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  127 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.
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, and Civil Rights Compliance Survey, and an Abbreviated Survey to investigate two Complaints completed on May 23, 2024, 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:


483.25 REQUIREMENT Quality of Care:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
§ 483.25 Quality of care
Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices.
Observations:

Based on clinical record review, observation, and staff interview, it was determined that the facility failed to provide the highest practicable care regarding physician ordered weights, medications, and vital signs for four of 25 residents (Resident 3, 41, 67, and 88).

Findings include:

Review of Resident 3's clinical documentation revealed current physician orders for the following:

On September 11, 2023, staff were to complete a daily weight every night shift and must be done before breakfast. Staff were to contact the physician if the weight dropped below 320 pounds.

On March 19, 2024, call the physician if their weight changes two to three pounds in one day or five pounds in one week, every day and evening shift for monitoring.

Review of Resident 3's clinical documentation revealed no documented weights on the following dates:

February 23, 2024
February 24, 2024

May 21, 2024

Further review of Resident 3's clinical documentation revealed that there was no physician notification regarding their weight being below 320 pounds on the following dates:

April 23, 24, 25, 26, 27, 28, and 29, 2024
May 6, 7, 9, 10, 11, 12, 13, 14, 15, 16, 17, and 18, 2024

Further review of Resident 3's clinical documentation revealed that there was no physician notification regarding their weight change of two to three pounds in a day or a five pounds in one week on the following dates:

March 21, 2024, 321.5 pounds to March 22, 2024, 325.5 pounds, 4-pound increase
March 27, 2024, 324.0 pounds to March 28, 2024, 327.0, 3-pound increase
March 28, 2024, 327.0 pounds to March 29, 2024, 323.0 pounds, 4-pound decrease
March 29, 2024, 323.0 pounds to March 30, 2024, 326.5 pounds, 3.5-pound increase

April 5, 2024, 325.0 pounds to April 6, 2024, 321.8 pounds, 3.2-pound decrease
April 9, 2024, 321.0 pounds to April 10, 2024, 324.0 pounds, 3-pound decrease
April 10, 2024, 324.0 pounds to April 11, 2024, 337.0 pounds, 13-pound increase
April 22, 2024, 320.5 pounds to April 23, 2024, 315.8 pounds, 4.7-pound decrease
April 27, 2024, 315.0 pounds to April 28, 2024, 317.5 pounds, 2.5-pound increase
April 29, 2024, 316.8 pounds to April 30, 2024, 320.0 pounds, 3.2-pounds increase

May 6, 2024, 319.5 pounds to May 7, 2024, 316.5 pounds, 3-pound decrease
May 12, 2024, 317.5 pounds to May 13, 2024, 319.8 pounds, 2.3-pound increase
May 17, 2024, 314.0 pounds, to May 18, 2024, 318.0 pounds, 4-pound increase

Clinical record review for Resident 41 revealed the following physician orders:

On November 29, 2023, for staff to monitor their blood sugar twice daily (BID) and notify the provider if it was less than 80 mg/dL or greater than 300 mg/dL (milligrams/deciliter).

On April 3, 2024, Lantus (insulin) 100 units/milliliter (u/ml) inject 66 units subcutaneously (SQ) at bedtime (HS) for Diabetes. HOLD Lantus if (Resident 41's) blood sugar was less than 120 milligrams/deciliter (mg/dL)

Review of Resident 41's clinical documentation revealed the following:

On March 24, 2024, at 9:00 PM, their blood sugar was not documented.
On March 26, 2024, at 6:00 AM, their blood sugar was not documented.
On March 29, 2024, at 9:00 PM, their blood sugar was 40 mg/dL.
On March 31, 2024, at 6:00 AM, their blood sugar was not documented.

On April 11, 2024, at 6:00 AM, their blood sugar was not documented.
On April 15, 2024, at 6:00 AM, their blood sugar was not documented.
On April 16, 2024, at 6:00 AM, their blood sugar was 78 mg/dL.
On April 17, 2024, at 6:00 AM, their blood sugar was 79 mg/dL.
On April 23, 2024, at 6:00 AM, their blood sugar was not documented.
On April 29, 2024, at 6:00 AM, their blood sugar was 77 mg/dL.
On April 30, 2024, at 6:00 AM, their blood sugar was 112 mg/dL.

On May 3, 2024, at 6:00 AM, their blood sugar was not documented.
On May 8, 2024, at 9:00 PM, their blood sugar was 106 mg/dL. Staff administered 66 units of Lantus though the order indicated to hold if Resident 41's blood sugar was less than 120 mm/dL.
On May 9, 2024, at 9:00 PM, their blood sugar was 88 mg/dL. Staff administered 66 units of Lantus though the order indicated to hold if Resident 41's blood sugar was less than 120 mm/dL.
On May 16, 2024, at 6:00 AM, their blood sugar was 78 mg/dL.
On May 16, 2024, at 9:00 PM, their blood sugar was 118 mg/dL. Staff administered 66 units of Lantus though the order indicated to hold if Resident 41's blood sugar was less than 120 mm/dL.
On May 21, 2024, at 6:00 AM, their blood sugar was 72 mg/dL.

There was no documentation indicating that staff notified Resident 3's physician regarding their weight as ordered or Resident 41's blood sugar levels being outside of the prescribed parameters prior to surveyor identification.

The surveyor reviewed the above information during an interview on May 22, 2024, 3:00 PM with the Nursing Home Administrator and Director of Nursing.

Clinical record review for Resident 88 revealed a current care plan that revealed the resident has constipation related to decreased mobility, diminished appetite, poor fiber intake, and poor fluid intake. Some interventions included the following: follow facility bowel protocol for bowel management and record bowel movement pattern each day and describe the amount, color, and consistency.

Clinical record review for Resident 88 revealed the following physician orders to promote bowel movements:

Gavilax Powder (Polyethylene Glycol 3350, medication used to treat constipation) give 17 grams by mouth as needed for day three with no bowel movement.
Enulose Solution 10 grams per 15 ml (a medication used to treat constipation) give 45 ml by mouth every 96 hours as needed for day four with no bowel movement.
Dulcolax suppository (Bisacodyl, a laxative medication used to relieve constipation) insert 10 milligrams rectally as needed for day five with no bowel movement.

Review of bowel elimination records for Resident 88 revealed that staff documented no bowel movements for May 15, 16, 17, 18, and 19, 2024.

There was no indication that staff offered (as per the physician orders and bowel management protocol), or Resident 88 refused, any PRN medications.

The above information for Resident 88 was reviewed in a meeting with the Nursing Home Administrator and Director of Nursing on May 22, 2024, at 2:00 PM.

Clinical record review for Resident 67 revealed a nurse practitioner progress note dated December 6, 2023, at 9:42 AM that indicated the resident was evaluated for hypotension (low blood pressure). The diagnosis was documented as hypotension and the treatment and plan of care included vital signs for three days.

A review of the vital signs flow sheet for resident 67 revealed the resident had a blood pressure taken on December 5, 2023, at 4:10 PM that noted a low blood pressure. The next set of vital signs was not taken until December 15, 2023, at 10:40 AM.

Facility documentation for Resident 67 revealed a "Physician/Provider Update" form that had a written order signed by the medical provider and a licensed practical nurse and dated December 6, 2023, that indicated "VS x3 days" (vital signs for three days).

Facility documentation for Resident 67 revealed another "Physician/Provider Update" form dated December 15, 2023, that noted "previously ordered and not completed." The order again noted "VS x3 days" (vital signs for three days).

Further review of the medical record for Resident 67 revealed no further evidence that the vital signs requested on December 6, 2023, were completed until December 15, 2023.

An interview with the Director of Nursing on May 23, 2024, at 10:09 AM revealed that the vital signs were not entered into the electronic health record (EHR) of Resident 67 as an order, so they were not completed.

The above information for Resident 67 was reviewed with the Nursing Home Administrator on May 23, 2024, at 2:00 PM.

483.25 Quality of Care
Previously cited 6/16/23

28 Pa. Code 211.10(c) Resident care policies

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


 Plan of Correction - To be completed: 07/09/2024

Unable to retroactively correct Rt 3's missed weights, Rt 88's missed bowel protocol, and Rt 67's missed vital signs.

Physician was notified regarding Rt 3's weight changes.

Physician was notified regarding Rt 41s blood sugar being outside of parameters.

UM/designee will perform a house audit to identify any residents on their floor with orders for daily weights, vitals, blood sugars & related physician notification, as well as any residents bowel tracking in the last 10 days.

ADON/designee will provide education to licensed clinical staff regarding following orders related to MD notification as well as following physician orders.

Unit managers will perform a random audit weekly x8 weeks of physician orders related to vitals, weight changes, blood sugar and related notifications to ensure compliance.

Results of these audits will be presented to the QA steering committee monthly x 2 months, at which time the committee will determine the need for future audits.
483.60(i)(1)(2) REQUIREMENT Food Procurement,Store/Prepare/Serve-Sanitary: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(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 the facility failed to store food in a safe and sanitary manner in the facility's main kitchen.

Findings include:

An observation of the facility's main kitchen on May 20, 2024, at 8:00 AM revealed the following:

The floor in the dry storage room was dirty with black marks and sticky. There were pieces of cardboard, plastic spoons and forks, and a coffee mate packet noted on the floor. On two food storage units there were black dirt particles on the top shelf of each. Employee 4, Dietary cook, indicated that the black particles were from the air-conditioning unit when they turn it on. The unit was not on at the time of the observation.

The refrigerator in the main kitchen, located to the left of the door to the dry storage area (as you are looking at it), had a bag of lettuce, waffles in plastic packaging, and sausage patties wrapped in foil with no date to indicate when they were placed in the refrigerator or an expiration date.

The bottom shelf of the freezer located next to the coffee pot had spillage noted on it with cardboard stuck to it.

The refrigerator beside the handwashing sink had two bags of cabbage with a use by date of May 11, 2024.

The second refrigerator located beside the handwashing sink had a sandwich and a salad with no date on it. Employee 4 indicated that they were not prepared that morning and he was unsure when they were from.

Review of the temperature logs for the dishwasher revealed that temperatures were logged for lunch time on the date of observation, and it was only 8:15 AM.

Review of the refrigerator temperatures for all three refrigerators (beverage, line, and salad) had no temperatures logged for evening shift on the dates from May 14-17, 2024.

Review of the temperature logs for all three freezers (ice cream, cooks, and vegetable) had no temperatures logged for evening shift from May 14-17, 2024.

All concerns were reviewed at the time of the observations with Employee 4.

The Nursing Home Administrator was made aware of the above noted concerns on May 21, 2024, at 2:42 PM.

42 CFR 483.60(i)(2) Store/Prepare/Distribute-Sanitary
Previously cited 7/25/23

28 Pa. Code 201.14 (a) Responsibility of licensee



 Plan of Correction - To be completed: 07/09/2024

Dry storage room was cleaned. Lettuce, sausage, waffles, cabbage, salad and sandwich were disposed of. Freezer was cleaned.

Residents were not affected by issues noted above.

Dietary manager/designee will provide education to dietary staff regarding cleaning procedures, labeling and dating, and completing temperature logs for the refrigerators and dish machine. NHA/designee will complete weekly audits of the kitchen x 4 weeks, then monthly x 2 months to ensure compliance with the areas noted above.

Results of these audits will be presented to the QA steering committee monthly x 3 months, at which time the committee will determine the need for future audits.
483.45(c)(3)(e)(1)-(5) REQUIREMENT Free from Unnec Psychotropic Meds/PRN Use: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.
§483.45(e) Psychotropic Drugs.
§483.45(c)(3) A psychotropic drug is any drug that affects brain activities associated with mental processes and behavior. These drugs include, but are not limited to, drugs in the following categories:
(i) Anti-psychotic;
(ii) Anti-depressant;
(iii) Anti-anxiety; and
(iv) Hypnotic

Based on a comprehensive assessment of a resident, the facility must ensure that---

§483.45(e)(1) Residents who have not used psychotropic drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record;

§483.45(e)(2) Residents who use psychotropic drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs;

§483.45(e)(3) Residents do not receive psychotropic drugs pursuant to a PRN order unless that medication is necessary to treat a diagnosed specific condition that is documented in the clinical record; and

§483.45(e)(4) PRN orders for psychotropic drugs are limited to 14 days. Except as provided in §483.45(e)(5), if the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she should document their rationale in the resident's medical record and indicate the duration for the PRN order.

§483.45(e)(5) PRN orders for anti-psychotic drugs are limited to 14 days and cannot be renewed unless the attending physician or prescribing practitioner evaluates the resident for the appropriateness of that medication.
Observations:

Based on clinical record review and staff interview, it was determined that the facility failed to ensure a resident's medication regime was free from potentially unnecessary medications for one of five residents reviewed (Resident 41).

Findings include:

Clinical record review for Resident 41 revealed the following physician orders:

Ordered on February 4, 2024, and discontinued on February 11, 2024, for Ativan 0.5 milligram (mg) by mouth PO every 8 hours as needed for increased anxiety.
Ordered on February 11, 2024, Ativan Oral Tablet 0.5 mg PO every 8 hours as needed for increased anxiety discontinue after 14 days nonuse.

Review of Resident 41's pharmacy recommendation dated February 8, 2024, revealed the pharmacist identified the concerns with the PRN Ativan and indicated for the physician to evaluate if the medication could be discontinued or if a 14 day stop date could be added. The physician's assistant responded on February 11, 2024, agreed with the pharmacist's recommendation, and indicated to "discontinue Ativan after 14 days non-use" (to be discontinued on February 25, 2024).

Review of Resident 41's February, March, April, and May 2024 MAR (medication administration record, a form to document medication administration) revealed the following:

Resident 41's PRN Ativan order continued throughout March, April, and May 2024, with staff continued administration noted. Staff administered it 17 times.

Staff did not attempt non-medicinal interventions 19 times prior to administering Resident 41's PRN Ativan on or after February 4, 2024.

There was 14 days of non-use noted between March 14, 2024, to April 3, 2024, and again on April 13, 2024, to April 27, 2024, if staff were to utilize/implement/identify the "14 days of non-use" as noted on Ativan PRN order dated February 11, 2024.

The surveyor reviewed the above for Resident 8 during an interview with the Nursing Home Administrator on May 22, 2024, at 1:35 PM.

483.45(c)(3)(e)(1)-(5) Free From Unnec Psychotropic Meds/prn Use
Previously cited 6/16/23

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

28 Pa. Code 211.10(a) Resident care policies

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


 Plan of Correction - To be completed: 07/09/2024

Unable to retroactively correct

Unit manager/designee will complete an audit of current residents with orders for prn psychotropic medication to ensure that appropriate stop dates are in place, as well as non-pharmacological interventions.

Unit manager/designee will complete random weekly audits x4 weeks, then monthly x 2 months, of residents on prn psychotropic medications to ensure that appropriate stop dates and non-pharmacological interventions are in place.

Results of these audits will be presented to the QA steering committee monthly x 3 months, at which time the committee will determine the need for future audits.
483.40(b)(3) REQUIREMENT Treatment/Service for Dementia: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.
§483.40(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 clinical record review and staff interview, it was determined that the facility failed to develop and implement individualized person-centered care plans to address dementia and cognitive loss displayed by two of three residents reviewed (Residents 34 and 87).

Findings include:

Clinical record review for Resident 34 revealed that the facility admitted her on January 4, 2024, with diagnoses including dementia (loss of memory, language, problem-solving, and other thinking abilities that interfere with daily life) with agitation. A review of her admission Minimum Data Set Assessment (MDS, a form completed at specific intervals to determine care needs) dated January 10, 2024, indicated that the facility assessed Resident 34 as having a diagnosis of dementia. The facility determined that a care plan for dementia and cognitive loss would be developed.

A review of Resident 34's care plan revealed that there was no indication that the facility had developed and implemented a person-centered care plan to address the resident's dementia and cognitive loss that would include direct care and activities that are focused on understanding, preventing, relieving, and accommodating a resident's distress or loss of abilities.

Clinical record review of Resident 87's diagnosis list revealed that he was diagnosed with dementia on October 1, 2022. A review of his significant change MDS dated May 3, 2024, indicated that the facility assessed him as having a diagnosis of dementia. The facility determined that a care plan for dementia and cognitive loss would be developed.

A review of Resident 87's care plan revealed that there was no indication that the facility developed and implemented a person-centered care plan to address Resident 87's dementia and cognitive loss that would include direct care and activities that are focused on understanding, preventing, relieving, and accommodating a resident's distress of loss of abilities related to his dementia.

These findings were reviewed with the Nursing Home Administrator and Director of Nursing during a meeting on May 22, 2023, at 2:12 PM for Residents 34 and 87.

483.40(b)(3) Dementia Treatment and Services
Previously cited 06/16/23.

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

28 Pa Code 211.11(d) Resident care plan


 Plan of Correction - To be completed: 07/09/2024

Unable to retroactively correct Rt 34 as resident has passed away. Rt 87's careplan has been updated.

Interdisciplinary care team will review current residents with dementia diagnoses who are experiencing cognitive loss. CTRS/designee will complete staff and family interviews with residents identified and update current resident careplans as appropriate.

ADON/designee will complete staff education related to dementia treatment and services. NHA/designee will complete random audits weekly x4 weeks, then monthly x2, of residents with dementia diagnoses to ensure that their careplans are individualized and appropriate.

Results of these audits will be presented to the QA steering committee monthly x 3 months, at which time the committee will determine the need for future audits.
483.25(m) REQUIREMENT Trauma Informed Care:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
§483.25(m) Trauma-informed care
The facility must ensure that residents who are trauma survivors receive culturally competent, trauma-informed care in accordance with professional standards of practice and accounting for residents' experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization of the resident.
Observations:

Based on clinical record review and staff interview, it was determined that the facility failed to identify triggers related to a resident's diagnosis of Post-Traumatic Stress Disorder, to provide culturally, competent, trauma-informed care, and to eliminate or mitigate re-traumatization for two of four residents reviewed for mood/behavior (Residents 93 and 112).

Findings include:

Clinical record review revealed the facility admitted Resident 93 on May 19, 2022, and added a diagnosis of Chronic Post Traumatic Stress Disorder (PTSD, a mental and behavioral disorder that develops related to a terrifying event) on October 9, 2022.

Review of a psychiatry note dated August 23, 2022, revealed Resident 93 had a history of premorbid PTSD (a vulnerability that can increase the severity of PTSD symptoms associated with previous trauma exposure when someone is exposed to new stressors).

Further review of Resident 93's clinical record there was no evidence that the facility identified Resident 93's history of trauma. A review of Resident 93's care plan revealed there were no identified triggers (everyday situations that cause a person to re-experience the traumatic event as if it was reoccurring).

Resident 93's clinical record contained no evidence the facility collaborated with the resident, and as appropriate, the resident's family, friends, and any other healthcare professionals (such as psychologists, and mental health professionals) to develop and implement individualized interventions.

Clinical record review revealed that the facility admitted Resident 112 on October 27, 2023, and added a diagnosis of PTSD on February 11, 2024.

Review of the psychiatry note dated February 5, 2024, revealed Resident 112 had a diagnosis of chronic PTSD. Further review of Resident 112's clinical record revealed there was no evidence that the facility identified Resident 112's history of trauma. A review of Resident 93's care plan revealed there were no identified triggers.

Resident 112's clinical record contained no evidence the facility collaborated with the resident, and as appropriate, the resident's family, friends, and any other healthcare professionals (such as psychologists, and mental health professionals) to develop and implement individualized interventions.

These findings were reviewed with the Nursing Home Administrator and Director of Nursing on May 22, 2024, at 2:30 PM.

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


 Plan of Correction - To be completed: 07/09/2024

Facility completed interviews to collaborate with providers& family members, identify triggers, and implement individualized interventions for Rt 93 & 112.

Address how the facility will identify other residents having the potential to be affected by the same deficient practice. How will the facility staff protect residents in similar situations?

The surveyor identified one or more residents with this immediate problem/concern. This means that there may be other residents who have the same immediate problems. Use this section to describe how you will identify those residents and what you will do. This correction, when possible should be immediate.

SS/designee will complete an audit of current residents to ensure that all residents with a dx of PTSD have a plan of care that addresses triggers, has been developed in collaboration with appropriate contacts & includes individualized interventions.

SS staff will receive re-education regarding required components of a trauma informed care plan.

NHA/designee will complete audits of new admissions to ensure that if a resident has a diagnosis of PTSD an appropriate care plan is developed.

Results of these audits will be presented to the QA steering committee monthly x 3 months, at which time the committee will determine the need for future audits.



483.25(k) REQUIREMENT Pain Management: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(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 review of facility policies, clinical record review, and staff interview, it was determined that the facility failed to provide the highest practicable care regarding physician ordered pain medications for four of four residents reviewed (Residents 3, 56, 96, and 123).

Findings include:

Review of Physiopedia's and Wikipedia's definition of the numeric pain rating scale (parameters) from zero to 10 indicated that no pain was identified as zero, mild pain was identified as one to three, moderate pain was identified as four to six, and severe pain was identified as seven to 10.

Clinical record review for Resident 3 revealed physician orders for the following pain medications:

Ordered on April 19, 2024, Acetaminophen (Tylenol, for mild pain) 325 milligrams (mg) 2 tablets by mouth (PO) every 4 hours as needed (PRN) for pain 1-10, not to exceed 3 grams per 24 hours.

Ordered on May 2, 2024, Oxycodone (for moderate to severe pain) 5 mg PO every 8 hours PRN for pancreatic pain.

There was no documentation that the facility identified which pain medication that staff were to administer for mild, moderate, and/or severe pain parameters, or that the facility identified that multiple medications were available for the same pain parameter.

Clinical record review for Resident 56 revealed physician orders for the following pain medications:

Ordered on October 19, 2023, Acetaminophen 650 mg PO every 6 hours PRN for arthritic pain.

Ordered on March 4, 2024, Tramadol (for moderate to severe pain) 50 mg PO every 6 hours PRN for pain 7-10.

Review of Resident 56's March, April, and May 2024 MAR (medication administration record, a form to document medication administration) revealed that staff administered the following PRN pain medications:

Acetaminophen 650 mg PO every 6 hours PRN for arthritic pain

March 5, 2024, at 8:53 PM for a pain level of 0.

May 12, 2024, at 11:06 AM for a pain level of 5.
May 13, 2024, at 4:13 AM for a pain level of 5.

Tramadol 50 mg PO every 6 hours PRN for pain 7-10

March 5, 2024, at 2:45 PM, for a pain level of 6.
March 6, 2024, at 7:39 PM, for a pain level of 0.
March 9, 2024, at 9:51 PM, for a pain level of 5.
March 11, 2024, at 8:06 PM, for a pain level of 3.
March 13, 2024, at 2:01 PM, for a pain level of 6.
March 16, 2024, at 7:59 PM, for a pain level of 0.
March 19, 2024, at 7:58 PM, for a pain level of 6.
March 21, 2024, at 7:53 PM, for a pain level of 5.
March 22, 2024, at 7:48 PM, for a pain level of 4.
March 25, 2024, at 6:50 PM, for a pain level of 6.
March 29, 2024, at 9:11 PM, for a pain level of 4.

April 5, 2024, at 9:17 PM, for a pain level of 5.
April 7, 2024, at 7:49 PM, for a pain level of 0.
April 9, 2024, at 8:21 PM, for a pain level of 0.
April 11, 2024, at 7:43 PM, for a pain level of 0.
April 13, 2024, at 4:04 PM, for a pain level of 3.
April 13, 2024, at 10:11 PM, for a pain level of 0.
April 18, 2024, at 4:03 PM, for a pain level of 0.
April 18, 24, at 10:44 PM, for a pain level of 4.
April 19, 2024, at 8:06 PM, for a pain level of 5.
April 23, 2024, at 4:01 PM, for a pain level of 4.
April 26, 2024, at 8:07 PM, for a pain level of 0.
April 28, 2024, at 7:09 PM, for a pain level of 3.

May 8, 2024, at 1:45 AM for a pain level of 6.
May 11, 2024, at 8:05 PM, for a pain level of 5.
May 12, 2024, at 10:20 PM, for a pain level of 3.
May 15, 2024, at 4:00 PM, for a pain level of 0.
May 18, 2024, at 8:17 PM, for a pain level of 5.
May 21, 2024, at 8:16 PM, for a pain level of 0.

Clinical record review for Resident 96 revealed physician orders for the following pain medications:

Ordered on October 14, 2022, Acetaminophen 650 mg PO every 6 hours PRN for pain 1-7, not to exceed 3 grams in 24 hours.

Ordered on September 11, 2023, Morphine Sulfate (for moderate to severe pain) 20 mg/milliliter (mg/ml) 0.25 ml PO every 2 hours PRN for pain 1-5 or dyspnea (difficulty breathing) and give 0.5 ml PO every 2 hours PRN severe pain 6-10 or dyspnea.

There was no documentation that the facility identified which pain medication that staff were to administer for mild, moderate, and/or severe pain parameters or that the facility identified that multiple medications were available for the same pain parameter.

Clinical record review for Resident 123 revealed physician orders for the following pain medications:

Ordered on May 3, 2024, Acetaminophen extra strength 500 mg 2 tablets via peg tube every 6 hours PRN for breakthrough pain 1-5.

Ordered on May 3, 2024, Percocet (for moderated to severe pain) 10-325 mg via peg tube every 4 hours PRN for pain 6-10.

Review of Resident 123's May 2024 MAR revealed that staff administered the following PRN pain medications:

Percocet 10-325 mg via peg tube every 4 hours PRN for pain 6-10

May 6, 2024, at 1:56 PM for a pain level of 0.
May 7, 2024, at 5:30 PM for a pain level of 3.
May 12, 2024, at 6:16 PM for a pain level of 0.
May 13, 2024, at 10:10 AM for a pain level of 5.
May 13, 2024, at 2:26 PM for a pain level of 5.
May 15, 2024, at 10:05 AM for a pain level of 5.
May 15, 2024, at 4:00 PM for a pain level of 0.
May 15, 2024, at 10:37 PM for a pain level of 3.
May 16, 2024, at 6:00 PM for a pain level of 4.
May 19, 2024, at 10:34 AM for a pain level of 5.
May 19, 2024, at 3:01 PM for a pain level of 5.

The surveyor reviewed the above pain information during an interview the Nursing Home Administrator and Director of Nursing on May 22, 2024, at 2:57 PM.

483.25(k) Pain Management
Previously cited 6/16/23

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


 Plan of Correction - To be completed: 07/09/2024

Unable to retroactively correct.

Unit manager/designee will complete an audit of all residents prn pain medication orders to ensure that all include a pain scale and that the scale is being followed.

ADON/designee will complete education with licensed clinical staff regarding administering prn pain medication per protocol.

Unit manager/designee will complete random audits weekly x 4, then monthly x 2 of residents receiving prn pain medication to ensure that parameters are followed.

Results of these audits will be presented to the QA steering committee monthly x 3 months, at which time the committee will determine the need for future audits.

483.25(c)(1)-(3) REQUIREMENT Increase/Prevent Decrease in ROM/Mobility: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(c) Mobility.
§483.25(c)(1) The facility must ensure that a resident who enters the facility without limited range of motion does not experience reduction in range of motion unless the resident's clinical condition demonstrates that a reduction in range of motion is unavoidable; and

§483.25(c)(2) A resident with limited range of motion receives appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion.

§483.25(c)(3) A resident with limited mobility receives appropriate services, equipment, and assistance to maintain or improve mobility with the maximum practicable independence unless a reduction in mobility is demonstrably unavoidable.
Observations:

Based on clinical record review and resident and staff interview, it was determined that the facility failed to provide services to maintain a resident's range of motion (ROM) for two of nine residents reviewed (Residents 28 and 56).

Findings include:

Clinical record review for Resident 28 revealed a current care plan for staff to provide a restorative program related to immobility including the following:

ROM (range of motion, movement of the body to maintain a resident's ability) supine and seated exercised to their BLLE (bilateral lower extremities)
AROM (active range of motion, AAROM (active assisted range of motion) and/or PROM (passive and BLUE (bilateral upper extremities) to maintain SBA (stand by assistance) sideboard transfer bed to wheelchair and/or wheelchair to bed and maintain current BLLE strength
Restorative transfer and OOB (out of bed) program to be OOB for at least one hour each day to build and/or maintain core strengthening.
Restorative OOB daily. Refer to therapy if change in current level of function (CLOF).

Review of task documentation for Resident 28 for March, April, and May 2024, revealed that staff did not document completion of the restorative task on the following dates:

For ROM supine and seated exercised to their BLLE:

March 22, 2024, day shift (no documentation)
March 19, 20, 25, 29, and 30, 2024, day shift (documented "not applicable")

April 7, 14, 18, and 24, 2024, day shift (no documentation)
April 17, 23, and 27, 2024, day shift (documented "not applicable")

May 6, 11, and 12, 2024, day shift (no documentation)
May 2, 7, 15, and16, 2024, day shift (documented "not applicable")

For AROM/AAROM/PROM for sideboard transfer from bed to wheelchair/wheelchair to bed:

March 3 and 22, 2024, day shift (no documentation)
March 5, 6, 25, 29, and 30, 2024, day shift (documented "not applicable")
March 3, 10, 22, and 23, 2024, evening shift (no documentation)
March 5, 6, 14, 19, 24, and 31, 2024, evening shift (documented "not applicable")

April 3 and 22, 2024, day shift (no documentation)
April 5 and 6, 2024, day shift (documented "not applicable")
April 3 and 22, 2024, evening shift (no documentation)
April 5 and 6, 2024, evening shift (documented "not applicable")

May 6, 11, and 12, 2024, day shift (no documentation)
May 2, 7, 15, and16, 2024, day shift (documented "not applicable")
May 2, 5, 7, and 18, 2024, evening shift (no documentation)
May 9 and 11, 2024, evening shift (documented "not applicable")

Restorative transfer and OOB program to be OOB for at least one hour each day to build and/or maintain core strengthening.

March 3 and 22, 2024, day shift (no documentation)
March 2, 5, 14, 20, and 25, 2024, day shift (documented "not applicable")

April 7, 14, 18, and 24, 2024, day shift (no documentation)
April 4, 6, 16, 17, 21, 23 and 27, 2024, day shift (documented "not applicable")

May 6, 11, and 12, 2024, day shift (no documentation)

Restorative OOB daily. Refer to therapy if change in CLOF.

March 22, 2024, day shift (no documentation)
March 5 and 20, 2024, day shift (documented "not applicable")

April 7, 14, 18, and 24, 2024, day shift (no documentation)
April 23 and 27, 2024, day shift (documented "not applicable")

May 6, 11, and 12, 2024, day shift (no documentation)
May 2, 2024, day shift (documented "not applicable")

Staff documented frequent refusals by Resident 28 throughout March, April, and May 2024 to get OOB. There was no facility documentation that identified this CLOF or notification to therapy.

Clinical record review for Resident 56 revealed a current care plan for staff to provide restorative nursing for AROM to maintain BLLE strength to decrease the risk for falls.

Review of task documentation for Resident 56 for March, April, and May 2024, revealed that staff did not document completion of the restorative task on the following dates:

March 19, 20, 21, 23, 24, 27, 28, 29, and 31, 2024, day shift (documented resident refusal of services by one specific employee)
March 26, 2024, day shift (documented "not applicable")
March 28, 2024, evening shift (no documentation)
March 24, 2024, evening shift (documented "not applicable")

April 1, 2, 3, 4, 6, 7, 9, 10, 11, 12, 15, 16, 17, 18, 19, 20, 21, 23, 24, 25, 26, 29, and 30, 2024, day shift (documented resident refusal of services by one specific employee)
April 5, 2024, day shift (no documentation)
April 13, 14, 22, and 28, 2024, day shift (documented "not applicable")
April 2, 11, and 25, 2024, evening shift (documented "not applicable")

May 1, 2, 4, 5, 7, 9, 10, 13, 14, 15, 16, 18, and 19, 2024, day shift (documented resident refusal of services by one specific employee)
May 5, 2024, evening shift (no documentation)
May 18, 2024, evening shift (documented "not applicable")

Further review of Resident 56's task documentation revealed that she usually accepts staff assistance as needed for care and services.

Interview with Resident 56 on May 20, 2024, at 10:27 AM revealed that she indicated she was independent with her care (including ambulation to the bathroom). She did not indicate refusals of her restorative program services from staff.

The surveyor reviewed the above information on May 22, 2024, at 2:57 PM with the Nursing Home Administrator and Director of Nursing.

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

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


 Plan of Correction - To be completed: 07/09/2024

Unable to retroactively correct

UM/designee will complete a review of current facility residents on a restorative program. Those residents identified as having a decline in transfers or dressing will be screened by therapy for modification to the resident's restorative program or will be evaluated and treated by therapy if indicated.

ADON/designee will provide in servicing related to the restorative nursing policy and procedure, which will include documentation of restorative programming, and notification to nursing/therapy if a decline in participation level is identified.

DON/designee will audit those residents on ordered restorative programming weekly x4 then twice monthly x1, to ensure documentation of participation and monitoring for decline in function. The results of the audits will be reported to the QA steering committee monthly x 3 months, at which time the committee will determine the need for future audits.
483.10(f)(1)-(3)(8) REQUIREMENT Self-Determination: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(f) Self-determination.
The resident has the right to and the facility must promote and facilitate resident self-determination through support of resident choice, including but not limited to the rights specified in paragraphs (f)(1) through (11) of this section.

§483.10(f)(1) The resident has a right to choose activities, schedules (including sleeping and waking times), health care and providers of health care services consistent with his or her interests, assessments, and plan of care and other applicable provisions of this part.

§483.10(f)(2) The resident has a right to make choices about aspects of his or her life in the facility that are significant to the resident.

§483.10(f)(3) The resident has a right to interact with members of the community and participate in community activities both inside and outside the facility.

§483.10(f)(8) The resident has a right to participate in other activities, including social, religious, and community activities that do not interfere with the rights of other residents in the facility.
Observations:

Based on review of select facility policy and procedures, observations, and resident and staff interviews, it was determined that the facility failed to ensure that residents could make choices about aspects of their lives that were significant to them, such as smoking, for one of 25 residents reviewed (Resident 1).

Findings include:

An interview with the Nursing Home Administrator (NHA) on May 20, 2024, at 8:22 AM revealed the facility was non-smoking. Smoking for residents was eliminated for new admissions beginning April 2023. However, there were three "grandfathered" residents that were still permitted to smoke. The NHA also reported that facility staff are permitted to smoke in a designated area, which is located on the facility property.

The NHA indicated that the skilled nursing facility has a designated smoking area located outside of the main lobby for the "grandfathered" residents to smoke. Staff are permitted to smoke during break times in their designated area.

Interview with Resident 1 on May 23, 2024, at 10:15 AM revealed that the resident does smoke but the facility indicated they are a non-smoking facility, so he is not able to smoke here. Resident 1 further indicated that it is unfair that others are allowed to smoke, and he is not, and this bothers the resident.

The Nursing Home Administrator was made aware of Resident 1's concern related to smoking during a meeting on May 23, 2024, at 11:15 AM. The NHA confirmed that staff and the three "grandfathered" residents could smoke at the facility in designated areas, but that newly admitted residents are not allowed to smoke since they have switched to a non-smoking facility. They also confirmed that residents are made aware of this on admission and stated Resident 1 signed a non-smoking agreement on admission.

Clinical record review for Resident 1 revealed documentation that the resident was admitted to the facility on April 26, 2024, at 2:22 PM. The documentation further noted the resident is a tobacco user.

Social Services documentation for Resident 1 dated May 3, 2024, at 3:23 PM revealed that social services and the registered nurse unit manager explained the non-smoking policy and the other residents that Resident 1 sees outside smoking were "grandfathered in." The documentation further noted that per the NHA, the resident would be permitted to smoke if he was off the facility property.

The facility failed to promote and facilitate resident self-determination through support of resident choice by not allowing the resident to smoke due to a non-smoking facility; however, allowing the facility staff to smoke in designated areas on the facility property.

28 Pa. Code 201.29(a) Resident rights


 Plan of Correction - To be completed: 07/09/2024

Unable to retro-actively correct.

NHA/designee will provide education to staff that smoking is not permitted on property effective 7/1/2024.

NHA/designee will conduct random audits of the smoking area 3x per week to ensure compliance with the above education.

Results of these audits will be presented to the QA steering committee monthly x 3 months, at which time the committee will determine the need for future audits.
483.90(i) REQUIREMENT Safe/Functional/Sanitary/Comfortable Environ: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.
§483.90(i) Other Environmental Conditions
The facility must provide a safe, functional, sanitary, and comfortable environment for residents, staff and the public.
Observations:

Based on observation and staff interview, it was determined that the facility failed to ensure a safe and clean environment in the facility laundry area.

Findings include:

Observation of the facility's main laundry area with Employee 1, laundry aide, and the Nursing Home Administrator on May 23, 2024, at 9:28 AM revealed an extensive build-up of wet lint, debris including three discarded medical gloves, a plunger head, and a dirty blanket behind the area of the main washing machines.

Excessive lint buildup not only affects dryer performance but can also be a fire hazard. Regular maintenance and cleaning are essential to keep the dryer functioning properly and safely.

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



 Plan of Correction - To be completed: 07/09/2024

The laundry room was deep cleaned

Residents were not affected by issues noted in the laundry room.

NHA/designee to provide education to the laundry staff regarding cleaning procedures.

NHA/designee to complete random weekly audits x 4 weeks of the laundry room to ensure compliance with cleaning procedures.

Results of these audits will be presented to the QA steering committee monthly x 1 month, at which time the committee will determine the need for future audits.
483.45(c)(1)(2)(4)(5) REQUIREMENT Drug Regimen Review, Report Irregular, Act On: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(c) Drug Regimen Review.
§483.45(c)(1) The drug regimen of each resident must be reviewed at least once a month by a licensed pharmacist.

§483.45(c)(2) This review must include a review of the resident's medical chart.

§483.45(c)(4) The pharmacist must report any irregularities to the attending physician and the facility's medical director and director of nursing, and these reports must be acted upon.
(i) Irregularities include, but are not limited to, any drug that meets the criteria set forth in paragraph (d) of this section for an unnecessary drug.
(ii) Any irregularities noted by the pharmacist during this review must be documented on a separate, written report that is sent to the attending physician and the facility's medical director and director of nursing and lists, at a minimum, the resident's name, the relevant drug, and the irregularity the pharmacist identified.
(iii) The attending physician must document in the resident's medical record that the identified irregularity has been reviewed and what, if any, action has been taken to address it. If there is to be no change in the medication, the attending physician should document his or her rationale in the resident's medical record.

§483.45(c)(5) The facility must develop and maintain policies and procedures for the monthly drug regimen review that include, but are not limited to, time frames for the different steps in the process and steps the pharmacist must take when he or she identifies an irregularity that requires urgent action to protect the resident.
Observations:

Based on clinical record review and staff interview, it was determined that the facility failed to ensure that pharmacy recommendations were responded to for one of five residents reviewed (Resident 87).

Findings include:

Review of Resident 87's clinical record revealed that the pharmacist completed monthly medication reviews and noted that a recommendation was made on the following dates: October 10, 2023, November 13, 2023, January 9, 2024, and February 8, 2024.

Review of the recommendation provided on October 10, 2023, November 13, 2023, January 9, 2024, and February 8, 2024, revealed a request for nursing to correct the diagnosis for Seroquel (a medication used to treat certain mental/mood disorders) on the medication administration record to bipolar disorder (a disorder associated with mood swings ranging from depressive lows to manic highs). Review of Resident 87's clinical record revealed that the diagnosis associated with his Seroquel is behaviors.

Interview with the Director of Nursing on May 23, 2024, at 1:30 PM confirmed the above noted findings related to Resident 87's pharmacy recommendations.

There was no evidence in Resident 87's clinical record that the facility addressed the above noted medication regimen reviews related to the diagnosis for his Seroquel.

28 Pa. Code 211.9 (d)(k) Pharmacy services

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


 Plan of Correction - To be completed: 07/09/2024

Rt 87s diagnosis for Seroquel was updated.

DON/designee will complete an audit of all residents who received pharmacy recommendations in the last 90 days to ensure that all recommendations received proper follow up.

DON/designee will provide education to Unit managers related to promptly following up on pharmacy recommendations.

NHA/designee will complete a random weekly audit of pharmacy recommendations to ensure appropriate follow up.

Results of these audits will be presented to the QA steering committee monthly x 3 months, at which time the committee will determine the need for future audits.
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 clinical record review and staff interview, it was determined that the facility failed to properly account for, secure, dispose of, or return physician ordered medications for two or 25 residents reviewed (Residents 125 and 126).

Findings include:

Closed clinical record review for Resident 125 revealed physician orders dated March 31, 2024, for the following:

Lorazepam (schedule 4, controlled medication) Tablet 0.5 milligram (mg) one tablet by mouth (PO) every 4 hours as needed (PRN) for restlessness or Anxiety.
Morphine Sulfate (narcotic, controlled medication) 20 mg/ml (milligrams/milliliter) give 0.25 ml PO every 2 hours PRN for pain or Dyspnea (difficulty breathing).
Hyoscyamine Sulfate 0.125 mg PO every 4 hours PRN for tracheal (throat) secretions.

Review of Resident 125's clinical documentation dated April 4, 2024, revealed that he expired at 3:50 AM.

There was documentation that the facility counted Resident 125's Lorazepam and Morphine medications. There was no documentation of the disposition or security of the resident's controlled medications. There was also no documentation accounting for Resident 125's Hyoscyamine after Resident 125 expired.

This surveyor reviewed the above information during an interview with the Director of Nursing on May 23, 2024, at 11:00 AM.

Closed clinical record review for Resident 126 revealed that she was admitted to the hospital on March 3, 2024, and expired while in the hospital on March 29, 2024.

Review of Resident 126's closed clinical record revealed physician orders dated March 3, 2024, for the following:

Dexamethasone (used to treat inflammation) 2 milligrams (mg)
Furosemide (a fluid pill) 40 mg
Gabapentin (used to treat nerve pain or seizures) 600 mg
Novolog (insulin used to treat high blood sugars)100units/ml
Cyclobenzaprine HCl (a muscle relaxant) 5 mg
Dicyclomine HCl (used to treat irritable bowel syndrome) 20 mg
Linzess (used to treat irritable bowel syndrome ad constipation)290 mcg
Methocarbamol (used to treat muscle pain and stiffness)500 mg
Apixaban (a blood thinner) 5 mg
Breo Ellipta Inhaler (used to treat asthma)
Cyanocobalamin (a supplement) 1000 mcg
Empagliflozin oral (used to lower blood sugars) 25 mg
Ergocalciferol (vitamin D that helps the body use more calcium) 1.25 mg
Fluoxetine HCI (used to treat depression) 40 mg
Insulin glargine (used to treat diabetes) 100 u/ml
Levothyroxine (used to treat hypothyroidism) 75 mcg
Ropinirole HCl (used to treat restless leg syndrome) 1 mg
Seroquel (used to treat certain mental and mood disorders such as bipolar and schizophrenia) 25 mg

There was no documentation in Resident 126's clinical record to indicate the disposition of the above medications upon her discharge from the facility.

This surveyor reviewed the above information during an interview with the Director of Nursing on May 23, 2024, at 11:40 AM.

28 Pa. Code 211.9 (k) Pharmacy services

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


 Plan of Correction - To be completed: 07/09/2024

Unable to retroactively correct

DON/designee will audit the last 10 discharges to ensure appropriate documentation related to disposition of medications.

Adon/designee will provide education to licensed staff regarding medication disposition and documentation on discharge.

DON/designee will complete weekly audits x4 weeks, then monthly x2 months, to ensure compliance.

The results of these audits will be reported to the QA steering committee monthly x3 months, at which time the committee will determine the need for future audits.
483.40(d) REQUIREMENT Provision of Medically Related Social Service: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(d) The facility must provide medically-related social services to attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident.
Observations:

Based on clinical record review and resident and staff interview, it was determined that the facility failed to ensure that medically related social services were provided to one of two residents reviewed (Resident 6).

Findings include:

Observation of the First Floor Nursing Unit on May 20, 2024, at 12:16 PM revealed Resident 6 was visibly upset and pacing in the hallway. Resident 6 approached the surveyor and asked if she worked for the Office of the Aging. Resident 6 opened a piece of paper with the local ombudsman's name and contact information on it and stated that the staff would not allow him to call her. Resident 6 stated that he is being kept prisoner and locked on the unit. Resident 6 proceeded to discuss how he fell at home and hit his head along with possible carbon monoxide poisoning. The resident then drove himself to the hospital. Resident 6 stated that he may have been confused in the hospital due to hitting his head, the hospital transferred him to the facility, and now the facility will not allow him to leave. Resident 6 asked the surveyor to review the resident rights posted on the wall and stated that the facility is not allowing him to have these rights.

Email correspondence with the local ombudsman on May 21, 2024, confirmed she had not received any calls from Resident 6.

Observation of the First Floor Nursing Unit on May 22, 2024, at 10:21 AM revealed that Resident 6 again was visibly upset and stated that he had requested to speak to the Nursing Home Administrator for over a month and she has not come to address his concerns.

Clinical record review revealed the facility admitted Resident 6 on April 1, 2024.

Clinical record review and an interview with Employee 6, social services, on May 23, 2024, at 12:53 PM confirmed that Resident 6 had a BIMS (Brief Interview for Mental Status) of 12, which indicated only mild cognitive impairment.

A medical provider note dated April 2, 2024, at 7:52 PM revealed the resident was able to complete the Mini Mental Status (a tool utilized to measure the cognitive status) examination, "fairly well, and was oriented x 3 (oriented to person, place, and time)." The documentation further noted, "The resident is generally alert, oriented, with very minimal periods of confusion."

A medical provider note dated April 8, 2024, at 1:29 PM revealed that it was reported by nursing staff that Resident 6 is preoccupied in finding ways to exit the facility and had mentioned about attempting to exit through the windows.
Nursing documentation for Resident 6 dated May 7, 2024, at 2:01 PM revealed the resident wanted to speak to the person that ran the facility. The resident was going to contact his lawyer to get him out of the facility because, "he isn't even sure why he is here."

Social services documentation for Resident 6 dated May 9, 2024, at 11:09 AM revealed that the resident's family had questions about the resident and his need for placement at the skilled nursing facility. However, minimal information was provided because they were not "on the profile." The family voiced concern about the resident's emergency contact.

Nursing documentation for Resident 6 dated May 16, 2024, at 2:16 PM revealed that the resident was very upset and asked staff to call the police because the resident is being held against his will. The staff informed the resident that the police could not be contacted for this matter. The documentation further noted the resident stated that, "he would do something serious enough if he had to for the police to be called." The resident was sitting next to the unit door most of the shift and upset that management had not been to see him; however, the Nursing Home Administrator (NHA) had been to see the resident this week according to the documentation.

Nursing documentation for Resident 6 dated May 18, 2024, at 3:04 PM revealed the resident told staff that they were going to be involved in a lawsuit and he was being held against his will and will get out of the facility one way or the other.

Nursing documentation for Resident 6 dated May 18, 2024, at 8:33 PM revealed the staff assisted the resident with calling his emergency contact. According to the documentation, the emergency contact asked to speak to staff and told them that the resident advised he needs " ...to get out of here and it is a matter of life and death for him," and "I'm starting to come unraveled here."

Facility documentation for Resident 6 dated May 21, 2024, at 11:36 AM revealed the emergency contact reported the resident's home is completely uninhabitable and the resident is unable to live alone safely. The emergency contact was unwilling to act as the resident's guardian and the facility will be pursuing guardianship.

There was no evidence in the clinical record to indicate that Resident 6 was deemed incapable by a medical professional to make his own decisions. This was confirmed in an interview with Employee 6 during an interview on May 23, 2024, at 12:53 PM.

There was no evidence provided to confirm that the facility addressed Resident 6's concerns related to wanting to leave the facility and being held against his will as noted in the nursing documentation or discussed alternative options with the resident (i.e., an assisted living facility). There was no evidence to confirm the facility requested a home assessment to confirm the allegations from the emergency contact that the resident's home was uninhabitable or a danger to the resident's health and safety.

The facility failed to provide medically related social services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident.

The above findings for Resident 6 were reviewed in a meeting with the NHA and Director of Nursing on May 22, 2024, at 2:00 PM.

28 Pa. Code 201.29 (a) Resident rights

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


 Plan of Correction - To be completed: 07/09/2024

Physician evaluated resident 6 and deemed him incapable of decision making.

AAA inspected resident 6's residence and deemed it uninhabitable. They have recommended that the resident be appointed a guardian. Guardianship is in process.

SS/designee will review current residents to ensure that their current discharge plans are appropriate.

NHA/designee will complete education with SS staff regarding involving the physician or other providers as appropriate if residents capability status is in question.

NHA/designee will complete audits of new admits to ensure appropriate discharge plans are in place, if applicable.

Results of these audits will be presented to the QA steering committee monthly x 3 months, at which time the committee will determine the need for future audits.
483.25(g)(1)-(3) REQUIREMENT Nutrition/Hydration Status Maintenance: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(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 clinical record review, review of select facility policies and procedures, and staff interview, it was determined that the facility failed to implement interventions to promote acceptable parameters of nutrition for one of nine residents reviewed (Resident 64).

Findings include:

The facility "Weight Policy," last reviewed without changes on May 4, 2024, revealed any resident with weight changes of five or more pounds will be re-weighed within 24 hours post the original weight. The dietitian will review the medical record of any resident with significant weight changes (greater than/equal to five percent in one month, greater than/equal to seven and a half percent in three months, and greater than/equal to 10 percent in six months). Interventions will be recommended, as needed. The nurse will confirm with the physician any order recommendations made by the dietician. Interventions that are initiated in response to a weight change will be reflected in the residents care plan. Residents with significant weight loss/ gain will be further reviewed by the interdisciplinary team meetings. The charge nurse will notify the resident and/or resident representative of weight and order changes.

Clinical record review revealed the facility admitted Resident 64 on July 9, 2021. Further review of Resident 64's clinical record revealed the following weight assessments:

December 6, 2023, 86.0 pounds
January 3, 2024, 106.0 pounds (a 20-pound, 23.26 percent severe weight gain)
January 9, 2024, 107.2 pounds
January 16, 2024, 93.0 pounds (a 14.2-pound, 13.25 percent severe weight loss)

Further review of Resident 64's clinical record revealed a weight change note dated January 16, 2024, noting significant weight loss and gain. The note revealed Resident 64's medications do not include any diuretics or appetite enhancing medications. Employee 3 (registered dietitian) had no new recommendations at this time.

An interview with Employee 3 on May 23, 2024, at 11:38 AM confirmed the above findings. She confirmed Resident 64's re-weight was not completed for seven days after her January 3, 2024, severe weight gain. Employee 3 confirmed there was no indication that the facility assessed Resident 64's severe weight gain or notified Resident 64's physician and responsible party.

28 Pa. Code 211.10(d) Resident care policies

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


 Plan of Correction - To be completed: 07/09/2024

Unable to retro-actively correct

RD/designee will complete an audit of residents at risk for weight loss/gain to ensure adequate interventions are in place.

RD/designee will complete random weekly audits of residents at risk for weight loss/gain to ensure that interventions are in place and effective.

Results of these audits will be presented to the QA steering committee monthly x 3 months, at which time the committee will determine the need for future audits.
483.25(b)(1)(i)(ii) REQUIREMENT Treatment/Svcs to Prevent/Heal Pressure Ulcer: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(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 clinical record review, review of select facility policies and procedures, and staff interview, it was determined that the facility failed to assess and implement treatment and services to prevent the development and promote the healing of a pressure ulcers for one of three residents reviewed for pressure ulcer concerns (Resident 64).

Findings include:

The facility policy entitled "Skin Integrity," last reviewed without changes on May 4, 2024, revealed residents will be assessed/observed for risk of skin breakdown, utilizing the Braden scale within 24 hours of admission, quarterly, and as necessitated by a residents change in condition. Wound status is monitored on a weekly basis. The interdisciplinary plan of care will address problems, goals, and interventions directed toward the prevention of pressure injuries and/or skin integrity concerns identified. If identified risk is present the interventions will be documented in the baseline plan of care and/or comprehensive care plan. If there is a decline in skin integrity pressure redistribution surfaces will be reviewed and interventions and plan of care updated as appropriate. Residents will be observed during care by nurse aides daily for reddened/open areas. Changes will be reported to the licensed nurse and documented. If identified at risk or with actual alterations in the skin integrity of feet, footwear will be addressed for appropriateness.

Clinical record review revealed the facility admitted Resident 64 on July 9, 2021.

A review of a skin check completed by a licensed practical nurse on January 9, 2024, noted Resident 64's ankle was red and Resident 64 was complaining of it hurting. The licensed practical nurse noted that a new treatment was started.

A review of Resident 64's Treatment Administration Record (TAR, a form utilized to document the administration of resident treatments) dated January 2024 revealed there were no new treatment orders for Resident 64's ankle. An interview with the Director of Nursing on May 23, 2024, at 12:27 PM confirmed these findings.

Further review of Resident 64's clinical record revealed an integrated wound care note on January 9, 2024, noting Resident 64 was being seen for evaluation and treatment recommendations regarding a pressure ulcer to her right ankle from home. The wound care note indicated Resident 64 has had the pressure area for a while (unsure how long) and it recently worsened gradually. Wound care assessed Resident 64's pressure ulcer to her right lateral ankle as a Stage 3 (full thickness tissue loss, subcutaneous fat may be visible), measuring 0.5 centimeters (cm) by 0.5 cm by 0.1 cm.

A review of Resident 64's clinical record revealed the last Braden assessment (a standardized, evidence-based assessment tool that helps predict a patient's risk of developing a pressure injury) before identification of Resident 64's pressure injury on January 9, 2024, was August 16, 2023, noting Resident 64 was at risk of developing a pressure ulcer. Further review of Resident 64's Braden assessments revealed Employee 5 (registered nurse) started a Braden assessment on January 4, 2024, noting Resident 64 was low risk, but did not sign off on the Braden assessment until January 11, 2024, (after identified Stage 3 pressure ulcer).

Review of Resident 64's physician assistant progress note dated January 15, 2024, revealed Resident 64 was seen for a follow-up on the integrated wound visit. The physician assistant noted Resident 64 has had a pressure ulcer on her right ankle for an unspecified duration, which recently worsened.

A review of Resident 64's plan of care revealed the facility did not initiate a plan of care to address Resident 64's new pressure ulcer until February 26, 2024, (7 weeks after identification of the pressure area).

The surveyor attempted to observe Resident 64's ankle on May 23, 2024, at 11:47 AM, and Resident 64 refused.

The facility did not assess and implement interventions timely to address the pressure area identified on Resident 64's right ankle on January 9, 2024.

Interview with the Director of Nursing on May 23, 2024, at 12:53 PM confirmed these findings. She could provide no further documentation that the facility assessed and implemented interventions to address Resident 64's identified pressure ulcer since January 15, 2024.

28 Pa. Code 211.10(d) Resident care policies

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


 Plan of Correction - To be completed: 07/09/2024

Unable to retroactively correct

UM/designee will complete an audit of all residents at risk for skin breakdown per braden scale to ensure appropriate interventions are in place.

ADON/ designee will provide education to clinical staff regarding skin integrity issues & appropriate documentation.

Don/designee will complete random weekly audits of recommendations for residents at risk for skin breakdown to ensure interventions and treatments are in place as recommended.

Results of these audits will be presented to the QA steering committee monthly x 3 months, at which time the committee will determine the need for future audits.
483.25(a)(1)(2) REQUIREMENT Treatment/Devices to Maintain Hearing/Vision: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(a) Vision and hearing
To ensure that residents receive proper treatment and assistive devices to maintain vision and hearing abilities, the facility must, if necessary, assist the resident-

§483.25(a)(1) In making appointments, and

§483.25(a)(2) By arranging for transportation to and from the office of a practitioner specializing in the treatment of vision or hearing impairment or the office of a professional specializing in the provision of vision or hearing assistive devices.
Observations:

Based on observation, clinical record review, and resident and staff interview, it was determined that the facility failed to obtain proper treatment and assistive devices to maintain vision for one of one resident reviewed (Resident 46).

Findings include:

An interview with Resident 46 on May 20, 2024, at 11:00 AM revealed the resident was at the eye doctor "last year" and was told she needed eyeglasses but has not received the eyeglasses. The resident further reported she utilizes "readers," which help her see up close, but has trouble viewing the television because it is blurred.

An optometry evaluation dated June 1, 2023, revealed that Resident 46 was seen by optometry for a new facility ordered vision consultation. The evaluation further indicated on the form to "Circle all that applies if dispensed or ordered any glasses or frames." "SPH (sphere) BF (bifocal)" was circled under the Frames section. The form also noted for the resident to follow-up in six months.

A Care Plan Note dated August 28, 2023, at 5:38 PM revealed Resident 46 asked about the delivery of her glasses ordered on June 1, 2023. The documentation further noted a voicemail was left to inquire about the eyeglasses.

Further clinical review for Resident 46 revealed no further documentation regarding the resident's eyeglasses, or evidence that the resident had a follow-up visit in six months as requested during the initial visit, or documentation to indicate the resident refused the eyeglasses or follow-up visit.

An interview with the Nursing Home Administrator on May 23, 2024, at 9:06 AM revealed that the glasses were supposedly sent to the facility. However, the facility is unable to locate them, so a new pair was ordered.

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


 Plan of Correction - To be completed: 07/09/2024

Rt 46 was provided with glasses.

Corporate office staff contacted the vendor to ensure that future visits will be performed as scheduled.

SS/designee will complete a 6 month lookback to identify other residents requiring services.

Social services/designee will complete an audit monthly x3 months to track optometry visits and related recommendations to ensure that recommendations are followed and equipment is received.

Results of these audits will be presented to the QA steering committee monthly x 3 months, at which time the committee will determine the need for future audits.
483.15(d)(1)(2) REQUIREMENT Notice of Bed Hold Policy Before/Upon Trnsfr: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.
§483.15(d) Notice of bed-hold policy and return-

§483.15(d)(1) Notice before transfer. Before a nursing facility transfers a resident to a hospital or the resident goes on therapeutic leave, the nursing facility must provide written information to the resident or resident representative that specifies-
(i) The duration of the state bed-hold policy, if any, during which the resident is permitted to return and resume residence in the nursing facility;
(ii) The reserve bed payment policy in the state plan, under § 447.40 of this chapter, if any;
(iii) The nursing facility's policies regarding bed-hold periods, which must be consistent with paragraph (e)(1) of this section, permitting a resident to return; and
(iv) The information specified in paragraph (e)(1) of this section.

§483.15(d)(2) Bed-hold notice upon transfer. At the time of transfer of a resident for hospitalization or therapeutic leave, a nursing facility must provide to the resident and the resident representative written notice which specifies the duration of the bed-hold policy described in paragraph (d)(1) of this section.
Observations:

Based on clinical record review and staff interview, it was determined that the facility failed to ensure that the resident or resident representative received written notice of the facility's bed hold policy at the time of transfer for two of 11 residents reviewed for hospitalizations (Residents 19 and 126 ).

Findings include:

Clinical record review for Resident 19 revealed he was transferred to the hospital from May 13-17, 2024. There was no evidence to indicate that Resident 19 or his responsible party were provided written notification of the facilities bed hold policy at the time of his transfer out of the facility.

A closed clinical record review revealed that Resident 126 went out to the hospital on March 3, 2024, related to a change in mental status. There was no evidence to indicate that Resident 126 or her responsible party were provided with written notification of the facilities bed hold policy at the time of her transfer.

The facility failed to provide written notice of their bed hold policy at the time of transfer for Residents 19 and 126.

The Nursing Home Administrator confirmed the above-noted findings related to bed hold notices during a meeting on May 23, 2024, at 12:10 PM.

28 Pa. Code 201.14(a) Responsibility of licensee


 Plan of Correction - To be completed: 07/09/2024

Bedhold notices were sent to resident 19 & 126.

Admissions director/designee will complete a 60 day lookback to identify other affected residents and send notices.

Admissions director and licensed clinical staff will be re-educated on the bedhold policy and requirements.

BOM /designee will complete transfer audits weekly x8 weeks to ensure compliance.

Results of these audits will be presented to the QA steering committee monthly x 2 months, at which time the committee will determine the need for future audits
483.10(i)(1)-(7) REQUIREMENT Safe/Clean/Comfortable/Homelike Environment: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(i) Safe Environment.
The resident has a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

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

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

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

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

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

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

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

Based on observation and resident and staff interview, it was determined that the facility failed to provide adequate housekeeping and maintenance services to ensure a clean, safe, and orderly environment on two of three nursing units (2nd and 3rd Floor Nursing Unit, Residents 56 and 60) and ensure properly functioning of resident equipment for one of 25 residents (Resident 1).

Findings include:

Interview with Resident 56 on May 20, 2024, at 10:27 AM revealed that she indicated concerns with her bathroom environment, noting the toilet was "dirty" and the floor was "black." Resident 60 stated that she was independent with her care and wears a brief due to incontinence. She indicated concerns with the hem/bottom of her pants becoming "soiled" from the condition of the bathroom.

Observation of Resident 56's bathroom on May 20, 2024, at 10:37 AM confirmed her statement. The floor around the base of the toilet was stained that extended four inches out on the floor from the toilet. Inside the toilet bowel, there were brown stains and material similar to feces. The bathroom smelled strongly of urine and a dank, musty smell.

The surveyor reviewed the above information during an interview with the Nursing Home Administrator and Director of Nursing on May 21, 2024, at 3:15 PM.

Observation of Resident 60's room on May 21, 2024, at 11:54 AM revealed the wall under the window was patched but not pained, there were holes in the wall under the vent that was located to the right (when looking at it) of Resident 60's dresser, and the wall between the two dressers in the room was marred.

The Nursing Home Administrator and the Director of Nursing were made aware of the environmental concerns in Resident 60's room in a meeting on May 21, 2024, at 3:00 PM.

An interview with Resident 1 on May 23, 2024, at 10:15 AM revealed that the resident had concerns related to the facility's bladder scanner (a non-invasive medical device that utilizes an ultrasound probe to measure the amount of urine in the bladder). Resident 1 indicated the bladder scanner is "broken" and the resident is supposed to be bladder scanned.

Clinical record review for Resident 1 revealed a current physician's order dated April 29, 2024, that instructed staff to bladder scan the resident five times a day as scheduled; if results are of 400 cubic centimeters (cc) straight catheterize (utilize a sterile catheter that is inserted into the bladder to drain urine) five times a day; DO NOT CHANGE TIMES PER THE PHYSICIAN ASSISTANT.

An interview with an anonymous staff member on May 23, 2024, at 10:55 AM revealed that the bladder scanner has been broken for "months" but could not specify an exact time period. The staff member further noted the probe to the bladder scanner was "cracked" and the accuracy of the device was "questionable." This was reported "many times" to supervisory personnel including the Director of Nursing according to the staff member.

Observation of the bladder scanner on May 23, 2024, at 10:59 AM revealed a large C-shaped crack at the tip of the probe (the part of the bladder scanner used to scan the bladder for urine) that was slightly indented. The probe had a sticky yellow substance accumulated on a section of it. There was a blue colored "Preventative Maintenance Inspection" sticker on the back of the bladder scanner main display unit with the last three dates marked as: "6/21," "6/27/20," and "6/28/19." The owner's manual and quick start guide was located in a plastic basket attached to the device and both were covered in a sticky, yellow substance with debris noted stuck to the manual.

Review of the Owner's Manual for the bladder scanner revealed on page 12 a section that noted start-up and shutdown of the device. The probe connection section noted: "Check to be certain the probe is properly connected, is not leaking fluid and is not damaged. Verify that the probe head surface and probe cable are in good condition."

Further review of the Owner's Manual for the bladder scanner revealed a section of recommended usage, warnings and troubleshooting located on page 37 that noted to, "Take special care to avoid physical shock and vibration when moving the device. Be especially careful when handling or transporting the probe, which contains especially sensitive components." Page 39 of the manual noted: "Avoid scratching the surface of the probe during use, charging, or transportation. If the probe is dropped, verify there is no visual damage and test it for proper function. If the probe is broken, please stop using it immediately and contact the company for repair/replacement. Replace the probe immediately if it is damaged or broken."

Nursing documentation for Resident 1 revealed the following:

April 28, 2024, at 2:07 PM: Staff attempted to use the bladder scanner however, "it is not turning on or in operating condition."

April 30, 2024, at 5:07 AM: Bladder scanner reading was zero and may be due to a large crack in the transmitter. The registered nurse (RN) supervisor was made aware per the documentation.

May 2, 2024, at 10:56 AM: "Attempted to use bladder scanner" and was reading zero.

May 6, 2024, at 2:16 AM: Staff unable to bladder scan due to a "non-functioning scanner."

May 6, 2024, at 5:57 PM: Staff noted the "bladder scanner not working."

May 8, 2024, at 7:33 PM: Staff noted the bladder scanner is not functioning.

May 8, 2024, at 10:26 PM: Staff noted the bladder scanner is broken.

May 8, 2024, at 10:30 PM: Staff noted they are unable to bladder scan the resident due to the machine being broken.

May 9, 2024, at 5:09 AM, 5:48 AM, and 5:49 AM: Staff noted unable to bladder scan the resident due to the machine being broken.

May 14, 2024, at 1:30 AM: Staff noted the bladder scanner does not work.

May 14, 2024, at 5:01 AM: Staff noted the bladder scanner is broken.

May 22, 2024, at 10:17 PM: Staff noted unable to bladder scan due to machine being broken and does not work.

May 23, 2024, at 3:35 AM: Staff noted the bladder scanner does not work.

Further clinical record review for Resident 1 revealed that there was no documentation that indicated the physician was aware the bladder scanner was damaged or not working as indicated by staff.

An interview with the Nursing Home Administrator (NHA) and Director of Nursing (DON) on May 23, 2024, at 11:08 AM revealed that the facility was aware the bladder scanner probe was broken. The DON indicated there was only one bladder scanner in the facility. They were unsure how long the machine was broken and would "have to check." They indicated that the company was contacted to repair it; however, it was unclear when this was done and would also "have to check."

Further questioning with the NHA and DON on May 23, 2024, at 1:08 PM and 2:00 PM regarding the date the bladder scanner repair was requested or any documentation to support this revealed no further information provided by the facility. The NHA further noted that "maybe corporate would know." No documentation or date was ever provided to the surveyor regarding information related to the requested repair of the device, obtaining a replacement part, or getting a loaner device to use in the interim.

483.10(i)(1)-(7) Safe/clean/comfortable/homelike Environment
Previously cited 8/1/23 and 6/16/23

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

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


 Plan of Correction - To be completed: 07/09/2024

Rt 56's bathroom floor was cleaned and the toilet base re-caulked.

Rt 60's room walls were repaired and painted.

The bladder scanner was replaced.

The management team/designee will complete audits of resident bathrooms and resident room walls to identify other rooms requiring deep clean or repair.

No other residents have orders for bladder scans.

The management team will receive education regarding how to note major repairs or deep clean requests on non-clinical room rounds. Non clinical form will be updated to capture these items. Room rounds audits be submitted 1x/week for 3 months.

Results of these audits will be presented to the QA steering committee monthly x 3 months, at which time the committee will determine the need for future audits.
483.12(a)(1) REQUIREMENT Free from Abuse and Neglect: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 Freedom from Abuse, Neglect, and Exploitation
The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms.

§483.12(a) The facility must-

§483.12(a)(1) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion;
Observations:

Based on clinical record review, review of facility documents, and resident and staff interview, it was determined that the facility failed to protect a resident to be free from neglect by not providing the services necessary to avoid physical harm resulting in injury for one of two residents reviewed (Resident 60).

Findings include:

Clinical record review for Resident 60 revealed a progress note dated April 19, 2024, at 11:00 AM that indicated she had a fall in her room. Staff members heard her yelling, entered her room, and observed her on the floor between the beds in the room. She was in a prone position, facing the wall. Blood was noted on the floor near her head. Her walker was in an upright position near her. A laceration was noted to the right side of her head just above her ear and measured 5.0 centimeters x 3.0 centimeters x 1.0 centimeters. Pressure was applied to the laceration. The Physician Assistant was notified and ordered staff to send the resident to the emergency room.

Further clinical record review for Resident 60 revealed a progress note dated April 19, 2024, at 6:10 PM that indicated Resident 60 returned from the emergency room at 3:55 PM. She had a dressing on the head laceration. It was noted that she received seven sutures to the head laceration. She was ordered Keflex (an antibiotic to prevent infection) 500 mg four times a day for seven days.

Interview with Resident 60 on May 21, 2024, at 11:54 AM revealed that she got up out of the stationary chair with her walker, and walked around the bottom of her bed, to the other side, to reach her call bell that was on the bed near the top of the bed. She stated that she wanted to talk to someone from the business office and needed her call bell. She took her hand off her walker to get the call bell, pushed the button, and as she was standing back up to get her walker, she lost her balance, and fell backwards to the floor.

A witness statement provided by Employee 2, physical therapist, dated April 19, 2024, indicated that she provided therapy in her room. Employee 2 ambulated her to the door and back with her walker and supervision. Then she sat her in a straight back chair at the end of her bed and completed exercises. When she was done, Resident 60 remained in the chair with her over bed table placed in front of her. Employee 2 indicated that she was told by a nurse aide (no name provided) to have the resident sit in the chair at the end of the bed instead of her wheelchair because it was her choice. Her statement indicated that she instructed Resident 60 not to get up on her own and that she stretched the call bell across the bed as far as possible.

Employee 2 placed Resident 60 in a stationary chair, in her room, then left the room without providing Resident 60 with a way to contact staff if she needed them. Employee 2 failed to alert nursing staff that she left Resident 60 in the stationary chair and that her call bell was not in reach.

Review of Resident 60's care plan for fall risk that was implemented on April 12, 2024, and revised on April 15, 2024, revealed an intervention for staff to make sure her call light was within reach and encourage her to use it for assistance as needed.

Employee 2 was re-educated on making sure the call bell was in reach on April 22, 2024.

Interview with the Nursing Home Administrator on May 23, 2024, at 11:00 AM revealed that the facility only educated Employee 2 and three other employees from the therapy department, and that they did not educate other staff that would be responsible for fall prevention and following care plans, to prevent this from reoccurring.

The above findings were reviewed during an interview with the Nursing Home Administrator and Director of Nursing on May 23, 2024, at 11:30 AM.

The facility failed to prevent neglect that resulted in injury for Resident 60.

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

28 Pa. Code 201.29(a) Resident rights


 Plan of Correction - To be completed: 07/09/2024

Unable to retroactively correct

DON/designee will complete a 60 day lookback of falls to identify any other residents affected.

ADON/designee will complete fall prevention education with staff.

Unit manager/designee will complete random audits of resident falls weekly x3 months to ensure compliance with above referenced education.

Results of these audits will be presented to the QA steering committee monthly x 3 months, at which time the committee will determine the need for future audits.
483.35(g)(1)-(4) REQUIREMENT Posted Nurse Staffing Information:Least serious deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents. This deficiency has the potential for causing no more than a minor negative impact on the resident.
§483.35(g) Nurse Staffing Information.
§483.35(g)(1) Data requirements. The facility must post the following information on a daily basis:
(i) Facility name.
(ii) The current date.
(iii) The total number and the actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift:
(A) Registered nurses.
(B) Licensed practical nurses or licensed vocational nurses (as defined under State law).
(C) Certified nurse aides.
(iv) Resident census.

§483.35(g)(2) Posting requirements.
(i) The facility must post the nurse staffing data specified in paragraph (g)(1) of this section on a daily basis at the beginning of each shift.
(ii) Data must be posted as follows:
(A) Clear and readable format.
(B) In a prominent place readily accessible to residents and visitors.

§483.35(g)(3) Public access to posted nurse staffing data. The facility must, upon oral or written request, make nurse staffing data available to the public for review at a cost not to exceed the community standard.

§483.35(g)(4) Facility data retention requirements. The facility must maintain the posted daily nurse staffing data for a minimum of 18 months, or as required by State law, whichever is greater.
Observations:

Based on observation, review of posted daily nurse staffing data, and staff interviews, it was determined that the facility failed to ensure nursing staffing information was posted on three of three resident floors (First, Second, and Third floors).

Findings include:

Observation of the facility on May 20, 2024, at 11:31 AM and again on May 23, 2024, at 11:27 revealed the facility failed to post the nurse staffing data daily on the First, Second, and Third floors in a prominent place that was readily accessible to residents and visitors at the beginning of every shift.

These findings were reviewed with the Nursing Home Administrator and Director of Nursing during a meeting on May 23, 2024, at 11:45 AM.

28 Pa. Code 201.14(a) Responsibility of licensee

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


 Plan of Correction - To be completed: 07/09/2024

Unable to retroactively correct

Staffing coordinator/designee will update the staffing sheet to ensure that it contains the required information and is posted on all 3 floors.

NHA/designee will provide education to the staffing coordinator related required postings.

DON/designee will complete random audits weekly to ensure that appropriate postings are in place on all 3 floors.

Results of these audits will be presented to the QA steering committee monthly x 3 months, at which time the committee will determine the need for future audits.
483.15(c)(3)-(6)(8) REQUIREMENT Notice Requirements Before Transfer/Discharge:Least serious deficiency but affects more than a limited number of residents, staff, or occurrences. This deficiency has the potential for causing no more than a minor negative impact on the resident but is not found to be throughout this facility.
§483.15(c)(3) Notice before transfer.
Before a facility transfers or discharges a resident, the facility must-
(i) Notify the resident and the resident's representative(s) of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand. The facility must send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman.
(ii) Record the reasons for the transfer or discharge in the resident's medical record in accordance with paragraph (c)(2) of this section; and
(iii) Include in the notice the items described in paragraph (c)(5) of this section.

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

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

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

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

Based on clinical record review and staff interview, it was determined that the facility failed to notify a resident and/or the resident's responsible party in writing of a transfer to the hospital for 5 of 11 residents reviewed (Residents 6, 64, 112, 19, and 126). The facility also failed to notify the Office of the State Long-Term Care Ombudsman of a transfer to the hospital for 4 of 11 residents reviewed (Residents 6, 64, 126, and 112).

Findings include:

A review of Resident 6's clinical record revealed that the facility transferred him to the hospital from April 18 to 19, 2024. There was no documented evidence to indicate that the facility provided a written notice to Resident 6's responsible party regarding his transfer to the hospital that included the required contents: reason for the transfer, effective date of the transfer, location to which the resident was transferred to, contact and address (mailing and email) information for the Office of the State Long-Term Care Ombudsman, and information (mailing and email address and telephone number) for the agency responsible for the protection and advocacy of individuals with developmental disabilities, and a statement of resident's appeal rights, including name, address (mailing and email) and telephone number of entity which receives requests. Further review of facility documentation revealed there was no documented evidence that the facility notified the Office of the State Long-Term Care Ombudsman of Resident 6's transfer to the hospital.

Clinical record review for Resident 64 revealed she was transferred to the hospital from February 15 to 16, 2024. There was no evidence to indicate that Resident 64's responsible party was provided written notification to include the above-required contents. Further review of facility documentation revealed there was no documented evidence that the facility notified the Office of the State Long-Term Care Ombudsman of Resident 64's transfer to the hospital.

Clinical record review for Resident 112 revealed he was transferred to the hospital from January 30 to 31, 2024. There was no evidence to indicate that Resident 112's responsible party was provided written notification to include the above-required contents. Further review of facility documentation revealed there was no documented evidence that the facility notified the Office of the State Long-Term Care Ombudsman of Resident 112's transfer to the hospital.

Clinical record review for Resident 19 revealed he was transferred to the hospital from May 13-17, 2024. There was no evidence to indicate that Resident 19 or his responsible party were provided written notification to include the above noted required contents related to his transfer out to the hospital.

Closed clinical record review revealed that Resident 126 went out to the hospital on March 3, 2024, related to a change in mental status. There was no evidence to indicate that Resident 126 or her responsible party were provided with written notification related to her transfer out to the hospital. Further review of facility documentation revealed there was no documented evidence that the facility provided the Office of the State Long-Term Care Ombudsman of Resident 126's transfer to the hospital.

The Nursing Home Administrator confirmed the above noted findings regarding transfer notices for Residents 6, 19, 64, 112, and 126 during an interview on May 22, 2024, at 11:08 AM.

483.15(c)(3)-(6)(8) Notice Requirements Before Transfer/discharge
Previously cited 06/16/23

28 Pa. Code 201.14(a) Responsibility of license

28 Pa. Code 201.29(a) Resident rights


 Plan of Correction - To be completed: 07/09/2024

Transfer notices were sent to resident 6,64,112,19 & 126. Ombudsman was notified of hospital transfers for 6, 64, 126 and 112.

Admissions director/designee will complete a 60 day lookback to identify other residents affected and send notices.

Admissions director and licensed clinical staff will be re-educated on the transfer policy and requirements. BOM/designee will complete transfer audits weekly x 4 weeks to ensure compliance.

Results of these audits will be presented to the QA steering committee monthly x 3 months, at which time the committee will determine the need for future audits.
§ 211.5(d) LICENSURE Medical records.:State only Deficiency.
(d) Records of discharged residents shall be completed within 30 days of discharge. Medical information pertaining to a resident ' s stay shall be centralized in the resident ' s record.

Observations:

Based on closed clinical record review and staff interview, it was determined that the facility failed to complete a discharge summary within 30 days of the resident's death or discharge from the facility for two of three closed records reviewed (Residents 125 and 126).

Findings include:

Closed clinical record review for Resident 125 revealed nursing documentation dated April 4, 2024, at 4:04 AM that noted the resident expired at 3:50 AM. The physician was notified.

Closed clinical record review for Resident 125 revealed no discharge summary, that also included the final diagnosis and cause of death, was completed within 30 days of the resident's death.

Closed clinical record review for Resident 126 revealed nursing documentation dated March 3, 2024, that noted the resident was admitted to the hospital.

Interview with the Director of Nursing and Nursing Home Administrator on May 21, 2024, at 2:30 PM revealed that Resident 126 expired at the hospital on March 29, 2024.

Closed clinical record review for Resident 126 revealed that there was no record of discharge completed by the physician within 30 days of the Resident's discharge from the facility.

The surveyor reviewed these findings during an interview on May 23, 2024, at 11:00 AM with the Nursing Home Administrator and Director of Nursing.


 Plan of Correction - To be completed: 07/09/2024

Unable to retroactively correct.

DON/desinee will complete an audit of discharges for the last 30 days to determine if there are other discharge summary notes missing.

NHA/designee will complete education with the facility Medical Director regarding the need for a record of discharge within 30 days of discharge from the facility.

The DON/designee will complete an audit of facility discharges weekly x4 weeks, then monthly x2 months.

The results of these audits will be reported to the QA steering committee x3 months, at which time the committee will determine the need for future audits.

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