Nursing Investigation Results -

Pennsylvania Department of Health
SIEMON'S LAKEVIEW MANOR NURSING AND REHABILITATION CENTER
Patient Care Inspection Results

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
SIEMON'S LAKEVIEW MANOR NURSING AND REHABILITATION CENTER
Inspection Results For:

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SIEMON'S LAKEVIEW MANOR NURSING AND REHABILITATION CENTER - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on a Medicare/Medicaid Recertification survey, State Licensure survey, Civil Rights Compliance survey, and a complaint survey completed on May 25, 2022, it was determined that Siemon's Lakeview Manor Nursing and Rehabilitation Center was not in compliance with the following requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care Facilities and the 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.




 Plan of Correction:


483.25(g)(4)(5) REQUIREMENT Tube Feeding Mgmt/Restore Eating Skills:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
483.25(g)(4)-(5) Enteral Nutrition
(Includes naso-gastric and gastrostomy tubes, both percutaneous endoscopic gastrostomy and percutaneous endoscopic jejunostomy, and enteral fluids). Based on a resident's comprehensive assessment, the facility must ensure that a resident-

483.25(g)(4) A resident who has been able to eat enough alone or with assistance is not fed by enteral methods unless the resident's clinical condition demonstrates that enteral feeding was clinically indicated and consented to by the resident; and

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


Based on a review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that nutrition through a feeding tube was provided as ordered for one of 39 residents reviewed (Resident 29).

Findings include:

The facility policy for enteral feeding (nutriton provided into a tube which goes directly to the stomach), dated
March 1, 2022, indicated that feeding is to be provided as ordered by the physician.

A diagnosis record for Resident 29, dated March 23, 2022, included diagnoses of stroke, gastrostomy (tube placed through the abdominal wall to provide nutrition), and dysphagia (difficulty swallowing).

An admission Minimum Data Set (MDS) assessment (mandated assessment of a resident's abilities and care needs) for Resident 29, dated March 29, 2022, indicated that he was sometimes understood and could understand, had a gastrostomy tube, and was totally dependent for eating.

Physician's orders for Resident 29, dated April 8, 2022, indicated that he was to be provided with 240 milliliters (ml) of Jevity 1.5 (enteral feeding, nutrition supplement) three times a day if intake of meals was less than 50 percent and 240 ml at bedtime.

The April 2022 medication administration record (MAR) for Resident 29 indicated that the bedtime enteral feeding was not provided on May 9, 11, 13, 15, 20, 21, 25, 2022.

The MAR documentation for April 2022 indicated that Resident 29's meal intake was 50 percent or greater at 9:00 a.m. on April 12, 16, 17, 18, 25 and 27; at 1:00 p.m. on April 15, 16, 17, 18, 25, 26 and 27; and at 6:00 p.m. on April 17, 18, 20, 25, 26 and 27, 2022. However, the Jevity order was signed as given. There was no documented evidence that the Jevity tube feeding was held at these times.

A physician's order for Resident 29, dated April 29, 2022, indicated that the feeding order was changed to Jevity 1.5, give 240 ml if intake of meals is less than 50 percent three times a day.

The May 2022 MAR documentation for Resident 29 indicated that the the resident's meal intake was greater than 50 percent at 9:00 a.m. on April 1, 2, 9-19, 21-23; at 1:00 p.m. on April 1, 2, 8-10, 13, 14, 16-19, 21 and 22; and at 5:00 p.m. on April 2, 8-11, 13, 14, 17-19, 21 and 22, 2022. However, the Jevity order was signed off as given. There was no documented evidence that the Jevity tube feeding was held at these times.

Interview with the Director of Nursing on May 24, 2022, at 9:36 a.m. confirmed that the bedtime Jevity should have been provided daily and the order should have been in two separate entries to ensure clarification. She further indicated that all staff should be documenting when the tube feeding was not provided due to the resident eating greater than 50 percent as per the physician's order and that there was no documented evidence they were held as ordered.

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




 Plan of Correction - To be completed: 07/06/2022

I. How the facility will correct the deficiency as it relates to the individual:
Resident 39 is receiving tube feed order per physician's order.

II. How the facility will act to protect residents in similar situations:
Residents with tube feedings were reviewed to ensure they were receiving feedings per physician's orders. Any interventions were implemented as appropriate.
Licensed staff will be re-educated, by facility Director of Nursing, on proper tube feeding per physician's order, including parameters of administering or holding tube feeding based on meal consumption, if applicable by 6/30/2022.

III. Measures the facility will take or systems it will alter to ensure that the problem does not recur:
The Director of Nursing/designee will conduct a random quality reviews of 5 tube feeding documentations to ensure tube feeding was completed per physician's order. Quality reviews will continue until 3 consecutive months of compliance is achieved.

IV. How the facility plans to monitor its performance to make sure that the solutions are permanent; i.e., what quality assurance programs will be established:
Results from the tube feeding quality reviews will be presented to the Quality Assurance Performance Committee during monthly meetings to ensure completion and compliance.

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

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

483.60(i)(2) - Store, prepare, distribute and serve food in accordance with professional standards for food service safety.
Observations:


Based on review of policies, as well as observations and staff interviews, it was determined that the facility failed to ensure that food items were properly dated and labeled in dietary refrigerators, freezers, dry storage, and in one of two nursing unit refrigerators (A wing).

Findings include:

The facility's policy regarding food storage of dried goods, dated March 1, 2022, indicated that all packaged and canned foods will be kept clean, dry and properly sealed. The storage areas will be neat, arranged for easy identification, and date marked as appropriate. The facility's policy regarding food storage of cold foods, dated March 1, 2022, indicated that the foods will be stored wrapped or in covered containers, labeled and dated, and arranged in a manner to prevent cross contamination.

Observations of the dietary department on May 22, 2022, at 9:20 a.m. revealed that in the glass, two-door "reach in" refrigerator there was a large, opened, undated container of butterscotch pudding, four undated plastic-covered stacks of sliced yellow cheese, and an opened, undated bag of yellow shredded mild cheddar cheese. The walk-in freezer had an opened, undated partially used bag of french fries, an uncovered, undated slice of pie with brown crust, two opened and undated plastic tubs of vanilla ice cream, three undated bags of whipped topping, undated bread sticks, two uncovered and undated plastic bags of vegetable patties, a large undated and unlabeled tin container of garlic toast covered with saran wrap, an opened and undated bag of chicken patties, and an undated bag of spinach. The large chest freezer had an undated and unlabeled box of muffins.

Observations of the dry storage area on May 22, 2022, at 9:34 a.m. revealed that items that were not dated included a 25-pound bag of thick and easy thickening powder that was opened and had a large hole in the plastic bag, two undated and unlabeled bags of dry cereal (rice krispies) that were out of their original boxes, opened and undated bags of wheat penne noodles, spaghetti and egg noodles.

Interview with the Dietary Manager in Training on May 24, 2022, at 9:39 a.m. indicated that all items should be dated, labeled and securely closed.

Observations of the kitchen work area on May 22, 2022, at 9:46 a.m. revealed a sink to the right of the steam table which had three large plastic containers with blue lids right under the sink (drain area) containing dry cereals that were undated or labeled. To the left of the sink area was a three-tier cart, and on the second shelf was an opened bag of brown sugar with plastic lying loosely over the opened side of the bag and was not dated.

Interview with the Dietary Manager on May 23, 2022, at 1:03 p.m. confirmed that all items should be dated and labeled.

The facility's policy regarding food safe handling for foods from visitors, dated March 1, 2022, indicated that when food items are intended for later consumption, the responsible facility staff member will label foods with the resident's name and the current date. There will be daily monitoring for refrigerated storage duration and any items that have been stored for greater than or equal to seven days will be discarded. Storage of frozen foods and shelf stable items may be retained for 30 days.

Observations of the resident snack and refreshment refrigerator on the A wing on May 24, 2022, at 12:05 p.m. revealed an undated and unlabeled container of Chinese food, an undated and unlabeled gob, an undated and unlabeled plastic bag with a styrofoam container of food. Other unopened items that were not labeled with resident names included a bag of individual Activia yogurts, a case of Activia yogurt, a yellow bag with orange juice, containers of chicken salad and egg salad, and a plastic container of cookies. Undated and unlabeled items in the freezer included a one-half gallon of chocolate marshmallow ice cream, and a plastic shopping bag with Italian bread.

Interview with Nurse Aide 5 on May 24, 2022, at 12:05 p.m. indicated that when items are put in the refrigerator they should be dated and labeled with the resident's name.

Interview with the Director of Nursing on May 24, 2022, at 1:10 p.m. indicated that the resident refrigerators on the nursing units should have all items dated and labeled when brought in.

28 Pa. Code 211.6(f) Dietary services.




 Plan of Correction - To be completed: 07/06/2022

I. How the facility will correct the deficiency as it relates to the individual:
No resident was identified to be affected by the finding.
Undated food in dietary was dated or disposed of as appropriate. The A wing refreshment refrigerator was cleaned and unlabeled/undated food was disposed of.

II. How the facility will act to protect residents in similar situations:
Staff will be re-educated, by the Healthcare Services Group District Manager, on labeling and dating food put into refreshment refrigerators.

III. Measures the facility will take or systems it will alter to ensure that the problem does not recur:
The facility administrator will conduct quality reviews of the refreshment refrigerators 2 times weekly to ensure all food is dated and labeled as appropriate. Quality reviews will continue until 3 consecutive months of compliance is achieved. The Healthcare Services Group Dietary Director/designee will complete weekly sanitation rounds, to include review of food storage, on a weekly ongoing basis.

IV. How the facility plans to monitor its performance to make sure that the solutions are permanent; i.e., what quality assurance programs will be established:
Results of the refreshment refrigerator quality reviews will be presented to the Quality Assurance Performance Improvement committee during monthly meetings to ensure completion and compliance.

483.45(g)(h)(1)(2) REQUIREMENT Label/Store Drugs and Biologicals: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(g) Labeling of Drugs and Biologicals
Drugs and biologicals used in the facility must be labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable.

483.45(h) Storage of Drugs and Biologicals

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

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


Based on review of policies and manufacturer's directions, as well as observations and staff interviews, it was determined that the facility failed to label multi-dose containers of insulin with the date they were opened in one of four medication carts reviewed (A Wing Long Hall medication cart), failed to label a bottle of testing solution when it was opened for two of four medication room refrigerators reviewed (A Wing white medication refrigerator, C Wing white medication refrigerator), and failed to ensure that medications were stored under proper temperatures in accordance with manufacturer's instructions in four of four medication refrigerators reviewed (A Wing white and black medication refrigerators, C Wing white and black medication refrigerators).

Findings include:

The facility's policy regarding storage and expiration of medications, dated March 1, 2022, indicated that once a medication is opened the facility should follow the manufacturer's guidelines with respect to the expiration dates for opened medications. Once opened, staff are to record the date opened on the medication container when the medication has a shortened expiration dated.

The pharmacy drug information for Humulin R insulin (a short-acting insulin that starts to work within 30 minutes), dated 2022, indicated that "in use" vials of the Humulin R insulin should be thrown away after 40 days, even if there is insulin left.

Observations during medication pass on May 24, 2022, at 11:39 a.m. revealed that Licensed Practical Nurse 3 administered 2 units of Humulin R insulin to Resident R 8. The 10 milliliter (ml) vial of Humulin R insulin was opened but not dated with the date it was opened.

Observations of the medication cart on A wing long hall on May 24, 2022, at 11:47 a.m. revealed that inside the cart was another 10 ml vial of Humulin R insulin that was opened and undated.

Interview with Licensed Practical Nurse 3 on May 24, 2022, at 11:43 p.m. indicated that the 10 ml vial of Humulin R should have been dated when it was opened.

The manufacturer's instructions for Tubersol (Purified Protein Derivative-a solution injected under the skin to test for tuberculosis - a lung infection), undated, revealed that vials that have been opened and used for 30 days should be discarded.

Observations of the white medication refrigerator on the A wing nursing unit on May 24, 2022, at 12:18 p.m. revealed that there was an opened multi-dose vial of tuberculin mantoux (a solution injected under the skin to test for tuberculosis). There was no date on the vial or box of when it was opened.

Observations of the C Wing Medication Room black refrigerator on May 24, 2022, at 12:32 p.m. revealed that a multidose vial of Tubersol was opened and was not labeled with the date it was opened. Interview with Licensed Practical Nurse 2 at the time of observation confirmed that the Tubersol vial should have been dated when it was opened.

Interview with the Director of Nursing on May 24, 2022, 1:09 p.m. confirmed that the multi-use vials of Tubersol and Tuberculin mantoux should have been dated when opened.


The manufacturer's instructions for Pneumovax (pneumonia vaccine), dated 2011, indicated that the vaccine was to be stored at 36 to 46 degrees Fahrenheit (F).

The manufacturer's instructions for influenza (flu) vaccine, undated, indicated that it was to be stored at 36 to 46 degrees F.

The manufacturer's instructions on vials of Tubersol indicated that the serum was to be stored 35 to 46 degrees F. Do not freeze. Discard product if exposed to freezing.

The manufacturer's instructions for unused NovoLog (a type of Insulin) indicated that it should be stored in a refrigerator between 36 to 46 degrees F. Do not store in the freezer or directly adjacent to the refrigerator cooling element. Do not freeze NovoLog and do not use NovoLog if it has been frozen.

The manufacturer's instructions for Humulin (a type of Insulin) indicated that if unopened and not currently being used should be stored in the refrigerator at 36 to 46 degrees F.

The manufacturer's instructions for Lantus (a type of Insulin) indicated to store unused vials in the refrigerator between 36 to 46 degree F.

The manufacturer's instructions for unused Victoza pens (a prefilled injectable device of diabetic medication) indicated that it should be stored in the refrigerator at 36 to 46 degrees F.

The manufacturer's instructions for latanoprost eye drops (a medication to treat pressure in the eyes), dated August 2011, indicated to store unopened bottle(s) under refrigeration at 36 to 46 degrees F.

The manufacturer's instructions for Ativan (an antianxiety medication), undated, indicated to store in a refrigerator between 36 to 46 degrees F.

The facility's policy for storage and expiration of medications, dated March 1, 2022, indicated that the facility was to ensure that medications and biologicals are stored at their appropriate temperatures and that vaccines should be monitored twice a day.

The facility policy (temperature log guidance), undated, indicated that the temperatures for the medication refrigerators were to be documented twice, at the beginning and end of the work day.

The pharmacy medication storage guidance, dated 2021, indicated that influenza vaccines and Tuberculin tests are to be stored at 36 to 46 degrees F.

Observations of the medication refrigerators on the A wing nursing unit on May 24, 2022, at 4:15 p.m. revealed that the white refrigerator contained boxes of fluzone (one-dose vials of immunizations) a total of 63 dosages, and boxes of fluzone high dose, single dose vials totaling 73 dosages. This refrigerator also included a container of multiple insulins, which was the facility kit for the omni cell dispensing unit. It also contained two multi-dose vials of Tuberculin mantoux serum. The black medication refrigerator contained items such as various resident-specific insulins Novolin, Humulin 70/30, Novolog, Lantus, Lispro, Glargine, Humulin R. and one container of liquid Ativan.

The 2022 medication refrigerator temperature log for the A wing white refrigerator indicated that for March through May 23, 2022, the temperatures were not documented for the day on March 11, 15, 19, 20, 25, 26 , 31; on April 2, 3, 5, 8-10, 12, 21, 22, 26, 28, 30; and May 1, 2, 5, 6, 13-15, 19, 22 (21 days). On the other days the temperature documentation indicated that the temperatures were only checked once per day (total of 55 days).

The 2022 medication refrigerator temperature log for A wing black refrigerator indicated that for March through May 23, 2022, the temperatures were not documented for the day on March 11, 15, 19, 20, 25, 26, 29, 31; on April 2, 3, 8-10, 21, 26, 28, 30; and on May 1, 2, 5, 6, 13-15, 19, 22 (total of 26 days). On the other days the temperature documentation indicated that the temperatures were only checked once per day (total of 56 days).

Interview with Licensed Practical Nurse 2 on May 24, 2022, at 4:15 p.m. revealed that the C Wing white refrigerator contained all of the back-up Insulins for the residents that are currently taking Insulin.

Observations of the C Wing white refrigerator on May 24, 2022, at 4:15 p.m revealed that there were multiple bags containing the residents' back-up Insulin pens and multidose vials of Insulin, which included, but was not limited to, Novolog, Humulin, and Lantus Insulins as well as Victoza.

Review of the C Wing Medication Room white refrigerator temperature log for March, April, and May 2022, revealed that staff did not record any temperatures on March 3 and 6, 2022; April 6, 8, 12, 14, 17, 18, 22, and 23, 2022; and May 1, 7, and 8, 2022. Staff recorded only one temperature on March 2, 4, 5, 7-31, 2022; April 1-5, 7, 9-11, 13, 15, 16, 19-21, and 24-30, 2022; and May 2-6, 9-13, and 16-24, 2022.

Observations of the C Wing black refrigerator on May 24, 2022, at 4:15 p.m revealed that there were three multidose vials of Tuberculin tubersol, one container of latanoprost eye drops, and one multidose vial of liquid Ativan.

Review of the C Wing Medication Room black refrigerator temperature log for March, April, and May 2022 revealed that staff did not record any temperatures on March 2, 3, and 6, 2022; April 6, 8, 12, 14, 17, 18, 22, and 23, 2022; and May 1, 7, and 8, 2022. Staff recorded only one temperature on March 1, 4, 5, 7-31, 2022; April 1-5, 7, 9-11, 13, 15, 16, 19-21, and 24-30, 2022, and May 2-6, 9, 11,12, 13, and 16-24, 2022.

Interview with the Director of Nursing on May 25, 2022, at 10:00 a.m. confirmed that the medication refrigerator temperatures were not checked and/or recorded on the above dates.

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

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






 Plan of Correction - To be completed: 07/06/2022

I. How the facility will correct the deficiency as it relates to the individual:
Opened, undated vials of medication were properly disposed of.
Resident's 8 vial of insulin is dated with date opened.
Medication refrigerator temperatures are monitored twice daily per policy.

II. How the facility will act to protect residents in similar situations:
A review of medications carts and medication refrigerators was conducted and any opened medication that was not dated was disposed of as appropriate.
Licensed staff will be re-educated, by the facility Director of Nursing, by 6/30/2022, on dating medications once opened and recording medication refrigerator temperatures.

III. Measures the facility will take or systems it will alter to ensure that the problem does not recur:
The Director of Nursing/designee will conduct random quality reviews of 4 vials of medication per week to ensure the vial was dated when opened. Quality reviews will continue until 3 consecutive months of compliance is achieved. The Director of Nursing/designee will quality review random medication refrigerator temperature logs 3 times per week to ensure compliance. Quality reviews will continue until 3 consecutive months of compliance is achieved. The Registered Nurse day shift supervisor(s) will routinely monitor on a daily, ongoing basis.

IV. How the facility plans to monitor its performance to make sure that the solutions are permanent; i.e., what quality assurance programs will be established:
Results of the medication vials and medication refrigerator logs quality reviews will be presented to the Quality Assurance Performance Improvement committee at monthly meetings to ensure completion and compliance.

483.45(f)(2) REQUIREMENT Residents are Free of Significant Med Errors:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
The facility must ensure that its-
483.45(f)(2) Residents are free of any significant medication errors.
Observations:


Based on review of manufacturer's instructions and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that it was free from significant medication errors for two of 39 residents reviewed (Residents 16, 78).

Findings include:

The facility's meal cart tray delivery time records indicated that the resident's meal carts were scheduled to be delivered at 7:45 a.m. for breakfast, at 12:30 p.m. for lunch, and at 6:00 p.m. for dinner.

Manufacturer's directions for use of NovoLog (Insulin aspart injection), dated December 2012, revealed that because Novolog has a more rapid onset and a shorter duration of activity than human regular insulin, it should be injected immediately (within 5-10 minutes) before a meal.

Physician's orders for Resident 16, dated May 21, 2022, included an order for the resident to receive five units of Novolog (a type of insulin used to lower blood sugar levels) with meals and it was to be held for a blood glucose reading of less than 100.

Physician's orders for Resident 16, dated July 22, 2021, included an order for the resident to receive Novolog Flexpen (a type of insulin used to lower blood sugar levels) before meals and at bedtime according to a sliding scale (a set of instructions for administering insulin dosages based on specific blood glucose readings). The sliding scale included giving various amounts of Novolog for blood sugar levels between 201-450 mg/dL, and 18 units for a blood sugar that was greater than 450 mg/dL, and to also notify the physician.

Resident 16's Medication Administration Records (MAR's) for May 2022 revealed that on May 18, 2022, staff administered the resident 5 units of Novolog at 11:49 a.m. (approximately forty-one minutes prior to receiving her meal) and 4:31 p.m. (approximately one hour twenty-nine minutes prior to receiving her meal); on May 19, 2022, at 11:44 a.m. (approximately forty-six minutes prior to receiving her meal) and 5:27 p.m. (approximately thirty-two minutes prior to receiving her meal); on May 20, 2022, at 11:35 a.m. (approximately fifty-five minutes prior to receiving her meal); on May 21, 2022, at 12:11 p.m. (approximately twenty-nine minutes prior to receiving her meal) and 5:45 p.m. (approximately fifteen minutes prior to receiving her meal); on May 22, 2022, at 7:05 a.m. (approximately thirty-five minutes prior to receiving her meal) and 11:41 a.m. (approximately forty-nine minutes prior to receiving her meal); on May 23, 2022, at 11:44 a.m. (approximately forty-six minutes prior to receiving her meal); and on May 24, 2022, at 11:49 a.m. (approximately forty-one minutes prior to receiving her meal) and 5:19 p.m. (approximately forty-one minutes prior to receiving her meal).

Resident 16's MAR's for May 2022, revealed that on May 23, 2022, at 4:17 p.m. (approximately one hour forty-three minutes prior to receiving her meal) staff administered three units of Novolog Flexpen according to the resident's sliding scale.

Observations during the medication administration on May 24, 2022, at 11:14 a.m. revealed that Licensed Practical Nurse 2 obtained Resident 16's blood glucose level (a blood test that screens for diabetes by measuring the level of glucose (sugar) in a person's blood). Licensed Practical Nurse 2 indicated at that time that the resident receives a routine five unit dose of Novolog before her meal; however, at this time it was too early to give because her lunch meal would not be there. At 11:49 a.m. Licensed Practical Nurse 2 administered five units of Novolog Insulin in the resident's left upper arm. The resident was taken to the solarium across from the C Wing nurse's station. At 12:29 p.m. the resident was taken back to her room where she was provided her lunch meal tray, which was approximately forty-one minutes after receiving her Novolog Insulin.

Interview with the Director of Nursing on May 25, 2022, at 10:10 a.m. confirmed that per the manufacturer's instructions, Licensed Practical Nurse 2 should have waited to give the Novolog Insulin to Resident 16.


A diagnosis record for Resident 78, dated May 4, 2022, included diabetes (a disease which cause high blood glucose in the blood).

Physician's orders for Resident 78, dated May 6, 2022, included an order for her to receive Lispro Insulin, 5 units subcutaneously before meals, and also to provide additonal insulin subcutaneously before meals and at bedtime as per sliding scale: if blood sugar 150-200 = 2 units, 201-250 = 4 units, 251-300 = 6 units, 301-350 = 8 units, 351-400 = 10 units, 401-450 = 12 units, if greater than 450 give 12 units and call the physician.

The manufacturer's instructions for Lispro, undated, indicated that the Lispro should be administered 15 minutes before or immediately after a meal.

Review of the medication administration record for Resident 78, for May 18-23, 2022, indicated that her routine lunch dose of 5 units of Lispro insulin was administered on May 18 at 11:25 a.m., May 19 at 11:32 a.m., May 21 at 11:28 a.m., May 23 at 11:51 a.m., and May 24 at 11:36 a.m. Her lunch meal sliding scale Lispro insulin was administered on May 18 at 11:24 a.m., May 19 at 11:32 a.m., and May 21 at 11:29 a.m. Her routine supper dose of 5 units of Lispro insulin was administered on May 18 at 4:14 p.m., May 19 at 4:58 p.m., May 20 at 5:26 p.m., May 21 at 4:36 p.m., May 22 at 5:25 p.m., May 23 at 4:21 p.m., and May 24 at 4:56 p.m. Her supper meal sliding scale Lispro insulin was administered on May 18 at 4:42 p.m., May 19 at 4:58 p.m., May 20 at 5:26 p.m., May 21 at 4:35 p.m., May 22 at 5:25 p.m., May 23 4:18 p.m., and May 24 at 4:56 p.m. A total of 22 times that Resident 78 was administered her Lispro fast acting insulin more than 30 minutes before her meal.

The May 2022 Medication Administration Record for Resident 78 indicated that her lunch insulin was scheduled to be given at 11:30 a.m. and supper insulin at 4:30 p.m.; however, her meals were not scheduled to be provided until 12:30 p.m. for lunch and 6:00 p.m. for supper.

Observations during medication administration on May 24, 2022, at 11:35 a.m. revealed that Licensed Practical Nurse 3 obtained a blood glucose sample for Resident 78. After obtaining the level she proceeded to administer the insulin as ordered to the resident, totaling 17 units of Lispro. Observations on May 24, 2022, at 12:29 p.m. (approx fifty-four minutes later) revealed that Resident 78 was provided her meal tray in her room.

Interview with the Director of Nursing on May 25, 2022, at 10:08 a.m. confirmed that the insulin should have been given per the manufacturer's instructions.

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





 Plan of Correction - To be completed: 07/06/2022

I. How the facility will correct the deficiency as it relates to the individual:
Resident 16 & 78 are receiving their insulin in accordance with physician's orders.

II. How the facility will act to protect residents in similar situations:
Insulin administration times have been reviewed and administration times adjusted, per physician approval, as appropriate.
Licensed nursing staff will be re-educated, by the facility Director of Nursing, on insulin administration, including following manufacturers instructions for short and long acting insulins, by 6/30/2022.

III. Measures the facility will take or systems it will alter to ensure that the problem does not recur:
The Director of Nursing/designee will quality review/observe insulin administration of 3 random residents per week to ensure insulin is administered per physician orders. Quality reviews/observations will continue until 3 consecutive months of compliance is achieved.

IV. How the facility plans to monitor its performance to make sure that the solutions are permanent; i.e., what quality assurance programs will be established:
Results of the insulin administration quality reviews/observations will be presented to the Quality Assurance Performance Improvement committee during monthly meetings to ensure completion and compliance.

483.45(f)(1) REQUIREMENT Free of Medication Error Rts 5 Prcnt or More:This is a less serious (but not lowest level) deficiency and 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(f) Medication Errors.
The facility must ensure that its-

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


Based on review of manufacturer's instructions and clinical records, as well as observations and staff interviews, it was determined that the facility failed to maintain a medication administration error rate of less than five percent.

Findings include:

Observations during medication administration on May 24, 2022, at 11:14 a.m. and 11:35 a.m. revealed that three medication administration errors were made during 26 opportunities for error, resulting in a medication administration error rate of 11.54 percent.

Manufacturer's directions for use for NovoLog (Insulin aspart injection), dated December 2012, revealed that because NovoLog has a more rapid onset and a shorter duration of activity than human regular insulin, it should be injected immediately (within 5-10 minutes) before a meal.

Physician's orders for Resident 16, dated May 21, 2022, included an order for the resident to receive five units of Novolog (Insulin Aspart) with meals and was to be held for a blood glucose reading of less than 100 mg/dL.

Observations during the medication administration on May 24, 2022, at 11:14 a.m. revealed that Licensed Practical Nurse 2 obtained Resident 16's blood glucose level (a blood test that screens for diabetes by measuring the level of glucose (sugar) in a person's blood). Licensed Practical Nurse 2 indicated at that time that the resident receives a routine five unit dose of Novolog before her meal; however, at this time it was too early to give because her lunch meal would not be there. At 11:49 a.m. Licensed Practical Nurse 2 administered five units of Novolog Insulin in Resident 16's left upper arm. The resident was taken to the solarium across from the C Wing nurse's station. At 12:29 p.m. the resident was taken back to her room where she was provided her lunch meal tray, which was approximately forty-one minutes after receiving her Novolog Insulin.

Interview with the Director of Nursing on May 25, 2022, at 10:10 a.m. confirmed that the nurse should have waited to give Resident 16's Novolog Insulin per the manufacturer's instructions.


The manufacturer's instructions for Lispro (a fast acting insulin), undated, indicated that the Lispro should be provided 15 minutes before or immediately after a meal.

A diagnosis record for Resident 78, dated May 4, 2022, included diabetes.

Physician's orders for Resident 78, dated May 6, 2022, included an order for her to be provided five units of Lispro Insulin subcutaneously before meals. In addition, give Lispro Insulin as per sliding scale (a set of instructions for administering insulin dosages based on specific blood glucose readings) before meals and at bedtime: if blood sugar is 150-200 = 2 units, 201-250 = 4 units, 251-300 = 6 units, 301-350 = 8 units, 351-400 = 10 units, 401-450 = 12 units, and if greater than 450 give 12 units and call the physician.

Observations during medication administration on May 24, 2022, at 11:35 a.m. revealed that Licensed Practical Nurse 3 obtained a blood glucose sample for Resident 78, and after obtaining the level she proceeded to administer the resident's routine five units and an additional 12 units per the sliding scale, totaling 17 units of Lispro.

Interview with Licensed Practical Nurse 3 on May 24, 2022, at 11:40 a.m. indicated that she had several residents with diabetes who had to have their blood sugars checked before their meals.

Observations on May 24, 2022, at 12:29 p.m. (approx fifty-four minutes later) revealed that Resident 78 was provided her meal tray in her room.

Interview with the Director of Nursing on May 25, 2022, at 10:08 a.m. indicated that the insulin should be given per the manufacturer's instructions.

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








 Plan of Correction - To be completed: 07/06/2022

I. How the facility will correct the deficiency as it relates to the individual:
Resident 16 & 78 are receiving their insulin in accordance with physician's orders.

II. How the facility will act to protect residents in similar situations:
Insulin administration times have been reviewed and administration times adjusted, per physician approval, as appropriate.
Licensed nursing staff will be re-educated, by the facility Director of Nursing, on insulin administration, including manufacturers instructions for short acting insulins, by 6/30/2022.

III. Measures the facility will take or systems it will alter to ensure that the problem does not recur:
The Director of Nursing/designee will quality review/observe insulin administration of 3 random residents per week to ensure insulin is administered per physician orders. Quality reviews/observations will continue until 3 consecutive months of compliance is achieved.

IV. How the facility plans to monitor its performance to make sure that the solutions are permanent; i.e., what quality assurance programs will be established:
Results of the insulin administration quality reviews/observations will be presented to the Quality Assurance Performance Improvement committee during monthly meetings to ensure completion and compliance.

483.35(d)(7) REQUIREMENT Nurse Aide Peform Review-12 hr/yr In-Service: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(d)(7) Regular in-service education.
The facility must complete a performance review of every nurse aide at least once every 12 months, and must provide regular in-service education based on the outcome of these reviews. In-service training must comply with the requirements of 483.95(g).
Observations:


Based on review of personnel files, as well as staff interviews, it was determined that the facility failed to ensure that nurse aide performance evaluations were completed annually based on hire dates for four of four nurse aides reviewed (Nurse Aides 6, 7, 8).

Findings include:

A list of nurse aides provided by the facility revealed that based on their months and days of hire, annual performance evaluations for Nurse Aides 6, 7, and 8 were due between March 7 and March 25, 2022. As of May 25, 2022, there was no documented evidence that annual performance evaluations were completed as required for Nurse Aides 6, 7, and 8.

Interview with the Director of Nursing on May 25, 2022, at 8:37 a.m. confirmed that he could not provide evidence that annual performance evaluations were completed as required for Nurse Aides 6, 7, and 8.

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

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

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

28 Pa. Code 201.20(a)(c) Staff development.




 Plan of Correction - To be completed: 07/06/2022

I. How the facility will correct the deficiency as it relates to the individual:
Performance Evaluations were completed for Nurse Aide 6, 7 & 8.

II. How the facility will act to protect residents in similar situations:
Nursing Assistant employee files were reviewed to determine if any annual evaluations were past due. Any found to be out of compliance were completed as appropriate.
The new facility Human Resource Coordinator was re-educated, by the Regional Director of Human Resources, on requirement for Nursing Assistant annual evaluations.

III. Measures the facility will take or systems it will alter to ensure that the problem does not recur:
The facility administrator/designee will conduct random monthly quality reviews of 3 Nursing Assistant employee files to ensure Performance Evaluations are complete and timely. Computer based training/education completion report will be reviewed monthly by the facility Human Resources Coordinator to ensure staff are completing monthly assigned education. Quality reviews will continue until 3 consecutive months of compliance are achieved.

IV. How the facility plans to monitor its performance to make sure that the solutions are permanent; i.e., what quality assurance programs will be established:
Results of the Performance Evaluation quality reviews will be presented to the Quality Assurance Performance Improvement committee during monthly meetings to ensure completion and compliance.

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


Based on review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that a dialysis access port was properly monitored for one of 39 residents reviewed (Resident 40).

Findings include:

The facility's policy for care of the resident's hemodialysis AV fistula/shunt (a graft-access port surgically placed to access the blood vessel for dialysis), dated March 1, 2022, indicated that the fistula site was to be monitored for signs of infection and thrombosis (clot) formation. The bruit should be heard and the thrill can be palpated as the arterial blood flows through the vein in a healthy fistula. Observe for arterial "steal" syndrome (reduced blood flow to the hand after a dialysis fistula is placed), resulting in coldness, poor functional ability or necrosis of the extremity tips.

A diagnosis record for Resident 40, dated February 25, 2022, included chronic respiratory failure, diabetes, chronic kidney disease (kidneys not working normally), and history of protein calorie malnutrition.

A significant change Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 40, dated April 13, 2022, indicated that she was alert and oriented, required set up for her meals, was on a therapeutic diet, and received dialysis (process of purifying the blood when the kidneys are not working normally).

The hospital discharge instructions for Resident 40, dated February 15, 2022, and instructions for after AVF (graft) surgery, included the diagnosis of AVF (graft) malfunction and that the resident had an AV fistulagram with the creation of an AV graft.

A nursing note for Resident 40, dated February 15, 2022, indicated that the resident returned from surgery after having a left upper extremity fistulagram with the creation of an AV (abnormal connection of an artery and a vein) graft.

The current plan of care for Resident 40, dated August 23, 2021, indicated that the staff were to check the AV fistula (graft) to the left upper extremity and assess for bruit and thrill every shift.

There was no documented evidence that the staff were monitoring the fistula every shift per the plan of care.

Interview with the Nursing Home Administrator on May 24, 2022, at 1:56 p.m confirmed that there was no documented evidence of monitoring Resident 40's fistula every shift and that it should have been done.

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




 Plan of Correction - To be completed: 07/06/2022

I. How the facility will correct the deficiency as it relates to the individual:
Resident 40's dialysis access port is monitored per facility policy.

II. How the facility will act to protect residents in similar situations:
There are currently no other residents receiving dialysis at this time.
Licensed staff will be re-educated, by the facility Director of Nursing, on dialysis access port assessments by 6/30/2022.

III. Measures the facility will take or systems it will alter to ensure that the problem does not recur:
The Director of Nursing/designee will randomly quality review the assessment of dialysis access ports 3 times per week to ensure proper compliance. Quality review will continue until 3 consecutive months of compliance are achieved.

IV. How the facility plans to monitor its performance to make sure that the solutions are permanent; i.e., what quality assurance programs will be established:
The Director of Nursing/designee will present the results of the quality reviews to the Quality Assurance Performance Improvement committee during monthly meetings to ensure completion and compliance.

483.10(j)(1)-(4) REQUIREMENT Grievances: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(j) Grievances.
483.10(j)(1) The resident has the right to voice grievances to the facility or other agency or entity that hears grievances without discrimination or reprisal and without fear of discrimination or reprisal. Such grievances include those with respect to care and treatment which has been furnished as well as that which has not been furnished, the behavior of staff and of other residents, and other concerns regarding their LTC facility stay.

483.10(j)(2) The resident has the right to and the facility must make prompt efforts by the facility to resolve grievances the resident may have, in accordance with this paragraph.

483.10(j)(3) The facility must make information on how to file a grievance or complaint available to the resident.

483.10(j)(4) The facility must establish a grievance policy to ensure the prompt resolution of all grievances regarding the residents' rights contained in this paragraph. Upon request, the provider must give a copy of the grievance policy to the resident. The grievance policy must include:
(i) Notifying resident individually or through postings in prominent locations throughout the facility of the right to file grievances orally (meaning spoken) or in writing; the right to file grievances anonymously; the contact information of the grievance official with whom a grievance can be filed, that is, his or her name, business address (mailing and email) and business phone number; a reasonable expected time frame for completing the review of the grievance; the right to obtain a written decision regarding his or her grievance; and the contact information of independent entities with whom grievances may be filed, that is, the pertinent State agency, Quality Improvement Organization, State Survey Agency and State Long-Term Care Ombudsman program or protection and advocacy system;
(ii) Identifying a Grievance Official who is responsible for overseeing the grievance process, receiving and tracking grievances through to their conclusions; leading any necessary investigations by the facility; maintaining the confidentiality of all information associated with grievances, for example, the identity of the resident for those grievances submitted anonymously, issuing written grievance decisions to the resident; and coordinating with state and federal agencies as necessary in light of specific allegations;
(iii) As necessary, taking immediate action to prevent further potential violations of any resident right while the alleged violation is being investigated;
(iv) Consistent with 483.12(c)(1), immediately reporting all alleged violations involving neglect, abuse, including injuries of unknown source, and/or misappropriation of resident property, by anyone furnishing services on behalf of the provider, to the administrator of the provider; and as required by State law;
(v) Ensuring that all written grievance decisions include the date the grievance was received, a summary statement of the resident's grievance, the steps taken to investigate the grievance, a summary of the pertinent findings or conclusions regarding the resident's concerns(s), a statement as to whether the grievance was confirmed or not confirmed, any corrective action taken or to be taken by the facility as a result of the grievance, and the date the written decision was issued;
(vi) Taking appropriate corrective action in accordance with State law if the alleged violation of the residents' rights is confirmed by the facility or if an outside entity having jurisdiction, such as the State Survey Agency, Quality Improvement Organization, or local law enforcement agency confirms a violation for any of these residents' rights within its area of responsibility; and
(vii) Maintaining evidence demonstrating the result of all grievances for a period of no less than 3 years from the issuance of the grievance decision.
Observations:


Based on review of policies, clinical records, and facility grievance/complaint logs, as well as staff interviews, it was determined that the facility failed to maintain a log of all received grievances/complaints and failed to ensure that a written copy of the grievance/compliant decision was provided to the resident and/or resident's representative for one of 39 residents reviewed (Resident 54).

Findings include:

The facility's policy regarding complaint/grievances, dated March 1, 2022, revealed that if the resident or the resident's designated person feel or believe that the resident's rights have been or are being violated by staff or another resident or in any other way, the resident and/or resident's designated person shall make his/her complaint known to the Nursing Home Administrator. The facility shall ensure investigation and resolution of the complaint. A staff member will be designated to receive complaints. A log will be kept of all complaints and outcomes. Within two business days after the submission of a written complaint, a status report shall be provided by the facility to the complainant, the resident or the resident's designated person indicating the steps that will be taken to address the concern. Within seven days after the submission of a written complaint, the facility will give the complainant, and if applicable the designated person, a written decision explaining the facility's investigation findings and actions to be taken for resolution. If the resident is not the complainant, the affected resident shall receive a copy of the decision unless contraindicated by the support plan.

A progress note for Resident 54, dated April 23, 2022, revealed that the resident's sister called and had complaints about the resident's call bell being out of reach, cell phone needing to be constantly on a charger, medications not arriving in a timely manner, and the resident being on isolation and not being allowed to go outside and smoke. The registered nurse who wrote the progress noted stated that all of the isolation and smoking should have been explained to the resident and/or whoever signed the paperwork pre-admission as well as on admission. The resident had two COVID-19 shots but no booster. The resident's sister stated that she was coming in and taking the resident outside. The registered nurse explained that she is not allowed to smoke (the resident is on continuous oxygen and is in isolation) until isolation is complete and the resident is deemed okay to be off supplemental oxygen while smoking, as well as being deemed a "safe" smoker. The physician and Director of Nursing were notified.

A progress note for Resident 54, dated May 5, 2022, revealed that the resident's sister called in complaining that the resident was not feeling well and was being neglected. This registered nurse went back to the resident's room and spoke with the resident who stated, "I feel fine. Pay no attention to my sister." The registered nurse asked the resident if she needed anything and the resident stated, "No. I'm fine. The aide answers my light as soon as it goes off." The registered nurse encouraged the resident to ask for the registered nurse if she had any issues.

There was no documented evidence that Resident 54's sister received a written grievance/complaint decision regarding her concerns form April 23, 2022, and May 5, 2022.

The facility's grievance/complaint logs dated February 2, 2022, until the start of the survey on May 22, 2022, revealed no documented evidence that grievances/complaints from Resident 54's sister were listed on the facility's grievance/complaint log.

Interview with the Nursing Home Administrator on May 23, 2022, at 12:47 p.m. confirmed that the grievances/complaints from Resident 54's sister were not listed on the facility's grievance/complaint log or that a written copy of the grievance/compliant decision was provided to the resident and/or the resident's sister.

28 Pa. Code 201.29(i) Resident rights.






 Plan of Correction - To be completed: 07/06/2022

I. How the facility will correct the deficiency as it relates to the individual:
Resident 54 no longer resides at the facility.

II. How the facility will act to protect residents in similar situations:
A review of resident's progress notes since 6/1/22 was conducted to ensure no Grievance issues had been documented without proper follow up. Grievance forms were completed as appropriate.
Staff will be re-educated, by the facility administrator, on the facility Grievance Procedure including follow-up time frames by 6/30/2022.

III. Measures the facility will take or systems it will alter to ensure that the problem does not recur:
The facility Grievance Log will be reviewed daily in Morning Stand-Up Meeting (M-F), to ensure the complainant, the resident or the resident's designated person is provided a status report and/or a written decision explaining the investigation findings and actions taken within the designated time frames per the Grievance Policy. Review will continue until 3 consecutive months of compliance is achieved.

IV. How the facility plans to monitor its performance to make sure that the solutions are permanent; i.e., what quality assurance programs will be established:
Results of the daily Grievance Log review will be presented to the Quality Assurance Performance Improvement committee during the monthly meetings.

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 facility policies and personnel records, as well as staff interviews, it was determined that the facility failed to ensure that reference checks were obtained prior to hire for one of five new employees reviewed (Temporary Nurse Aide 4).

Findings include:

The facility's policy regarding abuse, dated March 1, 2022, indicated that persons applying for employment with the facility would be screened for a history of abuse, neglect, exploitation, or misappropriation of resident property. This included but was not limited to employment history, criminal background check, abuse check with appropriate licensing board and registries prior to hire, sworn disclosure prior to hire, license or registration verification prior to hire, documentation of status of any disciplinary actions from licensing or registration boards and other registries, and information from former employers.

The personnel file for Temporary Nurse Aide 4 revealed that she was hired on April 22, 2022, and there was no documented evidence that reference checks from previous employers were obtained prior to the staff's start date.

Interview with the Human Resource Director on May 25, 2022, at 1:12 p.m. confirmed that there was no documented evidence of reference checks for Temporary Nurse Aide 4 and they should have been checked prior to her start date.

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





 Plan of Correction - To be completed: 07/06/2022

I. How the facility will correct the deficiency as it relates to the individual:
Previous employer reference checks have been completed for Temporary Nurse Aide 4 and in the employees file.

II. How the facility will act to protect residents in similar situations:
A review of employee files was conducted to ensure employees have 2 employee reference checks. Employee files were found to have 2 reference checks.
The facility's new Human Resource Coordinator will be re-educated, the Regional Director of Human Resources, on employee reference requirements by 6/30/2022.

III. Measures the facility will take or systems it will alter to ensure that the problem does not recur:
The facility administrator/designee will will review employee files prior to the first day of employment to ensure
pre-hire requirements are complete. Quality reviews will continue until 3 consecutive months of compliance is achieved.


IV. How the facility plans to monitor its performance to make sure that the solutions are permanent; i.e., what quality assurance programs will be established:
Results of the quality review will be presented to the Quality Assurance Performance Improvement committee during monthly meetings to ensure compliance.


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

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

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


Based on review of the Resident Assessment Instrument User's Manual and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that comprehensive admission Minimum Data Set assessments were completed in the required time frame for four of 39 residents reviewed (Residents 25, 94, 95, 96).

Findings include:

The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which provides instructions and guidelines for completing required Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2019, indicated that an admission MDS assessment was to be completed no later than 14 days following admission.

An admission MDS assessment for Resident 25 revealed that the resident was admitted to the facility on February 25, 2022, and the resident's admission MDS assessment was dated as completed on April 1, 2022, which was 36 days after admission.

An admission MDS assessment for Resident 94 revealed that the resident was admitted to the facility on April 12, 2022, and the resident's admission MDS assessment was dated as completed on April 26, 2022, which was 15 days after admission.

An admission MDS assessment for Resident 95 revealed that the resident was admitted to the facility on April 1, 2022, and the resident's admission MDS assessment was dated as completed on February 15, 2022, which was 15 days after admission.

An admission MDS assessment for Resident 96 revealed that the resident was admitted to the facility on February 1, 2022, and the resident's admission MDS assessment was dated as completed on February 15, 2022, which was 15 days after admission.

Interview with the RNAC (RNAC - a registered nurse who is responsible for the completion of MDS assessments) on May 25, 2022, at 4:29 p.m. confirmed that the admission MDS assessments for Residents 25, 94, 95, and 96 were completed late.

28 Pa. Code 211.5(f) Clinical records.




 Plan of Correction - To be completed: 07/06/2022

I. How the facility will correct the deficiency as it relates to the individual:
The facility is unable to correct late assessments for residents 25, 94, 95 & 96.


II. How the facility will act to protect residents in similar situations:
A look back of Minimum Data Set Assessments completed in the past 30 was done to ensure all assessments were completed timely.
The facility Minimum Data Set Coordinators will be re-educated, by the Regional Clinical Reimbursement Director, on assessment completion time frames by 6/30/2022.

III. Measures the facility will take or systems it will alter to ensure that the problem does not recur:
The Director of Nursing/designee will review the Minimum Data Set Dashboard in Point Click Care daily in Morning Clinical Meeting (M-F) to discuss Minimum Data Set Assessments due that day and review assessments due the prior day for completion. Quality reviews will continue until 3 consecutive months of compliance is achieved.

IV. How the facility plans to monitor its performance to make sure that the solutions are permanent; i.e., what quality assurance programs will be established:
Results of the quality reviews will be presented to the Quality Assurance Performance Improvement committee during monthly meetings to ensure completion and compliance.

483.25(b)(1)(i)(ii) REQUIREMENT Treatment/Svcs to Prevent/Heal Pressure Ulcer:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.25(b) Skin Integrity
483.25(b)(1) Pressure ulcers.
Based on the comprehensive assessment of a resident, the facility must ensure that-
(i) A resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable; and
(ii) A resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing.
Observations:


Based on clinical record reviews and staff interviews, it was determined that the facility failed to apply dressings to pressure ulcers as ordered by the physician for one of 39 residents reviewed (Resident 31).

Findings include:

An annual Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 31, dated April 6, 2022, revealed that the resident had diagnoses that included multiple sclerosis (MS - a chronic disease affecting the central nervous system (the brain and spinal cord), was understood, could understand, required extensive assistance from staff for her daily care tasks, and had one Stage 2 pressure ulcer (the skin breaks open, wears away, or forms an ulcer, which is usually tender and painful).

A Certified Registered Nurse Practitioner (CRNP - a professional nurse who is certified by the State Board of Nursing in a specialty and who functions in the expanded role as a professional nurse) note for Resident 31, dated May 23, 2022, revealed that the resident was seen on wound rounds for evaluation of her chronic Stage 2 pressure ulcer related to her MS, which had healed to closure several months ago. The resident continues to have skin loss and exacerbation related to moisture associated skin damage (MASD - caused by prolonged exposure to various sources of moisture). It was reported that it had declined and started to open again so will change back to Silver sulfadiazine (SSD - is an antibiotic cream), zinc oxide (used to treat and prevent diaper rash and other minor skin irritations such as burns, cuts, scrapes), and ABD pad (a highly absorbent dressing that provides padding and protection for large wounds).

Physician's orders for Resident 31, dated May 23, 2022, included an order to discontinue the previous treatment and to start by cleaning the coccyx (commonly referred to as the tailbone) with Normal Sterile Saline, then apply 4 percent zinc oxide, then SSD, and then cover with an ABD pad twice each day.

A review of Resident 31's Medication Administration Record (MAR), Treatment Administration Record (TAR), and clinical record revealed no documented evidence that the resident's treatment was completed as ordered during the evening shift on May 23, 2022, or during the day and evening shifts on May 24, 2022.

Interview with the Director of Nursing on May 25, 2022, at 1:40 p.m. confirmed that there was no documented evidence that Resident 31's wound care was provided as ordered on the above dates..

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




 Plan of Correction - To be completed: 07/06/2022

I. How the facility will correct the deficiency as it relates to the individual:
Resident 31's wound treatment is being completed timely per physician's orders.

II. How the facility will act to protect residents in similar situations:
A review of resident treatments was conducted to ensure timely completion per physician orders. Any issues were resolved as appropriate.
Licensed nursing staff will be re-educated, by the facility Director of Nursing, on treatment completion and documentation by 6/30/2022.

III. Measures the facility will take or systems it will alter to ensure that the problem does not recur:
The Director of Nursing will review treatment documentation during daily Clinical Meeting (M-F) to ensure appropriate treatment completion documentation is present. Review will continue until 3 consecutive months of compliance is achieved.

IV. How the facility plans to monitor its performance to make sure that the solutions are permanent; i.e., what quality assurance programs will be established:
Results from the daily treatment documentation quality reviews will be presented to the Quality Assurance Performance Improvement committee during monthly meetings to ensure completion and compliance.

483.25(d)(1)(2) REQUIREMENT Free of Accident Hazards/Supervision/Devices: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(d) Accidents.
The facility must ensure that -
483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and

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


Based on review of clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that residents were transported in a safe manner for one of 39 residents reviewed (Resident 32).

Findings include:

A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 32, dated April 7, 2022, revealed that the resident had diagnoses that included a stroke, dementia, and generalized muscle weakness, was usually understood, could usually understand, required extensive assistance from staff for her daily care tasks including with her locomotion on and off the unit, and had impaired range of motion on one side of her lower extremities. A care plan for the resident, dated February 26, 2020, revealed that the resident has a self-care performance deficit related to dementia and that the resident required extensive assistance from staff for transferring in her BRODA chair (a special type of wheelchair that offers tilt, recline and leg rest adjustments).

Observations on May 24, 2022, at 12:25 p.m. revealed that Nurse Aide 1 pushed Resident 32 down the hallway from her room to the solarium across from the nurse's station on C Wing without foot rests on the BRODA chair. During the transport, the resident's feet were sliding on the floor.

Interview with Nurse Aide 1 on May 24, 2022, at 12:40 p.m. revealed that Resident 32's foot rests must be in the main dining area and confirmed that she should have had them on when transporting the resident.

Interview with the Director of Nursing on May 24, 2022, at 1:09 p.m. confirmed that leg rests should be in place when a resident is being transported by staff.

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

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






 Plan of Correction - To be completed: 07/06/2022

I. How the facility will correct the deficiency as it relates to the individual:
Staff member has been re-educated on proper transporting of resident 32

II. How the facility will act to protect residents in similar situations:
Residents were reviewed for appropriate manner of transport within the facility.
Staff will be re-educated, by facility Director of Nursing, on proper transport techniques by 6/30/2022.

III. Measures the facility will take or systems it will alter to ensure that the problem does not recur:
The Director of Nursing/designee will conduct 4 random quality reviews/observations of resident transports within the facility to ensure proper transport technique is used. Quality reviews/observations will continue until 3 consecutive months of compliance is achieved.

IV. How the facility plans to monitor its performance to make sure that the solutions are permanent; i.e., what quality assurance programs will be established:
Results of quality reviews/observations will be presented to the Quality Assurance Performance Improvement committee during monthly meetings to ensure completion and compliance.

483.60(d)(4)(5) REQUIREMENT Resident Allergies, Preferences, Substitutes: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.
483.60(d) Food and drink
Each resident receives and the facility provides-

483.60(d)(4) Food that accommodates resident allergies, intolerances, and preferences;

483.60(d)(5) Appealing options of similar nutritive value to residents who choose not to eat food that is initially served or who request a different meal choice;
Observations:


Based on the review of policies and clinical records, as well as observations and resident and staff interviews, it was determined that the facility failed to ensure that residents were provided their food preferences for two of 39 residents reviewed (Residents 40, 87).

Findings include:

The facility policy for dining and food preferences, dated March 1, 2022, indicated that all residents' dining, food and beverage preferences are identified for all residents. The dining services director or the designee will interview the resident or resident representative to complete a food preference interview within 48 hours of admission to the facility. The individual tray assembly ticket will identify all food items appropriate for the resident based on their diet order, allergies, intolerances and preferences.

An interview with a group of residents on May 23, 2022, at 11:30 a.m. revealed that residents were not being provided their food preferences with their meals.

A diagnosis record for Resident 40, dated February 25, 2022, included chronic respiratory failure, diabetes, chronic kidney disease, and history of protein calorie malnutrition.

A significant change Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 40, dated April 13, 2022, indicated that she was alert and oriented, only required set up for her meals, was on a therapeutic diet, and she received dialysis.

A physician's order for Resident 40, dated February 24, 2022, included an order for a consistent carbohydrate diet (CCD) renal diet, regular texture, regular/thin liquid consistency with a fluid restriction.

Observation of Resident 40's meal on May 22, 2022, at 12:34 p.m. revealed that she was served cheese raviolis.

Interview with Resident 40 on May 22, 2022, at 12:34 p.m. indicated that she had told staff that she did not want to be provided items with cheese due to the salt content.

Interview with the Dietary Manager in Training and the Dietary Manager on May 23, 2022, at 1:39 p.m. indicated that the resident should not have been given the cheese raviolis because the resident had informed them she did not want any cheese items. However, they confirmed that Resident 40's dislike list had not been updated to include no cheese items.


A nursing note for Resident 87, dated May 10, 2022, at 12:05 a.m. revealed that the resident arrived at 5:10 p.m., was alert and oriented, and had poor oral intake.

A food and beverage preference list, dated May 12, 2022, revealed that Resident 87 liked apple and cranberry juice.

Observations of Resident 87's breakfast tray on May 24, 2022, at 8:29 a.m. revealed that the resident received a glass of orange juice. Interview with Resident 87 at that time revealed that orange juice upsets his stomach.

Interview with the Dietary Manager on May 25, 2022, at 9:40 a.m. confirmed that the resident preferred apple or cranberry juice.

28 Pa. Code 201.29(j) Resident rights.




 Plan of Correction - To be completed: 07/06/2022

I. How the facility will correct the deficiency as it relates to the individual:
Resident 87 no longer resides in the facility. A food preference assessment was completed for resident 40 by dietary staff.

II. How the facility will act to protect residents in similar situations:
Dietary staff completed updated dietary food preference assessments on all residents.
Dietary staff will be re-educated, by Healthcare Services Group District Manager, on honoring resident food preferences by 6/30/2022.

III. Measures the facility will take or systems it will alter to ensure that the problem does not recur:
The facility administrator/designee will conduct 3 random tray quality reviews per week to ensure meal ticket preferences match meal served. Quality reviews will continue until 3 consecutive months of compliance is achieved.

IV. How the facility plans to monitor its performance to make sure that the solutions are permanent; i.e., what quality assurance programs will be established:
The results of the tray quality reviews will be presented to the Quality Assurance Performance Improvement committee during monthly meetings to ensure completion and compliance.

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

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


Based on review of the facility's plans of correction for previous surveys, and the results of the current survey, it was determined that the facility's Quality Assurance Performance Improvement (QAPI) committee failed to correct quality deficiencies and ensure that plans to improve the delivery of care and services effectively addressed recurring deficiencies related to infection control.

Findings include:

The facility's deficiencies and plans of corrections for a State Survey and Certification (Department of Health) survey ending July 15, 2021, revealed that the facility developed a plan of correction that included quality assurance systems with audits, to ensure that the facility maintained compliance with cited nursing home regulations. The results of the audits were to be reported to the QAPI committee for review. The results of the current survey, ending May 25, 2022, identified a repeated deficiency regarding infection control, cited under F880, which revealed that the facility's QAPI committee was ineffective in maintaining compliance with the regulation regarding infection control.

Refer to F880.

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

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



 Plan of Correction - To be completed: 07/06/2022

I. How the facility will correct the deficiency as it relates to the individual:
No resident was identified as having been affected by the finding.

II. How the facility will act to protect residents in similar situations:
Facility Department Managers taking part in the Quality Assurance Performance Improvement committee will be re-educated, by the facility administrator, on function/purpose of the meeting. The Quality Assurance Performance Improvement committee will meet monthly to review metrics of the facility and identify opportunities for improvement.

III. Measures the facility will take or systems it will alter to ensure that the problem does not recur:
A member of the facility's regional management team will review and sign the monthly meeting minutes to ensure the Quality Assurance Performance Improvement team are meeting monthly to identify quality issues within the facility. Regional team's review of minutes will continue until 3 consecutive months of compliance is achieved.


IV. How the facility plans to monitor its performance to make sure that the solutions are permanent; i.e., what quality assurance programs will be established:
Quality reviews of the facility's Quality Assurance Performance Improvement plan will be reviewed by the Quality Assurance Performance Improvement committee monthly to ensure the facility's Quality Assurance Performance Improvement plan identifies ongoing quality issues. Findings to be reviewed via the Quality Assurance Performance Improvement committee meeting and updated as indicated. Quality Improvement schedule modified based on findings.

483.75(g)(1)(i)-(iii)(2)(i) REQUIREMENT QAA Committee: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.
483.75(g) Quality assessment and assurance.
483.75(g)(1) A facility must maintain a quality assessment and assurance committee consisting at a minimum of:
(i) The director of nursing services;
(ii) The Medical Director or his/her designee;
(iii) At least three other members of the facility's staff, at least one of who must be the administrator, owner, a board member or other individual in a leadership role;

483.75(g)(2) The quality assessment and assurance committee must:
(i) Meet at least quarterly and as needed to identifying issues with respect to which quality assessment and assurance activities are necessary.
Observations:


Based on review of facility policies and attendance records for the facility's Quality Assurance Committee, as well as staff interviews, it was determined that the facility failed to ensure that the Quality Assurance Committee met at least quarterly and/or as needed.

Findings include:

The facility's policy regarding performance improvement committee (Quality Assurance), dated March 1, 2022, revealed that the performance improvement committee will meet at least quarterly and as needed.

Review of the attendance records for the facility's Quality Assurance Committee meetings revealed that the Quality Assurance Committee did not met during the first quarter of 2022.

Interview with the Nursing Home Administrator on May 25, 2022, at 4:50 p.m. confirmed that there was no documented evidence that the Quality Assurance Committee met during the first quarter of 2022.

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

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




 Plan of Correction - To be completed: 07/06/2022

I. How the facility will correct the deficiency as it relates to the individual:
No resident was found to have been affected by the finding.

II. How the facility will act to protect residents in similar situations:
Facility Department Managers taking part in the Quality Assurance Performance Improvement committee will be re-educated, by the facility administrator, on function/purpose of the meeting and meeting frequency requirements.

III. Measures the facility will take or systems it will alter to ensure that the problem does not recur:
The minutes of the monthly Quality Assurance Performance Improvement will be reviewed by the Regional VP of Operations/designee monthly and signed as evidence of review to ensure meetings are being held in accordance with facility policy. Review/signing of the minutes will continue until 3 consecutive months of compliance is achieved.

IV. How the facility plans to monitor its performance to make sure that the solutions are permanent; i.e., what quality assurance programs will be established:
The monthly minutes of the Quality Assurance Performance Improvement committee signed by the Regional VP of Operations/designee will be reviewed during the meeting to show completion and compliance with review.

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

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

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

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

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

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

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


Based on review of policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that proper hand hygeine was followed while obtaining a blood glucose level and administering insulin for one of 39 residents reviewed (Resident 78).

Findings include:

The facility's policy regarding hand hygiene, dated March 1, 2022, indicated that hand hygiene should be performed before and after patient care, after contact with blood or body fluids, and after glove removal.

A diagnosis record for Resident 78, dated May 4, 2022, included diabetes (a disease that causes high blood sugar levels in the blood).

A physician's order for Resident 78, dated May 6, 2022, included an order for her to receive 5 units of Lispro Insulin (a fast acting insulin) subcutaneously (under the skin) before meals and to receive additional insulin as per sliding scale (a scale that determines the amount of insulin to be administered based on the resident's blood glucose result) before meals and at bedtime.

Observations during medication administration on May 24, 2022, at 11:28 a.m. through 11:35 a.m. revealed that Licensed Practical Nurse 3 obtained a blood glucose sample for Resident 78 and after obtaining the level she proceeded to place the blood glucose monitoring device on the medication cart, removed her gloves, donned new gloves, and cleaned the machine with a sanitizing wipe. Next, she cleaned the cart with the wipe, removed her gloves, placed the machine back in the cart, and removed the insulin pen from the top drawer of the medication cart for the resident. She then prepared and administered the insulin to Resident 78. She placed the insulin pen directly on the cart, removed her gloves, documented on the computer, then put the pen back in a plastic bag in the cart drawer. Licensed Practical Nurse 3 then opened the bottom drawer of the cart and obtained another blood glucose monitoring device for another resident. During this process Licensed Practical Nurse 3 did not perform any hand hygiene after glove removal and before touching other items and/or the medication cart drawers.

Interview with the Licensed Practical Nurse 3 on May 24, 2022, at 11:38 a.m. confirmed that she should have sanitized her hands after glove removal.

Interview with the Director of Nursing on May 25, 2022, at 11:08 a.m. confirmed that the nurse should do hand hygiene after glove removals.

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




 Plan of Correction - To be completed: 07/06/2022

I. How the facility will correct the deficiency as it relates to the individual:
Resident 78 receives their insulin and glucometer checks following proper infection control.

II. How the facility will act to protect residents in similar situations:
Licensed staff will be re-educated, by the facility Director of Nursing, on infection control techniques related to glove use.

III. Measures the facility will take or systems it will alter to ensure that the problem does not recur:
The Director of Nursing/designee will conduct random quality reviews of 3 insulin and/or glucometer checks weekly to ensure proper infection control technique. Quality reviews will continue until 3 consecutive months of compliance is achieved.

IV. How the facility plans to monitor its performance to make sure that the solutions are permanent; i.e., what quality assurance programs will be established:
Results of the insulin/glucometer check quality reviews will be presented to the Quality Assurance Performance Improvement committee during monthly meetings to ensure completion and compliance.

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 review of facility policies and residents' clinical records, as well as staff interviews, it was determined that the facility failed to ensure that each resident received the influenza immunization for one of five residents who were reviewed related to immunization concerns (Resident 11).

Findings include:

The facility's policy regarding influenza (flu) vaccines, dated March 1, 2022, revealed that all residents and staff are offered the vaccine unless there is a medical contraindication.

A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 11, dated March 3, 2022, revealed that the resident had received the influenza vaccine in the facility for the current influenza season; however, it indicated that it was given on October 2, 2020 (which was not during the current influenza season of October 1, 2021, through March 31, 2022).

A progress note for Resident 11, dated September 8, 2021, revealed that the writer contacted the resident's representative via telephone to discuss giving the influenza vaccine and obtain consent for the resident to receive the influenza vaccine for this season. There was no answer and a message was left.

However, there was no documented evidence that any further attempts were made to contact Resident 11's representative to discuss the resident receiving the influenza vaccine and/or obtain consent for the resident to receive the influenza vaccine for this season. There was no documented evidence that the facility administered the influenza vaccine to the resident during the current influenza season of October 1, 2021, through March 31, 2022.

Interview with the Assistant Director of Nursing/Infection Control Preventionist on May 25, 2022, at 4:30 p.m confirmed that there was no documented evidence that the influenza vaccine was administered to Resident 11. She indicated that further attempts should have been made to contact the resident's representative.

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

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

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





 Plan of Correction - To be completed: 07/06/2022

I. How the facility will correct the deficiency as it relates to the individual:
Resident 11's physician was notified and asked that the influenza vaccine be administered to resident at this time, however family declined influenza vaccine at this time.

II. How the facility will act to protect residents in similar situations:
A review of influenza vaccine consents was conducted to determine if any other resident had consented to the vaccine but did not receive. Any found issues were addressed as appropriate.
Licensed staff will be re-educated, by the facility Director of Nursing on consent and administration of annual influenza vaccines.

III. Measures the facility will take or systems it will alter to ensure that the problem does not recur:
The Director of Nursing/designee will conduct quality reviews of 4 vaccine consents per month to ensure proper follow up occurs. Quality reviews will continue until 3 consecutive months of compliance is achieved. The facility infection preventionist/designee will review the Immunization Report from Point Click Care and compare with current consents to ensure desired vaccines have been administered. Reviews will continue on an ongoing basis.

IV. How the facility plans to monitor its performance to make sure that the solutions are permanent; i.e., what quality assurance programs will be established:
Results from the vaccine consent quality reviews will be presented to the Quality Assurance Performance Improvement committee during monthly meetings to ensure completion and compliance.

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 review of Pennsylvania state law, policies and attendance records for the facility's Quality Assurance/Performance Improvement (QAPI) committee, as well as staff interviews, it was determined that the facility failed to ensure that the multi-disciplinary infection control committee included representation from the laboratory, pharmacy, and/or the community and failed to ensure that the QAPI committee at least quarterly.

Findings include:

The Act 52 Infection Control Plan, dated March 20, 2002, revealed 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 multi-disciplinary committee including a representative from each of the following, if applicable to the specific health care facility. Applicable members included medical staff that could include the chief medical officer or the nursing home medical director, the nursing home administrator, laboratory personnel, nursing staff that could include the director of nursing or a nursing supervisor, pharmacy staff, physical plant personnel, a patient safety officer, and a community member that may not be an agent, employee or contractor of the facility.

Interview with the Nursing Home Administrator on May 22, 2022, at 10:44 a.m. revealed that the facility's infection control committee was part of its QAPI committee.

The facility's QAPI committee meeting attendance records for the third quarter of 2021, dated August 16, 2021, September 24, 2021, and October 29, 2021, revealed that representatives of the laboratory, pharmacy, and the community were not present at the meeting.

The facility's QAPI committee meeting attendance records for the fourth quarter of 2021, dated November 19, 2021, and December 30, 2021, revealed that representatives of the laboratory, pharmacy, and the community were not present at the meeting.

Review of the attendance records for the facility's QAPI committee meetings revealed that the QAPI committee did not met during the first quarter of 2022.

Interview with the Nursing Home Administrator on May 25, 2022, at 4:50 p.m. confirmed that representatives of the laboratory, pharmacy, and community were not present at the above QAPI committee meetings and confirmed that there was no documented evidence that the QAPI committee met during the first quarter of 2022.





 Plan of Correction - To be completed: 07/06/2022

I. How the facility will correct the deficiency as it relates to the individual:
No resident was found to be affected by this finding.

II. How the facility will act to protect residents in similar situations:
The facility Assistant Director of Nursing/Infection Preventionist will be re-educated, by the facility Director of Nursing, on the requirements of the monthly infection control meetings by 6/30/2022.

III. Measures the facility will take or systems it will alter to ensure that the problem does not recur:
The facility administrator will review the monthly Infection Control Meeting minutes to ensure the meeting is occurring monthly per the requirements/guidelines. Review of the minutes will continue until 3 consecutive months of compliance is achieved.

IV. How the facility plans to monitor its performance to make sure that the solutions are permanent; i.e., what quality assurance programs will be established:
Minutes from the previous month's Infection Control meeting will be reviewed by the Quality Assurance Performance Improvement committee until 3 consecutive months of compliance is achieved.

201.20(b) LICENSURE Staff development.:State only Deficiency.
(b) An employe shall receive appropriate orientation to the facility, its policies and to the position and duties. The orientation shall include training on the prevention of resident abuse and the reporting of the abuse.
Observations:


Based on review of personnel files and staff interviews, it was determined that the facility failed to provide orientation to the facility, its policies, and to the duties of their positions for three of five new employees reviewed (Temporary Nurse Aide 4, Maintenance Director, Assistant Director of Nursing).

Findings include:

The personnel files for Temporary Nurse Aide 4, the Assistant Director of Nursing, and the Maintenance Director revealed hire dates of March 15, 2022, for the Assistant Director of Nursing; April 18, 2022, for the Maintenance Director; and April 22, 2022, for Temporary Nurse Aide 4. There was no documented evidence that the employees received orientation to the facility's policies and to the duties of their positions.

Interview with the Nursing Home Administrator on May 25, 2022, at 1:08 p.m. confirmed that there was no documented evidence that Temporary Nurse Aide 4, the Assistant Director of Nursing, and the Maintenance Director received orientation to the facility's policies and the duties of their positions.






 Plan of Correction - To be completed: 07/06/2022

I. How the facility will correct the deficiency as it relates to the individual:
The Assistant Director of Nursing, the Maintenance Director and temporary Nurse Aide 4 have completed documentation of orientation.

II. How the facility will act to protect residents in similar situations:
The facility's new Human Resource Coordinator will be re-educated, by the Regional Human Resource Director, on requirement for employee orientation documentation by 6/30/2022.

III. Measures the facility will take or systems it will alter to ensure that the problem does not recur:
While completing pre-hire employee file quality reviews the facility administrator will confirm with the Human Resource Coordinator that the employee has been schedule for orientation.
The facility administrator will conduct quality reviews of 3 random new employee files monthly to ensure there is documentation of facility orientation. Quality reviews will continue until 3 consecutive months of compliance is achieved.

IV. How the facility plans to monitor its performance to make sure that the solutions are permanent; i.e., what quality assurance programs will be established:
Results of the employee file quality reviews for orientation documentation will be presented to the Quality Assurance Performance Improvement committee during monthly meetings.


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