Pennsylvania Department of Health
EDISON MANOR NURSING & REHAB CENTER
Patient Care Inspection Results

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EDISON MANOR NURSING & REHAB CENTER
Inspection Results For:

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EDISON MANOR NURSING & REHAB CENTER - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on a Medicare/Medicaid Recertification, State Licensure, and Civil Rights Compliance Survey and Abbreviated Complaint Surveys completed on February 8, 2024, it was determined that Edison 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:


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

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

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

Based on review of facility policies, observations, and staff interviews, it was determined that the facility failed to maintain sanitary food service operations for one of one kitchens.

Findings include:

Review of facility policy entitled, "Dish Machine Use," last reviewed 1/17/2024, revealed "Prior to use, verify temperature and/or chemical sanitizer concentration are within specifications provided by the dish machine manufacturer (see note). If requirements are not met, immediately discontinue use of the dish machine and notify the person in charge."

Review of facility policy entitled, "Storage of refrigerated foods," last reviewed 1/17/2024, revealed "All refrigerated items must be stored at least six inches above the floor and eighteen inches from the refrigerator ceiling and sprinkler heads. Store all food/leftovers in covered, approved, food grade containers. Refrigerated, TCS foods, prepared and held for more than 24 hours will be marked to indicate the date the food will be consumed or discarded. Prepared TCS foods will be held a maximum of seven days with the day of preparation counted as day one."

Review of facility policy entitled, "Storage of dry food," last reviewed 1/17/2024, revealed "Dry storage rooms will be neat and orderly. when original packaging is opened, food must be stored in containers intended for food that are durable, leak proof, that can be sealed or covered. Except when holding food that can be unmistakably recognized such as dry pasta, these containers will be identified with the common name of the food item and date opened."

During an initial tour of the facility's kitchen on 2/5/2024, at 11:30 a.m., with the facility's Registered Dietitian (RD), the following was identified:

While checking the walk-in refrigerator, there was a bag of cooked beef on the second shelf with a date of 1/22/2024; a pan of cooked vegetables covered with a date of 1/28/2024; and a bag of pureed food stored in a bag with a date of 1/31/2024; a full crate of chocolate milk for use with an expiration date of 2/3/2024.

Upon observation of the walk-in freezer it was revealed that there were food items stored in boxes sitting on the floor of the freezer. It was also observed that there were food items and debris on the floor of the freezer. Upon observation of the dry food storage area, it was revealed that there were food wrappers, containers of juice, crumbs of food, saltine crackers, and graham crackers on the floor. Upon checking the food items on the shelves, it was observed that a box of taco shells were sitting on the top shelf unsealed and open to air with no opened or use by date.

During an interview with the RD on 2/5/2024 at the time of the observations, it was confirmed that the food items were stored past the use-by date or expiration date and should have been thrown away, the food items needed to be stored off of the floors, and the floors of food storage areas need to be swept and cleaned of food crumbs and debris to create a sanitary environment.

Upon observation of the dish machine on 2/7/2024, at 12:45 p.m., it was confirmed that the dish machine was a low temp machine requiring sanitizer. Upon checking the temperature, while staff members were washing dishes, it was confirmed that the wash temperature was 124 degrees Farenheit (F), and the rinse temperature was 136 degrees F. Upon checking the sanitizer with chlorine strips, it was confirmed that there was no reading on the strips after multiple checks, and the sanitizer pump was not pumping sanitizer. Upon checking the verification sheet which staff documents prior to use, it was confirmed it was not filled out and not checked by the staff.

Upon interview, on 2/7/2024, at 12:55 p.m. it was confirmed by the Regional RD and the Interim Dietary Manager, that the sanitizer to the low temp washing machine was not working properly, and the staff did not check the machine prior to washing dishes.

28 Pa. Code 211.6(f) Dietary services











 Plan of Correction - To be completed: 03/12/2024

The facility completed the following corrective actions; All items in the observation that were expired were immediately discarded. All items that were observed stored on the floor of the walk-in freezer were placed on shelving and floors of the freezer were cleaned. All food items in the dry storage were moved to an appropriate location and dry storage room was cleaned. The open to air bag of taco shells were discarded. On the day of observation that the dish machine sanitizer pump was not in operation the service technician was able to come out immediately and fix the pump. A proper reading was able to be read from the chlorine test strip.
To identify other areas of risk the facility checked expiration dates of all food items in all areas and completed a deep clean of the kitchen on 2/28/2024. Any items that were found beyond the expiration date were discarded. All plateware and kitchenware were washed with the proper sanitizing solution on 2/29/2024.
To prevent this from reoccurring the administrator and the dietary manager provided education to the food and nutritional services staff on 2-28-2024 to review the facility's policy and procedures related to keeping a sanitary environment, making sure food is stored properly and not beyond the expiration date, that floors are free from debris, and that the chemical dish machine sanitizer is working properly and at the proper dilution.
To monitor and maintain ongoing compliance the following actions will be taken: The administrator/or designee will complete an audit 3 x weekly for 4 weeks and then monthly for two months to ensure that food is stored properly and not beyond the expiration date, that floors are free from debris, and that the chemical dish machine sanitizer is working properly and at the correct dilution. Results of these audits will be reviewed by the facilities QAPI committee for further review, action and monitoring.

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

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

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

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

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

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

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

Based on review of facility policy, observations, and staff interviews, it was determined the facility failed to maintain infection control and prevention measures related to laundry services.

Findings include:

Review of facility policy entitled, "General Linen Handling Policy," dated 1/17/24, revealed "The facility will handle all used linen as potentially contaminated and will employ standard precautions in handling such linen. Linen will be handled in a manner which reduces the likelihood of contamination. Contaminated laundry/linens will be bagged or contained at the point of use or collection. Leak resistant bags or containers will be used for any linens contaminated with blood or body substances."

Observations in the laundry area on 2/07/24, at 10:20 a.m. revealed dirty linen and clothing covered with feces in a large laundry cart that was utilized for a collection device from bags delivered via the laundry chute. Soiled wash cloths and towels with large amounts of feces were observed in a garbage bag to be discarded related to the large amount of feces on them.

An interview with the Laundry Manager on 2/07/24, at 10:20 a.m. revealed that staff send down soiled clothing, linen and even depends (incontinence products) that are covered with large amounts of feces and mixed in with all resident clothing and linen; clothing and linen are also delivered blood covered. The Laundry Manager indicated that when the laundry is observed with large of amounts of feces, the items are discarded due to it cannot be placed in a washer safely. The Laundry Manager further indicated the laundry at times is delivered in open bags allowing the soiled laundry to scatter easily at the bottom of the laundry chute, and that no resident clothing or linen is delivered in red bags to signify special precautions for infection control and prevention measures. The Laundry Manager indicated that numerous staff educations have been provided regarding the safe and proper way to deliver linen and resident clothing via the laundry chute to laundry services, however, no positive resolution has occurred.

An interview with the Infection Control Registered Nurse on 2/07/24, at 10:30 a.m. revealed transmission-based precautions are maintained for five residents and that red bags should be utilized for their linen and clothing. He/She further indicated that the linen/clothing should be delivered to laundry services in closed bags without concern of large amount of feces and/or blood for proper infection control and prevention measures.

An interview with the Director of Nursing on 2/07/24, at approximately 11:00 a.m. confirmed that resident linen/clothing should not be delivered to laundry services with large amounts of feces and/or blood.

28 Pa. Code 201.14(a) Responsibility of Licensee

28 Pa. Code 211.10(d) Resident care policies

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

28 Pa. Code 205.26(c) Laundry



 Plan of Correction - To be completed: 03/12/2024

No specific resident identified were identified in this observation, however, the facility completed the following corrective actions; the facility removed the laundry chute from service until it was cleaned on 2/22/2024. Furthermore, at the time of the observation residents with transmission-based precautions were identified and prevention measures related to laundry services were put in place.
To identify other risks regarding this observation the facility reviewed all residents on 2/29/2024 to determine if other residents needed infection control and prevention measures related to laundry services. If needed, these precautions were put in place.
To prevent this from reoccurring the director of nursing provided education to all staff on 2-28-2024 regarding infection control and prevention measures related to laundry services including ensuring feces are removed from laundry prior to taking to laundry, that items to be disposed of are not mixed in laundry, that bags are closed and that laundry for residents with transmission-based precautions are maintained according to policy.
To monitor and maintain ongoing compliance the following actions will be taken: The administrator/or designee will complete an audit 4 x weekly for 4 weeks and then monthly for two months to ensure feces are removed from laundry prior to taking to laundry, that items to be disposed of are not mixed in laundry, that bags are closed and that laundry for residents with transmission-based precautions are maintained according to policy. Results of these audits will be reviewed by the facilities QAPI committee for further review, action and monitoring.

483.10(a)(1)(2)(b)(1)(2) REQUIREMENT Resident Rights/Exercise of Rights:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
§483.10(a) Resident Rights.
The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility, including those specified in this section.

§483.10(a)(1) A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the resident.

§483.10(a)(2) The facility must provide equal access to quality care regardless of diagnosis, severity of condition, or payment source. A facility must establish and maintain identical policies and practices regarding transfer, discharge, and the provision of services under the State plan for all residents regardless of payment source.

§483.10(b) Exercise of Rights.
The resident has the right to exercise his or her rights as a resident of the facility and as a citizen or resident of the United States.

§483.10(b)(1) The facility must ensure that the resident can exercise his or her rights without interference, coercion, discrimination, or reprisal from the facility.

§483.10(b)(2) The resident has the right to be free of interference, coercion, discrimination, and reprisal from the facility in exercising his or her rights and to be supported by the facility in the exercise of his or her rights as required under this subpart.
Observations:

Based on review of facility records and policy, review of clinical records, and the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual 2019 (RAI-assessment guide use to plan the provision of care for residents), observations, and resident and staff interviews, it was determined that the facility failed to ensure that a resident's dignity was maintained for nine of 24 residents reviewed (Residents R1, R11, R13, R26, R36, R44, R48, R66, and R78).

Findings include:

Review of "Resident Rights Inservice" provided by the Registered Nurse (RN) Regional Director on 2/07/24, at approximately 11:00 a.m. revealed "The Residents' Bill of Rights, The Nursing Home Reform Act established the following rights for nursing home residents: The right to be treated with dignity; The right to exercise self-determination; The right to communicate freely; Receive adequate and appropriate care; To be treated with consideration, respect, and dignity; and Participate in community activities, both inside and outside the nursing home."

Review of the facility policy, "Resident Communication System and Call Light Policy" dated 1/17/24, revealed "It is the policy of the facility to provide residents with a means of communicating with staff. A call system is installed in each resident room and toilet/bath areas. The facility responds to resident needs and requests. Procedure: 3. Staff will respond to call lights promptly. Answering Call Lights - General Guidelines: 1. Upon entering a resident room, turn off the call light. 6. Some residents may not be able to use their call light. Staff will check these residents more frequently. 8. Answer the resident's call light as soon as possible. 9. Be courteous when answering call lights. Steps in Procedure: 1. Turn off the call light. 2. Identify yourself and call the resident by his/her name (use Mr. or Mrs.) and ask 'how may I help you?' 3. Listen to the resident's request. 4. Do what the resident requests, if capable/allowed. Otherwise seek assistance of charge nurse or someone who can assist. If you have promised the resident you will return with an item or information, do so promptly."

Resident R78's clinical record revealed an admission date of 9/12/22, with diagnoses that included urinary tract infection, sepsis (a life-threatening complication of an infection), diabetes mellitus (a group of diseases that result in too much sugar in the blood), and gastro-esophageal reflux disease (a digestive disease in which the stomach acid irritates the food pipe lining.)

Review of the RAI manual instructions for Section C0500 "Brief Interview for Mental Status (BIMS)" revealed that a score of 13-15 identified a resident as cognitively intact and a score of 8-12 identified a resident as moderately impaired, and a score of 0-7 as severely impaired.

Revies of the Minimum Data Set (MDS-a periodic assessment of resident care needs) Section C0500 dated 1/23/24, revealed Resident R78 with a BIMS score of 12. Resident R78's Section GG0170 dated 1/23/24, Functional Abilities and Goals for Mobility, indicated that Resident R78's ability to transfer to and from a bed to a chair/wheelchair is independent (resident completes the activity by themselves with no assistance from a helper).

During an interview on 2/05/24, at 11:45 a.m. Resident R78 indicated he/she is frustrated over the way staff talk to him/her. Resident R78 verbalized, "When I do need help with something, the staff are very rude to me. They tell me I am selfish."

During an interview on 2/05/24, at 1:30 p.m., Resident R1 revealed that when staff respond to call light activation and the resident requests assistance, the responding staff act very irritated and make the resident feel as though they are a nuisance.

During an interview on 2/05/24, at 2:20 p.m., Resident R11 revealed that they don't like to use their call bell or ask for assistance because the staff talk down to them and belittle them for interrupting them.

Interviews during a Resident Council meeting on 2/06/24, at 10:30 a.m. revealed four of five residents (R13, R48, R66, and R78) in attendance with concerns of when they put their call bells on, staff will come into their room, turn the call bell off and not return. The residents further indicated after they turn their call bells back on, it could take an hour for staff to respond.

Resident R36's clinical record revealed an admission date of 7/12/23, with diagnoses that included diabetes mellitus, interstitial cystitis (a chronic painful bladder condition), unsteadiness on feet, and muscle weakness.

The MDS Section C0500 dated 11/08/23, indicated Resident R36 is alert and oriented with a BIMS score of 15. The Point of Care ADL Category Report (MDS 3.0) dated 2/07/24, indicated that Resident R36 for Transfers and Toilet use, was identified as limited assistance (one-person physical assist) and eating as supervision (set up assistance).

During an interview on 2/06/24, at 12:10 p.m. Resident R36 indicated that staff are rude and do not answer his/her call bell timely. Resident R36 further indicated his/her roommate will often have to go get staff to assist in his/her needs due to being blind. On 2/08/24, at 10:45 a.m. Resident R36 verbalized, "it took an hour for someone to answer my call bell last night."

Resident R26's clinical record revealed an admission date of 11/29/23, with diagnoses that included end stage renal disease (kidneys are not functioning properly), anemia (deficiency of healthy red blood cells), and muscle weakness.

The MDS Section C0500 dated 1/14/24, indicated Resident R26 is alert and oriented with a BIMS score of 15. Resident R26's Section GG0130 dated 1/14/24, Functional Abilities and Goals for Self-Care indicated Resident R26's ability to shower/bathe self requires partial/moderate assistance.

During a interview on 2/07/24, at approximately 12:00 p.m. Resident R26 indicated that he/she was placed in the shower room and the Nursing Assistant (NA) threw a washcloth at him/her and said, "wash yourself." The NA then left him/her unassisted in the shower room for an extended period of time.

Resident R44's clinical record revealed an admission date of 2/26/23, with diagnoses that included intestinal obstruction, anxiety, malignant neoplasm of the bronchus or lung (cancer), and hyperlipidemia (high cholesterol).

The MDS Section C0500 dated 11/15/23, indicated Resident R44 is alert and oriented with a BIMS score of 15. The Point of Care ADL Category Report (MDS 3.0) dated 11/15/23, indicated that Resident R44 for Transfers and Toilet hygiene was identified as dependent (helper does all of the effort. Resident does none of the effort to complete the activity).

During an interview on 2/06/24, at 9:45 a.m. Resident R44 indicated he/she placed his/her call bell on at 9:00 a.m. due to being incontinent of stool. Resident R44 verbalized, "They just came in and turned my call bell off and left. They do this all the time. They call me selfish and that I think I am a princess. They told me they are going to teach me to be patient." Resident R44 turned his/her call bell back on at 9:50 a.m. awaiting staff to return to his/her room. A further interview and observation at 10:10 a.m. revealed Resident R44 resting in bed still incontinent of stool. Resident R44 indicated staff came back into his/her room and turned the call bell off and left.

During an interview with RN Supervisor Employee E7 on 2/06/24, at 10:15 a.m. Resident R44 revealed to the RN Supervisor that staff were turning his/her call bell off for the past hour and he/she needed incontinence care. RN Supervisor Employee E7 further confirmed that Resident R44's call bell was not on and Resident 44's needs were not addressed in a dignified timely manner.

Observations on 2/07/24, at approximately 10:45 a.m. revealed Licensed Practical Nurse (LPN) Employee E8 speaking loudly with a harsh tone to Resident R44 regarding care being provided during a meal. LPN Employee E8 was overheard speaking loudly to Resident R44 stating, "It is a state regulation that care cannot be provided during a meal." The Infection Control RN interrupted LPN Employee E8 and requested him/her to step out of Resident R44's room and stop talking. The Infection Control RN further confirmed that LPN Employee E8 was not speaking to Resident R44 in a dignified manner.

An interview with the RN Regional Director on 12/07/24, at 12:20 p.m. confirmed that staff should always respond to resident call bells and needs in a dignified and timely manner.

28 Pa. Code 201.29(a) Resident Rights









 Plan of Correction - To be completed: 03/12/2024

The facility completed the following corrective actions; interviews were completed for residents R1, R11, R13, R26, R36, R44, R48, R66, R78 to determine if they have any additional concerns. Any concerns noted have been logged according to facility policy and appropriate follow up is being provided.
All residents have the potential to be affected and the administrator and department leaders will interview all residents with respect call lights being answered timely and if they are being treated with dignity and respect by 3-5-2024.
Any concerns noted will be logged according to facility policy and appropriate follow up will be provided. For residents who are non-interviewable the residents' primary contact will be interviewed.
To prevent this from reoccurring all staff will have completed assigned education on "Respect and Dignity in The Healthcare Setting" and "Communication and Customer Service Principles" to be completed by 3-12-2024. Furthermore, an all staff in service was conducted on 2-28-2024 by the administrator for all staff regarding resident rights, treating everyone with respect and dignity and expectations regarding answering call lights.
To monitor and maintain ongoing compliance the following actions will be taken: The administrator/or designee will complete a call light audit of 5 residents 3 times weekly for 4 weeks then monthly for 2 months to ensure call lights as being answered as expected. Furthermore, The administrator/or designee will complete review of 5 resident interviews 3 times weekly for 4 weeks then monthly for 2 months to learn if residents are being treated with dignity and respect. Results of these audits will be reviewed by the facilities QAPI committee for further review, action and monitoring.

483.21(c)(2)(i)-(iv) REQUIREMENT Discharge Summary:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
§483.21(c)(2) Discharge Summary
When the facility anticipates discharge, a resident must have a discharge summary that includes, but is not limited to, the following:
(i) A recapitulation of the resident's stay that includes, but is not limited to, diagnoses, course of illness/treatment or therapy, and pertinent lab, radiology, and consultation results.
(ii) A final summary of the resident's status to include items in paragraph (b)(1) of §483.20, at the time of the discharge that is available for release to authorized persons and agencies, with the consent of the resident or resident's representative.
(iii) Reconciliation of all pre-discharge medications with the resident's post-discharge medications (both prescribed and over-the-counter).
(iv) A post-discharge plan of care that is developed with the participation of the resident and, with the resident's consent, the resident representative(s), which will assist the resident to adjust to his or her new living environment. The post-discharge plan of care must indicate where the individual plans to reside, any arrangements that have been made for the resident's follow up care and any post-discharge medical and non-medical services.
Observations:


Based on review of facility policy, clinical record review and staff interview, it was determined that the facility failed to complete a discharge summary, which includes a recapitulation of the resident's stay, the resident's discharge status, reconciliation of all medications, and post-discharge plan for two of three closed records reviewed (Resident CR108 and Resident CR159).

Findings include:

Review of a facility policy dated 1/17/24, entitled "Discharge Planning Policy" indicated that when a discharge is anticipated, the facility will develop a Discharge Summary that includes summaries of the resident's stay, the resident's status at discharge, medication reconciliation, and summary of the resident's post-discharge plan of care.

Resident CR108's closed clinical record revealed an admission date of 11/17/23, with diagnoses that included diabetes (condition related to inadequate insulin and high blood sugars), Chronic Obstructive Pulmonary Disease (COPD - a condition that obstructs air flow in the lungs with symptoms of difficulty breathing, coughing and shortness of breath), and muscle weakness.

Resident CR108's clinical record revealed the resident was discharged from the facility against medical advice on 12/3/23. Further review of Resident CR108's clinical record lacked evidence of a discharge summary being completed.


Resident CR159's closed clinical record revealed an admission date of 6/30/23, with diagnoses that included repeated falls, anxiety, and muscle weakness.

Resident CR159's clinical record revealed the resident was discharged from the facility against medical advice on 10/31/23. Further review of Resident CR159's clinical record lacked evidence of a discharge summary being completed.

An interview on 2/8/24, at 12:37 p.m. with the Regional Director of Clinical Services, confirmed that Resident CR108 and CR159's closed clinical records lacked evidence of a discharge summary being completed.

28 Pa. Code 211.5(d)(f)(xi) Medical records







 Plan of Correction - To be completed: 03/12/2024

The facility completed the following corrective actions; discharge summaries have been completed for CR108 and CR159.
To identify other residents who are at risk the facility will review all discharges that have occurred within the last 60 days by 3/5/2024 to ensure there are discharge summaries for all discharged residents. If a discharge summary is not present one will be completed.
To prevent this from reoccurring the administrator provided education to facility leadership on 2-28-2024 regarding ensuring discharge summaries are completed as required.
To monitor and maintain ongoing compliance the following actions will be taken: The administrator/or designee will complete an audit 3 x weekly for 4 weeks and then monthly for two months to ensure discharge summaries are completed as required. Results of these audits will be reviewed by the facilities QAPI committee for further review, action and monitoring.

483.70(g)(1)(2) REQUIREMENT Use of Outside Resources: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.
§483.70(g) Use of outside resources.
§483.70(g)(1) If the facility does not employ a qualified professional person to furnish a specific service to be provided by the facility, the facility must have that service furnished to residents by a person or agency outside the facility under an arrangement described in section 1861(w) of the Act or an agreement described in paragraph (g)(2) of this section.

§483.70(g)(2) Arrangements as described in section 1861(w) of the Act or agreements pertaining to services furnished by outside resources must specify in writing that the facility assumes responsibility for-
(i) Obtaining services that meet professional standards and principles that apply to professionals providing services in such a facility; and
(ii) The timeliness of the services.
Observations:


Based on clinical record review and resident and staff interview, it was determined that the facility failed to schedule an appointment for outside services for one of 24 residents reviewed in a timely manner (Resident R99).

Findings include:

Resident R99's clinical record revealed an admission date of 10/27/2023, with diagnoses that inlcuded cervical (neck) spinal problems, difficulty walking, muscle weakness, cervical spinal fusion and pain disorder.

During an interview on 2/6/2024, at 1:55 p.m. Resident R99 revealed that facility staff were to schedule an appointment within one week of admission with an orthopedic surgeon (medical doctor that focuses on bones, muscles, joints, and nerves) specializing in spinal care, but that they failed to make the appointment until nearly a month after admission, prolonging their stay at the facility.

Resident R99's clinical record also contained hospital discharge/admission orders which directed the facility to make an appointment with an orthopedic surgeon specializing in spinal care within one week of admission (10/27/2023).

A nursing progress note dated 11/22/23, documented that an appointment for Resident R99 with the orthopedic surgeon specializing in spinal care was not made until 11/22/23, a period of 26 days after admission.

During interview on 2/7/24, at 2:48 p.m., Registered Nurse Supervisor Employee R10 confirmed that the appointment for Resident R99 with the orthopedic surgeon was not made until 11/22/23, more than three weeks after admission to the facility.

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





 Plan of Correction - To be completed: 03/12/2024

The facility completed the following corrective actions; Resident R99 was able to see the orthopedic surgeon for follow up on 12/20/2023 and surgery has been scheduled for 3-14-2024.
To identify other residents who are at risk the facility will audit all admission orders for residents that have been admitted in the last 60 days by 3/8/2024 to ensure all appointments for outside services have been scheduled.

To prevent this from reoccurring the Director of Nursing provided education with nursing staff and leadership team on 2-28-2024 regarding the process of scheduling appointments for outside services.

To monitor and maintain ongoing compliance the following actions will be taken: The director of nursing or designee will complete an audit of all admissions 3 x weekly for 4 weeks and then monthly for two months to ensure the facility has scheduled appointments for outside services.

Furthermore, the director of nursing or designee will complete an audit of 5 residents 3 times weekly for 4 weeks and then monthly for two months to ensure the facility has scheduled appointments for outside services.

Results of these audits will be reviewed by the facilities QAPI committee for further review, action and monitoring.

483.24(a)(2) REQUIREMENT ADL Care Provided for Dependent Residents:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
§483.24(a)(2) A resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene;
Observations:

Based on a review of facility documents and clinical records, and the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual 2019 (RAI-assessment guide use to plan the provision of care for residents), observations, and staff interviews, it was determined the facility failed to ensure dependent residents are assisted with meals for two of 24 residents reviewed (Residents R40 and R105).

Findings include:

No policy was provided regarding the facility's responsibility to ensure a dependent resident receives care/treatment.

Review of the "Resident Rights Inservice," provided by the Regional Director on 2/07/24, approximately 11:00 a.m. revealed "The Residents' Bill of Rights, The Nursing Home Reform Act established the following rights for nursing home residents: Receive adequate and appropriate care, Right to Dignity, Respect, and Freedom; and to be treated with consideration, respect, and dignity."

Resident R40's clinical record revealed an admission date of 5/02/22, with diagnoses that included acute respiratory failure with hypoxia (caused by a disease or injury that affects your breathing), metabolic encephalopathy (a problem in the brain caused by a chemical imbalance in the blood), severe protein-calorie malnutrition (a condition that happens when the nutrients the body receives don't meet its needs, tissues are broken down and functions are shut down), and down syndrome (a genetic chromosome disorder causing developmental and intellectual delays).

Review of the RAI manual instructions for Section C0500 "Brief Interview for Mental Status (BIMS)" revealed that a score of 13-15 identified a resident as cognitively intact and a score of 8-12 identified a resident as moderately impaired, and a score of 0-7 as severely impaired.

Review of the Minimum Data Set (MDS-a periodic assessment of resident care needs) Section C0500 dated 1/23/24, revealed that Resident R40 was severely impaired with a BIMS score of 0/15. Resident R40's Section GG0130 dated 1/23/24, Self-Care: indicated Resident R40 was dependent on staff for eating (helper does all the effort and resident does none).

During an observation on 2/05/24, at 12:15 p.m. Resident R40's lunch tray was observed sitting on his/her bedside tray with him/her resting in bed. Further observations on 2/05/24, at 12: 55 p.m. revealed staff picking of second-floor resident lunch trays and Resident R40's lunch tray still sitting on his/her bedside table untouched with him/her resting in bed.

During an interview at 2/05/24, at 12:55 p.m. with Registered Nurse (RN) Supervisor Employee E9 revealed that staff did not assist Resident R40 with his/her lunch and that Resident R40 was dependent on staff for assistance with meals.

During an interview on 2/07/24, at 12:20 p.m. the RN Regional Director confirmed that Resident R40 should have been assisted with his/her lunch meal immediately when it was brought to his/her room, and it was too long of a wait to consume the meal.


Resident R105's clinical record revealed an admission date of 1/23/24, with diagnoses that included acute kidney failure (a condition when the kidneys cannot suddenly filter waste from the blood), history of falling, anemia (a condition when the blood does not have enough healthy red blood cells and hemoglobin (a protein) to carry oxygen though the blood), and muscle weakness.

Review of the MDS Section C0500 dated 1/26/24, revealed that Resident R105 is severely impaired with a BIMS score of 5/15. Resident R105's Section GG0130 dated 1/26/24, Self-Care: indicated Resident R105 is setup or clean-up assistance by staff for eating (helper sets up or cleans up; resident completes activity. Helper assists only prior to or following the activity).

During an observation with the Director of Nursing (DON) on 2/08/24, at 12:45 p.m. the DON confirmed that Resident R105 could not open his/her milk carton on the lunch tray sitting at Resident 105's bedside. Resident R105 was observed reaching for an old milk carton full of milk and a glass half full of a liquid that appeared to be a juice or tea. The older beverage containers were observed to have fruit flies on them. The DON confirmed Resident R105's lunch tray was left at his/her bedside and that Resident R105 did need staff assistance to consume his/her meal, but it was not provided. The DON further confirmed that Resident R105 was attempting to drink from old beverages left from an earlier time in the morning with fruit flies surrounding them and staff did not discard when delivering the new lunch tray.

28 Pa. Code 211.12(d)(1)(2)(5) Nursing Services


 Plan of Correction - To be completed: 03/12/2024

The facility completed the following corrective actions; R40 and R105 each were able to get assistance in finishing their meal on 2/5/2024. Therapy screens will be completed by 3/5/2024 to determine if any additional ADL assistance
To identify other residents who are at risk the facility identified residents who require meal assistance and the facility will complete OT screens by 3-8-2024 to determine if additional interventions are needed for assistance with meals.
To prevent this from reoccurring the Director of Nursing and Administrator provided education to all staff on 2-28-2024 to discuss facility expectations with respect to providing dependent residents are assisted with meals.
To monitor and maintain ongoing compliance the following actions will be taken:
The administrator/or designee will complete an audit of 5 residents who need assistance with meals 4 x weekly for 4 weeks and then monthly for two months to ensure dependent residents are assisted with meals. Results of these audits will be reviewed by the facilities QAPI committee for further review, action and monitoring.

483.45(a)(b)(1)-(3) REQUIREMENT Pharmacy Srvcs/Procedures/Pharmacist/Records:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
§483.45 Pharmacy Services
The facility must provide routine and emergency drugs and biologicals to its residents, or obtain them under an agreement described in §483.70(g). The facility may permit unlicensed personnel to administer drugs if State law permits, but only under the general supervision of a licensed nurse.

§483.45(a) Procedures. A facility must provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident.

§483.45(b) Service Consultation. The facility must employ or obtain the services of a licensed pharmacist who-

§483.45(b)(1) Provides consultation on all aspects of the provision of pharmacy services in the facility.

§483.45(b)(2) Establishes a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation; and

§483.45(b)(3) Determines that drug records are in order and that an account of all controlled drugs is maintained and periodically reconciled.
Observations:


Based on review of facility policy, clinical records, and the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual 2019 (RAI-assessment guide used to plan the provision of care for residents), observations, and resident and staff interviews, it was determined that the facility failed to ensure medications were administered in accordance with professional standards for one of 24 residents reviewed (Resident R78).

Findings include:

Review of facility policy, "General Dose Preparation and Medication Administration," dated 1/17/24, revealed "1. Facility staff should comply with Facility policy, Applicable Law and the State Operations Manual when administering medications. 3. Dose Preparation: Facility should take all measures required by Facility policy and Applicable Law, including but not limited to the following: 3.10 Facility staff should not leave medications or chemicals unattended. 5. During medication administration, Facility staff should take all measures required by Facility policy and Applicable Law, including, but not limited to the following: 5.10 Observe the resident's consumption of the medications (s)."

Review of Resident R78's clinical record revealed an admission date of 9/12/22, with diagnoses that included urinary tract infection, sepsis (a life-threatening complication of an infection), diabetes mellitus (a group of diseases that result in too much sugar in the blood), and gastro-esophageal reflux disease (a digestive disease in which the stomach acid irritates the food pipe lining.)

Review of the RAI manual instructions for Section C0500 "Brief Interview for Mental Status (BIMS)" revealed that a score of 13-15 identified a resident as cognitively intact and a score of 8-12 identified a resident as moderately impaired, and a score of 0-7 as severely impaired. The Minimum Data Set (MDS-a periodic assessment of resident care needs) Section C0500 dated 1/23/24, indicated Resident R78 with a BIMS score of 12.

Review of Resident R78's MAR (Medication Administration Record) for February 2024 revealed that on February 5, 2024, 07:00 - 11:45 the following medications were documented as given: Ascorbic acid 1000 milligrams (mg) tablet oral, Cholecalciferol (Vitamin D3) 50 micrograms (mcg) (2,000 unit) tablet oral, Effexor XR (venlafaxine-medication to treat depression) capsule extended release 24 hr 75 mg oral, Metformin (medication to treat diabetes) tablet extended release 24 hr 500 mg oral.

Observation of the second-floor unit on 2/05/24, at 11:35 a.m. revealed Resident R78 asleep in bed with medications in a cup on his/her bedside table. Further observations revealed Resident R78 waking up to view the medications in the cup in front of him/her and stating, "Oh I guess these are my medications."

An interview on 2/05/24, at 11:40 a.m. with the second-floor nurse, Registered Nurse (RN) Employee E7 confirmed the medications, as noted above, were delivered to Resident R78 earlier in the morning. RN Employee E7 confirmed the medications were left unattended and not consumed by Resident R78. RN Employee E7 confirmed the medications should not be left unattended by the nurse responsible for the medication administration.

An interview with the Nursing Home Administrator on 2/06/24, at 12:50 p.m. confirmed medications should be observed consumed by a resident when administered and not left unattended by nursing staff.

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

28 Pa. Code 211.10(c) Resident care policies

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


 Plan of Correction - To be completed: 03/12/2024

The facility completed the following corrective actions; on the day of the observation the nurse assigned to R78 confirmed the medication was able to be administered appropriately.
To identify other residents who are at risk the facility a full house audit was conducted on 2-29-2024 by the assistant director of nursing and the RN nursing supervisor and no medication was left unattended.
To prevent this from reoccurring the Director of Nursing provided education to licensed nurses on 2-28-2024 regarding medication pass expectations and ensuring medication are not left unattended.
To monitor and maintain ongoing compliance the following actions will be taken: The Director of Nursing or designee will complete an audit of 5 residents during medication pass on each shift 3 times weekly for 4 weeks and then monthly for two months for each resident to ensure no medications have been left unattended with residents. Results of these audits will be reviewed by the facilities QAPI committee for further review, action and monitoring.

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

§483.45(h) Storage of Drugs and Biologicals

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

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

Based on review of facility policy, observations and staff interview, it was determined that the facility failed to label multi-dose containers of tuberculin solution (used to test for the disease tuberculosis) with the date they were opened in one of two medication storage rooms (Third Floor medication room).

Findings include:

Review of a facility policy entitled, "Storage and Expiration dating of Medication, Biologicals" dated January 2022, indicated that staff "should record the date opened on the primary medication container when the medication has a shortened expiration date once opened." The packaging for the tuberculin solution indicated that any unused solution was to be discarded after 28 days once opened.

Observation on 2/05/24, at 12:32 p.m. of the Third Floor medication room refrigerator revealed an opened multi-dose vial of tuberculin solution without a date when it was opened. At that time, Licensed Practical Nurse (LPN) Employee E6 confirmed that the multi-dose vial of tuberculin solution did not identify an open date. The LPN was able to confirm at that time that the date was not on the open multi dose vial of tuberculin solution.

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




 Plan of Correction - To be completed: 03/12/2024

No residents were identified in this observation, The facility completed the following corrective actions; on the date of the observation the multi dose containers of tuberculin solution were discarded.
To identify other risks on 2-29-2024 all medication storage rooms and med carts were checked to ensure drugs and biologicals were labeled appropriately.
To prevent this from reoccurring the Director of Nursing provided education to licensed nursing staff on 2-28-2024 regarding the facility's expectation regarding proper labeling of drugs and biologicals.
To monitor and maintain ongoing compliance the following actions will be taken: he Director of Nursing/or designee will complete an audit 3 x weekly for 4 weeks and then monthly for two months of each medication storage area to ensure drugs and biologicals are labeled appropriately. Results of these audits will be reviewed by the facilities QAPI committee for further review, action and monitoring.

483.60(i)(4) REQUIREMENT Dispose Garbage and Refuse Properly:Least serious deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents. This deficiency has the potential for causing no more than a minor negative impact on the resident.
§483.60(i)(4)- Dispose of garbage and refuse properly.
Observations:

Based on observations and staff interview, it was determined that the facility failed to properly store and contain refuse.

Findings include:

Initial observation of the dumpster located at the side of the facility by the parking lot on February 5, 2024, at 11:45 a.m., revealed that the dumpster was full of garbage bags with flies flying around the dumpster bags. The dumpsters do not have a privacy fence around the dumpsters exposing them to the parking lot. The sliding doors on both sides of the dumpster were observed to be open exposing the waste to visitors or employee parking. Open waste bins also expose the facility to possible pest and rodent issues.

During an interview with the Registered Dietitian on February 5, 2024, at 11:50 a.m., it was confirmed that the dumpster doors were open exposing the garbage to the facility parking lot, and possible pest infestation.

During an observation of the dumpster on February 6, 2024, at 8:45 a.m., it was observed that the dumpster doors were again left open exposing garbage to the parking lot area and potential pests.

28 Pa. Code 201.14(a) Responsibility of licensee






 Plan of Correction - To be completed: 03/12/2024

No specific residents were identified with this observation. The facility completed the following corrective actions; On the date of the observation the dumpster doors were immediately closed.
To identify other areas of risk the facility the facility has arranged for Pest Control Company ; to evaluate the garbage dumpster area to verify there is no pest infestation.
To prevent this from reoccurring the administrator provided education to all staff on 2-28-2024 regarding the facility's expectation that the dumpster doors remain closed at all times.
To monitor and maintain ongoing compliance the following actions will be taken:
The administrator/or designee will complete an audit twice a day 5 times weekly for 4 weeks and then monthly for two months to verify dumpster doors remain closed at all times. Results of these audits will be reviewed by the facilities QAPI committee for further review, action and monitoring.

§ 201.19(4) LICENSURE Personnel policies and procedures.:State only Deficiency.
(4) A determination by a health care practitioner that the employee, as of the employee's start date, is free from the communicable diseases or conditions listed in § 27.155 (relating to restrictions on health care practitioners).

Observations:


Based on review of facility policy and employee personnel records, and staff interviews, it was determined that the facility failed to ensure that personnel records included evidence that, as of the employee's start date, he/she was free from communicable diseases or conditions for five of five employees reviewed (Licensed Practical Nurse (LPN) Employee E1, Registered Nurse (RN) Employee E2, Dietary Aide Employee E3, RN Employee E4, and Nurse Aide (NA) Employee E5).

Findings include:

Review of facility policy dated 1/17/24, entitled "Employee Health and Return to Work Policy" indicated, "A post-offer employment physical will be conducted according to state specific guidance."

Review of LPN Employee E1's personnel record revealed a document dated 10/25/23, entitled, "Physical Assessment Form." The form lacked evidence that LPN Employee E1 was free from communicable diseases or conditions as of his/her start date.

Review of RN Employee E2's personnel record revealed a document dated 11/8/23, entitled, "Physical Assessment Form." The form lacked evidence that RN Employee E2 was free from communicable diseases or conditions as of his/her start date.

Review of Dietary Aide Employee E3's personnel record revealed a document dated 11/16/23, entitled, "Physical Assessment Form." The form lacked evidence that Dietary Aide Employee E3 was free from communicable diseases or conditions as of his/her start date.

Review of RN Employee E4's personnel record revealed a document dated 11/27/23, entitled, "Physical Assessment Form." The form lacked evidence that RN Employee E4 was free from communicable diseases or conditions as of his/her start date.

Review of NA Employee E5's personnel record revealed a document dated 12/14/23, entitled, "Physical Assessment Form." The form lacked evidence that NA Employee E5 was free from communicable diseases or conditions as of his/her start date.

During an interview on 1/7/24, at 1:36 p.m. the Regional Director of Clinical Services confirmed that the personnel files for Employees E1, E2, E3, E4, and E5 lacked evidence that the employees were free from communicable diseases or conditions as of his/her start date.





 Plan of Correction - To be completed: 03/12/2024

The facility will complete the following corrective actions; Licensed Practical Nurse (LPN) Employee E1, Registered Nurse (RN) Employee E2, Dietary Aide Employee E3, RN Employee E4, and Nurse Aide (NA) Employee E5 will have physical forms completed by 3-8-2024 that as of the employee's start date, he/she was free from communicable diseases.
To identify other employee files having incomplete physical forms the facility will conduct an audit of all staff to ensure there is a physical form that states that he/she is free from communicable diseases by 3/14/2024.
To prevent this from reoccurring the administrator provided education with human resource director and leadership team on 2-28-2024 regarding the requirement that personnel records included evidence that, as of the employee's start date, he/she was free from communicable diseases.
To monitor and maintain ongoing compliance the following actions will be taken: The administrator/or designee will complete an audit of all new employees weekly for 4 weeks and then monthly for two months to ensure personnel records included evidence that, as of the employee's start date, he/she was free from communicable diseases. Results of these audits will be reviewed by the facilities QAPI committee for further review, action and monitoring.

§ 201.19(5) LICENSURE Personnel policies and procedures.:State only Deficiency.
(5) Records relating to a medical exam, if required by a facility, or attestation that the employee is able to perform the employee ' s job duties.

Observations:


Based on review of facility policy and employee personnel records, and staff interviews, it was determined that the facility failed to ensure that personnel records included an attestation that the employee is able to perform his/her job duties for five of five employees reviewed (Licensed Practical Nurse (LPN) Employee E1, Registered Nurse (RN) Employee E2, Dietary Aide Employee E3, RN Employee E4, and Nurse Aide (NA) Employee E5).

Findings include:

Review of facility policy dated 1/17/24, entitled "Employee Health and Return to Work Policy" indicated, "A post-offer employment physical will be conducted according to state specific guidance."

Review of LPN Employee E1's personnel record revealed a document dated 10/25/23, entitled, "Physical Assessment Form." The form lacked evidence that LPN Employee E1 was able to perform his/her job duties.

Review of RN Employee E2's personnel record revealed a document dated 11/8/23, entitled, "Physical Assessment Form." The form lacked evidence that RN Employee E2 was able to perform his/her job duties.

Review of Dietary Aide Employee E3's personnel record revealed a document dated 11/16/23, entitled, "Physical Assessment Form." The form lacked evidence that Dietary Aide Employee E3 was able to perform his/her job duties.

Review of RN Employee E4's personnel record revealed a document dated 11/27/23, entitled, "Physical Assessment Form." The form lacked evidence that RN Employee E4 was able to perform his/her job duties.

Review of NA Employee E5's personnel record revealed a document dated 12/14/23, entitled, "Physical Assessment Form." The form lacked evidence that NA Employee E5 was able to perform his/her job duties.

An interview on 1/7/24, at 1:26 p.m. with the Human Resource & Payroll representative indicated that the "Physical Assessment Form" is signed by a physician then given to a facility nurse who obtains, documents, and dates the new employee's vital signs on the form, then the form is placed in the employee's file.

An interview on 1/7/24, at 1:34 p.m. with the Regional Director of Clinical Services confirmed that the personnel files for Employees E1, E2, E3, E4, and E5 lacked evidence that the employees are able to perform his/her job duties.





 Plan of Correction - To be completed: 03/12/2024

The facility will complete the following corrective actions; Licensed Practical Nurse (LPN) Employee E1, Registered Nurse (RN) Employee E2, Dietary Aide Employee E3, RN Employee E4, and Nurse Aide (NA) Employee E5 will have personnel records that include an attestation that the employee is able to perform his/her job duties by 3/8/2024.
To identify other employee files having incomplete documentation the facility will conduct an audit of all staff to ensure they have a personnel record that includes an attestation that the employee is able to perform his/her job duties by 3/14/2024.
To prevent this from reoccurring the administrator provided education with human resource director and leadership team on 2-28-2024 regarding the requirement that all staff have a personnel record that includes an attestation that the employee is able to perform his/her job duties
To monitor and maintain ongoing compliance the following actions will be taken: The administrator/or designee will complete an audit of all new employees weekly for 4 weeks and then monthly for two months to ensure all newly hired staff have a personnel record that includes an attestation that the employee is able to perform his/her job duties. Results of these audits will be reviewed by the facilities QAPI committee for further review, action and monitoring.

§ 205.72 LICENSURE Furniture.:State only Deficiency.
A resident shall be provided with a drawer or cabinet in the resident ' s room that can be locked.

Observations:

Based on observations, staff and visitors interviews, it was determined the facility failed to ensure that resident rooms were furnished with a drawer or cabinet that could be locked for one of 30 rooms reviewed (Room 212).

Findings include:

During an interview on 2/8/24, at 3:10 p.m., Facility Visitor V1 disclosed that in Room 212 the lock in the lockable cabinet drawer was not functioning.

During an observation on 2/8/24, at 3:20 p.m., with the Director of Nursing, it was observed and confirmed that the drawer lock was broken and unable to be locked.





 Plan of Correction - To be completed: 03/12/2024

The facility completed the following corrective actions; A locking drawer was given to room 212 on 2/8/2024.
To identify other residents who are at risk a complete house audit was completed on 2/29/2024 and arrangements have been made to ensure any rooms that have not been furnished a drawer or cabinet that can be locked get the proper furnishings.
To prevent this from reoccurring the administrator provided education with all staff on 2-28-2024 regarding the requirement that that resident rooms were furnished with a drawer or cabinet that can be locked.
To monitor and maintain ongoing compliance the following actions will be taken: The administrator/or designee will complete an audit 3 x weekly for 4 weeks and then monthly to ensure resident rooms are furnished with a drawer or cabinet that can be locked. Results of these audits will be reviewed by the facilities QAPI committee for further review, action and monitoring.


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