Nursing Investigation Results -

Pennsylvania Department of Health
 TWIN LAKES REHABILITATION AND HEALTHCARE CENTER
Patient Care Inspection Results

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TWIN LAKES REHABILITATION AND HEALTHCARE CENTER
Inspection Results For:
There are  143 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.
TWIN LAKES REHABILITATION AND HEALTHCARE 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 a complaint survey completed on August 8, 2019, it was determined that Twin Lakes Rehabilitation and Healthcare Center was not in compliance with the following requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care Facilities and the 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.


 Plan of Correction:


483.25(k) REQUIREMENT Pain Management:This is a more serious deficiency but is isolated to the fewest number of residents, staff, or occurrences. This deficiency results in a negative outcome that has negatively affected the resident's ability to achieve his/her highest functional status.
§483.25(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 policies and clinical records, as well as observations and resident and staff interviews, it was determined that the facility failed to provide pain management for one of 49 residents reviewed (Resident 33), resulting in intolerable pain during care.

Findings include:

The facility's policy regarding pain management, dated January 14, 2019, indicated that staff would implement the pain management program including evaluation/re-evaluation for residents experiencing either acute or chronic pain. The policy also indicated that "pain is whatever the experiencing person says it is, existing whenever the experiencing person says it does." Staff were to obtain information from the evaluation process to determine at what level pain will interfere with the resident's quality of life and prohibit them from carrying out normal life activities.

A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 33, dated June 8, 2019, revealed that the resident was cognitively intact, required limited assistance from staff for his care, and had diagnoses that include chronic obstructive pulmonary disease (COPD - a lung disease that makes it difficult to breathe), pain, muscle weakness and malnutrition.

Physician's orders for Resident 33, dated November 29, 2018, included orders for the resident to receive 800 milligrams (mg) of gabapentin (medication used to treat seizures and some types of pain) four times a day, two 5/325 mg tablets of Percocet (a narcotic pain medication) every six hours, a 0.025-1.25 percent Salonpas medicated patch (for pain) two times a day, and 650 mg of Tylenol every six hours as needed for mild pain. Physician's orders dated July 23, 2019, included orders to continue occupational therapy services five times a week for 30 days for therapeutic exercise, therapeutic activities, and self-care management training.

Resident 33's care plan for pain, dated December 12, 2018, revealed that he had chronic pain related to his back and general discomfort, and that the physician was to be notified if his pain medication was ineffective. A care plan related to a risk of altered skin integrity revealed a goal for the resident not to develop new areas.

A nursing note for Resident 33, dated July 26, 2019, at 11:00 p.m. revealed that pain-relieving gel was applied to the second toe on the right foot. A nursing note dated July 29, 2019, at 11:01 a.m. revealed that the resident had concerns regarding a scab to the second toe on his right foot, and the wound nurse was informed that the resident would like to see her.

A wound nurse note for Resident 33, dated August 1, 2019, at 2:34 p.m. revealed that the resident's right second toe was assessed due to a report that there was a scab. The area was 1.5 x 1.0 cm and was scabbed with some light serous exudate (a clear, thin, watery drainage). Physician's orders, dated August 1, 2019, were for the right second toe to be cleansed daily with normal saline solution, patted dry, painted with betadine, and then for a dry dressing to be applied.

Interview with Resident 33 on August 6, 2019, at 9:36 a.m., in the presence of the Wound Care Coordinator and immediately prior to wound care being provided, revealed that he did not sleep well the night before because of the severe pain he had been experiencing in his toe. The resident stated, "It kept me up most of the night." Observation of wound care to Resident 33's right second toe by the Wound Care Coordinator on August 6, 2019, at 9:39 a.m. revealed that the toe was very red and swollen from the base of the toenail to the bottom of the toe. A brownish, partially opened, partially scabbed area (approximately dime sized) was noted in the middle of the toe. The wound nurse cleansed the resident's toe using a gauze pad that had been soaked with normal saline. While cleaning the wound, Resident 33 was throwing his head back and pounding his fists on the mattress, then grabbing his head and squeezing while rocking back and forth. The resident continued these actions while the wound nurse continued the wound care. She painted the wound with a betadine soaked swab, applying it onto the open/scabbed area using a repeated circular motion. A dry gauze pad was then placed on top of the toe. At no time during Resident 33's wound care did the Wound Care Coordinator offer to stop and check for pain medication.

Interview with the Wound Care Coordinator on August 6, 2019, at 9:50 a.m. confirmed that Resident 33 was experiencing severe pain and she should have stopped the treatment and offered to see about additional pain medication, but she knew that he already received his routine pain medication that morning. She confirmed that the wound on the right second toe had deteriorated since she examined it a week ago, and she would now need to notify the wound doctor. When asked if Resident 33's primary care doctor or the wound doctor were notified when she first assessed the wound on August 1, 2019, she confirmed that neither were notified at that time, that the physician's order for wound care on August 1, 2019, was written as a verbal order based on the facility's wound protocol, and she did not actually speak with a physician for the order.

Interview with Licensed Practical Nurse 18 on August 6, 2019, at 10:03 a.m. revealed that she could administer 650 mg of Tylenol to Resident 33 because he had a routine dose of Percocet that morning and it was too early for another dose, and he received gabapentin and a Salonpas patch that morning.

A follow-up interview with Resident 33 on August 6, 2019, at 12:00 p.m. revealed that he has had neuropathy pain (a result of damage to the peripheral nerves, often causing weakness, numbness and pain, usually in the feet) for a while now. The resident stated, "This pain in my toe is worse than that, it's horrible. It's keeping me up at night, and I've asked to have the doctor look at it, but I don't think he was ever told. I get Percocet regularly but it doesn't touch this pain. It felt like a knife being shoved in there when she was doing whatever she was doing this morning. I don't know how much more of this I can take."

An interview with the Director of Nursing on August 6, 2019, at 12:47 p.m. confirmed that if Resident 33's pain was worse than usual, then the physician should have been notified about it. She also confirmed that she spoke with the Wound Care Coordinator, who told her that Resident 33 had really bad pain during the treatment.

Interview with Resident 33 on August 7, 2019, at 9:54 a.m. revealed that he started having the pain again a short while ago and that the doctor still has not seen him. He once again confirmed that the pain he had yesterday was unbearable and that he's afraid he may lose his toe. The resident stated that the pain is so bad that he is not able to complete his therapy and that they seem to be pushing him when he is not able. He stated, "If the pain wasn't so bad, I might be able to get through a therapy session."

Interview with Certified Occupational Therapy Assistant (COTA) 16 on August 7, 2019, at 11:42 a.m. confirmed that Resident 33 has not been able to complete some of his therapy treatments due to the pain in his right second toe, and there have been days recently when he refused to get out of bed because of the pain. As a result, therapy was not able to see him. She also stated that the area on his toe was noticed approximately two weeks ago as a scabbed area, and then it got "angry" looking and wound treatments were started. She confirmed that it is preventing him from progressing in his treatment.

An occupational therapy note for Resident 33, dated July 19, 2019, indicated that the resident was progressing well with therapy, was motivated to participate, and his maximum functional potential had yet to be achieved. An occupational therapy note dated August 5, 2019, indicated that over the course of the last couple of treatment sessions the resident has been declining the use of the sit-to-stand lift due to developing a sore area to the second toe on the right foot. An occupational therapy note dated August 6, 2019, indicated that discharge planning was completed consisting of a discussion of the appropriateness of using a sit-to-stand lift with staff now that the resident had a wound to the anterior side of the second toe. The therapist offered discharge now and to revisit continuing the use of the sit-to-stand lift when the wound was healed, or if he felt he would be able to continue treatment and begin using a sit-to-stand lift with staff primarily.

Interview with the Director of Nursing and Nursing Home Administrator on August 6, 2019, at 1:45 p.m. revealed that they were not aware that the pain was affecting Resident 33's therapy treatment. The Director of Nursing indicated that Resident 33 was not a drug seeker and would not put on an act to obtain more pain medication.

There was no documented evidence in Resident 33's clinical record to indicate that as of August 8, 2019, at 3:00 p.m. a physician was notified about the wound on the right second toe (first noted on July 26, 2019) or the change in condition with deterioration and increased pain. Interview with the Director of Nursing on August 8, 2019, at 3:00 p.m. confirmed that she was not aware of any progress notes from Resident 33's primary care physician or wound physician to indicate that the resident was seen by either of them related to his toe.

42 CFR 483.25(k) Pain Management.
Previously cited 8/17/18.

28 Pa. Code 211.12(d)(3) Nursing services.
Previously cited 7/17/19, 2/13/19, 10/10/18, 10/1/18, 8/17/18, 5/11/18.

28 Pa. Code 211.12(d)(5) Nursing services.
Previously cited 7/17/19, 3/29/19, 2/13/19, 10/10/18, 10/1/18, 8/17/18, 7/19/18, 5/11/18.


 Plan of Correction - To be completed: 09/19/2019

Resident R33 had a new pain assessment completed.

All residents requiring wound care will have new pain assessments completed.

The Director of Nursing/Designee will meet with residents admitted with or newly developed wounds to determine collaboratively what their tolerable pain level is during treatments.

The facility currently has a FT Wound nurse position available.

Directed in servicing will be completed by covering required topics as stated in the Field Office letter. Slide Presentation available upon request.
The Clinical Educator/Designee will also provide education for the licensed staff on the facility's pain management policy.

An audit will be completed by the Director of Nursing/Designee on pain evaluations and compliance with the facility policy. These audits will be completed on 10% of residents with wounds weekly times eight weeks

Findings of the audits will be reported to the facility Quality Assurance Performance Improvement committee for review. The committee will determine the need for further audits and or action plans.

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 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.
§483.15(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 review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to provide written information about the facility's bed-hold policy to the resident and/or the resident's representative at the time of a transfer for seven of 49 residents reviewed (Residents 4, 6, 10, 22, 42, 48, 58).

Findings include:

The facility's policy regarding bed-holds, dated January 14, 2019, indicated that a bed-hold policy was to be signed at the time a resident leaves.

A nursing note for Resident 4, dated May 24, 2019, at 8:51 p.m. revealed that the resident's left knee x-ray showed a severe posterior (to the rear) dislocation at the knee joint. The physician was notified and gave an order to send the resident to the emergency room, and the resident left facility via ambulance at 9:58 p.m. A nursing note for Resident 4, dated July 12, 2019, at 9:38 a.m. revealed that the resident fell and was transferred to the emergency room for evaluation. There was no documented evidence in Resident 4's clinical record that written information regarding the facility's bed-hold policy was provided to the resident and/or responsible party at the time of his transfers to the hospital.

A change in condition report and nursing note for Resident 6, dated June 7, 2019, at 10:52 a.m. revealed that the resident's hemaglobin level (a protein in red blood cells that carries oxygen throughout the body) was low and the resident was transferred to the hospital and admitted with severe anemia. There was no documented evidence in Resident 6's clinical record that written information about the facility's bed-hold policy was provided to the resident and/or responsible party at the time of her transfer to the hospital.

Nursing notes and a census report dated May 8, 2019, revealed that Resident 10 was admitted to hospital with septic shock (a widespread infection causing organ failure and dangerously low blood pressure); on May 31, 2019, the resident was admitted to the hospital with a urinary tract infection and sepsis (potentially life-threatening complication of an infection); and on July 31, 2019, the resident was sent to the hospital and admitted with sepsis. There was no documented evidence in Resident 10's clinical record that written information about the facility's bed-hold policy was provided to the resident and/or responsible party at the time of her transfers to the hospital.

Nursing notes for Resident 22, dated March 7 and May 20, 2019, revealed that the resident was transferred to the hospital related to changes in her medical condition. There was no documented evidence in Resident 22's clinical record that written information about the facility's bed-hold policy was provided to the resident and/or responsible party at the time of her transfers to the hospital.

A nursing note for Resident 42, dated April 7, 2019, revealed that the resident had audible congestion, was nonverbal and was moaning. She was transferred to the hospital and admitted with sepsis, hypernatremia (high sodium levels), and a urinary tract infection. There was no documented evidence in Resident 42's clinical record that written information about the facility's bed-hold policy was provided to the resident and/or responsible party at the time of her transfer to the hospital.

Physician's progress notes and/or nursing notes for Resident 48, revealed that the resident was transferred to the hospital related to changes in his medical condition on April 14, June 1, June 13, July 9 and July 15, 2019. There was no documented evidence in Resident 48's clinical record that written information about the facility's bed-hold policy was provided to the resident and/or responsible party at the time of his transfers to the hospital.

A nursing note for Resident 58, dated August 2, 2019, at 5:50 p.m. revealed that the resident requested to go to the hospital related to long-standing pain, and the resident was transferred to the hospital as requested. There was no documented evidence in Resident 58's clinical record that written information about the facility's bed-hold policy was provided to the resident and/or responsible party at the time of her transfer to the hospital.

Interview with the Nursing Home Administrator on August 7, 2019, at 3:55 p.m. confirmed that there was no documented evidence that written information about the facility's bed-hold policy was provided to residents at the time of transfers to the hospital. He indicated that residents are given the bed-hold policy only upon admission.

28 Pa. Code 201.14(a) Responsibility of licensee
Previously cited 5/17/19, 2/13/19, 10/1/18, 8/17/18, 7/19/18, 5/11/18.

28 Pa. Code 201.18(b)(3) Management
Previously cited 5/17/19, 2/13/19, 5/11/18.





 Plan of Correction - To be completed: 09/19/2019

Resident R4 no longer resides in the facility.
Resident R6 is currently out of the facility with return anticipated.
Resident 22 no longer resides in the facility.

Resident 10, Resident 42, Resident 48 and Resident 58 currently reside at the facility and either the resident or responsible party has been given the facility bed-hold policy.
A root cause was not identified

A new policy has been developed with a tracking system. for this federal regulation and the Social Services department will now be responsible for the oversight of this regulation regarding bed hold notification.

Education by the Clinical Educator/Designee will be completed for the licensed nursing and social services staff on bed hold notification.

The Administrator / Designee will complete an audit on bed hold notifications daily times one week and weekly times four weeks.


Findings of the audits will be reported to the facility Quality Assurance Performance Improvement committee for review. The committee will determine the need for further audits and or action plans.

483.75(g)(2)(ii) REQUIREMENT QAPI/QAA Improvement Activities: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.
§483.75(g) Quality assessment and assurance.

§483.75(g)(2) The quality assessment and assurance committee must:
(ii) Develop and implement appropriate plans of action to correct identified quality deficiencies;
Observations:


Based on clinical record reviews, observations and staff interviews, it was determined that following the identification of an issue with lack of safety assessments with the use of speciality mattresses via the Quality Assurance (QA) process, that the facility failed to ensure that it corrected an identified quality deficiency regarding resident safety, and based on the facility's plans of correction for previous surveys, and the results of the current survey, it was determined that the facility's Quality Assurance Performance Improvement (QAPI) committee failed to correct quality deficiencies and ensure that plans to improve the delivery of care and services effectively addressed recurring deficiencies.

Findings include:

Interview with Registered Nurse 7 (the facility's wound coordinator) on August 8, 2019, at 10:50 a.m. revealed that via her QA process she identified on June 20, 2019, that specialty mattress assessments were not done, so at that time she obtained physician's orders for an assessment to be completed every three months for residents who had specialty mattress in use.

However, clinical record reviews, observations and staff interviews identifed that safety assessments for the use of air mattress were not completed prior to air mattresses being placed on the beds of Residents 4, 30, 42, 48, 63, 239 and 289.

Interview with the Director of Nursing on August 8, 2019, at 10:59 a.m. confirmed that there was no documented evidence that the use of air mattresses were assessed for potential safety hazards for the residents above.

Refer to F689.


The facility's deficiencies and plans of correction for a State Survey and Certification (Department of Health) survey ending February 13, 2019, revealed that the facility developed plans of correction that included quality assurance systems to ensure that the facility maintained compliance with cited nursing home regulations. The results of the current survey, ending August 8, 2019, identified repeated deficiencies related to physician's orders, proper catheter care, weight loss management, tube feeding management, and proper labeling and storage of drugs.

The facility's plan of correction for a deficiency regarding a failure to follow physician's orders and provide needed care, cited during the survey ending February 13, 2019, revealed that the facility would complete audits and the results would be reviewed as part of quality assurance. The results of the current survey, cited under F684, revealed that the facility's QAPI committee was ineffective in maintaining compliance with the regulation regarding following physician's orders and providing needed care.

The facility's plan of correction for a deficiency regarding a failure to provide proper catheter care, cited during the survey ending February 13, 2019, revealed that the facility would complete audits and the results would be reviewed as part of quality assurance. The results of the current survey, cited under F690, revealed that the facility's QAPI committee was ineffective in maintaining compliance with the regulation regarding catheter care.

The facility's plan of correction for a deficiency regarding weight loss management, cited during the survey ending February 13, 2019, revealed that the facility would complete audits and the results would be reviewed as part of quality assurance. The results of the current survey, cited under F692, revealed that the facility's QAPI committee was ineffective in maintaining compliance with the regulation regarding weight loss management.

The facility's plan of correction for a deficiency regarding a failure to provide proper care for tube feedings, cited during the survey ending February 13, 2019, revealed that the facility would complete audits and the results would be reviewed as part of quality assurance. The results of the current survey, cited under F693, revealed that the facility's QAPI committee was ineffective in maintaining compliance with the regulation regarding tube feedings.

The facility's plan of correction for a deficiency regarding a failure to label and store medications properly, cited during the survey ending February 13, 2019, revealed that the facility would complete audits and the results would be reviewed as part of quality assurance. The results of the current survey, cited under F761, revealed that the facility's QAPI committee was ineffective in maintaining compliance with the regulation regarding labeling and storing medications properly.

Refer to F684, F690, F692, F693, F761.

42 CFR 483.75(g)(2)(ii) QAPI/QAA Improvement Activities.
Previously cited 2/13/19, 8/17/18, 7/19/18, 5/11/18.

28 Pa. Code 201.14(a) Responsibility of licensee.
Previously cited 5/17/19, 2/13/19, 10/1/18, 8/17/18, 7/19/18, 5/11/18.

28 Pa. Code 201.18(e)(1) Management.
Previously cited 2/13/19, 10/10/18, 8/17/18, 7/19/18, 5/11/18.





 Plan of Correction - To be completed: 09/19/2019

The facility has changed the format of the Quality Assurance Performance Improvement meeting to focus more on correcting any quality deficiencies and review of the facilities plans of corrections for previous surveys to prevent recurring deficiencies that involve delivery of care and services.
Specific areas of deficient practice involving quality of care will be chosen for each Quality Assurance Performance Improvement meeting to review and assess the facility 's plan for correction. Root Cause Analysis in not used.

Specific areas of deficient practice involving quality of care will be chosen for each QAPI meeting to review and assess the facility 's plan for correction.

The Administrator/Designee will educate the Quality Assurance and Performance Improvement committee members on plans and actions to meet the requirements of the regulation.

Repeat deficiency audits will be reviewed monthly at the Quality Assurance and Performance committee meeting.

Findings of the audits will be reported to the facility Quality Assurance Performance Improvement committee for review. The committee will determine the need for further audits and or action plans.


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

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

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

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

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

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


Based on review of policies, lists provided by the pharmacy, and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that residents' clinical records were complete and included monthly pharmacy reviews that were completed for four of 49 residents reviewed (Resident 3, 6, 29, 37), and failed to ensure that records were complete and included the documentation of a registered nurse assessment for one of 49 residents reviewed (Resident 4).

Findings include:

The facility's policy regarding the role of the consultant pharmacist, dated January 14, 2019, indicated that the consultant pharmacist would perform drug regimen reviews for each resident at least monthly, and any findings or irregularities would be reported to the Director of Nursing.

A list of monthly resident medication reviews provided by the facility revealed that medication reviews were completed by the facility's pharmacy for Resident 3 on April 18, May 23, June 14 and July 21, 2019; however, there was no documented evidence that the pharmacy reviews were a part of the resident's clinical record.

A list of monthly resident medication reviews provided by the facility revealed that medication reviews were completed by the facility's pharmacy for Resident 6 on May 23, June 14 and July 21, 2019; however, there was no documented evidence that the pharmacy reviews were a part of the resident's clinical record.

A list of monthly resident medication reviews provided by the facility revealed that medication reviews were completed by the facility's pharmacy for Resident 29 on March 23, April 18 and July 21, 2019; however, there was no documented evidence that the pharmacy reviews were a part of the resident's clinical record.

A list of monthly resident medication reviews provided by the facility revealed that medication reviews were completed by the facility's pharmacy for Resident 37 on March 23, April 18, May 23, June 14 and July 21, 2019; however, there was no documented evidence that the pharmacy reviews were a part of the resident's clinical record.

Interview with the Director of Nursing on August 8, 2019, at 5:08 p.m. revealed that the monthly pharmacy reviews should be part of each resident's clinical record, but the pharmacy did not put them on the records unless there was a recommendation to the physician.


A nursing note for Resident 4, dated August 5, 2019, at 2:48 a.m.. and completed by a licensed practical nurse, revealed that respiratory therapy was called to the resident's room to suction and assess the resident's oxygen saturation (level of oxygen in the blood) of 76 percent (normal readings usually range from 95 to 100 percent). A nursing note that day at 2:51 a.m., completed by a licensed practical nurse, revealed that the registered nurse was notified and assessed the resident at that time.

However, as of August 7, 2019, there was no documented evidence that the registered nurse's progress note was including in Resident 4's clinical record.

Interview with Registered Nurse 3 on August 6, 2019, at 3:58 p.m. confirmed that Resident 4's clinical record contained no documented evidence that the registered nurse completed a progress note related to the assessment of the resident's condition on August 5, 2019.

Interview with the Director of Nursing on August 7, 2019, at 8:40 a.m. confirmed that there was no documented evidence that the registered nurse documented a progress note regarding her assessment of Resident 4's condition on August 5, 2019.

42 CFR 483.20(f)(5), 483.70(i)(1)-(5) Resident Records - Identifiable Information.
Previously cited 8/17/18.

28 Pa. Code 211.5(f) Clinical records.
Previously cited 7/17/19, 8/17/18, 5/11/18.

28 Pa. Code 211.12(d)(5) Nursing services.
Previously cited 7/17/19, 3/29/19, 2/13/19, 10/10/18, 10/1/18, 8/17/18, 7/19/18, 5/11/18.


 Plan of Correction - To be completed: 09/19/2019

The facility will review the role and responsibilities of a consultant pharmacist with the current contracted pharmacy consultant in order to meet the needs of the residents, regulations, and facility.

The facility will review the role and responsibilities of the consultant pharmacist with completion of the medical record.

The Clinical Educator/Designee will educate licensed staff on the pharmacy consultant role in the facility and the policy of what is included in a complete medical record; to include Registered Nurse assessments.

An audit will be completed by the Director of Nursing/designee on monthly pharmacy consultant reports to confirm there is evidence that all residents' medications were reviewed. This audit will be completed monthly times three months.

Findings of the audits will be reported to the facility Quality Assurance Performance Improvement committee for review. The committee will determine the need for further audits and or action plans.


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 review of policies, cleaning schedules and clinical records, as well as observations and staff interviews, it was determined that the facility failed to maintain a clean and sanitary environment in the kitchen, as well as in one of three microwave ovens located on the nursing units (Mellon unit).

Findings include:

The facility's policy regarding cleaning kitchen floors, dated January 14, 2019, indicated that kitchen floors would be swept and cleaned after each meal, and major appliances would be moved at least once a month (as appropriate) in order to facilitate cleaning behind and underneath them.

The kitchen's cleaning schedules for June, July and August 2019 revealed no documented evidence that floors were cleaned daily as scheduled.

Observations in the kitchen on August 6, 2019, at 1:21 p.m. revealed that there was debris accumulated on the floor under a large wire shelving unit in the back of the kitchen. The debris included an empty milk carton, a plastic cup, a straw, a plastic bag, a plastic dessert dish, dirt, dust and food particles. Observations behind the stove on August 6, 2019, at 1:23 p.m. revealed that there was an accumulation of debris on the floor that included a hard plastic serving dish, a stack of plastic lids, paper, dirt and food particles.

Interview with the Dietary Manager on August 6, 2019, at 1:24 p.m. confirmed that the cleaning schedules were not complete and areas of the kitchen floors were dirty and should not have been.


The facility's policy regarding cleaning microwave ovens, dated January 14, 2019, indicated that the interior of the microwave oven was to be cleaned with hot sudsy water and food particles were to be removed.

Observations in the medication room on the Mellon unit on August 6, 2019, at 11:45 a.m. revealed that there was a heavy accumulation of a brown substance on the sides and top inner surfaces of the microwave oven.

Interview with Registered Nurse 4 on August 6, 2019, at 11:48 a.m. confirmed that the inside of the microwave oven was heavily soiled and needed to be cleaned.

42 CFR 483.60(i)(1)(2) Food Procurement, Store/Prepare/Serve - Sanitary.
Previously cited 2/13/19, 5/11/18.

28 Pa. Code 211.6(f) Dietary services.
Previously cited 2/13/19.
28 Pa. Code 207.2(a) Administrator's responsibility.




 Plan of Correction - To be completed: 09/19/2019

The facility will be deep cleaning the kitchen including the floors.

The daily cleaning schedule for the kitchen now includes the floors and the microwave.
A new microwave oven was purchased for Mellon unit.

The Dietary Director/Designee will educate dietary staff on the new cleaning schedule and this Federal Regulation.

An audit of cleanliness of the kitchen will be completed by the Dietary Director/Designee. These audits will be completed daily times one week and weekly times four weeks.


Findings of the audits will be reported to the facility Quality Assurance Performance Improvement committee for review. The committee will determine the need for further audits and or action plans.


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 review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that non-pharmacological (non-medication) interventions were attempted prior to the administration of anti-anxiety medications for one of 49 residents reviewed (Resident 58), and failed to ensure that the physician responded timely to pharmacy recommendations related to possible unnecessary medications for four of 49 residents reviewed (Residents 22, 39, 53, 61).

Findings include:

The facility's policy regarding medication administration, dated January 14, 2019, indicated that "as needed" medications were to be kept separate on the Medication Administration Record (MAR) with the indication for use.

A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 58, dated June 4, 2019, indicated that the resident was alert and oriented, had no behavior symptoms, and had diagnoses that included anxiety. Physician's orders, dated May 7, 2019, included an order for the resident to receive 0.5 milligrams (mg) of lorazepam (an anti-anxiety medication) twice a day "as needed" for anxiety.

Resident 58's care plan, initiated December 17, 2018, revealed that staff were to always approach the resident calmly and unhurriedly and speak in a calm voice; attempt to refocus behaviors to something positive when depressed; encourage activities of Resident 58's choice (crafts, games, outings, reading, television, educational programs, helping at social parties, and word puzzles); and were to attempt non-medication interventions and document on the behavior tracking sheets every shift. Non-medication interventions included but were not limited to activity programs (crafts, games, outings, reading, television, educational programs, helping at socials parties, word puzzles, quiet time/rest, and reassurance).

Resident 58's MAR's for July and August 2019 revealed that staff administered 0.5 mg of "as needed" lorazepam for anxiety on July 13 at 9:28 p.m., July 14 at 10:08 p.m., July 16 at 9:56 p.m., July 18 at 8:32 p.m., July 19 at 11:51 p.m., July 20 at 8:20 p.m., July 21 at 8:06 p.m., July 22 at 11:45 p.m., July 23 at 9:06 p.m., July 24 at 9:24 p.m., July 25 at 8:50 p.m., July 27 at 8:38 p.m., July 28 at 8:44 p.m., July 29 at 10:19 p.m., July 30 at 9:43 p.m., July 31 at 9:06 p.m., August 1 at 9:30, August 4 at 8:00 p.m., August 5 at 10:27 p.m., August 6 at 8:06 p.m., and August 7 at 11:01 p.m.

There was no corresponding documentation in Resident 58's clinical record regarding any non-medication interventions that were attempted in accordance with the resident's care plan and prior to the administration of lorazepam on the above days, and/or no documented evidence that other interventions were attempted when one intervention was ineffective.

Interview with Registered Nurse 8 on August 8, 2019, at 7:01 p.m. confirmed that there was no documented evidence that staff attempted one or more non-medication interventions listed in Resident 58's care plan prior to administering "as needed" lorazepam on the above dates.


The facility's consultant pharmacy policy, dated January 14, 2019, indicated that the consultant pharmacist would perform a drug regimen review for each resident at least monthly, and any findings or irregularities were to be reported to the Director of Nursing and Nursing Home Administrator. The consultant was responsible for evaluating medication orders, monitoring medication administration, evaluating response to medication therapy, communicating observations and recommendations, and providing in-service to the staff and/or residents of the facility.

Physician's orders for Resident 22, dated May 26, 2019, included orders for 60 mg of Cymbalta (used to treat depression) once daily, 75 mg of Trazadone (used to treat depression) every evening at bedtime, 10 mg of Buspar (sometimes used to treat anxiety) twice each day, 5 mg of Zyprexa (used to treat psychotic disorders) twice each day, and 1 mg of Klonopin (used to treat anxiety) twice each day.

A pharmacy medication review for Resident 22, dated March 23, 2019, revealed that the resident had been using 60 mg of Cymbalta daily since May 2018, and if this dose was required to prevent future depressive episodes, the pharmacist requested the physician to please document to that effect in a progress note. There was no documented evidence in Resident 22's clinical record that the physcian responded to the pharmacist's recommendation.

A pharmacy medication review for Resident 22, dated April 16, 2019, revealed that the resident had been taking 5 mg of Zyprexa twice each day since November 2018 and without a Gradual Dose Reduction (GDR). The pharmacist asked if a dose reduction could be attempted at this time to verify that the resident was on the lowest possible dose, and if not, to please indicate a response. The pharmacy review was signed by the physician on May 15, 2019, with a response of "Cont. use" and no rationale or reason for its continued use or why a dose reduction was contraindicated.

A pharmacy medication review for Resident 22, dated April 16, 2019, revealed that the resident had been taking 10 mg of Buspar twice each day since November 2018 without a GDR, and the pharmacist requested if a dose reduction could be attempted at this time to verify that the resident was on the lowest possible dose, and if not, to please indicate a response. The physician signed the pharmacy review on May 15, 2019, and the response was "need it." There was no documentation regarding the rationale for its continued use or why a dose reduction was contraindicated.

A pharmacy medication review for Resident 22, dated May 10, 2019 revealed that the resident had been taking 75 mg of Trazodone each day since November 2018. The pharmacist requested that the resident be reviewed for a GDR and to document if any change in therapy was contraindicated for the resident. There was no documented evidence in Resident 22's clinical record to indicate that the physcian responded to the pharmacist's recommendation.

A pharmacy medication review for Resident 22, dated July 9, 2019, revealed that the resident had been taking 1 mg of clonazepam (Klonopin) twice each day since January 2019 without a GDR, and the pharmacist asked if a dose reduction could be attempted at this time. There was no documented evidence in Resident 22's clinical record that the physician responded to the pharmacist's recommendation.


Physician's orders for Resident 39, dated December 20, 2018, included an order for 250 mg of Depakote (used to treat seizures and sometimes used to treat psychotic disorders) twice each day. An order dated June 7, 2019, was for 25 mg of Seroquel (used to treat psychotic disorders) every day and an order on June 8, 2019, was for 50 mg of Seroquel every evening at bed time.

A pharmacy medication review for Resident 39, dated April 16, 2019, revealed that the resident was on Seroquel 50 mg twice daily since October 2018 without a GDR, and an attempt at a dose reduction was requested at this time to verify that the resident was on the lowest dose. There was no documented evidence in Resident 39's clinical record that the physcian responded to the pharmacist's recommendation.

A pharmacy medication review for Resident 39, dated June 14, 2019, revealed that the resident had been on Depakote 250 mg twice daily since December 2018 and requested that the physician review for a GDR and document if any change in therapy was contraindicated for the resident. There was no documented evidence in Resident 39's clinical record that the physcian responded to the pharmacist's recommendation.


Physician's orders for Resident 53, dated October 22, 2018, included an order for a half of a 10 mg tablet (5 mg) of Celexa (used to treat depression) daily.

A pharmacy medication review for Resident 53, dated July 9, 2019, revealed that the resident had been using Celexa 5 mg daily since October 2018, and if the medication was required to prevent future depressive episodes, to please document to that effect in a progress notes. There was no documented evidence in Resident 53's clinical record to indicate that the physician responded to the pharmacist's recommendation.


Physician's orders for Resident 61, dated June 20, 2019, included and order for 0.5 mg of Ativan (used to treat anxiety) every four hours as needed for generalized anxiety disorder.

A pharmacy medication review for Resident 61, dated July 9, 2019, revealed a recommendation for the discontinuation/re-evaluation of "as needed" Ativan, which was to be limited to 14 days, except when the attending physician or prescribing practitioner believed that it was appropriate for the "as needed" order to be extended beyond 14 days. The physician was to document the rationale in the resident's medical record and indicate the duration (i.e.; in days, weeks or months) for the new "as needed" order, and extending the "as needed" order for an "Indefinite" time did not meet the intent of the federal regulation. There was no evidence in Resident 61's clinical record that the physician responded to the pharmacists' recommendation.

Interview with Registered Nurse 20 on August 8, 2019, at 12:50 p.m. confirmed that she was not able to find physician responses to the consultant pharmacist's recommendations for Residents 22, 39, 53 and 61.

28 Pa. Code 211.12(d)(3) Nursing services.
Previously cited 7/17/19, 2/13/19, 10/10/18, 10/1/18, 8/17/18, 5/11/18.

28 Pa. Code 211.12(d)(5) Nursing services.
Previously cited 7/17/19, 3/29/19, 2/13/19, 10/10/18, 10/1/18, 8/17/18, 7/19/18, 5/11/18.


 Plan of Correction - To be completed: 09/19/2019

Resident R58 resides at the facility and non-pharmacological interventions will be attempted prior to the use of her anti-anxiety medication.
Resident R22 no longer resides at the facility
Residents 39,53, and 61 remain in the facility.
Physician reviewed pharmacy recommendations on R39, R53, and R61.

No root cause identified. No other residents were identified.

The Director of Nursing now receives the consultant report, including any pharmacist recommendations in email and general mail.

The Director of Nursing now receives copies of all addressed recommendations to confirm the physician addressed the recommendations on their next visit after receiving them.

The Clinical Educator/Designee will educate nursing staff on the importance of non-pharmacological interventions prior to medication administration and on compliance with physician responses to pharmacy recommendation.

An audit will be completed by the Director of Nursing/Designee on the use of non-pharmacological interventions. This audit will be completed on a 5% random residents daily times one-week, weekly times 4 weeks.

Findings of the audits will be reported to the facility Quality Assurance Performance Improvement committee for review. The committee will determine the need for further audits and or action plans.

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 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(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 review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that monthly pharmacy medication reviews were completed for four of 49 residents reviewed (Residents 8, 47, 53, 58).

Findings include:

The facility's policy regarding for role of the consultant pharmacist, dated January 14, 2019, indicated that the consultant pharmacist was to perform a drug regimen review for each resident at least monthly, and any findings or irregularities were to be reported to the Director of Nursing.

A nursing note for Resident 8, dated May 10, 2019, revealed that the resident was admitted to the facility from the hospital. Review of Resident 8's clinical record revealed no documented evidence that the pharmacist performed a monthly review of medication for the resident in June 2019.

Review of Residents 47 and 53's clinical records revealed no documented evidence that the pharmacist performed a monthly review of medications in May or June 2019.

A list of residents' completed drug regimen reviews provided by the facility's contracted pharmacy, dated May 1 to 23 and June 1 to 14, 2019, revealed that Residents 8, 47, and 53 were not listed as being reviewed in May and June 2019.

Review of Resident 58's clinical record revealed no documented evidence that the pharmacist performed a monthly review of medications in April and July 2019.

Interview with the Director of Nursing on August 8, 2019, at 12:10 p.m. confirmed that there was no documented evidence that monthly medication reviews were completed as above. She indicated that the consultant pharmacist only documents on a resident's record if there is a recommendation.

28 Pa. Code 211.9(a)(1) Pharmacy services.
Previously cited 5/11/18.

28 Pa. Code 211.12(d)(3) Nursing services.
Previously cited 7/17/19, 2/13/19, 10/10/18, 10/1/18, 8/17/18, 5/11/18.


 Plan of Correction - To be completed: 09/19/2019

Resident R53 was discharged to home.

Residents R8, R58, R47 remain at the facility in stable condition.

All residents in the facility are at risk. No other residents were identified.

The pharmacy consultant will add a progress note that residents medications were reviewed when completed.

The Clinical Educator/Designee will educate licensed staff on the pharmacy consultant role in the facility and the Federal Regulation 0756.

An audit will be completed by the Director of Nursing/designee on monthly pharmacy consultant reports to confirm there is evidence that all residents' medications were reviewed. This audit will be completed monthly times three months.

Findings of the audits will be reported to the facility Quality Assurance Performance Improvement committee for review. The committee will determine the need for further audits and or action plans.


483.25(d)(1)(2) REQUIREMENT Free of Accident Hazards/Supervision/Devices:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
§483.25(d) Accidents.
The facility must ensure that -
§483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and

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


Based on review of facility policies, manufacturer's instructions and clinical records, as well as observations and staff interviews, it was determined that the facility failed to maintain an environment that was free from accident hazards for two of 49 residents reviewed (Residents 10, 30) who used bolsters on their bed, failed to ensure that an air mattress and/or bolster safety assessments were completed prior to use to identify potential safety hazards for seven of 49 residents (Residents 4, 14, 42, 48, 63, 239, 289), and failed to ensure that residents were transported in a safe manner for three of 49 residents reviewed (Residents 11, 31, 43) who were transported by staff without leg rests on their wheelchairs.

Findings include:

The facility's policy regarding fall prevention, dated January 14, 2019, indicated that if a fall occurred, the resident would be evaluated for any injury, there would be immediate interventions as necessary, the fall would be investigated related to the potential reason for the fall, and appropriate interventions to prevent further falls would be determined.

The manufacturer's instructions for roll control bolsters (wedge type devices strapped together and placed on each side of a resident's mattress), undated, indicated that they were used to prevent rolls from the bed, measured 7 inches in height, were to be positioned with the base of the bolster (measuring 8 inches) directly on top of the mattress, and the velcro between the two bolsters was to be adjusted to ensure proper placement. When connecting the two bolsters together, the velcro strap was to be placed through the webbing loop on the bottom of the opposing bolster, then traced over the bolster and threaded through the rectangular ring on the bottom back of the bolster.

A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 10, dated May 20, 2019, indicated that the resident was confused, required the extensive assistance of two staff for bed mobility and transfers and was totally dependent for hygiene and bathing, was non-ambulatory (could not walk), and had impaired range of motion (joint movement) on both sides of her body. The resident's care plan, initiated December 28, 2018, and updated on August 4, 2019, indicated that she was at risk of falls due to spastic movements of her upper body and a history of falls, and that she had a low bed with bolsters in use.

An incident report dated February 1, 2019, revealed that Resident 10 was found with her legs on the floor and her upper body on the bed, and that she had a low bed and bolsters in use. It was found that the bolsters were improperly applied with one tie under the bed frame instead on top of the bar under the bed, and that education was completed regarding the proper application of the bolsters on air mattresses.

Interview with the Maintenance Director on August 8, 2019, at 2:38 p.m. revealed that he did not have a record of the staff who were educated on the proper placement of the bolsters after Resident 10's fall; however, he was aware that he educated all of the licensed staff on the shift at the time of the incident.

Observations of Resident 10 while in bed on August 5, 2019, at 10:59 a.m. revealed that she had an air mattress in use and that there were two bed bolsters attached to the bed (one on each side of the resident). The bolster on the right side of the bed was in an upright position with the base of the bolster sitting on the mattress; however, the left bolster base was over the side of the mattress, causing the bolster's inner aspect to be in a lateral (sideways) position to the mattress and not upright.

Interview with Registered Nurse 4 on August 5, 2019, at 12:15 p.m. confirmed that Resident 10's bolster on the left side of the bed was not in the proper, upright position and that it needed to be secured more tightly with the bed straps to hold it in place, due to the resident moving and randomly kicking with her legs. When the nurse repositioned the right bolster more toward the edge of the mattress, it caused the left bolster to stand more upright.

Observations of Resident 10 while in bed on August 8, 2019, at 8:36 a.m. revealed that she was positioned on her back with a pillow by her left shoulder area. The bed bolster on right side of the bed was on top of the mattress and upright, but the bolster base on the left side of the resident was partially off the bed. The right bolster's blue strap in the middle of the bolster was tight, the two smaller straps on each side of the middle strap were taunt, and there was inward compression of the side of the air mattress. On the left side of the bolster, the smaller outer straps were not threaded through the rectangular ring (as per the manufacturer's instructions) on the bottom back of the bolster and the straps were around the the outer aspect of the bolster.

Interview with the Director of Nursing on August 8, 2019, at 9:04 a.m. and 10:28 a.m. confirmed that Resident 10's bolster was not in the upright position and that there were no straps going through the rectangular rings.

There was also no documented evidence that a thorough safety assessment was completed to ensure that no accident hazards were created by using the bolster with an air mattress.


An admission MDS assessment for Resident 30, dated March 14, 2019, and a quarterly MDS assessment dated June 10, 2019, indicated that the resident was confused, required the extensive assistance of two with bed mobility and transfers, and ambulated with the limited assistance of two to walk in her room. A fall risk assessment, dated March 7, 2019, indicated that the resident had a history of falls and was at high risk for further falls. An occupational therapy note, dated March 8, 2019, indicated that the resident had an air mattress in use with bolsters and fall mats.

Nursing notes and incident reports for Resident 30, dated March 8, 10, 13 and 14, 2019; April 4 and 6, 2019; and May 7 and 29, 2019, revealed that the resident had a fall out of bed with the specialty air mattress and bolsters in use, and that seven of the eight falls from bed occurred between the hours of 10:00 p.m. and 2:30 a.m. A report dated March 13, 2019, indicated that the resident was forcing herself over the bolsters. A report dated April 4, 2019, indicated that staff were educated to ensure that the bolsters were attached tightly to the bed. A report dated May 29, 2019, indicated that the resident said she "slipped off the bed."

There was no documented evidence that a safety assessment was completed related to the use of the specialty mattress with bolsters and related to the resident's fall risk. There was no documented evidence of any assessments of the resident's falls related to the times they occurred, and no evidence that new or revised interventions to prevent further falls and/or injury were developed and initiated.

Observations of Resident 30 on August 8, 2019, at 9:18 a.m. and 10:17 a.m. revealed that she was in bed with a specialty air mattress in use with attached bolsters, and the over-the-bed table was across her bed with the base of the stand on the left side of the bed. The bolster on the right side of the bed was in an upright position with the base resting on top of the mattress, and the left bolster base was leaning partially over the edge of the mattress, resulting in a more lateral instead of an upright position of the bolster on the bed.

Observations and interview with the Director of Nursing on August 8, 2019, at 10:17 a.m. confirmed that the bolster on the right side of Resident 30's bed was in an upright position, and that the left bolster was not in an upright position with the base flat on the mattress.


An admission MDS assessment for Resident 4, dated May 14, 2019, revealed that the resident was sometimes understood and could sometimes understand, required either extensive assistance from two staff or was dependent on staff for daily care tasks, and had a medical history that included seizure disorder. The resident's care plan, dated July 11, 2019, revealed that the resident had a pressure ulcer (skin breakdown caused by prolonged, unrelieved pressure) to his left hip and was to use a specialty air mattress for pressure reduction and wound prevention/healing. A care plan dated August 6, 2019, revealed that the resident was at risk for falls and was to have a bolster cover to the mattress to aid in prevention of rolling out of bed.

Observations of Resident 4 on August 5, 2019, at 10:55 a.m. revealed that the resident was lying in bed, and the bed was equipped with an air mattress and a bolster.

There was no documented evidence that the use of an air mattress and/or a bolster was assessed for potential safety hazards prior to placing the air mattress and bolster on Resident 4's bed.


A quarterly MDS assessment for Resident 14, dated May 28, 2019, revealed that the resident was confused, required extensive assistance with bed mobility, and had a history of falls. Physician's orders dated March 7, 2019, included orders for an air mattress to be applied to the bed and for an air mattress evaluation to be completed every three months.

There was no documented evidence that the use of an air mattress was assessed for potential safety hazards prior to the air mattress being placed on Resident 14's bed, and no documented evidence that the air mattress was assessed for safety until June 1, 2019.

Observations on August 8, 2019, at 3:53 p.m. revealed that Resident 14's bed was equipped with an air mattress.


A quarterly MDS assessment for Resident 42, dated June 14, 2019, revealed that the resident was comatose, was dependent for bed mobility, had pressure ulcers, and had diagnoses that included persistent vegetative state. A physician's order, dated June 20, 2019, included orders for an air mattress bed applied to the bed for pressure reduction and wound healing and for an air mattress evaluation to be completed every three months.

Observations on August 5, 2019, at 12:27 p.m. revealed that Resident 42's bed was equipped with an air mattress.

As of August 8, 2019, there was no documented evidence that the use of an air mattress was assessed for potential safety hazards prior to the air mattress being placed on Resident 42's bed.


An annual MDS assessment for Resident 48, dated June 23, 2019, revealed that the resident was understood and could understand, required extensive assistance from two staff for daily care, and the resident's care plan, dated August 6, 2019, revealed that due to pressure ulcers (skin impairment caused by prolonged, unrelieved pressure), the resident's bed was to be equipped with a specialty mattress for pressure reduction, prevention and wound healing.

Observations of Resident 48 on August 5, 2019, at 12:07 p.m. and August 7, 2019, at 3:32 p.m. revealed that the resident was lying in a bed that was equipped with an air mattress.

There was no documented evidence that the use of an air mattress was assessed for potential safety hazards prior to the air mattress being placed on Resident 48's bed.


A quarterly MDS assessment for Resident 63, dated July 16, 2019, revealed that the resident was cognitively intact, required extensive assistance with bed mobility, had pressure ulcers, and had limited range of motion to both lower extremities. Physician's orders, dated June 20, 2019, included orders for an air mattress to be applied to the bed for pressure reduction and wound healing, and for an air mattress evaluation to be completed every three months.

There was no documented evidence that the use of an air mattress was assessed for potential safety hazards prior to the air mattress being placed on Resident 63's bed.

Observation on August 6, 2019, at 1:50 p.m. revealed that Resident 63's bed was equipped with an air mattress.


An annual MDS assessment for Resident 239, dated July 12, 2019, revealed that the resident was cognitively intact, required extensive assistance for daily care tasks, and was at risk for falls. The resident's care plan, dated July 14, 2019, revealed that she was at risk for falls due to involuntary muscle movements, psychotropic drug use and generalized weakness. Physician's orders, dated June 20, 2019, included an order for a specialty air mattress for pressure reduction and wound healing, and this order was discontinued on August 2, 2019.

Observations of Resident 239 on August 5, 2019, at 10:39 a.m. and August 6, 2019, at 9:15 a.m. revealed that the resident was in bed sleeping on an air mattress.

There was no documented evidence that the use of an air mattress was assessed for potential safety hazards prior to the air mattress being placed on Resident 239's bed.


A nursing note for Resident 289, dated August 1, 2019, revealed that the resident was admitted that day from the hospital, the resident was awake and could mouth words, but was unable to speak. Physician's orders, dated August 8, 2019, included an order for the resident to have a specialty mattress for pressure reduction and/or wound healing.

Observations of Resident 289 on August 5, 2019, at 11:08 a.m. and August 8, 2019, at 9:25 a.m. revealed that the resident was lying in a bed that was equipped with an air mattress and bolsters.

There was no documented evidence that the use of an air mattress and/or bolsters was assessed for potential safety hazards prior to the air mattress and bolsters being placed on Resident 289's bed.

Interview with the Director of Nursing on August 8, 2019, at 10:59 a.m. confirmed that there was no documented evidence that the use of air mattresses and/or bolsters were assessed for potential safety hazards for the residents above.


A comprehensive MDS assessment for Resident 11, dated June 17, 2019, revealed that the resident required extensive assistance for movement on the unit. The resident's care plan, dated June 24, 2019, revealed that she was at risk for falls related to immobility, and diagnosis information dated July 1, 2019, revealed that the resident had diagnoses that included muscle wasting and atrophy (decrease in the strength of muscles).

Observations of Resident 11, on August 5, 2019, at 12:40 p.m. revealed that she was pushed in her wheelchair down the hall and into the activities room by the Activities Director, and during the transport, the resident was holding her feet up. There where no leg rests on the wheelchair.

There was no documented evidence that an assessment was completed to determine if Resident 11 was safe to transport in a wheelchair while holding her feet up.

Interview with the Activities Director on August 5, 2019, at 12:44 p.m. confirmed that leg rests are to be used when transporting residents in wheelchairs.


An annual MDS assessment for Resident 31, dated June 7, 2019, revealed that the resident was understood and could understand, and required assistance from staff for his care. The resident's care plan, dated June 20, 2019, revealed that he was at risk for falls.

Observations of Resident 31 on August 5, 2019, at 12:20 p.m. revealed that he was pushed in his wheelchair into the dining room by Nurse Aide 9, and his feet were sliding along on the floor. There were no leg rests on the chair.

There was no documented evidence that an assessment was completed to determine if Resident 31 was safe to transport in a wheelchair while attempting to hold his feet up.

Interview with Nurse Aide 9 on August 5, 2019, at 12:22 p.m. confirmed that leg rests were to be used when transporting residents in a wheelchair.


A quarterly MDS assessment for Resident 43, dated June 15, 2019, revealed that the resident was cognitively impaired, required supervision with his care, and had a history of falls.

Observations of Resident 43 on August 5, 2019, at 12:31 p.m. revealed that he was being transported in his wheelchair into the dining room by Nurse Aide 10. The wheelchair was not equipped with leg rests, and the resident was holding his feet up during the transport.

There was no documented evidence that an assessment was completed to determine if Resident 43 was safe to transport in a wheelchair while holding his feet up.

Interview with Nurse Aide 10 at that time confirmed that there should have been leg rests on Resident 43's wheelchair during transport.

42 CFR 483.25(d)(1)(2) Free of Accident Hazards/Supervision/Devices.
Previously cited 10/1/18, 7/19/18, 5/11/18.

28 Pa. Code 211.12(d)(3) Nursing services.
Previously cited 7/17/19, 2/13/19, 10/10/18, 10/1/18, 8/17/18, 5/11/18.

28 Pa. Code 211.12(d)(5) Nursing services.
Previously cited 7/17/19, 3/29/19, 2/13/19, 10/10/18, 10/1/18, 8/17/18, 7/19/18, 5/11/18.




 Plan of Correction - To be completed: 09/19/2019

Resident 10, and 30 remain in the facility. Therapy referrals were made to determine whether use of bolsters were needed for the individual resident.
Resident R4 was out of facility during the survey and remains out of the facility.
Resident 14, 42, 48, and 63 remain in the facility and an air mattress evaluation has been completed.
Resident 239, and 289 are no longer in the facility.
Residents 11, 31, and 43 remain independently mobile in their wheelchair.
No root cause analysis was completed.

All residents with air mattress/bolsters are at risk.
Air mattress evaluations were completed on all residents with air mattresses. Therapy referrals were made for recommendations of bolsters if found to be safe for the resident.
Air Mattress evaluations will now be included in the admission packet and done on admission, quarterly and with any change in condition that would require a re-evaluation.
Leg rest bags were purchased and are on all wheelchairs to store leg rests for use during staff transportation.

Education will be provided to nursing staff on safety measures including air mattresses, bolsters, and the use of leg rests. This education will be provided by the Clinical Educator/ Designee.

An audit will be completed by the Director of Nursing/Designee on the use of safety measures on 5% of facility census daily times one week and weekly times four weeks.

Findings of the audits will be reported to the facility Quality Assurance Performance Improvement committee for review. The committee will determine the need for further audits and or action plans.

483.20(c) REQUIREMENT Qrtly Assessment at Least Every 3 Months: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.
§483.20(c) Quarterly Review Assessment
A facility must assess a resident using the quarterly review instrument specified by the State and approved by CMS not less frequently than once every 3 months.
Observations:


Based on review of the Resident Assessment Instrument User's Manual and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that quarterly Minimum Data Set assessments were completed within the required time frame for eight of 49 residents reviewed (Residents 11, 16, 17, 18, 44, 59, 60, 73).

Findings include:

The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which provides instructions and guidelines for completing Minimum Data Set (MDS) assessments (federally-mandated assessments of a resident's abilities and care needs), dated October 2018, indicated that the assessment reference date (ARD - the last day of the assessment's look-back period) of a quarterly MDS assessment must be no more than 92 days after the ARD of the most recent assessment of any type, and the assessment was to be completed no later than the ARD plus 14 calendar days.

A quarterly MDS assessment for Resident 11 had an ARD of April 12, 2019, requiring the MDS assessment to be completed by April 26, 2019. However, the MDS assessment was not signed as completed until May 2, 2019.

A quarterly MDS assessment for Resident 16 had an ARD of April 14, 2019, requiring the MDS assessment to be completed by April 29, 2019. However, the MDS assessment was not signed as completed until May 3, 2019.

A quarterly MDS assessment for Resident 17 had an ARD of May 23, 2019, requiring the MDS assessment to be completed by June 6, 2019. However the MDS assessment was not signed as completed until June 8, 2019.

A quarterly MDS assessment for Resident 18 had an ARD of April 16, 2019, requiring the MDS assessment to be completed by April 30, 2019. However the MDS assessment was not signed as completed until May 3, 2019.

A quarterly MDS assessment for Resident 44 had an ARD of April 19, 2019, requiring the MDS assessment to be completed by May 3, 2019. However the MDS assessment was not signed as completed until May 6, 2019.

A quarterly MDS assessment for Resident 59 had an ARD of April 12, 2019, requiring the MDS assessment to be completed by April 26, 2019. However the MDS assessment was not signed as completed until May 3, 2019.

A quarterly MDS assessment for Resident 60 had an ARD of April 12, 2019, requiring the MDS assessment to be completed by April 26, 2019. However the MDS assessment was not signed as completed until April 30, 2019.

A quarterly MDS assessment for Resident 73 had an ARD of April 11, 2019, requiring the MDS assessment to be completed by April 25, 2019. However the MDS assessment was not signed as completed until May 1, 2019. Additionally, a quarterly MDS assessment for Resident 73 had an ARD of April 23, 2019, requiring the MDS assessment to be completed by May 7, 2019. However the MDS assessment was not signed as completed until May 8, 2019.

Interview with the Registered Nurse Assessment Coordinator (a registered nurse who is responsible for the completion of MDS assessments) on August 7, 2019, at 3:00 p.m. confirmed that the quarterly MDS assessments for Residents 11, 16, 17, 18, 44, 59, 60 and 73 were not completed within the required time frame.

28 Pa. Code 211.5(f) Clinical records.
Previously cited 7/17/19, 8/17/18, 5/11/18.


 Plan of Correction - To be completed: 09/19/2019

Residents 11, and 44 remain at the facility.
Residents 16,17,18,59,60, and 73 are not listed on the resident Roster and therefore cannot be addressed.

No root cause was identified

Any resident requiring a quarterly assessment is at risk.

A new Registered Nurse has been hired and trained as the lead Assessment Coordinator.
This Registered Nurse will oversee the other employees in the Assessment Office.

The Registered Nurse Assessment Coordinator will be educated on timeliness of quarterly assessment submissions by the Director of Nursing.

The Director of Nursing / Designee will complete an audit for timeliness of submissions on 10% of facility census weekly for eight weeks.


Findings of the audits will be reported to the facility Quality Assurance Performance Improvement committee for review. The committee will determine the need for further audits and or action plans.

483.10(c)(7) REQUIREMENT Resident Self-Admin Meds-Clinically Approp:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
§483.10(c)(7) The right to self-administer medications if the interdisciplinary team, as defined by §483.21(b)(2)(ii), has determined that this practice is clinically appropriate.
Observations:


Based on review of policies and clinical records, as well as observations, and resident and staff interviews, it was determined that the facility failed to ensure that residents were assessed for self-administration of medications for one of 49 residents reviewed (Resident 32).

Findings include:

The facility's policy regarding medication administration, dated January 14, 2019, indicated that residents were permitted to self-administer medications when specifically authorized by the attending physician and in accordance with the procedure for self-administration.

The facility policy regarding self-administration of medications, dated January 14, 2019, indicated that if a resident desired to self-administer medications, an assessment of the resident's cognitive, physical and visual abilities to carry out this responsibility was to be completed.

A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 32, dated June 8, 2019, revealed that the resident was cognitively intact. A diagnosis record dated May 29, 2019, revealed that the resident had diagnoses that included chronic obstructive pulmonary disease (COPD - a lung disease that makes it difficult to breathe), gastroesophageal reflux disease (GERD - gastric reflux), high blood pressure, anxiety and heart failure.

Observations on August 5, 2019, at 10:21 a.m. revealed that Resident 32 was sitting on the edge of her bed and there was a medication cup with one capsule and eleven tablets sitting on her over-the-bed table. Interview with the resident at that time revealed that nurses leave her medications at bedside, and she noticed that she only received one capsule and should have received two.

Resident 32's Medication Administration Record (MAR) for August 5, 2019, at 9:00 a.m. indicated that Licensed Practical Nurse 2 documented that she administered one 2.5 milligram (mg) tablet of amlodopine (treats high blood pressure), one 600 mg tablet of caltrate (calcium supplement), one 80 mg tablet of Lasix (diuretic to help excrete excess fluid), one 40 mg tablet of lisinopril (treats high blood pressure), two 200 mg tablets of magnesium (mineral supplement), one 50 mg tablet of metoprolol (treats high blood pressure, one multivitamin tablet, two 10 milliequivalent (mEq) capsules of potassium chloride (a mineral supplement), half of a 400 mg tablet (200 mg) of theophylline (helps breathing), and two 75 mg tablets of Zantac (decreases acid in the stomach), for a total of 11 tablets and 2 capsules.

Resident 32's clinical record contained no documented evidence that an assessment of her ability to self-administer medications was completed.

Interview with Licensed Practical Nurse 2 on August 5, 2019, at 12:08 p.m. revealed that as far as she knew, Resident 32 was permitted to have her medications left at her bedside. She also indicated that she was made aware of the resident's concern about getting only one capsule when she was to receive two capsules.

Interviews with Licensed Practical Nurse 1 and the Director of Nursing on August 6, 2019, at 1:56 p.m. and 2:52 p.m. confirmed that Resident 32 did not have an assessment completed for self-administration of medications, and an assessment should have been done.

28 Pa. Code 211.12(d)(5) Nursing services.
Previously cited 7/17/19, 3/29/19, 2/13/19, 10/10/18, 10/1/18, 8/17/18, 7/19/18, 5/11/18.


 Plan of Correction - To be completed: 09/19/2019

Resident R32 had a self-administration medication observation completed.

Residents who are cognitively intact are at risk.

Moving forward, any resident with a BIMS of 15 will have a self-administration medication observation completed upon admission. Other residents will be assessed for appropriateness if desired.

Education will be provided to licensed staff on this change and completion of the self-administration medication observation. This education will be completed by the Clinical Educator/Designee.

The Director of Nursing/Designee will audit new admissions with a BIMS of 15 for self-administration medication observation completion. This audit will be completed weekly times 4 weeks.

Findings of the audits will be reported to the facility Quality Assurance Performance Improvement committee for review. The committee will determine the need for further audits and or action plans.

483.10(g)(14)(i)-(iv)(15) REQUIREMENT Notify of Changes (Injury/Decline/Room, etc.):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(g)(14) Notification of Changes.
(i) A facility must immediately inform the resident; consult with the resident's physician; and notify, consistent with his or her authority, the resident representative(s) when there is-
(A) An accident involving the resident which results in injury and has the potential for requiring physician intervention;
(B) A significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications);
(C) A need to alter treatment significantly (that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment); or
(D) A decision to transfer or discharge the resident from the facility as specified in §483.15(c)(1)(ii).
(ii) When making notification under paragraph (g)(14)(i) of this section, the facility must ensure that all pertinent information specified in §483.15(c)(2) is available and provided upon request to the physician.
(iii) The facility must also promptly notify the resident and the resident representative, if any, when there is-
(A) A change in room or roommate assignment as specified in §483.10(e)(6); or
(B) A change in resident rights under Federal or State law or regulations as specified in paragraph (e)(10) of this section.
(iv) The facility must record and periodically update the address (mailing and email) and phone number of the resident
representative(s).

§483.10(g)(15)
Admission to a composite distinct part. A facility that is a composite distinct part (as defined in §483.5) must disclose in its admission agreement its physical configuration, including the various locations that comprise the composite distinct part, and must specify the policies that apply to room changes between its different locations under §483.15(c)(9).
Observations:


Based on clinical record reviews and staff interviews, it was determined that the facility failed to ensure that the resident's attending physician was notified about changes in condition for two of 49 residents reviewed (Residents 8, 33).

Findings include:

An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 8, dated May 17, 2019, revealed that the resident was understood and could understand, required extensive assistance for daily care tasks, and had medical diagnoses that included a seizure disorder (a sudden, uncontrolled electrical disturbance in the brain). The resident's care plan, dated May 12, 2019, revealed that he was at risk for injury related to the seizure disorder, and staff were to report all seizures to the physician promptly.

A nursing note for Resident 8, dated July 23, 2019, at 1:25 p.m. revealed that the resident had seizure activity during a.m. care, and his sister was notified and hospice (end-of-life services) was in to evaluate.

A nursing note for Resident 8, dated August 7, 2019, at 12:29 a.m. revealed that the nurse was called into the resident's room by a nurse aide for seizure-like activity that included shaking of arms and the resident not responding. This lasted approximately one minute.

There was no documented evidence that Resident 8's physician was contacted promptly after the seizure activity on July 23 and August 7, 2019.

Interview with Registered Nurse 6 on August 7, 2019, at 5:15 p.m. confirmed that there was no documented evidence that Resident 8's physician was contacted promptly after the seizure activity on July 23 and August 7, 2019.


A quarterly MDS assessment for Resident 33, dated June 8, 2019, revealed that the resident was cognitively intact, required limited assistance from staff for his care, and had diagnoses that include chronic obstructive pulmonary disease (COPD - a lung disease that makes it difficult to breathe), pain, muscle weakness and malnutrition.

Physician's orders for Resident 33, dated November 29, 2018, included orders for the resident to receive 800 milligrams (mg) of gabapentin (medication used to treat seizures and some types of pain) four times a day, two 5/325 mg tablets of Percocet (a narcotic pain medication) every six hours, a 0.025-1.25 percent Salonpas medicated patch (for pain) two times a day, and 650 mg of Tylenol every six hours as needed for mild pain. Physician's orders dated July 23, 2019, included orders to continue occupational therapy services five times a week for 30 days for therapeutic exercise, therapeutic activities, and self-care management training.

Resident 33's care plan for pain, dated December 12, 2018, revealed that he had chronic pain related to his back and general discomfort, and that the physician was to be notified if his pain medication was ineffective. A care plan related to a risk of altered skin integrity revealed a goal for the resident not to develop new areas.

A nursing note for Resident 33, dated July 26, 2019, at 11:00 p.m. revealed that pain relieving gel was applied to the second toe on the right foot. A nursing note dated July 29, 2019, at 11:01 a.m. revealed that the resident had concerns regarding a scab to the second toe on his right foot, and the wound nurse was informed that the resident would like to see her.

A wound nurse note for Resident 33, dated August 1, 2019, at 2:34 p.m. revealed that the resident's right second toe was assessed due to a report that there was a scab. The area was 1.5 x 1.0 cm and was scabbed with some light serous exudate (a clear, thin, watery drainage). Physician's orders, dated August 1, 2019, were for the right second toe to be cleansed daily with normal saline solution, patted dry, painted with betadine, and then for a dry dressing to be applied.

Interview with Resident 33 on August 6, 2019, at 9:36 a.m., in the presence of the Wound Care Coordinator and immediately prior to wound care being provided, revealed that he did not sleep well the night before because of the severe pain he had been experiencing in his toe. The resident stated, "It kept me up most of the night." Observation of wound care to Resident 33's right second toe by the Wound Care Coordinator on August 6, 2019, at 9:39 a.m. revealed that the toe was very red and swollen from the base of the toenail to the bottom of the toe. A brownish, partially opened, partially scabbed area (approximately dime sized) was noted in the middle of the toe.

Interview with the Wound Care Coordinator on August 6, 2019, at 9:50 a.m. confirmed that Resident 33's wound on the right second toe had deteriorated since she examined it a week ago, and she would now need to notify the wound doctor. When asked if Resident 33's primary care doctor or the wound doctor were notified when she first assessed the wound on August 1, 2019, she confirmed that neither were notified at that time, that the physician's order for wound care on August 1, 2019, was written as a verbal order based on the facility's wound protocol, and she did not actually speak with a physician for the order.

A follow-up interview with Resident 33 on August 6, 2019, at 12:00 p.m. revealed that he has had neuropathy pain (a result of damage to the peripheral nerves, often causing weakness, numbness and pain, usually in the feet) for a while now. The resident stated, "This pain in my toe is worse than that, it's horrible. It's keeping me up at night, and I've asked to have the doctor look at it, but I don't think he was ever told. I get Percocet regularly but it doesn't touch this pain. It felt like a knife being shoved in there when she was doing whatever she was doing this morning. I don't know how much more of this I can take."

An interview with the Director of Nursing on August 6, 2019, at 12:47 p.m. confirmed that if Resident 33's pain was worse than usual, then the physician should have been notified about it.

Interview with Resident 33 on August 7, 2019, at 9:54 a.m. revealed that he started having the pain again a short while ago and that the doctor still has not seen him. He once again confirmed that the pain he had yesterday was unbearable and that he's afraid he may lose his toe. The resident stated that the pain is so bad that he is not able to complete his therapy and that they seem to be pushing him when he isn't able. He stated, "If the pain wasn't so bad I might be able to get through a therapy session."

Interview with Certified Occupational Therapy Assistant (COTA) 16 on August 7, 2019, at 11:42 a.m. confirmed that Resident 33 has not been able to complete some of his therapy treatments due to the pain in his right second toe, and there have been days recently when he refused to get out of bed because of the pain. As a result, therapy was not able to see him. She also stated that the area on his toe was noticed approximately two weeks ago as a scabbed area, and then it got "angry" looking and wound treatments were started. She confirmed that it is preventing him from progressing in his treatment.

There was no documented evidence in Resident 33's clinical record to indicate that as of August 8, 2019, at 3:00 p.m. a physician was notified about the wound on the right second toe (first noted on July 26, 2019) or the change in condition with deterioration and increased pain. Interview with the Director of Nursing on August 8, 2019, at 3:00 p.m. confirmed that she was not aware of any progress notes from Resident 33's primary care physician or wound physician to indicate that the resident was seen by either of them related to his toe.

42 CFR 483.10(g)(14)(i)-(iv)(15) Notify of Changes (Injury/Decline/Room, Etc.)
Previously cited 10/10/18.

28 Pa. Code 211.12(d)(3) Nursing services.
Previously cited 7/17/19, 2/13/19, 10/10/18, 10/1/18, 8/17/18, 5/11/18.

28 Pa. Code 211.12(d)(5) Nursing services.
Previously cited 7/17/19, 3/29/19, 2/13/19, 10/10/18, 10/1/18, 8/17/18, 7/19/18, 5/11/18.


 Plan of Correction - To be completed: 09/19/2019

The physician was notified on Resident R8 and Resident R33.

Any resident having a change in condition is at risk. No root cause was identified.

Any residents with changes in condition will be reviewed at the clinical meeting and physicians will be notified if they have not been.

Education will be provided to licensed staff on changes in condition and physician notification. This will be completed by the Clinical Educator/designee. This education will also be completed in new hire orientation.

The Director of Nursing / Designee will audit for physician notification with changes in condition daily times one week and weekly times 4 weeks.

Findings of the audits will be reported to the facility Quality Assurance Performance Improvement committee for review. The committee will determine the need for further audits and or action plans.


483.10(g)(17)(18)(i)-(v) REQUIREMENT Medicaid/Medicare Coverage/Liability Notice: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(g)(17) The facility must--
(i) Inform each Medicaid-eligible resident, in writing, at the time of admission to the nursing facility and when the resident becomes eligible for Medicaid of-
(A) The items and services that are included in nursing facility services under the State plan and for which the resident may not be charged;
(B) Those other items and services that the facility offers and for which the resident may be charged, and the amount of charges for those services; and
(ii) Inform each Medicaid-eligible resident when changes are made to the items and services specified in §483.10(g)(17)(i)(A) and (B) of this section.

§483.10(g)(18) The facility must inform each resident before, or at the time of admission, and periodically during the resident's stay, of services available in the facility and of charges for those services, including any charges for services not covered under Medicare/ Medicaid or by the facility's per diem rate.
(i) Where changes in coverage are made to items and services covered by Medicare and/or by the Medicaid State plan, the facility must provide notice to residents of the change as soon as is reasonably possible.
(ii) Where changes are made to charges for other items and services that the facility offers, the facility must inform the resident in writing at least 60 days prior to implementation of the change.
(iii) If a resident dies or is hospitalized or is transferred and does not return to the facility, the facility must refund to the resident, resident representative, or estate, as applicable, any deposit or charges already paid, less the facility's per diem rate, for the days the resident actually resided or reserved or retained a bed in the facility, regardless of any minimum stay or discharge notice requirements.
(iv) The facility must refund to the resident or resident representative any and all refunds due the resident within 30 days from the resident's date of discharge from the facility.
(v) The terms of an admission contract by or on behalf of an individual seeking admission to the facility must not conflict with the requirements of these regulations.
Observations:


Based on clinical record reviews and staff interviews, it was determined that the facility failed to provide an Advance Beneficiary Notice of Non-Coverage (ABN) to two of 49 residents reviewed (Residents 13, 140) who remained in the facility after their Medicare coverage ended.

Findings include:

A Skilled Nursing Facility (SNF) Beneficiary Protection Notification Review form completed by the facility revealed that Medicare coverage for Resident 13 started on April 3, 2019, and the resident's last covered day was April 30, 2019. The form indicated that the facility initiated discontinuation from Medicare Part A coverage and that the resident's benefit days were not exhausted. There was no documented evidence that Resident 13 was provided with an ABN as required.

A SNF Beneficiary Protection Notification Review form completed by the facility revealed that Medicare coverage for Resident 140 started on March 18, 2019, and the resident's last covered day was April 17, 2019. The form indicated that the facility initiated discontinuation from Medicare Part A coverage and that the resident's benefit days were not exhausted. There was no documented evidence that Resident 140 was provided with an ABN as required.

Interview with Social Service Worker 5 on August 8 2019, at 9:06 a.m. confirmed that Residents 13 and 140 were not provided with an ABN as required when their Medicare coverage ended.

28 Pa. Code 201.18(e)(1) Management.
Previously cited 2/13/19, 10/10/18, 8/17/18, 7/19/18, 5/11/18.





 Plan of Correction - To be completed: 09/19/2019

Resident 13 remains at the facility.

Resident 140 no longer resides at the facility.

Any Medicare insured resident is at risk. No root cause or any other residents identified.

The Social Services department is now responsible for providing the residents with Advanced Beneficiary Notices when applicable and has developed a tracking system.

Education will be completed on F0582 and the ABN process to the Social Service Department. This education will be provided by the Administrator/Designee.

An audit will be completed on ABN eligible residents daily times one week and weekly times four weeks.


Findings of the audits will be reported to the facility Quality Assurance Performance Improvement committee for review. The committee will determine the need for further audits and or action plans.

483.20(b)(1)(2)(i)(iii) REQUIREMENT Comprehensive Assessments & Timing:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
§483.20 Resident Assessment
The facility must conduct initially and periodically a comprehensive, accurate, standardized reproducible assessment of each resident's functional capacity.

§483.20(b) Comprehensive Assessments
§483.20(b)(1) Resident Assessment Instrument. A facility must make a comprehensive assessment of a resident's needs, strengths, goals, life history and preferences, using the resident assessment instrument (RAI) specified by CMS. The assessment must include at least the following:
(i) Identification and demographic information
(ii) Customary routine.
(iii) Cognitive patterns.
(iv) Communication.
(v) Vision.
(vi) Mood and behavior patterns.
(vii) Psychological well-being.
(viii) Physical functioning and structural problems.
(ix) Continence.
(x) Disease diagnosis and health conditions.
(xi) Dental and nutritional status.
(xii) Skin Conditions.
(xiii) Activity pursuit.
(xiv) Medications.
(xv) Special treatments and procedures.
(xvi) Discharge planning.
(xvii) Documentation of summary information regarding the additional assessment performed on the care areas triggered by the completion of the Minimum Data Set (MDS).
(xviii) Documentation of participation in assessment. The assessment process must include direct observation and communication with the resident, as well as communication with licensed and nonlicensed direct care staff members on all shifts.

§483.20(b)(2) When required. Subject to the timeframes prescribed in §413.343(b) of this chapter, a facility must conduct a comprehensive assessment of a resident in accordance with the timeframes specified in paragraphs (b)(2)(i) through (iii) of this section. The timeframes prescribed in §413.343(b) of this chapter do not apply to CAHs.
(i) Within 14 calendar days after admission, excluding readmissions in which there is no significant change in the resident's physical or mental condition. (For purposes of this section, "readmission" means a return to the facility following a temporary absence for hospitalization or therapeutic leave.)
(iii)Not less than once every 12 months.
Observations:


Based on review of the Resident Assessment Instrument User's Manual and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that comprehensive annual Minimum Data Set assessments were completed in the required time frame for four of 49 residents reviewed (Residents 16, 19, 20, 36).

Findings include:

The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which provides instructions and guidelines for completing required Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2018, indicated that the assessment completion date was to be within 14 days of the Assessment Reference Date (ARD - the last day of an assessment's look-back period).

A comprehensive annual MDS assessment for Resident 16, with an ARD of May 22, 2019, was not signed as complete until June 8, 2019, which was 17 days after the ARD.

A comprehensive annual MDS assessment for Resident 19, with an ARD of May 28, 2019, was not signed as complete until June 14, 2019, which was 17 days after the ARD.

A comprehensive annual MDS assessment for Resident 20, with an ARD of May 28, 2019, was not signed as complete until June 12, 2019, which was 15 days after the ARD.

A comprehensive annual MDS assessment for Resident 36, with an ARD of May 11, 2019, was not signed as complete until May 28, 2019, which was 17 days after the ARD

Interview with the Registered Nurse Assessment Coordinator (RNAC - a registered nurse who is responsible for the completion of MDS assessments) on August 7, 2019, at 3:00 p.m. confirmed that the annual MDS assessments for Residents 16, 19, 20 and 36 were not completed within the required time frame.

28 Pa. Code 211.5(f) Clinical records.
Previously cited 7/17/19, 8/17/18, 5/1/18.






 Plan of Correction - To be completed: 09/19/2019

Resident R19 no longer resides at this facility.
Resident R16, Resident R20, Resident R36 are not listed on the Resident Roster and therefore cannot be addressed.

No root cause analysis was completed.
Any resident requiring a comprehensive assessment is at risk.

A new Registered Nurse has been hired and trained as the lead Assessment Coordinator.
This Registered Nurse will oversee the other employees in the Assessment Office.

The Registered Nurse Assessment Coordinator will be educated on timeliness of comprehensive assessment submissions by the Director of Nursing.

The Director of Nursing / Designee will complete an audit for timeliness of submissions on 10% of facility census weekly for eight weeks.


Findings of the audits will be reported to the facility Quality Assurance Performance Improvement committee for review. The committee will determine the need for further audits and or action plans.

483.20(f)(1)-(4) REQUIREMENT Encoding/Transmitting Resident Assessments:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
§483.20(f) Automated data processing requirement-
§483.20(f)(1) Encoding data. Within 7 days after a facility completes a resident's assessment, a facility must encode the following information for each resident in the facility:
(i) Admission assessment.
(ii) Annual assessment updates.
(iii) Significant change in status assessments.
(iv) Quarterly review assessments.
(v) A subset of items upon a resident's transfer, reentry, discharge, and death.
(vi) Background (face-sheet) information, if there is no admission assessment.

§483.20(f)(2) Transmitting data. Within 7 days after a facility completes a resident's assessment, a facility must be capable of transmitting to the CMS System information for each resident contained in the MDS in a format that conforms to standard record layouts and data dictionaries, and that passes standardized edits defined by CMS and the State.

§483.20(f)(3) Transmittal requirements. Within 14 days after a facility completes a resident's assessment, a facility must electronically transmit encoded, accurate, and complete MDS data to the CMS System, including the following:
(i)Admission assessment.
(ii) Annual assessment.
(iii) Significant change in status assessment.
(iv) Significant correction of prior full assessment.
(v) Significant correction of prior quarterly assessment.
(vi) Quarterly review.
(vii) A subset of items upon a resident's transfer, reentry, discharge, and death.
(viii) Background (face-sheet) information, for an initial transmission of MDS data on resident that does not have an admission assessment.

§483.20(f)(4) Data format. The facility must transmit data in the format specified by CMS or, for a State which has an alternate RAI approved by CMS, in the format specified by the State and approved by CMS.
Observations:


Based on review of the Resident Assessment Instrument Manual and clinical records, as well as staff interviews, it was determined that the facility failed to complete and/or transmit Minimum Data Set (MDS) assessments to the required electronic system, the CMS Quality Improvement and Evaluation System (QIES) Assessment Submission and Processing (ASAP) System, within the required time frame for two of 49 residents reviewed (Residents 6, 13, 17).

Findings include:

The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which provides instructions and guidelines for completing Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2018, indicated that Entry, Death in Facility, and Discharge tracking records must be completed and transmitted within 14 days of the Event Date (Section A1600 plus 14 days for Entry records, Section A2000 plus 14 days for Death in Facility records, and Section A2300 plus 14 days for Discharge records). The manual also indicated that comprehensive assessments must be transmitted electronically within 14 days of the Care Plan Completion Date (Section V0200C2 + 14 days), and all other assessments must be submitted within 14 days of the MDS Completion Date (Section Z0500B + 14 days).

A discharge MDS tracking record for Resident 6, dated June 7, 2019 (A2300), indicated that the resident was discharged from the facility on June 7, 2019; however, the discharge tracking record was not completed until June 25, 2019 (Section A2300 plus 18 days).

A discharge MDS tracking record for Resident 13, dated May 13, 2019 (A2300), indicated that the resident was discharged from the facility on May 13, 2019; however, the discharge tracking record was not completed until May 28, 2019 (Section A2300 plus 15 days).

A discharge MDS tracking record for Resident 17, dated May 13, 2019 (A2300), indicated that the resident was discharged from the facility on May 13, 2019; however, the discharge tracking record was not completed until May 28, 2019 (Section A2300 plus 15 days).

Interview with the Registered Nurse Assessment Coordinator (RNAC - a registered nurse who is responsible for the completion of MDS assessments) on August 7, 2019, at 3:00 p.m. confirmed that the discharge tracking records for Residents 6, 13 and 17 were not completed within the required time frame.

28 Pa. Code 211.5(f) Clinical records.
Previously cited 7/17/19, 8/17/18, 5/11/18.


 Plan of Correction - To be completed: 09/19/2019

Residents 6, and 13 reside in the facility
Resident R7 is not listed on the Resident Roster and therefore cannot be addressed.

A root cause was not identified. This is not one of the five requirements for submitting a plan of correction.

Any resident being discharged from the facility is at risk.

A new Registered Nurse has been hired and trained as the lead Assessment Coordinator.
This Registered Nurse will oversee the other employees in the Assessment Office.

The Registered Nurse Assessment Coordinator will be educated on timeliness of discharge tracking records by the Director of Nursing. Other types of assessments were addressed in previous tags.

The Director of Nursing / Designee will complete an audit for timeliness of submissions on 10% of facility census weekly for eight weeks.


Findings of the audits will be reported to the facility Quality Assurance Performance Improvement committee for review. The committee will determine the need for further audits and or action plans.

483.21(b)(1) REQUIREMENT Develop/Implement Comprehensive Care Plan:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
§483.21(b) Comprehensive Care Plans
§483.21(b)(1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at §483.10(c)(2) and §483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following -
(i) The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under §483.24, §483.25 or §483.40; and
(ii) Any services that would otherwise be required under §483.24, §483.25 or §483.40 but are not provided due to the resident's exercise of rights under §483.10, including the right to refuse treatment under §483.10(c)(6).
(iii) Any specialized services or specialized rehabilitative services the nursing facility will provide as a result of PASARR recommendations. If a facility disagrees with the findings of the PASARR, it must indicate its rationale in the resident's medical record.
(iv)In consultation with the resident and the resident's representative(s)-
(A) The resident's goals for admission and desired outcomes.
(B) The resident's preference and potential for future discharge. Facilities must document whether the resident's desire to return to the community was assessed and any referrals to local contact agencies and/or other appropriate entities, for this purpose.
(C) Discharge plans in the comprehensive care plan, as appropriate, in accordance with the requirements set forth in paragraph (c) of this section.
Observations:


Based on clinical record reviews, observations and staff interviews, it was determined that the facility failed to develop care plans to address individualized resident care needs for three of 49 residents reviewed (Residents 33, 58, 88).

Findings include:

A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 33, dated June 8, 2019, revealed that the resident was cognitively intact, required limited assistance from staff for daily care, and had diagnoses that included chronic obstructive pulmonary disease (COPD - a lung disease that makes it difficult to breathe), pain, muscle weakness and malnutrition.

A nursing note for Resident 33, dated July 26, 2019, at 11:00 p.m. revealed that pain relieving gel was applied to the second toe on the right foot. A nursing note dated July 29, 2019, at 11:01 a.m. revealed that the resident had concerns regarding the scab to the second toe on his right foot and the wound nurse was informed that the resident would like to see her.

A wound note for Resident 33, dated August 1, 2019, at 2:34 p.m. revealed that the resident's right second toe was assessed and was scabbed with some light serous exudate (a clear, thin, watery drainage) and the area measured 1.5 x 1.0 centimeters (cm). Physician's orders dated August 1, 2019, were to cleanse the right second toe daily with normal saline solution (sterile salt and water solution), pat dry, paint with betadine and apply a dry dressing.

Interview with Resident 33 on August 6, 2019, at 9:36 a.m., in the presence of the Wound Care Coordinator and immediately prior to wound care being provided, revealed that he did not sleep well the night before because of the severe pain he had been experiencing in his toe. The resident stated, "It kept me up most of the night." Observation of wound care to Resident 33's right second toe by the Wound Care Coordinator on August 6, 2019, at 9:39 a.m. revealed that the toe was very red and swollen from the base of the toenail to the bottom of the toe. A brownish, partially opened, partially scabbed area (approximately dime sized) was noted in the middle of the toe.

As of August 6, 2019, there was no documented evidence that a care plan was developed to address Resident 33's care needs related to the area on his right second toe.

An interview with the Director of Nursing on August 6, 2019, at 12:47 p.m. confirmed that a care plan should have been developed to address care needs related to Resident 33's right second toe wound.


A quarterly MDS assessment for Resident 58, dated June 4, 2019, indicated that the resident was cognitively intact, continent of urine, and had a urinary tract infection within the last 30 days. Physician's orders, dated June 29, 2019, included an order for the resident to receive 500 milligrams (mg) of Keflex (an antibiotic) four times a day for 40 doses for a urinary tract infection.

As of August 7, 2019, there was no documented evidence that a care plan was developed to address Resident 58's care needs related to the prevention and treatment of urinary tract infections.

Interview with the Director of Nursing on August 7, 2019, at 8:39 a.m. confirmed that a care plan was not developed to address Resident 58's care needs related to the urinary tract infection.


An admission MDS assessment for Resident 88, dated June 24, 2019, indicated that the resident was cognitively intact, received oxygen therapy, and had diagnoses that included septicemia (a blood infection). Physican's orders dated July 17, 2019, included an order for the resident to receive 0-6 liters of oxygen per minute to maintain a pulse oximetry (a reading of oxygen in the blood) of equal or greater than 92 percent.

As of August 7, 2019, there was no documented evidence that a care plan was developed to address Resident 88's care needs related to oxygen therapy.

Interview with the Director of Nursing on August 7, 2019, at 10:03 a.m. confirmed that a care plan was not developed to address Resident 88's care needs related to oxygen therapy.

42 CFR 483.21(b)(1) Care Plan Timing and Revision.
Previously cited 10/1/18, 8/17/18, 5/11/18.

28 Pa. Code 211.11(d) Resident care plan.
Previously cited 7/17/19, 2/13/19, 10/1/18, 8/17/18, 5/11/18.

28 Pa. Code 211.12(d)(5) Nursing services.
Previously cited 7/17/19, 3/29/19, 2/13/19, 10/10/18, 10/1/18, 8/17/18, 7/19/18, 5/11/18.


 Plan of Correction - To be completed: 09/19/2019

Residents 33, 58, and 88 had their care plans reviewed and were revised as needed to address their individualized care.
No root cause was identified. No other residents were identified.

Resident who live in the facility are at risk for this deficiency.

The interdisciplinary clinical meeting will review five resident care plans per day until all resident care plans have been reviewed/revised for individual needs.
The clinical meeting will now begin reviewing care plans on all new admissions the next business day of the admission.

Education will be provided to licensed nursing staff on individualized care plans. This education will be completed by the Clinical Educator/Designee.

An audit will be completed on new admissions to review individual needs are being met. This audit will be completed by the Director of Nursing/Designee weekly times four weeks.

Findings of the audits will be reported to the facility Quality Assurance Performance Improvement committee for review. The committee will determine the need for further audits and or action plans.

483.21(b)(3)(i) REQUIREMENT Services Provided Meet Professional Standards:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
§483.21(b)(3) Comprehensive Care Plans
The services provided or arranged by the facility, as outlined by the comprehensive care plan, must-
(i) Meet professional standards of quality.
Observations:


Based on review of Pennsylvania's Nursing Practice Act, facility policies and residents' clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that physician's orders for medications were clarified prior to administration for two of 49 residents reviewed (Residents 34, 77), failed to ensure that a professional (registered) nurse completed an assessment of a resident following a change in condition for one of 49 residents reviewed (Resident 8), and failed to obtain a physician's order prior to applying a treatment for one of 49 residents reviewed (Resident 33) who had a vascular wound.

Findings include:

The Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, 21.11 (a)(1)(2)(4) indicated that the registered nurse was to collect complete and ongoing data to determine nursing care needs, analyze the health status of individuals and compare the data with the norm when determining nursing care needs, and carry out nursing care actions that promote, maintain and restore the well-being of individuals.

The facility's policy regarding medication administration, dated January 14, 2019, revealed that the Medication Administration Record (MAR) was always employed during medication administration. Prior to administration of any medication, the medication and dosage schedule on the resident's MAR were to be compared with the label on the medication. If the label and MAR were different, and the container was not already flagged indicating a change in directions, or if there was any other reason to question the dosage or directions, the physician's orders was to be checked for the correct dosage schedule. Medications were to be administered in accordance with written orders of the prescriber.

Current physician's orders for Resident 34 included orders for the resident to receive one 500 milligram (mg) tablet of cranberry (a supplement suggested for use in preventing urinary tract infections) daily.

Observations during medication administration on August 7, 2019, at 8:44 a.m. revealed that Licensed Practical Nurse 17 obtained Resident 34's cranberry tablet from the medication cart and administered it to the resident. The label on the bottle containing the cranberry tablets indicated that the dosage was 450 mg.

Interview with Licensed Practical Nurse 17 on August 7, 2019, at 10:25 a.m. confirmed that the dose on the bottle of cranberry tablets did not match the physician's order for Resident 34's cranberry, and this should have been clarified with the physician.


Physician's orders for Resident 77, dated June 21, 2019, included orders for the resident to receive one 500 mg tablet of cranberry daily.

Observations during medication administration on August 6, 2019, at 8:46 a.m. revealed that Registered Nurse 3 obtained Resident 77's cranberry tablet from the medication cart and administered it to the resident. The label on the bottle containing the cranberry tablets indicated that the dosage was 450 mg.

Interview with the Director of Nursing on August 7, 2019, at 11:15 a.m. confirmed that the nurse should have clarified the cranberry dosage with the physician.


An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 8, dated May 17, 2019, revealed that the resident was understood and could understand, required extensive assistance for daily care tasks, and had medical diagnoses that included a seizure disorder (a sudden, uncontrolled electrical disturbance in the brain). The resident's care plan, dated May 12, 2019, revealed that he was at risk for injury related to the seizure disorder, and staff were to report all seizures to the physician promptly.

A nursing note for Resident 8, dated July 23, 2019, at 1:25 p.m. and completed by a licensed practical nurse, revealed that the resident had seizure activity during a.m. care, and his sister was notified and hospice (end-of-life services) was in to evaluate.

However, there was no documented evidence that Resident 8 was assessed by a registered nurse after the seizure activity on July 23, 2019.

Interview with Registered Nurse 6 on August 7, 2019, at 5:15 p.m. confirmed that there was no documented evidence that a registered nurse completed an assessment after Resident 8's seizure activity on July 23, 2019, or that there was a progress note from the Hospice registered nurse regarding the resident's seizure activity on July 23, 2019.

Interview with the Director of Nursing on August 8, 2019, at 10:55 a.m. confirmed that there was no documented evidence that a registered nurse completed an assessment after Resident 8's seizure activity on July 23, 2019.


A quarterly MDS assessment for Resident 33, dated June 8, 2019, revealed that the resident was cognitively intact, required limited assistance from staff for his care, and had diagnoses that include chronic obstructive pulmonary disease (COPD - a lung disease that makes it difficult to breathe), pain, muscle weakness and malnutrition.

A nursing note for Resident 33, dated July 26, 2019, at 11:00 p.m. revealed that pain-relieving gel was applied to the second toe on the right foot. A nursing note dated July 29, 2019, at 11:01 a.m. revealed that the resident had concerns regarding a scab to the second toe on his right foot, and the wound nurse was informed that the resident would like to see her.

A wound nurse note for Resident 33, dated August 1, 2019, at 2:34 p.m. revealed that the resident's right second toe was assessed due to a report that there was a scab. The area was 1.5 x 1.0 cm and was scabbed with some light serous exudate (a clear, thin, watery drainage). Physician's orders, dated August 1, 2019, were for the right second toe to be cleansed daily with normal saline solution, patted dry, painted with betadine, and then for a dry dressing to be applied.

Interview with Resident 33 on August 6, 2019, at 9:36 a.m., in the presence of the Wound Care Coordinator and immediately prior to wound care being provided, revealed that he did not sleep well the night before because of the severe pain he had been experiencing in his toe. The resident stated, "It kept me up most of the night." Observation of wound care to Resident 33's right second toe by the Wound Care Coordinator on August 6, 2019, at 9:39 a.m. revealed that the toe was very red and swollen from the base of the toenail to the bottom of the toe. A brownish, partially opened, partially scabbed area (approximately dime sized) was noted in the middle of the toe.

Interview with the Wound Care Coordinator on August 6, 2019, at 9:50 a.m. confirmed that Resident 33's wound on the right second toe had deteriorated since she examined it a week ago, and she would now need to notify the wound doctor. When asked if Resident 33's primary care doctor or the wound doctor were notified when she first assessed the wound on August 1, 2019, she confirmed that neither were notified at that time, that the physician's order for wound care on August 1, 2019, was written as a verbal order based on the facility's wound protocol, and she did not actually speak with a physician for the order.

Interview with the Director of Nursing on August 8, 2019, at 3:00 p.m. revealed that the facility did not have a wound protocol.

42 CFR 483.21(b)(3)(i) Services Provided Meet Professional Standards.
Previously cited 5/11/18.

28 Pa. Code 211.12(d)(3) Nursing services.
Previously cited 7/17/19, 2/13/19, 10/10/18, 10/1/18, 8/17/18, 5/11/18.

28 Pa. Code 211.12(d)(5) Nursing services.
Previously cited 7/17/19, 3/29/19, 2/13/19, 10/10/18, 10/1/18, 8/17/18, 7/19/18, 5/11/18.


 Plan of Correction - To be completed: 09/19/2019

Physician was notified and clarification was given for medications for Resident 34.
Resident 77 in not listed on the Resident Roster and therefore cannot be addressed.

No root cause analysis completed. No further residents identified.

Any resident residing at the facility are at risk.
Orders will be reviewed daily and discussed in clinical meeting for clarification as needed and to ensure a Registered Nurse Assessment were completed on changes in condition.

Education will be provided to licensed staff by the Clinical Educator/Designee on Professional Standards including orders, clarification of orders, Registered Nurse assessment with changes in condition.

An audit will be completed during clinical meeting by the Director of Nursing/Designee. These audits will be completed daily times one week, then weekly times four weeks.

Findings of the audits will be reported to the facility Quality Assurance Performance Improvement committee for review. The committee will determine the need for further audits and or action plans.



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


Based on clinical record reviews and staff interviews, it was determined that the facility failed to ensure that physician's orders for medications were followed for one of 49 residents reviewed (Resident 58).

Findings include:

A quarterly Minimum Data Set (MDS) assessment (a federally-mandated assessment of a resident's abilities and care needs) for Resident 58, dated June 4, 2019, indicated that the resident was alert and oriented, continent of urine, and had a urinary tract infection within the last 30 days. Physician's orders, dated June 29, 2019, included an order for the resident to receive 500 milligrams (mg) of Keflex (an antibiotic) four times a day for 40 doses for a urinary tract infection.

The resident's Medication Administration Record (MAR) for June and July 2019 indicated that the resident received 500 mg doses of Keflex four times a day from June 29 through July 9, 2019, for a total of 42 doses, instead of 40 doses as ordered by the physician.

Interview with the Director of Nursing on August 8, 2019, at 6:36 p.m. confirmed that Resident 58's Keflex was administered longer than ordered by the physician.

42 CFR 483.25 Quality of Care.
Previously cited 2/13/19, 5/11/18.

28 Pa. Code 211.12(d)(5) Nursing services.
Previously cited 7/17/19, 3/29/19, 2/13/19, 10/10/18, 10/1/18, 8/17/18, 7/19/18, 5/11/18.


 Plan of Correction - To be completed: 09/19/2019

Resident 58 has had no adverse reactions for receiving two extra doses of antibiotics.
A root cause analysis was not completed.

Any resident on antibiotics is at risk.
The Supervisors will now check antibiotic orders to ensure the correct number of doses has been ordered and implemented.
The redlining process will also be completed at end of day to make sure all orders received daily are
correctly transcribed and followed.

Education will be completed with licensed staff by the Clinical Educator/Designee on following physician orders.

An audit on following physician orders will be completed by the Director of Nursing/designee. These will be completed on 5 random resident charts daily times one week, then weekly times four weeks.

Findings of the audits will be reported to the facility Quality Assurance Performance Improvement committee for review. The committee will determine the need for further audits and or action plans.

483.25(e)(1)-(3) REQUIREMENT Bowel/Bladder Incontinence, Catheter, UTI: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(e) Incontinence.
§483.25(e)(1) The facility must ensure that resident who is continent of bladder and bowel on admission receives services and assistance to maintain continence unless his or her clinical condition is or becomes such that continence is not possible to maintain.

§483.25(e)(2)For a resident with urinary incontinence, based on the resident's comprehensive assessment, the facility must ensure that-
(i) A resident who enters the facility without an indwelling catheter is not catheterized unless the resident's clinical condition demonstrates that catheterization was necessary;
(ii) A resident who enters the facility with an indwelling catheter or subsequently receives one is assessed for removal of the catheter as soon as possible unless the resident's clinical condition demonstrates that catheterization is necessary; and
(iii) A resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible.

§483.25(e)(3) For a resident with fecal incontinence, based on the resident's comprehensive assessment, the facility must ensure that a resident who is incontinent of bowel receives appropriate treatment and services to restore as much normal bowel function as possible.
Observations:


Based on the review of clinical records and facility policies, as well a staff interviews, it was determined that the facility failed to ensure the proper care of urinary catheters for two of 49 residents reviewed (Resident 10, 289).

Findings include:

The facility's policy regarding cleaning and maintaining catheters (tube inserted and held in the bladder to drain urine), dated January 14, 2019, indicated that the catheter (drainage bag) was to be maintained below the level of the bladder to prevent back flow and decrease the risk of catheter-related urinary tract infections. To achieve this, the catheter bag was to be kept in a privacy bag, and the bag was not to touch the floor.

A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 10, dated May 20, 2019, indicated that the resident was cognitively impaired, required assistance for her daily care tasks, and she had an indwelling urinary catheter. Physician's orders, dated August 4, 2019, indicated that the indwelling urinary catheter was in place due to a neurogenic bladder (dysfunction in which the bladder does not empty completely). A physician's discharge summary, dated June 6, 2019, indicated that the resident was discharged from the hospital back to the facility with diagnoses that included sepsis (a serious condition resulting from the body's response to infection) and urinary tract infection, and a nursing note dated July 31, 2019, indicated that she was admitted to the hospital with sepsis.

Observations of Resident 10 while in her bed on August 5, 2019, at 11:05 a.m., 12:02 p.m., and 12:15 p.m. revealed that her catheter bag was on the right side of the her bed and the bottom of the bag was in direct contact with the floor. At these times, there was a privacy bag noted on the left side of the bed, attached to the bed frame.

Interview with the Registered Nurse 4 on August 5, 2019 at 12;15 p.m. indicated that the catheter bag should not be on the floor and that it should be in privacy bag,


A nursing note for Resident 289, dated August 1, 2019, revealed that the resident arrived at the facility from the hospital with a urinary catheter that was patent and draining yellow urine. A baseline (initial) care plan, dated August 1, 2019, revealed that the resident was a new admission and that the use of an indwelling urinary catheter was due to medical diagnoses that included neurogenic bladder.

Observations of Resident 289 on August 5, 2019, at 11:08 a.m. and 11:34 a.m. revealed that the resident was lying in bed, the indwelling urinary catheter bag was hanging on the bed to the resident's right side, and the catheter bag was partially lying on the floor.

Interview with Licensed Practical Nurse 1 on August 5, 2019, at 11:34 a.m. confirmed that Resident 289's indwelling catheter drainage bag was on the floor and that it should not be touching the floor.

Interview with the Director of Nursing on August 6, 2019, at 11:50 a.m. confirmed that Resident 289's indwelling urinary catheter should not have been on the floor.

42 CFR 483.25(e)(1)-(3) Bowel/Bladder Incontinence, Catheter, UTI.
Previously cited 2/13/19, 5/11/18.

28 Pa. Code 211.12(d)(5) Nursing services.
Previously cited 7/17/19, 3/29/19, 2/13/19, 10/10/18, 10/1/18, 8/17/18, 7/19/18, 5/11/18.




 Plan of Correction - To be completed: 09/19/2019

Resident 10 remains in the facility with Foley catheter in dignity bag.
Resident 289 no longer resides in the facility.

No root cause analysis was completed.

All residents in the facility with indwelling catheters are at risk.

All residents with catheters will be assessed to determine the best way in which to keep the tubing of the catheter off the floor.
Environmental rounds will be initiated on each unit to make sure indwelling catheters are in dignity bags and tubing is not on the floor.

Education will be provided to nursing staff by the Clinical Educator/Designee on the need to keep indwelling catheters covered and off the floor.

An audit will be completed by the Director of Nursing/Designee on residents with Foley catheters daily times one week, then weekly times four weeks.

Findings of the audits will be reported to the facility Quality Assurance Performance Improvement committee for review. The committee will determine the need for further audits and or action plans.

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 review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that there was timely physician notification and evaluation for a weight loss for one of 49 residents reviewed (Resident 47).

Findings include:

The facility's policy regarding weight loss, dated January 14, 2019, revealed that any weight variance of five percent or greater from the previous weight was to be documented, repeated in 24 hours, and reported to the resident, the resident's family, the physician, and the Nutrition/Culinary Services Director if the weight loss or gain was greater than or equal to five percent.

An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 47, dated June 26, 2019, revealed that the resident was cognitively intact and required extensive assistance from staff for daily care tasks. The resident's weight records revealed that she experienced an 8.74 percent (eleven pound) weight loss in less than one month when her weight dropped from 123 pounds on July 29, 2019, to 112 pounds on August 2, 2019. There was no documented evidence that a repeat weight was obtained within 24 hours, and no documented evidence that the resident, the resident's family, the physician, and the Nutrition/Culinary Services Director were notified. Resident 47 was weighed again on August 5, 2019, and weighed 108 pounds.

Interview with the Director of Nursing on August 8, 2019, at 12:46 p.m. confirmed that Resident 47 should have been re-weighed within 24 hours of weight obtained on August 2, 2019, which showed an eleven-pound weight loss. She also confirmed that there was no documented evidence that the resident, the resident's family, the physician, and the Nutrition/Culinary Services Director were notified about the resident's weight loss.

42 CFR 483.25(g)(1)-(3) Nutrition/Hydration Status Maintenance.
Previously cited 2/13/19.

28 Pa. Code 211.12(d)(3) Nursing services.
Previously cited 7/17/19, 2/13/19, 10/10/18, 10/1/18, 8/17/18, 5/11/18.

28 Pa. Code 211.12(d)(5) Nursing services.
Previously cited 7/17/19, 3/29/19, 2/13/19, 10/10/18, 10/1/18, 8/17/18, 7/19/18, 5/11/18.


 Plan of Correction - To be completed: 09/19/2019

Resident R47 was discharged to home.

All residents residing in the facility are at risk.
Weights that are greater than or equal to five percent loss/gain will now be reviewed in the clinical meeting to confirm a repeat weight is received and notifications were completed.
No root cause cause identified and no other residents identified.

Education will be provided to nursing staff by the Clinical Educator/Designee on the facility weight policy.

An audit will be completed on any weight loss/gains greater to or equal than 5%. These audits will be completed by the Director of Nursing/Designee weekly times eight weeks.

Findings of the audits will be reported to the facility Quality Assurance Performance Improvement committee for review. The committee will determine the need for further audits and or action plans.

483.25(g)(4)(5) REQUIREMENT Tube Feeding Mgmt/Restore Eating Skills: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)(4)-(5) Enteral Nutrition
(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)(4) A resident who has been able to eat enough alone or with assistance is not fed by enteral methods unless the resident's clinical condition demonstrates that enteral feeding was clinically indicated and consented to by the resident; and

§483.25(g)(5) A resident who is fed by enteral means receives the appropriate treatment and services to restore, if possible, oral eating skills and to prevent complications of enteral feeding including but not limited to aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, and nasal-pharyngeal ulcers.
Observations:


Based on review of policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that tube feeding formula was monitored and administered as ordered by the physician for one of 49 residents reviewed (Resident 10).

Findings include:

The facility's policy regarding tube feedings (nutritional formula delivered through a tube), dated January 14, 2019, indicated that a physician' order was to be obtained for all feedings in relation to the rate, frequency and duration of the feedings, to maintain or improve nutritional and hydration needs.

A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 10, dated May 20, 2019, indicated that the resident was cognitively impaired, dependent on staff for care, and had a feeding tube for nutrition. A diagnosis record dated August 4, 2019, revealed that the resident had diagnoses that included a gastrostomy (tube surgically inserted through the abdomen into the stomach) and anoxic brain damage (harm to the brain due to a lack of oxygen).

Physician's orders for Resident 10 upon return from a hospitalization, dated August 4, 2019, revealed that at 6:40 p.m. an order was given for the resident's feeding tube to be flushed with 50 cubic centimeters (cc's) of water every hour x 24 hours (around the clock), and at 9:56 p.m. an order was given for the resident to receive Jevity 1.5 (a tube feeding formula) at 45 cc/hr continuously.

Resident 10's Medication Administration Record (MAR) for August 2019 indicated that the tube feeding flushes every hour were documented as "not provided due to discontinued" at 11:17 p.m. on August 4, 2019, and the tube feeding (Jevity) was documented as not provided due to hospitalization. There was no documented evidence that the tube flushes were actually discontinued, and there was no documented evidence that staff administered the tube feeding formula as ordered by the physician upon the resident's return from the hospital on August 4, 2019.

Observations of Resident 10 while in bed on August 5, 2019, at 11:01 a.m. and 2:10 p.m. revealed that a bottle of Jevity 1.5 and a bag of water flush were hanging on a feeding pole and were connected to a pump (mechanical device used to administer and monitor tube feeding infusion), but the pump, feeding formula and flush were not connected to the resident's gastrostomy tube. The feeding formula bottle (Jevity 1.5) was full and was labeled to start on August 4, 2019, at 11:37 p.m. at a rate of 45 cc/hr. The flush bag (1,000 cc capacity) was labeled to be provided at 50 cc's every hour.

Interviews with the Director of Nursing on August 5, 2019, at 3:31 p.m. and August 6, 2019, at 9:00 a.m. confirmed that Resident 10's tube feeding and flushes should have been started when ordered, and they were not started until August 5, 2019, at approximately 2:30 p.m.

42 CFR 483.25(g)(4)(5) Tube Feeding Management/Restore Eating Skills.
Previously cited 2/13/19, 8/17/18, 7/19/18.

28 Pa. Code 211.12(d)(5) Nursing services.
Previously cited 7/17/19, 3/29/19, 2/13/19, 10/10/18, 10/1/18, 8/17/18, 7/19/18, 5/11/18.


 Plan of Correction - To be completed: 09/19/2019

Resident R10 resides in the facility and is receiving her enteral feeding as ordered by the physician.

No root cause was identified.

All residents receiving Enteral feeding are at risk.

Residents receiving enteral feeding were reviewed and are receiving the feeding as ordered.
It will now be the responsibility of the supervisor on the shift of admission to initiate the enteral feedings as ordered by the physician.

The Clinical Educator/Designee will educate licensed staff on enteral feedings and initiation of feedings based on physician orders.

An audit will be completed by the Director of Nursing/Designee on all enteral feedings for following physician orders. This audit will be completed daily times one week then weekly times four weeks.

Findings of the audits will be reported to the facility Quality Assurance Performance Improvement committee for review. The committee will determine the need for further audits and or action plans.



483.45(f)(1) REQUIREMENT Free of Medication Error Rts 5 Prcnt or More:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
§483.45(f) Medication Errors.
The facility must ensure that its-

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


Based on review of policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that its medication error rate was less than five percent.

Findings include:

Observations during medication administration on August 6, 2019, revealed that two medication administration errors were made during 29 opportunities for error, resulting in a medication administration error rate of 6.9 percent.

The facility's medication management program policy, dated January 14, 2019, revealed that licensed staff must follow the eight "rights" for administering medication - the right patient, drug, dose, time, route, charting, results and reason.

Current physician's orders for Resident 34 included an order for the resident to receive 25 milligrams (mg) of Movantik (used to treat constipation that is caused by opioid pain medication) on an empty stomach, do not give one hour before or two hours after a meal.

Observations during medication administration on August 7, 2019, at 9:44 a.m. revealed that Resident 34 returned from a breakfast buffet in the main dining room and Licensed Practical Nurse 17 immediately administered the resident's medications, which included Movantik.

Interview with Licensed Practical Nurse 17 on August 7, 2019, at 10:25 a.m. confirmed that she did not wait for two hours to give Resident 34 Movantik as directed.


The facility's policy regarding administering medications via an enteral tube (a tube inserted into the stomach), dated January 14, 2019, revealed that medications should be crushed and administered individually if administered via tube, to avoid interaction and clumping. The policy included that crushed medications were not to be administered together, and the powder from each crushed medication was to be mixed with 10 milliliters (ml) of water before each administration, and the enteral tubing was to be flushed with at least 10 ml of water between each medication to avoid physical interactions of the medications.

A nursing note for Resident 89, dated July 29, 2019, revealed that the resident was admitted to the facility with an intact and patent gastrostomy tube (a tube surgically inserted through the abdomen and into the stomach). Physician's orders, dated July 29, 2019, included orders for the resident to receive nothing by mouth, to flush the gastrostomy tube with 30 ml of warm water before and after medication administration, and to administer 250 mg of Florastor (a probiotic supplement) via the gastrostomy tube daily, and 7.5 mg of clorazepate (treats anxiety disorders, certain types of seizures, or alcohol withdrawal symptoms) via the gastrostomy tube twice a day.

Observations during medication administration on August 6, 2019, at 8:29 a.m. revealed that Registered Nurse 3 obtained Resident 89's Florastor and clorazepate from the medication cart, placed both medications into a small plastic bag, and crushed both medications together. She then placed the medications into a small plastic cup, added water, and administered the medications to the resident via her gastrostomy tube.

Interview with Registered Nurse 3 on August 6, 2019, at 8:57 a.m. confirmed that she should have crushed Resident 89's medications individually, as well as administered the medications separately via the gastrostomy tube.

Interview with the Director of Nursing on August 6, 2019, at 2:25 p.m. revealed that she felt that if a person takes all medications together by mouth, they all end up in the same place. She indicated that she has not yet reviewed and revised all of the facility's policies.

28 Pa. Code 211.12(d)(1) Nursing services.
Previously cited 2/13/19, 10/10/18, 10/1/18, 8/17/18, 7/19/18, 5/11/18.

28 Pa. Code 211.12(d)(5) Nursing services.
Previously cited 7/17/19, 3/29/19, 2/13/19, 10/10/18, 10/1/18, 8/17/18, 7/19/18, 5/11/18.


 Plan of Correction - To be completed: 09/19/2019

All residents including those cited will receive medications as order by physician.


Medication Observations will now be completed on new licensed staff hires during their probation period. These observations will be completed by the Clinical Educator/Designee.

Random medication observations will be completed on existing staff. These random observations will be completed by the Clinical Educator/Designee. Any employees with greater than 5% error rate will complete a classroom session on medication administration.

The Clinical Educator/Designee will provide education to licensed staff on the eight rights of medication administration and the proper procedure for administering medications via an enteral tube.

An audit will be completed by the Director of Nursing/Designee on medication administration. This audit will be completed on a 5% random residents daily times one-week and weekly times 4 weeks.

Findings of the audits will be reported to the facility Quality Assurance Performance Improvement committee for review. The committee will determine the need for further audits and or action plans.

483.45(g)(h)(1)(2) REQUIREMENT Label/Store Drugs and Biologicals:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
§483.45(g) Labeling of Drugs and Biologicals
Drugs and biologicals used in the facility must be labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable.

§483.45(h) Storage of Drugs and Biologicals

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

§483.45(h)(2) The facility must provide separately locked, permanently affixed compartments for storage of controlled drugs listed in Schedule II of the Comprehensive Drug Abuse Prevention and Control Act of 1976 and other drugs subject to abuse, except when the facility uses single unit package drug distribution systems in which the quantity stored is minimal and a missing dose can be readily detected.
Observations:


Based on review of facility policies and medication package inserts, as well as observations and staff interviews, it was determined that the facility failed to label medications with the date they were opened, and failed to store medications at proper temperatures for one of three medication rooms reviewed (Rogers) and one of five medication carts reviewed (Mellon).

Findings include:

The facility's policy regarding medications, dated January 14, 2019, revealed that once opened, each medication was to be properly labeled with an expiration date.

The package insert for Tubersol (a medication used to test for tuberculosis- a bacterial infection), dated September 2015, revealed that the vial should be stored at 35 to 46 degrees Fahrenheit.

Observations in the Rogers Unit medication refrigerator on August 6, 2019, at 11:30 a.m. revealed that an open vial of tubersol was not labeled with an expiration date.

Interview with Registered Nurse 4 on August 6, 2019, at 11:30 a.m. confirmed that the opened vial of tubersol was not properly labeled with an expiration date.


Observations in the Mellon Unit medication cart on August 8, 2019, at 5:51 p.m. revealed that an open vial of tubersol was not labeled with an expiration date and was stored in the medication cart instead of in the refrigerator.

Interview with Registered Nurse 15 on August 8, 2019, at 5:51 a.m. confirmed that the opened vial of tubersol was not labeled with an expiration date, and it should have been stored in the refrigerator, not the medication cart.

Interview with the Director of Nursing on August 8, 2019, at 6:18 p.m. confirmed that the opened vials of tubersol should have been labeled with an expiration date and stored in the refrigerator.

42 CFR 483.45(g)(h)(1)(2) Label/Store Drugs and Biologicals.
Previously cited 2/13/19, 5/11/18.

28 Pa. Code 211.9(a)(1) Pharmacy services.
Previously cited 5/11/18.



 Plan of Correction - To be completed: 09/19/2019

Any tubersol solution that was found open and not refrigerated was discarded and replaced at the facility's expense.

The evening shift will check the medication cart and refrigerator to confirm proper temperature and storage of tubersol prior to taking the keys.
\The Clinical Educator/Designee will provide education to licensed staff on the new process and proper storage of biologicals.

An audit will be completed by the Director of Nursing/Designee for proper storage and labeling of biologicals. These audits will be completed daily times one week then weekly times four weeks

Findings of the audits will be reported to the facility Quality Assurance Performance Improvement committee for review. The committee will determine the need for further audits and or action plans.

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

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

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

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

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

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

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


Based on review of policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that proper infection control practices were followed while administering medications for two of 49 residents reviewed (Residents 77, 89).

Findings include:

Physician's orders for Resident 89, dated July 29, 2019, included orders for the resident to receive one 250 milligram (mg) tablet of Florastor (a daily probiotic supplement) via gastrostomy tube (a tube surgically inserted through the abdomen and into the stomach) daily.

Observations during medication administration on August 6, 2019, at 8:29 a.m. revealed that while preparing medications for Resident 89, Registered Nurse 3 obtained Florastor from the medication cart, poured the Florastor tablet from the medication bottle onto her bare hand, and then placed the medication into a souffle cup. She then administered the Florastor to the resident.

Physician's orders for Resident 77, dated June 21, 2019, included orders for the resident to receive one 500 mg tablet of cranberry (a supplement used to prevent urinary tract infection) daily, one 500 mg tablet of magnesium oxide (a mineral supplement) twice a day, one 20 milliequivalent (mEq) tablet of potassium chloride (a supplement) twice a day, and one 75 mg tablet of venlafaxine (a medication used to treat major depressive disorder, anxiety and panic disorder) daily.

Observations during medication administration on August 6, 2019, at 8:46 a.m. revealed that while preparing medications for Resident 77, Registered Nurse 3 obtained cranberry and magnesium oxide from the medication cart, poured the medications from the bottles onto her bare hand, then placed the medications into a souffle cup. She then obtained potassium chloride and venlafaxine from the medication cart, popped the medications from the blister packages (a package has individual compartments for each dose) onto her bare hand, and placed the medications into a souffle cup. She then administered the medications to the resident.


The facility's policy regarding medication administration, dated January 14, 2019, revealed that the person administering medications was to adhere to good hand hygiene, which included washing the hands thoroughly before beginning a medication pass, prior to handling any medication, and after coming into direct contact with a resident.

Observations during medication administration on August 6, 2019, at 8:46 a.m. revealed that Registered Nurse 3 prepared Resident 77's medications, obtained the resident's blood pressure, and then administered the medications to the resident. She then stopped at the foot of the bed closest to the door, picked up exam gloves that were lying on the floor, disposed of the exam gloves, returned to the medication cart, and began typing on the computer. The nurse then moved the medication cart across the hall to another resident's room, and without washing her hands or performing hand hygiene, she obtained medications for the resident in the room.

Interviews with Registered Nurse 3 on August 6, 2019, at 8:57 a.m. and with the Director of Nursing on August 7, 2019, at 11:15 a.m., confirmed that Registered Nurse 3 should not have touched Residents 77 and 89's medications with her bare hands, and she should have washed her hands or performed hand hygiene after leaving Resident 77's room and before starting to prepare medications for the next resident.

42 CFR 483.80(a)(1)(2)(4)(e)(f) Infection Prevention and Control.
Previously cited 2/13/19, 10/1/18, 8/17/18, 7/19/18, 5/11/18.

28 Pa. Code 211.12(d)(1) Nursing services.
Previously cited 2/13/19, 10/10/18, 10/1/18, 8/17/18, 7/19/18, 5/11/18.

28 Pa. Code 211.12(d)(5) Nursing services.
Previously cited 7/17/19, 3/29/19, 2/13/19, 10/10/18, 10/1/18, 8/17/18, 7/19/18, 5/11/18.


 Plan of Correction - To be completed: 09/19/2019

Resident 89 ceased to breathe on 5/9/19 prior to this survey.

Resident 77 remains at the facility and is receiving medications while being compliant with infection control practices.

Staff will adhere to facility infection control guidelines and practices that have been established.

Education will be provided to the licensed staff by the Clinical Educator/Designee on infection control practices during medication administration.

An audit will be completed by the Director of Nursing/Designee on infection control practices. These audits will be completed daily times one week and weekly times four weeks.

Findings of the audits will be reported to the facility Quality Assurance Performance Improvement committee for review. The committee will determine the need for further audits and or action plans.


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 observations and staff interviews, it was determined that the facility failed to maintain a clean and sanitary environment for residents and staff in shower rooms on one of three nursing units (Palmer) and one of three medication rooms reviewed (Mellon).

Findings include:

Observations in the Palmer unit shower room on August 5, 2019, at 10:38 a.m. and August 6, 2019, at 11:11 a.m. revealed that there was a dark substance along the edge of the floor in the shower stall and in the tile grout extending up the side and back walls to approximately forty-eight inches.

Interview with the Director of Environmental Services on August 6, 2019, at 11:17 a.m. confirmed that the shower stall needed to be cleaned and that the dark substance appeared to be mold. He also confirmed that staff are assigned to do a deep cleaning of the shower rooms each month, which included the walls.

Observations in the Mellon unit medication room on August 6, 2019, at 11:26 a.m. revealed that there was an accumulation of dirt, dust and debris on the floor and under the medication cart. In addition to dirt and dust, there were two alcohol wipes, six caps off medication vials, three pieces of sugar packets, four pieces of loose paper, one plastic bottle that squirted oil, and one plastic medication bag.

Interview with Registered Nurse 1 on August 6, 2019, at 11:26 a.m. confirmed that the medication room floor should not have dirt, dust and debris on it.

28 Pa. Code 207.2(a) Administrator's responsibility.
Previously cted 5/11/18.




 Plan of Correction - To be completed: 09/19/2019

The Palmer shower room, along with all other shower rooms have been deep cleaned.
The Mellon medication room has been deep cleaned and the microwave was replaced with a new one.
Cleaning Schedules have been updated to include these areas.
Education will be provided to the housekeeping staff by the Director of Environmental Services/Designee on deep cleans and the new cleaning schedule.
An audit for cleanliness of shower and medication rooms will be completed by the Director of Environmental Services/Designee. These audits will be completed daily times one week and weekly times four weeks.

Findings of the audits will be reported to the facility Quality Assurance Performance Improvement committee for review. The committee will determine the need for further audits and or action plans.

§ 211.10(d) LICENSURE Resident care policies.:State only Deficiency.
(d) The policies shall be designed and implemented to ensure that the resident receives proper care to prevent pressure sores and deformities; that the resident is kept comfortable, clean and well-groomed; that the resident is protected from accident, injury and infection; and that the resident is encouraged, assisted and trained in self-care and group activities.
Observations:


Based on review of information provided by the facility and residents' clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that there was a care policy related to the use of specialty air mattress and bed bolsters.

Findings included:

A current facility list of residents who used specialty air mattresses revealed that 21 residents had air mattresses in use, and eight of the 21 residents also had some type of bed bolster in use.

Observations for Residents 4, 10, 30 and 289 revealed that they had bed bolsters attached to their beds, and they also had specialty air mattresses in use. There was no documented evidence that safety assessments related to the use of bed bolsters and air mattress were completed for these residents, and no evidence that the facility had a policy related to the use of bed bolsters and air mattresses.

Interview with the Director of Nursing on August 8, 2019, at 5:06 p.m. confirmed that the facility did not have a care policy related to the use of air mattresses and bolsters.






 Plan of Correction - To be completed: 09/19/2019

A policy has been developed related to the use of specialty air mattresses.

New policy will be used for residents using specialty air mattresses.

The Clinical Educator/Designee will provide education to licensed staff on the new policy.

An audit will be completed by the Director of Nursing /Designee on proper use of air mattresses and bolsters based on this policy. These audits will be completed weekly times 4 weeks.

Findings of the audits will be reported to the facility Quality Assurance Performance Improvement committee for review. The committee will determine the need for further audits and or action plans.



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