Nursing Investigation Results -

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

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WILLIAMSPORT NORTH REHABILITATION AND NURSING CENTER
Inspection Results For:

There are  106 surveys for this facility. Please select a date to view the survey results.

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WILLIAMSPORT NORTH REHABILITATION AND NURSING CENTER - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on a Medicare/Medicaid Recertification Survey, State Licensure Survey, Civil Rights Compliance Survey, and an Abbreviated Survey to review two Complaints, completed on July 1, 2022, it was determined that Williamsport North Rehabilitation and Nursing Center was not in compliance with the following requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care and the 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.



 Plan of Correction:


483.10(i)(1)-(7) REQUIREMENT Safe/Clean/Comfortable/Homelike Environment:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
§483.10(i) Safe Environment.
The resident has a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

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

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

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

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

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

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

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

Based on observations and staff and resident interviews, it was determined that the facility failed to provide a clean, comfortable environment on three of three nursing units (first floor nursing unit, second floor nursing unit, third floor nursing unit; Residents 2, 4, 10, 13, 21, 27, 39, 43, 57, 60, 65, 69, 83, 103, and 415).

Findings include:

Observation of the first-floor nursing station on June 28, 2022, from 10:04 AM to 10:32 AM revealed the following:

The lobby area outside the entrance to the nursing unit had a vent above a large portrait painting with a substantial build-up of dust.

A vent on a wall behind the first floor nurse's station had a substantial build-up of dust. Accumulated dust was observed on the vent, the surrounding wall, and the ceiling directly above the vent.

A vent located on the ceiling of the first floor nurse's station above a sink had an accumulation of dust.

A painted wall located next to the door to the dining room of the first floor nursing unit had damage that included chipped paint in several areas. There were multiple dime-sized areas of missing paint that were located between the floor and about three feet off the floor.

Several cobwebs were observed hanging from the ceiling of the patio area just off the main dining room of the first floor nursing unit. An air circulator in the upper corner of the room had an accumulation of dust on the air vents.

At the entrance to the patio area from the main dining room of the first floor nursing unit, wallpaper was observed coming off the wall on the right corner of the wall. The area was located one foot off the ground and peeling from the ground up. The damaged area also included the cove base molding that was partially detached from the wall.

Wallpaper and the cove base molding located on the first floor nursing unit in the dining room behind the dining room entrance/exit door was observed peeling from the wall.

A vent in the first floor nursing unit dining room above the sink and cupboards was covered in a black-colored unidentified substance. The span of wallpaper bordering the ceiling above the cupboards was peeling and curling at the bottom edge of the wallpaper.

A fluorescent light, an orange light protruding from the ceiling, and four ceiling tiles above the sink area in the first floor nursing unit dining room were partially covered with a build-up of dust.

Wallpaper was observed that had peeled from the wall about four feet from the ground on the right corner of a wall going from the first floor nursing unit dining room into the resident lounge. A black-colored unidentified substance was noted underneath the peeled section of wallpaper.

Observation of the main shower room on the first floor nursing unit on June 28, 2022, at 10:32 AM revealed two brown stained ceiling tiles above a commode located in the shower room. Another stained ceiling tile was located above the tub.

Two air circulating devices located on the ceiling of the first floor nursing unit shower room had a dust build-up on the vents.

A large vent adjacent to the tub in the first floor nursing unit shower room had a substantial build-up of dust and cobwebs.

Observation of Resident 60's room on June 28, 2022, at 10:45 AM revealed peeling wallpaper and a section of cove base molding was loose and peeling away from the wall. The wallpaper was easily pulled away from the wall about six-inches from the floor directly in front of Resident 60's bed. The wall appeared to be crumbling behind the impacted area and the wallpaper was not attached to the supporting wall.

Observation of Residents 21 and 39's room on June 29, 2022, at 8:57 AM revealed a section of the cove base molding just inside the entrance to the room was coming off the wall. Further observation on June 30, 2022, at 1:10 PM revealed the cove base molding was still coming off the wall and what appeared to be a six-inch section of crumbling wall was visible behind the molding.

Observation of Residents 43 and 65's room revealed cobwebs above both the bathroom door entrance and also a vent in the corner of the room adjacent to the window.

Observation of Resident 415's room revealed a board that was nailed to the wall that spanned the top border of the closet just inside the entrance/exit door. The board was not secured firmly to the wall and was loose when touched.

Observation on June 30, 2022, at 12:35 PM revealed a light at the front entrance just inside the first set of main doors to the facility. The light was filed with a significant number of debris and dead insects.

The above concerns were reviewed in a meeting with the Nursing Home Administrator (NHA) and Director of Nursing (DON) on June 30, 2022, at 2:00 PM.

Observation of Resident 13's room on June 29, 2022, at 9:02 AM revealed the wall under the window was marred and dry wall was exposed. The wall between the two dressers in the room was marred and there was a brown spill noted on the wall. A brown spill was noted on the side of the dresser closest to the door. The closet door near the bottom was marred. There was a broken plate cover on the wall between the two dressers with a cord coming out of it.

Observation of Resident 2's room on June 29, 2022, at 10:31 AM revealed the night light was protruding and appeared to be falling from the wall.

Observation of 2nd floor east unit on June 29, 2022, at 11:30 AM revealed stained floor tiles outside the central bath and outside the soiled utility room. There was wallpaper and baseboard coming off the left side of the alcove that led to the central bath.

The NHA and DON were made aware of the environmental concerns for Residents 2 and 13 and on the 2 East hallway on June 29, 2022, at 2:18 PM.

Observation of the second-floor nursing unit on June 30, 2022, at 9:30 AM, revealed the following:

Resident 4's nightlight had exposed wiring with no cover, a top handle missing off the chest of drawers, and dry wall exposed above the cove basing by the closet.

Resident 10's sliding closet had a broken floor bracket resulting in the back door of the closet swinging back and forth from the top brackets.

Resident 27's cove basing behind the toilet was lifting up, exposing part of the sub floor and wall.

Resident 69's sliding closet had a broken floor bracket resulting in the front door of the closet swinging back and forth from the top brackets

Resident 83's cove basing on the outside corner of the bathroom was peeling away from the wall exposing a large part of the wall.

In an interview with Resident 57, who resides on the third-floor nursing unit, on June 28, 2022, at 10:49 AM, the resident indicated it was not a pleasant experience getting a shower. The resident stated, "there is mold in the shower room, and clutter all over the place, you can't even see the tub, there is stuff stacked in it and the other is so packed with shower chairs, there is just stuff stacked all over the place, and it is disgusting in there."

An observation of the third floor shower room from the second entrance from the nursing station on June 28, 2022, at 11:00 AM revealed a large room with two shower stalls, one shower stall had hair observed in the floor drain, the flooring grout was black in color compared to some other areas of the shower room where the grout appeared white, the black color in the grout was also observed in the corners of the shower stall and around the shower floor drain.

A wooden door in the shower room to the toilet room was significantly marred. The toilet room contained several shower chairs packed around the toilet area and stacked on top of each other, blocking access to the toilet.

Additional shower stalls and a bathtub stall were observed off another door of the toilet room in the shower room.
There were several empty trash receptacles observed in the bathtub stall stacked on top of one another and additional trash cans were stacked inside the bathtub. Another shower stall had a wet towel hanging on the grab bar and hair was observed in the drain.

A shower stall along the back wall also had several shower chairs sitting in it.

Black grout was observed on the flooring inside the first entrance to the shower room from the nursing station, and several places throughout the shower room.

An observation of Resident 103 on June 28, 2022, at 11:57 AM revealed she was sitting in her room with her roommate. The slats of the window blinds covering the window were broken and hanging down on several spots. The resident stated the blinds were like that when she was admitted. Clinical record review for Resident 103 revealed the resident was admitted to the facility on June 8, 2022.

The above environmental concerns regarding the third-floor shower room and Resident 103's room were reviewed with the Nursing Home Administrator and Director of Nursing on June 29, 2022, at 2:00 PM.

483.10(i)(1)-(7) Safe/clean/comfortable/homelike Environment
Previously cited deficiency 7/16/21

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

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



 Plan of Correction - To be completed: 08/04/2022

1. The lobby portrait was dusted, first floor nurse's station and dining room vents, wall, and ceiling were dusted, chipped paint on wall fixed, first floor dining room was dusted, wallpaper and cove base in first floor dining room fixed,
First floor nursing shower room ceiling tiles were replaced, ceiling devises dusted, and vents dusted.
Resident 60's wallpaper and cove base molding was fixed.
Residents 21 and 39's cove base molding was fixed.
Residents 43 and 65's room and vents were dusted.
Resident 415's board was repaired.
The front entrance light was cleaned.
Resident 13's dry wall was fixed, the wall and dresser were cleaned, the closet door was repaired, and the plate cover cord was repaired.
Resident 2's night light was fixed.
2nd floor east stained floor tiles were replaced, wallpaper fixed and baseboard fixed.
Resident 4's nightlight wiring fixed, handle of chest of drawers replaced, and dry wall fixed.
Resident 10's closet bracket repaired.
Resident 27's cove basing was fixed.
Resident 69's closet bracket repaired.
Resident 83's cove basing fixed.
Third floor shower room grout cleaned, door repaired, shower chairs removed from toilet, empty trash receptacles removed, wet towel removed, hair cleaned from drain. The ceiling and air circulator on 1st floor cleaned.
Several shower chairs in 3rd floor shower room removed.
Resident 103 slats of the window blinds were replaced.
2. Facility wide audit was completed to identify wallpaper, baseboards, stains on wall, night light protrusion, exposed wires that need repaired and areas needing cleaned.
3. Maintenance Director and housekeeping staff will be educated to ensure the environment is safe, clean, and homelike.
4. Maintenance director and housekeeping supervisor will audit facility for safe, clean, and homelike environment weekly x3 and monthly x3.

483.80(a)(1)(2)(4)(e)(f) REQUIREMENT Infection Prevention & Control:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
§483.80 Infection Control
The facility must establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections.

§483.80(a) Infection prevention and control program.
The facility must establish an infection prevention and control program (IPCP) that must include, at a minimum, the following elements:

§483.80(a)(1) A system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon the facility assessment conducted according to §483.70(e) and following accepted national standards;

§483.80(a)(2) Written standards, policies, and procedures for the program, which must include, but are not limited to:
(i) A system of surveillance designed to identify possible communicable diseases or
infections before they can spread to other persons in the facility;
(ii) When and to whom possible incidents of communicable disease or infections should be reported;
(iii) Standard and transmission-based precautions to be followed to prevent spread of infections;
(iv)When and how isolation should be used for a resident; including but not limited to:
(A) The type and duration of the isolation, depending upon the infectious agent or organism involved, and
(B) A requirement that the isolation should be the least restrictive possible for the resident under the circumstances.
(v) The circumstances under which the facility must prohibit employees with a communicable disease or infected skin lesions from direct contact with residents or their food, if direct contact will transmit the disease; and
(vi)The hand hygiene procedures to be followed by staff involved in direct resident contact.

§483.80(a)(4) A system for recording incidents identified under the facility's IPCP and the corrective actions taken by the facility.

§483.80(e) Linens.
Personnel must handle, store, process, and transport linens so as to prevent the spread of infection.

§483.80(f) Annual review.
The facility will conduct an annual review of its IPCP and update their program, as necessary.
Observations:

Based on review of select facility policy and procedures, observation, staff interview, and infection control surveillance documentation, it was determined that the facility failed to implement proper visitor screening measures related to COVID-19 and implement source control to prevent the spread of COVID-19 among visitors to residents (Third floor, Resident 61)

Findings include:

The facility's current policy entitled "COVID - Visitation (Pennsylvania)" revealed it is the purpose of the facility to provide residents with the right to receive visitors of his or her choosing at the time of his or her choosing and such visitation will follow the adherence to the core principles of COVID-19 infection. The facility will not limit the frequency, length of visits and number of visitors while following the core principles of COVID-19 infection prevention, and not increasing the risk to other residents. The policy also indicated the facility will maintain core infection prevention and control practices to prevent and contain outbreak to ensure delivery of quality and safe care.

The facility's core principles of COVID-19 infection prevention included visitors who have a positive viral test for COVID-19, or currently meet the criteria for quarantine, should not enter the facility until they meet the criteria used for residents to discontinue transmission-based precautions (quarantine), and the facility will screen all who enter for these visitation exclusions. Visitors should wear face coverings or masks and physical distance when around other residents or health care personnel, regardless of vaccination status. If the county community level of transmission is substantial to high all residents and visitors, regardless of vaccination status should always wear face coverings or masks and physically distance.

The policy indicated that all visitors would be screened for signs and symptoms of COVID-19, including but not limited to coughing, congestion, runny nose, shortness of breath, headache, new loss of taste or smell, diarrhea, chills, muscle pain or body aches, sore throat, nausea or vomiting, or fatigue, and the facility would prohibit visitation regardless of their vaccination status if they have current SARS-CoV-2 (COVID-19) or have symptoms of COVID-19.

During an interview with the Nursing Home Administrator and Director of Nursing upon completion of the entrance conference on June 28, 2022, at 8:21 AM, the NHA indicated personal protective equipment (PPE) required on the nursing units for staff was an N95 mask (a respiratory protective device designed to achieve a very close facial fit and very efficient filtration of airborne particles) and eye protection due to the county COVID-19 transmission rate being in substantial status.

A review of the facility's COVID-19 county transmission rates revealed the facility has been in a high transmission rate status from May 9, 2022, and most recently changed to substantial on June 27, 2022.

Review of the CMS QSO-20-39-NH revised on March 10, 2022, indicated that residents must be allowed to receive visitors as he/she chooses, and visitation can be conducted through different means based on the facility's structure, and resident needs, such as in resident rooms, dedicated visitation spaces, and outdoors, and regardless of how visits are conducted, the core principles consistent with the Centers for Disease Control and Prevention (CDC) guidance for nursing homes, should be adhered to at all times. These core principles include screening all who enter the facility, wearing a face covering or mask (covering mouth and nose) and physical distancing at least six feet between people. If the nursing homes county COVID-19 community level of transmission is substantial to high, all residents and visitors, regardless of vaccination status should wear face coverings or masks and physically distance at all times in a communal area of the facility, and although not recommended, only remove face coverings or masks as long as it is the resident's choice and it does not put other residents at risk. This would occur only while not in a communal area.

An observation on the third-floor nursing unit on June 29, 2022, at 11:55 AM revealed two visitors, a young woman pushing a man in a wheelchair, walked out of the elevator to the lobby/nursing station area of the unit, neither were wearing any face covering. The woman approached a staff member at the desk and asked if staff could assist in taking her grandmother (Resident 61) down to the first floor so she could color her hair. The man was identified as the spouse of Resident 61. The staff member indicated lunch was coming soon, so the resident may not want to have her hair done. The woman proceeded to walk down the hall without any mask, where unmasked residents were sitting, and met Resident 61 in the hallway. Resident 61, the granddaughter, and the resident's spouse were then observed talking outside the dining room where other residents, and staff were present. The granddaughter and Resident 61's spouse then exited the unit via the elevator. No staff were observed instructing the granddaughter or Resident 61's spouse to don a mask.

Concurrent review of the facility COVID-19 screening log for visitors located on the second floor of the facility at the facility entrance, did not reveal any evidence of any visitors for Resident 61 on June 29, 2022, being screened for entrance to the facility for signs or symptoms of COVID-19 before entering the facility, proceeding to the third floor, interacting with a resident, and being in common areas of the facility where other resident and staff were present without any facial covering or mask.

In an interview with the Nursing Home Administrator and Director of Nursing on June 29, 2022, at 2:00 PM the Director of Nursing indicated the facility does not restrict any visitors at any time and visitors are not required to wear person protective equipment such as a mask or facial covering to enter the facility if they do not want to and the facility "can't make them."

Further review of the facility's screening tool for entrance to the facility for June 29, 2022, revealed one visitor noted a temperature greater than 99 degrees Fahrenheit and six additional visitors did not complete the COVID-19 screening questions at all prior to visitation.

Additional concerns regarding screening visitors for signs/symptoms of COVID-19 prior to entry to the facility were reviewed with the Nursing Home Administrator and Director of Nursing on June 30, 2022, at 9:00 AM.

An observation on the third- floor nursing unit on July 1, 2022, at 12:40 PM again revealed an adult male and male child standing outside the dining room waiting for the elevator without any facial covering or mask, staff and unmasked residents were in the same common area.

483.80 (a)(1) Infection Prevention & Control
Previously cited 7/16/21

28 Pa. Code 211.10(d) Resident care policies

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



 Plan of Correction - To be completed: 08/04/2022

1. Receptionist and supervisor educated on completion and review of screening logs. PPE and signage at entrance for visitors. Visitation discussed with Resident 61 and roommate, both consent to having visitation in their room.
2. Audit screening log past 7 days to ensure completion of questionnaire. Robo call to families and staff to educate on PPE requirement while visiting.
3. Educate staff on visitation policy.
4. Infection preventionist or designee will complete audit of screening log and visitors weekly x3 and monthly x3.

483.10(c)(7) REQUIREMENT Resident Self-Admin Meds-Clinically Approp: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(c)(7) The right to self-administer medications if the interdisciplinary team, as defined by §483.21(b)(2)(ii), has determined that this practice is clinically appropriate.
Observations:

Based on observation and resident and staff interview, it was determined that the facility failed to assess for the clinical appropriateness of self-administration of medications for one of one resident reviewed (Resident 103).

Findings include:

Observation of Resident 103 on June 28, 2022, at 11:57 AM revealed she was in her room sitting on the edge of her bed. A box labeled "Fluticasone propionate," (a steroidal nasal spray), was observed sitting on the bedside stand beside the resident.

An observation on June 29, 2022, at 11:34 AM revealed the box of nasal spray still sitting on the resident's stand beside the bed.

Clinical record review for Resident 103 did not reveal any physician's order for the resident to receive Fluticasone propionate. A medication self-administration form completed by staff on June 9, 2022, revealed the resident did not wish to self-administer medications and further assessment was not completed.

The above information was reviewed with the Nursing Home Administrator and Director of Nursing on June 29, 2022, at 2:00 PM.

In a follow up interview with Resident 103 on July 1, 2022, 9:45 AM the resident stated someone came in and took the nasal spray, and told her she could not have it, and now she was "stuffy.

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

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


 Plan of Correction - To be completed: 08/04/2022

Submission of our plan of correction does not constitute an admission or agreement with the facts and conclusions set forth on the survey report. Our plan of correction is prepared and executed as a means to continually improve the quality of care for our residents and to comply with all applicable state and federal regulatory requirements.


1. Self-administration of medication UDA completed for Resident 103. Resident does not wish to self-administer nasal spray. Nasal spray removed from room.
2. Audit of facility found only one resident assessed to be able to self-administer medication.
3. Licensed nursing staff will be educated on process to self-administer medications. Self-administration of medication UDA completed on admission, quarterly, and as needed.
4. Nursing unit managers or designee will complete weekly audits x3 and monthly x3. The results of the audit will be reviewed at the monthly QAPI meeting.

483.10(c)(6)(8)(g)(12)(i)-(v) REQUIREMENT Request/Refuse/Dscntnue Trmnt;Formlte Adv Dir: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(c)(6) The right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.

§483.10(c)(8) Nothing in this paragraph should be construed as the right of the resident to receive the provision of medical treatment or medical services deemed medically unnecessary or inappropriate.

§483.10(g)(12) The facility must comply with the requirements specified in 42 CFR part 489, subpart I (Advance Directives).
(i) These requirements include provisions to inform and provide written information to all adult residents concerning the right to accept or refuse medical or surgical treatment and, at the resident's option, formulate an advance directive.
(ii) This includes a written description of the facility's policies to implement advance directives and applicable State law.
(iii) Facilities are permitted to contract with other entities to furnish this information but are still legally responsible for ensuring that the requirements of this section are met.
(iv) If an adult individual is incapacitated at the time of admission and is unable to receive information or articulate whether or not he or she has executed an advance directive, the facility may give advance directive information to the individual's resident representative in accordance with State Law.
(v) The facility is not relieved of its obligation to provide this information to the individual once he or she is able to receive such information. Follow-up procedures must be in place to provide the information to the individual directly at the appropriate time.
Observations:

Based on review of select facility policies and procedures, clinical record review, and staff interview, it was determined that the facility failed to determine a resident's wishes regarding an advance directive for one of three residents reviewed (Resident 2).

Findings include:

The facility readmitted Resident 2 to the facility on June 20, 2022, after a hospital admission for an abscess of a surgical area on her lower back.

A physician's progress note dated June 21, 2022, revealed that Resident 2 was a full code (all measures would be provided to keep the resident alive if her heart stopped beating and/or her breathing stopped). Further clinical record review revealed a physician's order dated June 20, 2022, that indicated the Resident was to be a full code.

There was no documented evidence in Resident 2's clinical record to confirm a discussion occurred with her or her responsible party to determine her wishes related to her code status.

The facility provided a POLST (Pennsylvania's orders for life-sustaining treatment) form to the surveyor that was signed by Resident 2 on July 1, 2022, indicating that her wishes were for her to be a full code with limited additional interventions. The POLST form was not completed or signed until after the surveyor brought this to the attention of the Director of Nursing and Nursing Home Administrator on June 30, 2022, at 2:22 PM.

An interview with the Director of Nursing on July 1, 2022, at 10:20 AM confirmed that there was no evidence in Resident 2's clinical record that a discussion was held with her or her responsible party to determine her wishes related to her code status prior to the surveyor's discussion with the facility on June 30, 2022, at 2:22 PM.

The facility failed to determine Resident 2's wishes related to code status prior to obtaining a physician's order for code status.

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

28 Pa. Code 201.29(a) Resident rights

28 Pa. Code 211.5(f) Clinical records



 Plan of Correction - To be completed: 08/04/2022

1. Resident 2 had a POLST completed.
2. An audit of current residents completed to ensure residents have advance directive discussion.
3. Licensed nursing staff will be educated on formulating advance directives.
4. Nursing unit managers or designee will complete weekly audits x3 and monthly x3 of new residents to ensure advance directive discussions have been completed.

483.12(b)(1)-(3) REQUIREMENT Develop/Implement Abuse/Neglect Policies: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(b) The facility must develop and implement written policies and procedures that:

§483.12(b)(1) Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property,

§483.12(b)(2) Establish policies and procedures to investigate any such allegations, and

§483.12(b)(3) Include training as required at paragraph §483.95,
Observations:

Based on review of select facility policies and procedures, employee personnel records, and staff interviews, it was determined that the facility failed to implement an abuse prohibition policy that required a thorough investigation of prospective employee's employment history for two of five newly hired employees reviewed (Employees 3 and 4).

Findings include:

In accordance with Act 13 Elder Abuse Mandatory Reporting and Act 169 Criminal Background Checks, nursing facilities are required to obtain a criminal background check on all newly hired employees. Facilities are required to obtain the Pennsylvania State Police background check on all prospective employees. If the prospective employee does not have continuous residency in Pennsylvania for two years prior to employment, then the facility is required to obtain a Federal Bureau of Investigation (FBI) national criminal history record check.

The policy titled, "Freedom from Abuse, Neglect, and Exploitation" last reviewed without changes on June 1, 2022, revealed the purpose was to keep the residents free from abuse, neglect, and corporal punishment of any kind by any person. The facility will provide a safe resident environment and protect the residents from abuse.

The partial policy section provided by the facility titled "Criminal Background Check," indicated that if an applicant/employee had not been a resident of the Commonwealth of Pennsylvania for two years immediately preceding the application date for employment the facility will obtain an FBI criminal history check.

Review of Employee 3's, registered nurse, personnel file revealed that the facility hired Employee 3 on May 4, 2022. There was no documented evidence in Employee 3's personnel file that Employee 3 attested to living in the Commonwealth of Pennsylvania for a continuous two years prior to employment. There was no evidence that the facility obtained an FBI criminal history check for Employee 3.

Review of Employee 4's, nurse aide, personnel file revealed that the facility hired Employee 4 on April 6, 2022. There was no documented evidence in Employee 4's personnel file that Employee 4 attested to living in the Commonwealth of Pennsylvania for a continuous two years prior to employment. There was no evidence that the facility obtained an FBI criminal history check for Employee 4.

Interview with Employee 5, Director of Human Resources, on July 1, 2022, at 2:30 PM confirmed that the facility did not obtain a residency attestation or FBI check on Employees 3 and 4.

The above findings were reviewed with the Nursing Home Administrator on July 1, 2022, at 2:35 PM.

28 Pa. Code 201.19 Personnel policies and procedures

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


 Plan of Correction - To be completed: 08/04/2022

1. Employees 3 and 4 have signed attestation forms and required background checks completed.
2. Audit completed of new hires past 45 days to ensure background checks were completed.
3. Human Resources Director will be educated to ensure background checks are completed prior to orientation of new staff members.
4. NHA or designee will audit new staff for completion of background checks weekly x3 and monthly x3.

483.24(a)(1)(b)(1)-(5)(i)-(iii) REQUIREMENT Activities Daily Living (ADLs)/Mntn Abilities: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.
§483.24(a) Based on the comprehensive assessment of a resident and consistent with the resident's needs and choices, the facility must provide the necessary care and services to ensure that a resident's abilities in activities of daily living do not diminish unless circumstances of the individual's clinical condition demonstrate that such diminution was unavoidable. This includes the facility ensuring that:

§483.24(a)(1) A resident is given the appropriate treatment and services to maintain or improve his or her ability to carry out the activities of daily living, including those specified in paragraph (b) of this section ...

§483.24(b) Activities of daily living.
The facility must provide care and services in accordance with paragraph (a) for the following activities of daily living:

§483.24(b)(1) Hygiene -bathing, dressing, grooming, and oral care,

§483.24(b)(2) Mobility-transfer and ambulation, including walking,

§483.24(b)(3) Elimination-toileting,

§483.24(b)(4) Dining-eating, including meals and snacks,

§483.24(b)(5) Communication, including
(i) Speech,
(ii) Language,
(iii) Other functional communication systems.
Observations:

Based on resident and staff interview, and clinical record review, it was determined that the facility failed to implement a restorative nursing program for one of one resident reviewed for rehabilitation concerns (Resident 44).

Findings include:

In an interview with Resident 44 on June 29, 2022, at 10:59 AM, the resident stated he was admitted to the facility in March 2022, and had three weeks of therapy, and was told that someone would continue to work with him walking in the hallway. Resident 44 stated it has been four months and it "hasn't happened yet," and he wants to get well enough to move near his daughter and stated he "can't be on a kidney transplant list until he is stronger."

Clinical record review for Resident 44 revealed an active plan of care, which indicated the resident requires a restorative program related to unsteady gate, and to encourage the resident to participate in restorative programs, both initiated on March 31, 2022.

A review of Resident 44's physical therapy discharge instructions dated March 30, 2022, revealed the resident was to start a restorative ambulation program to ambulate with a rolling walker 120-200 feet supervised 5-7 times a week.

There was no evidence staff started Resident 44 on a restorative ambulation program that therapy initiated from March 30, 2022, until June 28, 2022, after it was brought to the facility's attention by the surveyor.

Interview with the Director of Nursing on July 1, 2022, at 12:22 PM confirmed that that facility did not initiate or complete a restorative nursing program for ambulation for Resident 44 from March 30, 2022, until June 28, 2022.

483.24 (a)(1) Services to maintain activities of daily living

28 Pa. Code 211.11(d) Resident care plan

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


 Plan of Correction - To be completed: 08/04/2022

1. Facility reviewed restorative nurse program for Resident 44. Resident able to meet goals and will continue with RNP.
2. Review of residents on RNP to ensure goals are being met.
3. Licensed nursing staff will be educated on level of participation and documentation of restorative nurse programming. Unit managers will review RNP monthly to ensure participation and goals are being met. Therapy will be educated on developing RNPs.
4. Unit managers or designee will audit RNPs weekly x3 and monthly x3.

483.25(k) REQUIREMENT Pain Management:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
§483.25(k) Pain Management.
The facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences.
Observations:

Based on clinical record review, review of select facility policies, and staff and resident interview, it was determined that the facility failed to ensure the highest practicable pain management for one of four residents reviewed (Resident 54).

Findings include:

The facility policy entitled "Pain Management," last reviewed on June 1, 2022, revealed a licensed nurse will complete a pain evaluation upon admission, readmission, quarterly, and as needed for each resident. A plan of care for pain management will be initiated, if indicated, to decrease or eliminate pain using pharmacological and/or non-pharmacological approaches. Resident preferences for the method(s) used for pain management will be respected. As needed pain medications will be administered according to physician orders. If the as needed pain medication is ineffective, the physician will be informed immediately for further interventions/orders. The physician will be notified of the need to evaluate pain management when multiple use of as needed medications is needed.

Interview with Resident 54 on June 28, 2022, at 11:56 AM revealed that she has pain that is worse when she is on her bottom. She indicated that she takes tramadol (a medication used to treat moderate to severe pain) for pain, but she is not on a routine dose of pain medication. She stated that she does not get out of bed or go for a shower because the pain makes it too uncomfortable to sit in a wheelchair for any length of time.

Review of Resident 54's medication administration record (MAR, documentation of medications administered) from May 11, 2022, through June 29, 2022, revealed an order for Tramadol HCI 50 milligrams (mg) give one tablet by mouth every four hours as needed for pain level 7-10 on a 1-10 scale with 10 being the worst pain.

Further review of Resident 54's MAR from May 11, 2022, through June 29, 2022, revealed that Resident 54 received the as needed Tramadol 50 mg 52 times. There was no evidence in the clinical record that Resident 54's physician was notified regarding her multiple use of as needed pain medication or the ineffectiveness of her current pain regimen.

Interview with the Director of Nursing on June 30, 2022, at 2:15 PM confirmed the above noted findings related to pain management for Resident 54.

The facility failed to ensure the highest practicable pain management for Resident 54.

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

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



 Plan of Correction - To be completed: 08/04/2022

1. Met with Resident 54 relating to pain management. Resident declined knee injection, was placed on routine Tramadol and continues with prn pain medications along with non-pharmaceutical interventions to maintain pain goal.
2. Audit of residents receiving prn pain medications to ensure pain goals are met. Pain UDAs to be conducted on admission, quarterly, and as needed.
3. Licensed nursing staff will be educated on monitoring pain scores qshift and notifying the provider.
4. Unit managers or designee will audit residents weekly x3 and monthly x3.

483.30(c)(1)-(4) REQUIREMENT Physician Visits-Frequency/Timeliness/Alt NPP: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.
§483.30(c) Frequency of physician visits
§483.30(c)(1) The residents must be seen by a physician at least once every 30 days for the first 90 days after admission, and at least once every 60 thereafter.

§483.30(c)(2) A physician visit is considered timely if it occurs not later than 10 days after the date the visit was required.

§483.30(c)(3) Except as provided in paragraphs (c)(4) and (f) of this section, all required physician visits must be made by the physician personally.

§483.30(c)(4) At the option of the physician, required visits in SNFs, after the initial visit, may alternate between personal visits by the physician and visits by a physician assistant, nurse practitioner or clinical nurse specialist in accordance with paragraph (e) of this section.
Observations:

Based on clinical record review and resident and staff interview, it was determined that the facility failed to ensure that a resident's physician made timely physician visits for one of one resident reviewed (Resident 44).

Findings include:

In an interview with Resident 44 on June 29, 2022, at 10:59 AM, the resident stated he has not been physically seen by a physician, nurse practitioner, or physician assistant in four months. Resident 44 stated he saw a man when he was first admitted but no one since. Resident 44 stated he had lots of questions for a doctor.

Clinical record review for Resident 44 revealed Resident 44 was admitted to the facility on March 4, 2022, and an initial physician assessment was completed on March 5, 2022. There was no evidence the resident had a physician visit, nurse practitioner, or physician's assistant visit at the facility since March 5, 2022.

The above information was reviewed with the Nursing Home Administrator and Director of Nursing on June 29, 2022, at 2:00 PM.

The facility failed to ensure timely (every 30 days after initial admission to the facility) physician visits for Resident 44.

28 Pa. Code 211.2 (a) Physician services


 Plan of Correction - To be completed: 08/04/2022

1. Physician visit with Resident 44 occurred on 6/29/2022.
2. Audit of physician visits past 45 days to ensure timely visits have been conducted.
3. Educate Medical Records director to track physician visits to ensure they are conducted in a timely manner. Educate physicians on physician visit regulation.
4. Medical records director will audit physician visits weekly x3 and monthly x3.

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, review of select facility policies and procedures, and staff interview, it was determined that the facility failed to ensure a medication error rate below five percent (Resident 35).

Findings include:

The facility's medication error rate was 6.25 percent based on 32 medication opportunities with two medication errors.

The policy entitled "Administering Medications," last approved on June 1, 2022, indicates that medications must be administered in accordance with the (physician) orders. The individual administering the medications must check the label to verify the right medication, right dosage, right time, and the right method of administration before giving the medication.

Observation of a medication administration pass on June 28, 2022, at 8:00 AM revealed Employee 1, licensed practical nurse, administering Metformin (treats diabetes) ER (extended release) 500 mg (milligrams) to Resident 35. Employee 1 indicated that Resident 35 keeps his Saline Nasal Spray in his room to administer himself. Review of Resident 35's clinical record revealed a physician's order dated December 22, 2021, that indicated the Saline Nasal Spray 0.65% nasal gel, was to be administered in each nostril three times a day. The physician order for Resident 35's nasal spray did not indicate he self-administered.

Employee 1 crushed the Metformin 500 mg tablet prior to administering it to Resident 35. The label for the Metformin clearly indicated that the medication was not to be crushed. Employee 1 did not administer the saline nasal spray to Resident 35. Review of Resident 35's Medication Administration Record (MAR, a form used to document the administration of medications) dated June 2022, indicated that Employee 1 signed off on Resident 35's saline nasal spray to indicate that she administered the spray, when it was omitted.

Interview with the Administrator and the Director of Nursing, on June 30, 2022, at 2:00 PM, acknowledged the above findings.

483.45(f) Medication Errors
Previously cited 7/16/21

28 Pa. Code 211.10(a) Resident care policies

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


 Plan of Correction - To be completed: 08/04/2022

1. Employee 1 educated on the 6 rights of medication administration. Nasal spray will now be administered by licensed staff. Resident 35 showed no signs or symptoms of hyper/hypoglycemia. Provider made aware.
2. Audit of residents receiving Metformin and of residents self-administering nasal spray to ensure Metformin is not being crushed and nasal spray is being administered.
3. Educate licensed nursing staff on the 6 rights of medication administration.
4. IP/Staff Educator or designee will audit med passes to ensure the 6 rights of medication rights are being followed and the med error rate is less than 5% weekly x3 and monthly x3.

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 and staff interview, it was determined that the facility failed to secure medications on one of three nursing units (Second Floor Nursing Unit, Resident 113).

Findings include:

Observation of the Second floor Nursing Unit on June 28, 2022, at 7:45 AM revealed four medication cards sitting on top of a cabinet. The medications were accessible to other non-licensed staff, visitors, and residents. The medication cards were labeled with Resident 113's information and contained the following medications:

Coreg (treats high blood pressure) 12.5 mg (milligrams)
Atorvastatin (treats high cholesterol) 40 mg
Lisinopril (treats high blood pressure) 40 mg
Glipizide (regulates blood sugars) 5 mg

Interview with Employee 6, licensed practical nurse, on June 28, 2022, at 8:15 AM confirmed that the medications should have been in a secured room.

28 Pa. Code 211.9 (k) Pharmacy services

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


 Plan of Correction - To be completed: 08/04/2022

1. Resident 113 medication cards returned to medication room.
2. Sweep of facility conducted to ensure no medication cards were outside of appropriate medication storage areas.
3. Licensed nursing staff will be educated on proper procedure for returning or disposing discontinued medications.
4. Unit managers or designee will complete audit of facility to ensure no medication cards are outside of appropriate medication storage weekly x3 and monthly x3.

483.20(f)(5), 483.70(i)(1)-(5) REQUIREMENT Resident Records - Identifiable Information: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.
§483.20(f)(5) Resident-identifiable information.
(i) A facility may not release information that is resident-identifiable to the public.
(ii) The facility may release information that is resident-identifiable to an agent only in accordance with a contract under which the agent agrees not to use or disclose the information except to the extent the facility itself is permitted to do so.

§483.70(i) Medical records.
§483.70(i)(1) In accordance with accepted professional standards and practices, the facility must maintain medical records on each resident that are-
(i) Complete;
(ii) Accurately documented;
(iii) Readily accessible; and
(iv) Systematically organized

§483.70(i)(2) The facility must keep confidential all information contained in the resident's records,
regardless of the form or storage method of the records, except when release is-
(i) To the individual, or their resident representative where permitted by applicable law;
(ii) Required by Law;
(iii) For treatment, payment, or health care operations, as permitted by and in compliance with 45 CFR 164.506;
(iv) For public health activities, reporting of abuse, neglect, or domestic violence, health oversight activities, judicial and administrative proceedings, law enforcement purposes, organ donation purposes, research purposes, or to coroners, medical examiners, funeral directors, and to avert a serious threat to health or safety as permitted by and in compliance with 45 CFR 164.512.

§483.70(i)(3) The facility must safeguard medical record information against loss, destruction, or unauthorized use.

§483.70(i)(4) Medical records must be retained for-
(i) The period of time required by State law; or
(ii) Five years from the date of discharge when there is no requirement in State law; or
(iii) For a minor, 3 years after a resident reaches legal age under State law.

§483.70(i)(5) The medical record must contain-
(i) Sufficient information to identify the resident;
(ii) A record of the resident's assessments;
(iii) The comprehensive plan of care and services provided;
(iv) The results of any preadmission screening and resident review evaluations and determinations conducted by the State;
(v) Physician's, nurse's, and other licensed professional's progress notes; and
(vi) Laboratory, radiology and other diagnostic services reports as required under §483.50.
Observations:

Based on clinical record review and staff interview, it was determined that the facility failed to ensure accurate and complete clinical documentation for one of 24 residents reviewed (Resident 35).

Findings include:

Review of Resident 35's clinical record revealed a physician order dated December 22, 2019, that indicated a Saline Nasal Spray 0.65% gel could be kept at his bedside.

During a meeting with the Administrator and Director of Nursing on June 30, 2022, at 2:00 PM it was revealed that Resident 35 was not to keep the nasal spray medication at his bedside, and that nursing staff revised the nasal spray order on June 29, 2022, to indicate that.

Review of Resident 35's clinical record after the medication revision on June 29, 2022, revealed that the term "may keep at bedside" was gone, but there was now no history of what the medication indicated previously. This revision also changed the verbiage regarding the nasal spray order on all of Resident 35's previous electronic Medication Administration Records (MAR, a form used to document the administration of medications) since his admission. There was no longer documented evidence to indicate that Resident 35's saline nasal spray directed "may keep at bedside" once the revision was done.

Interview with the Director of Nursing on July 1, 2022, at 11:30 AM indicated that Resident 35's nasal spray should have been discontinued first, then reentered into the electronic record as a new medication. Revision of the verbiage of the medication order should not have been an option because it does not accurately reflect what took place.

483.70 (i)(1)(ii) Medical Records
Previously cited 7/16/21

28 Pa. Code 211.5 (f) Clinical records

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


 Plan of Correction - To be completed: 08/04/2022

1. Resident 35's order now reflects resident is not able to self-administer nasal spray.
2. Audit of resident MARs/TARs completed to ensure proper revision of orders.
3. Licensed nursing staff will be educated when an order update for revision is acceptable and when a new order needs entered to account for a revision.
4. Unit manager or designee will complete audit of 5 resident MARs/TARs weekly x3 and monthly x3.

483.80 (h)(1)-(6) REQUIREMENT COVID-19 Testing-Residents & 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.
§483.80 (h) COVID-19 Testing. The LTC facility must test residents and facility staff, including
individuals providing services under arrangement and volunteers, for COVID-19. At a minimum,
for all residents and facility staff, including individuals providing services under arrangement
and volunteers, the LTC facility must:

§483.80 (h)((1) Conduct testing based on parameters set forth by the Secretary, including but not
limited to:
(i) Testing frequency;
(ii) The identification of any individual specified in this paragraph diagnosed with
COVID-19 in the facility;
(iii) The identification of any individual specified in this paragraph with symptoms
consistent with COVID-19 or with known or suspected exposure to COVID-19;
(iv) The criteria for conducting testing of asymptomatic individuals specified in this
paragraph, such as the positivity rate of COVID-19 in a county;
(v) The response time for test results; and
(vi) Other factors specified by the Secretary that help identify and prevent the
transmission of COVID-19.

§483.80 (h)((2) Conduct testing in a manner that is consistent with current standards of practice for
conducting COVID-19 tests;

§483.80 (h)((3) For each instance of testing:
(i) Document that testing was completed and the results of each staff test; and
(ii) Document in the resident records that testing was offered, completed (as appropriate
to the resident’s testing status), and the results of each test.

§483.80 (h)((4) Upon the identification of an individual specified in this paragraph with symptoms
consistent with COVID-19, or who tests positive for COVID-19, take actions to prevent the
transmission of COVID-19.

§483.80 (h)((5) Have procedures for addressing residents and staff, including individuals providing
services under arrangement and volunteers, who refuse testing or are unable to be tested.

§483.80 (h)((6) When necessary, such as in emergencies due to testing supply shortages, contact state
and local health departments to assist in testing efforts, such as obtaining testing supplies or
processing test results.
Observations:

Based on standards established by the Centers for Medicare and Medicaid Services (CMS), review of the facility's COVID-19 employee testing, and staff interview, it was determined that the facility failed to conduct testing of asymptomatic employees per parameters set forth by the Secretary for one of three employees reviewed (Employee 2).

Findings include:

A review of Center for Clinical Standards and Quality/Survey & Certification Group, Ref: QSO - 20-38-NH dated August 26, 2020, last revised March 10, 2022, revealed a final ruling, which establishes Long-Term Care (LTC) Facility Testing Requirements for Staff and Residents. Specifically, facilities are required to test residents and staff, including individuals providing services under arrangement and volunteers, for COVID-19 based on parameters set forth by the Secretary of Health and Human Services.

The guidance indicates that routine staff testing for staff who are not up to date with COVID-19 immunizations should be based on the extent of the virus in the community; therefore, facilities should use their community transmission level as the trigger for staff testing frequency. Table 2 (of this QSO-20-38 document) should be referenced for guidance on testing frequency:

Low community COVID-19 transmission in the past week, testing is not recommended.

Moderate COVID-19 transmission in the past week, requires testing once a week.

Substantial COVID-19 transmission in the past week, requires twice a week testing.

High COVID-19 transmission in the past week, requires twice a week testing.

The facility should test all staff, who are not up to date, at the frequency prescribed in the routine testing table based on the level of community transmission reported in the past week. Facilities should monitor their level of community transmission every other week (e.g., first and third Monday of every month) and adjust the frequency of performing staff testing according to the table referenced above.

Review of testing guidelines for the facility revealed the facility would test staff who are not up to date with COVID-19 vaccinations twice a week with a rapid test when the facility was not in outbreak mode, and the county COVID rates would be monitored for continued testing as needed.

Review of the facility's tracking of county transmission rates of COVID-19, revealed the facility had a high rate of transmission the weeks of May 31, June 6, June 13, June 20, and substantial the week of June 27, 2022.

In an interview with Employee 2, laundry aide, on June 28, 2022, at 11:00 AM, as the employee was putting laundry away in resident rooms on the third-floor nursing unit, Employee 2 indicated she was recently hired on June 3, 2022, and was not vaccinated for COVID-19.

A review of the facility's COVID-19 vaccine matrix revealed Employee 2 had been granted an exemption from receiving the COVID-19 vaccination.

Upon request of Employee 2's COVID-19 testing results since her hire date of June 3, 2022, revealed only two tests dated June 19, and 23 with negative results. An additional test was completed on July 1, 2022, with negative results, after it was brought to the facility's attention by the surveyor.

In an interview with Employee 2, on July 1, 2022, at 1:48 PM, Employee 2 stated she was informed upon hire that she did not have to test for COVID-19 since she worked in laundry and did not have resident contact. Employee 2 stated she was tested on June 19, 2022, because she "wasn't feeling well," and did not recall testing on June 23, 2022, as a report indicated. Employee 2 stated she was only tested twice, on June 19, and then today, July 1, 2022. Employee 2 then indicated she was to now be tested once a week on a Tuesday or Thursday.

In an interview with the Nursing Home Administrator on July 1, 2022, at 1:45 PM it was confirmed Employee 2, who was not up to date with COVID-19 vaccinations, had not been tested twice weekly since her hire date of June 3, 2022, despite the facility being in a county with a COVID-19 transmission level of high or substantial from her hire date to present. The facility failed to follow guidance set forth by CMS/CDC to ensure the facility continues to respond effectively to the COVID-19 Public Health Emergency.

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

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

28 Pa. Code: 211.12 (c) Nursing services

28 Pa. Code 211.12(a)(d) Resident care policies


 Plan of Correction - To be completed: 08/04/2022

1. Employee 2 was tested and results were negative.
2. Audit conducted to ensure biweekly testing was completed by appropriate staff past 7 days.
3. Educate Infection Preventionist on tracking covid testing of staff and educate staff on testing policy.
4. DON or designee will complete audit of testing log weekly x3 and monthly x3.

§ 201.18(b)(1)-(3) LICENSURE Management.:State only Deficiency.
(b) The governing body shall adopt and enforce rules relative to:

(1) The health care and safety of the residents.

(2) Protection of personal and property rights of the residents, while in the facility, and upon
discharge or after death.

(3) The general operation of the facility.
Observations:

Based on closed clinical record review and staff interview, it was determined that the facility failed to account for the disposition of personal property for one of three residents reviewed (Resident 115).

Findings include:

Review of Resident 115's closed clinical record revealed that he was admitted to the facility on August 7, 2019, and discharged on April 11, 2022. There was no documented evidence in Resident 115's closed clinical record to indicate that the facility ensured disposition of his personal belongings upon discharge after living at the facility for almost three years.

Interview with the Director of Nursing on July 1, 2022, at 2:15 PM, confirmed the above findings.


 Plan of Correction - To be completed: 08/04/2022

1. Resident 115's belongings sheet located.
2. Medical records director to audit past 45 days of discharged resident belongings sheets to ensure completion.
3. Educate medical records director on ensuring resident belonging sheet completed within 30 days. Licensed nursing staff will be educated to ensure property sheets are reviewed and signed upon discharge.
4. Medical records director or designee will audit discharged residents belongings sheets weekly x3 and monthly x3.


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