable.

A review of the resident's October 2021 TAR revealed that weekly wound measurements were not obtained on October 1, 2021 and on October 15, 2021 as ordered. The physician ordered wound treatment was not completed 4 times out of 31 ordered on day shift, not completed twice out of 31 times on evening shifts, and staff documented that the resident refused 20 times out of 31 times, and not completed 9 times out of 31 as ordered on the night shift.

Interview with the Director of Nursing (DON) on November 4, 2021, at 12:45 PM, revealed that Resident 52's wife was a registered nurse (not employed by the facility) and that she completed the resident's wound care treatments in the evenings and on the weekends when she visited the resident. The DON also stated the resident's wound usually "did not change much from week to week," but that wound measurements should be obtained and documented weekly in the resident's clinical record.

Observation of Resident 52's sacral pressure ulcer on November 4, 2021, at 1:40 PM, with Employee 2, LPN, and Employee 3, LPN, revealed a very large beefy red, stage IV pressure ulcer with a large amount of bloody drainage on ABD pads. The area measured 28 cm in length by 18.7 cm in width. There were two other pressure areas near the large pressure sore, one at the top of the ulcer that had no depth and another area mid-way that measured 0.5 cm in depth. Employee 2 reported that the resident's wound care dressing was changed approximately one-hour prior to this observation.

During interview with Resident 52 at the time of this observation, he reported that, according to his physician orders, his sacral wound care was to be completed twice each day. Resident 52 stated that the facility's nurse staffing on 3 PM to 11 PM shift was not adequate to provide his wound care and the resident relayed the problem to his wife who is a registered nurse. The resident stated that in response, his wife came to the facility every evening and on the weekends at 6 PM to provide his wound care treatment. Resident 52 stated that if the staff don't perform his dressing change by 12 PM on the dayshift, he's "sitting 18 hours on saturated ABD pads." Resident 52 stated that the facility nurse staffing was "very poor on the weekends, especially on the weekend of October 30 and October 31, 2021."

Interview with Resident 52's wife on November 5, 2021, 12:30 PM, revealed that she stated that the facility was "very short staffed" and that if she didn't come in to do the resident's wound care treatments, that "they wouldn't get done."

Interview with the nursing home administrator (NHA) on November 5, 2021, at 10:30 AM, confirmed that the facility failed to complete weekly wound measurements and consistently perform physician ordered wound treatments as prescribed to promote healing and prevent worsening of the resident's pressure sore.

Review of Resident 123's clinical record revealed that she was admitted to the facility on September 21, 2021 with diagnoses to include left broken femur, right broken hip and dementia.

A review of Resident 123' clinical record and admission MDS Assessment dated September 23, 2021, revealed that Resident 123's cognition was impaired. The resident's BIMS (brief interview for mental status, the cognitive portion of the assessment) score was 04/15. The resident required extensive assistance with activities of daily living, including bed mobility, transfers, dressing, toilet use, personal hygiene and without pressure injuries at the time of admission, however noted at risk for the development of pressure injuries. The resident had functional limitation in range of motion in her lower extremity, impairment on one side.

Review of Resident 123's Braden Scale Assessment (a standardized, evidence -based assessment tool commonly used in health care to assess and document a patient's risk for developing pressure injuries) dated September 21, 2021, revealed that the resident scored an 11 (total score of 10-12 indicates the resident was at HIGH RISK).

A review of Resident 123's current care plan revealed the resident was identified as having a potential for breakdown from pressure and the intervention to "turn and reposition the resident every 2 hours around the clock, utilize protective/preventative skin creams to buttocks every shift and as needed, pressure relieving mattress to bed check every shift and 4 inch foam cushion to the wheelchair with dycem below check every shift."

Review of documentation of staff performing the care planned task of "turn and reposition around the clock" from September 21, 2021 through the time of the survey ending November 5, 2021, revealed that the task was not consistently performed for Resident 123.

A review of September 2021 "Turn and reposition every 2 hours around the clock" task completion revealed that staff failed to perform the task 74 times during September 2021.

A review of October 2021 "Turn and reposition every 2 hours around the clock" task record revealed that staff failed to perform the task 260 times during the month.

Review of Resident 123's clinical record revealed an initial wound assessment form entitled: "INITIAL SKIN CONDITION NURSING FORM" dated October 5, 2021 at 12:07 PM, indicating that the resident had a left heel "stage one (I) pressure ulcers 1.5 centimeters x 2.5 cm x 0 cm." The left heel was described "with discoloration of left heel, area oblong, purplish discolored. Surrounding skin soft & boggy with blanchable redness". Interventions identified to be implemented included: Pressure reducing mattress, pillows under calves and a protective boot."

The resident's October 2021 Treatment administration record revealed a physician order dated October 24, 2021, at 3:00 PM for heel floats to be worn at all times while in bed. This pressure relieving measure was initiated 19 days after the pressure area on the resident's left heel was identified. The order was then discontinued on October 28, 2021 at 5:48 AM.

Resident 123's October 2021 Treatment administration record revealed an order dated October 12, 2021, for weekly wound measurement of the left heel pressure sore every Tuesday on the dayshift.

Review of Resident 123's weekly wound form revealed that the wound measurement of the resident's left heel were not completed on October 12, 2021, October 19, 2021, or October 26, 2021. However, the resident's October 2021 Treatment Administration Record, indicated that staff signed the TAR (initials of facility staff) indicating that the weekly wound form with the measurements had been completed.

On October 22, 2021 the "WEEKLY/ONGOING SKIN CONDITION FORM" was completed and indicated that there was a decline in the resident's pressure sore left heel pressure sore.

Resident 123's October 2021 Treatment Administration Record revealed an order dated October 8, 2021, at 3:00 PM for Dermaseptin (skin protectant) to open excoriation on the resident's coccyx area every shift, and as needed, cover with abdominal dressing until resolved.

Review of the Resident's clinical record revealed an initial wound assessment form dated October 8, 2021. The type of wound was identified as "excoriation/dermatitis" with measurements of 3.2 centimeter x 2.5 cm x 0.1 cm. There was no further documentation regarding the status of the skin damage to the resident's coccyx available at the time of the survey ending November 5, 2021.

A physician order dated October 22, 2021 at 3:00 PM, indicated that the treatment to the "excoriation/dermatitis" on the coccyx was changed to Silvadene (cream used to prevent and treat wound infections) to wound bed on coccyx, zinc to perimeter, cover with bordered gauze until healed.

A review of the November 2021 "Turn and reposition every 2 hours around the clock" task was not performed 42 times at the time of the survey ending November 5, 2021.

Observation of Resident 123's coccyx and left heel on November 4, 2021 at 2 PM in the presence of Employee 2, LPN and Employee 3, LPN revealed that the wound on the coccyx measured 2.8 centimeters x 1.8 cm x 0.1 cm. Employee 2 did not measure the depth, but stated based on visual observation that the depth was 0.1 cm. Additionally, an open area was observed to the left of the existing open area on the coccyx at approximately 7 o'clock, which measured 0.4 mm x 0.4 mm. This area also presented with depth, but neither Employee 2 nor Employee 3 attempted to measure the depth. The larger area observed on the coccyx appeared crater like, a thin light tan film covered approximately half of the would bed, the wound bed edges appeared rolled (epibole) and lighter in color, no drainage was noted, the surrounding skin (periwound) was dark in appearance. This area on the coccyx was identified by the facility as "excoriation /dermatitis", which according to the facility policy is "open or closed reddened areas." However, according to the facility policy the presentation of the areas on the coccyx was consistent with a "Stage III Pressure Ulcer ( a full-thickness skin loss. Subcutaneous fat may be visible but not bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of the tissue loss. The ulcer presents clinically as a deep crater and may include undermining and/or tunneling)". Employee 3 confirmed this skin injury was over a boney prominence and more consistent with a pressure area than excoriation/dermatitis. Employee 3 confirmed that the wound's appearance was not consistent with the facility's documented description of the wound.

Observation of Resident 123's left heel at this time revealed that the wound was not measured due to the resident's expressed discomfort. Employee 3 stated this pressure area was also not consistent with the documented description of the wound, which the facility identified as a Stage 1 (intact skin with non-blanchable redness of a localized area usually over a bony prominence). The area on the resident's left heel was observed by the surveyor and the wound bed was covered in eschar (blackened dead tissue), the edges of the wound appeared reddened and dry, no drainage was noted, the periwound was reddened and was blanchable. Employee 3 stated that the appearance of wound on the resident's left heel was more consistent with a "deep tissue injury" and not a Stage I pressure as documented. However, based on the surveyor's observation and according the facility policy/protocol the presentation of this wound it was more consistent with an "unstageable pressure ulcer- full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/ or eschar (tan, brown, or black)."

Resident 123 developed a pressure sore on the left heel and coccyx and both wounds worsened. The facility was unable to demonstrate that the development and worsening of these pressure sores was unavoidable due to the facility's failure to consistently implement preventative measures, turning and repositioning around the clock, and accurately assess and identify pressure sores according to facility policy to assure appropriate treatment.

Interview with the Nursing Home Administrator on November 5, 2021, revealed that "wound rounds are being completed, however documentation related to pressure ulcers is lacking." The NHA confirmed that the facility failed to prevent the development and worsening of pressure ulcers for Resident 123.

A review of the clinical record revealed that Resident 53 was admitted to the facility on December 19, 2017, with diagnoses to include dementia (a chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning).

A review of a Quarterly Change Minimum Data Set assessment dated May 15, 2021, revealed that the resident was severely cognitively impaired, required extensive assistance with the assistance of two people activities of daily living, and at risk for developing pressure sores.

A review of the resident's plan of care for potential for breakdown from pressure, initiated December 20, 2017, revealed interventions to prevent skin breakdown that included turn and repositioning every two hours, air mattress to the bed and check placement every shift, gel cushion to the wheelchair, and preventative skin cream to the buttocks every shift.

A review of tasks completed for April 2021, revealed turning and repositioning was not completed 14 times, air mattress to bed and check was not completed 9 times on the 11:00 PM to 7:00 AM shift and no documentation was present to demonstrate that it was checked on the 7:00 AM to 3:00 PM shift and 3:00 PM to 11:00 PM shift, protective skin cream was not applied nine times, and the gel cushion to the wheelchair was not checked nine times.

A review of an initial skin condition nursing form dated May 19, 2021, revealed that the resident developed an unstageable (full thickness loss in which the base of the wound is cover in a slough \ or eschar pressure wound (injury to the skin and underlying tissue due to pressure) on her right buttocks measuring 1.2 cm x 1.5 cm x 0.1 cm.

A review of tasks completed for May 2021, revealed turning and repositioning was not completed 28 times, air mattress to bed and check was not completed 10 times on the 11:00 PM to 7:00 AM shift and no documentation was found that staff checked it on the 7:00 AM to 3:00 PM shift and 3:00 PM to 11:00 PM shift, protective skin cream was not applied 14 times, and the gel cushion to the wheelchair was not checked 14 times.

A review of tasks completed for June 2021, revealed turning and repositioning was not completed 39 times, air mattress to bed and check was not completed eight times on the 11:00 PM to 7:00 AM shift and no documentation was found that it was checked on the 7:00 AM to 3:00 PM shift and 3:00 PM to 11:00 PM shift, protective skin cream was not applied 15 times, and the gel cushion to the wheelchair was not checked two times.

A review of a weekly/ongoing skin condition form dated June 23, 2021, revealed the pressure sore became larger and now measured 3 cm x 2 cm x 2cm. Slough (dead tissue shedding) and granulation (healing tissue) were present in the wound.

A review of tasks completed for July 2021, revealed turning and repositioning was not completed 78 times, air mattress to bed and check was not completed 16 times, protective skin cream was not applied 22 times, and the gel cushion to the wheelchair was changed to an air cushion and was not checked 16 times.

A review of a weekly/ongoing skin condition form dated July 14, 2021, revealed that the resident's pressure sore again worsened and measured 3.9 cm x 2.3 cm. The staff did not measure the depth of the wound. However, undermining (tissue under the wound edges becomes eroded, resulting in a pocket beneath the skin at the wound's edge) was noted at the 9:00 o' clock position, but staff failed to measure the length of the undermining.

At the time of the survey, there was no documented evidence that the facility had assessed the resident's wound on July 21, 2021.

A review of a weekly/ongoing skin condition form dated July 28, 2021, revealed the wound declined further and now measured 4.7 cm x 5 cm. The staff did not measure the depth of the wound. Undermining was noted at the 1:00 o'clock and 9:00 o'clock, position but staff failed to measure the length the undermining.

A review of tasks completed for August 2021, revealed turning and repositioning was not completed 86 times, air mattress to bed and check was not completed 27, protective skin cream was not applied 25 times, and the air cushion to the wheelchair was not checked 27 times.

A review of a weekly/ongoing skin condition form dated August 4, 2021, revealed the wound declined further and now measured 6 cm x 5 cm. The staff did not measure the depth of the wound. Undermining was noted, but staff failed to assess and document the location or the extent of the undermining.

A review of an outpatient wound care consult note dated August 23, 2021, indicated that the resident now had a stage IV pressure sore measuring 6.4 cm x 5 cm x 5.9 cm of the right buttocks. The wound contained 26% to 50% necrotic tissue (dead tissue), had a moderate amount of drainage, and the bone was exposed.

A review of a nursing note date August 25, 2021, at 1:50 PM indicated the resident had returned to the facility after having surgery to debride (remove damaged tissue) the pressure wound. The facility failed to demonstrate the consistent implementation of measures to prevent development and promote healing of the resident's pressure sore.

Resident 53's developed an unstageable pressure sore, which progressively increased in size to a Stage IV pressure sore requiring surgical debridement. The facility failed to consistently implement care planned measures to prevent pressure sore development, promote healing and prevent worsening and as a result of these failures was unable to demonstrate that the pressure sore development and deterioration was unavoidable.


Review of Resident 254's clinical record revealed she was admitted to the facility on October 8, 2021 with diagnoses to include diabetes mellitus and malnutrition.

An Admission MDS Assessment dated October 12, 2021, revealed that Resident 254's cognition was intact. The resident's BIMS (brief interview for mental status, the cognitive portion of the assessment) score was 14/15. The resident required extensive assistance with activities of daily living, including bed mobility, transfers, dressing, toilet use, personal hygiene and was admitted with an unstageable pressure injury at the time of admission and was noted at risk for the development of pressure injuries.

Review of Resident 254's Braden Scale Assessment dated October 8, 2021, revealed that Resident scored an 17 (total score of 15 to 18 indicates the resident was at LOW RISK).

An initial wound assessment dated October 8, 2021, revealed that the resident had an identified as "unstageable" wound on the sacrum with measurements of "1 centimeter x 1 cm x "?" cm."

Resident 254's clinical record revealed no documentation of the weekly wound monitoring for the week of October 21, 2021

A review of Resident 254's current plan revealed that the resident was identified with the potential for breakdown from pressure and was admitted with an unstageable on her sacrum, interventions prior to the development of a pressure area on the resident's left heel included "turn and reposition the resident every 2 hours around the clock."

Resident 254's clinical record revealed an initial wound assessment form dated October 30, 2021, at 3:15 PM, indicating that the resident had a left heel "stage two (II) pressure ulcers 2.5 centimeters x 1.5 cm x fluid filled." The form noted that the resident's left heel presented as a "small blood blister."

Review of documentation related to "turn and reposition around the clock" from October 8, 2021 through the time of the survey ending on November 5, 2021, revealed no documented evidence that staff were consistently performing the task.

A review of Resident 254's turn and reposition around the clock documentation revealed on October 30, 2021, the date the resident's left heel pressure injury was found, revealed no documented evidence that the resident had been repositioned from 2:00 AM until the finding of the area on the resident's left heel on October 30, 2021, at 3:15 PM.

Interview with the director of nursing on November 5, 2021 at approximately 1:00 PM confirmed that the facility failed to demonstrate the consistent implementation of measures planned to prevent pressure ulcers for a resident at low risk for pressure sore development and to promote healing of pressure sores for Resident 254.

28 Pa. Code 211.5(f) Clinical records
Previously cited 6/24/21, 1/22/21, 1/3/21, 8/30/19

28 Pa. Code 211.10(a)(d) Resident care policies
Previously cited 8/24/21, 8/30/19

28 Pa. Code 211.12(a)(c) Nursing services
Previously cited 10/14/21, 8/24/21, 6/24/21, 1/22/21, 9/29/20, 7/27/20, 1/3/20, 8/30/19

28 Pa. Code 211.12(d)(1) Nursing services
Previously cited 10/14/21, 6/24/21, 9/29/20, 1/3/20, 8/30/19

28 Pa. Code 211.12(d)(3) Nursing services
Previously cited 6/24/21, 1/22/21, 8/30/19

28 Pa. Code 211.12(d)(5) Nursing services
Previously cited 10/14/21, 8/24/21, 6/24/21, 1/22/21, 7/27/20, 1/3/20, 8/30/19





















 Plan of Correction - To be completed: 12/14/2021

1. Resident 123 and 254 have been discharged from the facility. Resident 58 and 52's wounds have been assessed.
2. New wounds will be reviewed during clinical meeting for appropriate follow up and assessment.
3. Nursing staff will be educated on pressure ulcer avoidance and treatment of pressure ulcers.
4. Random audits will be completed on pressure ulcers weekly x 4 weeks, results will be reviewed at QAPI.

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.

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).

The initial tour of the kitchen was conducted with the Director of Food Service/CDM (Certified Dietary Manager), on November 2, 2021, at 9:50 AM, that revealed the following unsanitary practices with the potential to introduce contaminants into food and increase the potential for food-borne illness, were identified:

Some of the garbage cans in the kitchen areas did not have lids covering trash. Near the tray line area, a green garbage can with a lid that was splattered with a red substance with debris stuck to it was observed.


Several open bags of buns, plastic containers and cluttered kitchen items were observed on a metal wire rack, near the reach-in freezer. There was a cracked plastic bin and staff's personal items piled around the bread on this rack.

Observation of the walk-in cooler revealed pizza and plastic grocery bags of food, that the food service director identified as belonging to a resident, that was brought into the facility from outside. These items were not labeled or dated and stored among food/ingredients used for the preparation of facility meals and near items that would be placed on resident trays. Two undated cartons of milk were observed.

Observation revealed cases of thawed 4-ounce nutritional shakes, which did not have a thaw or discard date. The manufacturer's label noted the nutritional shakes and drinks were to be used within 14 days of thawing.

Observation in the the walk-in cooler, revealed a sheet pan of frosted cake that was placed on the top rack of a metal rack that was not covered and undated when prepared. Underneath the cooler shelving dirt and debris was observed. Shelled eggs on the self with one in the carton cracked were observed and there were remnants of a broken egg caked onto the floor.
The flooring located in the center of the cooler was peeling.

Inside the reach-in freezer, a storage plastic bag with food encased in ice crystals that the Service Director identified as stuffing was observed. There was no label or date listed on the plastic bag. There was an opened freezer burned half-gallon of ice cream that did not have an open date list and was identified as a resident's personal food item. The freezer door shelves were dirty with a spilled substance was frozen to the shelving. There were additional opened food items stored on the freezer door shelves that were not labeled or dated.

Alongside of the reach-in freezer, observation revealed a stand-up fan and the blades and wire covering was covered with dust. The dirty fan faced a food preparation area and was next to the three-compartment sink where there were clean dishes drying.

Above the three-compartment sink, kitchen equipment/dishes were left to dry on the windowsill. The food service director confirmed that equipment should not be dried on a windowsill.

In the cook's area, observation revealed a stainless table along side the stove that was covered with dust and debris with a dirty grill scrub pad on the bottom shelf. Under the stove and behind the cook's equipment there was dust, cobwebs, and debris.

A staff member's eye protection, PPE (personal protective equipment), was left shelf with clean pans.

In the dish room, plastic bowls, identified as clean by the food service director, were observed with food residue around the rim.

Observation revealed dirty ceiling tiles and cracked light covers in the dish room and kitchen area.

In the dry storage area, several boxes of paper products were observed stored in direct contact with the floor and there were broken cookies and debris on the floor.

During an observation in the resident dining room that was conducted on November 4, 2021, at 11:45 AM, near clean tables that were set for the lunch meal a food service worker was observed scraping dirty dishes from breakfast into a garbage can. There was a full black garbage bag on the floor near the food serving station. Clean utensils were observed to stored in a dirty utensil holder.

Further observation revealed that the blinds near the food serving area were splattered with food.

The above observations were confirmed by the food service director.

Interview with the NHA on November 4, 2021, at 1:00 PM, confirmed that food should be stored, prepared and served under sanitary conditions.


28 Pa. Code 211.6 (f) Dietary services.

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






 Plan of Correction - To be completed: 12/14/2021

1. The facility will ensure the sanitation and proper food storage of the dietary department.
2. An initial audit will be completed regarding the cleanliness and proper storage of food.
3. Dietary staff will be educated on the sanitation and proper storage of food in the dietary department.
4. Random audits will be completed to ensure the proper sanitation and food storage of the dietary department.

483.25(d)(1)(2) REQUIREMENT Free of Accident Hazards/Supervision/Devices:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
483.25(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 observations, a review of clinical records, resident incident/accident reports, information submitted by the facility and staff interviews, it was determined that the facility failed to provide adequate staff supervision as planned to monitor a resident with known unsafe behavior to prevent an unsupervised exit from the facility and threat to the resident's safety while ambulating outside the facility for two residents (Resident 62 and 46) out of 20 reviewed.


Findings included:

A review of facility policy entitled "Elopement Policy and Procedure" last reviewed by the facility January 20, 2021, revealed that the facility will provide a safe and secure environment with adequate supervision and assistive devices to prevent elopements and accidents.

A review of the clinical record revealed that Resident 62 was admitted to the facility on May 16, 2021. The resident's diagnoses included Dementia (a chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning).

A review of Resident 62's admission Minimum Data Set assessment (MDS- a federally mandated standardized assessment process conducted periodically to plan resident care) dated May 18, 2021, revealed that the resident's cognition was severely impaired with a BIMS score (brief interview for mental status -section of MDS that assesses cognition) of 4 (a score of 0 -7 indicates severe impaired cognition) and was noted to have behaviors of wandering.

A review of a Behavior Management Review note dated May 17, 2021, at 9:01 AM indicated that the resident was reviewed due to the application of a wanderguard.

A review of a nursing note dated June 2, 2021, at 5:57 PM, revealed that the resident was wandering all shift. The resident was stating that he needs a ride. The resident would curse at staff when told there was no one to give him a ride. Staff indicated that the resident was not able to be redirected.

A review of a nursing note dated June 3, 2021, at 6:10 PM, revealed that the resident was wandering through out the unit and asking for a ride.

A review of a health status note dated June 4, 2021, at 1:06 PM, revealed that the resident wanders frequently throughout the unit and goes into other residents' rooms.

A review of a new order note dated June 9, 2021, at 2:37 PM, indicated that the resident was placed on 15 minute checks for exit seeking behavior. It was noted the resident was at an exit door and pushing on the handle and the door opened. The resident was escorted to the television room.

A review of a nursing note dated June 15, 2021, at 1:39 PM, revealed that the resident was wandering in and out of other residents' rooms, continually exit seeking. The resident was removing things from the medication cart and attempts to redirect the resident were unsuccessful.

A review of a nursing note dated June 16, 2021, at 9:44 AM, indicated that the resident had been irritated and having increasingly aggressive outbursts. The resident was hard to redirect out of other resident's rooms according to nursing documentation.

A review of a social service note dated June 29, 2021, at 7:53 AM, revealed that the resident had a medication change, but still was noted to have behaviors of exit seeking and wandering.

A review of a progress note dated July 19, 2021, at 6:01 PM, revealed that the resident was exit seeking more than usual. The resident was asking staff, residents, and visitors, for a ride. Nursing noted that the resident becomes upset when told he cannot have a ride.

A nursing note dated August 29, 2021, at 10:10 AM indicated that the resident got out of the backdoor of the facility and was found outside the building standing in the grass.

A review of a facility incident report dated August 29, 2021, at 10:10 AM revealed that the resident got out the back door of the pavilion unit. Staff found the resident outside. It was noted that the resident's wanderguard was in place when he was able to exit the building. Every 10 minute checks of the resident were to be initiated as the result of this resident's elopement.

A review of a witness statement from Employee 8 NA (nurse aide) dated August 29, 2021, revealed that the employee stated that she came out of a room and out of the corner of her eye she saw Resident 62 was outside. Employee 8 stated the alarm was sounding.

A review of a behavior management review note dated September 1, 2021, at 9:44 AM revealed that the resident had 23 episodes of exit seeking behavior. The note indicated that interventions are effective, even though the resident did elope from the facility three days prior.

A review of a facility incident report dated September 4, 2021, at 4:50 PM revealed that the resident was ambulating outside the building and brought back into the facility. The report indicated that the door alarm did not sound when the resident exited the building.

A review of a witness statement from Employee 9 LPN (license practical nurse) dated September 4, 2021, revealed that Employee 9 stated that another staff member saw the resident walking around the building while she was passing medications. Employee 9 stated that she went out the door to bring him back into the building.

No witness statement was obtained from the employee that reportedly saw the resident outside the building.

There was no documentation in the resident's clinical record on September 4, 2021, that the resident had eloped from the facility at a time when the resident was wearing a wanderguard and on every 10 minute checks.

A review of the resident's clinical record revealed that the resident was on every 10 minute checks from August 30, 2021, until discontinued on November 3, 2021.

A review of the resident's clinical record revealed the resident was placed on one to one observation on September 5, 2021 and was discontinued October 27, 2021.

A review of 10 minute check documentation conducted during the survey on November 3, 2021, revealed Resident 62's 10 minute observation checks were not completed on November 2, 2021, from 11:40 AM to 12:10 PM, and at 3:10 PM to 8:50 PM.

Further review of the 10 minute check observation revealed that on November 3, 2021, the resident's every 10 minute observation was not complete from 7:00 AM to 9:40 AM.

One to one observation of the resident was initiated on November 3, 2021.

Observations conducted on the pavilion nursing unit on November 4, 2021, at 11:25 AM revealed the door from which the resident had eloped on September 4, 2021, was a locked emergency door with a stop sign in place. When the wanderguard system was tested by the surveyors, the alarm was barely audible at the nursing station. The alarm could not be heard when surveyors were in the opposite hall from the exit door.

Observation of the pavilion nursing unit on November 4, 2021, at approximately 11:30 AM revealed Resident 62 wandering the hall without staff present providing one to one observation of the resident. The resident was observed at the exit door looking outside the facility.

A review of the clinical record revealed that Resident 46 was admitted to the facility on December 12, 2015. The resident's diagnoses included Alzheimer's disease (A progressive disease that destroys memory and other important mental functions).

A review of Resident 46's quarterly Minimum Data Set assessment dated August 12, 2021, revealed that the resident's cognition was severely impaired.

A review of a late entry nursing note dated October 25, 2021, at 1:10 PM but entered into the clinical record on October 26, 2021, at 11:40 AM, 22 hours and 30 minutes after the incident occurred, revealed that the resident was noted with exit seeking behaviors and was assisted back into the facility.

A review of a facility incident report dated October 25, 2021, at 1:10 PM indicated that the resident was found in the front parking lot by another resident and a visitor helped bring Resident 46 back into the building.

A review of Employee 10's receptionist witness statement dated October 25, 2021, revealed that Employee 10 stated a visitor, who was coming to pick up a basket, brought Resident 46 back into the building. Employee 10 stated that she did not see the resident exit the building. The employee stated that she believed the resident went around other visitors who were talking to their father outside.

A review of Resident 97's witness statement dated October 25, 2021, revealed that the resident stated that Resident 46 was outside in the parking lot about six cars down. The resident stated he tried to get her back inside when a visitor helped bring her back in the building.

A review of Employee 11, restorative nurse aide, witness statement dated October 25, 2021, revealed that the employee brought the resident back to the east wing multiple times from the front entrance the morning of the incident.

Observations of the wanderguard on the east and west nursing units on November 4, 2021, at 11:00 AM revealed that the front door will lock and alarm will sound when a resident with a wanderguard approaches the door. Further observations revealed that if the front unlocked glass door is already opened, a resident with a wanderguard bracelet would be able to exit the building and an alarm will sound. During the observations the alarm was barely audible at the east wing nursing station and had a low audible sound at the west wing nursing station. When the survey team activated the door alarm system no facility staff initially responded to the alarm. It took over 5 minutes for Employee 1, RN (registered nurse) to respond to the alarm, at which time a surveyor was on the nursing unit to check volume of the audible alarms.

An interview was completed with Employee 10 on November 4, 2021, at 11:11 AM. The employee stated she did not see the resident go out the door or hear the alarm sound. The employee stated that the alarm was turned off by Employee 12 RN when she heard the alarm. She further stated she does not believe the employee checked to see if any resident left the building after she had turned off the alarm.

An interview with the NHA on November 5, 2021, at approximately 1:00 PM confirmed that the facility failed to provide adequate supervision for residents with known exit seeking behavior, with over reliance on the wanderguard system, to prevent the residents from exiting the facility without staff supervision placing the resident at risk for accidents and injury.


28 Pa Code: 201.19(e)(1) Management

28 Pa Code:201.18(e)(3) Management

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






 Plan of Correction - To be completed: 12/14/2021

1. Resident 62 and 46's care plans are reviewed to keep them accident free.
2. An audit will be completed to assure residents with exit seeking behaviors are identified.
3. An education will be provided to staff regarding the elopement policy.
4. Random audit will be conducted regarding elopements weekly x4 weeks, results will be reviewed at QAPI.

483.95(c)(1)-(3) REQUIREMENT Abuse, Neglect, and Exploitation Training: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.
483.95(c) Abuse, neglect, and exploitation.
In addition to the freedom from abuse, neglect, and exploitation requirements in 483.12, facilities must also provide training to their staff that at a minimum educates staff on-

483.95(c)(1) Activities that constitute abuse, neglect, exploitation, and misappropriation of resident property as set forth at 483.12.

483.95(c)(2) Procedures for reporting incidents of abuse, neglect, exploitation, or the misappropriation of resident property

483.95(c)(3) Dementia management and resident abuse prevention.
Observations:


Based on a review of select facility policy and staff interviews, it was determined that the facility failed to implement procedures contained in its orientation policy & procedure to ensure all agency staff working in the facility are educated on the facility's abuse prohibition policy and procedures

Findings include:

A review of the facility policy for Orientation revealed: "1. Each new employee will be scheduled for an orientation period during, but not limited to, his/her first ten working days. Designated employees will supervise the new employee, though the immediate supervisor is directly responsible for each new employee's orientation. 2. On his/her first scheduled day, a detailed checklist and personnel handbook will be given to each new employee. 3. Each new employee will be responsible for thoroughly understanding each item on the orientation checklist. 4. All orientation checklists are placed in the employee's personnel file as a permanent record".

Interview with Employee 6, Licensed Practical Nurse (agency nurse), on November 3, 2021 at 9:08 AM, revealed that it was her second day of work at the facility. During the interview Employee 6 stated that she had not been trained facility's abuse prevention policy and procedures or provided with any orientation to the facility.

Interview with Employee 7, Nurse Aide (agency nurse), on November 3, 2021 at 11:30 AM, revealed that it was her first day of work at the facility. During the interview Employee 7 indicated she did not receive any training or orientation to the facility, she noted the only training she received is through her agency.

Interview with the Nursing Home Administrator on November 3, 2020 at 2:15 PM confirmed that the facility was unable to provide documented evidence that the facility provided orientation on the first day prior to the start of their shift to agency staff as stated in the orientation procedure.



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

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

28 Pa. Code 201.19 Personnel Policies and Procedures













 Plan of Correction - To be completed: 12/14/2021

1. The facility will ensure agency staff had been trained on abuse.
2. The facility will audit agency files to ensure abuse training has occurred.
3. The HR director will be educated on completing abuse training with agency staff.
4. Random audits will be completed to ensure agency staff have abuse training weekly x4 weeks, results will be reviewed at QAPI.

483.60(f)(1)-(3) REQUIREMENT Frequency of Meals/Snacks at Bedtime:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
483.60(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 a review of select facility policy and meal committee meetings, resident, and staff interviews, it was determined that the facility failed to routinely offer evening snacks to at least 4 out of five residents interviewed during a group meeting (Residents 18, 40, 85, and 100).

Findings include:

A review of the facility's policy entitled "Between Meal Snack Policy" (June 2021), revealed that snacks will be available at each nursing unit for residents.

Review of the October 13, 2021, meal committee meeting minutes revealed that residents in attendance at the meeting voiced concerns about not receiving snacks.

During a group interview with five alert and oriented residents on November 3, 2021, at 10:00 a.m., four of four residents (Residents 18, 40, 85, and 100) in attendance stated that they are not offered snacks during the evening hours before bed as desired. All residents in attendance agreed that "no one ever offers" them an evening snack and they were unaware they could ask staff for a bedtime snack.

During an interview with the Nursing Home Administrator (NHA) on November 4, 2021 at 2:00 p.m., the NHA was unable to explain why the residents are not consistently offered a snack at bedtime and as desired.


28 Pa. Code: 211.6 (b)(c) Dietary services

28 Pa. Code 211.2(a) Nursing Services






 Plan of Correction - To be completed: 12/14/2021

1. Resident 18, 40, 85, and 100 are now receiving HS snacks.
2. DON/designee will interview 5 alert and oriented residents from each unit to see if they are receiving HS snacks.
3. Nursing staff will be educated on frequency of meals and snacks.
4. Random audits will be conduct to ensure HS snacks are available weekly x4 weeks, results will be reviewed at QAPI.

483.45(f)(2) REQUIREMENT Residents are Free of Significant Med Errors: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.
The facility must ensure that its-
483.45(f)(2) Residents are free of any significant medication errors.
Observations:

Based on a review of select facility policy and clinical records, observations and staff interview it was determined that the facility failed to assure that two residents out of 30 sampled were free from significant medication errors (Resident 255 and 68).

Findings include:


A review of facility policy entitled: "Medication Administration" indicated that medications are administered within 60 minutes of scheduled time, except before or after meal orders, which are administered based on meal times.

A review of the clinical record of Resident 255 revealed admission to the facility on October 8, 2021 with a diagnosis to include type 2 diabetes (a condition that affects the way the body processes blood sugar).

Review of Resident 255's physician order dated October 8, 2021 revealed Humalog 100 units/ml insulin inject per sliding scale was to be administered at before meals at 7:30 AM, 11:30 AM, 4:30 PM and at bedtime 9:00 PM.

Observation of a medication administration on November 3, 2021, at 9:20 AM, Employee 6, LPN, administered medications to Resident 255. The resident had already eaten breakfast at that time.

Employee 6 obtained the resident's blood glucose level at that time and stated that the resident's blood glucose reading was 170 mg/dl and he required 1 unit Humalog Insulin coverage. Employee 6 administered 1 unit of Humalog insulin to Resident 255 at 9:25 AM. Employee 6 stated that the insulin was administered late. Employee 6 stated the resident's blood glucose level should have been obtained before his breakfast meal and insulin administered if required.

An interview with Employee 6 at this time confirmed she had not obtained the resident's blood glucose reading before breakfast and had not administered the insulin prior to the resident's meal according to the physician order.

A review of Resident 255's October 2021 Medication Administration Audit Report and October Medication Administration Record (MAR) revealed that on October 9, 2021, the resident received Humalog Insulin 1 units for a blood glucose reading of 159 at 5:35 PM, one hour and 5 minutes after the scheduled administration time.

On October 12, 2021 the resident received Humalog Insulin 1 unit for a blood glucose reading of 159 at 1:32 PM, two hours after the scheduled time.

On October 15, 2021 the resident received Humalog Insulin 1 unit for a blood glucose reading of 174 at 1:27 PM, one hour and 57 minutes after the scheduled time.

On October 16, 2021 the resident received Humalog Insulin 1 unit for a blood glucose reading of 167 at 12:37 PM, one hour and 7 minutes after the scheduled time.

On October 17, 2021 the resident received Humalog Insulin 1 unit for a blood glucose reading of 191 at 12:44 PM, one hour and 14 minutes after the scheduled time.

On October 18, 2021 the resident received Humalog Insulin 1 unit for a blood glucose reading of 181 at 5:47 PM, one hours and 17 minutes after the scheduled time.

On October 20, 2021 the resident received Humalog Insulin 1 unit for a blood glucose reading of 194 at 12:44 PM, one hour and 14 minutes after the scheduled time.

On October 22, 2021 the resident received Humalog Insulin 2 units for a blood glucose reading of 215 at 12:52 PM, one hour and 22 minutes after the scheduled time.

On October 23, 2021 the resident received Humalog Insulin 1 unit for a blood glucose reading of 178 at 1:12 PM, one hour and 42 minutes after the scheduled time.

On October 24, 2021 the resident received Humalog Insulin 1 unit for a blood glucose reading of 160 at 12:55 PM, one hour and 25 minutes after the scheduled time.

On October 25, 2021 the resident's blood glucose reading was 163 at 1:38 PM, two hours and 8 minutes after the scheduled time and there was no documented evidence the resident received the insulin per sliding scale.

On October 26, 2021 the resident received Humalog Insulin 1 unit for a blood glucose reading of 156 at 1:20 PM, one hour and 50 minutes after the scheduled time.

On October 26, 2021 the resident received Humalog Insulin 1 unit for a blood glucose reading of 194 at 5:42 PM , one hour and 12 minutes after the scheduled time.

On October 27, 2021 the resident received Humalog Insulin 1 unit for a blood glucose reading of 172 at 1:43 PM , two hours and 13 minutes after the scheduled time.

On October 28, 2021 the resident received Humalog Insulin 1 unit for a blood glucose reading of 167 at 6:41 PM, two hours and 11 minutes after the scheduled time.

On November 2, 2021 the resident received Humalog Insulin 2 units for a blood glucose reading of 242 at 5:37 PM, one hour and 7 minutes after the scheduled time.

A review of the clinical record of Resident 68 revealed admission to the facility on September 8, 2016, with a diagnosis to include type 2 diabetes.

A review of Resident 68's physician orders revealed the resident was to Receive Humalog Solution 100 unit/ml insulin inject per sliding scale: if 151-200 = 2 units; 201-250 = 4 units; 251-300 = 6 units; 301-350 = 8 units, subcutaneously before meals and at bedtime for DM2 (Diabetes Mellitus Type 2) (an injectable medication used to control blood sugars in diabetes); call MD (physician) if blood glucose is 60 and/or greater than 350 at 7:30 AM, 11:30 AM, 4:30 PM and 9:00 PM, dated December 16, 2020 and discontinued on September 14, 2021.

According to manufacturer's product information, Humalog (injected under the skin) is a rapid acting human insulin analog indicated to improve glycemic control in adults with diabetes mellitus. Humalog is Rapid acting insulin you should take 15 minutes before eating. Follow to instructions provided by your healthcare provider about the type or types or insulin you are using and do not make any changes with your insulin unless you have talked to your provider. of Resident 68 September 2021 Medication Administration Audit Report and September Medication Administration Record (MAR) revealed that on September 3, 2021, the resident received Humalog Insulin 2 units for a blood glucose reading of 162 at 1:50 PM, two hours and 20 minutes after the scheduled time.

On September 4, 2021, the resident received Humalog Insulin 4 units for a blood glucose reading of 202 at 1:14 PM, one hour and 44 minutes after the scheduled time.

On September 5, 2021 the resident received Humalog Insulin 4 units for a blood glucose reading of 211 at 12:46 PM, one hour and 16 minutes after the scheduled time.

On September 7, 2021 the resident received Humalog Insulin 2 units for a blood glucose reading of 174 at 12:33 PM, one hour and 3 minutes after the scheduled time.

Interview with the Nursing Home Administrator on November 5, 2021, at approximately 2:00 PM confirmed that physician's orders were not followed and the facility administer insulin before meals and failed to ensure residents were free of significant medication errors.


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







 Plan of Correction - To be completed: 12/14/2021

1. Resident 68 and 255 will receive medications timely.
2. Licensed nurses will be audited on medication pass. DON/designee will review appropriate deployment of staff to ensure timely accuchecks and insulin administration.
3. Licensed nurses will be educated on current medication pass policy.
4. Random audits will be completed on late or missing medication entries weekly x4 weeks, results will be review at QAPI.

483.25(l) REQUIREMENT Dialysis:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
483.25(l) Dialysis.
The facility must ensure that residents who require dialysis receive such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences.
Observations:

Based on observations, clinical record and select policy review and resident and staff interview it was determined that the facility failed to ensure the ready availability of necessary emergency supplies for a resident receiving hemodialysis for two of 30 residents sampled. (Resident 84 and 253) and failed consistently monitor a resident's fluid intake prescribed a fluid restriction related to kidney disease and dialysis treatment for one resident out of 30 residents sampled (Resident 15).

Findings include:

According to the National Kidney Foundation patients receiving hemodialysis should keep emergency care supplies on hand.

A review of Resident 84's clinical record revealed that the resident was admitted to the facility was on May 28, 2020, with diagnoses that included end stage renal disease and receiving dialysis.

Review of the Resident's current plan of care initiated May 29, 2020 revealed an intervention for an emergency pack consisting of 4 x 4 gauze and a hemostat will be located at the head of the bed.

Observations conducted on November 5, 2021, at 11:40 AM and revealed there was no emergency supplies available in the resident's room as noted on the resident's care plan.

Interview with Employee 1, RN, on November 5, 2021, at 11:43 AM revealed that each resident in the facility receiving dialysis should have emergency supplies at the bedside. Employee 1 confirmed there were no emergency supplies at the resident's bedside as planned for the resident.

A review of Resident 253's clinical record revealed that the resident was admitted to the facility on October 18, 2021 with end stage renal disease and was receiving dialysis.

Review of Resident 253's current plan of care dated October 18, 2021, revealed an intervention for an emergency pack consisting of 4 x 4 gauze and a hemostat will be located at the head of the bed.

Review of Physician Order's revealed an order dated October 18, 2021 at 11:00 PM to assess tunneled catheter site for signs and symptoms of infection every shift (dressing to be changed at dialysis).

Observations conducted on November 5, 2021, at 11:40 AM and revealed there was no emergency supplies available in the Resident 253's room as care planned.

Interview with Resident 253 on November 5, 2021, at 11:40 AM, who was cognitively intact, revealed that the resident stated that some of the facility nursing staff do not even know she is on dialysis. The resident explained that she had to inform them that she is not allowed to get her (dialysis) access site wet. She stated that staff never observe the access site for signs and symptoms of infection or to check if "there is a problem of any kind for that matter." The resident stated there is not a bedside emergency kit readily available.

Interview with Employee 13, Licensed Practical Nurse on November 5, 2021, at 11:50 AM confirmed that there is not an emergency bedside kit readily available. Employee 13 also confirmed she has never looked at Resident 253's dialysis access site port stating "it is not listed for her to perform on her shift (dayshift)."

Review of Resident 253's October 2021 Treatment Administration Record (TAR) and Medication Administration Record (MAR) revealed no documented evidence staff were assessing the tunneled catheter site for signs and symptoms of infection every shift.

Review of Resident 253's November 2021 Treatment Administration Record (TAR) and Medication Administration Record (MAR) failed to reveal documented evidence staff were assessing the tunneled catheter site for signs and symptoms of infection every shift.

Interview with the Director of Nursing on November 5, 2021, at approximately 1:00 PM confirmed that the facility failed to ensure monitoring of an access site according to physician orders and professional standards and failed to assure the ready availability of necessary emergency supplies at the residents' bedside.

Review of a facility policy entitled "Fluid Restriction" reviewed by the facility January 1, 2021, indicated that the physician will be notified by the RN Supervisor for any resident who exceeds their fluid restriction for 3 consecutive days.

Review of Resident 15's clinical record revealed that she was admitted to the facility December 26, 2016, with diagnoses to have included chronic kidney disease with hemodialysis [process of removing waste products and excess fluid from the body when the kidneys are not able to adequately filter the blood].

A physician order was noted August 11, 2017, for a 1,000 milliliter (ml) fluid restriction daily.

Review of Resident 15's current care plan indicated that the distribution of fluids was breakfast 4-ounces of skim milk and a 4-ounce sugar free shake, lunch 4-ounce beverage and a 4-ounce sugar free shake, and dinner a 4-ounce sugar free shake and 90 cc free fluids each shift.

Resident 15's September 2021 MAR revealed that she exceeded the 1000 ml physician prescribed fluid restriction 25 times out of 30 days during the month. On 5 days, Resident 15's fluid intake was not monitored.

The resident's October 2021 MAR revealed that she exceeded the fluid restriction 25 times out of 31 days and the fluid intake was not monitored 5 days.

The facility was unable to provide documented evidence that the physician was notified that the resident was regularly exceeding the prescribed fluid restriction.

Interview with the Director of Nursing (DON) on November 5, 2021, confirmed that the facility failed to accurately document fluid intakes for a resident ordered on a fluid restriction and failed to provide documented evidence that the physician was notified that the resident was frequently exceeding fluid restriction orders.



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











 Plan of Correction - To be completed: 12/14/2021

1. Resident 253 has been discharged. Resident 84 currently has all parameters in place according to the dialysis policy.
2. An audit will be completed on all dialysis residents to ensure all parameters of the dialysis policy is followed.
3. Nursing staff will be educated on current dialysis policy.
4. Random audits will be completed on dialysis protocol weekly x4 weeks, results will be reviewed at QAPI.

483.25(g)(1)-(3) REQUIREMENT Nutrition/Hydration Status Maintenance:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
483.25(g) Assisted nutrition and hydration.
(Includes naso-gastric and gastrostomy tubes, both percutaneous endoscopic gastrostomy and percutaneous endoscopic jejunostomy, and enteral fluids). Based on a resident's comprehensive assessment, the facility must ensure that a resident-

483.25(g)(1) Maintains acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that this is not possible or resident preferences indicate otherwise;

483.25(g)(2) Is offered sufficient fluid intake to maintain proper hydration and health;

483.25(g)(3) Is offered a therapeutic diet when there is a nutritional problem and the health care provider orders a therapeutic diet.
Observations:


Based on review of clinical records and select facility policies and staff interviews, it was determined that the facility failed to timely and adequately address significant weight loss displayed by two residents out of eight sampled (Resident 64 and Resident 117) to deter further weight loss and ensure adequate hydration for one resident out of 8 residents sampled (Resident 119).

Findings include:

A review of the facility's policy "Weight Guidelines" with policy review date of January 1, 2021, indicated that any weight gain or loss of 5% or more in 1 month, 7.5% or more weight gain or loss in 3 months, and 10% or more weight gain or loss in 6 months is assessed. If there is a significant weight gain or loss of 5% or more in 1 month, 7.5% or more weight gain or loss in 3 months, or 10% or more weight gain or loss in 6 months a re-weight will be obtained within 48 hours. The Charge Nurse will notify dietary and the resident/responsible party if there is a significant weight gain or loss of 5% or more in 1 month, 7.5% or more weight gain or loss in 3 months, and 10% or more weight gain or loss in 6 months. The Charge Nurse will complete a Weight Gain & Weight Loss Assessment Form in Point Click Care and notify the Supervisor RN for completion of physician notification documentation. The dietary manager/dietitian/diet technician will investigate the weight change and provide interventions as deemed necessary.

Further review of facility policy entitled "Nutritionally at Risk" with a policy review date of January 1, 2021, indicated to provide adequate nutrition intervention(s) and ensure documentation on nutritional status. The registered dietitian (RD), DTR, or certified dietary manager (CDM) were to be notified for weight loss (5% in 1 month, 7.5% in 3 months, and 10% in 6 months), weight loss or gain greater than 5 pounds, physician order to restrict or force fluids, poor intake of meals (50% or less for 3 days), and not meeting baseline minimum fluid needs for 3 days.

Review of Resident 64's clinical record revealed that the resident was admitted to the facility on October 13, 2021, with diagnoses that included Parkinson's disease [is a chronic and progressive movement disorder that initially causes tremor in one hand, stiffness or slowing of movement], dysphagia (difficulty swallowing), and malignant neoplasm of the prostate [is cancer that occurs in the prostate, which is a small walnut-shaped gland in males that produces the seminal fluid that nourishes and transports sperm].

A review of a quarterly MDS (Minimum Date Set) assessment (a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated August 18, 2021, revealed that Resident 64 was cognitively impaired, had an unplanned significant weight loss in loss of 5% or more in the last month or loss of 10% or more in last 6 months, required a mechanically altered diet, and was not on a therapeutic diet.

Resident 64's care plan initiated February 22, 2018, revealed that the resident was nutritionally at risk due to the potential for dehydration, Parkinson's disease, and dementia. The resident's goal was for a stable weight plus or minus 2%, oral intakes greater than 75%, and exhibit no signs or symptoms of dehydration. Interventions planned were to report significant weight gain or loss to dietary, encourage adequate oral beverage intake, and monitor for signs and symptoms of dehydration.

Review of Resident 64's weight record revealed that on May 4, 2021, the resident weighed 157.4 pounds (lbs.). On June 14, 2021, the resident's weight had decreased to 140.2 pounds, a significant weight loss of 17.4 pounds in a month.

According to the facility's weight policy a re-weight would be obtained within 48 hours, but the resident was not reweighed until June 18, 2021, 4 days later.

A Dietary Progress Note" completed by the dietitian on June 15, 2021, at 9:05 AM, revealed that the resident had a significant loss over 3 months. The resident was placed on weekly weights and would be offered ice cream at lunch and dinner for weight support. The dietitian noted that the resident was made aware of the weight loss and he didn't think he lost that much weight.

A physician order was noted June 15, 2021, at 9:09 AM, for ice cream with lunch and dinner, 2 Cal HN (a high calorie, high protein oral nutrition supplement) 60 cc four times per day for weight support and nutrition support) and weekly weights.

Review of Resident 64's "Medication Administration Record (MAR)" dated July 2021, revealed that there was no documented evidence that the ice cream was provided or accepted by the resident at lunch and dinner as planned. According to the MAR staff failed to provide the resident the 2 Cal Supplement on four occassions during the month and weekly weights were not obtained on July 2, 2021, July 16, 2021, and on July 30, 2021.

On August 13, 2021, the resident's weight was recorded at 134.1 pounds (lbs.), and on August 20, 2021 the weight was at 126 pounds (lbs.), an 8.1-pound significant weight loss in 1 week. No reweight was obtained to verify the weight loss.

A "Nutritional Assessment" completed by the dietitian dated August 18, 2021, revealed that Resident 64's ideal body weight range was between 153 and 185 pounds, body mass index was at 19.7 (normal weight). The assessment noted that the resident received a regular diet mechanical soft texture with additional moisture, and received ice cream as a nourishment/supplement with lunch and dinner due to weight losses. The dietitian noted that the resident consumed 0% of the nourishment/supplement and that resident had declining intakes that ranged between 33%-38%. The dietitian noted that the resident's weight and intakes were declining and the goal was to stop weight losses of plus or minus 2% and for intakes greater than 50% to be consumed. The dietitian recommend discontinuing ice cream with lunch and dinner and to give a fruit juice supplement at lunch and dinner.

A physician order was noted August 24, 2021, at 10:44 AM, for the fruit juice supplement with lunch and dinner. The order for this nutritional intervention was not obtained until 6 days after the dietitian had made the recommendation.

Review of the resident's MAR for August 2021 revealed that the resident's weekly weight were not obtained on August 26, 2021 as per physician orders.

Review of the September 2021 MAR revealed that the weekly weights were not obtained on September 10, 2021, September 17, 2021, or September 24, 2021 as per physician orders.

The resident's "Weight Record" revealed that on October 8, 2021, the resident's weight was 126.9 pounds. On October 22, 2021, the resident's weight had further decreased to 115 pounds, significant weight loss of 11.9 pounds in 2 weeks. The resident's BMI was then 17.6, underweight status.

There was no documented evidence that the dietitian or physician were notified of the significant weight loss identified October 22, 2021. There was no documented evidence that the dietitian identified or addressed the resident's significant weight loss and reviewed and revised the resident's nutrition interventions in an effort to impede the resident's progressive weight loss.

Review of Resident 117's clinical record revealed that the resident was admitted to the facility on March 17, 2020, with diagnoses that included malnutrition and adult failure to thrive.

A review of a quarterly MDS dated June 20, 2021, indicated that Resident 117 was cognitively impaired, had an unplanned significant weight loss in loss of 5% or more in the last month or loss of 10% or more in last 6 months, required a mechanically altered diet, and was not on a therapeutic diet.

A physician order dated March 18, 2020, was noted for weekly weights. Review of resident's Medication Administration Record for July 2021 revealed that the weekly weights were not completed as ordered. The resident's August 2021 MAR revealed that weekly weights were not obtained as ordered on August 4, 2021 and August 11, 2021.

The facility failed to consistently monitor the resident's weight as ordered by the physician.

Review of Resident 119's clinical record revealed that the resident was admitted to the facility on September 17, 2021, with diagnoses that included moderate protein calorie malnutrition, malignant neoplasm of left main bronchus and dysphagia and the resident was to receive nothing by mouth (NPO) and nutrition and hydration were to be provided via tube feeding.

A review of a quarterly MDS assessment dated September 20, 2021, indicated that Resident 119 was cognitively impaired.

A physician order dated September 17, 2021, was noted for 250 milliliters of water to flush the feeding tube every 6 hours.

A review of Resident 119's admission Nutritional Risk Assessment dated September 20, 2021 revealed that Resident 119 was to receive was 1120 cc of free water, plus tube feeding flushes.

Resident 119's September 2021 MAR, October 2021 MAR and November 2021 MAR (up to the survey ending 11/5/21) revealed no indication that the resident was receiving 250 ml of water flushes every 6 hours as ordered.

During an interview with the Nursing Home Administrator (NHA) on November 5, 2020, at 10:30 AM, confirmed that the facility to provide the prescribed flushes to maintain adequate hydration status of Resident 119.


28 Pa Code 211.6(c)(d) Dietary services.

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



.







 Plan of Correction - To be completed: 12/14/2021

1. Residents 64, 117, and 199 will have adequate nutrition and hydration as well as documented weights.
2. DON/designee will complete a weight variance report for all resident, any discrepancies will be reviewed by the Registered Dietician/designee for evaluation.
3. Nursing staff and registered dietician/ designee will be educated on weight attainment and weight policy.
4. Random audits will be completed on weight discrepancies and follow up weekly x4 weeks, results will be reviewed at QAPI.

483.10(a)(1)(2)(b)(1)(2) REQUIREMENT Resident Rights/Exercise of Rights:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.10(a) Resident Rights.
The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility, including those specified in this section.

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

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

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

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

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

Based on observations, review of clinical records, and staff interview, it was determined that the facility failed to promote the personal dignity of one of 30 residents reviewed (Resident 203).

Findings include:


Review of Resident 203's clinical record revealed an admission date of October 15, 2021, with diagnoses that included down's syndrome (a genetic disorder associated with physical growth delays, characteristic facial features and mild to moderate developmental and intellectual disability).

The resident was assessed to require maximum assistance with activities of daily living and was severly cognitively impaired according to the clinical record and most recent MDS (Minimum Data Set) assessments.

Observation on November 5, 2021, at 11:15 a.m. revealed Resident 203 lying in a gerichair in the east unit lounge with other residents also present in this lounge area. Resident 203's upper body was exposed. The resident was wearing an open gown, and a blanket which was at his feet. Multiple staff members were observed to walk by the resident in this lounge area, but no staff was observed attempting to cover up the resident. Further observations at 11:45 a.m., revealed that the resident remained in the east lounge with his upper body completely exposed.

During an interview on November 5, 2021, at 1:30 p.m. the Director of Nursing confirmed that Resident 203 should have been covered and not left exposed.



28 Pa. Code 201.29(j) Resident rights

28 Pa. Code 211.12(c) Nursing services





 Plan of Correction - To be completed: 12/14/2021

1. Resident 203's gown was closed.
2. The facility will complete an audit of residents to ensure proper attire.
3. Nursing staff will be educated to ensure proper attire of residents.
4. The facility will conduct random audits to ensure proper attire of residents weekly x 4 weeks, results will be reviewed at QAPI.

483.12(c)(1)(4) REQUIREMENT Reporting of Alleged Violations: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.
483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must:

483.12(c)(1) Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures.

483.12(c)(4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken.
Observations:

Based on a review of clinical records and select facility investigative reports and staff interviews it was determined that the facility failed to timely report and investigate potential physical abuse of two residents (Residents 116 and 78) out of 30 residents sampled.

Findings include:


A review of Resident 116's clinical record revealed admission date to the facility, October 30, 2017, with diagnoses including cerebral vascular accident (when blood flow to a part of your brain is stopped either by a blockage or the rupture of a blood vessel).

A review of Resident 116's most recent MDS Assessment dated September 19, 2021, (Minimum Data Set - a federally mandated standardized assessment completed at intervals to plan resident care) revealed that the resident was mildly cognitively impaired (score 12/15).

A review of Resident 78's clinical record revealed admission to the facility October 1, 2018 with diagnoses including dementia without behavioral disturbance (the loss of cognitive functioning; thinking, remembering, and reasoning to such an extent that it interferes with a person's daily life) A review of Resident 78's most recent MDS Assessment dated August 28, 2021, revealed that the resident was severely cognitively impaired (score 3 out of 15).

A review of a facility incident report revealed that Resident 78 and 116 were involved in a physical altercation during which the residents were striking each other and pulling each other's hair in the TV room on October 20, 2021. The report noted that both residents are cognitively impaired. However, Resident 116 stated she wanted Resident 78 out of the TV room, which was the reason for the physical altercation.

There was no documented evidence that the facility had reported the physical abuse that had occurred during the physical altercation between Residents' 78 and 116 to the State Survey Agency or the Area Agency on Aging.

At the time of the survey ending November 5, 2021, there was no documented evidence that the facility had investigated this resident altercation to determine if planned interventions were necessary to deter further physically abusive behaviors.

Interview conducted on November 5, 2021, at 10:00 a. m. revealed that the Director of Nursing Services confirmed that the facility had not reported nor investigated the incident further because she "didn't feel there was intent."



28 Pa. Code 201.14 (a) Responsibility of licensee

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

28 Pa. Code 201.29(a)(c)(d) Resident Rights

28 Pa. Code 211.12(a)(c)(d)(5) Nursing Services
















 Plan of Correction - To be completed: 12/14/2021

1. The facility has reported the resident to resident altercation.
2. The facility will conduct an audit to resident to resident altercations within the past two weeks to ensure proper reporting.
3. Staff will be educated on reporting guidelines.
4. Random audits will be conducted on resident to resident altercations to ensure reporting guidelines are met weekly x 4 weeks, results will be reviewed at QAPI.

483.35(a)(3)(4)(c) REQUIREMENT Competent Nursing Staff:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.35 Nursing Services
The facility must have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment required at 483.70(e).

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

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

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

Based on a review of facility policy, observations, and staff interview, it was determined that the facility failed to provide nursing services with the necessary skills and competencies to ensure that a resident received physician prescribed medications for one resident (Resident 69) out of 30 residents reviewed.

Findings include:


The Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, 21.145 Functions of the Licensed Practical Nurse (LPN) (a) The LPN is prepared to function as a member of the health-care team by exercising sound nursing judgment based on preparation, knowledge, experience in nursing and competency. The LPN participates in the planning, implementation and evaluation of nursing care using focused assessment in settings where nursing takes place. (2) An LPN shall obtain instruction and supervision if implementing new or unfamiliar nursing practices or procedures. (3) An LPN shall follow the written, established policies and procedures of the facility that are consistent with the act. (b) The LPN administers medication and carries out the therapeutic treatment ordered for the patient.

A review of facility policy entitled "Medication Administration" last reviewed January 20, 2021, indicated that the nurse is to remain with the resident to ensure the medication is swallowed.

An observation of the medication administration to Resident 69 by Employee 4 LPN (license practical nurse) on November 4, 2021, at approximately 9:20 AM revealed that Employee 4 prepared the following medications for administration to the resident: Calcitriol Capsule 0.25 MCG one tablet, Folic Acid 800 MCG one tablet, Levothyroxine Sodium 75 MCG one tablet, Loratadine 10 MG one tablet, Sodium Bicarbonate 650 MG two tablets, and PhosLo 667 MG two capsules.

Continued observation on November 4, 2021, at 9:20 AM revealed that Employee 4 walked into Resident 69's room, placed the medications on the resident's bedside table and walked out of the room without assuring that the resident had taken the medications.

An interview with Employee 4 on November 4, 2021, at that time of the obseration revealed that Employee 4 stated the resident "will take them when she is ready" and that she "is not going to argue with her (the resident)." Employee 4 stated that Resident 69 is "capable of taking her medications."

An interview with the director of nursing on November 5, 2021, at approximately 1:00 PM confirmed that Employee 4 failed to properly administer Resident 69's medications according to professional standards by failing to assure that Resident 69 had taken the medications.



28 Pa. Code 211.12 (a)(c)(d)(1)(5) Nursing Services.





 Plan of Correction - To be completed: 12/14/2021

1. Resident 69 is aware of the facility's medication pass policy.
2. The facility will ensure staff follow the medication pass policy.
3. Nursing staff will be educated on the facility medication pass policy.
4. Random medication pass audits will be completed weekly x4 weeks, results will be reviewed at QAPI.

483.40(b)(3) REQUIREMENT Treatment/Service for Dementia:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.40(b)(3) A resident who displays or is diagnosed with dementia, receives the appropriate treatment and services to attain or maintain his or her highest practicable physical, mental, and psychosocial well-being.
Observations:


Based on a review of clinical records, and staff interview, it was determined that the facility failed to develop and implement an individualized a person-centered plan to address a resident's dementia-related behavioral symptoms for two out of two residents reviewed with dementia diagnoses (Residents 78 and 204).

Findings include:

A review of Resident 78's clinical record revealed an admission date of October 1, 2018, with diagnoses including dementia without behavioral disturbance (the loss of cognitive functioning; thinking, remembering, and reasoning to such an extent that it interferes with a person's daily life) A review of Resident 78's most recent MDS Assessment dated August 28, 2021, (Minimum Data Set - a federally mandated standardized assessment completed at intervals to plan resident care) revealed that the resident was severely cognitively impaired with a BIMS score of 3 out of 15.

A facility incident report revealed an incident occurred involving Residents' 78 and 116 on October 20, 2021. According to the incident report the residents were striking each other and pulling each other's hair in the main TV room. The report noted that both residents are cognitively impaired. However, Resident 116 stated that she wanted Resident 78 out of the TV room and that was the reason for the physical altercation.

A review of Resident 78's current care plan, in effect at the time of the survey of November 5, 2021, revealed that the facility had not reviewed or revised the resident's care plan after the physical altercation with Resident 116 that had occurred on October 20, 2021.

A review of Resident 204's clinical record revealed an admission date of October 15, 2021, with diagnoses including dementia without behavioral disturbance (the loss of cognitive functioning; thinking, remembering, and reasoning to such an extent that it interferes with a person's daily life) A review of Resident 204's most recent MDS Assessment dated October 19, 2021, revealed that the resident was severely cognitively impaired (BIMS score 5).

Review of Resident 204's Medication Administration Record (MARS), used by the facility to track resident behavior, for the months of October 2021 and November 2021, revealed that the facility had not monitored Resident 204's behaviors.

Resident 204's current care plan, in effect at the time of the survey of November 5, 2021, did not identify the specific dementia related behaviors the resident exhibits and individualized person-centered interventions to address each of these behaviors.

The facility failed to develop and implement an individualized person-centered plan to address, modify and manage the residents' dementia-related behaviors. The resident's care plan for behavioral symptoms failed to include individualized interventions based on an assessment of the resident's preferences, social/past life history, customary routines and interests in an effort to manage the resident's dementia-related behavioral symptoms.

Interview with Director of Nursing and Nursing Home Administrator on November 5, 2021 at approximately 10:00 a.m., confirmed that the facility was unable to provide evidence of the development and implementation of an individualized person-centered plan to address dementia-related behaviors and consistent and accurate monitoring of the resident's dementia related behaviors and any approaches used to manage or modify those behaviors.



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

28 Pa Code 211.6(g)(h) Clinical records

28 Pa. Code 211.11(d)(e) Resident care plan











 Plan of Correction - To be completed: 12/14/2021

1. Identified resident have care plans in place with specific behaviors defined and interventions.
2. The IDT will audit the last two weeks of resident to resident altercations to ensure the residents involved have dementia care plans.
3. Nursing staff and IDT will be educated on appropriate behavior follow up and care planning.
4. Random audits will be completed regarding appropriate behavior follow up and care plan revision weekly x4 weeks, results will be reviewed at QAPI.

483.45(a)(b)(1)-(3) REQUIREMENT Pharmacy Srvcs/Procedures/Pharmacist/Records: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 Pharmacy Services
The facility must provide routine and emergency drugs and biologicals to its residents, or obtain them under an agreement described in 483.70(g). The facility may permit unlicensed personnel to administer drugs if State law permits, but only under the general supervision of a licensed nurse.

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

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

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

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

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

Based on review of narcotic shift count records and staff interview, it was determined that the facility failed to implement procedures to promote accurate narcotic medication records on two of four medication carts observed.

Finding include:

A review of the facility "Narcotic Count Sheet" revealed that the signature of each nurse arriving on duty and nurse departing from duty is required at change of shift which would indicate that all controlled substances are accounted for by both responsible parties.

A review of the facility " Narcotic Count Sheet" on November 3, 2021 at 11:15 AM on East Wing Hall C, revealed that the nurse on the 7:00 AM to 3:00 PM shift failed to sign the sheet on November 3, 2021.

Employee 5, Licensed Practical Nurse confirmed at this time she did not sign the "Narcotic Count Sheet" on East Wing Hall C.

A review of the facility "Narcotic Count Sheet" on November 4, 2021, revealed that the nurse on the on-coming 11:00 PM to 7:00 AM shift failed to sign the sheet on November 3, 2021.

Interview with the Director of Nursing on November 5, 2021, at approximately 1:00 PM revealed that a physical inventory of all controlled medications is conducted by two licensed nurses and documented on the Narcotic Count Sheets and confirmed the facility failed to demonstrate consistent implementation of facility procedures for promoting accurate controlled drug records.


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

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









 Plan of Correction - To be completed: 12/14/2021

1. The facility cannot retroactively correct the deficient practice.
2. The facility will ensure narcotic count sheets are signed after a narcotic count occurs.
3. Licensed nurses will be educated on shift to shift narcotic sign in sheets.
4. Random audits will be completed to ensure compliance with shift to shift narcotic sheets weekly x4 weeks, results will be reviewed at QAPI.

483.45(f)(1) REQUIREMENT Free of Medication Error Rts 5 Prcnt or More: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(f) Medication Errors.
The facility must ensure that its-

483.45(f)(1) Medication error rates are not 5 percent or greater;
Observations:

Based on observation, a review of select facility policy and clinical records and staff interview, it was determined that the facility failed to maintain a medication error rate of less than five percent as evidenced by two of two residents observed during the medication pass (Resident 256 & 255).

Findings include:

A review of facility policy entitled: "Medication Administration" indicated that Medications are administered within 60 minutes of scheduled time, except before or after meal orders, which are administered based on meal times.
If a medication is ordered and not present: a. check other resident's drawers to see if it was placed in the wrong drawer and b. Call the pharmacy or supervisor to obtain the medication.

During observation of a medication administration on November 3, 2021, at 9:08 AM, Employee 6, LPN (Licensed Practical Nurse), administered medications to Resident 256. A review of the clinical record revealed that the resident was scheduled to receive Omeprazole 20 mg, Aspirin EC 81 mg, Lasix 40 mg, metoprolol ER 25 mg, Tamsulosin 0.4 mg and Vitamin D-3, two tablets, 25 mcg. Observations revealed that Employee 6 did not administer the Vitamin D-3 two tablets, 25 mcg medication as scheduled.

Employee 6 stated that at this time, the medication was not available and Employee 6 made an entry in the clinical record noting that the vitamin D-3 was not available and moved on to administer medications to the next resident.

Review of Resident 255's physician order dated October 8, 2021 revealed Humalog 100 units/ml insulin inject per sliding scale was to be administered at 7:30 AM before meals and at bedtime.

Observation of a medication administration on November 3, 2021 at 9:20 AM, Employee 6, LPN, administered medications to Resident 255. Resident 255 had already eaten breakfast. The resident was scheduled to receive Allopurinol 300 mg, Eliquis 5 mg, doxycycline 100 mg, Prenatal Vitamin 27-0.8 mg Vit-Fe Fumarate- FA, Senna- S 8.6-50 mg, MiraLAX 17 grams, Aspirin EC 81 mg, oxycodone 5 mg tablet.

Employee 6 administered Resident 255 his medications and obtained the resident's blood glucose level at that time. Employee 6 stated that the resident's blood glucose reading was 170 mg/dl and he required 1 unit Humalog coverage. Employee 6, drew up 1 unit of Humalog insulin and administered it in Resident 255's left lower abdomen at 9:25 AM. Employee 6 stated that the insulin was administered late, explaining that his blood glucose level should have been obtained prior to his meal, and then insulin administered if required, before the resident's breakfast. Employee 6 stated that this was her second day working at the facility and that she was responsible for working two medication carts and as a result, she was "really behind" in administering the residents' morning medications.

An interview with Employee 6 at this time confirmed she had not obtained Resident 255's blood glucose reading or administered the insulin prior to the resident's breakfast meal according to the physician order.

These observations revealed two medication errors out of 28 opportunities for error and a medication error rate of 7.1%.

An interview with the Nursing Home Administrator on November 5, 2021, at approximately 1:30 PM confirmed the facility failed to maintain a medication error rate of less than 5 percent.



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

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








 Plan of Correction - To be completed: 12/14/2021

1. Resident 256 and 255 will receive medications timely.
2. The pharmacy consultant will review current medication orders for possible reduction in polypharmacy for all residents to promote timely administration.
3. Licensed nurses will be educated on current medication pass policy.
4. Random audits will be completed on late or missing medication entries weekly x4 weeks, results will be review at QAPI.

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 identify use by/discard dates for multidose insulin pens and multidose vials for two residents on two medication carts (Residents 68 and 115)

Findings include:

A review of the facility's policy and procedure entitled "Insulin and Other Biological Storage Policy" last revised January 20, 2021, revealed once a vial is opened it must be dated with the date it was opened. Further is was indicated if the medication is Lantus or Novolog (types of insulins) they expire 28 days after opening.

An observation on the East Hall Medication Cart November 3, 2021, at 11:26 AM revealed two vials of insulin, Novolog 100 units/ml and Levemir 100 units/ml, for Resident 115. The two vials were opened and in use with no documentation of open date or use/discard date.

An interview with Employee 5, LPN, at that time confirmed that the insulin vials located in the medication care observed on November 3, 2021, were not labeled when opened or dated to discard.

An observation of the West Hall Medication Cart on November 4, 2021, at 10:13 AM revealed two Lantus Pens (an injectable device used to deliver medication for the management of diabetes) for Residents 68. The two pens were opened and in use with no documentation of an open date or use/discard date.

An interview with Employee 2, LPN, at that time confirmed that the insulin pens located in the medication cart observed on November 4, 2021, were not labeled when opened or dated to discard.


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

28 Pa Code 211.9(k)(1)(2) Pharmacy services







 Plan of Correction - To be completed: 12/14/2021

1. The facility cannot retroactively correct the deficient practice.
2. The facility will conduct an initial audit to ensure medications are appropriately stored and labeled.
3. Licensed nurses will be education on the proper storage and labeling of medications.
4. Random audits will be completed weekly x4 weeks to ensure proper storage and labeling of medications, results will be reviewed at QAPI.


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