Nursing Investigation Results -

Pennsylvania Department of Health
EMBASSY OF HEARTHSIDE
Patient Care Inspection Results

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
EMBASSY OF HEARTHSIDE
Inspection Results For:

There are  196 surveys for this facility. Please select a date to view the survey results.

Surveys don't appear on this website until at least 41 days have elapsed since the exit date of the survey.
EMBASSY OF HEARTHSIDE - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on a Medicare/Medicaid Recertification Survey, State Licensure Survey, an Abbreviated Survey to review two Complants, and a Civil Rights Compliance Survey completed on May 25, 2022, it was determined that Embassy of Hearthside was not in compliance with the following requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care and the 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.


 Plan of Correction:


483.60(i)(1)(2) REQUIREMENT Food Procurement,Store/Prepare/Serve-Sanitary:This is a less serious (but not lowest level) deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents.  This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.60(i) Food safety requirements.
The facility must -

483.60(i)(1) - Procure food from sources approved or considered satisfactory by federal, state or local authorities.
(i) This may include food items obtained directly from local producers, subject to applicable State and local laws or regulations.
(ii) This provision does not prohibit or prevent facilities from using produce grown in facility gardens, subject to compliance with applicable safe growing and food-handling practices.
(iii) This provision does not preclude residents from consuming foods not procured by the facility.

483.60(i)(2) - Store, prepare, distribute and serve food in accordance with professional standards for food service safety.
Observations:
Based on observation and staff interview, it was determined that the facility failed to store and prepare food items in a safe and sanitary manner in the facility's main kitchen.

Findings include:

Initial tour of the facility's main kitchen was conducted on May 22, 2022, at 9:35 AM.

Observation revealed there were no paper towels at the handwashing sink. The surveyor used paper napkins to dry her hands.

Observation of the walk-in freezer revealed there was an open cardboard box of individual tubes of ground beef wrapped in plastic on the floor.

Observation of the lower metal shelving unit storing the Robot Coupe (food processer), the plastic liner on the bottom shelf storing pots, and the bottom shelf of the metal table rack in the center of the kitchen had a build-up of greasy crumbs.

Observation of the plate warmer revealed plates were facing upward and were not covered, exposing the top plate to debris. The outside of the plate warmer unit had a build-up of dirt. Employee 2, cook, indicated that he could not find the lids to the plate warmer.

Observation of the floors revealed a dried dead light tan bug on the floor under the shelving unit storing the pots. Employee 2 referred to the bug as "a thousand legger." The floor edges behind the double oven, tilt skillet, and gas stove had a dirty build-up.

Observation of the dry storage room revealed a cobweb in the corner of the window that extended to the ceiling. The floor under the ice machine had a dirty build-up.

Prior to exiting the kitchen, the surveyor reviewed these findings with Employee 2.

The above findings for the kitchen were reviewed with the Nursing Home Administrator on May 23, 2022, at 10:00 AM.

483.60(i)(1)(2) Food Procurement, Store/Prepare/Serve-Sanitary
Previously cited 8/18/21, 7/27/21, 5/26/21

28 Pa. Code 211.6 (d) Dietary services


 Plan of Correction - To be completed: 06/28/2022

1.No residents have exhibited ill effects from the issues identified in the kitchen.
-Paper towels have been placed at the handwashing sink.
- The tubes of ground beef observed in a box on the floor were discarded.
-The lower metal shelving unit, the plastic liner on the bottom shelf and the metal rack in the center of the kitchen were cleaned.
-The plate warmer was cleaned and the lids/covers are placed on the unit as required.
- The dry storage room was cleaned as was the floor beneath the ice machine.

2. All residents have the potential to be affected by unsanitary food preparation or storage.

3. The dietary staff will be re-educated on the necessity to maintain sanitary food storage and preparation areas.

4. A random audit of sanitary conditions in the kitchen will be completed by the Nursing Home Administrator/designee weekly for 4 weeks.

Results of this audit will be reported to the Quality Assurance and Performance Improvement committee who will determine the necessity of continued audits.

483.80(a)(1)(2)(4)(e)(f) REQUIREMENT Infection Prevention & Control:This is a less serious (but not lowest level) deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents.  This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.80 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 infection control surveillance documentation, observation, and staff interview, it was determined that the facility failed to implement proper visitor and staff screening measures related to COVID-19.

Findings include:

Review of the Centers for Medicare and Medicaid Services QSO-20-39-NH memo revised on March 10, 2022, indicated facilities should screen all who enter for temperature and signs and symptoms of COVID-19, as a core principle of COVID-19 infection prevention.

Upon entrance to the facility on May 22, 2022, at 9:25 AM observation of the main entrance revealed that there was a COVID-19 screening log/binder for staff and visitors to complete upon entry to the facility. One of the entry logs was a request for the person's temperature. There was no thermometer available at the time of the survey team's entrance to facilitate an appropriate COVID-19 screening prior to entry to the facility. The survey team was permitted to enter the building without having their temperature(s) screened.

Concurrent review of the facility's COVID-19 screening log/binder from May 9, 2022, until current revealed that of the 199 COVID-19 screening entries, 37 of them failed to indicate that a temperature screening was completed and/or documented and seven of them failed to indicate if they had any signs and symptoms of COVID-19 at the time of entry to the facility.

Observation of the main entrance of the facility on May 22, 2022, at 9:46 AM revealed that a thermometer was now located near the COVID-19 screening log/binder.

In an entrance interview with Employee 5, registered nurse, regional nurse consultant, on May 22, 2022, at 10:00 AM and during an interview on May 23, 2022, at 12:51 PM with Employee 1 registered nurse, regional nurse consultant, the two employees acknowledged the above findings.

The facility failed to properly screen staff and visitors to prevent or contain COVID-19 in the facility.

483.80(a)(1)(2)(4)(e)(f) Infection Prevention & Control
Previously cited deficiency 7/27/21 and 5/26/21

28 Pa. Code 211.10(d) Resident care policies

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



 Plan of Correction - To be completed: 06/14/2022

1. The facility cannot retroactively correct the identified failures of the 37 temperature screenings and the 7 identified failures to indicate if they had any signs or symptoms of COVID-19 at the time of entry into the facility.

2. No evidence exist that any residents having any potential to be affected by this deficient practice.

3. The Director of Nursing/Infection Control Preventionist reviewed, implemented, and will monitor effective policies/procedures to ensure infections are prevented, treated, and/or controlled in accordance with the latest CDC and/or CMS guidelines.

Staff will receive re-education on the appropriate screening process and requirements for completion of log in sheets.

The facility conducted a Root Cause Analysis and took the appropriate actions to secure the signing-in process to include:
-Login form amended to included highlighted column titles to bring to the attention the requirements of those completing the form.
-New signage and login area created.
-Permanent thermometer is in place to ensure availability of the necessary tools.
-A letter is being sent to families and/or responsible parties reminding them of the importance of signing into the facility when visiting residents within the facility.


4. The Nursing Home Administrator/designee will perform audits on the "Log-In" sheets daily for 4 weeks to ensure accurate use of the available tools and to ensure compliance with the guidelines for visitor/staff screening related to COVID-19.

Results of the audits will be reported to the Quality Assurance and Performance Improvement Committee who will determine the necessity of continued audits.

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

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

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

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

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

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

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

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

Based on observation and resident, staff, and responsible party interview, it was determined that the facility failed to provide adequate housekeeping and maintenance services to ensure a clean, safe, and homelike environment on two of three nursing units (University, Residents 15, 32, 46, 58; and Heirloom, Residents 5, 12, 37, and 38).

Findings include:

Observation on May 22, 2022, at 1:32 PM revealed a bath blanket on the floor under the air conditioner in Resident 46's room. Concurrent interview with the responsible party for Resident 46 revealed the air conditioner leaks.

Observation on May 23, 2022, at 10:46 AM revealed the overbed tray in Resident 32's room had peeling rough edges.

Observation of Resident 58's room on May 23, 2022, at 10:50 AM revealed the paint was chipped from the wall next to the hand sanitizer unit. The pain chip was the same size as the current hand sanitizer unit.

Observation on May 23, 2022, at 10:53 AM revealed a folded sheet was on the floor under the air conditioning unit where Resident 15 resided. Concurrent interview with the resident revealed the air conditioner leaks.

Observation on the Heirloom unit on May 22, 2022, at 12:47 PM revealed the paint was chipped form the lower wall across from the nurse's station. The dining lounge door frame was marred with chipped paint, the wall to the left as you enter the dining lounge had a large area where the paint was chipped off. The windows in the dining lounge were dirty and there were cobwebs between the windows. The exit door that was located near the dining lounge had paint chipping and a piece that housed the alarm corded wires was pulled away from the wall and hanging loose.

Observation of Resident 5's room on May 23, 2022, at 10:52 AM revealed the paint on the door to his room was all chipped. The door frame was all marred with paint chipped. The wall between the closet and bathroom had adhesive strips stuck to it and there were four holes that were not repaired.

Observation of Resident 12's room on May 23, 2022, at 11:45 AM revealed that the name plate outside of her room had been removed and there was an area of missing paint where the name plate had been.

Observation of Resident 37's room on May 23, 2022, at 12:54 PM revealed the door of the room with chipped paint. There were also unrepaired holes in the wall to the right of the closet.

Observation of Resident 38's room on May 23, 2022, at 10:09 AM revealed the paint on the door to her room was chipped and the door was all marred. The closet door was dirty with brown spillage. The frame around the closet near the bottom had chipped paint areas and the baseboard beside the closet was coming off.

The above findings were reviewed with the Nursing Home Administrator and Director of Nursing on May 24, 2022, at 1:40 PM.

483.10(i)(1)-(7) Safe/Clean/Comfortable/Homelike Environment
Previously cited 5/26/21

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

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


 Plan of Correction - To be completed: 06/28/2022

1. There have been no noted ill effects to Residents 15, 32, 46, 58; 5, 12, 37, or 38 from the noted failure to provide adequate housekeeping or maintenance services.
-The air conditioning units for Resident 46 and 15 were checked and repaired so that they no longer leak.
-The over-bed tray table for Resident 32 was immediately removed and discarded. A new tray table was provided to Resident 32
-Resident 58's wall was repaired and painted.
-On Heirloom, the wall across from the nurse's station, dining lounge door frame, the exit door located near the dining lounge, the paint to Resident 5's door and the wall to the left as you enter the dining lounge were sanded and painted to correct the chipped paint.
- The windows in the dining lounge were cleaned
-The alarm cord wires near the exit door were secured.
-Resident 5's wall was cleaned to remove the adhesive strips and the four holes were repaired.
-The wall outside of Resident 12's room is being repaired and painted.
-The door to resident 37's room was sanded and painted and the 4 holes to the right of the closet are in the process of being repaired.
-Resident 38s door was sanded and painted to repair the chips and mars. The closet door was cleaned, the baseboard was reattached to the wall and the chipped paint around the closet frame was sanded and painted.

2. A comprehensive review of each resident's room and each unit will be completed to identify and correct any other housekeeping or maintenance issues.

3. Ambassador Rounds will be completed by management staff identify housekeeping and environmental issues.

4. A random audit for the correction of issues noted on Ambassador Rounds will be completed by the Director of Nursing and the Nursing Home Administrator. This audit will be completed for 4 weeks.

Results of this audit will be reported to the Quality Assurance and Performance Improvement committee who will determine the necessity of continued audits.

483.45(c)(1)(2)(4)(5) REQUIREMENT Drug Regimen Review, Report Irregular, Act On:This is a less serious (but not lowest level) deficiency and 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 select facility policies and procedures, clinical record review, and staff interview, it was determined that the facility failed to ensure an appropriate physician response to the consultant pharmacist's recommendation for five of five residents reviewed (Residents 80, 43, 5, 12, and 37)

Findings include:

The facility policy titled, "Consulting Pharmacy Monthly Drug Review," last reviewed without changes on July 26, 2021, revealed that the consultant pharmacist reviews the medication regimen of each resident at least monthly. Medication irregularities noted by the consultant pharmacist shall be documented on a separate, written report and sent to the physician, Director of Nursing, and Medical Director within 24 hours. The resident's attending physician must document in the medical record that the irregularity has been reviewed and what, if any, action has been taken to address it.

Clinical record review for Resident 80 revealed that the monthly drug reviews were completed for the past year and new pharmacy recommendations were made on January 24, 2022, and March 23, 2022.

Clinical record review for Resident 43 revealed that monthly drug reviews were completed by the pharmacist and pharmacy recommendations to the physician were made on October 21, 2021, and January 23, 2022.

Clinical record review for Resident 12 revealed that monthly drug reviews were completed by the pharmacist and pharmacy recommendations to the physician were made on February 23, 2021, and April 14, 2022.

Further review of the clinical record revealed no evidence as to what the recommendations were for these dates or any evidence that the physician responded to the recommendations for the residents listed above.

An interview with the Director of Nursing on May 25, 2022, at 9:34 AM, revealed that the facility is unable to locate the recommendations for those dates or provide evidence that they were reviewed and acted upon by the physician.

Clinical record review for Resident 5 revealed that monthly drug reviews were completed by the pharmacist and pharmacy recommendations to the physician were made on October 20, 2021, January 23, 2022, and April 14, 2022. There was no evidence in the clinical record that the physician reviewed the pharmacy recommendations.

Clinical record review for Resident 37 revealed that monthly drug reviews were completed by the pharmacist and pharmacy recommendations to the physician were made on January 23, 2022 and April 14, 2022. There was no evidence in the clinical record that the physician reviewed the pharmacy recommendations.

An interview with the Director of Nursing on May 24, 2022, at 1:45 PM, confirmed the above noted findings for Resident 5 and 37, that the physician failed to address the pharmacy recommendations.

The facility failed to ensure physician response to pharmacy monthly reviews.

28 Pa. Code 211.2(a) Physician services

28 Pa. Code 211.9(k) Pharmacy services

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








 Plan of Correction - To be completed: 06/28/2022

1.Requests for medication reviews by the Consultant Pharmacist will be made for Residents 80, 43, 5, 12, and 37. Any recommendations from this review will be addressed with the physician.

2. Recommendations made by the consultant pharmacist following medication reviews for other residents will be submitted to the physician for review.

3. Licensed nursing staff will be educated on monthly drug reviews by the consultant pharmacist, timely review of recommendations by the physician and documentation of these reviews.

4. Any audit of drug regimen reviews will be completed for 2 months by the Director of Nursing/designee to ensure that the recommendations from reviews are addressed by the physician and evidence of the completed review is entered into the resident's medical record.

Results of this audit will be reported to the Quality Assurance and Performance Improvement committee who will determine the necessity of continued audits.

483.35(a)(1)(2) REQUIREMENT Sufficient Nursing Staff: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.
483.35(a) Sufficient Staff.
The facility must have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment required at 483.70(e).

483.35(a)(1) The facility must provide services by sufficient numbers of each of the following types of personnel on a 24-hour basis to provide nursing care to all residents in accordance with resident care plans:
(i) Except when waived under paragraph (e) of this section, licensed nurses; and
(ii) Other nursing personnel, including but not limited to nurse aides.

483.35(a)(2) Except when waived under paragraph (e) of this section, the facility must designate a licensed nurse to serve as a charge nurse on each tour of duty.
Observations:

Based on review of facility documentation, and staff, resident, and resident's responsible party interview, it was determined that the facility failed to ensure sufficient nursing staff to ensure appropriate care and services and call bell response for two of three nursing units (Beaver and University Nursing Units; Residents 11, 18, 20, 26, 28, 30, 32, 36, 47, 65, 70, 76, and 289)

Findings include:

Interview with Resident 30's responsible party on May 22, 2022, at 12:31 PM revealed that she had concerns with only having one nurse aide on the unit to provide resident care. She indicated that this was due to staff call-offs, especially during the weekends. She revealed that she visited daily to ensure that her daughter was fed lunch and help provide her care.

Review of Concern Reports (a form to voice concerns with facility response) dated between February 25, 2022, to current revealed the following resident concerns:

On February 25, 2022, at 1:00 PM Resident 36 voiced concerns that her roommate needed incontinence care. At 1:40 PM, Resident 36 needed to utilize the restroom. At 2:00 PM, a staff member entered and informed Resident 36 that she would tell the second shift (staff) of their concerns. At 2:40 PM, Resident 36 indicated that the Ombudsman visited and noted a puddle on the floor. A staff statement revealed that "it is extremely difficult to do your job and answer call bells for 36 residents with two (nurse) aides." The facility educated staff on time management.

On March 16, 2022, Resident 65 reported that she waited over 1 hour and 10 minutes on first shift for someone to answer her call bell. The facility educated staff on monitoring and answering call bells.

On March 28, 2022, Resident 65 reported that on March 27, 2022, around 6:00 AM staff provided incontinence care. She indicated that she did not receive incontinence care again until 8:00 PM when she went to bed. It was determined that Resident 65's call bell was answered several times throughout the day, however, she refused care when answered by a male nurse aide. Resident 65 was to receive care by female nurse aides per her preference. Staff were educated on monitoring call bells.

On May 2, 2022, Resident 289's responsible party reported concerns with long call bell wait times, noting a 20-minute call bell at the time. The responsible party did not feel that the resident should have to wait to receive care. She was informed that if immediate assistance was needed, to notify the registered nurse and other staff would be called to assist.

Review of February, March, April, and May 2022's resident council meeting documentation revealed that several residents voiced concerns with not receiving showers per their preference, concerns with lengthy staff response to their call bells, and that there were not more staff on the nursing units.

Review of facility documentation entitled "Call Bell Audit" (a form used to interview residents regarding call bell response times) revealed that staff asked residents, "Do you feel that your call bell is answered timely, if not, how long (in minutes) do you feel it takes them to answer your bell, and do you know a day/shift that this occurred?"

During the week of February 21, 2022, staff interviewed residents regarding call bells with the following responses:

Resident 76 indicated that staff response time was 30 to 40 minutes on all shifts.
Resident 28 indicated that staff response time was "sometimes hours" on first and second shift.
Resident 70 indicated that staff response time was "an hour" on second and third shift.

During the week of February 28, 2022, staff interviewed residents regarding call bells with the following responses:

Resident 18 indicated that staff response was 15 to 20 minutes on second shift
Resident 32 indicated that staff response was "sometimes hour" on second shift
Resident 36 indicated that staff response was greater than 45 minutes on second shift
Resident 65 indicated that staff response was "over an hour" on second shift.

During the week of March 7, 2022, staff interviewed residents regarding call bells with the following responses:

Resident 47 indicated that staff response time was "long" on all shifts.

Staff also followed up with Residents 28 and 70 from the week of February 21, 2022, with the following results:

Resident 28 continued to indicate that staff response time was not timely. That it takes "a while" for them to respond on second shift.
Resident 70 continued to indicate that staff response time was still the "same."

During the week of March 14, 2022, staff interviewed residents regarding call bells with the following responses:

Resident 47 continued to indicate that staff response time was 15 to 20 minutes on second shift.
Resident 20 indicated that staff response time was "most times" 15 minutes on second shift.

The surveyor reviewed the above information during an interview on May 25, 2022, at 10:10 AM with the Director of Nursing and Employee 1, registered nurse, regional nursing consultant, and on May 25, 2022, at 10:25 AM with the Nursing Home Administrator. All three acknowledged the concerns identified with sufficient staffing to ensure care and services are received timely and staff response to call bells. Employee 1 indicated that the facility's call bell system does not have the ability to provide call bell response logs upon request.

During an interview with Resident 11 on May 22, 2022, at 12:52 PM the resident reported that he rang his call bell at 6:45 PM and it took almost two hours for anyone to answer it. The resident could not provide a date. The resident also reported that getting staff to answer the call bell on second shift around 7:00 PM is a problem as it takes 30 minutes to one and a quarter hours to get it answered. The resident indicated that he reported it before to the social worker, and the response times did not get better.

An interview with Resident 26 on May 23, 2022, at 10:19 AM revealed the resident has had to wait 30 minutes for staff to answer the call bell. The resident was unable to provide an exact date but reported this occurred during the "early morning."

During an interview with the Nursing Home Administrator and Director of Nursing on May 24, 2022, at 1:30 PM the above findings for Resident 11 were reviewed and the surveyor asked for call bell logs or audits and was told the social worker will provide audits.

During an interview with Employee 4, social worker, on May 25, 2022, at 11:15 AM the audits completed by the social worker were reviewed. The audits consisted of asking alert and oriented residents on Beaver and University units if they feel their call bells were answered timely. Employee 4 indicated that she follows up with the residents later if a concern was identified. The audits were completed for the weeks of February 21 and 28, 2022, and March 7 and 14, 2022. The audits did not list Resident 11. In a concurrent interview with Employee 1, registered nurse consultant, the above information for Resident 11 was reviewed.

483.35(a)(1)(2) Sufficient Nursing Staff
Previously cited 5/26/21

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

28 Pa. Code 211.12(a)(c)(d)(1)(3)(4)(i)(5) Nursing services



 Plan of Correction - To be completed: 06/28/2022

1.Residents 11, 18, 20, 26, 28, 30, 2, 36, 47, 65, 70, 76, and 289 show no ill effect relating to the identified call bell responses.

2. All residents have the potential to be affected with the lack of responsiveness in a timely manner. To ensure the facility continues to avoid such issues, these corrective plans will be brought to resident council as well as the grievance process to assurance the intent of all involved is to follow up on the need to respond to residents' needs.

3. Clinical staff including all ancillary and administrative staff will be re-educated on the importance and the necessity of responding to resident needs in a timely and appropriate manner.

4. The director of nursing and nursing leadership will monitor staff responses to resident needs while on the floor. Concerns will be addressed immediately with individual staff.

On-going call bell audits will be performed on all shifts daily for 4 weeks to monitor the responsiveness of staff.

In addition, continued monitoring will be conducted through the monthly resident council meetings.

Audit findings and resident council actions will be presented to the Quality Assurance Performance Improvement committee for review, discussion and recommendations.


483.25(c)(1)-(3) REQUIREMENT Increase/Prevent Decrease in ROM/Mobility:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
483.25(c) Mobility.
483.25(c)(1) The facility must ensure that a resident who enters the facility without limited range of motion does not experience reduction in range of motion unless the resident's clinical condition demonstrates that a reduction in range of motion is unavoidable; and

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

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

Based on clinical record review and staff interview, it was determined that the facility failed to provide physician ordered services to maintain a resident's range of motion (ROM) for two of four residents reviewed (Residents 48 and 16).

Findings include:

Clinical record review for Resident 48 revealed a care plan for staff to provide a restorative nursing program (RNP) of passive ROM (PROM, range of motion, movement of the body in an attempt to maintain a resident's ability) of his bilateral (B/L, both) lower extremities (LE, legs) in a lying or sitting position. The PROM was to consist of hip, knee, and ankle flexion and extension for three sets of 10 repetitions each. This care plan was implemented on January 31, 2020.

On December 27, 2021, therapy re-evaluated Resident 48, and continued his B/L LE PROM RNP program and provided education to the facility's nurse aide staff on his RNP program.

Review of Resident 48's RNP documentation revealed that there was no documentation available indicating that staff provided restorative PROM to his B/L LE since his care plan was implemented.

Clinical record review for Resident 16 revealed MDS (Minimum Data Set, an assessment completed at intervals by the facility to determine care needs) assessments dated February 4, 2022, and May 4, 2022, that indicated Resident 16 had an impairment on one side of his body for both upper and lower extremities.

Further clinical record review revealed a care plan entitled Restorative Program, last revised on October 3, 2019, that revealed Resident 16 was to receive PROM to his bilateral upper and lower extremities.

Review of Resident 16's clinical record for RNP documentation from February 2022 through May 23, 2022, revealed that there was no documentation available indicating that the staff provided PROM to his bilateral upper and lower extremities.

The surveyor reviewed the above information on May 24, 2022, at 1:45 PM with the Nursing Home Administrator and Director of Nursing.

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

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


 Plan of Correction - To be completed: 06/28/2022

1.Range of motion programs for Residents 48 and 16 will be evaluated by physical therapy due to the lack of documentation that range of motion was provided.

2. Tasks for other residents with restorative nursing programs will be reviewed to determine if the programs remain appropriate and if the Task is set up to trigger documentation through the electronic documentation system (Point of Care).

3. Licensed nursing staff will be educated on entering Tasks into the electronic documentation system to ensure that documentation will be triggered for completion.

4. A random audit of newly initiated restorative nursing programs will be completed by the MDS Coordinator/ designee to ensure that the Tasks set up for these programs triggers for documentation to be completed. This audit will be completed weekly for 4 weeks.

Results of this audit will be reported to the Quality Assurance and Performance Improvement Quality Assurance and Performance Improvement committee who will determine the necessity of continued audits.

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 review and staff interview, it was determined that the facility failed to consult a physician for a deterioration in health status for one of 18 residents reviewed (Resident 11).

Findings include:

Clinical record review for Resident 11 revealed a quarterly MDS (Minimum Data Set, an assessment tool completed at specific intervals to determine resident care needs) dated February 3, 2022, which revealed the resident can make himself understood, understands others, and had no signs of delirium (an abrupt change in the brain that causes mental confusion and emotional disruption that one of the causes is an infection) such as signs of inattention, disorganized thinking, altered level of consciousness such as being easily startled, lethargy (a physical or mental state of sleepiness or unresponsiveness and inactivity), difficult to arouse, or unable to be aroused.

Record review for Resident 11 revealed a nursing progress note dated May 8, 2022, at 6:17 AM that the resident was administered Acetaminophen (medication to relieve pain or fever) 650 mg (milligrams) due to a temperature of 104.4 (normal adult temperatures can range between 97 degrees Fahrenheit and 99 degrees Fahrenheit or more). Cold compresses were placed under the resident's armpits and forehead. He was tested for COVID-19 (highly infectious respiratory disease).

A nursing progress note dated May 8, 2022, at 6:22 AM indicated that Resident 11's COVID-19 test was negative.

Clinical record review for Resident 11 revealed a nursing progress note dated May 8, 2022, at 9:14 AM that the acetaminophen was effective as the resident's temperature was 98.6 degrees.

A nursing progress note dated May 8, 2022, at 2:01 PM indicated the resident had been lethargic in the afternoon screaming when awake, and did not stay awake, dropping water on himself, and confused. The registered nurse was made aware.

Clinical record review for Resident 11 revealed a nursing progress note as a late entry for May 8, 2022, (no time listed) dated May 9, 2022, at 11:19 AM that indicated the nurse attempted to wake the resident for a shower times three, unable to arouse the resident, the resident would throw his arms in the air and then flop them down, his eyes would open for a second, then close, then flop head to the side, lethargy continued throughout 6-2 shift, the nurse would attempt at a later time.

A nursing progress note dated May 9, 2022, at 4:57 AM indicated that Prilosec (medication for stomach reflux disease) was held due to the resident being too lethargic to take medication.

Record review for Resident 11 revealed a nursing progress note dated May 9, 2022, at 6:06 AM that indicated the resident was too lethargic to take medications. The resident's catheter (a flexible tube from the urethra and into the bladder to drain urine) was changed and a specimen was sent for urinalysis and culture and sensitivity (specimen to diagnose a UTI, urinary tract infection). The RN (registered nurse) was made aware.

A nursing progress note dated May 9, 2022, at 8:45 AM indicated the RN spoke to the CRNP (clinical registered nurse practitioner, a medical provider) and updated the CRNP and received an order for Macrobid (antibacterial often used to treat a UTI) 100 mg twice daily for seven days.

Clinical record review for Resident 11 revealed a nursing progress note dated May 9, 2022, at 1:17 PM that indicated the resident was lethargic, and medications were unable to be safely administered.

A nursing progress note dated May 9, 2022, at 2:20 PM indicated the resident had a change in mental status. When left alone, he was sleeping. When verbally stimulated, he threw his arms around and made noises. With a sternal rub (a method used for applying a painful stimulus by rubbing the knuckles of a closed fist firmly and vigorously on the breastbone to assess the neurological status), he opened his eyes looked at nurse and pushed her hand away. When oxygen was applied, he removed it. The residents' vital signs (temperature, pulse, respirations, and blood pressure) were within normal limits and pulse oximetry 94 percent (normal oxygen level range for Resident 11). The resident did not eat or drink or have any medications on this date. The resident was seen by the medical doctor and an order was received to send him to the emergency room. The note indicated that his usual mental state is alert and oriented and verbal.

Record review for Resident 11 revealed a nursing progress note dated May 11, 2022, at 5:45 PM that indicated the resident was readmitted from the hospital with a diagnosis of a complicated UTI. He was alert and oriented on return.

There was no documented evidence that the facility notified the physician/medical provider of Resident 11's change in condition as evidenced by a fever of 104.4 degrees Fahrenheit on May 8, 2022, at 6:17 AM and subsequent changes his in mental status (lethargy, confusion, inability to take medications), until the CRNP was notified, which was approximately 26 hours later. Resident 11's mental status continued to decline. There was no documented evidence that the medical provider was contacted until approximately five hours later from the order for Macrobid until the time the resident was examined by the physician and orders were received to send the resident to the emergency room.

During an interview with Employee 1, RN consultant, it was confirmed that there was no documented evidence of the nurse notifying the physician of Resident 11's fever, subsequent lethargy, and change in condition.

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



 Plan of Correction - To be completed: 06/28/2022

1. The facility cannot retroactively correct the delay in physician notification for the change in conditions for Resident 11.

2. A seven day look back of other resident's medical records will be completed and any noted change in condition with be reported to the physician or extender to be addressed.


3. Licensed nursing staff will be educated on identification and timely notification of resident change in condition to the physician or extender.

4. Resident progress notes will be audited by the Director of Nursing/designee to ensure that timely notification of resident change is condition to the physician or extender has occurred. Any change in condition not already reported will be reported to the physician or extender to address.

A random audit of 10 resident's charts will be completed weekly for 4 weeks. Results of this audit will be reported to the QA committee who will determine the necessity of continued audits.

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 review and staff interview, it was determined that the facility failed to provide the required NOMNC (Notice of Medicare Provider Non-Coverage) in writing to a responsible party of a resident whose payment coverage changed for two of three residents reviewed (Residents 42 and 46).

Findings include:

Clinical record review for Resident 42 revealed that her payment coverage changed on January 19, 2022, when her Medicare payment for services stopped. Review of a CMS-10123 form indicated Resident 42's responsible party was informed telephonically on January 14, 2022; however, there was no documented evidence that the written form was provided to the responsible party.

Clinical record review for Resident 46 revealed that his payment coverage changed on January 17, 2022, when his Medicare payment for services stopped. Review of a CMS-10123 form indicated Resident 46's responsible party was informed telephonically on January 14, 2022; however, there was no documented evidence that the written form was provided to the responsible party.

Interview with Employee 1, Registered Nurse consultant on May 24, 2022, at 12:20 PM confirmed that written copies of the NOMNC notices were not provided to the above responsible parties.

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

28 Pa. Code 201.29(a) Resident rights


 Plan of Correction - To be completed: 06/28/2022

1.NOMNCs (Notice of Medicare Provider Non-Coverage) will be provided in writing to the responsible party of Residents 42 and 46.

2. A 30-day look review of any other residents whose payment coverage changed from Medicare will be completed. Responsible parties for those residents with be provided and NOMNC in writing.

3. Facility employees responsible for issuing NOMNCs will be educated on the requirement to provide a written copy of the NOMNC to the resident's responsible party.

4. Residents whose Medicare coverage has ended will be reviewed to ensure that a written copy of the NOMNC was provided to the resident's responsible party. A weekly audit of these residents with change in coverage will be completed by the Nursing Home Administrator/designee for 4 weeks.

Results of this audit will be reported to the Quality Assurance and Performance Improvement committee who will determine the necessity of continued audits

483.12(b)(1)-(3) REQUIREMENT Develop/Implement Abuse/Neglect Policies:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.12(b) The facility must develop and implement written policies and procedures that:

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

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

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

Based on review of select facility policy and procedures, select facility documents, and staff interview, it was determined that the facility failed to implement its established abuse prevention procedures for one of five employees reviewed (Employee 3)

Findings include:

The facility policy entitled, "Abuse, Neglect, Exploitation, and Misappropriation of Resident Property" last reviewed on July 26, 2021, revealed that the facility will conduct background checks of all employees and retain on file applicable records of current employees regarding such checks. The facility will do the following prior to hiring a new employee: conduct a criminal background check.

Review of Employee 3's personnel file on May 25, 2022, revealed that she was hired on March 28, 2022, as the facility's human resource director. Her background check entitled, "Pennsylvania State Policy Response to Criminal Record Check, was not completed until May 25, 2022, after the surveyor inquired about Employee 3's background check. Further review of Employee 3's personnel record revealed no evidence that the facility completed reference checks prior to her starting her employment at the facility.

Interview with Employee 3, Human Resource Director, at 12:30 PM on May 25, 2022, confirmed the above noted findings related to her background and reference checks.

The Nursing Home Administrator and Director of Nursing were made aware of the above noted findings during a meeting on May 25, 2022, at 2:15 PM.

28 Pa. Code 201.14(a) Responsibility of Licensee

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

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




 Plan of Correction - To be completed: 06/28/2022

1.The facility cannot retroactively correct the delay in completion of Employee 3's background check. Reference checks for Employee 3 will be completed.

2. A review of new hire files from the previous 90 days will be completed to ensure that background and reference checks have been completed. Any missing background or reference checks will be completed.

3. The Human Resources Director will be educated on the facility policy entitled, "Abuse, Neglect, Exploitation, and Misappropriation of Resident Property" and the requirement to complete criminal background and reference checks for all new hires.

4. New hire files will be audited by the Nursing Home Administrator/designee to ensure that background and reference checks have been completed. This audit will be completed on new hires files for 4 weeks.

Results of this audit will be reported to the Quality Assurance and Performance Improvement committee who will determine the necessity of continued audits.

483.12(c)(2)-(4) REQUIREMENT Investigate/Prevent/Correct Alleged Violation:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must:

483.12(c)(2) Have evidence that all alleged violations are thoroughly investigated.

483.12(c)(3) Prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress.

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

Based on clinical record review, review of select facility polices, and staff interview, it was determined that the facility failed to thoroughly investigate an injury of unknown origin for one of two residents reviewed (Resident 16).

Findings include:

The facility policy entitled, "Abuse, Neglect, Exploitation, and Misappropriation of Resident Property" last reviewed without changes on July 26, 2021, revealed that the facility will investigate all alleged violations involving abuse, neglect, exploitation, and mistreatment, or misappropriation of resident property, including injuries of unknown source. An injury is classified as an injury of unknown source when both the following conditions are met: the source of the injury was not observed by any person, or the source of the injury could not be explained by the resident; and the injury is suspicious because of the extent of the injury, the location, the number of injuries observed at one time, or the incidence of injuries over time.

Clinical record review for Resident 16 revealed a nursing progress note dated May 15, 2022, at 5:45 PM that indicated the resident was noted to have bruising to his left lateral foot, minimal swelling, and some bruising and edema extending towards his ankle area.

A nursing progress note dated May 15, 2022, at 5:52 PM revealed that during care the nurse aide found two bruises to Resident 16's left lateral foot measuring 10 cm (centimeters) by 3 cm and 4 cm by 4 cm, slightly swollen on left side of foot extending towards ankle.

A nursing progress note dated May 15, 2022, at 8:53 PM revealed that Resident 16's physician was notified of the injury to his left foot and that the family requested an x-ray of the foot.

An x-ray report dated May 16, 2022, revealed suspected acute avulsed bony fragment (a small chunk of bone attached to a tendon or ligament gets pulled away from the main part of the bone) along the anterior aspect of the talus bone (a small bone that sits between the heel bone and the two bones of the lower leg), and suggested a CT scan (a computerized tomography, a scan that provides more detailed images) for correlation.

Review of the facility investigation into the injury of unknown origin dated May 15, 2022, revealed a statement dated May 15, 2022, from Employee 6, nurse aide, that indicated she did not notice a bruise when she changed him at 1:45 PM because the resident had socks on. When she changed him at 5:25 PM on the same day she noticed the bruise because the resident had kicked his socks off.

The facility investigation revealed a statement from Employee 8, nurse aide, dated May 16, 2022, that indicated on May 14, 2022, Resident 16 was up in his chair, and he put him into bed around 4:00 PM. He stated Resident 16 was lifted out of his chair with him having no contact with the ground. He also indicated that possible causes for the bruise could be that when he is placed on a shower chair his foot may get stuck behind the bottom bar or when people transfer him, they "aren't picking him up high enough, so his feet touch the ground and his weight is put on them from the side because his feet aren't flat, but more angled."

A statement provided by Employee 7, nurse aide dated May 16, 2022, at 4:47 via telephone, revealed that on May 14, 2022, she transferred Resident 16 from his bed to the shower chair, then to his wheelchair with another nurse aide, Employee 9, and there were no problems noted with the transfer. There was no statement from Employee 9 obtained by the facility.

There were no other statements present with the investigation documents provided to the surveyor.

An interview with the Director of Nursing on May 25, 2022, at 12:32 PM revealed that the facility protocol for investigating injuries of unknown origin is to interview all staff, including ancillary staff, who worked on the resident's unit during the past 72 hours. She confirmed that she did not do this as part of the investigation into the injury of unknown origin to Resident 16's foot.

The facility failed to thoroughly investigate an injury to Resident 16's left foot to rule out neglect or abuse.

28 Pa. Code 201.14(a) Responsibility of licensee

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

28 Pa. Code 201.29(c)(d) Resident rights

28 Pa. Code 211.10(d) Resident care policies

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




 Plan of Correction - To be completed: 06/28/2022

1.The investigation into the injury of unknown origin for Resident 16 has been completed by obtaining statements from all staff who worked on his unit in the 72 hours prior to the discovery of his injury. The exact cause of the injury remains unknown.

2. A review of other residents with injuries of unknown origin in the previous 30 days will be completed to ensure that the investigation into possible causes of the injury is complete.

3. Nursing staff will be educated on the policy entitled, "Abuse, Neglect, Exploitation, and Misappropriation of Resident Property" the specifies the need to investigate all alleged violations involving abuse, neglect, exploitation, and mistreatment, or misappropriation of resident property, including injuries of unknown source.

4. An audit of the completion of thorough investigations for injuries of unknown origin will be completed by the Director of Nursing/Designee weekly for 4 weeks.

Results of this audit will be reported to the Quality Assurance and Performance Improvement committee who will determine the necessity of continued audits.

483.15(c)(3)-(6)(8) REQUIREMENT Notice Requirements Before Transfer/Discharge:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.15(c)(3) Notice before transfer.
Before a facility transfers or discharges a resident, the facility must-
(i) Notify the resident and the resident's representative(s) of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand. The facility must send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman.
(ii) Record the reasons for the transfer or discharge in the resident's medical record in accordance with paragraph (c)(2) of this section; and
(iii) Include in the notice the items described in paragraph (c)(5) of this section.

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

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

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

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

Based on clinical record review and staff interview, it was determined that the facility failed to notify a resident and/or their responsible party in writing with the required contents of a transfer notice to the hospital for one of five residents reviewed for hospitalizations (Resident 54).

Findings include:

Clinical record review for Resident 54 revealed that the resident was transferred to the hospital on February 12, 2022, after there was a change in their condition. There was no documentation that the facility provided written notification to the resident or their responsible party regarding the transfer that included the required contents: specific reason for the transfer, contact and address information for the Office of the State Long-Term Care Ombudsman, information for the agency responsible for the protection and advocacy of individuals with developmental disabilities, and information for the agency responsible for the protection and advocacy of mentally ill individuals.

The surveyor reviewed the above information for Resident 54 during an interview with the Director of Nursing on May 25, 2022, at 12:29 PM.

28 Pa. Code 201.14 (a) Responsibility of license

28 Pa. Code 201.29(a) Resident rights



 Plan of Correction - To be completed: 06/28/2022

1.A Bedhold/Transfer Notice will be provided to Resident's 54's responsible party that contains the required information.

2. Record reviews for residents transferred to the hospital in the previous 30 days will be completed to ensure that a bedhold/transfer notice was provided that contained the required information. A notice will be provided to the resident's responsible party for any notices identified as lacking this information.

3. The Bedhold/Transfer form will be reviewed and revised to include the specific reason for the transfer, contact and address information for the Office of the State Long-Term Care Ombudsman, information for the agency responsible for the protection and advocacy of individuals with developmental disabilities, and information for the agency responsible for the protection and advocacy of mentally ill individuals.

Licensed Nursing staff will be educated on the requirement for and use of this notice.

4. Hospital transfers will be audited by the Director of Nursing/designee to ensure that a bedhold/transfer notice containing the required information was provided to the resident/responsible party. This audit will be completed weekly for 4 weeks.

Results of this audit will be reported to the Quality Assurance and Performance Improvement Committee who will determine the necessity of continued audits.

483.20(k)(1)-(3) REQUIREMENT PASARR Screening for MD & ID: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(k) Preadmission Screening for individuals with a mental disorder and individuals with intellectual disability.

483.20(k)(1) A nursing facility must not admit, on or after January 1, 1989, any new residents with:
(i) Mental disorder as defined in paragraph (k)(3)(i) of this section, unless the State mental health authority has determined, based on an independent physical and mental evaluation performed by a person or entity other than the State mental health authority, prior to admission,
(A) That, because of the physical and mental condition of the individual, the individual requires the level of services provided by a nursing facility; and
(B) If the individual requires such level of services, whether the individual requires specialized services; or
(ii) Intellectual disability, as defined in paragraph (k)(3)(ii) of this section, unless the State intellectual disability or developmental disability authority has determined prior to admission-
(A) That, because of the physical and mental condition of the individual, the individual requires the level of services provided by a nursing facility; and
(B) If the individual requires such level of services, whether the individual requires specialized services for intellectual disability.

483.20(k)(2) Exceptions. For purposes of this section-
(i)The preadmission screening program under paragraph(k)(1) of this section need not provide for determinations in the case of the readmission to a nursing facility of an individual who, after being admitted to the nursing facility, was transferred for care in a hospital.
(ii) The State may choose not to apply the preadmission screening program under paragraph (k)(1) of this section to the admission to a nursing facility of an individual-
(A) Who is admitted to the facility directly from a hospital after receiving acute inpatient care at the hospital,
(B) Who requires nursing facility services for the condition for which the individual received care in the hospital, and
(C) Whose attending physician has certified, before admission to the facility that the individual is likely to require less than 30 days of nursing facility services.

483.20(k)(3) Definition. For purposes of this section-
(i) An individual is considered to have a mental disorder if the individual has a serious mental disorder defined in 483.102(b)(1).
(ii) An individual is considered to have an intellectual disability if the individual has an intellectual disability as defined in 483.102(b)(3) or is a person with a related condition as described in 435.1010 of this chapter.
Observations:

Based on clinical record review and staff interview, it was determined that the facility failed to screen residents for a mental disorder or an intellectual disability prior to admission to the facility for two of five residents reviewed (Residents 16 and 38).

Findings include:

Clinical record review for Resident 16 revealed that the facility admitted him on March 2, 2015, with a diagnosis of psychosis (a condition that affects the way your brain processes information and causes you to lose touch with reality). There was no evidence in the clinical record that the facility screened Resident 16 prior to admission for a mental disorder or intellectual disability.

Clinical record review for Resident 38 revealed that the facility admitted her on February 7, 2017, with diagnosis of depressive disorder (sadness severe enough or persistent enough to interfere with function and often decreased interest or pleasure in activities), mental disorder (a behavioral disorder that interferes with impairment of personal functioning), and Lewy bodies dementia (a disease that affects chemicals in the brain and causes problems with thinking, movements, behaviors, and mood). There was no evidence in Resident 38's clinical record that the facility screened her prior to admission for a mental disorder or intellectual disability

Interview with the Director of Nursing and Employee 1 (Nurse consultant) on May 24, 2022, at 2:00 PM confirmed that the facility was unable to provide evidence that Residents 16 and 38 were screened for mental health or intellectual disability according to the federal requirement with a completed PASARR (Preadmission Screening and Resident Review) prior to admission to the facility.

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


 Plan of Correction - To be completed: 06/28/2022

1.Based on the admission documentation, the facility has recreated the PASARR documents for both resident 16 and resident 38.

2. A facility-wide review of all residents will be conducted to ensure any resident with a screening outcome of a mental disorder or an intellectual disability prior to admission has a PASARR on file. If a resident meeting such criteria exist and does not have a PASARR on file, a document will be created at that time.

3. Facility staff (Social Service and Admissions) who are responsible for conducting the initial screening will be re-educated on the requirements to screen individuals who may have mental disorder or an individual with intellectual disability.

4. Director of Nursing/or designee perform audits on all new admissions for a period of 4 weeks to ensure the PASARR are being completed for any potential resident meeting such criteria.

Results of the audits will be reported to the Quality Assurance and Performance Improvement Committee who will determine the necessity of continued audits.

483.25(n)(1)-(4) REQUIREMENT Bedrails: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(n) Bed Rails.
The facility must attempt to use appropriate alternatives prior to installing a side or bed rail. If a bed or side rail is used, the facility must ensure correct installation, use, and maintenance of bed rails, including but not limited to the following elements.

483.25(n)(1) Assess the resident for risk of entrapment from bed rails prior to installation.

483.25(n)(2) Review the risks and benefits of bed rails with the resident or resident representative and obtain informed consent prior to installation.

483.25(n)(3) Ensure that the bed's dimensions are appropriate for the resident's size and weight.

483.25(n)(4) Follow the manufacturers' recommendations and specifications for installing and maintaining bed rails.
Observations:

Based on review of select facility policies and procedures, clinical record review, observation, and resident and staff interview, it was determined that the facility failed to complete an assessment for the use of bilateral side rails, obtain consent, or provided the responsible party with the risks and benefits for the use of side rails for one of eight residents reviewed (Resident 84).

Findings include:

The policy titled "Bed Safety," last reviewed without changes on July 26, 2021, revealed a policy statement that noted the facility will strive to provide a safe sleeping environment for residents. The policy revealed that if side rails are used, there will be input from the resident and/or legal representative; the staff will obtain consent from the resident or resident's legal representative prior to use; and side rails may be used after consult with the attending physician to determine they are needed.

Observation of Resident 84 on May 22, 2022, at 12:34 PM revealed the resident was in bed and had enabler bars up on both sides of the bed.

A concurrent interview with Resident 84 on May 22, 2022, at 12:34 PM confirmed that Resident 84 had enabler bars and stated they were used to help move around in the bed.

A review of the current physician orders for Resident 84 revealed no orders for any type of bed rails.

There was no documented evidence in Resident 84's clinical record to indicate that the facility completed an assessment for the use of bilateral grab bars, obtained consent, or provided the responsible party with the risks and benefits of the use.

The above findings for Resident 84 were reviewed in an interview with the Nursing Home Administrator and Director of Nursing on May 24, 2022, at 2:00 PM.

483.25(n)(2) Bedrails
Previously cited deficiency 5/26/2021

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


 Plan of Correction - To be completed: 06/28/2022

1.An assessment was completed for the use of enabler bars for Resident 84 which determined that enabler bars were appropriate. Education was provided to Resident 84 (BIMS 15/15) on the risks and benefits of their use. Following the education, consent for use of bilateral enabler bars was obtained.

2. Inspection of all occupied beds in the facility will be completed to determine which beds have enabler bars. Those resident's records will reviewed to ensure than an assessment for enabler bar use, education on risk and benefit and consent to use the enabler(s) is present. These steps will be completed for any record not containing assessment, education or consent.

3. Facility maintenance staff will be educated that any bed will have enabler bars removed before being placed in a resident's room unless enabler bars have been specifically requested by a nurse who has completed the assessment, education and consent.

4. A random weekly audit of 20 resident beds will be completed by the Director of Nursing/designee to identify beds with enabler bars and ensure that the resident's record contains assessment, education and consent for use. This audit will be completed for 4 weeks.

Results of this audit will be reported to the Quality Assurance and Performance Improvement committee who will determine the necessity of continued audits.

483.55(b)(1)-(5) REQUIREMENT Routine/Emergency Dental Srvcs in NFs: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.
483.55 Dental Services
The facility must assist residents in obtaining routine and 24-hour emergency dental care.

483.55(b) Nursing Facilities.
The facility-

483.55(b)(1) Must provide or obtain from an outside resource, in accordance with 483.70(g) of this part, the following dental services to meet the needs of each resident:
(i) Routine dental services (to the extent covered under the State plan); and
(ii) Emergency dental services;

483.55(b)(2) Must, if necessary or if requested, assist the resident-
(i) In making appointments; and
(ii) By arranging for transportation to and from the dental services locations;

483.55(b)(3) Must promptly, within 3 days, refer residents with lost or damaged dentures for dental services. If a referral does not occur within 3 days, the facility must provide documentation of what they did to ensure the resident could still eat and drink adequately while awaiting dental services and the extenuating circumstances that led to the delay;

483.55(b)(4) Must have a policy identifying those circumstances when the loss or damage of dentures is the facility's responsibility and may not charge a resident for the loss or damage of dentures determined in accordance with facility policy to be the facility's responsibility; and

483.55(b)(5) Must assist residents who are eligible and wish to participate to apply for reimbursement of dental services as an incurred medical expense under the State plan.
Observations:

Based on clinical record review, review of select facility policies and procedures, and staff and resident interview, it was determined that the facility failed to provide referral services to meet the dental needs for one of three residents reviewed (Resident 26).

Findings include:

The policy entitled "Dental Services," last reviewed without changes on July 26, 2021, revealed that routine and emergency dental services are available to meet the resident's oral health services in accordance with the resident's assessment and plan of care. Social services representatives will assist residents with appointments, transportation arrangements, and for reimbursement of dental services under the state plan, if eligible. The policy does not address referrals to oral surgery.

Observation and interview with Resident 26 on May 23, 2022, at 10:22 AM revealed that the resident has natural teeth and claimed they "haven't seen a dentist in a while."

Clinical record review of Census information for Resident 26 revealed that the facility receives Medicaid reimbursement for Resident 26's care.

Clinical documentation from the consultant dentist dated January 12, 2022, revealed the resident had an exam on this date. A section of the documentation instructed facility staff to refer the resident to an oral surgeon for radiographic examination (x-rays) and extractions (removal) of any teeth with a less than favorable prognosis. Another section of the documentation also instructed nursing home staff to refer the resident to an oral surgeon for recommended treatment.

Further review of the clinical record revealed there was no evidence to indicate the resident was referred to the oral surgeon as instructed by the consultant dentist.

An interview with the Director of Nursing on May 25, 2022, at 11:35 AM revealed an appointment was possibly made, but cancelled due to the resident's hospitalization.

An interview with Employee 1 (Registered Nurse Consultant) on May 25, 2022, at 1:45 PM revealed the facility had no further information to indicate that an appointment was scheduled with an oral surgeon or that a scheduled appointment with an oral surgeon was scheduled and later cancelled.

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

28 Pa. Code 211.15(a) Dental services

28 Pa. Code 211.16(a) Social services


 Plan of Correction - To be completed: 06/28/2022

1.Resident 26 has been scheduled the soonest available appointment at a dental facility that accepts his insurance plan on July 14 2022. Resident 26 has had no ill effects in the delay in dental consult. He will be monitored for complaints of pain and medicated as needed.

2. Dental consults for the previous 3 months will be reviewed to determine if there were any other recommendations to schedule appointments with outside dental services. Appointments will be scheduled as identified.

3. Licensed nursing staff and Social Service will be educated on the "Dental Services" policy and following recommendations to meet the resident's oral health needs.

4. An audit of other resident's dental recommendations will be completed by the Director of Nursing/designee to ensure that recommendations for outside dental services have been addressed. This audit will be completed for 2 months.

Results of this audit will be reported to the Quality Assurance and Performance Improvement committee who will determine the necessity of continued audits.

483.80(d)(1)(2) REQUIREMENT Influenza and Pneumococcal Immunizations: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(d) Influenza and pneumococcal immunizations
483.80(d)(1) Influenza. The facility must develop policies and procedures to ensure that-
(i) Before offering the influenza immunization, each resident or the resident's representative receives education regarding the benefits and potential side effects of the immunization;
(ii) Each resident is offered an influenza immunization October 1 through March 31 annually, unless the immunization is medically contraindicated or the resident has already been immunized during this time period;
(iii) The resident or the resident's representative has the opportunity to refuse immunization; and
(iv)The resident's medical record includes documentation that indicates, at a minimum, the following:
(A) That the resident or resident's representative was provided education regarding the benefits and potential side effects of influenza immunization; and
(B) That the resident either received the influenza immunization or did not receive the influenza immunization due to medical contraindications or refusal.

483.80(d)(2) Pneumococcal disease. The facility must develop policies and procedures to ensure that-
(i) Before offering the pneumococcal immunization, each resident or the resident's representative receives education regarding the benefits and potential side effects of the immunization;
(ii) Each resident is offered a pneumococcal immunization, unless the immunization is medically contraindicated or the resident has already been immunized;
(iii) The resident or the resident's representative has the opportunity to refuse immunization; and
(iv)The resident's medical record includes documentation that indicates, at a minimum, the following:
(A) That the resident or resident's representative was provided education regarding the benefits and potential side effects of pneumococcal immunization; and
(B) That the resident either received the pneumococcal immunization or did not receive the pneumococcal immunization due to medical contraindication or refusal.
Observations:

Based on clinical record review and staff interview, it was determined that the facility failed to ensure residents received pneumococcal immunizations for three of five residents reviewed for immunization concerns (Residents 23, 37, and 46).

Findings include:

Clinical record review for Resident 23 revealed an informed consent to receive the pneumococcal vaccine dated October 4, 2021.

Resident 23's clinical record contained no evidence that the facility administered the pneumococcal vaccine after obtaining the consent; or evidence that Resident 23 had received the pneumococcal vaccine before her admission to the facility.

Clinical record review for Resident 37 revealed an informed consent to receive the pneumococcal vaccine dated October 1, 2021.

Resident 37's clinical record contained no evidence that the facility administered the pneumococcal vaccine after obtaining the consent; or evidence that Resident 37 had received the pneumococcal vaccination before his admission to the facility.

Clinical record review for Resident 46 revealed an informed consent to receive the pneumococcal vaccination dated October 8, 2021.

Resident 46's clinical record contained no evidence that the facility administered the pneumococcal vaccine after obtaining the consent; or evidence that Resident 46 had received the pneumococcal vaccine before his admission to the facility.

Interview on May 25, 2022, at 11:00 AM with the Director of Nursing acknowledged the above findings and that the currently available clinical records do not contain the vaccine information as noted above.

28 Pa. Code 201.14(a) Responsibility of licensee

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

28 Pa. Code 211.5(f) Clinical records

28 Pa. Code 211.10(d) Resident care policies

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


 Plan of Correction - To be completed: 06/28/2022

1.Residents 23, 37, and 46 or their responsible parties will be contacted regarding their current wishes for the pneumococcal vaccine. Vaccines will be administered per their wishes and acceptable medical standards.

2. A review will be completed to determine which residents are not currently up to date on their pneumococcal vaccines. Residents or their responsible parties will be contacted regarding their wishes for the pneumococcal vaccine. Vaccines will be administered per their wishes and acceptable medical standards.

3. A communication form will be created to inform the Infection Preventionist when a consent for vaccination has been received through the admission process, care plan meeting or other communication with a resident or responsible party.

Licensed nursing staff, Social Services and the Admission Coordinator will be educated on this communication process.

4. A random weekly audit of consent forms completed through admissions or care plan meeting will be completed by the Director of Nursing/designee to ensure that there is timely follow through with administration of the pneumococcal vaccine following consent. This audit will be completed for 4 weeks.

Results of this audit will be reported to the Quality Assurance and Performance Improvement committee who will determine the necessity of continued audits.

483.80(d)(3)(i)-(vii) REQUIREMENT COVID-19 Immunization: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(d) (3) COVID-19 immunizations. The LTC facility must develop and implement policies and procedures to ensure all the following:
(i) When COVID-19 vaccine is available to the facility, each resident and staff member
is offered the COVID-19 vaccine unless the immunization is medically contraindicated or the resident or staff member has already been immunized;
(ii) Before offering COVID-19 vaccine, all staff members are provided with education
regarding the benefits and risks and potential side effects associated with the vaccine;
(iii) Before offering COVID-19 vaccine, each resident or the resident representative
receives education regarding the benefits and risks and potential side effects associated with the COVID-19 vaccine;
(iv) In situations where COVID-19 vaccination requires multiple doses, the resident,
resident representative, or staff member is provided with current information regarding those additional doses, including any changes in the benefits or risks and potential side effects associated with the COVID-19 vaccine, before requesting consent for administration of any additional doses;
(v) The resident or resident representative, has the opportunity to accept or refuse a COVID-19 vaccine, and change their decision;
Note: States that are not subject to the Interim Final Rule - 6 [CMS-3415-IFC], must comply with requirements of 483.80(d)(3)(v) that apply to staff under IFC-5 [CMS-3414-IFC]
and
(vi) The resident's medical record includes documentation that indicates, at a minimum,
the following:
(A) That the resident or resident representative was provided education regarding the
benefits and potential risks associated with COVID-19 vaccine; and
(B) Each dose of COVID-19 vaccine administered to the resident; or
(C) If the resident did not receive the COVID-19 vaccine due to medical
contraindications or refusal; and
(vii) The facility maintains documentation related to staff COVID-19 vaccination that
includes at a minimum, the following:
(A) That staff were provided education regarding the benefits and potential risks
associated with COVID-19 vaccine;
(B) Staff were offered the COVID-19 vaccine or information on obtaining COVID-19 vaccine; and
(C) The COVID-19 vaccine status of staff and related information as indicated by the Centers for Disease Control and Prevention's National Healthcare Safety Network (NHSN).
Observations:

Based on clinical record review and staff interview, it was determined that the facility failed to ensure the administration of a COVID-19 immunization for two of five residents selected for immunization review (Residents 37 and 45).

Findings include:

Clinical record review for Resident 37 revealed a consent form for a COVID-19 vaccine that indicated Resident 37's responsible party consented for him to receive the vaccine on October 1, 2021.

Resident 37's clinical record contained no evidence that he received the COVID-19 vaccination.

Clinical record review for Resident 45 revealed a consent form for a COVID-19 vaccine that indicated Resident 45's responsible party consented for her to receive the vaccine on March 10, 2022.

Resident 45's clinical record contained no evidence that she received the COVID-19 vaccination.

The surveyor reviewed the above findings during an interview with the Director of Nursing on May 25, 2022, at 11:00 AM.

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


 Plan of Correction - To be completed: 06/28/2022

1.Resident 45 and the responsible party for resident 37 will be contacted regarding their current wishes for the Covid 19 vaccine. Vaccines will be administered per their wishes and acceptable medical standards.

2. A review will be completed to determine which residents are not currently up to date on their Covid 19 vaccine or booster vaccines. Residents or their responsible parties will be contacted regarding their wishes for the vaccine or boosters. Vaccines will be administered per their wishes and acceptable medical standards.

3. A communication form will be created to inform the Infection Preventionist when a consent for vaccination has been received through the admission process, care plan meeting or other communication with a resident or responsible party. Licensed nursing staff, Social Services and the Admission Coordinator will be educated on this communication process.

4. A random weekly audit of consent forms completed through admissions or care plan meeting will be completed by the Director of Nursing/designee to ensure that there is timely follow through with administration of the Covid 19 vaccine or booster following consent. This audit will be completed for 4 weeks.

Results of this audit will be reported to the Quality Assurance and Performance Improvement committee who will determine the necessity of continued audits.

201.14(a) LICENSURE Responsibility of licensee.:State only Deficiency.
(a) The licensee is responsible for meeting the minimum standards for the operation of a facility as set forth by the Department and by other State and local agencies responsible for the health and welfare of residents.
Observations:

Based on staff interviews and facility documentation, it was determined that the facility did not comply with the multidisciplinary committee requirements of the Act 52 Infection Control Plan.

Findings include:

Act 52 Infection Control Plan, states that a health care facility should develop and implement an internal infection control plan that should be established for the purpose of improving the health and safety of residents and health care workers and should include a multidisciplinary committee including a representative from each of the following, if applicable to the specific health care facility:

(i) Medical staff that could include the chief medical officer or the nursing home medical director
(ii) Administration representatives that could include the chief executive officer, the chief financial officer, or the nursing home administrator
(iii) Laboratory personnel
(iv) Nursing staff that could include a director of nursing or a nursing supervisor
(v) Pharmacy staff that could include the chief of pharmacy
(vi) Physical plant personnel
(vii) A patient safety officer
(viii) Members from the infection control team, which could include an epidemiologist.
(ix) The community, except that these representatives may not be an agent, employee, or contractor of the health care facility.

Interview on May 25, 2022, at 12:10 PM with the Nursing Home Administrator revealed that the facility could not provide documentation that verified attendance by laboratory personnel since the last full health survey as a required mandatory committee member noted in Act 52.



 Plan of Correction - To be completed: 06/28/2022

1.The facility cannot retroactively correct the lack of attendance of laboratory personnel in the infection control meetings required by Act 52 . No resident was affected by this action.

2. No evidence exist that any residents having any potential to be affected by this deficient practice.

3. The Director of Nursing will reach out to the laboratory manager to set a schedule for laboratory personnel attendance to the infection control meetings.

4. An audit of laboratory personnel's attendance to the infection control meetings will be completed by the Nursing Home Administrator/designee monthly for 3 months.

Results of this audit will be reported to the Quality Assurance and Performance Improvement Quality Assurance and Performance Improvement committee who will determine the necessity of continued audits.

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

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

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

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

Based on closed clinical record review and staff interview, it was determined that the facility failed to ensure the disposition of personal effects upon discharge for one of three closed records sampled (Resident 90).

Findings include:

Closed clinical record review for Resident 90 revealed that the facility admitted the resident on August 24, 2020.

Further closed clinical record review revealed that Resident 90 expired at the facility on March 10, 2022.

Resident 90's closed clinical record revealed no personal belonging inventory sheet, or any documentation accounting for the disposition of Resident 90's personal effects upon discharge.

The Director of Nursing confirmed the above findings in an interview on May 25, 2022, at 11:00 AM.



 Plan of Correction - To be completed: 06/28/2022

1.Resident 90's personal effects remain in the facility. A personal inventory sheet will be completed and his family member will be contacted regarding his wishes for Resident 90's personal effects. Documentation will be made in the resident's medical record regarding those wishes as well as for any personal effects released to him.

2. Any resident discharged from the facility has the potential to be affected.

3. Licensed nursing staff will be re-educated on the process for documentation for the resident's personal belongings on discharge.

4. A weekly audit of documentation for resident's personal belongings on discharge will be completed by Medical Records /designee for all discharged residents. This audit will be completed weekly for 4 weeks.

Results of this audit will be reported to the Quality Assurance and Performance Improvement committee who will determine the necessity of continued audits.

211.9(j) LICENSURE Pharmacy services.:State only Deficiency.
(j) Disposition of discontinued and unused medications and medications of discharged or deceased residents shall be handled by facility policy which shall be developed in cooperation with the consultant pharmacist. The method of disposition and quantity of the drugs shall be documented on the respective resident's chart. The disposition procedures shall be done at least quarterly under Commonwealth and Federal statutes.
Observations:

Based on closed clinical record review and staff interview, it was determined that the facility failed to ensure the disposition of medication upon discharge for one of three closed records reviewed (Resident 90).

Findings include:

Closed clinical record review for Resident 90 revealed that the facility admitted the resident on August 24, 2020.

Further closed clinical record review revealed that Resident 90 expired at the facility on March 10, 2022.

There was no documentation to indicate that the facility accounted for the disposition or quantity of Resident 90's medication upon discharge from the facility.

The Director of Nursing confirmed the above findings in an interview on May 25, 2022, at 11:00 AM.



 Plan of Correction - To be completed: 06/28/2022

1.The facility cannot retroactively correct the lack of documentation regarding the disposition of medications for Resident 90.

2. Any resident discharged from the facility has the potential to be affected.

3. Licensed nursing staff will be re-educated on the process for documentation of the disposition of resident's medications on discharge.

4. A weekly audit will be completed by Medical Records /designee for all discharged residents to ensure that disposition of the resident's medications is documented. . This audit will be completed weekly for 4 weeks.

Results of this audit will be reported to the Quality Assurance and Performance Improvement committee who will determine the necessity of continued audits.


211.12(i) LICENSURE Nursing services.:State only Deficiency.
(i) A minimum number of general nursing care hours shall be provided for each 24-hour period. The total number of hours of general nursing care provided in each 24-hour period shall, when totaled for the entire facility, be a minimum of 2.7 hours of direct resident care for each resident.
Observations:

Based on a review of nursing time schedules and resident census information, it was determined that the facility failed to ensure sufficient staffing to provide a minimum of 2.7 hours of direct resident care for each resident on 10 of 21 days reviewed.

Findings include:

Review of the facility nursing time schedules and resident census information from April 17, 2022, to May 7, 2022, revealed that the facility provided insufficient hours of direct nursing care per resident on the following dates:

April 23, 2022, 2.65 hours of direct nursing care per resident
April 24, 2022, 2.39 hours of direct nursing care per resident
April 30, 2022, 2.62 hours of direct nursing care per resident
May 1, 2022, 2.57 hours of direct nursing care per resident
May 2, 2022, 2.11 hours of direct nursing care per resident
May 3, 2022, 2.54 hours of direct nursing care per resident
May 4, 2022, 2.59 hours of direct nursing care per resident
May 5, 2022, 2.50 hours of direct nursing care per resident
May 6, 2022, 2.32 hours of direct nursing care per resident
May 7, 2022, 2.29 hours of direct nursing care per resident

The surveyor reviewed the above findings with the Nursing Home Administrator on May 25, 2022, at 2:00 PM.


 Plan of Correction - To be completed: 06/28/2022

1.The facility cannot retroactively correct the identified days the facility was under the required PPD.

2. No evidence exist that any residents having any potential to be affected by this deficient practice.

3. The facility has implemented the following system changes to ensure the identified deficient practice does not reoccur:
- Implementation of a "Daily Labor Meeting" with attendance of Nursing Home Administrator, Director of Nursing, Scheduler, and Human Resources Director.
o Focus on daily PPD, daily needs, future needs for clinical coverage and the safety of the residents.
o Review of daily/weekly schedules.
o Meeting is held twice a day and reported to regional staff daily illustrating our current staffing status.
o All avenues for staffing, i.e., agency use, bonus program have been exhausted.
- Increased recruitment and retention efforts have been implemented in an effort to both hire and retain staff to ensure the well-being of our residents.
- Approval for a fulltime in-house recruiter for clinical staff has been approved and will be advertised in various venues.

4. Actions will be monitored by the Director of Nursing and Nursing Home Administrator with the continued use of the daily labor meeting reports, and the ongoing daily labor meeting. Trending and monitoring data/ information will be reported daily at the morning leadership team meeting and at the monthly Quality Assurance and Performance Improvement committee meeting for further discussion and recommendations by all in attendance.


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